Improving Drug Abuse

Treatment

Editors:

Roy W. Pickens, Ph.D.

Carl G. Leukefeld, D.S.W.

Charles R. Schuster, Ph.D.

Research Monograph 106

1991

U.S. 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, MD 20857

For sale by the Superintendent of Documents, U.S. Government Printing Office

Washington, DC 20402
ACKNOWLEDGMENT

This monograph is based on the papers and discussion from a technical

review on “Improving Drug Abuse Treatment,” held on August 28-30, 1989,

in Bethesda, MD. The review meeting was sponsored by the National Institute

on Drug Abuse.

COPYRIGHT STATUS

The National Institute on Drug Abuse has obtained permission from the

copyright holders to reproduce certain previously published material as noted in

the text. Further reproduction of this copyrighted material is permitted only as

part of a reprinting of the entire publication or chapter. For any other use, the

copyright holder’s permission is required. All other 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, proprietary, or company names appearing in this

publication are used only because they are considered essential in the context

of the studies reported herein.

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.

DHHS publication number (ADM)91-1754

Printed 1991

ii
Contents

Page

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Frederick K. Goodwin

Overview of Treatment Issues . . . . . . . . . . . . . . . . . . . . . . . . .

Roy W. Pickens and Bennett W. Fletcher

1

Drug Treatment Services: Funding and Admissions . . . . . . . . . . 20

William Butynski

Do More . . . and Do It Better: Staff-Related Issues

in the Drug Treatment Field That Affect

the Quality and Effectiveness of Services . . . . . . . . . . . . . . . . . . . . . 53

John S. Gustafson

Outpatient Drug Abuse Treatment Services, 1988: Results of

a National Survey . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Richard H. Price, A. Celeste Burke,

Thomas A. D’Aunno, David M. Klingel, William C. McCaughrin,

Jane A. Rafferty, and Thomas E. Vaughn

Treatment Outcomes for Drug Abuse Clients . . . . . . . . . . . . . . . 93

Frank M. Tims, Bennett W. Fletcher,

and Robert L. Hubbard

Patient Treatment Matching: A Conceptual

and Methodological Review With Suggestions

for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

A. Thomas McLellan and Arthur I. Alterman

iii
Client Issues in Drug Abuse Treatment: Addressing

Multiple Drug Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Thomas R. Kosten

Addressing Psychiatric Comorbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

George E. Woody, A. Thomas McLellan,

Charles P. O’Brien, and Lester Luborsky

Are There Minimum Conditions Necessary

for Methadone Maintenance To Reduce Intravenous

Drug Use and AIDS Risk Behaviors? . . . . . . . . . . . . . . . .

Anna Rose Childress, A. Thomas McLellan,

George E. Woody, and Charles P. O’Brien

Reducing Illicit Drug Use Among Methadone Patients . . . . . . . .

Maxine L. Stitzer and Kimberly C. Kirby

Improving Client Compliance in Outpatient Treatment:

Counselor-Targeted Interventions . . . . . . . . . . . . . . . .

Mary E. McCaul and Dace S. Svikis

Retention in Drug-Free Therapeutic Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

George De Leon

Using Methadone Effectively: Achieving Goals by

Application of Laboratory, Clinical, and Evaluation

Research and by Development of Innovative Programs . . . . . . . . . . . . . . . . . . . . . . .

Mary Jeanne Kreek

Using Psychotherapy Effectively in Drug Abuse Treatment . . . . . . . . . . . . . . . . . . . .

Lisa Simon Onken

Relapse Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sharon M. Hall, David A. Wasserman.

and Barbara E. Havassy

Conditioning Factors May Help To Understand

and Prevent Relapse in Patients Who Are

Recovering From Drug Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Charles P. O’Brien, Anna Rose Childress,

and A. Thomas McLellan

136

152

167

178

204

218

245

267

279

293

iv
Some Special Considerations for Treatment of

Drug Abuse and Dependence in Women . . . . . . . . . . . . . . . . . . . . . . . . . .

Jack H. Mendelson, Roger Weiss, Margaret Griffin,

Steven M. Mirin, Siew K. Teoh, Nancy K. Mello,

and Barbara W. Lex

Opportunities for Enhancing Drug Abuse Treatment

With Criminal Justice Authority . . . . . . . . . . . . . . . . . . . . . . . . . . .

Carl G. Leukefeld

Contemporary Issues in Drug Abuse Treatment

Linkage With Self-Help Groups...........................................................

David N. Nurco, Philip Stephenson,

and Thomas E. Hanlon

Primary Care and Intravenous Drug Abuse Treatment . . . . . . . . . . . . . . . . . .

Richard J. Russo

Establishing a Methadone Quality Assurance System:

Rationale and Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

James R. Cooper

Methadone Maintenance and Patients in

Alcoholism Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Enoch Gordis

Community Resistance to Drug Treatment Program Placement . . . . . . . . . . . .

Chauncey L. Veatch Ill

The Impact of AIDS on Drug Abuse Treatment . . . . . . . . . . . . . . . . .

Lawrence S. Brown, Jr.

Improving Drug Abuse Treatment: Recommendations

for Research and Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Carl G. Leukefeld, Roy W. Pickens,

and Charles R. Schuster

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

313

328

338

349

358

365

373

385

394

407

v

Preface

In recent years, the role of effective, research-based clinical treatment

increasingly has been recognized as central to the success of the Nation’s

overall efforts to eliminate illicit drug use and to reduce the spread of HIV

infection associated with drug use. Acknowledgment of the importance of

treatment has been reinforced by accumulating information regarding the

neurobiological bases of substance use and dependence and, in turn, by

scientific evidence that these conditions can be ameliorated through specific

medical and behavioral interventions.

Many existing treatment approaches are recognized as being clinically effective;

given the vast social and health costs that stem from untreated substance

abuse disorders, a strong case also can be made for the cost-effectiveness of

these treatments. Yet, much room exists for improvement. Basic studies,

including those employing animal models, and clinical research promise to

improve and expand the array of existing interventions, while research

demonstrations are uniquely capable of evaluating large-scale applications of

new treatment models.

In the interest of strengthening its treatment research agenda and portfolio, the

National Institute on Drug Abuse convened a conference on improving drug

abuse treatment in Bethesda, Maryland, in August 1989. Leading authorities

were invited to review the current status of treatment, to identify areas where

improvements are needed, to recommend research strategies, and to discuss

policy concerns germane to treatment improvement. Key policy questions

extend from the conduct to the implementation of research: how to make

optimum clinical use of existing knowledge, how to generate new information

that will be useful in modifying drug use behavior, and how to develop

accountability standards to ensure high-quality, research-based clinical care.

vii
This monograph is a report of that session. It is our hope that the discussions

will be useful to clinicians who wish to incorporate recent research findings into

their practices, to basic and clinical researchers who wish to focus on highpriority areas, and to policymakers whose responsibilities for allocating limited

social resources necessitate a clear understanding of sound strategies for

improving health.

Frederick K. Goodwin, M.D.

Administrator

Alcohol, Drug Abuse, and Mental Health Administration

viii
Overview of Treatment Issues

Roy W. Pickens and Bennett W. Fletcher

INTRODUCTION

The effectiveness of treatment in reducing illicit drug use is widely recognized.

This has been shown repeatedly in large-scale multisite evaluation projects

(Sells 1974; Hubbard et al. 1986) and in individual clinical investigations

(Newman and Whitehill 1979; McLellan et al. 1982). Treatment also is

associated with a reduction in crime and an improvement in social and

occupational functioning (McLellan et al. 1986; Bale et al. 1980; Simpson and

Sells 1982). More recently, drug abuse treatment also has been put forth as an

acquired immunodeficiency syndrome (AIDS) prevention strategy, as it deals

directly with risk behaviors involved with human immunodeficiency virus (HIV)

transmission (Public Health Service 1986).

This chapter presents an overview of current knowledge regarding the

effectiveness of drug abuse treatment. It also identifies several areas in which

improvement would make treatment an even more effective drug abuse and

AIDS control strategy.

NATURE OF ADDICTION

Treatment is intended for individuals who are drug dependent. Dependence is

a clinical syndrome that consists of multiple symptoms, including an inability to

control drug use, impairment of normal functioning, and physiological evidence

of chronic drug use (American Psychiatric Association 1987). Individuals may

become dependent on a variety of drugs, but the more severe types of

dependence are associated with such drugs as opiates (heroin) and cocaine

and with routes of administration that include intravenous (IV) injection and

smoking (Jaffe 1985).

Natural history studies have shown that drug dependence is a chronic disorder

that typically begins in late adolescence or early adulthood and continues for

more than 10 years (Vaillant 1966). Many addicts continue using opiates for 20

years or longer (Maddux and Desmond 1981). Over this time, periods of daily

or almost daily drug use are separated by periods of voluntary and involuntary

1
abstinence (Nurco et al. 1981). During periods of drug use, addicts often

engage in crimes such as theft, drug sales, and prostitution to support their drug

dependence (Inciardi 1981; Nurco et al. 1985). Also common during periods of

drug use is needle-sharing, a major vector in HIV transmission (Battjes and

Pickens 1988). Among drug addicts, treatment often is associated with onset of

abstinence periods (Rounsaville et al. 1987).

Although addicts are heterogeneous as a group, many addicts are socially

disadvantaged and distrustful of authority, with higher than average rates of

psychopathology and involvement with the criminal justice system (Rounsaville

et al. 1982; Nurco et al. 1985). The death rate among addicts is several times

higher than that in the general population (Maddux and Desmond 1981) and is

now increasing due to AIDS and other HIV-related disorders (Selwyn et al.

1989). As an addict ages, illicit drug use tends to decline. In a 12-year followup

of treated opiate addicts, Joe and colleagues (1990a) found that 75 percent of a

sample had quit daily opiate use, and for these addicts, the length of time

addicted to opiates averaged 9 years. Vaillant (1966) found that almost half of

the treated addicts in his sample had achieved stable abstinence by age 40.

EARLY TREATMENT EFFORTS

Until the mid-1920s drug abuse treatment was focused on the problem of opiate

addiction. It was delivered almost entirely by private practitioners and was

concerned primarily with the medical management of the opiate abstinence

syndrome (Terry and Pellens 1970). After the Harrison Act of 1914, use of

opiates came to be viewed as a criminal rather than a medical problem (Bates

and Crowther 1974). The resulting growth in the number of opiate addicts in

Federal prisons led to the opening of the Public Health Service (PHS) hospitals

at Lexington, Kentucky, in 1935 and at Fort Worth, Texas, in 1938. These

hospitals provided the first systematic data on treatment outcome of drug

abusers. Treatment in the PHS hospitals consisted of gradually withdrawing

addicts from opiates to minimize the abstinence syndrome, then providing them

with a drug-free environment in which to recover (Maddux 1978). Although the

facilities were established primarily to treat narcotic addicts convicted of Federal

law violations, most admissions were voluntary.

Early treatment efforts at these facilities were regarded as ineffective, with many

patients failing to complete treatment and high relapse rates following

treatment. Approximately 70 percent of voluntary admissions left treatment

against medical advice (Rasor and Maddux 1966). In addition, voluntary

admissions to the Lexington PHS hospital in the 1940s through the early 1960s

showed high relapse rates 6 to 12 months after discharge, ranging from 87 to

96 percent (Maddux 1988). The failure of patients to maintain abstinence after

2
leaving the PHS hospitals fit well with the prevailing view that opiate addiction

was incurable.

MODERN ERA

Two new forms of treatment that gained prominence in the 1960s called this

view into question. The first new treatment was the therapeutic community

(TC), exemplified by Synanon, which was founded in 1958 and evolved at least

in part from the philosophy of Alcoholics Anonymous. It used nonprofessional

staff, mostly recovering addicts, to resocialize clients to an abstinence-oriented

lifestyle in a residential setting (Glasser 1974). While resisting objective

evaluation, Synanon made remarkable claims for the successful rehabilitation of

drug abusers and established itself as a viable treatment modality. It laid the

groundwork for the opening of other TCs, including Daytop Village in 1964 and

Phoenix House in 1968.

The second form of treatment to gain prominence in the 1960s was methadone

maintenance. Dole and Nyswander (1965) reported remarkable success with a

group of 22 heroin addicts who were being maintained on daily oral doses of

methadone hydrochloride. Methadone prevented the psychological craving and

physiological effects of the opiate abstinence syndrome and, in sufficient

dosages, blocked the euphoric effects of heroin as well. Addicts who formerly

engaged in crime to support their drug habits were able with methadone

maintenance to engage in productive social behavior. Based on the success of

the Dole-Nyswander approach, several outpatient clinics opened around the

country, dispensing methadone under medical supervision and providing drug

counseling to addicts.

PRESENT TREATMENT SYSTEM

At present, the U.S. drug abuse treatment system consists of (1) detoxification

programs, which gradually withdraw addicts from illicit drugs to minimize the

abstinence syndrome; (2) drug-free programs, which have drug abstinence as

the primary treatment goal and also treat the psychological/behavioral aspects

of drug dependence; and (3) medication maintenance programs, which employ

medications that are longer acting substitutes for illicit drugs (e.g., methadone)

or block the effects of illicit drugs (e.g., naltrexone), allowing addicts to function

more normally in society. Drug-free programs may be outpatient or residential.

Residential programs may be long term (greater than 3 months) or short term

(less than 3 months). The longer duration and more intense programs (i.e.,

TCs) are intended for clients with more severe dependence problems. In

addition, self-help programs (e.g., Narcotics Anonymous) are an important part

of the treatment system.

3
TREATMENT EVALUATION

Evaluating treatment effectiveness has proven difficult for several reasons.

Random assignment of clients to treatment or no-treatment (control) groups has

not been ethically possible, although some studies have used detoxificationonly as a control (Newman and Whitehill 1979). In studies that attempt to

randomly assign drug abusers to different programs or modalities, clients are

often unwilling to accept placement in distant programs or in nonpreferred

modalities (Bale et al. 1980). Also, due to high utilization rates, treatment

programs may not be able to accommodate a randomly assigned client

(McLellan et al. 1983a).

For these reasons, most treatment evaluation studies focus on changes that

occur between pretreatment and treatment or between pretreatment and

posttreatment. Typically, at the time of admission, clients are asked to report on

previous rates of such behaviors as drug use and crime. These same behaviors

are assessed during and/or after treatment, and differences between the

pretreatment and treatment or posttreatment rates are used to determine

treatment effectiveness. Although the strategy does not control for changes in

behavior that may have occurred over time in the absence of treatment, it

nevertheless offers a convenient method for assessing changes in behavior that

are associated with treatment.

DRUG ABUSE REPORTING PROGRAM (DARP)

In 1966 Federal grants to States and localities, authorized under title IV of the

Narcotic Addict Rehabilitation Act, helped to establish a community-based drug

abuse treatment system, which grew rapidly from 6 programs in June 1969 to

more than 200 in 1974. In 1969 the DARP project was initiated to characterize

the treatment system, to identify the characteristics of clients entering treatment,

and to evaluate treatment outcomes. During 1969-74, DARP obtained data on

almost 44,000 clients in 52 programs (Sells 1974). Outcome was reported for

methadone maintenance, residential drug-free, outpatient drug-free, and

detoxification-only programs.

Although detoxification-only programs were effective in safely reducing

physiological dependence, they did not show effectiveness in reducing illicit

drug use in the year after treatment. However, all other modalities were

effective in reducing illicit use both during and after treatment. For example, in

a group of 405 male heroin addicts followed over time, daily opiate use across

all modalities declined from 100 percent in the 2 months preceding treatment, to

47 percent for 1 or more months in the first year, and to 25 percent in the sixth

year after DARP treatment (Simpson et al. 1986). Although 36 percent of this

4
sample relapsed one or more times after treatment and 1 percent used

continuously throughout the 6 years, 44 percent quit daily opiate use during

DARP treatment and reported no relapses to daily opiate use in the 6 years

after treatment. Another 19 percent quit after leaving DARP treatment and

reported no relapses at 6-year followup (Simpson and Marsh 1986). However,

comparison of relative effectiveness of the different modalities was limited due

to nonrandom distribution of addicts to the various modalities.

The DARP project identified several factors that influence treatment outcomes.

A finding consistent across all treatment modalities and client characteristics

was that the most favorable outcomes, defined as no illicit drug use and no

arrests, were related to the amount of time spent in treatment. Significantly

poorer outcomes resulted from treatment episodes shorter than 90 days, and

the percentage with favorable outcomes improved in direct proportion to the

length of time spent in treatment beyond 90 days (Simpson 1984). In addition,

individuals with high social adjustment (i.e., married, older, better educated,

better employed, fewer arrests, and better psychologically adjusted) had lower

risk of relapse to daily opiate use (Simpson and Marsh 1986).

TREATMENT OUTCOME PROSPECTIVE STUDY (TOPS)

The evolution of the Federal treatment system during the 1970s led to a second

major evaluation study, TOPS, which involved followup of samples from a

population of 11,750 clients admitted to drug abuse treatment in 41 programs

during 1979-81. The TOPS project replicated many of the findings of previous

studies, including the effectiveness of treatment in reducing drug use and

criminal activity both during and after treatment and the importance of the

amount of time spent in treatment on outcome (Hubbard et al. 1989). Striking

changes were found in the drug use patterns of clients seeking treatment. From

1969 to 1974, most clients sought treatment for heroin addiction, but by 1980

many of those entering treatment reported patterns of multiple substance

abuse, with use seemingly dictated as much by availability as by

pharmacological effect (Hubbard et al. 1986).

To determine the effectiveness of compulsory treatment, the TOPS project also

included agencies participating in Treatment Alternatives to Street Crime

(TASC) in its sample of treatment programs. In contrast to the earlier findings

of institutional treatment in PHS hospitals (Maddux 1988) and in some State

facilities (Inciardi 1988) TOPS found that clients who entered community-based

treatment under criminal justice referral did as well as or better than voluntary

clients. Criminal justice involvement helped to retain clients in treatment, and

drug use and criminal activity decreased substantially during treatment for those

on probation or facing the threat of prosecution (Hubbard et al. 1989).

5
Treatment as AIDS Prevention

IV drug abusers currently represent the second largest group at risk for

acquiring and transmitting HIV. Altogether, about one-third of AIDS cases

reported during 1988 were associated with IV drug abuse (Centers for Disease

Control 1989). IV drug abusers acquire and transmit HIV infection by the

sharing of infected needles, unprotected sexual contact with an infected

individual, and perinatal transmission. In 1988 AIDS associated with IV drug

abuse accounted for more than half of all AIDS cases in blacks and Hispanics

(Centers for Disease Control 1989).

Evidence suggests that drug abuse treatment is an effective AIDS prevention

strategy. Addicts in methadone maintenance programs have lower rates of HIV

seropositivity than do addicts not in treatment. In addition, the longer addicts

have been in treatment, the lower their HIV seropositivity rates (Novick et al.

1986). This is because methadone maintenance (as well as other treatment

modalities) reduces IV drug use, and reductions in IV drug use are associated

with reductions in the needle-sharing and promiscuous sexual behaviors that

are associated with HIV transmission (Battjes et al. 1988; Ball et al. 1988). In a

study by Ball and coworkers (1988) more than 70 percent of addicts in

treatment no longer were using drugs intravenously, a percentage that varied

greatly (from 43 to 90 percent) among six methadone programs. The

importance of continued medication was emphasized by the finding that 82

percent of addicts who dropped out of methadone maintenance had relapsed to

IV drug use within 10 months after leaving treatment.

Cost-Effectiveness

If the costs of drug abuse treatment are compared with the alternative costs of

continued drug abuse, associated criminal activity, and medical treatment of

AIDS, there is no question that the societal benefits are worth the expense of

drug abuse treatment. In the TOPS project, the economic consequences of

drug-associated crime in the year before and the year after treatment show that

treatment substantially lowered the societal cost on all economic measures,

including costs to victims, the criminal justice system, and employers. The

economic impact of treatment was greatest for legally involved clients. When

treatment benefits were compared with the costs of providing treatment, the

estimated treatment costs were recaptured during the treatment, and the

posttreatment gains were an economic bonus (Hubbard et al. 1989).

In addition to crime-related costs, the recent costs of health care to HIV-infected

individuals and to the sexual partners and infants of drug addicts have become

a concern as well. By preventing the spread of HIV infection and by intervening

6
in maternal drug abuse, treatment may substantially reduce health care costs

paid by both public and private reimbursers. Recently, the lifetime medical care

cost of treating a person with AIDS was estimated at $75,000 (Hellinger 1990).

In contrast, the mean cost per slot for drug abuse treatment is estimated to be

$3,992, which is for both private and publicly supported drug abuse treatment

programs (National Institute on Drug Abuse/National Institute on Alcohol Abuse

and Alcoholism 1989).

Areas for Improvement

Although treatment is widely recognized as being effective in reducing illicit drug

use, deficiencies exist in the current treatment system. Most treatment

professionals agree that, given the necessary resources, treatment can be

made into a more effective behavior change strategy and that the result will be

an enhanced savings of both money and lives. Because of the burgeoning drug

abuse problem and the AIDS epidemic, it is important to do whatever is possible

to improve the effectiveness of the system.

Several major areas for improvement are recognized. Although immediate

improvement could result from the application of existing research knowledge,

the development of new knowledge (and the transfer of this knowledge to

clinicians) also will be necessary, The present treatment system has several

areas needing attention.

Too Few Drug Abusers Are Attracted to Treatment. A recent National

Institute on Drug Abuse (NIDA) survey of IV drug abusers not currently in

treatment found that approximately half never have been enrolled in a treatment

program (Nemeth-Coslett and colleagues, personal communication, 1990). The

reasons for this are many. Some drug abusers would rather continue with their

drug use than achieve abstinence. In some areas, treatment may be

unavailable or accessible only to those with third-party coverage. Individual

programs may vary in their services, rules for entry and discharge, tolerance of

deviant behavior, and treatment philosophies. Clients also may have a

preference for a particular program or type of treatment. Furthermore,

treatment may bring knowledge of a drug problem to legal authorities or

employers. Treatment must be made more attractive to clients, and more

effective strategies for recruiting clients into treatment must be developed.

Rates of Illicit Drug Use by Clients In Treatment Are Unacceptably High.

Recently, when a single urine specimen was obtained from clients in

methadone maintenance programs and analyzed by enzyme immunoassay

technique for evidence of illicit drug use, 15 percent of clients showed evidence

of illicit opiate use, 26 percent cocaine use, 35 percent benzodiazepine use,

7
and 54 percent any type of drug use (excluding marijuana, methadone, and

alcohol) (Magura and Lipton 1988). Illicit drug use prevents clients from

engaging fully in the therapeutic process. It also places them at increased risk

of HIV infection. Although abstinence from illicit drug use is the primary

objective of treatment, the therapeutic process is often lengthy and complex.

Deeply ingrained behaviors are difficult to change, and clinicians must judge

whether clients are achieving progress while not demanding the impossible

(Senay 1978). However, continued use of illicit drugs in treatment probably

indicates a failure of the therapeutic process that may lie with the client,

program, or both. Reducing illicit drug use would allow clients better contact

with the therapeutic process and improve the overall effectiveness of treatment.

Clients Are Not Clinically Matched With Treatment Programs. In most

cases, either the clients self-select their treatment program or no attempt is

made by staff members to match the needs of clients to the services provided

by different treatment programs. Sociodemographic and background

characteristics of clients account for only minor variation in posttreatment

outcome, giving no basis for treatment matching on these measures (Simpson

and Savage 1981-82). Psychiatric severity has been found to be predictive of

outcome (McLellan et al. 1983b, 1984), suggesting that benefits might be

derived from this measure for matching clients to treatment. However, the level

of psychiatric impairment is only one of many factors entering into the treatment

process. Others include the availability of treatment, geographic proximity,

clients preference for modality, clients ability to pay for treatment services, and

judgment of program staff regarding the treatment needs of the client. In one

study that attempted to match clients with inpatient or outpatient treatment, only

53 percent of clients could be matched, with assignment thwarted by lack of

treatment availability (27 percent), client inability or refusal to accept the

assigned treatment (13 percent), and assignment errors or staff overrides of

assigned treatment (7 percent) (McLellan et al. 1983a).

Treatment Retention Rates Are Too Low. Twelve-month retention rates

range from 34 to 85 percent for outpatient clients in methadone maintenance

(O’Brien 1987; Hubbard et al. 1989) to 4 to 21 percent for clients in TCs (De

Leon and Schwartz 1984; De Leon 1984). Within a few days or weeks after

leaving treatment, most addicts relapse to illicit drug use (Hubbard and Marsden

1986) but many eventually return to treatment. Demographic variables do not

consistently predict who will drop out of treatment. However, certain types of

psychopathology are associated with early treatment dropout (Stark and

Campbell 1988).

The consistent relationship between time in treatment and treatment outcomes

(Simpson 1981; Hubbard et al. 1989) emphasizes the importance of keeping

8
clients in treatment. Various means of increasing retention have been tried.

The most direct approach, civil commitment to treatment, has met with mixed

results. Addicts in the California Civil Addict Program spent more time in

treatment, with consequent reductions in illicit drug use and criminal behavior,

than a comparison group released from treatment on procedural grounds

(Anglin 1988). Other attempts at civil commitment, including Federal treatment

in the PHS hospitals (Maddux 1988) and New York’s Narcotic Addiction Control

Commission program (Inciardi 1988) were unsuccessful. As previously

mentioned, TASC program referrals appear to have increased retention in

treatment (Hubbard et al. 1989).

Less coercive approaches also are needed. Increasing the quality and variety

of services in treatment may encourage retention. Strategies to be investigated

include increased counseling and other treatment services, improved staff

training, reduced cost to clients, increased education and job training, longer

methadone dispensing hours, and increased availability of methadone takehome doses.

Relapse Rates After Treatment Are Unacceptably High. In a DARP study of

posttreatment outcome in methadone maintenance clients, 57 percent relapsed

to some opiate use in the year following treatment (Savage and Simpson 1980).

Of the TOPS clients admitted to methadone maintenance who used opiates at

least weekly before treatment, 43 percent had relapsed to weekly or more often

opiate use in the year following treatment (Hubbard et al. 1984).

Addicts are at highest risk of relapse in the first 3 months after treatment. In a

DARP sample followed over 12 years, 27 percent relapsed to daily opiate use in

the first 3 months following treatment; 44 percent relapsed to daily opiate use

within 36 months; and 71 percent relapsed one or more times in the 12 years

following treatment (Joe et al. 1990b). Hubbard and Marsden (1986) found that

51 percent of TOPS clients with an opiate or nonnarcotic pattern of use

relapsed to regular use in the year following treatment. Two-thirds of TOPS

clients relapsed in the first 3 months.

Given the high likelihood of relapse after termination of methadone treatment, it

has been argued that the goal of methadone treatment for some clients should

not be eventual detoxification, but rather long-term maintenance (Dole and

Joseph 1978; Rounsaville et al. 1987; Stimmel et al. 1977). According to this

argument, if continued abstinence is not an achievable goal for an addict, then

greater benefit may accrue to the client and to society from a treatment

philosophy that is compatible with extended methadone medication.

9
Although methadone maintenance clients frequently return to heroin use within

several months after dropping out of treatment, relapse rates are relatively low

for those who successfully complete treatment (i.e., achieve the goals of

treatment and are gradually detoxified). For clients who successfully completed

methadone maintenance treatment, Stimmel and coworkers (1977) found that

83 percent were narcotic free at 26-month followup, compared with only 21

percent of those who dropped out of treatment. Unfortunately, only 17 percent

of those leaving treatment did so after completing the program (the remainder

voluntarily discontinued treatment, violated rules, or were arrested). This

suggests that outcome from methadone maintenance would be improved if

clients could be retained in programs until they meet criteria for completion.

Treatment Programs Are Not Adopting Useful Research Findings Into

Clinical Practice. Higher doses of methadone are more effective in

suppressing illicit opiate use than are lower dosages of methadone (Ling et al.

1976; National Institute on Drug Abuse 1978). Yet, many treatment programs

today are attempting to maintain some clients on inadequate dosages of

methadone, which results in increased rates of illicit drug use and associated

AIDS risk behaviors. Typical daily methadone dosage levels in 1979 were 20 to

39 mg (National institute on Drug Abuse 1979, cited in Hargreaves 1983, p. 54).

D’Amanda (1983) suggested a general downward trend in prescribed dosage

levels over the previous decade. Hubbard and colleagues (1989) reported that,

at admission, most TOPS clients received methadone dosages of 10 to 40 mg

per day, with only 3 percent receiving dosages of more than 70 mg. At 3

months in treatment, 40 percent of TOPS clients were receiving dosages below

30 mg per day. Dosages tended to be low but were highly variable across

programs. Mean daily methadone dosages in the six purposively selected

programs studied by Corty and Ball (1987) and colleagues ranged from 27 to 67

mg.

Similarly, knowledge concerning the clinical usefulness of contingent take-home

privileges also is not being widely applied. Often, take-home dosages of

methadone are permitted to exempt clients from having to make daily trips to

treatment programs. Typically, take-homes are permitted without any

contingency applied. Research has shown that making take-homes contingent

on drug-free urinalysis results in less illicit drug use (Stitzer et al. 1982).

The failure to adopt new research findings into clinical practice is not entirely the

fault of treatment programs. Some research findings have no practical clinical

usefulness. Others may be useful but cannot be implemented because of

financial or staffing inadequacies. Also, to be adopted, research findings first

must come to the attention of treatment personnel, and program administrators

must encourage staff to adopt such findings.

10
The Spirit or Morale of Staff in Treatment Programs Is Too Low. The high

demand for treatment places extraordinary demands on program personnel.

Drug treatment facilities operate close to or over their budgeted capacity.

Nationwide utilization rates for 1,067 private and public drug-only facilities are

91 percent (National Institute on Drug Abuse/National Institute on Alcohol

Abuse and Alcoholism 1989). Overwork resulting from excessive client

caseloads and associated administrative tasks may be related to increased

counselor turnover, as well as to decreased counselor efficiency and

therapeutic performance (Bruni et al. 1981). Others must seek employment

outside of the drug abuse field because of low pay and poor working conditions.

Attitudes of staff regarding treatment may lessen the ability of the programs to

recruit new patients and also may contribute to poorer outcomes. Although

aware of the chronic nature of drug dependence, some staff members become

discouraged after witnessing repeated relapse in treated clients or early dropout

from treatment. The attitude of the staff is directly communicated to clients and

is a major factor in determining the effectiveness of a treatment program.

Services Provided in Treatment Programs Have Been Reduced. Over the

past two decades there has been a significant reduction in the quantity and

quality of services being provided to clients in at least some treatment

programs. Ball and colleagues (1986) have documented the variability in

medical services provided across seven methadone maintenance programs.

Notable differences were found in the availability of medical staff in the various

programs, with the proportion of clients in each program receiving medical

treatment each week varying from 14 to 53 percent. On the other hand, the

need for providing additional medical services to clients in treatment programs

is particularly acute now, given the high rates of psychiatric comorbidity and

HIV-related diseases associated with drug abuse.

In addition to reductions in medical services, there is evidence of other services

being reduced in some treatment programs. Recently, there has been

discussion of proposals to provide “no-frills” methadone to clients in interim

clinics. Many methadone maintenance programs have reduced the number and

duration of client-counselor contacts, and similar reductions in counseling and

treatment services have occurred in drug-free inpatient and outpatient programs

as well. However, many treatment professionals believe that providing a range

of quality services may attract more clients to treatment and may improve

retention rates and outcome as well.

11
IMPROVING TREATMENT

Many drug abuse experts contend that all these problems, at least in part, are

caused by one factor—lack of money to support adequate services. Indeed, in

the decade between 1977 and 1987, treatment funding per client slot

decreased significantly (J. Kaple, personal communication, 1989). This caused

a reduction in both quality and quantity of client services, with a resultant

reduction in the effectiveness of the intervention. The Anti-Drug Abuse Acts of

1986 and 1988 have provided significant funding to help restore the reduced

services. However, although adequate funding is important, it generally is

agreed that money alone will not fully address the problems of recruitment,

retention, and relapse by clients in treatment.

Some have suggested that attempts to improve treatment should focus on the

less effective programs. Ball and coworkers (1986) have documented the

heterogeneity in services being provided by treatment programs and also the

direct relationship between quality of care in treatment programs and outcome.

To some extent, raising the quality of care in the less effective treatment

programs will improve the treatment system significantly. However, given the

severity of drug abuse and AIDS, all aspects of the treatment system should be

improved, not just the effectiveness of certain programs.

In addition to adequate funding and improvement of poorer programs, attention

must be paid to changes in the treatment process that will improve the

effectiveness of the system. Changing the treatment process will focus on

developing improved methods for recruiting clients into treatment, retaining

them in treatment, reducing illicit drug use by clients in treatment, and reducing

relapse rates among clients after they leave treatment. This will involve

incorporating existing research findings into actual clinical practice and

developing and applying new interventions.

Finally, improving treatment will require educating the public and policymakers

about the nature of drug dependence and the effectiveness of treatment to

overcome community resistance to establishing new treatment programs. At

present, the concept of drug dependence as a chronic relapsing disorder that

requires chronic management is difficult for most people to understand.

Instead, the public thinks of drug dependence as an acute problem that can be

“cured” by quick and simple interventions. Some treatment strategies also are

difficult for many people to understand, particularly those involving maintenance

on medications such as methadone. Furthermore, many fail to recognize drug

dependence as a public health problem and view it instead as a moral failing

that must be controlled with criminal sanctions.

12
CURRENT CHALLENGES

At the same time that increased demands are being placed on treatment by

drug abuse and AIDS, there is evidence to suggest that clients coming into

treatment today are more difficult to treat than they were 10 to 20 years ago.

One line of evidence is suggested by the changing drug scene. From 1969 to

1971,85 percent of DARP clients used opiates daily or weekly in the 2 months

before admission (Simpson 1974). Hubbard and coworkers (1989, pp. 90-92)

compared DARP admissions with 1979-81 TOPS admissions and found that

TOPS clients were more likely to have patterns of multiple drug abuse. This

was found to be true for every treatment modality. Among daily drug users in

methadone maintenance programs, for example, 45 percent of DARP clients

were principally opiate users, whereas 49 percent used nonopiates as well as

opiates. This compared with 21 percent of TOPS admissions who were

principally opiate users and 60 percent who used nonopiates as well as opiates

(Hubbard et al. 1986). Compared with DARP admissions, TOPS daily drug

users were also more likely to be female, white, and older and to have longer

treatment histories.

Furthermore, over the past 10 to 20 years, drug preferences have shifted. In

1988 cocaine replaced heroin as the primary abused drug reported by clients

entering treatment programs (Butynski et al. 1989). Also, over the past several

years there has been the advent of new and more potent types of abused

drugs. For example, “crack cocaine” use first was reported in 1985 and has

since become a major epidemic in certain cities.

A second line of evidence suggesting more difficult treatment problems is

changes in the clinical characteristics of the clients being admitted to treatment.

Although no significant trends are evident in demographic characteristics of

drug abusers between 1980 and 1987, there has been an increase in the

severity of problems in clients being admitted for treatment. Between 1972 and

1978, for example, inpatients admitted to a Veterans Administration treatment

program showed increased criminal involvement, social instability, employment

problems, and psychiatric illness (McLellan et al. 1979). Similar changes have

been reported in other treatment programs (De Leon 1984). Changes in client

population may represent a “silting up” of the treatment system with clients who

have a poor prognosis, as clients more capable of improvement are

successfully treated and clear the treatment system.

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AUTHORS

Roy W. Pickens, Ph.D.

Acting Director

Addiction Research Center

National Institute on Drug Abuse

4940 Eastern Avenue

Baltimore, MD 21224

Bennett W. Fletcher, Ph.D.

Research Psychologist

Treatment Research Branch

Division of Clinical Research

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, MD 21057

19
Drug Treatment Services: Funding

and Admissions

William Butynski

INTRODUCTION

With support from the National Institute on Alcohol Abuse and Alcoholism

(NIAAA) and the National Institute on Drug Abuse (NIDA), in 1983 the National

Association of State Alcohol and Drug Abuse Directors, Inc. (NASADAD)

initiated work with State alcohol and drug (A/D) agencies to design a voluntary

data collection system on “State Resources and Needs Related to Alcohol and

Drug Services.” This system has evolved from one that collected aggregate

information on State agency “estimates” of “overall allocations” for all alcohol

and other drug services (fiscal years 1983 and 1984) to one that collects data

on “actual expenditures” for “only those programs which received at least some

funds administered by the State Alcohol/Drug Agency” (FYs 1985, 1986, 1987,

and 1988). Moreover, the data universe was narrowed to collect and provide

more comparable fiscal data across all States.

In addition, beginning with FY 1983, data were collected on client “admissions”

to those treatment units that received at least “some funds administered by the

State Alcohol/Drug Agency during the State’s Fiscal Year.” This voluntary

aggregate fiscal and client admission data collection system is called the State

Alcohol and Drug Abuse Profile (SADAP).

This chapter presents data primarily from SADAP organized into the following

sections:

Funding of alcohol and other drug services (treatment cost information from

SADAP)

Client admissions to alcohol and other drug treatment services (treatment

capacity information from SADAP)

20
Treatment funding and admissions related to the Federal block grant

Information on treatment cost and capacity from sources other than SADAP

data collected from States

Summary and conclusions

FUNDING OF ALCOHOL AND OTHER DRUG SERVICES

In October 1988 NASADAD’s president requested that by December 1988 all

State A/D agencies provide data on total expenditures for alcohol and other

drug services by source of funding and type of program activity for FY 1988.

Forty-eight States, the District of Columbia, Guam, Puerto Rico, and the Virgin

Islands responded to this request.

Before presenting and analyzing the findings, it is important to note that these

data have several inherent limitations. They should not be used without an

appreciation of the qualifications that apply. One major qualification is that the

States were asked to report total expenditures for “only those programs that

received at least some funds administered by the State Alcohol/Drug Agency

during the State’s Fiscal Year (FY) 1988.” The data presented do not include

information on those programs that did not receive any funding from the State

A/D agency (e.g., most, if not all, private for-profit programs, some private notfor-profit programs, and some public programs). As a result, the overall fiscal

estimates contained herein are conservative in nature and, to varying degrees,

underestimate funding expenditures by other departments of State government,

by Federal agencies such as the Department of Veterans Affairs, and by

private, non-State agency-supported alcohol and other drug abuse treatment

and prevention programs.

The financial and related data collected from States for FY 1988 are organized

within two major subsections: financial expenditures by type of program activity

and total number and percent of treatment units that received funds

administered by the State A/D agency in FY 1988.

Financial Expenditures by Type of Program Activity

This section provides information on the amount of monies expended during FY

1988 for different types of alcohol and other drug program activities. Data are

presented on a State-by-State basis for three program activities, including

treatment, prevention, and other. Total expenditures are reported for each

State and for each program activity category (table 1).

21
TABLE 1. Expenditures for State-supported alcohol and other drug abuse

services by State and by type of program activity for fiscal year

1988

22
The total monies expended within 48 States (data were not available for New

Mexico and Wyoming), the District of Columbia, Guam, Puerto Rico, and the

Virgin islands during FY 1988 in those programs that received at least some

State A/D agency funds were $2.1 billion. All these States and territories

reported the breakout of the funds into the different types of alcohol and other

drug program activities. Of the total, approximately $1.6 billion (77.4 percent)

was spent for other activities (e.g., training, research, and administration).

Over the past several years, many States have substantially increased their

commitment to and financial expenditures for prevention programs. However,

within every State A/D agency the expenditures for treatment remain much

higher than those for prevention. Overall, the expenditures for treatment are

more than five times as great as for prevention.

Total Number and Percent of Treatment Units That Received Funds

Administered by the State A/D Agency

This section provides information on the total number of treatment units that

received funds administered by the State A/D agency in FY 1988. The data are

presented by primary orientation of the treatment units: alcohol, drug, or

combined alcohol/drug. An estimate also is provided of the percent of treatment

units in the State in FY 1988 that received any funds administered by the State

A/D agency.

The State agencies identified a total of 6,926 alcohol and/or other drug

treatment units that received funds administered by the State A/D agency in FY

1988. With regard to the orientation of the treatment units, 1,806 (26.1 percent)

were identified as alcohol units, 1,614 (23.3 percent) as other drug units, and

3,506 (50.6 percent) as combined alcohol and other drug treatment units (table

2).

An estimate of the percent of total alcohol and/or drug treatment units in the

State that received any funds administered by the State A/D agency in FY 1988

was provided by 47 States, the District of Columbia, Guam, Puerto Rico, and

the Virgin Islands. The estimates ranged from a State low of 24 percent in

Indiana, to a territorial high of 100 percent in the Virgin Islands and a State high

of 96 percent in Rhode Island (table 3).

CLIENT ADMISSIONS TO ALCOHOL AND OTHER DRUG TREATMENT

SERVICES

Each State A/D agency was asked to provide information on client admissions

to treatment units that received funds administered by the State agency during

23
FY 1988. All but three of the States have combined alcohol and other drug

abuse treatment responsibilities within one agency. Several of these agencies

have established combined (e.g., substance abuse, chemical dependency)

treatment systems and/or dient reporting systems and preferred to report

combined alcohol and other drug client data. However, in response to a

specific request from NIAAA and NIDA (each of which has a distinct

congressional mandate), NASADAD asked the States to separate questions

relating to alcohol and other drug abuse treatment services. This was done to

obtain data that would be generally consistent with past data collection efforts

and to be responsive to those States that have separate alcohol and other drug

agencies.

In reviewing and interpreting client admission data, it is important to recognize

that the client admissions figures are limited to those treatment units that

received at least “some funds administered by the State A/D Agency during the

State’s Fiscal Year 1988.” However, States reporting client information on

those treatment units that received only partial funding from the State agency

were instructed to report data on all client admissions to the program, not just

data on those client admissions supported by State agency funds. The data

presented do not include client admissions to treatment units that did not

receive any funds administered by the State A/D agency during FY 1988.

Because this chapter concentrates on drugs other than alcohol, SADAP

alcohol-related admissions data are not presented. However, to ensure that at

least basic knowledge on the respective magnitudes of treatment admissions

related to alcohol and other drugs is available, the following information is

presented:

Total client admissions to treatment for alcohol abuse and alcoholism

problems during FY 1988 = 1,217,285.

Total client admissions to treatment for all other drug abuse and

dependency problems during FY 1988 = 518,851.

The remainder of this section includes dient data in four areas: client

admissions data by environment and modality; client admissions data by sex,

age, and race/ethnicity; client admissions data by primary drug of abuse; and

comparisons of client admissions data for FYs 1985, 1988, 1987, and 1988.

Client Admissions Data by Environment and Modality

Each State drug (and combined A/D) agency was asked to provide data on the

“number of DRUG client treatment admissions” in all units that received at least

26
“some funds administered by the State Drug Agency during the State’s fiscal

Year 1988.” The information requested included client admissions data

organized by environment (hospital, residential, or outpatient) and by modality

(detoxification, maintenance, or drug-free) (tables 4a and 4b).

A total of 46 State agencies and those of the District of Columbia, Guam,

Puerto Rico, and the Virgin Islands provided at least partial data on other drug

(not alcohol) client treatment admissions by modality and environment. The

total of other drug client treatment admissions during FY 1988 for these State

agencies was 518,851. Of the other drug client admissions, 20,454 (3.9

percent) were to hospitals, 121,765 (23.5 percent) to residential facilities, and

358,475 (69.1 percent) to outpatient programs; 18,157 (3.5 percent) admissions

were not specified as to environment.

In terms of treatment modality, 95,932 (18.5 percent) of other drug client

admissions were for detoxification, 47,608 (9.2 percent) for maintenance, and

357,154 (68.8 percent) for drug-free types of treatment services; 18,157 (3.5

percent) admissions were not specified as to modality. Within two of these

three types of treatment modalities, the type of environment most often used

was outpatient. The outpatient environment was used for 96.6 percent of the

maintenance admissions and 77.5 percent of the drug-free admissions.

Residential environments, however, were used more than outpatient

environments for detoxification admissions. Residential facilities accounted for

49.5 percent of the detoxification admissions, whereas outpatient services

accounted for only 37.3 percent of the detoxification admissions.

In interpreting the client admissions data, it is important to note that the figures

include only those programs that received some State drug agency funds. It is

also important to note that some States were not able to report the information

in the format requested.

Client Admissions Data by Sex, Age, and Race/Ethnicity

Each State drug (and combined A/D) agency was asked to provide data on “the

number of DRUG client treatment admissions during FY 1988” in all units

“which received some funds administered by the State Drug Agency” in each of

a number of specific sex, age, and race/ethnicity categories.

Forty-seven States, the District of Columbia, Puerto Rico, and the Virgin Islands

reported other drug (not alcohol) client admissions data by sex (table 5).

Overall, 66.8 percent of the other drug client admissions were male, and 32.5

percent were female; data on sex were not reported for .7 percent of the other

drug client admissions.

27
TABLE 4a. Number of drug client treatment admissions by type of environment, type of modality, and State for

fiscal year 1988*

TABLE 4b. Number of drug client treatment admissions by type of environment, type of modality,

and State for fiscal year 1988*

TABLE 5. Number of drug client treatment admissions by sex and State for

fiscal year 1988

32
Forty-four State agencies, the District of Columbia, Guam, Puerto Rico, and the

Virgin Islands provided at least partial information on other drug client

admissions by age. The proportions of client admissions that fell within the agerange categories requested were as follows:

Age Percent of Admissions

Younger than 18

18 to 20

21 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 and older

Not reported

14.5%

7.1%

14.0%

38.3%

15.0%

2.9%

.9%

.3%

7.0%

These percentages should be interpreted with caution because several States

reported admissions by some but not all of the age categories specified.

In comparing total other drug client admissions by age with total alcohol client

admissions, other drug clients tend to be much younger, whereas the alcohol

clients tend to be older (e.g., 21.6 percent of other drug clients are younger than

21 compared with only 8.3 percent of alcohol clients).

With regard to other drug client treatment admissions by age and sex, 42

States, the District of Columbia, Guam, Puerto Rico, and the Virgin Islands

provided at least partial data according to the age categories specified. Several

States encountered problems in reporting client admissions data by age and

sex combined. The increased male ratio with increased age did not appear as

strongly as with alcohol clients. In fact, male other drug client admissions

represented 62.5 percent of those older than 65, whereas male alcohol client

admissions represented 82.7 percent of alcohol admissions older than 65.

With regard to other drug client treatment admissions information by race/

ethnicity, 47 States, the District of Columbia, Guam, Puerto Rico, and the Virgin

Islands provided at least partial data. Among the States reporting data, the

percents of client admissions that fell within the race/ethnicity categories

specified were as follows:

33
Race/Ethnicity Percent of Admissions

White, not of Hispanic origin

Black, not of Hispanic origin

Hispanic

Asian or Pacific Islander

Native American (American Indian,

Alaska Native)

Other

Not Reported

52.7%

25.3%

11.8%

.4%

.9%

.4%

8.4%

A comparison of total other drug client admissions with total alcohol client

admissions in terms of race/ethnicity indicates that other drug clients include a

higher proportion of blacks, Hispanics, and Asians or Pacific Islanders. The

alcohol client admissions include more whites (70.7 percent compared with 52.7

percent among other drug clients) and Native Americans (3.1 percent compared

with .9 percent among other drug clients).

Client Admissions Data by Primary Drug of Abuse

Each State drug (and combined A/D) agency was asked to provide information

on the number of client admissions by the primary drug of abuse. Forty-one

States, the District of Columbia, Guam, Puerto Rico, and the Virgin Islands

provided at least partial data in response to this question (tables 6a and 6b).

The totals indicate that, overall, if alcohol admissions are excluded, cocaine

admissions exceeded heroin admissions as the primary drug of abuse for the

highest number of treatment admissions during FY 1988 with a total of 139,663

admissions. The total of cocaine admissions increased by 49,956 in FY 1988,

an increase of 59 percent compared with FY 1987. Heroin admissions

numbered 116,654 in FY 1988, up 19 percent from FY 1987. The third highest

number of treatment admissions during FY 1988 by primary drug of abuse was

for marijuana/hashish at 60,561 admissions. The fourth, fifth, and sixth highest

primary drugs of abuse related to treatment admissions were, respectively,

amphetamines at 16,491 admissions, other opiates/synthetics (beyond heroin

and nontreatment methadone) at 15,717 admissions, and PCP at 6,401

admissions. Although the national statistics on primary drug of abuse related to

treatment admissions are as noted above, it is important to recognize that there

exists tremendous variance among States as to the primary drug of abuse. For

example, among the 41 States and territories that reported relevant data with

regard to the specific primary drug of abuse (excluding the “Alcohol,” “Other,”

and “Not Reported” categories) the drugs that ranked highest in each State

were as follows:

34
TABLE 6a. Number of drug client treatment admissions in State-supported facilities by primary drug of abuse

and State for fiscal year 1988*

TABLE 6b. Number of drug client treatment admissions in State-supported facilities by primary drug of abuse

and State for fiscal year 1988*

Marijuana/hashish was the primary drug of abuse related to treatment

admissions within 15 States.

Cocaine was the primary drug of abuse related to treatment admissions

within 18 States, the District of Columbia, and the Virgin Islands.

Heroin was the primary drug of abuse related to treatment admissions

within 8 States, Guam, and Puerto Rico.

No other single drug of abuse was ranked first among treatment

admissions in any State.

A careful review of table 6 demonstrates that different States have very different

drug abuse patterns, at least as related to the primary drug of abuse for client

treatment admissions.

Comparisons of Client Admissions Data for FYs 1985, 1986, 1987, and

1988

Several comparisons were conducted on data provided by those State agencies

that submitted information on other drug client admissions for FYs 1985, 1986,

1987, and 1988. Forty-four States, the District of Columbia, and Puerto Rico

were able to provide some relevant information for all four FYs. The total other

drug client admissions figures for these State agencies rose from 301,283 in FY

1985 to 370,887 in FY 1986, to 433,839 in FY 1987, and to 511,484 in FY 1988

(an increase of 210,201 admissions or more than 69.7 percent during this 3-

year period). However, these data reveal considerable variability across States

in terms of increases and/or decreases in other drug client admissions. The

overall trend of significant increases in the number of other drug client

admissions is confirmed by the fact that most of the States and territories that

report comparable other drug client treatment admissions data also report an

increase in admissions. However, several States have begun to use more

comprehensive reporting systems. Therefore, caution should be exercised in

the interpretation of these data; it is likely that the increased levels of other drug

admissions reported by States may be related not only to increased numbers of

actual other drug clients being admitted to treatment but also to the more

complete reporting now possible through more comprehensive and complete

data systems (e.g., the addition in some States of admissions data on other

drug clients served through the community mental health center service system

whose client admissions were not reported in earlier years).

Another comparison of other drug client treatment admissions during FYs 1985,

1986, 1987, and 1988 focused on the primary drugs of abuse. An analysis was

39
conducted on roughly comparable data provided by 40 States, the District of

Columbia, Guam, Puerto Rico, and the Virgin Islands on the top three primary

drugs of abuse other than alcohol (i.e, heroin, cocaine, and marijuana/ hashish).

Number of Admissions

Marijuana/

F Y Heroin Cocaine Hashish

1985 89,458 39,696 61,900

1986 84,618 55,040 70,959

1987 97,291 82,321 59,569

1988 114,920 134,734 74,583

These data exhibit considerable variation from year to year, and caution must

be exercised in attempting to extract trend data from only a 3-year period.

However, the increases in client treatment admissions related to cocaine as a

primary drug of abuse are clear and compelling. The data demonstrate an

increase of 15,344 admissions or 38.7 percent from FY 1985 to FY 1986, an

increase of 27,271 admissions or 49.5 percent from FY 1986 to FY 1987, and

an increase of 52,413 or 63.7 percent from FY 1987 to FY 1988. Client

treatment admissions with cocaine as the primary drug of abuse from FY 1985

to FY 1988 increased by 95,038 admissions or 239.4 percent. Over that same

3-year period client admissions related to heroin increased by 28.5 percent,

while admissions related to marijuana/hashish increased by 20.5 percent.

TREATMENT FUNDING AND ADMISSIONS RELATED TO THE FEDERAL

BLOCK GRANT

The following section presents Federal funds by type of primary problem,

Federal funds by number of treatment units, and Federal funds for treatment

admissions by type of primary problem.

Federal Funds by Type of Primary Problem

This section provides information on the amount of Federal Alcohol, Drug, and

Mental Health Services (ADMS) block grant and Alcohol and Drug Treatment

Rehabilitation (ADTR) funds expended during FY 1988 to serve persons with

primary alcohol problems, primary other drug problems, and combined alcohol

and other drug problems. The total level of Federal money expended by 48

States, the District of Columbia, Guam, Puerto Rico, and the Virgin Islands

40
during FY 1988 for alcohol and other drug treatment services was

$274,561,870 (table 7). This figure does not include Federal money expended

for services other than treatment (e.g., prevention, training, research). It also

does not include some Federal monies that may have been allocated or even

obligated by the States in FY 1988 but expended during a later fiscal year.

Of the total of $274,561,870 in Federal monies expended by States in FY 1988

the largest share, $111,080,307, was expended to serve persons with primary

other drug problems; $85,662,385 was expended to serve persons with primary

alcohol problems; and $77,819,178 was expended to serve persons with

primary combined alcohol and other drug problems.

Federal Funds by Number of Treatment Units

This section provides information on the number of alcohol and/or other drug

treatment units that received any Federal ADMS block grant or ADTR funds. A

total of 45 States, the District of Columbia, Puerto Rico, and the Virgin Islands

reported that 4,786 separate treatment units received some of these Federal

monies during FY 1988 (table 8). More than half of these treatment units

(2,537) provide services for persons with both alcohol and other drug problems.

A total of 1,296 other treatment units concentrate on serving persons with

primary alcohol problems, and 953 treatment units concentrate on serving

persons with primary drug problems other than alcohol.

Federal Funds for Treatment Admissions by Type of Primary Problem

This section provides information on the specific number of alcohol and/or other

drug treatment admissions supported by Federal monies during FY 1988. The

total number of these treatment admissions reported by 44 States, the District of

Columbia, Guam, Puerto Rico, and the Virgin Islands was 1,164,294 (table 9).

Of this total, 549,081 were alcohol problem admissions; 352,958 were primary

combined alcohol and other drug problem admissions; and 262,255 were

primary other drug problem admissions. It should be noted that due in part to

their treatment philosophy and data reporting systems, some States and

programs did not report treatment admissions in all three categories. Some

States divide all their admissions between primary alcohol problems and

primary other drug problems, whereas other States believe that there is so

much overlap between persons who are dependent on alcohol and other drugs

that they reported all their admissions as combined alcohol and other drug

treatment admissions.

41
TABLE 7. Expenditures of Federal block grant treatment funds by State and

by type of primary problem for fiscal year 1988

42
TABLE 8. Number of alcohol and/or drug treatment units that received

Federal block grant funds by State for fiscal year 1988

43
TABLE 9. Total number of client admissions to alcohol and/or drug

treatment units that received Federal block grant funds by

State and by type of primary problem for fiscal year 1988

44
INFORMATION ON TREATMENT COST AND CAPACITY FROM SOURCES

OTHER THAN SADAP DATA COLLECTED FROM STATES

The following information on treatment cost and capacity is organized according

to data source, induding a meeting on drug treatment costs with selected

experts on September 2, 1987, and the National Drug and Alcoholism

Treatment Unit Survey (NDATUS) conducted on October 30, 1987.

Meeting on Drug Treatment Costs With Selected Experts on September 2,

1987

On September 2, 1987, NASADAD, with support from NIAAA and NIDA,

organized and summarized the results from a meeting of State and other

experts “To Develop Reasonable Estimates on Drug Treatment Costs for

Needle Drug Abusers.” Participants in this meeting included representatives

from States (Ms. Jeanne Brinkley, California; Mr. John S. Gustafson, New York;

and Mr. Richard Russo, New Jersey), other national and local organizations

(Mr. Mark Benecivengo of Philadelphia; Mr. David Mactus of Therapeutic

Communities of America; and Mr. Mark Parrino of the Northeast States

Methadone Conference), the Institutes (Mr. Angelo Bardine and Mr. Salvatore di

Menza of NIDA and Mr. David Sanchez of NIAAA), and NASADAD staff (Dr. Bill

Butynski and Dr. Diane Canova).

From the data collected by the various participants and from the discussion at

the meeting it was clear that treatment costs vary considerably due to several

factors, including but not limited to geographical location, modality of treatment,

severity of client problem, site of treatment (e.g., hospital or nonhospital

residential), type of drug dependency, type of staff, and extent of ancillary and

other support services provided.

Following are the “Reasonable national estimates of annual drug abuse

treatment operational costs by environment and modality of treatment for

needle-drug-dependent persons” that were developed by the group on

September 2, 1987:

OUTPATIENT METHADONE MAINTENANCE: $3,000/PATIENT

TREATMENT SLOT/YEAR. Services include physical exam, medication,

counseling, blood and urine laboratory testing, and ancillary services.

OUTPATIENT DRUG-FREE: $2,300/PATIENT TREATMENT SLOT/YEAR.

Services usually include all those mentioned above except for methadone

medication. Because it is usually not possible to successfully treat needledrug-dependent persons initially on an outpatient drug-free basis, this

45
environment and modality of treatment should be considered primarily as

followup and aftercare to residential treatment or methadone maintenance

treatment.

NONHOSPITAL RESIDENTIAL DRUG-FREE:

-$14,600/ADULT CLIENT TREATMENT SLOT/YEAR (APPROXIMATELY

$40/DAY). Services include physical exam, intensive counseling and

therapy, laboratory testing, housing, food, clothing, education, job

placement, and ancillary services.

-$18,000/ADOLESCENT CLIENT TREATMENT SLOT/YEAR. Services

include all those noted above; the higher cost is due primarily to more

intensive education support services.

The other drug treatment costs noted above appeared to be reasonable

national estimates as of September 1987. However, actual costs will vary

across cities and programs due to differences in salaries, cost of living, specific

services components, the age and type of buildings, and related factors. The

experts who developed these figures also developed estimated costs for drug

detoxification, which follow. However, due to several factors, including but not

limited to less reliable data and differences among drugs, the drug experts had

less confidence in the validity of these detox cost estimates.

OUTPATIENT DETOXIFICATION: $4,000/PATIENT TREATMENT SLOT/

YEAR (APPROXIMATELY $11/DAY)

NONHOSPITAL INPATIENT RESIDENTIAL DETOXIFICATION:

$31,000/PATIENT TREATMENT SLOT/YEAR (APPROXIMATELY $85/

DAY)

Because the costs noted above were developed as of September 2, 1987, it is

likely that today, approximately 3 years later, actual costs would be 10 to 20

percent higher than those shown.

National Drug and Alcoholism Treatment Unit Survey (NDATUS)

Conducted on October 30, 1987

As stated in the 1987 NDATUS Final Report published in 1989, NDATUS “is a

national survey which is designed to measure the location, scope, and

characteristics of drug abuse and alcoholism treatment and prevention facilities,

services, and activities throughout the United States, the District of Columbia,

and the U.S. Territories.” It includes not only public and private not-for-profit

46
TABLE 10. Number of drug abuse and combined treatment units, drug

abuse clients in treatment, budgeted capacity, and utilization rate

by State: October 30, 1987

47
facilities (as does SADAP for those programs funded by the State agencies) but

also attempts to include all non-State-funded programs such as all private forprofit programs. It was conducted as a point prevalence survey based on data

collected as of October 30, 1987.

Table 10 is the NDATUS table that includes information on the “Number of Drug

Abuse and Combined Treatment Units, Drug Abuse Clients in Treatment,

Budgeted Capacity, and Utilization Rate by State: October 30, 1987.” The

overall utilization rate shown is 79.1 percent, ranging from lows of 28.0 percent

in South Dakota and 31.9 percent in Alaska to highs of 109.3 percent in Puerto

Rico and 97.8 percent in New York.

Table 11 is the NDATUS table that presents information on the “Number of

Drug Abuse Treatment Units, Drug Abuse Clients in Treatment, Budgeted

Capacity, and Utilization Rate According to Unit Orientation and Ownership:

TABLE 11. Number of drug abuse treatment units, drug abuse clients in

treatment, budgeted capacity, and utilization rate according to unit

orientation and ownership: October 30, 1987

Unit Orientation

Unit Ownership

Private Public

For-Profit Nonprofit State/Local Federal Total

Drug-Only

Units

Clients

Capacity

Utilization rate

83 705 266 13 1,067

14,372 87,843 39,202 1,846 143,263

19,629 93,426 41,844 2,286 157,185

73.2 94.0 93.7 80.8 91.1

Combined

Units

Clients

Capacity

Utilization rate

645 2,595 604 104 3,948

14,498 71,235 24,875 6,280 116,888

27,621 105,154 30,699 8,179 171,653

52.5 67.7 81.0 76.8 68.1

Total

Units 728

Clients

3,300 870 117 5,015

28,870 159,078 64,077 8,126 260,151

Capacity 47,250 198,580 72,543 10,465 328,838

Utilization rate 61.1 80.1 88.3 77.6 79.1

NOTE: Excludes data from units that did not report budgeted capacity.

SOURCE: NIDA and NIAAA, 1987 National Drug and Alcoholism Treatment Unit Survey.

48
TABLE 12. Number of drug abuse units reporting funding, total funding,

average funding per unit, annual unduplicated client count, and

average funding per client by source of funds: funding for fiscal

year, including October 30, 1987, and clients treated in 12-month

period ending with that date

October 30, 1987.” The utilization rate ranges from highs of 88.3 percent in

“Public State/Local” units, 80.1 percent in “Private Nonprofit” units, and 77.6

percent in “Public Federal” units to a low of 61.1 percent in “Private For-Profit

units.

Finally, table 12 is the NDATUS table that includes information on the “Number

of Drug Abuse Units Reporting Funding, Total Funding, Average Funding Per

Unit, Annual Unduplicated Client Count, and Average Funding Per Client by

Source of Funds: Funding for Fiscal Year, Including October 30, 1987, and

Clients Treated in 12-Month Period Ending With That Date.” The total average

49
funding per client is $1,707. From this table it is not clear as to precisely what

proportion of these clients receive hospital inpatient, residential, or outpatient

services, nor is the length of stay specified. However, another NDATUS table

on the “Number of Drug and Combined Units, Drug Abuse Clients in Treatment,

Budgeted Capacity and Utilization Rate by Unit Location and Treatment

Environment: October 30, 1987” contains the following information, which

indicates that a very high proportion (85.5 percent) of the clients are served on

an outpatient basis:

Type of Service Number of Clients Utilization Rate

Hospital Inpatient 10,579 (4.1%) 57.2%

Residential 27,230 (10.5%) 76.8%

Outpatient 222,342 (85.5%) 80.9%

Total 260,151 79.1%

However, the average length of stay for clients as outpatients or in other

environments is not specified within the NDATUS report.

SUMMARY AND CONCLUSIONS

Data from SADAP indicate that total alcohol and other drug treatment monies

expended during FY 1988 in programs that receive at least some State funds

were more than $1.6 billion. Also, data from NDATUS for the fiscal year

encompassing October 30, 1987, demonstrate that total monies from all

sources for drug abuse treatment (excluding alcohol, but including non-Statefunded programs) exceeded $1.3 billion.

Total other drug client treatment admissions as reported in SADAP for FY 1988

were 518,851; the number of other drug abuse clients in treatment as reported

in NDATUS as of October 30, 1987, was 260,151.

From a meeting of experts convened by NASADAD on September 2, 1987, the

annual estimated cost of drug treatment (excluding detoxification) for needle

users at that time ranged from $2,300 for outpatient drug-free, to $3,000 for

outpatient methadone maintenance, to $14,600 for adult nonhospital residential

drug-free, to $18,000 for adolescent nonhospital residential drug-free.

The above data and lack of data point to the need for more extensive welldesigned data collection studies on the cost, capacity, and utilization of drug

50
treatment services. Today, significant information gaps exist. Such data are

required for the administration, Congress, and States to better plan for the

availability, accessibility, and support of expanded alcohol and other drug

dependency treatment services for persons in need of such treatment services.

BIBLIOGRAPHY

Butynski, W. Special Report on Meeting of Selected State Directors and Other

Experts To Develop Reasonable Estimates on Drug Treatment Costs for

Needle Drug Abusers. National Association of State Alcohol and Drug

Abuse Directors, Inc., Washington, DC, September 1987.

Butynski, W., and Canova, D. State Resources and Services Related to

Alcohol and Drug Abuse Problems: Fiscal Year 1987. An Analysis of State

Alcohol and Drug Abuse Profile (SADAP) Data. Washington, DC: National

Association of State Alcohol and Drug Abuse Directors, Inc., August 1988.

Butynski, W.; Canova, D.; and Jensen, S. State Resources and Services

Related to Alcohol and Drug Abuse Problems: Fiscal Year 1988. An

Analysis of State Alcohol and Drug Abuse Profile (SADAP) Data.

Washington, DC: National Association of State Alcohol and Drug Abuse

Directors, Inc., August 1989.

Butynski, W., and Record, N. State Resources and Needs Related to Alcohol

and Drug Services: Fiscal Year 1983. Washington, DC: National

Association of State Alcohol and Drug Abuse Directors, Inc., March 1983.

Butynski, W.; Record, N.; Bruhn, P.; and Canova, D. State Resources and

Servkes Related to Alcohol and Drug Abuse Problems: Fiscal Year 1986.

An Analysis of State Alcohol and Drug Abuse Profile (SADAP) Data.

Washington, DC: National Association of State Alcohol and Drug Abuse

Directors, Inc., May 1987.

Butynski, W.: Record, N.; and Yates, J. State Resources and Services Related

to Alcohol and Drug Abuse Problems. An Analysis of State Alcoholism and

Drug Abuse Profile (SADAP) Data. Washington, DC: National Association

of State Alcohol and Drug Abuse Directors, Inc., April 1984.

Butynski, W.; Record, N.; and Yates, J. State Resources and Services for

Alcohol and Drug Abuse Problems: Fiscal Year 1984. An Analysis of State

Alcohol and Drug Abuse Profile (SADAP) Data, Washington, DC: National

Association of State Alcohol and Drug Abuse Directors, Inc., May 1985.

Butynski, W.; Record, N.; and Yates, J. State Resources and Services Related

to Alcoholism and Drug Abuse Problems: Fiscal Year 1985. An Analysis of

State Alcohol and Drug Abuse Profile (SADAP) Data. Washington, DC:

National Association of State Alcohol and Drug Abuse Directors, Inc., May

1986.

National Institute on Drug Abuse and National Institute on Alcohol Abuse and

Alcoholism. National Drug and Alcoholism Treatment Unit Survey

51
(NDATUS). 1987: Final Report. National Institute on Drug Abuse and

National Institute on Alcohol Abuse and Alcoholism. DHHS Pub. No.

(ADM)89-1626. Rockville, MD: U.S. Department of Health and Human

Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health

Administration, 1989.

AUTHOR

William Butynski, Ph.D.

Executive Director

National Association of State Alcohol and Drug Abuse Directors, Inc.

Suite 520

444 North Capitol Street, N.W.

Washington, DC 20001

52
Do More. . . and Do It Better:

Staff-Related Issues in the Drug

Treatment Field That Affect the

Quality and Effectiveness of Services

John S. Gustafson

lNTRODUCTlON

Drug treatment programs in the United States are straining to meet two equally

pressing demands: Do more and do it better. The urgency of these

requirements has escalated as a direct result of several dramatic societal

trends, including the spread of acquired immunodeficiency syndrome (AIDS),

the “crack” epidemic, and the increase in homeless persons, mentally ill

chemical abusers, and substance abusers who are parents.

Although much emphasis at the Federal and State levels has been placed on

the expansion of services for individuals with acute needs, there also is

widespread recognition of the need to ensure the quality and effectiveness of

services being provided. The compelling pressure to expand services and

create new treatment slots to accommodate more people has overshadowed

the need to step back and examine (1) the present-day problems faced by

individual drug treatment providers, program administrators, counselors, and

line staff and (2) the challenges presented to the substance abuse field by the

mandate to do more and do it better.

This chapter highlights some prominent and critical staffing issues in the drug

treatment field that affect the quality and effectiveness of services rendered.

This examination touches on the following issues:

1. Program staff recruitment and retention problems

2. The need for credentialing of persons providing substance abuse services

53
3. Capital improvement needs as they relate to facility maintenance,

provision of services, and staff morale

4. Dealing with persons with AIDS and human immunodeficiency virus (HIV)

5. Staff training and development

By remaining sensitive to and addressing the needs, problems, and issues

faced by drug treatment program staff, Federal and State policymakers and

service regulators make an important investment in the efficacy of the system.

PROGRAM STAFF RECRUITMENT AND RETENTION PROBLEMS

In recent years, much concern has been expressed over difficulties in recruiting

and retaining substance abuse treatment program personnel. Precise and

current data on the problem at the national level are severely limited. The most

“contemporary” perspective on staffing patterns in the United States is found in

the 1982 National Drug and Alcohol Treatment Utilization Survey (NDATUS)

carried out by the National Institute on Drug Abuse (NIDA) (1982). The survey

showed that there were 3,381 paid staff separations from the reporting drug

abuse treatment units for October 1980 through September 1982. When

viewed against a total full-time paid staff work force of 13,130 the level of staff

turnover becomes apparent. The paid staff categories experiencing the largest

number of separations were counselors, administrative or support staff, and

counselors who were credentialed and/or had a counseling degree. NIDA plans

to include staffing data again in the 1989 NDATUS.

On this subject, it is generally acknowledged by the New York State Division of

Substance Abuse Services and practitioners in the field that unless an effort is

made to improve the salaries and benefits of frontline clinical staff, our

treatment system will deteriorate to where it will be impossible to attract

qualified personnel. Ultimately, client services will suffer. This assessment is

not unlike conclusions reached by other State drug authorities and drug

program personnel.

In cooperation with local service providers, the Division recently carried out a

survey of all its funded treatment programs on this issue (Kott and Watkins

1989). Specifically, the survey was conducted in an effort to (1) determine the

range of current staff salaries for selected critical staff positions (e.g.,

paraprofessional counselors, social workers, and medical doctors), (2) identify

the extent of staff recruitment and retention problems and the causes thereof,

(3) determine the comprehensiveness of fringe benefit packages offered by

54
drug treatment programs, and (4) determine the costs to the Division of raising

salaries and fringe benefits to reasonable levels if necessary.

The survey revealed that across the State salaries were unacceptably low. The

most serious recruitment problems experienced by Division-funded treatment

programs lay in the paraprofessional counselor, vocational specialist, bachelor’s

degree-level counselor, and social worker positions. By far, the worst retention

problem existed among the paraprofessional counselors where 70 percent of

the programs reported such difficulties. Shortages of qualified candidates,

although apparent for all positions, were particularly acute among the

paraprofessional counselors and social workers. Of the 2,165 full-time

equivalent positions reported by these treatment programs, 276 (13 percent)

were vacant, 109 (5 percent) for more than 6 months.

Reasons for high turnover other than salary structure, cited by treatment

programs and identified below, point out other areas of remediation that need to

be addressed to attract and retain qualified staff:

1. Inadequate fringe benefit packages

2. Reluctance of program job applicants to work with drug abusing

populations

3. Location of drug treatment programs in less desirabie areas

4. Shortage of job candidates with relevant experience and qualifications

5. Fear of AIDS

Conclusions reached by the survey/report indicate that drug programs

traditionally have been at a disadvantage when competing for qualified clinical

staff. The primary factors that put drug programs low on the list of places that

counselors and other clinicians want to work are the negative stereotype of drug

abusers, the location of treatment programs in lower socioeconomic

neighborhoods, and recently, the AIDS epidemic. Perhaps the most negative

aspect of employment in drug programs is the low salaries paid to substance

abuse workers. As a result, the best counselors/clinicians seek jobs elsewhere.

Less qualified staff accept jobs in drug treatment programs, receive experience

and training to improve their skills, and within a year or two leave for jobs in

government or other social service agencies where the salaries are significantly

better.

55
These problems are not unique to New York State but mirror a problem of

national scale and significance. Given that staff turnover results in low staff

morale, disruption of services, lack of client progress, untimely termination of

clients, and other management and compliance problems, it is paramount that

local staffing needs to be addressed and remedied.

NEED FOR CREDENTIALING

The pros and cons of developing counselor credentialing systems have

received considerable discussion over the years. In her review of counselor

credentialing issues, Dr. Felice Schulman-Marcus notes that

On one side are those who contend that credentialing will lead to

improved client care, greater professionalism, and eventually third

party payments. On the other side are those. who feel that while there

may be some benefits, these are outweighed by the effort and financial

commitment that would be required to develop and operate such a

system (Schulman-Marcus 1986, p. 1).

The trend in the drug field nationally, however, has been toward the adoption of

credentialing. Certification is the most commonly used method of credentialing

drug counselors because this is viewed as a better method of recognizing the

nontraditional learning and work experience in the field. Many States are

establishing consortiums to standardize aspects of their systems and grant

reciprocity. On a local level, the question of credentialing substance abuse

counselors has received renewed attention with the implementation of a system

for credentialing alcoholism counselors. Many in the drug prevention and

treatment system advocate a comparable system so that they too can receive

the recognition attached to credentialing. These factors have combined to

create an added impetus to define the elements unique to the areas of

substance abuse counseling and to set up a process to measure and recognize

the qualifications of workers in the field.

According to Schulman-Marcus, proponents of credentialing contend there are

several important benefits that support the worth of such systems. They view

credentialing as an effective means to:

1. Ensure a qualified work force that can provide professional services to

clients

2. Increase feelings of professionalism among substance abuse workers,

leading to greater job satisfaction, improved performance, and less staff

turnover

5 6
3.

4.

5.

6.

Upgrade the status of the substance abuse field in a society where

credentials are viewed as equivalent to competency

Provide recognition to substance abuse workers who have acquired

valuable skills through nontraditional means and work experience

Convince third-party payers to provide reimbursement for substance abuse

treatment

Increase the career mobility for substance abuse workers by making it

easier for them to enter other human service fields (Schulman-Marcus

1986, p. 4)

In recognition of the complexities of substance abuse and the need for

expertise in the provision of substance abuse services, the Division established

a credentialing advisory board, composed of service provider representatives,

health and mental health professionals, and members of the general public, to

review the subject of credentialing for substance abuse specialists and to

provide recommendations for the development of a credentialing system.

Based on the advisory board’s recommendations, the Division recently

published proposed standards and requirements for the credentialing of

substance abuse specialists who provide direct client services, including

counseling, assessment, referral, and prevention and education. Under the

proposed system, individuals who meet minimum eligibility requirements

(education, experience, character, and competence) would qualify to take the

necessary written and oral exam for the credentialing, which would remain valid

for 3 years. Renewal would be dependent on completion of a minimum number

of education and/or training hours.

Importantly, our proposed credentialing system supports the delivery of services

by former substance abusers and recognizes the contributions they make to the

field. Program graduates are vivid proof that treatment works: through their

personal experience with the perils of drug abuse, they provide a powerful

message, which is demonstrated by the valuable role played by former abusers,

for example, in AIDS outreach efforts to intravenous (IV) drug users, which is

described in New York State’s Five-Year Interagency AIDS Plan:

The subculture of IV drug users has been historically difficult to engage

in education and drug treatment due to a lifestyle outside of the

mainstream of society, distrust of government and fear of arrest for

engaging in illegal behavior. Knowledge, Attitude and Behavior (KAB)

studies involving IVDUs demonstrate the need for outreach conducted

by indigenous counselors who speak the language, know the drug

57
culture and can blend in with street activity with minimal disruption.

These ex-addict counselors interact with targeted groups to gain their

trust and provide one-to-one education (New York State 1989, pp. 41-

42).

CAPITAL IMPROVEMENT NEEDS

The poor physical working environment of some drug programs is also a factor

affecting their ability to attract and retain qualified personnel and has serious

and negative consequences on the morale of program staff. It is increasingly

obvious that the infrastructure of the drug treatment system needs to be shored

up, if only to maintain existing services delivery. Many community-based

treatment facilities are in dire need of physical plant renovation. Over the past

decade, increased funding for treatment was used to create additional slots at

the expense of the capital improvement needs of programs. Existing facilities in

many instances are old, are in poor repair, and have large deferred

maintenance needs. Without a significant capital rehabilitation effort-one that

is supported and not hindered by Federal regulation such as that governing the

Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) block

grant—the treatment system is in danger of further deterioration.

Physical plant problems pose serious challenges to the continued expansion of

this Nation’s treatment capacity. It is evident that additional capacity can only

be built with new capital investment at present sites, together with the

identification of new sites and provision of substance abuse treatment services

at nontraditional locations.

DEALING WITH PERSONS WITH AIDS AND HIV INFECTION

Certainly, AIDS has changed substance abuse treatment programs in very

significant and basic ways. The range of services and personnel required to

meet the needs of the individual in treatment demands that programs offer more

linkages to primary health care, medical treatment, social services, housing,

and other needs. The difficulty of talking with clients about AIDS-related issues

and behavior change means that an enriched counselor-to-client ratio is needed

and that intensive staff training needs to take place. The demand for qualified

staff in an underpaid field where there is already a shortage of personnel further

exacerbates the situation.

The Division has been engaged in several AIDS initiatives related to staff

development needs and issues. This involvement, for example, has included

the development of an AIDS prevention and risk reduction model for treatment

programs known as the “Comprehensive AIDS Risk-Reduction Effort”

58
(C.A.R.E.) (Bixler et al. 1987). The model not only stresses the need for

behavior change among drug treatment clients and their sexual partners who

engage in high-risk drug and sexual behavior but also provides a framework for

program administrators to deal with AIDS and substance abuse and its

consequence on the relationship between drug counselors and clients. The

model promotes an administrative policy that recognizes that clients and staff

need the reassurance that, if they come down with AIDS, they will not be

abandoned by their program. Staff education and training also are strong

components of the overall C.A.R.E. approach.

The Division also has been involved with the funding and placement of AIDS

coordinators in community-based treatment programs. Individuals in these

positions are responsible for providing education and training to clients and

staff, initiating AIDS support groups, providing case management services, and

acting as liaisons with appropriate service agencies. The coordinators also

ensure that treatment programs function as community centers for AIDS

prevention and oversee the delivery of crucial risk-reduction information to

affected individuals and their families.

Efforts to control the spread of AIDS and HIV infection have also led to several

innovative and exciting outreach programs that target IV drug users who

typically shun the traditional delivery of services and assistance. One such

effort is the AIDS Prevention Training for Intravenous Drug Abusers Paroled

from Prison (ARRIVE) project developed by Narcotic and Drug Research, Inc.

The primary purposes of this 3-year research and demonstration project,

supported by NIDA, are to develop, implement, and evaluate an AIDS

prevention training program for parolees with histories of IV drug use (Wexler,

personal communication, 1989). The primary goals are as follows:

1. Prevent relapse to IV drug use and associated AIDS risk behaviors

2. Help parolees become productively reintegrated into the community

3. Create a network of trained persons with appropriate life experience who

will be of service to their communities in AIDS prevention

Participants in the project take part in an 8-week, 48-hour, 24-session training

program. Areas covered include defining HIV, AIDS, and AIDS-related

complex; AIDS transmission, prevention, and risk reduction; AIDS, condom use,

and drug paraphernalia: needs of AIDS victims and those at risk; clinical

symptoms of AIDS; issues involved with HIV testing and interpretation of test

results; defining and creating a support group; anxiety and stress reduction

methods; dealing with anger and powerlessness; recognition of and responses

59
to depression; approaches to drug relapse prevention; and differentiating

between abstinence and recovery. The ARRIVE training program also offers

participants an opportunity to be tested for HIV (on a free, confidential, and

voluntary basis) as well as job readiness preparation for employment in the

AIDS prevention/outreach field. This program has considerable potential for

assisting a population that is a potentially dangerous AIDS vector.

STAFF TRAINING AND DEVELOPMENT

When you consider the goal of meeting “treatment on demand” as

recommended by the chairman of the Presidential Commission on the Human

lmmunodeficiency Virus Epidemic (Watkins 1988) the necessity for

comprehensive staff training and development activities is evident. Among the

recommendations, the chairman notes the following:

A significant increase in trained personnel will be necessary in order to

implement new programs (32,000 individuals will have to be enlisted

into joining the ranks of drug abuse workers). Staff training should be

enhanced through developing new programs at community colleges,

universities, vocational and technical schools offering internships in

existing drug programs, and training of ex-addicts. Federal leadership

is needed in the development of model curricula for training programs

as well as establishing drug abuse prevention, treatment and research

as viable and rewarding professions (Watkins 1988, p. 10).

Training has demonstrable benefit in other areas as well, such as upgrading the

skills and knowledge base of existing drug treatment personnel and providing

workers in allied human service agencies with an understanding of substance

abuse. Training also is a common element in credentialing systems.

In New York State, the Training Institute—under contract to the Division—

provides more than 36 training programs to personnel working with clients who

have substance abuse problems (Narcotic and Drug Research, Inc. 1989).

They address such areas as individual, group, and family counseling; different

treatment populations; chemotherapy issues; general substance abuse issues;

program management; staff and trainer development; and drug abuse

prevention. Importantly, academic credit and/or continuing education units are

available for many of the training programs offered by the Institute.

In terms of long-range plans, the Training Institute is contemplating a training

delivery model based on a systems rather than a generic approach. This

assessment is based on the Institute’s extensive work with AIDS and IV drug

use curriculum development as well as the recognition of the multiplicity of

60
needs faced by distinct service provider groups. Curriculums, training courses,

manuals, and related items would therefore be developed and delivered for

specific systems such as methadone maintenance, residential therapeutic

communities, and school-based and community-based prevention programs.

CONCLUSION

In 1988, $2.1 billion from all sources was expended to provide for alcohol and

other drug abuse services (Butynski et al. 1989). Of this amount, State funding

accounted for nearly $910 million, and local funding accounted for $191 million.

The Federal Government, through ADAMHA and Alcohol and Drug Abuse

Treatment and Rehabilitation block grants, contributed almost $355 million.

With the passage of the 1988 Anti-Drug Abuse Act (Public Law 100-690),

Federal responsibilities have increased due to new data collection mandates,

technical assistance requirements, and additional treatment outcome studies. It

is hoped that, as the new provisions of the act are implemented, the Federal

Government, via ADAMHA and NIDA, will again take a position of national

leadership in assisting the States and local communities to expand and improve

drug abuse treatment services.

Generally, new funding for drug abuse treatment is specifically identified for

capacity (“slot”) expansion. Programs’ contractual capacities can continue to be

increased, but unless staffing problems are resolved, additional clients will not

be able to be served. Specific funds must be earmarked to address salary and

fringe benefit increases, training programs, an internship system with colleges

and universities, and maintenance and renovation of deteriorating facilities. We

must “get our house in order” if we are to provide effective, quality services to

those desperately in need of help. Although some States may individually

assess the impact of expanding drug treatment capacity on the workload of

existing program staff and the need to attract and retain additional qualified

personnel, a national perspective on the problem is lacking. This void

represents an excellent opportunity for ADAMHA and NIDA, in conjunction with

the States, to provide the national leadership that is critically needed.

REFERENCES

Bixler, R.; Palacios-Jimenez, L.; and Springer, E. Comprehensive AIDS RiskReduction Effort - AIDS Prevention for Substance Abuse Treatment

Programs. New York: Narcotic and Drug Research, Inc., 1987.

Butynski, W.; Canova, D.; and Jensen, S. State Resources and Services

Related to Alcohol and Drug Abuse Problems: Fiscal Year 1988. An

61
Analysis of State Alcohol and Drug Abuse Profile Data. Washington, DC:

National Association of State Alcohol and Drug Abuse Directors, Inc., 1989.

Kott, A., and Watkins, T. Report on the DSAS Personal Services Survey. New

York: New York State Division of Substance Abuse Services, Bureau of

Research and Evaluation, 1989.

Narcotic and Drug Research, Inc. Training Institute Program Guide 1989-1990.

New York: Narcotic and Drug Research, Inc., 1989.

National Institute on Drug Abuse. Main Findings for Drug Abuse Treatment

Units, September 1982: Data from the National Drug and Alcoholism

Treatment Utilization Survey, NDATUS. Statistical Series, Series F, No. 10.

Rockville, MD: National Institute on Drug Abuse, 1982.

New York State. AIDS - New York’s Response - A Five-Year Interagency Plan.

Albany, NY: New York State Department of Health, 1989.

Schulman-Marcus, F. Counselor Credentialing - Exploration of the Issues.

New York: Narcotic and Drug Research, Inc., 1986.

Watkins, J. Chairman’s Recommendations for Consideration by the Full

Presidential Commission on the Human lmmunodeficiency Virus Epidemic,

1988.

AUTHOR

John S. Gustafson, M.A.

Deputy Director for Government and Community Relations

New York State Division of Substance Abuse Services

Executive Park South

Albany, NY 12203

62
Outpatient Drug Abuse Treatment

Services, 1988: Results of a National

Survey

Richard H. Price, A. Celeste Burke, Thomas A. D’Aunno,

David M. Klingel, William C. McCaughrin, Jane A. Rafferty,

and Thomas E. Vaughn

INTRODUCTION

The Nation’s system of outpatient treatment for drug abuse is undergoing large

systemic changes that have important implications for the organization and

effectiveness of outpatient drug abuse treatment. Two major changes are of

particular significance: (1) the movement of outpatient drug abuse treatment

services into the mental health sector and the health care system in general

(Drug Abuse Policy Office 1984) and (2) the shift of drug abuse treatment from

Federal to State control (Tims 1984). These changes in the environment

influencing outpatient drug abuse services affect the way in which services are

delivered and may ultimately shape treatment efficiency and effectiveness

(Burke et al. 1983; D’Aunno and Price 1985; Price and D’Aunno 1984).

From a policy perspective, these changes have important implications for the

effectiveness of drug abuse treatment (Hubbard et al. 1983, 1984; Jaffee 1984;

Senay 1983, 1984). For example, a 1984 national survey of drug-free

outpatient treatment addressed the question of the appropriateness of the

community mental health center for the delivery of this treatment (Burke et al.

1983). Jaffee (1984) and Frances (1988) observed that a substantial portion of

drug abuse patients show signs of psychopathology and depression in

particular. Will drug abuse treatment delivered in the mental health system be

more responsive to multiproblem patients with both drug abuse and mental

health problems or will one set of problems receive undue attention at the

expense of the other?

A second set of questions is raised by the passage of the Omnibus

Reconciliation Act of 1981, which dramatically changed the way Federal support

is provided to drug abuse treatment. The act provides that alcohol, drug abuse,

63
and mental health block grants be administered by individual States rather than

by the National Institute on Drug Abuse (Tims 1994). In outpatient treatment

programs, this shift to State authority may provide the opportunity for better

coordination of outpatient drug treatment at the State level.

These changes in the drug abuse treatment system and their relationships to

treatment can be understood in the context of a framework that relates the

organizational environment of treatment programs, including funding sources,

licensing authorities, and referral sources, to changes in the treatment

organizations themselves. These organizational changes may in turn affect the

relationship between clients and treatment organizations and ultimately have an

impact on the effectiveness of treatment itself (D’Aunno and Price 1985; Price

and D’Aunno 1994; Friedman and Fulop 1988). This current national survey of

outpatient drug abuse treatment organizations provides an opportunity both to

monitor changes in the treatment system and to examine differences in

outpatient drug abuse treatment services that are associated with differences in

organizational affiliation. These differences include (1) the context of service

delivery, including services provided in hospital settings, mental health settings,

and other human service settings, and (2) differences in treatment modality,

particularly methadone outpatient treatment programs, compared with those in

drug-free outpatient programs.

In 1987 a research team convened a major policy review meeting (Price et al.

1987) that involved experts in the outpatient drug abuse treatment sector

(including authorities on service provision), representatives of the health

insurance industry, and authorities on the treatment system from the public and

private sectors as well as from methadone and drug-free programs. This policy

group was asked to address major questions concerning current and

anticipated changes in the outpatient drug abuse treatment system: changes in

the composition of the client population requiring treatment, problems and

needs in terms of access and availability, and several other critical questions.

Among the client needs identified were increased access to care, higher quality

treatment, relapse prevention, better trained personnel, and concern with the

special needs associated with comorbidity due to AIDS and psychopathology.

This chapter provides an initial response to some of the questions and concerns

raised by this policy group as well as the first opportunity to report the results of

the National Drug Abuse Treatment System Survey (NDATSS). These initial

data contrast services delivered in different organizational settings (hospitals,

mental health centers and other human service organizations, and drug-free

64
versus methadone outpatient treatment programs) by addressing the following

questions:

Who is receiving outpatient drug abuse treatment services, and where are

clients coming from? This information concerns not only the demographic

characteristics of clients but also the nature of drug problems encountered

by clients in the outpatient treatment system. This chapter examines the

sources of referrals to outpatient treatment, because some referral sources

may be heavily represented, whereas other potential referral sources may

refer few clients to the outpatient treatment system.

What do outpatient treatment services look like? These data focus on a

variety of characteristics of treatment services and how they vary across

major dimensions of the treatment system. This concerns the nature of

staffing in the treatment system and how units vary in terms of the

credentials of their staffs (e.g., professional certification and training and

years of education). This chapter also describes treatment services as the

client progresses through the system, that is, an examination of the client’s

career beginning with diagnostic services to an identification of core

treatment services and the availability of special or additional services. At

the end of the clients career, of course, the nature of referral patterns from

outpatient drug abuse treatment to other treatment or aftercare facilities

also are examined in this chapter.

What are the reported outcomes of treatment? This survey is primarily

descriptive in nature and cannot provide data of the sort obtained in

controlled clinical trials. However, respondents were asked about a range

of treatment outcomes that they believe are being achieved in their

treatment programs. This chapter reports these outcomes and

respondents’ perceptions of the degree to which treatment goals are being

met.

What efforts are being made to increase the effectiveness or quality of

treatment? Scientific information from clinical trials is one ingredient for

improving the effectiveness of the outpatient drug abuse treatment system.

However, licensing and quality assurance efforts are also under way to

improve the quality of treatment in the outpatient drug abuse sector just as

they are in the health sector in general. Information is reported from a

national sample of treatment programs on licensing as well as quality

improvement efforts and licensing requirements aimed at providing and

maintaining the quality of treatment.

65
What do outpatient drug abuse treatment personnel believe about the

ingredients of effective treatment? Existing beliefs about what constitutes

effective treatment, whether derived from clinical experience, scientific

findings, or the ideological doctrines of various groups, may well affect

clinical practice in the treatment system. For example, Friedman and

Glickman (1987) found some beliefs about effective treatment that were

negatively correlated to treatment effectiveness. This chapter reports

respondents’ beliefs about what makes clients ready for treatment, about

appropriate qualifications of treatment personnel, and about the critical

ingredients of effective treatment.

METHOD

National Sample of Outpatient Drug Abuse Treatment Programs

The Survey Research Center of the Institute for Social Research at the

University of Michigan has developed the sampling frame for NDATSS. The

sampling frame is a composite list of the names, addresses, and telephone

numbers of approximately 8,500 drug abuse treatment programs across the

United States. The frame is a large-scale, first-phase probability sample that

has been compiled from available national lists and State and local directories

and through contacts with local health officials. Each drug treatment program in

the frame has been included with a known probability. Programs are crossclassified by public/private status, treatment modality (methadone or drug-free),

and organizational affiliation—mental health center, hospital, or other human

service organization.

The national frame was developed through the integration of four separate lists:

(1) a national list of methadone treatment programs, (2) a national list of

hospital-based drug treatment programs, (3) a comprehensive list of drug

treatment programs developed for the 84 primary sampling units (PSUs) of the

Survey Research Center’s 1980 national sample design, and (4) a national onein-three subsample of program listings from directories supplied to the Survey

Research Center by the 50 states. The four component lists, which have been

integrated to form the national sampling frame for outpatient drug treatment

programs, are described briefly below.

National List of Methadone Treatment Programs. The source of the

computerized national list of methadone treatment programs is the listing

published by the 1984 National Alcohol and Drug Abuse Treatment Program

Inventory (NADATPI) directory, which was supplemented with additional

methadone programs identified through screening of the sample program

listings from the Survey Research Center national list and the one-in-three at66
large sample of programs from the State directories. Approximately 580

methadone program listings are included.

National List of Hospital-Based Drug Treatment Programs. A national list of

hospital-based, drug-free (nonmethadone) treatment programs was directly

derived from the 1984 NADATPI directory, including approximately 1,020

program listings, each of which was included in the composite national frame

with certainty.

Comprehensive List of Drug Treatment Programs for the PSUs of the

Survey Research Center’s 1980 National Design. To achieve a probability

sample of the Nation’s private drug treatment programs, a two-stage sample

design was used. A primary-stage sample of standard metropolitan statistical

areas (SMSAs) and counties was drawn, followed by a second-stage sampling

of drug treatment programs within selected PSUs. For this design, the chosen

PSUs are the 84 PSUs of the 1980 Survey Research Center national sample.

Within each of the 84 national sample PSUs, surveyors created a complete

listing of all drug treatment programs currently operating within the sample

SMSA or county. All known listing sources were extracted from existing lists;

yellow page listings from telephone service areas were added; and all data

were collated into a single combined list with obvious duplicates removed.

Furthermore, printed listings were mailed to county senior health officers for

review. Cooperation on the part of county health officers and staff was

excellent. At the completion of this process, this list contained approximately

5,200 listings.

National One-In-Three Subsample From State Directory Lists. The center

contacted State officials in each of the 50 states to obtain a current statewide

directory of drug treatment programs. All states but one (Georgia) provided a

directory of current programs. A total of 2,100 programs are included in this list,

and a one-in-three sample of program listings was selected for the national list

frame.

Integrating the Multiple Lists To Form a National Sample Frame of Drug

Treatment Programs. A two-step procedure was used to integrate the multiple

lists into a single, comprehensive national frame for the sampling of outpatient

drug abuse treatment programs. After merging and identifying obvious

duplicates, each program listing was assigned its correct total inclusion

probability based on the separate probabilities of its inclusion on one or more of

the four overlapping lists.

Telephone Screening Procedure. Based on the sampling frame, 2,442

programs were screened by telephone to ascertain their eligibility for the study.

67
Units were considered eligible if (1) they defined themselves as an outpatient

substance abuse treatment unit, (2) the majority of their clients were outpatient

substance abuse clients, and (3) they did not exclusively serve alcohol clients.

Each program was contacted to determine its public/private status, treatment

modality, and organizational affiliation—mental health center, hospital, or other

human service affiliation. These programs were then reassigned to strata in the

sample based on the screening information provided. Based on this screening

information, outpatient drug abuse treatment programs were interviewed as

shown in table 1. (These data are based on all respondents in the national

sample. Weighted data to better reflect national representativeness will be

used in forthcoming reports.)

TABLE 1. Outpatient drug abuse treatment system survey: treatment units

responding by treatment modality and organizational context

Organizational Context

Treatment Mental Health

Modality Center Hospital Other Total

Methadone 17 34 74 125

Drug-Free 134 96 214 444

Total 151 130 238 569

Design and Development of the National Drug Abuse Treatment System

Telephone Survey

The national telephone survey of outpatient drug abuse treatment programs

involved the development and administration of two different interviews.

Typically, one survey was administered to treatment unit directors and the other

to clinical supervisors in the units. For the most part, the director’s survey

focused on the relationship of the treatment unit to key actors and organizations

in the treatment organization’s environment. The clinical supervisor’s survey

covered topics that concern the actual delivery of treatment services.

68
The director’s survey began with a brief section on unit history and mission

followed by questions on unit funding, licensing and accreditation, treatment

unit data collection on clients, evaluation and client monitoring, collaboration

and competition with other treatment organizations, relationships between the

treatment unit and any parent organization, recent programmatic changes in the

unit, and questions about respondent demographics.

The clinical supervisor’s survey began with questions about referral sources to

the treatment unit and organizations to which the unit referred clients, followed

by information about treatment unit staff and staff relations and patterns of

treatment, including information about client assessment, types of services

delivered, special outpatient programs or services, treatment goals, and

perceived treatment outcomes. In addition, clinical supervisors were asked

about client characteristics, both in terms of client demographics and patterns of

substance use. Finally, respondents were asked about their own demographic

characteristics.

Two pretests were used to refine these interviews before the actual field

interview period. The two separate interviews in the survey averaged about 90

minutes each to complete. Respondents seemed to be highly motivated,

expressed interest in the survey, and often took considerable time to calculate

figures or refer to reference materials or reports to enhance the accuracy of

their responses. Overall, the refusal rate was low. The result was that 82

percent of the eligible units agreed to participate. The telephone survey

produced 530 completed pairs of interviews.

RESULTS OF THE 1999 OUTPATIENT DRUG ABUSE TREATMENT

SYSTEM SURVEY

In providing preliminary answers to the five questions introduced earlier, overall

results are sometimes reported for the entire sample. The answers to survey

questions, which often differ sharply depending on whether methadone or drugfree treatment is being described or whether the outpatient treatment unit is

located in a mental health center, hospital, or some other setting, highlight

differences in treatment practices that emerge when treatment modalities are

contrasted or when treatment in different organizational contexts is compared.

For the purposes of this report, methadone units are defined as those reporting

at least 50 percent of their current outpatient substance abuse treatment clients

as methadone clients. The remaining units are designated as drug-free

treatment units. In assessing differences in clients and treatment patterns

associated with different organizational contexts, the sample is divided into units

delivering services in mental health centers, hospitals, and other organizational

contexts.

69
Who Is Receiving Outpatient Drug Abuse Treatment Services, and Where

Are Clients Coming From?

Respondents were asked to estimate the percent of outpatient clients over the

past complete fiscal year with different types of substance abuse problems

(table 2). For the entire sample, an average unit client caseload of

approximately 715 outpatient clients was seen in the last complete fiscal year;

42 percent had alcohol problems as their primary problem, and 53 percent had

drug abuse as their primary problem. Across the entire outpatient drug

TABLE 2. Percent of outpatient substance abuse treatment unit clients

reported to have various drug problems

Organizational Context

Treatment Modality

Mental Health Hospital Other Total

Center Sample

Metha DFb Meth DF Meth DF Mean N

C

Primary Problem

Alcohol

Drug abuse

Type of Drug Abuse

Heroin

Nonprescription methadone

Opiates or synthetics

Barbiturates

Other sedatives

Cocaine (other than crack)

Crack

Amphetamines

Quaaludes

Over-the-counter drugs

Inhalants

Tranquilizers

PCP

Marijuana or hashish

LSD

Other hallucinogens

Multiple drugs

Other

16.8 52.8 10.9 58.3 8.0 46.5 41.6 536

85.6 37.6 93.4 35.7 91.5 46.7 53.1 537

73.4 7.5 73.8 5.2 78.0 8.8 23.7 530

7.2 1.7 10.4 1.0 6.4 1.2 2.7 522

27.7 9.9 24.9 6.2 18.4 8.6 11.5 522

9.5 6.7 7.0 7.5 7.3 6.8 7.1 525

11.5 8.1 7.1 8.9 8.6 8.7 8.6 523

40.2 20.8 35.3 27.0 32.9 26.3 27.1 526

18.7 11.4 14.4 12.5 13.7 13.9 13.2 509

11.6 11.9 5.4 11.0 7.5 11.4 10.5 527

4.8 2.4 1.8 2.2 2.2 2.7 2.5 516

17.7 6.5 5.6 7.9 3.9 7.7 7.1 517

2.3 2.7 1.3 5.0 1.1 3.2 2.9 523

27.0 11.0 18.7 12.1 18.9 10.2 13.0 519

3.5 2.4 1.8 3.2 2.7 4.4 3.3 523

45.1 39.9 45.1 37.6 31.1 45.2 40.8 532

3.5 4.5 1.8 5.6 1.7 5.3 4.4 522

3.3 2.8 1.8 4.1 1.0 2.5 2.5 516

69.8 49.3 55.7 53.5 50.4 57.2 54.1 526

21.2 4.3 8.4 6.1 6.0 4.9 5.8 526

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

70
treatment system, respondents reported that 54 percent of their clients had

multiple drug problems. Furthermore, 41 percent of outpatient clients were

reported to have marijuana problems, 27 percent cocaine problems, 24 percent

heroin problems, 13 percent crack abuse problems, and 13 percent tranquilizer

abuse problems.

As might be expected, the types of drug abuse problems reported differed

strikingly when comparing methadone with drug-free programs. Methadone

programs tended to have markedly fewer clients with alcohol as the primary

problem; more heroin problems: more problems with nonprescription

methadone, cocaine, and tranquilizers; but fewer clients with amphetamine or

LSD problems. More clients who tested positive or were diagnosed to have

AIDS were found in hospital treatment settings, and mental health centers

tended to have fewer clients whose primary problem was drug abuse.

Overall, survey data on client demographics (table 3) indicated that two-thirds of

clients being served were male, 11 percent were Hispanic, and 19 percent were

black; 78 percent of the sample was 39 years or younger. Clients in methadone

programs tended to be older, Hispanic or black, or HIV positive or diagnosed to

have AIDS. Furthermore, although 2.5 percent of all clients were estimated to

test positive for HIV across the entire sample, the estimate in methadone

programs was 7 percent versus 1 percent in drug-free programs.

Respondents were asked the extent to which their treatment unit received

referrals from many different sources (table 4). Here again, differences

according to treatment modality and organizational context were striking in

some cases. For example, when comparing the referral patterns of methadone

programs to those of drug-free programs, methadone programs received

markedly more self-referrals or referrals from friends and received far fewer

referrals from human service agencies. This finding, of course, is open to

several interpretations. Either methadone clients are not initially connected to

human service agencies and therefore are not referred to treatment by them or

human service organizations are less likely to know where to refer clients with

opiate addiction problems. This also may suggest the need for more

aggressive outreach by methadone units and a need for increased treatment

capacity. Clearly this is a question open to further research.

Organizational context also plays a role in referral patterns to drug treatment

units. For example, hospitals reported significantly fewer referrals from a range

of human service agencies, including courts, the police, schools, and

departments of social services, and more referrals from physicians.

71
What Outpatient Treatment Services Look Like: Staffing, Diagnosis, and

Treatment

On the average, outpatient treatment units tended to be fairly small, with about

13 treatment staff members in methadone units and about 9 in drug-free units.

The educational background of staff in methadone units tended to be

characterized by medical backgrounds, especially registered nurses and

physicians (table 5). Methadone units also tended to have fewer Ph.D.s fewer

master’s degree-level staff members, and fewer staff members with substance

abuse treatment certification or training.

TABLE 3. Percent of outpatient substance abuse treatment unit clients by

gender, ethnicity, and age

Organizational Context

Treatment Modality

Mental Health Hospital Other Total

Center Sample

Metha DFb Meth DF Meth DF Mean N

C

Gender

Males

Females

61.1 68.7 64.5 68.1 62.6 65.9 66.3 542

38.9 31.3 35.5 31.9 37.4 34.1 33.7 542

Ethnicity

American Indian or

Alaska Native 1.1 4.1 0.4 2.6 0.5 3.8 2.9

Asian or Pacific Islander 0.9 0.6 0.3 1.2 1.1 1.3 1.0

Hispanic 11.6 7.6 22.7 8.8 18.4 9.3 11.0

Black (not of Hispanic origin) 20.8 18.5 25.3 14.7 26.8 17.8 19.3

White (not of Hispanic origin) 65.7 69.3 51.2 72.9 53.2 67.9 65.9

Age

Younger than 20 years 3.7 16.4 4.3 15.3 1.9 19.2 14.3

20-29 years 22.8 34.0 34.5 31.3 31.4 34.8 33.2

30-39 years 41.2 29.1 42.1 28.5 43.5 26.1 30.9

40-49 years 22.4 12.7 12.7 14.7 16.5 12.1 13.6

50-64 years 6.3 5.9 5.7 7.7 5.7 5.7 6.1

65 or older 3.4 2.1 0.7 2.6 1.1 2.1 2.0

530

530

530

530

530

531

531

531

531

531

531

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

72
TABLE 4. Extent to which the outpatient substance abuse treatment unit

receives referrals from various sources

Organizational Context

Treatment Modality

Mental Health Hospital Other Total

Center Sample

Metha DFb Meth DF Meth DF Mean N

C

Referral Source

Vocational rehabilitation

centers 1.6

Courts 2.9

Hospitals 2.5

Private clinics 2.5

Physicians 2.4

Departments of social services 2.8

Mental health agencies 2.9

Employee assistance programs 1.7

Police 2.1

Schools 1.7

Churches 1.8

Self-referrals 4.2

Friends of clients 3.3

Family of clients 3.0

Other 1.8

2.0 1.4 1.6 1.6 1.9 1.8 553

3.9 2.3 3.3 2.7 3.9 3.5 553

2.8 3.0 3.1 2.5 2.7 2.8 553

2.3 2.1 2.4 2.3 2.2 2.3 552

2.4 2.3 2.8 2.1 2.2 2.3 553

2.9 2.6 2.4 2.3 2.9 2.7 550

3.1 2.1 2.6 2.3 2.7 2.7 552

2.4 1.7 2.8 1.9 2.5 2.4 552

2.4 1.4 1.9 1.8 2.1 2.1 553

2.7 1.3 2.3 1.5 2.8 2.4 553

1.9 1.3 1.7 1.4 1.9 1.8 553

3.6 4.4 3.6 4.2 3.4 3.7 552

3.1 3.5 3.3 3.6 3.2 3.3 552

3.3 2.8 3.4 3.1 3.3 3.2 552

1.8 1.7 2.1 1.4 2.0 1.9 529

KEY: 1 = no extent, 2 = little extent, 3 = some extent, 4 = great extent, 5 = very great extent

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

As expected, staffing differences can also be observed in units embedded in

different organizational contexts. Mental health centers tended to have the

most highly educated staff members and those with the most months of

substance abuse training. Mental health centers also tended to have fewer exaddicts as staff members. Treatment units that are either free-standing or

embedded in human service organizations other than hospitals and mental

health centers tended to have lower levels of educational qualifications among

their staff and more part-time staff.

Diagnostic procedures and client assessment procedures also varied

considerably by modality and organizational context of the unit (table 6). For

73
TABLE 5. Description and qualifications of outpatient substance abuse

treatment staff

Organizational Context

Treatment Modality

Mental Health Hospital Other Total

Center Sample

Metha DFb Meth DF Meth DF Mean N

C

Employment Status

All unit’s staff

(average number per unit)

Full-time paid staff 13.0 8.6 13.9 8.1 16.6 9.1 10.3

Part-time paid staff 2.8 1.7 2.4 2.4 4.1 2.6 2.5

Consultants and independent

contractors 1.3 1.8 1.0 1.8 2.2 2.0 1.9

Volunteers 0.1 1.8 0.2 3.4 0.4 1.7 1.7

Educational Background

Treatment staff only

(average percent of staff)

Ph.D. as highest degree 1.8 6.4 3.2 7.3 4.1 6.2 5.9

M.D. or D.O. 16.0 9.5 15.7 9.6 13.5 6.9 9.7

Master’s degree 26.9 45.1 22.4 38.9 19.7 33.4 34.3

Bachelor’s degree

(excluding R.N. degree) 11.9 21.8 17.2 17.5 25.3 27.8 23.2

R.N. 16.6 3.1 22.9 4.9 13.6 3.1 6.4

Fewer than 4 years of college

or associate degree

(excluding R.N. degree) 16.2 10.9 12.4 15.8 17.3 14.7 14.3

High school diploma or less 10.5 3.2 6.2 6.0 6.5 7.9 6.3

Percent of Treatment Staff Who

Are Ex-Addicts or Recovering

Alcoholics 9.4 26.8 9.6 37.1 9.6 33.8 27.3

Training and Certification

(average percent of staff)

Specialized training in

substance abuse treatment 65.8 77.7 56.4 74.0 55.1 71.8 70.2

Special certification in

substance abuse treatment 20.9 35.6 14.7 48.7 22.7 44.6 37.7

549

550

546

549

547

547

547

547

547

547

547

540

541

544

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

74
example, although severity of drug problems, drug abuse histories, and clients’

perceptions of their problems are almost always assessed, mental health

assessments using DSM-III occurred for only 70 percent of clients, and physical

examinations and other medical tests tended to occur for only about half of all

clients.

TABLE 6. Percent of outpatient substance-abuse treatment unit clients

receiving various types of assessment and diagnostic procedures

Organizational Context

Treatment Modality

Mental Health Hospital Other Total

Center Sample

Metha DFb Meth DF Meth DF Mean N

C

Procedure

Evaluate severity of drug

problem 98.8

Obtain drug abuse history 100.0

Information on client

perception of dependence 99.1

Test specifically for AIDS 16.6

Assess client support

networks 90.9

Conduct physical

examinations 88.8

Conduct medical tests to

assess health status 83.2

Assess current or pest mental

health problems 89.1

Use DSM-IIId diagnosis 89.7

96.6 93.4 97.9 97.4 95.7 96.5 548

99.0 98.8 97.2 99.4 99.4 98.9 550

96.6 98.5 97.1 93.7 96.6 97.3 548

7.1 23.0 8.5 23.6 10.9 12.1 540

92.3 83.9 94.5 87.0 93.5 91.9 549

22.6 98.4 48.2 95.2 30.3 46.2 549

24.3 92.8 45.1 90.9 29.9 44.7 545

87.1 81.7 68.8 79.5 64.1 85.0 548

87.6 56.2 82.3 45.4 61.3 69.6 541

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

d

 Diagnostic and Statistical Manual of Mental Disorders (DSM-Ill). New York: American

Psychiatric Association, 1980

SOURCE: Price et al. 1988.

Methadone programs tended to offer a wider range of medical tests but

significantly fewer mental health assessments using DSM-III than drug-free

units. Predictably, mental health units were most likely to use DSM-III

diagnoses, whereas hospitals tended to be oriented toward the provision of

medical tests and physical examinations.

75
Outpatient substance abuse treatment units varied substantially in their

treatment goals (table 7). In particular, methadone units, much more than drugfree units, tended to foster responsible use of drugs, steady employment, and

positive health outcomes. Drug-free units were considerably more oriented to

the goal of abstinence, development of spiritual strength, and client participation

in establishing their own treatment goals.

To assess the range of services provided to outpatient clients, respondents

were asked about the proportion of clients receiving each of a range of possible

treatment services (table 8). Virtually every outpatient unit, regardless of

organizational context or treatment modality, offered individual therapy as the

major treatment modality. Group therapy was almost as universal, with the

TABLE 7. Agreement that various treatment goals are important in outpatient

substance abuse treatment units

Organizational Context Mental Health Hospital Other Total

Center Sample

Treatment Modality Metha DFb

 Meth DF Meth DF Mean N

C

Treatment Goals

Complete abstinence from

alcohol and drugs 4.6 4.8 4.9 4.9 4.7 4.8 4.8 549

Socially responsible use of

alcohol or drugs 1.7 1.9 2.2 1.4 2.2 1.9 1.9 547

Steady employment 4.6 4.5 4.9 4.4 4.7 4.6 4.6 550

Stable social relationships 4.8 4.7 4.9 4.7 4.8 4.8 4.8 549

Positive physical health 4.7 4.7 4.9 4.7 4.8 4.8 4.8 550

Positive emotional well-being 4.8 4.8 4.9 4.8 4.9 4.9 4.9 549

Improved spiritual strength 4.5 4.5 4.4 4.6 4.3 4.6 4.5 549

Meeting legally mandated

requirements for those

with legal problems 4.4 4.6 4.8 4.5 4.7 4.8 4.7 548

KEY: 1 = strongly disagree, 2 = somewhat disagree, 3 = neither agree nor disagree,

4 = somewhat agree, 5 = strongly agree

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

76
TABLE 8. Outpatient substance abuse treatment services provided

Organizational Context

Treatment Modality

Mental Health Hospital Other Total

Center Sample

Metha DFb Meth DF Meth DF Mean N

c

Percent of Units Providing

Individual therapy

Group therapy

Percent of Clients Receiving

Education regarding the

addiction process

Medical care

Mental health treatment

Treatment for use of

multiple drugs

Employment counseling

Financial counseling

Legal counseling

Driving-while-intoxicated

programs

Antabuse

Naltrexone

Other services

100.0 98.5 97.1 96.7 97.3 98.5 98.0

100.0 95.4 82.4 97.8 77.0 98.0 93.6

92.6 90.7 87.3 92.1 88.4 91.9 90.9

66.5 28.9 94.6 44.6 73.4 34.3 44.7

67.3 39.0 49.0 40.5 37.8 31.1 37.7

72.2 54.0 56.8 61.2 56.4 64.7 60.2

35.1 29.3 59.4 28.8 47.3 35.4 35.9

36.0 23.4 48.1 17.7 42.6 30.8 29.7

19.9 15.1 25.1 15.6 23.4 23.4 20.1

11.9 32.2 10.6 23.0 11.9 31.1 25.6

9.7 9.6 3.5 8.3 2.6 7.3 7.2

0.9 0.6 0.4 1.4 2.1 1.4 1.2

22.4 16.2 19.3 20.5 34.9 23.4 22.5

550

550

549

549

548

537

548

546

546

543

549

544

544

a

 Methadone treatment unit with 50 percent or more methadone dients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

exception of methadone programs in which approximately 80 percent of

programs offered group therapy in nonmental health settings and hospitals.

In addition, a range of other services tended to be offered. Ninety-one percent

of treatment units reported providing education regarding the addiction process.

About 60 percent of outpatient clients received a special treatment for multiple

drug problems, and about 40 percent received medical care. Furthermore,

about a third of outpatient clients were reported to receive mental health

services, employment counseling, and financial counseling services.

Methadone units provided financial and employment counseling to a

significantly greater number of clients than did drug-free units. Finally,

77
approximately one-quarter of all outpatient clients received special treatment in

a program for those arrested for driving while intoxicated.

For all units, clients were expected to wait an average of 10 days, but the

waiting period for methadone treatment was approximately 14 days and

approximately 9 days for drug-free treatment. It also should be noted that

respondents for methadone programs were significantly more likely to report

client loads that were too high for available treatment capacity.

Staff activities and knowledge regarding the treatment of AIDS clients and

practices aimed at the prevention of further HIV infection is a critical issue.

Questions were asked about treatment and prevention practices concerning

AIDS (table 9). In general, considerably more was reported being done in

methadone programs by teaching staff how to work with AIDS clients. A higher

level of staff readiness to work with AIDS clients existed, and a wider range of

community-oriented AIDS informational activities was available in methadone

programs than in drug-free programs.

As part of the treatment process, outpatient units may make referrals to other

agencies for other services or treatment (table 10). Methadone programs

reported significantly more referrals to hospitals, departments of social services,

and other outpatient substance abuse treatment units but significantly fewer

referrals to Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) groups.

Reported Outcomes of Treatment

Although the survey cannot provide the kind of information on treatment

outcomes that would be available from controlled clinical trials, respondents

were asked to estimate various outcomes for clients who had ended treatment

in the past complete fiscal year (table 11). These estimates provided some

sense of the functioning of the treatment system and comparative information

among different modalities and/or organizational contexts of treatment. It

should be noted, however, that these outcomes may be interrelated in complex

ways and require different interpretations for different modalities and for clients

with different characteristics.

Overall, respondents reported that 32 percent of clients who ceased treatment

over the past year continued to have substance abuse problems, whereas

approximately 45 percent met their treatment goals. Major reasons for

discontinued treatment were that 24 percent of clients did not comply with the

treatment plan and 19 percent voluntarily left treatment. Interestingly,

approximately 70 percent of all clients had some sort of posttreatment plan

established for them. Why aftercare plans are not a universal feature of

treatment requires further investigation.

78
TABLE 9. Extent to which outpatient substance abuse treatment units

engage in various treatment and prevention practices for AIDS

Organizational Context

Treatment Modality

Mental Health Hospital Other Total

Center Sample

Metha DFb

 Meth DF Meth DF Mean N

C

Staff Activities and Knowledge

Knowledge to inform clients

about prevention 4.5

Special training for teaching

clients about prevention 4.5

Special training about how

to work with AIDS clients 4.1

Special training about risks

of staff acquiring AIDS

from clients 4.4

Staff fear of acquiring AIDS

from clients 2.1

Prevention Resources and Activities

Adequate unit funds for

AIDS prevention 2.8

Enough staff members or

hours to devote to

prevention 2.8

Counseling of clients about

risks of transmitting AIDS

through sexual contact 3.9

Counseling of dients about

preventing AIDS transmission

through IV needle use 4.2

Counseling of dients about

risks of transmitting AIDS

to unborn children 3.8

Distribution to dients of

written materials about

AIDS prevention 4.2

Use of mass media for AIDS

prevention 2.1

Staff members who work

specifically on AIDS

prevention 3.1

4.0 4.6 4.1 4.4 4.0 4.1 548

3.8 4.3 3.6 4.3 3.7 3.8 549

3.3 4.2 3.4 4.0 3.2 3.5 548

3.7 4.4 3.8 4.2 3.7 3.8 549

1.9 2.0 1.8 2.1 1.9 1.9 549

2.1 2.7 2.0 2.6 2.0 2.2 544

2.2 2.7 2.4 3.0 2.3 2.4 547

3.5 3.9 3.5 4.0 3.5 3.6 547

3.8 4.0 3.3 4.1 3.5

3.3 4.0 3.2 3.8 3.3

3.6 547

3.4 546

3.4 4.1

1.5 1.8

1.9 3.1

3.0

1.2

1.7

4.0 3.4 3.5 547

2.0 1.6 1.6 545

2.9 1.8 2.1 545

KEY: 1 = no extent, 2 = little extent, 3 = some extent, 4 = great extent, 5 = very great extent

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

79
TABLE 10. Extent to which outpatient substance abuse treatment units

refer clients to other agencies for treatment or other services

Organizational Context

Treatment Modality

Mental Health

Center

Metha DFb

Referral Destination

Hospitals 2.9 2.8

Private clinics 2.2 2.1

Physicians 2.7 2.4

Vocational rehabilitation

centers 2.8 2.8

Departments of social services 2.9 2.8

Mental health agencies 2.9 2.8

Other outpatient substance

abuse treatment units 3.1 2.4

Schools 1.9 1.9

Churches 1.9 1.7

Self-help groups such as

AA or NA 3.8 4.4

Other groups or organizations 1.9 2.3

Hospital

Meth DF

Other Total

Sample

Meth DF Mean N

C

3.3 2.6 3.0 2.7 2.8 553

2.1 2.2 2.3 2.3 2.2 553

2.3 2.5 2.5 2.5 2.5 553

3.1 2.5 2.9 2.8 2.8 552

3.3 2.4 3.0 2.8 2.8 548

2.6 2.6 2.9 2.8 2.8 550

2.8 2.3 2.8 2.3 2.4 553

2.1 1.8 2.1 2.1 2.0 550

1.7 1.7 1.7 1.9 1.8 552

3.5 4.7 3.9 4.4 4.3 553

1.9 2.2 1.8 2.3 2.2 533

KEY: 1 = no extent, 2 = little extent, 3 = some extent, 4 = great extent, 5 = very great extent

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

Outcomes were strikingly different for methadone and drug-free programs,

presumably in part because of the different types of client population served by

each type of program. Methadone programs had significantly more clients who

ended treatment with continued use or because they failed to pay or died. Two

reported important outcomes are as follows: (1) Only 26 percent of methadone

clients were reported to have ended treatment because they met their treatment

goals as opposed to 51 percent for drug-free programs; and (2) approximately

50 percent of methadone clients had a posttreatment plan established for them

compared with 75 percent of clients in drug-free programs.

80
TABLE 11. Percent of outpatient substance abuse clients who ended

treatment with various outcomes in the past fiscal year*

Organizational Context Mental Health Hospital Other

Center

Treatment Modality Metha

 DFb Meth DF Meth DF

Outcomes

Continued to use drugs or

alcohol 56.3 32.4 25.2 24.8 36.6 32.4

Were incarcerated 9.8 8.3 7.7 4.9 9.5 8.1

Died 2.4 1.4 2.4 0.9 2.7 1.3

Failed to comply with

treatment plan 35.2 25.6 17.0 24.6 20.2 25.3

Failed to for treatment 7.9 4.0 3.7 6.0 16.6 4.4

Exhausted insurance coverage 4.7 1.0 1.0 6.5 0.7 1.4

Were free from drug or

alcohol use 15.1 42.1 22.1 45.0 14.8 43.3

Other reasons 10.4 7.1 8.9 8.3 8.6 7.3

Ended treatment involuntarily 30.3 15.0 20.3 15.8 26.2 19.6

Met treatment goals 34.8 46.0 31.1 58.1 20.9 51.3

Ended treatment with

individual written plans

for continued care 48.9 69.0 54.4 82.4 48.2 74.8

Total

Sample

Mean N

C

32.1 520

7.9 530

1.5 536

24.4 535

6.2 536

2.2 523

37.3 535

7.8 531

19.2 535

45.4 535

69.1 540

* For each unit, the timeframe for the question was that unit’s most recent complete fiscal year.

For 71 percent of the units, the most recent complete fiscal year ended in 1988; for 29

percent of the units, it ended in 1987.

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

Efforts Being Made To Increase the Effectiveness and Quality of

Treatment

Respondents were asked to describe a variety of efforts aimed at increasing

treatment quality or effectiveness. They also were asked about methods for

monitoring client progress (table 12), licensing arrangements (table 13), types of

followup information collected on clients (table 14), and methods to ensure

quality of the referral process (table 15).

81
TABLE 12. Extent to which outpatient substance abuse client progress is

monitored by various sources of information

Organizational Context

Treatment Modality

Mental Health Hospital Other Total

Center Sample

Metha DFb

 Meth DF Meth DF Mean

Source of Information

Client case record or chart

Client self-report

Urinalysis

Report of significant others

Therapists evaluation

Report from employer

Probation officer or legal

records

Record of appointments

broken by the client

Record of appointments

broken by unit staff

Other sources

4.3 4.6 4.4 4.6

3.4 3.9 3.5 4.0

3.8 2.8 4.1 2.9

2.8 3.3 2.6 3.7

3.9 4.1 3.9 4.1

2.4 2.6 1.9 2.9

3.3 3.2 2.5 3.0

3.4 3.6 3.3 3.6

2.5 2.8 2.6 2.6

2.1 2.0 1.5 1.9

4.5 4.5 4.5 550

3.6 3.7 3.8 549

4.1 3.0 3.2 549

2.9 3.2 3.2 548

3.7 4.0 4.0 548

2.1 2.6 2.5 550

2.7 3.2 3.1 549

3.3 3.6 3.5 548

2.7 2.7 2.7 540

1.7 1.8 1.8 527

N

c

KEY: 1 = no extent, 2 = little extent, 3 = some extent, 4 = great extent, 5 = very great extent

a

 Methadone treatment unit with 50 percent or more methadone dients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

As expected, urinalysis was a major method of monitoring treatment in

methadone programs. Methadone programs also reported significantly less

monitoring by means other than urinalysis, including reports by significant

others, therapist evaluations, reports from employers, and other informants. All

of these forms of monitoring treatment were more prevalent in drug-free

programs, and both hospitals and methadone programs tended to obtain

physical health information on followup (table 12). Of course, licensing drug

abuse treatment units is a major strategy to ensure the quality of treatment and,

not surprisingly, methadone programs tended to be more heavily licensed,

particularly a Food and Drug Administration license. They also had a

significantly higher total number of licenses than drug-free programs (table 13).

82
TABLE 13. Percent of outpatient substance abuse treatment units licensed or

accredited by various organizations

Organizational Context

Treatment Modality

Mental Health Hospital Other Total

Center Sample

Metha DFb Meth DF Meth DF Mean N

C

Licensing or Accrediting

Organization

Joint Commission on the

Accreditation of Health care

Organizations 12.5 17.2 69.0 82.2 6.0 12.4 27.8 525

Food and Drug Administration 87.5 15.7 93.1 11.2 97.0 9.0 29.3 522

Drug Enforcement

Administration 75.0 17.4 93.1 12.4 98.5 10.5 30.3 522

State agency or office 100.0 97.6 96.6 81.1 97.0 94.0 93.3 526

City or county agency or

Office 37.5 14.8 17.2 16.9 29.9 12.0 16.8 523

Other organizations 6.3 8.1 17.2 11.2 3.0 8.5 8.6 525

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

What Outpatient Drug Abuse Treatment Personnel Believe About the

Ingredients of Effective Treatment

Whether beliefs about the ingredients of effective treatment are supported by

research findings, they are frequently strongly held. Such beliefs also almost

surely influence major decisions about client treatment, assessment of client

motivation, and hiring decisions for treatment staff. Respondents were asked to

describe the degree to which they endorsed beliefs about the characteristics of

clients and treatment that are associated with more or less effective treatment

(table 16). In general, respondents were much more likely to believe that client

sobriety is essential for effective treatment and that court- or employer-ordered

treatment is less effective. They also were more likely to endorse the belief that

a client’s insight into his or her own condition is important in providing effective

treatment. Furthermore, drug-free treatment program personnel were much

more likely to endorse the AA/NA model as effective than were methadone

program staff.

83
TABLE 14. Percent of outpatient substance abuse treatment units that collect

various types of client followup information*

Organizational Context

Treatment Modality

Mental Health Hospital Other Total

Center Sample

Metha DFb Meth DF Meth DF Mean N

C

Type of Information

Living arrangement 75.0 76.0 78.9 70.6 70.8 68.9 71.6

Employment or student status 83.3 81.3 84.2 89.7 87.5 84.5 85.1

Health status 83.3 70.7 100.0 85.3 89.6 79.1 81.1

Legal probation status 91.7 81.3 73.7 70.6 79.2 75.0 76.5

Financial status 58.3 49.3 57.9 55.9 50.0 49.3 51.4

Whether client is in

recommended treatment 100.0 82.7 89.5 89.7 95.8 90.5 89.7

Drug or alcohol use 91.7 97.3 94.7 94.1 97.9 97.3 96.5

Clients evaluation of the

treatment experience 50.0 86.7 78.9 79.4 83.3 81.8 81.4

Clients evaluation of the

agency 41.7 72.0 63.2 66.2 66.7 74.3 69.7

Information to get dropouts

to return to treatment 50.0 68.0 73.7 58.8 70.8 69.6 67.0

Other information 16.7 18.1 5.3 23.5 6.3 12.2 14.4

370

370

370

370

370

370

370

370

370

370

367

* Among those units (N = 370) that reported collecting any followup information

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

Questions about hiring policies and staff characteristics associated with

effective treatment produced striking findings for the drug-free versus

methadone comparison (table 17). Methadone programs were less likely to

search for staff with previous substance abuse work experience, special training

in substance abuse treatment, or a history of substance abuse and more likely

to hire staff who were not certified or had less clinical experience than drug-free

programs. interestingly, methadone programs were also much less likely than

drug-free programs to endorse the idea that ex-addicts can be effective

treatment staff.

84
TABLE 15. Frequency of use by oupatient substance abuse treatment units

of various procedures to ensure quality of the referral process

Organizational Context Mental Health Hospital Other Total

Center Sample

Treatment Modality Metha DFb

 Meth DF Meth DF Mean N

C

Procedure

Send a written summary 3.5 3.9 3.8 3.9 3.7 3.7 3.8 550

Send a complete chart 1.4 1.6 1.6 1.8 1.9 1.7 1.7 550

Case summary by telephone 3.3 3.3 2.8 3.4 2.9 3.2 3.2 552

Make appointment for client 3.2 3.2 3.4 3.2 3.2 3.1 3.2 548

Make followup call to

receiving agency 3.6 3.7 3.9 3.7 3.8 3.9 3.8 551

Receive written report from

receiving agency 2.5 3.2 2.8 3.0 2.9 3.3 3.1 552

Other procedures 1.6 1.7 1.2 1.7 1.6 1.6 1.6 526

KEY: 1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always

a

 Methadone treatment unit with 50 percent or more methadone dients

b

 Drug-free treatment unit with fess than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

DISCUSSION

The results reported here should be regarded as preliminary, descriptive, and

partial because additional analyses will be needed to clarify their meaning and

estimate their representativeness more precisely. Nevertheless, some answers

to the initially posed questions are emerging.

Who is receiving outpatient drug abuse treatment services, and where are

clients coming from? Overall, treatment units report drug abuse as the primary

problem; however, there are some notable exceptions. Drug-free treatment

programs have at least as many clients whom they describe as having alcohol

abuse as their primary problem. Furthermore, the largest category of drug

abuse problems reported involves multiple drug abuse followed by marijuana,

cocaine, and heroin abuse. it would be useful to compare the prevalence of

various drug problems reported by treatment units with existing epidemiological

data on the prevalence of various drug abuse problems in the general

population. Such comparisons could provide information about which types of

85
TABLE 16. Perceived client and treatment characteristics needed for effective

outpatient substance abuse treatment

Organizational Context

Treatment Modality

Mental Health Hospital Other Total

Center Sample

Metha DFb

 Meth DF Meth DF Mean N

C

Importance of Client

Characteristics*

Maintain sobriety 4.3

Acknowledge self as substance

abuser 4.5

Accept personal responsibility

for recovery 4.6

Learn new skills for dealing

with problems and stress 4.4

Gain insight into the role of

substance abuse in their life 4.1

Recognize they will never be

able to use particular

substances again 4.4

“Hit bottom” or experience a

crisis related to their substance

abuse problem 2.9

Effectiveness of Treatment

Characteristics”

Mandated

by employer or

legal system 2.7

The AA or NA 12-step model 3.8

4.6 4.5 4.8

4.5 4.6 4.5

4.7 4.6 4.7

4.6 4.5 4.7

4.5 4.2 4.6

4.4 4.4

3.1 3.4

3.2 2.8

4.1 3.4

4.5

3.3

3.4

4.3

4.4 4.6 4.6 546

4.4 4.5 4.5 546

4.5 4.6 4.7 546

4.6 4.6 4.6 547

4.3 4.5 4.5 547

4.4 4.4 4.4 545

3.1 3.3 3.2 547

2.7 3.2 3.1 539

3.4 4.1 4.0 547

KEY: *1 = not at all important, 2 = little important, 3 = somewhat important, 4 = very important,

5 = extremely important

 **1 = no extent, 2 = little extent, 3 = some extent, 4 = great extent, 5 = very great extent

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

drug abuse problems are less likely to receive the attention of the outpatient

treatment sector and, therefore, may be deserving of additional efforts to

increase client access. The population in outpatient drug treatment is reported

to be predominantly male and young. Black clients and older clients are

86
TABLE 17. Agreement with statements about hiring policies and staff

characteristics pertaining to effective substance abuse treatment

Organizational Context

Treatment Modality

Mental Health Hospital Other Total

Center Sample

Metha

 DFb Meth DF Meth DF Mean N

C

Hiring Requirements

Professional degree

Work experience in a

substance abuse agency

Specialized training in

substance abuse field

Personal history of substance

abuse problems

Certification as a substance

abuse counselor

Clinical supervision

experience during training

Staff Characteristics

Ex-addicts or recovering staff

are more effective with

clients

Staff with professional degrees

are more effective

Recovering staff deal better

with client denial and

resistance

Staff with professional degrees

can be more objective

3.9 4.3 4.2 4.1 3.9 4.1 4.1 548

4.0 4.4 4.0 4.6 4.1 4.2 4.3 549

4.3 4.6 3.9 4.7 3.9 4.4 4.4 548

2.1 2.5 2.0 2.8 2.0 2.7 2.5 549

3.4 3.5 3.0 3.9 3.3 3.8 3.6 548

4.5 4.6 4.5 4.8 4.3 4.6 4.6 549

2.6

3.4

2.7

3.3

3.1

3.4

3.0

3.4

2.6 3.3 2.6 3.2

3.5 3.3 3.5 3.2

2.6 2.9 2.6

3.6 3.2 3.3

2.9

3.1

3.1 549

3.3 547

2.9 548

3.3 549

KEY: 1 = strongly disagree, 2 = somewhat disagree, 3 = neither agree nor disagree,

4 = somewhat agree, 5 = strongly agree

a

 Methadone treatment unit with 50 percent or more methadone clients

b

 Drug-free treatment unit with less than 50 percent methadone clients

c

 Number of outpatient substance abuse treatment units responding to the item

SOURCE: Price et al. 1988.

overrepresented in methadone programs. Again, comparison of these data with

epidemiological data could provide useful information about population groups

with lower access or opportunity for treatment.

87
Clearly, self-referral and the courts are major avenues to treatment in the

outpatient sector, but they play very different roles for methadone and drug-free

programs. Our data suggest that courts are the dominant referral source in the

drug-free treatment sector, whereas self-referral remains the dominant source

for methadone programs. The predominance of court referrals invites questions

about the comparative effectiveness of mandated versus voluntary treatment. It

is interesting to note that respondents did not believe that mandated court

referral was associated with more effective treatment. Similarly, the high rate of

self-referrals in the methadone sector raises questions about the role of other

human service agencies in referring clients for methadone treatment. Are

methadone clients less well connected to the human service system? If so,

then more rigorous outreach efforts by methadone programs may be indicated.

What do outpatient treatment services look like? Clearly, masters- and

bachelor’s-level educational backgrounds dominate in the outpatient treatment

sector, particularly in drug-free programs. Although methadone programs have

relatively more medical staff, drug-free programs show a very high proportion of

treatment staff who are recovering persons. Because recovering addicts

represent such a large proportion of outpatient treatment staff, it would be of

interest to discover the degree to which these treatment staff have special

training or certification for outpatient treatment and/or other special

qualifications that make them especially well suited for the treatment role.

Methadone programs also have substantially lower proportions of staff with

special training or certification for substance abuse treatment. It is possible that

methadone programs view the higher proportion of medical staff as appropriate

for the type of treatment delivered in these settings and, therefore, see less

need for staff with special training or certification.

How are clients assessed in outpatient drug treatment programs? Diagnostic

and assessment services differ by modality, with physical exams more common

in the methadone programs and mental health assessments more common in

drug-free programs; the question remains whether physical needs are being

adequately assessed in drug-free programs. Mental health needs may be

adequately assessed in methadone programs but much less frequently result in

a DSM-III diagnosis unless the program is in a mental health setting.

What form do treatment goals and services take in outpatient treatment?

Although treatment goals in the outpatient drug treatment sector take a variety

of different forms, clearly responsible use is not a widely embraced treatment

goal in the outpatient treatment system. The two treatment services that are

almost universally available are individual and group therapy. However, the

relatively low incidence of reported availability of such special services as

employment training, financial counseling, legal services, and other

88
“habilitation”-oriented services may be cause for concern. New needs such as

services concerned with AIDS are more likely to appear in methadone treatment

than in drug-free programs, but special staff and additional funds for AIDSrelated services are reported to be a need in all outpatient programs.

What are the reported outcomes of treatment? It seems clear that drug-free

programs report more favorable outcomes, but it is not clear whether these

more favorable outcomes are due to important differences in the populations

under treatment or to other factors. For example, because remaining in

treatment in methadone maintenance programs is a key indicator of treatment

success, those who left methadone maintenance programs and whose

outcomes are estimated in the survey may be expected to have less favorable

reported outcomes, In addition, it would be interesting to compare these

reported outcomes with the types of outcomes reported in actual controlled

treatment trials. Further analyses will be conducted to identify program

characteristics associated with more favorable treatment outcomes.

What efforts are being made to increase the effectiveness or quality of

treatment? The enhancement of treatment quality is an emerging concern in

the outpatient treatment sector, and efforts to influence quality through

licensing, for example, are widespread. Methadone programs are much more

heavily involved with licensing and certification arrangements. Other efforts

associated with treatment quality enhancement such as client followup are less

widespread; indeed, only about two-thirds of all treatment units report any

followup efforts at all. In light of the renewed emphasis on improving treatment

quality and effectiveness, these findings may raise concerns about the degree

to which requirements for quality assurance or client followup exist or are

enforced.

What do outpatient drug abuse treatment personnel believe about the

ingredients of effective treatment? Outpatient programs have their own views of

which aspects of treatment are important for effectiveness. Client sobriety tops

the list as a major criterion for effective treatment. Interestingly, there is

considerably more skepticism about the idea that clients must “hit bottom” or

must engage in mandated treatment for treatment to be effective. Beliefs about

the qualifications for staff effectiveness also are fairly well defined in the

outpatient treatment system, with a strong endorsement of work experience and

specialized training as preferred criteria for selecting treatment staff. There is

considerably more skepticism about the value of personal experience with

substance abuse as a qualification for treatment staff effectiveness,

These data provide an initial and preliminary portrait of the clients, treatment

practices, outcomes, and ideas about what is needed for treatment

89
effectiveness in the outpatient drug abuse treatment system. They raise

several policy questions concerning access to the outpatient treatment system,

qualifications for treatment staff effectiveness, the adequacy of client

assessment and diagnosis, the availability of needed treatment services, and

what might be viewed as an adequate outcome of outpatient treatment. As part

of a longitudinal research effort, combined with epidemiological and treatment

outcome data, these findings may help to point to new initiatives to enhance

treatment effectiveness and access to treatment in the outpatient drug abuse

treatment system.

REFERENCES

Burke, C.; D’Aunno, T.; and Price, R.H. “Outpatient Drug Abuse Treatment:

Organizational Environment and Patterns of Care.” Unpublished manuscript,

Survey Research Center, Institute for Social Research, University of

Michigan, 1983. 42 pp.

D’Aunno, T., and Price, R.H. Organizational adaptation to changing

environments: Community mental health and drug abuse services. Am

Behav Scientist 28(5):669-693, 1985.

Drug Abuse Policy Office, Office of Policy Development, The White House.

1984 National Strategy for Prevention of Drug Abuse and Drug Trafficking.

Washington, DC: U.S. Govt. Print. Off., 1984.

Frances, R.J. Update on alcohol and drug disorder treatment. J Clin Psychiatry

49(9)[Suppl]:13-17, 1988.

Friedman, A.S., and Glickman, N.W. Residential program characteristics for

completion of treatment by adolescent drug abusers. J Nerv Ment Dis

175(7):419-424, 1987.

Friedman, T.C., and Fulop, G. Disulfiram use at hospital-based and freestanding alcoholism treatment centers. J Subst Abuse Treat 5:139-143,

1988.

Hubbard, R.L.; Allison, M.; Bray, R.M.; Craddock, S.G.; Rachal, J.V.; and

Ginzburg, H.M. An overview of client characteristics, treatment services, and

during-treatment outcomes for outpatient methadone clinics in the Treatment

Outcome Prospective Study (TOPS). In: 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 Series. DHHS Pub. No. (ADM)83-1281. Washington,

DC: Supt. of Docs., U.S. Govt. Print. Off., 1983. pp. 714-751.

Hubbard, R.L.; Rachal, J.V.; Craddock, S.G.; and Cavanaugh, E.R. Treatment

Outcome Prospective Study (TOPS): Client characteristics and behaviors

before, during, and after treatment. In: Tims, F.M., and Ludford, J.P., eds.

Drug Abuse Treatment Evaluation: Strategies, Progress, and Prospects.

National Institute on Drug Abuse Research Monograph 51. DHHS Pub. No.

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(ADM)86-1329. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1984. pp. 42-68.

Jaffe, J.H. Evaluating drug abuse treatment: A comment on the state of the

art. In: Tims, F.M., and Ludford, J.P., eds. Drug Abuse Treatment

Evaluation: Strategies, Progress, and Prospects. National Institute on Drug

Abuse Research Monograph 51. DHHS Pub. No. (ADM)86-1329.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 13-28.

Price, R.H.; Burke, C.; D’Aunno, T.; Hooijberg, R.; and Shore, K. Critical Issues

in National Drug Abuse Treatment Policy and Organization: Results of a

Consensus Development Conference. Ann Arbor, Ml: Survey Research

Center, Institute for Social Research, University of Michigan, 1987, 15 pp.

Price, R.H.; Burke, A.C.; D’Aunno, T.A.; Klingel, D.M.; McCaughrin, W.C.;

Rafferty, J.A.; and Vaughn, T.E. National Drug Abuse Treatment System

Survey. Ann Arbor, Ml: Survey Research Center, Institute for Social

Research, University of Michigan, 1988.

Price, R.H., and D’Aunno, T. “Organizational Adaptation to Changing

Environments: Community Mental Health and Drug Abuse Services.” Paper

presented at the National Institute of Mental Health conference, The

Organization of Mental Health Agencies and Systems. Rockville, MD,

September 17-18, 1964.

Senay, E. Critique of treatment characteristics associated with outcome, by

G.E. Woody. In: 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 Series.

DHHS Pub. No. (ADM)63-1281. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1963. pp. 565-572.

Senay, E.C. Clinical implications of drug abuse treatment outcome research.

In: Tims, F.M., and Ludford, J.P., eds. Drug Abuse Treatment Evaluation:

Strategies, Progress, and Prospects. National Institute on Drug Abuse

Research Monograph 51. DHHS Pub. No. (ADM)86-1329. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 139-150.

Tims, F.M. Introduction. In: Tims, F.M., and Ludford, J.P., eds. Drug Abuse

Treatment Evaluation: Strategies, Progress, and Prospects. National

Institute on Drug Abuse Research Monograph 51. DHHS Pub. No. (ADM)86-

1329. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984.

pp. 9-12.

ACKNOWLEDGMENT

This chapter was prepared with support from the National Institute on Drug

Abuse grant DA-03272.

9 1
AUTHORS

Richard H. Price, Ph.D.

Research Scientist

A. Celeste Burke, M.S.W.

Research Assistant

Thomas A. D’Aunno, Ph.D.

Assistant Professor

David M. Klingel, B.A.

Research Associate

William C. McCaughrin, M.P.H.

Research Assistant

Jane A. Rafferty, M.A.

Research Assistant

Thomas E. Vaughn, M.H.S.A.

Research Associate

University of Michigan

Institute for Social Research

Room 2267

P.O. Box 1248

Ann Arbor, Ml 48106-1248

92
Treatment Outcomes for Drug Abuse

Clients

Frank M. Tims, Bennett W. Fletcher, and Robert L. Hubbard

INTRODUCTION

The available evidence from treatment outcome studies shows that drug abuse

treatment works for significant numbers of clients who enter treatment.

Whether treatment for drug abuse is effective is a separate question or rather a

sequence of questions. It does not “work” as well as we would like; for a

significant number of clients it does not work at all, and there is little information

to explain why. Moreover, drug abusers currently entering treatment appear to

be more problematic, especially in terms of client psychopathology (De Leon

1989). Because many addicts return to drug use after treatment, some would

argue that treatment is not effective. Data published by Simpson and

colleagues (1982) indicate that 21 percent of Drug Abuse Reporting Program

(DARP) clients continued daily use of illicit opioids over the long term. A

smaller percentage (18 percent) ceased daily opioid use but manifested other

problems (e.g., chipping, heavy nonopioid use, heavy alcohol use, long-term

incarceration). That such a large percentage had poor outcomes or that relapse

rates are high should not be construed as an indictment of treatment but rather

a reflection of the chronicity of drug dependence in conjunction with imperfect

treatments. This chapter briefly but systematically explores the evolution and

role of treatment outcome research in evaluating treatment.

Evaluation of treatment for biobehavioral disorders involves multiple criteria,

some of which are paramount. Cessation or reduction of illicit drug use is a

central criterion, and there are many studies that are encouraging in this regard.

It is also important to assess the clients social functioning. The early studies of

methadone maintenance by Dole and Nyswander (1976) and Gearing and

associates (1975) reflected the awareness that the client had to learn to live

and function in a complex world and that such variables as cessation of

criminality and involvement in a socially productive lifestyle were important.

Depending on the type of treatment and its implicit or explicit model of the

disease or disorder, a variety of outcome measures may be of particular

interest. In addition to drug use, such “core measures” of outcome as

93
employment and criminality frequently have been used. Also of interest are

other social adjustment measures, comorbidity, and use of alcohol and

marijuana (Anglin et al. 1989; Rounsaville et al. 1982; Simpson et al. 1979).

EARLY STUDIES

Studies of outcomes for opioid addicts treated in the Federal facility at

Lexington, Kentucky, proved disappointing because almost all usually returned

to opioid use and were classified as readdicted. O’Donnell (1969) realized that

such an approach did not properly take into account the episodic nature of drug

abuse, in which periods of abstinence are interspersed with periods of drug use.

Thus, he developed the approach of measuring outcomes in terms of “average

number of days using narcotics” rather than an all-or-nothing approach in which

addicts were defined as either abstinent or readdicted. O’Donnell’s invaluable

approach contributed greatly to the evolution of treatment outcome research

methodology. It is especially evident in the work of McGlothlin and colleagues

(1977) and Ball and coworkers (1983) and is reflected in the prevailing

approaches to current studies.

The opioid epidemic of the 1960s occasioned the development of a national

system of community-based facilities. Under the Narcotic Addict Rehabilitation

Act (NARA) of 1966 (Public Law 89-793) Federal financial support was made

available for treatment of drug abusers in institutional settings and in the

community. During this same period, State programs such as the New York

State civil commitment program (under the Narcotic Addict Control

Commission) and the California Civil Addict Program were providing treatment

in special institutional facilities set aside for that purpose. The Federal effort

grew rapidly and, with it, the need to develop systematic information on the

effectiveness of treatment. At the time this system was being established,

evidence for the general effectiveness of treatment for alcohol and drug abuse

and mental health disorders was lacking. Claims were made for the success of

many programs, particularly therapeutic communities (TCs), but no systematic

body of evaluative data on entire treatment populations existed.

During the establishment of the system of community-based facilities under

Federal sponsorship, the DARP national data system was established under

contract between the National Institute of Mental Health and Texas Christian

University. During the years 1969-74, information was collected on 44,000

clients across 52 treatment programs at admission, during treatment, and at

discharge. The DARP treatment population was sampled for the first national

followup study that assessed treatment effectiveness on the basis of first-year

posttreatment outcomes and provided the earliest evidence of the general

effectiveness of community-based treatment (Sells et al. 1978). Additional

94
studies based on the DARP population were conducted over succeeding

periods, up to 12 years after admission.

NATURALISTIC VS. CONTROLLED STUDIES

A major methodological dilemma grows out of the inherent limitations on

inference in studies in which experimental controls are impractical,

inappropriate, or impossible. The evaluative study of treatment process and

outcome in diverse sets of programs must necessarily make inferences

regarding treatment effects and make these inferences based on the behavior

of samples that normally self-select in some way. Such studies often have had

to rely on comparisons with other “untreated” or “minimally treated” groups or on

statistical controls to assess “treatment effects” in evaluations of existing

treatment programs. The normative pressures on evaluation researchers to use

approximations of true experimental designs are considerable. The well-known

effort of Bale and colleagues (1980) at the Palo Alto Veterans Administration

(VA) Hospital points up the basic problem of imposing a controlled trial design

on studies of existing treatment programs in which more than one modality is

concerned. Subjects were heroin addicts who entered a 5-day detoxification

program; agreed to be randomly assigned to methadone maintenance, a shortterm TC, or a long-term TC; and were barred from entering one of the other

programs for 30 days if they left the treatment to which they were assigned. A

large percentage of those assigned to TC treatment dropped out of those

programs and either enrolled in a non-VA methadone program or waited 30

days and enrolled in a VA methadone program. This is a clear example of the

difficulty of ignoring the voluntary element in treatment choice, which plays a

major role in the process of seeking and obtaining treatment. A treatment

assignment that frustrates the client’s treatment-seeking behavior conceivably

may introduce additional, unmeasured variance into the study.

Woody and colleagues’ (1983) psychotherapy study provides an example of

how a controlled study might work. In that study, randomization took place in a

single modality (methadone maintenance), and subjects were not denied their

treatment of choice. For most large evaluations of treatment, a more

naturalistic approach has been necessary. Researchers have had to rely on

comparative or quasi-experimental designs and accept the resulting inferential

limitations.

STUDIES REVIEWED

There are many interesting and potentially useful studies of treatment outcome

available; this chapter focuses only on selected works to sketch major themes

and highlight significant issues and findings. Of particular interest are selected

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studies that have made unique substantive or methodological contributions to

the development of knowledge regarding treatment effectiveness and a series

of large-scale, multiprogram studies of treatment outcome. In addition, the Drug

Abuse Treatment Outcome Study (DATOS), a major new research effort that

will constitute the National Institute on Drug Abuse’s (NIDA) next large-scale

evaluation of current drug abuse treatment, will be described. Without intending

to neglect other important studies, this chapter focuses primarily on six bodies

of research, which represent major investments by NIDA and provide findings of

special significance in understanding treatment effectiveness in and across

major modalities. Because of the large volume of data presented in each of the

completed studies, it is not possible to present all data of interest in this chapter.

Many readers will wish to consult the publications cited for more detailed

understanding of the research. These six studies are depicted in table 1.

The McGlothlin and De Leon studies and the DARP research by Sells and

Simpson make an impressive case for effectiveness, and each also illuminates

major research issues and makes important methodological contributions. The

Methadone Research Project conducted by Ball and associates has provided

valuable information on differential outcomes across programs and methadone

dose-related outcomes and will provide a wealth of new findings as it is

analyzed further. The DARP research, which has contributed major

improvements in methodology, was the first national study to systematically

investigate treatment effectiveness and to extend the followup period far

beyond the index treatment episode. The Treatment Outcome Prospective

Study (TOPS) research by Hubbard and associates (1989) built on the

foundation of the DARP research, provided valuable findings regarding

heterogeneous and complex drug abuse patterns and outcomes for a national

sample, and further developed the methodology. DATOS will be the next

national treatment outcome study, taking advantage of the sophistication in

knowledge that has evolved from research, including that shown in table 1. In

particular, the plans for DATOS include taking into account major currently

prevailing drug abuse patterns, psychopathology, the concept of client

impairment as it relates to treatment needs and potential for favorable

outcomes, and change measures as they relate to the treatment process.

California Civil Addict Program

One of NIDA’s early studies of treatment outcome was the evaluation of the

California Civil Addict Program (CAP). Under CAP, addicted felons had their

sentences set aside on condition that they be civilly committed to inpatient

treatment and supervised parole for a total of 7 years. This “parole with a long

tail” had consequences for drug use, namely, that those found to be using

narcotics faced a return to inpatient treatment in the Prison Hospital at Corona.

This study used an interesting design, comparing outcomes over time for a

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TABLE 1. Key evaluative studies of treatment outcome
group of addicts committed to the program in 1964 with a group of addicts

committed during 1962-63 who, due to procedural errors, were released on

writs of habeas corpus. The released addicts constituted an “untreated”

comparison group that did not participate in CAP. Those who went through the

program had substantially better outcomes on all criteria—narcotics use,

employment, and criminality—during the period of supervision than did the “writ”

or comparison group.

Figure 1 shows a comparison of these two groups over time on the criterion of

average percentage of nonincarcerated days using narcotics. Both groups had

immediate dedines in narcotic use upon entering the program. This

improvement persisted for the group staying in the program, whereas the writ

group returned to drug use at a significantly higher rate. Beginning in 1970,

when methadone maintenance became available in California, both groups

showed marked improvement on the narcotics use measure, but the committed

group continued to do better. The better performance of the treatment group is

attributed in large part to the continued supervision with sanctions as well as to

treatment.

CAP was especially important because it demonstrated the potential value of

treatment with parole supervision in reducing overall narcotics use and provided

an example of how historical events can be used imaginatively to develop valid

comparison groups for assessing treatment. McGlothlin and Anglin were able

to capitalize on events in other investigations as well, including their studies of

the impact of local decisions to discontinue public methadone programs in

Bakersfield and San Diego (McGlothlin and Anglin 1981; Anglin and McGlothlin

1984).

Phoenix House Study

The De Leon (1984) study of admissions to Phoenix House, a TC in New York

City, was important for several reasons. Research shows that most persons

entering a TC do not stay to complete treatment, but it is also known from other

research and anecdotal reports that many of those not staying the full course of

treatment improved (Collier and Hijazi 1974). De Leon’s approach was to follow

up and interview a sample of 400 dropouts and 125 graduates from Phoenix

House. The followup was at 2 years postadmission for a cohort entering

treatment in 1974 and 5 years for those entering in 1970-71. For the 1974

cohort, De Leon extensively tested new admissions and retested them 4

months later using a battery of personality tests and depression and anxiety

scales. He noted marked improvement at retest. He also retested them at

followup and found the improvement to be stable. Among De Leon’s findings

were:

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In terms of a composite score based on drug use, employment, and

criminality, the graduates tended to have highly favorable outcomes. The

dropouts showed improvement, too, but to a lesser degree overall.

FIGURE 1. Percent of nonincarcerated time using narcotics daily; CAP

treatment and comparison samples

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A time-in-treatment effect was observed, with better outcomes for those in

longer tenure groups.

Although outcomes on multiple criteria were found to be good, the

reduction in drug use was striking. In the 1970-71 admissions cohort, any

opioid use at followup had declined to 3.6 percent of the graduates and

24.8 percent of the dropouts. For the 1974 cohort, the comparable figures

were 0 percent for graduates and 23 percent for dropouts.

Among the 1974 cohort, outcomes for primary nonopioid abusers reflected

improvement but were not as encouraging as those for opioid abusers.

Primary alcohol abusers did worse, with 50 percent of the graduates in this

group returning to daily alcohol use.

Drug Abuse Reporting Program

The DARP research, which became available in the mid- to late-1970s

established treatment effectiveness on the basis of followup research. The

DARP research was based on a population of 44,000 clients admitted to drug

abuse treatment among 52 programs during 1969-74. The clients were

classified into three admission cohorts. Five DARP index treatment

classifications were developed: outpatient detoxification, methadone

maintenance, therapeutic community, and drug-free outpatient; a fifth group

labeled “Intake Only,” persons who were interviewed and scheduled for

treatment but who did not subsequently show up at the program, was used as a

comparison group.

The DARP samples, consisting largely of opioid addicts, were interviewed at

admission and during treatment and followed up subsequently in the community

to assess outcome (Simpson and Sells 1982). The DARP research, which is

widely published, made an enormous contribution to knowledge about

treatment outcome. Due to space limitations, it is possible to highlight only a

few of them here.

The effectiveness of treatment was established empirically. Drug use for

the followup sample declined dramatically pretreatment to posttreatment

and continued to diminish over years 2 and 3 posttreatment.

Comparative effectiveness was assessed. Three major modalities—

methadone maintenance, TC, and drug-free outpatient—each were found

to be effective, whereas detoxification alone was considerably less

effective. As figure 2 shows, using very strict criteria or more lenient

criteria, the pattern holds for opioid addicts, with dramatic improvement

during the first year after treatment.

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The time-in-treatment effect is another well-known finding from the DARP

research. Clients who stayed in treatment less than 90 days did no better

FIGURE 2. Drug use and crime in year 1 post-DARP

101
than detoxification clients, but for those who stayed more than 90 days,

improvement was directly related to length of stay (figure 3).

FIGURE 3. Outcomes by time in treatment—no drug use and no crime in

year 1 post-DARP

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The DARP contribution was both substantive and methodological. As outcome

was considered in the context of many outcome patterns, it became evident that

first-year outcomes, although important, did not tell the full story. Several

approaches were tried in classifying outcomes, and the most useful proved to

be a set of longitudinal composite measures that took into account both the

achievement of abstinence from illicit opioids—the primary objective of

treatment—and freedom from other problems such as heavy use of alcohol,

heavy nonopioid use, and long-term incarceration. The long-term pattern

shown in figure 4 is a composite of several DARP samples over a 12-year

FIGURE 4. Outcomes over time

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period. It shows the improvement previously noted in years 1 through 3

posttreatment and outcomes at year 6 postadmission; most of the clients had

ceased daily opioid use. These outcomes tended to be stable. By year 10,

two-thirds of the addicts had stopped daily opioid use and maintained that

status through year 12.

Treatment Outcome Prospective Study

TOPS differed from DARP in several important ways. It took place at a later

point in the evolution of our national treatment system, and at a point where

drug abuse patterns were more diverse. Like DARP, it used a design with three

admission cohorts and intake samples at participating programs and attempted

to capture the major modalities among those programs. Neither DARP nor

TOPS has ever claimed to have samples representative of the universe of

programs, nor were the resources necessary for such representativeness

available.

What they did have were programs with geographic dispersion and the major

modalities available for study at that time. Although DARP had fewer programs

to draw from, TOPS had the luxury of sampling programs recommended as

better programs by single-state agencies. This is a reasonable approach to the

study of treatment, but it may well account for some of the better outcomes

among the opioid addicts in TOPS.

Like DARP, the TOPS followup was constrained by the available mechanisms

and resources. The DARP followup was under a series of grants and used a

retrospective interview with an activities chart to reconstruct events and periods

of drug use over time. TOPS followed up two cohorts (1979 and 1980

admissions) under a contract and interviewed clients at 3 months and 1 year

posttreatment.

The TOPS data showed many different abuse patterns. It was not unusual for

clients to report as many as four different regular drugs of abuse. Pretreatment

and postreatment comparisons showed general improvement, although the

data contain some puzzles. For example, TOPS opioid clients have a much

greater tendency to get arrested and incarcerated after treatment than DARP

clients. Table 2 shows some comparisons between the DARP and TOPS data

sets, using the same criteria for identifying those addicted to opioids at

admission, that is, daily or near-daily use of opioids. Because the DARP

sample is dominated by opioid addicts, their numbers are much larger; the

TOPS sample had only 50 drug-free outpatient clients who met the criteria of

daily opioid use at admission. Also, because the published DARP data used

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TABLE 2. Pretreatment and posttreatment outcome measures for opioid addicts admitted to DARP and

TOPS (black and white male clients only)a
here are only for black and white males, these preliminary comparisons were

limited further by excluding females from the TOPS data.

The apparently better outcomes in terms of daily opioid use are dramatic.

Whereas 36 to 44 percent of DARP clients returned to daily opioid use during

the first year, only 20 to 24 percent of the TOPS clients did so. The figures for

any opioid use are almost identical, about 60 percent for each sample. The

difference in daily use may be a function of greater diversity in drug abuse

patterns or of learning to substitute alcohol and nonopioids for opioids.

DARP clients showed somewhat greater reductions than TOPS clients in use of

nonopioids. The percentage of DARP clients using marijuana and drinking

heavily tended to increase, a pattern opposite of that observed in TOPS.

Among TOPS daily opioid clients, the reductions in percent using cocaine were

small.

There are differences in other outcome measures for opioid addicts. Arrests of

TOPS clients seem to be greater than DARP clients. The contrast in

employment also is striking. For DARP clients employment improved

dramatically across all modalities; TOPS clients, whose employment

levels were generally higher than those of DARP clients at intake, either failed

to improve or worsened on this measure. Economic conditions in the United

States during the followup period for TOPS may explain partially the failure of

TOPS clients to improve in the area of employment (Hubbard et al. 1989).

Outcomes for clients remaining in treatment at least 90 days are depicted in

figure 5 for two TOPS subgroups: regular cocaine users (at least once weekly)

and regular users of drugs in a category labeled “sedatives, hypnotics, and

tranquilizers.”

Regular Cocaine Users. Attempts to develop meaningful classifications by

drugs of special interest other than opioids were frustrated by the drug abuse

patterns present in the sample. To the extent that the sample could not be

characterized as opioid addicts, it tended to comprise “former addicts” (i.e.,

primary opioid abusers transferring from jail or other programs) and polydrug

abusers. The number of TOPS clients who were using cocaine at least once a

week (but not using opioids daily at that time) during the 3-month pretreatment

baseline period was relatively small, and they showed a tendency to use

numerous other drugs. After treatment, there was some reduction in cocaine

use, nonopioid use, and heavy drinking for TC and drug-free outpatient clients.

For all three modalities, pretreatment to posttreatment employment essentially

did not change.

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FIGURE 5. Outcome patterns for TOPS clients in treatment 3 months or

longer

FIGURE 5a. Changes in prevalence of regular heroin use

FlGURE 5b. Changes in prevalence of regular cocaine use

107
FIGURE 5c. Changes in predatory crime

FIGURE 5d. Changes in full-time employment

108
Sedative, Amphetamine, and Tranquilizer Users. A category of regular (at

least weakly) “psychotherapeutic nonopioid” users (i.e., sedative-hypnotics,

amphetamines, and tranquilizers but excluding hallucinogens), excluding daily

opioid or cocaine users, was examined. Outcomes for this group were mixed,

with decreases in some drug use and increases in others. Pretreatment and

posttreatment employment for drug-free residential and drug-free outpatient

programs essentially were unchanged, although more than half of the clients in

these modalities were employed.

The TOPS pattern suggests that although treatment can bring about positive

and significant changes in clients, there is much room for improvement. Instead

of focusing on an immediate isolated problem, more attention needs to be given

to overall improvement and specialized services, especially daily marijuana use,

heavy drinking, criminality, and employment.

Northeast Methadone Research Project

A recent noteworthy study that is not national in scope is the Methadone

Research Project conducted by Ball and associates (1999) in the northeastern

United States. This study focused on six methadone maintenance programs in

Baltimore, Philadelphia, and New York City. Much of this database is still being

analyzed, but several interesting papers have resulted.

Among the most interesting findings are the large degree of variability in

outcomes among the six programs and the role of methadone dosage in

reducing intravenous (IV) drug use. Ball and colleagues found that programs

had IV drug use rates ranging from 10 to 57 percent. Further analysis of the

data revealed that methadone dosage accounted for half of the explained

variance in current IV drug use (Ball et al. 1999).

Drug Abuse Treatment Outcome Study

The next major national treatment followup study will be DATOS, which is being

conducted under the general direction of the authors. Among the major

features of DATOS are:

A sample of 50 programs with major modalities, including detoxification,

methadone maintenance, therapeutic community, drug-free outpatient, and

chemical dependency units. The sampling approach emphasizes capturing

the types of programs most commonly used in treating drug abusers in the

United States and includes publicly funded as well as private, for-profit

clinics.

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Use of sampling frame based on a national survey of programs recently

conducted by the University of Michigan’s Institute for Social Research,

with indepth organization and clinical information available on program

selected.

Intake sample of 20,000 and followup sample of 4,500 from two 1-year

admission cohorts.

Use of the Addiction Severity Index and a structured diagnostic interview to

assess problem severity and psychopathology.

Followup sample stratified by drug abuse (opioids, cocaine, other

polydrug), modality, and impairment measures. A key feature of the study

will be conceptualization and measurement of the underlying dimension of

impairment, which at this time is expected to use a composite of substance

dependence, psychiatric severity, and deficits in social functioning.

Emphasis on the process of treatment and client change measures during

treatment.

Interviews at admission and at treatment intervals, treatment termination

reports, and followup interviews at 3 months and 12 months

posttermination.

CONCLUSIONS

Although drug abuse treatment has been shown to be effective and the longterm course of recovery appears encouraging for those entering treatment, the

evaluation of drug abuse treatment continues to be beset by numerous

problems. With the exception of some types of psychopathology, attempts to

isolate prognostic variables generally have not been successful. This may be

due partially to not having asked the right questions and partially to the

complexity of the presenting problems of drug abuse. Future evaluative

research must attempt to capture critical client variables that have scientific,

clinical, and policy relevance such as degree of impairment. Ultimately,

evaluative research must address questions of client-treatment matching, which

requires that the treatment process be characterized and measured in ways that

allow generalizability about what takes place in treatment of drug abusers—

what services are received, what processes are activated, and what changes

result. This requires not only careful conceptualization and measurement of

client and treatment variables but also sampling programs that represent

prevailing models of treatment. Nothing is gained by proving that poorly run

programs do not accomplish what is expected of well-run programs.

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Outcome studies must sample treatment populations that reasonably represent

contemporary drug abuse patterns. Just as the shift from opioid addiction to

multiple drug abuse was seen in the DARP and TOPS research, DATOS must

focus on the major drug abuse problems of 1990—cocaine, opioids, and

polydrug abuse—among various socioeconomic groups and impairment levels.

Generalizability must be improved by conducting studies on populations of

special interest such as adolescents and women of childbearing age.

The valuable lessons learned from the growing body of treatment outcome

studies will aid in the development of outcome studies that use a variety of

perspectives and timeframes—what happens at intake and during treatment

and posttreatment, both with respect to immediate outcomes and longer term

patterns. Natural history studies of nonopioid abuse, especially cocaine abuse,

are needed to understand treatment outcomes in a longer term context.

Development of a systematic, well-integrated body of treatment outcome

research will result in an enhanced understanding of drug abuse, its treatment,

and its course with or without treatment. Such knowledge should be developed

and disseminated with the express purpose of improving drug abuse treatment.

REFERENCES

Anglin, M.D.; Almog, I.J.; Fisher, D.G.; and Peters, K.R. Alcohol use by heroin

addicts: Evidence for an inverse relationship. A study of methadone

maintenance and drug-free treatment samples. Am J Drug Alcohol Abuse

15(2):191-207, 1989.

Anglin, M.D., and McGlothlin, W.H. Outcome of narcotic addict treatment in

California. In: Tims, F.M., and Ludford, J.P., eds. Drug Abuse Treatment

Evaluation: Strategies, Progress, and Prospects. National Institute on Drug

Abuse Research Monograph 51. DHHS Pub. No. (ADM)86-1329.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 106-128.

Bale, R.M.; Van Stone, W.W.; Kuldau, J.M.; Engelsing, T.M.J.; Elashoff, R.M.;

and Zarcone, V.P., Jr. Therapeutic communities vs. methadone

maintenance. Arch Gen Psychiatry 37(2):179-193, 1980.

Ball, J.C.; Lange, W.R.; Myers, C.P.; and Friedman, S.R. Reducing the risk of

AIDS through methadone maintenance treatment. J Health Soc Behav

29:214-226, 1988.

Ball, J.C.; Shaffer, J.H.W.; and Nurco, D.N. The day-to-day criminality of heroin

addicts in Baltimore: A study in the continuity of offense rates. Drug Alcohol

Depend 12:119-142, 1983.

Collier, W.V., and Hijazi, Y.A. A follow-up study of former residents of a

therapeutic community. Int J Addict 9:805-826, 1974.

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De Leon, G. The Therapeutic Community: Study of Effectiveness. Treatment

Research Monograph Series. DHHS Pub. No. (ADM)84-1286. Washington,

DC: Supt. of Docs., U.S. Govt. Print. Off., 1984.

De Leon, G. Psychopathology and substance abuse: What is being learned

from research in therapeutic communities. J Psychoactive Drugs 21:177-

188, 1989.

Dole, V.P., and Nyswander, M.E. Methadone maintenance treatment: A tenyear perspective. JAMA 235:2117-2119, 1976.

Gearing, F.R.; D’Amico, D.A.; and Thompson, F. What’s good about

methadone maintenance after ten years? Drug Abuse—Modern Trends,

Issues, and Perspectives. Proceedings of the Second National Drug Abuse

Conference, Inc., New Orleans, 1975. pp. 645-666.

Hubbard, R.L.; Marsden, M.E.; Rachal, J.V.; Harwood, H.J.; Cavanaugh, E.R.;

and Ginzburg, H.M. Drug Abuse Treatment: A National Study of

Effectiveness. Chapel Hill, NC: University of North Carolina Press, 1989.

McGlothlin, W.H., and Anglin, M.D. Shutting off methadone: Cost and benefits.

Arch Gen Psychiatry 38:885-892, 1981.

McGlothlin, W.H.; Anglin, M.D.; and Wilson, B.D. Evaluation of the California

Civil Addict Program. National Institute on Drug Abuse Services Research

Monograph Series. DHEW Pub. No. (ADM)78-558. Washington, DC: Supt.

of Docs., U.S. Govt. Print. Off., 1977.

O’Donnell, J.A. Narcotic Addicts in Kentucky. DHEW Pub. No. (PHS)69-1881.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1969.

Rounsaville, B.J.; Weissman, M.M.; Kleber, H.; and Wilber, C. Heterogeneity of

psychiatric diagnosis in treated opiate addicts. Arch Gen Psychiatry 39:161-

166, 1982.

Sells, S.B.; Demaree, R.G.; Simpson, D.D.; and Joe, G.W. Evaluation of

present treatment modalities: Research with DARP admissions, 1969-1973.

Ann N Y Acad Sci 311:270-281, 1978.

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.

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., and Sells, S.B. Effectiveness of treatment for drug abuse: An

overview of the DARP research program. Adv Alcohol Subst Abuse 2(1):7-

29, 1982.

Woody, G.E.; Luborsky, L.; McLellan, A.T.; 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.

112
AUTHORS

Frank M. Tims, Ph.D.

Deputy Branch Chief

Bennett W. Fletcher, Ph.D.

Research Psychologist

Treatment Research Branch

Division of Clinical Research

National Institute on Drug Abuse

Parklawn Building, Room 10A-30

5800 Fishers Lane

Rockville, MD 20857

Robert L. Hubbard, Ph.D.

The Center for Social Research and Policy

Research Triangle Institute

P.O. Box 12194

Research Triangle Park, NC 27709

113
Patient Treatment Matching:

A Conceptual and Methodological

Review With Suggestions for

Future Research

A. Thomas McLellan and Arthur I. Alterman

INTRODUCTION

The idea of matching patients and treatments is not a new one and has become

even more attractive over the past decade for several reasons. First, the

number of treatment programs has increased rapidly over the past decade with

the expanded availability of employee assistance programs, mandated

insurance benefits for drug dependence, and the increased emergence of

private treatment centers for addicted individuals. A second factor is the

increasing pressure throughout the health care field to reduce the costs of

treatment by limiting the length of stay in hospitals or rehabilitation facilities.

This pressure has increased the variety of rehabilitation modalities available,

such as outpatient and/or partial hospital programs. This is a rather big change,

because in the not too distant past, the great majority of treatments in the

substance abuse field relied almost exclusively on the inpatient modality. Third,

the recent wave of cocaine abuse has led to increases in the number and

variety of treatment approaches within the substance abuse field. Formerly

alcohol-only programs now admit patients with alcohol and/or cocaine

problems.

These recent developments have added political and financial pressure to the

already earnest efforts of clinicians and treatment researchers to find patienttreatment or patient-program combinations that would provide optimum

recovery and potential cost savings. However, it must be admitted that the idea

of “matching” has been as methodologically elusive to researchers as it has

been conceptually attractive to clinicians. Virtually every treatment evaluation

study has concluded with the speculation that, given the “right” combination of

variables, patients could be matched to the most appropriate treatments.

Similarly, virtually every clinician shares the belief that certain types of

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treatments are “best” for certain kinds of patients. Despite the methodological

speculations and clinical impressions, there have been very few matching

studies attempted (approximately 15 at this writing) and very little evidence thus

far that a matching strategy can be a practical or worthwhile procedure in most

clinical settings.

The discussions of matching as a desirable clinical concept seldom consider the

conceptual and methodological problems associated with demonstrating the

viability of such a concept. For example, it should be clear that matching is

viable only in a treatment network in which each of the programs is both

different and effective. For example, it is at least conceptually possible for there

to be differential effectiveness in rehabilitation strategies that are as different as

a methadone maintenance program and a drug-free therapeutic community

(TC). In this case, the programs differ in terms of setting (inpatient vs.

outpatient), orientation (medication vs. no medication), structure (strict patient

self-government vs. hour visit to the clinic), and major therapeutic intervention

(group vs. individual counseling). There are therefore many reasons to believe

that these two types of programs could be differentially effective with selected

segments of the patient population. However, in a comparison of two drug

outpatient programs in which one of the programs has more Narcotics

Anonymous (NA) or Cocaine Anonymous (CA) meetings and fewer relapse

prevention meetings than the other, there is less reason to believe that the

programs are conceptually or methodologically different enough to produce a

differential spectrum of outcomes. It is much more likely in this case that the

programs will be attractive to and effective with the same segment of the patient

population. Therefore, on conceptual grounds, they should be expected not to

show a matching effect.

The overall efficacy of a treatment program is also a major issue in any

matching strategy. It will not be possible to demonstrate that a treatment

program is differentially suited to a specific “type” of individual if the program is

generally poorly administered and only minimally effective. If it cannot be

specified that a treatment was delivered in the intended manner, in sufficient

quantity and intensity to effect the desired changes in at least some segment of

the patient population, then conclusions regarding matching hypotheses are

simply not possible.

This chapter first examines conceptual and methodological considerations

associated with the matching strategy and discusses the many methodological

difficulties involved in performing this type of study and in actually

demonstrating a matching effect. This is considered germane to the specific

discussion that follows in that many of the studies that have failed to

demonstrate a relationship between a patient variable and differential treatment

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outcome in two or more different treatments were not designed in a way that the

effect reasonably could have been expected in the first place. This part of the

chapter draws heavily on the prior work and excellent methodological

discussions of Annis (1987), Finney and Moos (1986), Miller and Hester

(1986a), Skinner (1981), Simpson and Sells (1982), and Simpson and

colleagues (1979). Finally, the chapter discusses different types of matching

studies at different points during the course of rehabilitation and suggests

issues and methods that are pertinent for matching studies in the future.

PART I—METHODOLOGICAL CONSIDERATIONS IN PERFORMING

MATCHING STUDIES

The Concept of Patient-Treatment Matching: What Is a Reasonable

Expectation?

Perhaps the most important consideration in a treatment matching study is a

clear understanding of what a treatment (if it works perfectly) would be expected

to accomplish and of how a treatment (if it works the way it is supposed to)

would accomplish these effects. A comparison of two common treatments may

serve to illustrate the point. The use of naltrexone (Trexan) in the treatment of

opiate dependence is widespread as a blocker of drug-taking behavior. It is

essentially atheoretical in its approach and makes no assumptions regarding

the etiology or complexity of the drug problems under treatment.

This type of atheoretical treatment has a basic and direct set of expectations

regarding the following:

1.

2.

3.

4.

5.

Patient selection criteria for the treatment—it should work with any opiate

addict who complies with the dosing regimen.

Duration and intensity of treatment necessary to produce the desired

effects—it should work almost immediately; its efficacy has virtually nothing

to do with intermediate changes in the patient or his or her behavior (other

than compliance with the dosing).

Requirements for the treatment to take place—it should work in virtually

any setting in which appropriate pharmacologic supervision is available.

Criteria for judging if the treatment has been able to do what was

intended—it should reliably reduce opiate use, nothing more.

Range of outcome criteria that would reasonably be affected by this

intervention—opiate use alone; there are (should be) no expectations that

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this medication alone will provide the patient with “insight,” reduce “denial,”

or assist with the social/economic/emotional adjustment of the recovering

patient (although these may be subsequent effects of the extended drugfree status produced by the medication).

6. Duration of benefits—it should lose its effectiveness almost immediately

following cessation of dosing, unless other behavior change-oriented

interventions accompany the medication.

In contrast, some treatments in the substance abuse field that are based on

theoretical assumptions about the “underlying” causes of substance

dependence work indirectly to effect change and are not immediate in their

effects. Good examples are found in the widely used varieties of

psychotherapy (group and individual; dynamic and behavioral) for the treatment

of alcohol dependence. These treatments are theory driven, assuming that a

primary (if not the only) reason for the excessive drinking is an underlying

emotional problem in the patient, which functions to provide motivation for the

“stress reduction/affect relieving” properties of the alcohol. That is, the

treatment is based on the theory that emotionally troubled individuals have

learned that their problems could be ameliorated by alcohol and that this quickly

became habit-forming. The expectations regarding the effects of psychotherapy

on alcohol dependence are necessarily indirect. That is, if the patient is

emotionally troubled and if the psychotherapy can reduce these problems, then

the patient should have less motivation to drink, and this should result in lower

levels of drinking following treatment.

It should be dear that this type of theory-driven treatment has fundamentally

different expectations regarding the following:

1.

2.

3.

Patient selection criteria for the treatment—it should only work with

alcoholics who have emotional problems.

Duration and intensity of treatment necessary to produce the desired

effects—it should only work with those patients (assuming again that they

are “appropriate” to start with) who have had enough of the treatment to

correct the target problem, that is, the underlying emotional discomfort.

Requirements for the treatment to take place—it should only work where

appropriate facilities and trained staff have employed the prescribed

amount and intensity of treatment in the manner that it is intended to be

delivered; obviously, these requirements will be different but equally.

relevant for various types of psychotherapies.

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4. Criteria for judging if the treatment has been able to do what was

intended—it should reduce emotional problems but should not be expected

to reduce alcohol use (this would be, at best, an indirect effect).

5. Range of outcome criteria that would reasonably be affected by this

intervention—if an underlying emotional problem is the central problem that

has been manifest as alcoholism, then the reduction of that problem should

have positive effects on other areas, for example, family and social

relations, employment opportunities, and general psychological adjustment.

6. Duration of benefits—it should continue its effectiveness following

completion of treatment because it is conceived as a relatively enduring

behavioral change.

Although this comparison is by design extreme for the purposes of illustration,

there are many other treatment contrasts within the substance abuse field that

offer similar levels of disparity with regard to the expectations associated with

them. Examples include methadone maintenance and TC treatments, aversion

therapies, skills-training, acupuncture, and relapse prevention.

At What Level is the Matching Expected?

Many studies have examined different treatment settings or intensities

(inpatient, outpatient, day-hospital, partial hospital) for evidence of differential

patient outcomes. Other studies have examined different modalities of

treatment (controlled drinking, drug-free abstinence, antagonist-assisted

abstinence), whereas the majority of studies have looked at treatment programs

(a particular combination of setting and modality) as the unit of analysis. Very

few studies have examined the more subtle treatment elements or ingredients

within programs (group therapy, education, social work services, etc.) that

would be associated with actual patient-treatment matching.

It should be clear that different types of patient variables will be important in

matching at each of these levels, and unless the level of measurement is

appropriate to the level of matching desired, it can restrict the interpretation of

the results. Perhaps the best example of this problem is seen in the series of

studies by McLellan and colleagues (1982, 1983a, 1983b). In these studies,

“treatments” were six existing treatment programs from two different treatment

settings (inpatient and outpatient). The inpatient treatments were all from the

TC orientation with at least nominally the same abstinence treatment philosophy

and the same general staffing guidelines. Furthermore, no attempt was made

to measure the extent to which the “ingredients” of treatment (such as individual

counseling, group therapy, education, recreation, medications, social work

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services, patient governance, etc.) were offered or received during the

treatment process. Therefore, although these investigators did find very clear

evidence of patient-setting matches and more modest evidence of some

patient-program matches, the gross level of measurement did not permit

evidence for patient-treatment matches.

The failure to measure the actual treatment ingredients provided in this study

can produce at least two errors of interpretation. First, it is possible for an

investigator in a matching study to conclude that a setting is “matched” to a

patient when, in fact, it was the particular combination of treatment ingredients

within the program that was responsible for the positive outcome. A replication

study with the same setting and similar patient sample might result in poor

outcomes if there were changes in the ingredients of treatment. Second, it

would be possible (in fact, likely) for a patient-program matching study to find no

evidence of differential outcomes across a variety of patient subtypes in two

treatment programs (perhaps even within the same modality) and to conclude

that there was no evidence of patient-treatment matching. If the actual

treatments (the nature and duration of the ingredients delivered to the patients)

were not measured, this type of conclusion would go well beyond the level of

data available.

What Kind of Treatment Is Delivered? How Much of It? How Long and

How Well?

The problems raised above illustrate that different levels of conclusions are

possible with more refined levels of measurement, particularly in the case of

treatment process. It will not be possible to demonstrate that a treatment

program is differentially suited to a specific type of individual if the program is

poorly run and cannot effect intended changes with any segment of its

population. If it cannot be specified that a treatment was delivered in the

intended manner by adequately trained individuals and in sufficient quantity and

intensity to effect the desired change in a majority of patients, then conclusions

regarding matching hypotheses are not possible.

Other Methodological Problems

There are several types of design and analysis problems that can place

limitations on the value of conclusions drawn from matching studies. The major

problems are discussed briefly below, but more complete and detailed

discussions of design and analysis issues pertinent to the matching

issue have been presented by Skinner (1981), Simpson and Sells (1982)

Simpson and the TCU-DARP group (1979) and Longabough (1986).

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Adequate Sample Sizes. Because the matching effects that have been

observed account for less than 10 percent of outcome variability, it is necessary

to employ sample sizes that permit enough statistical power to detect a

matching effect. Many published matching studies have not had sample sizes

adequate to detect a matching effect even in an appropriate design.

Closely related to this is the need for significant variability across the variables

measured. It is not statistically possible to detect an important relationship

between a pretreatment measure and an outcome criterion if there is only a

small amount of variability within the samples on that pretreatment measure.

This has been particularly important with respect to the drug use severity

measure because it is often the most homogeneous of all background variables

in a treatment population.

Prospective vs. Post Hoc Analyses. Very few studies have prospectively

tested specific matching variables that were posited to be related to outcome

based on prior work or on a relevant theory. Results from these prospective

studies hold greater conceptual validity than those derived from a large-scale

post hoc analysis of a collection of potential predictors. It should be clear that

post hoc analyses, especially those in which a large number of items are

examined, run the risk of simply uncovering an isolated or spurious relationship.

Furthermore, simple correlations between sets of predictors and an outcome

variable do not provide important information regarding the relationships among

predictor variables.

Differentiation or Prediction. Perhaps the most common misinterpretation of

results occurs in post hoc studies in which poor performance patients (based on

some valid criterion) are found to be significantly different from good

performance patients on pretreatment or demographic variable x. Results such

as these often were extrapolated to the conclusion that patients with variable x

should not be treated in the particular treatment modality. Depending on the

variability in the population and the number of subjects used, it is possible for

many variables to be “significantly different” among different segments of the

population. However, these variables may not be meaningfully associated with

the outcome criterion in a predictive sense. This may happen because variable

x accounts for only a small part of the total variation in outcome or because

variable x is closely related to another variable (which may or may not have

been included in the analyses) that is itself predictive of outcome. Truly reliable

and valid estimates of prediction or of matching require multivariate analyses

that can take into consideration these complex relationships and adjust the

estimates appropriately.

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PART II—AN EXAMINATION OF MATCHING ISSUES AT SEVERAL LEVELS

The results of this review suggest that the most potential for advancement will

come from the analysis of more discrete and better defined stages of the

rehabilitation process, that is, from the process of treatment selection, through

the provision of specific treatment elements during rehabilitation, to the services

offered in the posttreatment environment. Just as each of these stages of the

rehabilitation process has a different context in which it takes place and a

different set of goals for the patient, the clinical possibilities for patient-treatment

matching and the potential for matching research also will be different among

these stages. Therefore, the remaining portion of this chapter examines the

potential for matching research in each of four areas that coincide with the

typical context in which treatment is provided. In each of these parts, there is

critical commentary regarding the matching research done to date, and there

are suggestions for future methods to be applied and examples of specific types

of studies that could be performed.

Matching Before the Treatment Starts: Program-Patient Matching

Because the nature of a treatment program (including its location, cost, referral

network, charter, and preferred modalities) will determine in large part the types

of patients who present for treatment, the sample of patients evaluated at a

specific treatment program will not even be representative of the total

population of treatment-seeking individuals. This is important in that

conclusions from these results often are discussed in terms of what they mean

to “the treatment community” or to “the substance abuse field.”

Of course, treatment programs have recognized and used patient self-selection

in their marketing strategies and their clinical attempts to “. . . develop programs

tailored to the individual needs of the patient . . . .” This marketing process of

solicited self-selection is sensible in that it is not likely that the effects of even

conceptually identical and comparably applied treatments would be similar for

both a sample of older, lower socioeconomic, chronic alcoholic males treated in

a Veterans Administration hospital and a sample of adolescent, middle-class

girls at a private facility who were referred to treatment early in the course of

their substance abuse careers.

This means that a form of matching takes place before the initiation of treatment

through the process of specialization and the selective marketing and referral

for “seemingly appropriate” patients. This has spawned the development of

“special programs” for “special populations” such as adolescents, Native

Americans, women, abused women, adult children of alcoholics, homeless

men, and many others. This is by far the most extensive and possibly the most

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relevant of all the matching work done in this country, yet little more than

descriptive information is available on this level of effort.

The research that has been done in this area has attempted to determine if

differential outcomes are seen among these groups treated in the same

program. Although this is technically a true matching design, the issue is

important and clearly related to the larger matching issue. To date, the meager

amount of research that has been completed has found no clear indication that

these group designations are associated with different outcomes among those

patients who have entered treatment. However, it is clear that members of

these groups do not enter available “mainstream” treatments in proportions that

are representative of the substance abuse problems within those groups. For

this reason, the major efforts in this area related to program-patient matching

have been in the development of tailored programs designed and operated by

and for selected special population groups. The goal of this effort has been to

attract more substance-abusing individuals from these groups into treatment.

Although there has been a marked increase in the number of these programs

available, it is not yet clear whether proportionally more members of these

groups have been attracted into treatments or whether higher proportions of

special populations enter special programs than enter traditional programs.

Furthermore, although these programs have generally offered attractions that

are specially suited to their target populations (e.g., child care for women’s

programs and special access for handicapped programs), it is not clear whether

or to what extent the treatments provided within these programs differ from

more “mainstream” types of treatments and/or whether they are associated with

differential outcomes.

Research Opportunities at This Level. Studies could be carried out to

address the following questions for programs designed with special populations

in mind:

1. Do the patients with the “right” patient profile stay longer, show more

improvement, and remain improved longer than patients with the “wrong”

profile?

2. Is greater demographic and socioeconomic homogeneity among patients

associated with better retention in a specific treatment, that is, how much

and what types of diversity can a patient population tolerate and still

maintain cohesiveness? This is relevant to the increasing amount of

cocaine and alcohol use found in patients presenting for treatment at

traditional alcohol programs: Can these patients be treated with alcoholonly patients? Are the treatment goals and methods compatible for these

two types of patients? Can women be treated as effectively in mixed male

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and female settings as in specialized women’s facilities? Similar questions

could be asked regarding adolescent and adult substance abusers as well

as other significant subgroups in the total patient population.

3. Do two conceptually and methodologically different treatments (e.g.,

naltrexone vs. relapse prevention) tailored to the same patient profile have

differential effects?

Matching at the Initiation of Treatment: Patient-Setting or Patient-Intensity

Matching

There are at least four levels of treatment intensity or treatment settings that

have been offered to substance-abusing patients and studied with regard to

matching:

1. Advice/self-help

2. Brief interventions (usually fewer than five counselor/therapist

appointments) lasting about a week

3. Outpatient or partial hospitalization

4. Inpatient care (either at a rehabilitation facility or as part of a hospital)

Table 1 describes available results from matching or prediction-of-outcome

studies done to date. The questions that have been asked to date regarding

these treatment levels have been principally economic in origin. What patient

factors predict favorable outcomes in these treatment settings? Is one of these

treatment intensities significantly better than another for randomly selected

groups of patients? Not all pertinent studies are represented in the table, just

those that are more carefully conceived and controlled. Blanks indicate the

absence of a representative study or conclusion. Other, very useful tabular

presentations of similar data include those of Longabough (1986) and Annis

(1987).

Although there are several points of interest in this table, one methodologically

significant point is that the patient factors that are predictive of treatment

outcome at a reduced level of treatment intensity (e.g., none or brief treatment)

usually continue to be predictive even at more structured or intensive levels of

treatment. Thus, as can be seen, social and economic factors (i.e., social

supports) have been reliably associated with posttreatment outcome in studies

at all levels of treatment intensity. This is important in matching studies that

examine two or more levels of treatment intensity (e.g., outpatient drug-free

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TABLE 1. A proposed hierarchy of treatment interventions and their known outcome predictors
counseling vs. inpatient relapse prevention). This is an interesting example of a

situation in which random patient assignment might not be the best way to

examine the matching issue. In a situation such as the one described, simply

randomly assigning patients to each of the treatments would ensure variability

(hopefully, equal variability) on the social support measure for patients assigned

to both programs. Subsequent analyses almost certainly would show a

pronounced effect of the social support variable and, depending on the

available number of subjects, overshadow other variables. Not only would

conclusions based on this design not offer useful information (Who of those

among the treatment field does not already realize that those with better social

supports at the time of treatment admission are likely to have better outcomes

at the time of followup?), but also it would not be consistent with the “real world”

in that there is usually not an equal range of variability in the social supports

between inpatient and outpatient populations (i.e., outpatient samples often

have better living and employment situations than inpatient samples). Because

these social support variables are likely to be major influences on treatment

outcome, one solution would be to equate or stratify samples on these variables

during the treatment assignment process.

Research Opportunities at This Level. It seems that there is now enough

conceptual clarity regarding the various levels of treatment structure or intensity

to permit the use of more carefully staged or hierarchical designs. These

staged designs tailor matching hypotheses to the treatment goals and patient

populations appropriate for different levels of treatment structure (no treatment,

brief treatment; outpatient, inpatient). In this way, it seems possible to build on

those conclusions from the past several years that have been replicated and

that make clinical sense. For example, the work of many investigators in the

alcohol treatment field (Sanchez-Craig 1984; Miller and Hester 1986a) indicates

that individuals with less severe and shorter periods of problem drinking, better

social supports, and fewer medical and psychological problems can improve

problems without intensive treatments. Therefore, such studies as the following

are suggested:

1. Studies of matching between different levels of treatment intensity should

attempt to select patients with approximately the same levels of treatment

problems and social supports. For example, in a study of inpatient vs.

outpatient treatment, it would be preferable to include only those patients

who were considered (based on clinical and research data) appropriate for

outpatient care. Results then might permit a better understanding of the

patient factors within the “clinically appropriate” group that are associated

with outcome from each level of treatment intensity.

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2. Existing models of patient assignment to different levels of treatment

intensity (e.g., Hoffman et al. 1987) should be evaluated in a series of

controlled evaluations at various sites and with various segments of the

patient population. Explicit patient assignment models have been

developed based on specified theories offering face-valid ideas for

appropriate levels of care and clear improvement criteria for transferring

patients among these levels. These models offer promising and practical

approaches to an important and expensive problem confronting patients,

treatment providers, and third-party payers. These models may be facevalid enough to permit clinical adoption and, thus, a wider range of

treatment programs evaluating them.

Matching During the Treatment Process: Patient-Treatment Matching

There is a fairly discrete set of treatment components available to most

substance-abusing patients in treatment, regardless of the modality or setting.

These include the following:

1.

2.

3.

4.

5.

Group therapy (usually focused on issues of treatment need and denial)

Individual therapy (usually personal counseling regarding relationship

problems and crises)

Substance abuse education

Self-help groups such as Alcoholics Anonymous (AA), NA, CA—12 steps

(either as part of the treatment or through referral)

Social service assistance (referral to home or work placement)

Table 2 presents a series of treatment methods and the patient and treatment

component factors that this review has found to be associated with outcome.

Although there has been at least a moderate amount of work looking at

matching in treatment settings (inpatient vs. outpatient) and among programs,

there has been little matching work done at the treatment component

(medication, therapy, education, etc.) level and even less at the therapist or

counselor technique level. This is potentially important in that the failure to find

evidence of matching between different programs or settings may be due to the

similarity of the therapeutic methods or components employed between

treatment programs and settings. Again, this highlights the need for more

detailed measurement of the treatment process and for examinations to assess

or determine the “active ingredients“ of treatment. If these active ingredients

are at the process level and if they are applied comparably across treatment

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TABLE 2. Predictors of improvement in programs using the following components
settings and programs, then it should not be surprising that there would not be

much evidence of patient-setting or patient-program matching other than at the

grossest levels (e.g., based on levels of social supports, psychiatric severity,

etc.).

Research Opportunities at This Level. Matching research at the program

level is likely to be the area that is most easily addressed by treatment

researchers because it can be done within a single program, thus eliminating

the kinds of methodologic and logistic problems that confront workers who study

matching among programs. Furthermore, this type of matching study may

 provide the most practical information to program directors and often can be

completed as part of ongoing quality assurance or program evaluation duties.

The following types of studies could be considered at this level:

1. Random patient assignment methods in controlled experimental trials can

be most profitably used in studies within a treatment program to investigate

the addition of a specific component to treatment as usual. Woody’s study

of psychotherapy as an adjunct to standard counseling (Woody et al. 1983,

1984, 1985) is an example of such an approach that can provide clear data

on the worth of specific treatment components. Virtually all of the standard

treatment components now used in rehabilitation programs (education,

relapse prevention, group therapy, etc.) could be evaluated for their

contribution to outcome against groups having all other aspects of the

treatment except the target component. This type of study could be

implemented across various treatment settings and patient populations.

2. Treatment methods and techniques that have been predictive of favorable

outcome in less structured treatments (e.g., individual therapy,

nonconfrontative approach, and patient participation in treatment goals) are

typically not those used in the more structured treatments (e.g., group

therapy, confrontation, and program-directed goals). There may be a very

good reason for this, but there has not been much research in this area that

supports the differentiation. More research is indicated here.

Matching Following Primary Rehabilitation: The Role of the Posttreatment

Environment

In the past the posttreatment environment of patients was a direct function of

the pretreatment resources of the patient. Most programs have concentrated

on “primary care” (i.e., 28 days of inpatient treatment) and have not had the

resources to develop tailored posttreatment arrangements. Furthermore, the

continued treatment possibilities offered to patients who completed primary care

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generally have been restricted to NA, CA, or AA and possibly a weekly or

monthly continuing care meeting at the primary care site.

Research Opportunities at This Level. Certain research (e.g., Finney et al.

1980; Moos et al. 1982; Finney and Moos 1981) has shown that the effects of

the posttreatment environment can exert profound influence on the magnitude

and duration of benefits shown among treated alcohol abusers. Because of this

work, the ever-reducing length of reimbursed care in primary rehabilitation, and

the financial push toward outpatient treatments, clinical programs have devoted

more time to development of posttreatment “continuing care programs” and

have attempted to bring the families of patients into the continuing treatment

process. With the addition of these available services comes the opportunity

for patient-treatment matching research following the period of primary

rehabilitation.

1. Comparative studies of AA/NA/CA, relapse prevention, individual therapy,

and/or family therapy following completion of primary rehabilitation could be

initiated in a variety of treatment settings and patient populations. Do these

interventions add anything to primary care alone? What types of patients

can benefit differentially from each of these? Ideally, these should be

parametric studies investigating the optimum duration and intensity of

treatments and should include measures of cost-effectiveness.

2. Comparative studies of family treatments (independent of the patient) could

evaluate the contributions of various forms of family education to the

posttreatment adjustment of the patient. For example, during the course of

a patient’s substance abuse rehabilitation, his or her family could be

assigned to Al-Anon, family therapy, drug education, or individual

counseling. This family/environment focus could help to determine if these

interventions add anything to simple primary care for the affected patient

and if these differentially focused approaches could be matched to specific

types of families. There are studies of this within the alcohol treatment

field, but this type of work has not received appropriate attention within the

drug abuse treatment field.

CONCLUSIONS

The work to date on patient-treatment matching has been productive and has

suggested three conclusions:

1. Patient factors have been more predictive of outcome from treatment

generally and of differential effectiveness of specific treatments than have

treatment process factors. However, techniques for patient measurement

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2.

have shown major development in breadth, reliability, and validity over the

past decade. In contrast, treatment process or methods have been almost

unstudied, and there are no available instruments for reliable and valid

treatment measurement. The broader range of treatments now available

may reveal more potent treatment process factors if provided in an

appropriate manner and for an adequate duration.

Of the patient variables studied, social, economic, and psychiatric factors

have been among the most important predictors of outcome from different

treatment intensities (e.g., inpatient, partial hospitalization, and outpatient).

Specifically, patients with better social and economic supports and fewer

psychiatric problems do well in most treatments and seem to benefit

equally from inpatient or outpatient interventions. Lower socioeconomic

strata patients and those having more serious psychiatric problems do less

well in treatment generally, but they do particularly poorly in outpatient care.

Patient factors such as severity of drug dependence, family history of

substance abuse, and (especially) presence of antisocial personality

disorder have been generally predictive of poorer outcomes from all

treatments but not differentially predictive of response to specific

treatments.

3. There have been very few studies of matching patients to different

treatment components (e.g., group therapy, individual therapy, medication,

and relapse prevention) within a given level of treatment intensity. There

are at this time no clear predictors of differential outcomes from any of

these components.

Recommendations

The matching work in the coming years gives every indication of potential for

significant, practical advances. To this end, the following recommendations are

offered.

As has been discussed by Annis (1987) and Longabough (1986). there is a

need for more specific focusing on matching questions. Efforts should be made

to study well-specified treatments that have clear therapeutic goals in specified

segments of the patient population (e.g., antidepressant medication vs.

cognitive-behavioral psychotherapy for depression in patients meeting DSM-IIIR criteria for opiate dependence and major depressive disorder). These types

of designs offer a much greater likelihood of providing interpretable results and

a better understanding of the mechanisms responsible for those results.

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One type of research design (e.g., randomized controlled trials) may not always

be appropriate for matching studies at every level of the rehabilitation process.

For example, at the level of referral to the treatment program (primary care) and

of referral to the posttreatment environment (aftercare), it might be reasonable

to consider nonexperimental designs employing a cafeteria approach (Ewing

1977) or a feedback system (Glaser 1980) due to the often extremely high rates

of patient dropout associated with randomized assignment to different levels of

care or different treatment programs (Bale et al. 1980). At the level of assigning

treatment components or treatment providers within the program (the treatment

plan), experimental designs with random patient assignment generally would be

preferable in evaluating the differential efficacy of components with

approximately equal attractiveness and comparable intensity.

There is a need for more innovative interventions and programs designed to

address specific treatment problems in the population (e.g., the psychiatrically ill

substance abuser, the antisocial substance abuser, the cocaine- and alcoholdependent patient, etc.). Similarly, there is a need to continue evaluation and

patient-treatment matching work with recently developed treatments such as

relapse prevention (Marlatt and Gordon 1985; Gorski and Miller 1982) and

community reinforcement (Azrin et al. 1982). As has been discussed by

Skinner (1981) and others, it is difficult to study the optimum matching of

patients and treatments when there is so little variability in the philosophy,

duration, or basic therapeutic components (e.g., group therapy, education, and

NA/CA/12 steps) of most treatments.

There has been much research in the treatment of substance dependence over

the past two decades, but only recently has any of it translated into truly

innovative modifications of the basic treatment process (Miller and Hester

1986b). In some quarters, the suggestion that new treatments are needed has

been considered defamation of existing methods and philosophies. There is

every reason to feel heartened by the efficacy shown by existing treatments

(McLellan et al. 1982; Miller and Hester 1986b). However, the results of

treatment evaluations and patient-treatment matching studies to date indicate

that no single treatment is effective for all patients; that many patients have

been admitted to inpatient treatments when short-term, less intensive

treatments could have worked; and that many other patients will not accept or

benefit from any of the existing interventions.

Perhaps the clearest need within the area of patient-treatment matching is for

the development of a reliable, valid, practical, and generalizable instrument to

measure the types, amounts, and duration of treatment interventions applied to

a patient during the course of rehabilitation. This is necessary for many

reasons but primarily for training of therapists and evaluation of treatment

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efficacy. If treatments are not applied in a manner consistent with their

philosophy, then it is not reasonable to think that they will work. We rarely know

if even a specific intervention (e.g., group therapy for denial), much less a

multiservice treatment program, is practiced in the manner originally intended.

We do not know the extent to which different individuals in a single treatment

receive the same types, amounts, or durations of treatment components. The

often repeated claim that patient factors account for more outcome variation

than treatment factors may simply be due to the lack of measurement now

available in the treatment domain. The ability to characterize a treatment

intervention or program in the same way that patients are now characterized will

effectively double the current ability to predict outcomes and to optimally assign

(i.e., match) patients to available treatments.

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AUTHORS

A. Thomas McLellan, Ph.D.

Scientific Director

Arthur I. Alterman, Ph.D.

Associate Scientific Director

Center for Studies of Addiction

Philadelphia Veterans Affairs Medical Center

University and Woodland Avenues

Philadelphia, PA 19104

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Client Issues in Drug Abuse Treatment:

Addressing Multiple Drug Abuse

Thomas R. Kosten

ABSTRACT

Multiple drug abuse may involve the whole range of abused drugs, but the most

critical problems exist with cocaine, alcohol, opioids, and benzodiazepines. The

medical and psychosocial consequences of abusing these drugs in various

combinations are often more severe than abusing each drug alone, and specific

combinations of treatment options may be needed for many of these drugs.

These combination treatments may include relapse prevention psychotherapies

targeted toward drug-related cues that are specific to each type of drug as well

as pharmacotherapies targeted toward specific drugs of abuse, such as

naltrexone for opioid abuse and disulfiram for alcohol abuse. Few controlled

clinical trials are available with multiple drug abusers, but successful treatments

using pharmacological adjuncts such as disulfiram and amantadine have been

described with cocaine-abusing or alcoholic methadone-maintained patients.

CONTEXT OF MULTIPLE DRUG ABUSE

Multiple drug abuse has become an increasing problem among opioid and

cocaine abusers, the two major risk groups for infection with acquired

immunodeficiency syndrome (AIDS). The management of multiple drug abuse

is particularly important among the abusers of these two drugs because a key

means for controlling the AIDS epidemic among drug abusers is the successful

treatment of intravenous (IV) drug abuse (Battjes and Pickens 1988). Among

those patients who abuse both opioids and cocaine together (“speedballs”), the

IV route of administration is quite common, and the direct relationship to the

spread of AIDS is quite clear. The other two substances that are substantially

abused by opioid and cocaine abusers are alcohol and sedatives, particularly

benzodiazepines. Although alcohol and benzodiazepines are not abused

intravenously in the United States, abuse of these two substances is associated

with complications in the management of both opioid and cocaine abusers.

These complications include difficulties in detoxification as well as in

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maintenance treatments. Other drugs of abuse, such as hallucinogens,

marijuana, and solvents, rarely present major complications in treating cocaine

and opioid abusers. In summary, this chapter focuses on the abused

substances that significantly complicate the treatment of patients at highest risk

of acquiring and spreading AIDS.

EXTENT OF MULTIPLE DRUG USE

For more than 15 years, surveys of opioid abusers applying for treatment have

reported frequent multiple drug abuse, but not until the past few years of the

cocaine abuse epidemic has multiple drug abuse become a major problem

among cocaine abusers. Cocaine abusers in a recent study of 300 treatmentseeking patients reported multiple drug abuse with alcohol abuse in 70 percent

and sedative abuse in 43 percent (Kosten et al. 1989). In this study, opioid

abusers were specifically excluded. The alcohol abuse rate among these

cocaine abusers was quite interesting in that only 20 percent of the cocaine

abusers were primary alcoholics who had become alcoholic before becoming

cocaine abusers. For the rest of the alcohol abusers, the alcohol was used to

cope with the dysphoria that followed cocaine use (the “crash”) (Gawin and

Ellinwood 1988); and when they abstained from cocaine, they also did not

abuse alcohol. For sedative abuse, the pattern was primarily sporadic use, with

only 11 percent of cocaine abusers reporting weekly use. These findings

suggest that although multiple drug abuse is quite prevalent, for many abusers

treatment of cocaine abuse alone may be sufficient to control the abuse of the

alcohol or sedatives. Thus, the major treatment efforts for these multidrug

abusers can be focused on the relatively easier task of detoxification alone,

rather than on simultaneous maintenance treatments for several abused drugs

(Smith et al. 1975). Unfortunately, the situation with opioid abusers appears

more complex, with concurrent abuse of nonopioid drugs occurring rather

commonly both outside and within treatment programs.

Data on multiple drug abuse were collected in a national collaborative study

conducted in the late 1970s (Gardner 1980). In this study, 96 percent of heroin

addicts also abused alcohol at some time in their lives, and 76 percent abused

alcohol within the 3 months before beginning treatment for heroin addiction.

Sedative (43-percent lifetime rate) and cocaine abuse (50-percent lifetime rate)

also were relatively common among heroin addicts. Current multiple drug

abuse rates were somewhat lower, but among opioid addicts in this survey,

current alcohol abuse was reported by 48 percent, cocaine abuse by 29

percent, and sedative abuse by 23 percent.

The reasons for cocaine and alcohol abuse by heroin addicts appear to be quite

different, and this may affect the design and relative success of treatment

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interventions. Even in this relatively older survey, cocaine was used by 70

percent of those heroin addicts who used cocaine to “improve” the euphoria

from heroin, whereas the much more prevalent use of alcohol was not

particularly associated with “improving” the euphoria. Only 16 percent of heroin

addicts who abused alcohol reported using alcohol to augment the heroin

“high.” These findings suggest that control of heroin abuse in many patients

may directly reduce cocaine abuse, and the reduction in cocaine abuse

reported by several surveys of methadone maintenance programs supports this

assertion (Nurco et al. 1988; Ball et al. 1988). Alcohol abuse may not be

directly reduced by effective treatment of the heroin addiction, however,

because alcohol is not used to alter the effects of heroin in the majority of

heroin addicts. Instead, alcohol abuse may require separate treatment not only

for detoxification but also for maintenance of the abstinent state.

Benzodiazepine abuse in heroin addicts appears to fall in between these two

extreme patterns of abuse, with a little less than half of the heroin addicts

reporting benzodiazepine use to “improve” their euphoria or “boost” their

methadone.

Within treatment programs, multiple drug abuse is a problem for initial retention

of patients and for rehabilitation in those programs with good retention such as

those providing methadone maintenance (Kosten et al. 1987; 1988). Initial

retention is reduced by the need for prolonged multiple detoxifications because

patients tend to leave the hospital or drop out of outpatient detoxification

programs. In programs with better outpatient retention (such as those providing

methadone maintenance), multiple drug abuse undermines efforts at social

rehabilitation. The cocaine-abusing or alcoholic methadone patient will be

unable to have sustained employment or education, and the cocaine abuser

may continue to engage in criminal activity to obtain the drug (Kosten et al.

1987; Stimmel et al. 1988; Rounsaville et al. 1982).

DETOXIFICATION FROM MULTIPLE DRUG ABUSE

Detoxification from multiple drug abuse can often be a complex procedure and

require inpatient treatment. Although inpatient detoxification may not be

required for dependence on such drugs as cocaine or for treatments that do not

require a patient to be drug free, such as initiation of methadone maintenance,

the combination of sedatives, and sometimes alcohol, with opioid or cocaine

dependence may require extended and carefully monitored inpatient treatment

protocols. In particular, if drug-free outpatient therapies such as naltrexone are

being considered for patients with multiple drug dependence on sedatives or

alcohol in addition to opioids, detoxification will probably require inpatient

facilities because of the potential for seizures, organic psychotic states, and

death. Substantial medical interventions may be needed when an alcoholic

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develops delirium tremens (DT) and other problems when clonidine is used in

the detoxification of opioid addicts with covert sedative dependence. This is

because clonidine will mask symptoms of sedative withdrawal but will not

prevent sedative-induced withdrawal seizures (Sellers and Kallant 1976; Sellers

et al. 1981; Hughes and Morse 1985).

The recommended procedure for mixed opioid/sedative dependence is to

sequentially withdraw each of the drugs because withdrawal symptoms from

opioids and sedatives have symptoms in common, and the clinical picture is

difficult to assess if both drugs are withdrawn at the same time (Czechowicz

1980). The sequence is to gradually withdraw the sedative (such as

alprazolam) first, while preventing opioid withdrawal using methadone. Current

practice would suggest that a long-acting benzodiazepine such as clonazepam

be substituted for the abused drug and then the clonazepam be gradually

withdrawn (Patterson 1988; Browne 1978). An alternative may be to use

carbamazepine to substitute for the benzodiazepine because this substitution

has been quite effective for alcohol withdrawal therapy (Butler and Messiha

1986). A future development in this area may be to use a benzodiazepine

antagonist to precipitate withdrawal and thereby greatly shorten the duration of

the withdrawal syndrome, because it can now be quite prolonged, lasting

several weeks. The key issue in using this approach will be the development of

a medication that prevents withdrawal-induced seizures in the presence of the

antagonist. Carbamazepine may meet this requirement but has not yet been

tested. After the sedative detoxification is finished, opioid withdrawal may then

be completed either by tapering the dosage of methadone or by clonidine

substitution (Gold et al. 1978).

For alcohol, the safest technique in combined abuse is to substitute

chlodiazepoxide for the alcohol and gradually decrease the dosage over 5 to 10

days, while maintaining the patient on methadone and then tapering the

methadone. Again, the alternative use of carbamazepine should be considered

(Butler and Messiha 1986). During withdrawal, the clinician must be prepared

to manage “impending DT,” because mortality from untreated DT may be as

high as 15 percent (Sellers and Kallant 1976). The mainstays of treatment are

providing sedation, maintaining fluid and electrolyte balance, preventing

hypoglycemia, and using anticonvulsants, as needed. Following detoxification,

use of disulfiram may be considered, although liver functioning must be

assessed and followed, because alcohol is a liver toxin.

In opioid addicts, the management of combined sedative and alcohol

withdrawal often requires an inpatient setting: for cocaine abusers, outpatient

detoxification from these other two substances may be more feasible. Although

the interruption of binges of cocaine abuse may require hospitalization for some

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patients, cocaine abusers sometimes are treated as outpatients with the use of

adjunctive medications to reduce cocaine-craving and to maintain abstinence

(Kosten 1989). For those cocaine abusers who are also dependent on alcohol

or sedatives, outpatient detoxification from either of these two nonstimulants

might be considered using either carbamazepine or clonazepam given in

tapering dosages over several days to treat alcohol (5 days of tapering) or other

sedatives (10 to 12 days of tapering) (Butler and Messiha 1986; Patterson

1988; Browne 1978). The cocaine would be discontinued abruptly without

needing detoxification. The major issue after stopping cocaine is careful

observation of the patient during the cocaine crash. The risks during a crash

can be substantial because a severe postcocaine depression may precipitate

suicide attempts or be associated with a paranoid psychosis, but this degree of

severity is unusual (Gawin and Ellinwood 1988). Thus, hospitalization may be

required for management of the cocaine abuse independent of other concurrent

drug dependence.

Detoxification from the combination of cocaine and opioid dependence usually

is managed in the outpatient setting. Detoxification from the opioid is needed if

long-term residential or outpatient naltrexone treatment is being considered, but

opioid detoxification is not needed for maintenance on methadone or on the

investigational medication buprenorphine. As indicated above, cocaine

dependence usually does not require inpatient treatment for detoxification, and

the most common treatment for these dually addicted patients is methadone

maintenance. For those entering residential treatment, opioid detoxification

using clonidine alone or clonidine with naltrexone precipitation of withdrawal

might be considered (Gold et al. 1978; Vining et al. 1988). Among those being

detoxified using clonidine, it is important that tricyclic antidepressants—a

treatment for cocaine abuse—not be started until the opioid detoxification is

complete, because the tricyclics may interfere with the withdrawal-suppressing

effects of clonidine.

PSYCHOTHERAPEUTIC APPROACHES FOR MULTIPLE DRUG ABUSERS

The psychotherapeutic approaches for multiple drug abusers are generally not

substantially different from the approaches for abusers of single drugs, although

different treatment models for alcohol and drug abuse have evolved that may

conflict at certain points. A great deal of discussion has been generated about

these conflicts in combined treatment for alcohol- and other drug-dependent

patients, but overall the literature is positive about the merits of combining

approaches (Carroll and Malloy 1977). The distinctions in program staffing and

procedures for treating multiple drug abuse, moreover, may depend on

distinctions that are not directly related to the types of drugs abused. For

example, Wesson and colleagues (1975) have suggested that “streetwise” and

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“non-streetwise” polydrug abusers require different types of treatment

programing. In developing psychotherapies for multiple substance abusers, two

issues need particular consideration: increased comorbid psychopathology and

insistence on complete abstinence from drugs, including alcohol.

Several diagnostic studies have found higher rates of psychopathology among

multiple drug abusers than among abusers of only a single drug. In a large

survey of opioid addicts that we conducted, the alcoholic opioid addicts had

significantly higher rates of affective disorders and personality disorders such as

borderline and antisocial personality (Rounsaville et al. 1982). A similar

analysis of cocaine-abusing opioid addicts found higher rates of depression and

antisocial personality disorder than in opioid addicts who did not abuse cocaine

(Kosten et al. 1986). Specific psychotherapeutic approaches have been

developed for depression, and the resources to provide these professional

services may be more frequently required when treating multiple drug abusers

(Rounsaville et al. 1983). Smith and Wesson (1981) have suggested that these

higher rates of psychopathology in polydrug abusers require more professional

psychological involvement in programs treating these patients.

A second issue in the treatment of multiple drug abusers is controlled alcohol

use among former alcohol abusers. Although complete abstinence from heroin,

cocaine, and sedatives is generally considered the treatment goal, some

serious consideration has been given to controlled drinking among “recovering”

alcoholics and may be considered among alcoholic methadone-maintained

patients (Gerston et al. 1977). This issue of abstinence versus controlled

drinking has been examined in a study by Stimmel and colleagues (1983) in

treating alcoholic methadone-maintained patients. They compared 36 control

patients with 42 patients entering an abstinence-oriented Alcoholics

Anonymous treatment and with 42 entering a controlled-drinking, behavior

modification program. During a 6-week educational period for the two treatment

groups, dropout was quite high (58 percent), making later comparisons difficult.

Furthermore, after 12 additional weeks of treatment, the only significant

difference was in 2-day alcohol consumption, and the abstinence-oriented

group had done worse than the control group. Overall, this study showed no

efficacy for additional psychotherapies aimed at alcoholism among alcoholic

methadone-maintained patients.

Psychotherapeutic approaches for substance abuse may involve self-help,

behavioral, cognitive, interpersonal, or family approaches. Woody and

colleagues (1983) have examined both a cognitive and a psychodynamic form

of therapy for methadone-maintained patients; it does not appear that any

specific changes would be needed to use these therapies with methadone

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patients who were abusing cocaine or alcohol. Family approaches to therapy

have been described for opioid addicts who are treated in either methadone

maintenance or naltrexone programs (Kosten et al. 1987; Stanton et al. 1982)

as well as for cocaine abusers (O’Malley and Kosten 1988). Behavioral

therapies have been described in conjunction with naltrexone treatment for

opioid addicts (Callahan 1980) and can be an important part of residential

treatment programs such as Daytop. Two particular forms of substance abuse

psychotherapy may require some modifications or additions for multiple drugs of

abuse: relapse prevention and interpersonal psychotherapy.

Relapse prevention (RP) therapy may require specific interventions for each of

several drugs abused by a polydrug user because it is based on precipitants

that have been identified as associated with risk of returning to abuse of each

drug (Marlatt and Gordon 1980). These precipitants, which include negative

emotional states, interpersonal conflict, social pressure, and specific drugrelated cues, may be quite different for different drugs of abuse. For example,

in a methadone-maintained patient, the precipitants for his or her using heroin

or cocaine may be closely related to being with particular “friends” and then

“getting high,” whereas the precipitants for that same patient to get intoxicated

with alcohol may be interpersonal tension with his or her spouse. Selfmonitoring is used to identify risk situations for the specific drug, and then

coping strategies are developed using rehearsal of coping behaviors such as

anger management and social skills. RP focuses on ensuring that brief lapses

to drug use or drinking do not become full relapses by reframing a lapse as a

discrete isolated event that is not uncommon in recovery and does not nullify all

progress. Reducing this “abstinence violation effect” by reframing uses

generally the same approach for all drugs of abuse, although in multiple drug

abusers sequential lapses involving each drug must be prevented by carefully

emphasizing the importance of abstinence and not giving “permission” for

experimenting with isolated use of the various abused drugs. Thus, RP has

several areas in which management of the multiple drug abuser may require

some modification and additional emphasis.

Interpersonal psychotherapy (IPT) was first developed as a treatment for

depression and was adapted for opioid addicts and later for cocaine abusers by

Rounsaville and colleagues (1983, 1985). This psychotherapy for substance

abusers is based on the premise that drug abuse is one way in which an

individual attempts to cope with problems in interpersonal functioning. An

exploratory stance is used to focus on interpersonal relationships and on the

impact of drug abuse on these relationships. In helping the patient stop his or

her substance abuse, the important components of treatment include

documenting the adverse effects of the drugs compared with their perceived

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benefits, identifying the thoughts and behaviors that precede drug use, and

developing strategies to deal with drug-related cues and high-risk situations.

Only after attaining abstinence are interpersonal difficulties directly addressed,

including the roles of drug use in these relationships.

A key strategy with IPT is to develop more productive means for achieving the

desired social gratification or tension reduction for which the drug abuse

substitutes. This substitution may differ markedly for various drugs that a

multiple drug abuser may be using. For example, the abuser may be using

cocaine to reduce social isolation and “meet exciting new people” but be

abusing alcohol because the cocaine crash is reduced by the alcohol. Because

only the cocaine, and not the alcohol, is directly related to the social deficit, only

the cocaine abuse will directly benefit from interpersonal therapy. In general,

the interpersonal impact will be somewhat different for abuse of licit drugs such

as alcohol, illicit drugs such as heroin and cocaine, and “doctor-shopping” drugs

such as benzodiazepines. Among heroin addicts, for example, the licit drugs

(such as alcohol) are often used in response to interpersonal tension, whereas

the illicit drugs (such as cocaine) lead to consequences of increased

interpersonal tension, rather than being used in response to tension. In

summary, interpersonal therapy must distinguish the relationship of each

particular drug to the interpersonal setting as either primary association or

secondary to other drug effects and as either a tension reliever or inducer.

MAINTENANCE PHARMACOTHERAPIES FOR MULTIPLE DRUG ABUSERS

Maintenance pharmacotherapies have been developed for opioid dependence,

and to a lesser extent, for alcohol and cocaine dependence, but no specific

maintenance pharmacotherapy has been developed for sedative dependence.

Maintenance pharmacotherapies have developed from somewhat different

rationales for each of the abused drugs: agonists (methadone) or antagonists

(naltrexone) for opioids, aversive agents (disulfiram) for alcohol, and anticraving

agents (desipramine, amantadine) for cocaine. In general, the preferred

approach in using pharmacotherapy for the multiple drug abuser would be to

select a single medication to manage all abused drugs or at least the most

problematic drug of abuse and then use nonpharmacological approaches for

the other abused drugs. The various agents used to treat each abused drug

can be combined for multiple drug abusers; however, this type of polypharmacy

has been assessed systematically only in the combined treatment of

methadone-maintained alcoholic or cocaine-abusing opiate addicts.

The simplest approach for the pharmacotherapy of multiple drug abusers is to

use a single medication that would reduce the abuse of all the drugs involved.

The pharmacological mechanism for such a medication might be quite different

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for its effects on each of the abused drugs, but the net effect would be reduction

in use of all. The closest approximation to such a medication for opioid,

cocaine, and alcohol dependence is naltrexone, a long-acting opioid antagonist

used primarily in the treatment of opioid addicts (Kosten and Kleber 1984).

Recent data have suggested that it may also decrease relapse to alcohol abuse

by preventing “slips” or relatively brief lapses into alcohol use from developing

into full alcoholic relapses (Volpicelli, unpublished manuscript). The efficacy of

naltrexone in reducing cocaine abuse has not been subjected to a placebocontrolled, randomized clinical trial, but preliminary data have shown

significantly less cocaine abuse in naltrexone- than in methadone-maintained

former opioid addicts (Kosten et al. 1989a). If compliance with naltrexone

treatment can be maintained through nonpharmacological approaches, this may

be a viable pharmacological treatment for some drug abusers who are involved

with any of these three drugs.

Another medication that may be useful for more than one abused drug is

buprenorphine (Lewis 1985). This partial opioid agonist has been shown to

reduce opioid abuse in both outpatient clinical and inpatient experimental

human studies (Mello and Mendelson 1980; Bickel et al. 1988a; Kosten and

Kleber 1988). More recent work has suggested that it may reduce cocaine

abuse among cocaine-abusing opiate addicts (Kosten et al. 1989a, 1989b), but

double-blind, controlled studies comparing 6-month maintenance on

buprenorphine to methadone are not yet available. Buprenorphine may have

much greater potential than naltrexone because of its greater acceptability and

better treatment retention, although no data suggest that buprenorphine shares

naltrexone’s utility for treating alcohol dependence.

The most important maintenance treatment for opioid addicts is methadone

maintenance. Within this treatment modality, several clinical trials have

examined the utility of multiple pharmacotherapies for alcohol and for cocaine

abusers. For alcohol abuse, disulfiram has been examined; and for cocaine

abuse, desipramine and amantadine have been examined in placebo-controlled

trials, although some pilot trials also have been done.

Liebson and colleagues (1973) used disulfiram in six methadone-maintained

patients randomized to receive disulfiram on either a contingent or a

noncontingent plan over a 3-month study period. Four of the six were in a

crossover design. The contingency consisted of getting their daily dose of

methadone only after ingesting the disulfiram. During the contingency alcohol

abuse was significantly less—22 of 128 days drinking, or 17 percent drinking

days for noncontingency, vs. 3 of 274 days, or 1 percent for contingency

periods. During the noncontingency periods, patients would stop taking the

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disulfiram and consume alcohol. A key point of this study was not the efficacy

of disulfiram but the efficacy of the delivery system and of developing an

effective strategy for compliance with disulfiram. With good compliance,

disulfiram can be effectively combined with methadone maintenance for

alcoholic opioid addicts. These investigators replicated this study in 25

methadone patients and found similar encouraging results (Liebson et al. 1978).

A similar small study was reported recently by Bickel and coworkers (1988b). In

this study, disulfiram ingestion was linked to methadone clinic privileges, and

this significantly reduced drinking days and improved laboratory measures of

liver function. Although these small studies do not appear to have been

followed by any larger studies, a major Veterans Administration cooperative

study comparing disulfiram with placebo in 605 alcoholics (not on methadone

maintenance) concluded that disulfiram did lead to significantly fewer drinking

days and that medication compliance was associated with patients remaining

completely abstinent from alcohol (Fuller et al. 1986). The methadone

maintenance field is clearly ripe for a larger study of this use of disulfiram.

The treatment of cocaine-abusing opiate addicts is becoming one of the most

well-researched areas in the treatment of multiple drug abusers. Placebocontrolled trials are being conducted with desipramine, amantadine, and

buprenorphine, and several other medications, including mazindol and

bromocriptine, have been investigated in pilot studies. The pilot studies with all

five of these agents had been quite promising, but early results from the

placebo-controlled studies have not confirmed the initial hopes for these agents.

In a pilot study of desipramine among 16 methadone-maintained cocaine

abusers, desipramine-treated patients over an 8-week trial had significantly less

cocaine craving and abuse than did untreated patients in the same program

(Kosten et al. 1987c). In a double-blind, placebo-controlled 12-week study by

Arndt and colleagues (1988) and in a similar controlled study (Kosten et al.

1989), however, desipramine was not found to be superior to placebo

treatment. The first 51 patients completing the Arndt study were presented

recently and shown to have very high rates of cocaine-positive urines, with 78

percent of the desipramine and 74 percent of the placebo urines being positive.

An even more discouraging finding was that at the 3- and 6-month followups

after discontinuing medications the desipramine group’s urines were 78 percent

and 80 percent positive for cocaine, whereas the placebo group’s urines were

46 percent and 38 percent positive for cocaine, suggesting that patients on

methadone maintenance treated with desipramine may do less well in the long

run. Twenty-one methadone-maintained, cocaine-abusing patients treated with

desipramine and 18 treated with placebo were analyzed in a double-blind study

of desipramine. Neither craving nor use of cocaine was reduced significantly

145
below that of placebo treatment, and abstinence was attained by 55 percent of

the placebo group and only 38 percent of the desipramine group. Thus,

although the initial data were quite encouraging, both controlled studies indicate

the limitations of desipramine for this population of multiple drug abusers.

Similar promising pilot data have been presented for amantadine in 12

methadone-maintained patients, including 3 who remained abstinent for 2

months after treatment (Handelsman et al. 1988). We are currently conducting

a double-blind, placebo-controlled 8-week trial of amantadine in methadone

patients and have compared 20 amantadine-treated patients with 18 placebo

patients (Kosten et al. 1989). Although amantadine reduces cocaine-craving

significantly more than placebo, it does not have a significantly greater impact

on cocaine use. Both amantadine and placebo have been associated with a

reduction in cocaine use of more than 50 percent. A larger sample is being

accumulated in this study, and subsequent analyses will examine various

prognostic stratifications, such as comorbid psychopathology, to detect any

subgroups of patients for whom amantadine may be particularly useful.

Pilot studies using bromocriptine and mazindol in methadone-maintained

patients have demonstrated decreases in craving and use of cocaine (Berger et

al. 1989; Kosten et al. 1988). Bromocriptine has had some limitations in its

acceptability to patients due to side effects of headache, nausea, and vomiting;

whereas mazindol has not demonstrated these problems and methadone

patients have demonstrated good compliance in its use. Because mazindol has

some stimulant properties and is related to amphetamines, there is concern that

it might increase craving and use of cocaine. Although this has been a problem

with the therapeutic use of another stimulant, methylphenidate, there was no

increased craving using mazindol with 15 patients treated for up to 2 months

(Gawin et al. 1985). Controlled clinical trials with this medication therefore

seem indicated.

CLIENT ISSUES IN ADDRESSING MULTIPLE DRUG ABUSE

The treatment of multiple drug abuse clearly depends on the specific

combination of drugs being abused. Controlled studies are available for opioid

and either cocaine or alcohol dependence, and these studies suggest that

pharmacotherapy can be a useful adjunct to treatment. In general, monitoring

of treatment compliance and illicit drug use are essential, including randomized

urine monitoring. The matching of patients to specific types of treatment in this

area has not been considered from a research perspective, but there is a fairly

clear hierarchy in using various treatment options, starting with

nonpharmacological agents and proceeding through single agents in

combination with psychotherapy to multiple agent pharmacotherapy. This

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multiple agent pharmacotherapy might include such combinations as

methadone plus disulfiram for alcoholic opioid addicts, methadone plus

amantadine for cocaine-abusing opioid addicts, or desipramine plus disulfiram

for cocaine-abusing alcoholics. Much more work will need to be done on

specific modifications of available, structured psychotherapies and on

combination pharmacotherapies as the client population increasingly becomes

multiple drug abusers.

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ACKNOWLEDGMENT

Support was provided by National Institute on Drug Abuse grants DA-04060,

DA-04505, DA-05626, and DA-00112.

AUTHOR

Thomas Kosten, M.D.

Acting Director

Substance Abuse Treatment Unit

Psychiatry Department

Yale University School of Medicine

27 Sylvan Avenue

New Haven, CT 06511

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Addressing Psychiatric Comorbidity

George E. Woody, A. Thomas McLellan, Charles P. O’Brien, and

Lester Luborsky

INTRODUCTION

This chapter provides an overview of responses that treatment programs may

consider for patients with substance abuse dependence who have additional

psychiatric disorders. These patients are commonly labeled as having dual

diagnoses, often nicknamed “double trouble.” Such patients can present

difficult management problems, and they usually identify themselves

immediately to treatment staff by demands for attention or other extreme

behaviors. Much time is spent trying to help them, often with few positive

results (McLellan et al. 1963). Many clinicians believe that dual diagnosis

patients are being seen more often now than in years past, and most programs

struggle to find ways to manage them.

IDENTIFYING CAUSALITY

A first step in developing an effective response is to identify the approximate

cause of the psychiatric disorder(s), which can be more complicated than it

appears. For example, many drugs of abuse can cause psychiatric disorders.

The form and duration of these disorders is influenced by the class of drug

being abused, the duration of drug use, and individual sensitivities to drug

effects and whether the patient is experiencing the effects of acute drug

administration or withdrawal.

Disorders Related to Drug Administration

One of the best documented psychiatric disorders induced by drug

administration is depression resulting from alcohol dependence. Mendelson

and Mello (1966) and Mendelson (1964) showed that the administration of

alcohol to alcoholics was perceived as improving one’s mood immediately

following consumption, but the long-term consequence of continued selfadministration was a clearly measurable increase in depressive symptoms.

Accordingly, alcoholics usually have depressive symptoms on admission to

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treatment, but most symptoms disappear with abstinence during the first several

weeks of treatment (Schuckit 1983). Another drug-induced psychiatric disorder

is paranoia secondary to stimulant abuse. A third is aggressive behavior,

hallucinations, and paranoid ideation following phencyclidine abuse. Each of

these substance-induced disorders can develop rapidly, and each usually

disappears within hours or days following discontinuation of drug use.

Disorders Related to Withdrawal

Common psychiatric symptoms that result from drug withdrawal are anxiety and

depression following discontinuation of sedatives, narcotics, or alcohol and

depression following discontinuation of stimulants. As in the case of psychiatric

symptoms that are caused by acute drug administration, symptoms caused by

drug withdrawal usually disappear within a relatively short period.

Residual Drug Effects

In some cases, drug-induced psychiatric disorders seem to remain for extended

periods. Such conditions, often termed “residual drug effects,” were the subject

of a recent National Institute on Drug Abuse (NIDA) technical review meeting

(Spencer, in press). A study by McLellan and colleagues (1979) is especially

pertinent in this regard. These investigators followed a group of patients who

were readmitted for substance abuse treatment to the Coatesville Veterans

Affairs Medical Center at least once every 6 months for 6 years. As suggested

by the history of repeated admissions, these patients were some of the most

refractory and chronic substance abusers treated at that institution during the

years 1972-78, when the study was conducted. All subjects had a psychiatric

interview on admission and were administered the Minnesota Multiphasic

Personality Inventory (MMPI) approximately 2 weeks after hospitalization. This

2-week interval was sufficient for most acute drug effects to have disappeared,

thus minimizing the chances for acute effects to interfere with the MMPI scores

or psychiatric assessments. The patients studied were grouped into three

categories based on the class of drugs that they used: stimulants (mainly

amphetamines at that time; today, cocaine would be the stimulant drug of

choice); depressants (barbiturates, methaqualone, glutethamide,

benzodiazepines); and narcotics (heroin, hydromorphone, methadone).

Demographic variables and MMPI scores were similar for all subjects at their

first admission. Patients differed only in the drugs that they typically abused at

this early stage in their drug-taking career. However, a much different picture

emerged over the period of study. The stimulant group developed significant

increases in schizophrenic-like symptoms, especially paranoia. The sedative

abusers developed increases in depressive symptoms, cognitive impairment,

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and anxiety. The narcotic addicts had elevations in depression and sociopathy

on admission, but unlike the abusers of other drug classes, these symptoms

remained unchanged over the 6-year period.

These psychiatric effects were minimally influenced by acute drug effects or by

drug withdrawal because the evaluations were done at least 2 weeks after

admission. The results were interpreted as indicating that prolonged use of

stimulants can be associated with the emergence of schizophrenic-like

symptoms, that prolonged use of depressants can produce depression, and that

prolonged narcotic administration results in no increase in psychiatric

symptoms. Thus, of these three drug classes, two seemed capable of

producing residual effects. Only narcotics appeared to be free of significant

“psychotoxicity.”

These conclusions must be considered tentative, however, due to

methodological problems. Because the patients were observed only after the

drug use had started, it was impossible to be certain that the effects were due

only to the drug and not to an underlying, nondrug condition that would have

emerged even in the absence of drug abuse. Nevertheless, the tentative

conclusions are intuitively sensible because the apparent residual disorders that

emerged are consistent with psychiatric disorders that can be caused by the

acute effects of each drug class, which logically might become persistent as a

consequence of prolonged dependence.

Many other examples of drug-induced psychiatric disorders could be provided,

and most of these are included in the section entitled “Psychoactive SubstanceInduced Organic Mental Disorders” of the Diagnostic and Statistical Manual,

Third Edition, Revised (American Psychiatric Association 1987). One of the

most common of these is cognitive impairment that is associated with alcohol

dependence.

Problems of Differential Diagnosis

As seen in the above discussion, the etiology of symptoms that are seen in the

psychiatrically ill substance abuser often presents problems of differential

diagnosis, which can be summarized as acute drug effects (agonistic), drug

withdrawal effects (antagonistic), persistent (residual) drug effects, or underlying

(nondrug) conditions.

Of course, these conditions are not mutually exclusive. For example, a patient

can demonstrate psychiatric symptoms that are either acute or result from

withdrawal and, at the same time, have an underlying nondrug condition that, in

turn, may be accentuated by either acute drug effects or by withdrawal.

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Thus, the problems of differential diagnosis can be subtle and may require a

reasonably thorough knowledge of psychopharmacology, psychiatry, and drug

abuse. Accurate identification of the cause of psychiatric symptoms is

important in designing a treatment plan. For example, a specific psychiatric

treatment might be attempted if the therapist or program staff determines that

the patient has either an underlying psychiatric disorder or a psychiatric

condition that is probably a residual drug effect and is persistent and produces

significant impairment. A disorder that is primarily drug-induced and is not a

residual drug effect will usually disappear shortly after drugs are stopped, and

patients with this disorder need no treatment except effective drug-focused

therapy.

NIDA STUDIES ON PSYCHOPATHOLOGY AND ADDICTION

NIDA has had a particular interest in the relationship between psychopathology

and addiction (Blaine and Julius 1977) and, as a consequence, funded a series

of studies on this topic during the late 1970s and early 1980s. These studies

were developed before the cocaine epidemic; thus, their focus was on the types

and frequencies of psychiatric disorders that are seen among opiate addicts.

The patients in these studies, though addicted primarily to opiates, often were

abusing other drugs as well. Most of the diagnostic interviews were done while

patients were stabilized on methadone, thus reducing the chances for including

psychiatric symptoms that were caused by acute drug effects or withdrawal.

Three such studies were done in different locations (New Haven, Philadelphia,

and Boston), and all obtained very similar results. These have been described

in a series of published reports (Khantzian and Treece 1985; Woody et al.

1988; Rounsaville et al. 1982, 1988) and are briefly summarized as follows. All

found that 80 to 85 percent of the methadone patients had a range of

psychiatric disorders in addition to opiate dependence, either currently or in the

past. The most common (occurring in 50 to 60 percent of the patients) were

depressive disorders, usually major depression. Antisocial personality was

found in approximately 20 to 50 percent of each sample, depending on whether

the Research Diagnostic Criteria or the Diagnostic and Statistical Manual, Third

Edition, criteria were used. Alcohol dependence, either current or past, was

found in 15 to 25 percent; anxiety disorders were found in 10 to 20 percent; and

an assortment of other problems, often reflecting disorders of mood (such as

labile personality or bipolar II disorder), was found in 2 to 10 percent.

The New Haven study also evaluated a group of addicts who were not in

treatment and found the same types of problems as in the treated sample;

however, the out-of-treatment subjects had fewer disorders (Rounsaville and

Kleber 1985). One interpretation of this finding was that coexisting psychiatric

155
problems may have contributed to the decision to enter treatment. Thus, these

studies supported the impressions of many clinicians that opiate addicts

commonly have dual diagnoses and gave impetus to studies of combined

treatments for psychiatric disorders and addiction.

OVERVIEW OF TREATMENTS AND ORDER OF APPLlCATlON FOR DUAL

DIAGNOSIS PATIENTS

Treatments

The treatments that have been used are generally similar to those applied to

psychiatric disorders in nondrug-abusing patients. They include psychotherapy,

pharmacotherapy, behavior therapy, or combinations of one or more of these

modalities. These treatments usually are modified according to the special

needs of the drug-abusing patients. They are delivered or supervised by

psychiatrically trained staff (psychiatrists, psychologists, social workers) and are

combined with a drug-focused therapy that is usually administered by

paraprofessionals. Although substance abuse patients who have little

additional psychopathology often show rapid and significant improvement in

response to counseling by paraprofessionals, the psychiatrically ill substance

abuser may show exacerbated psychopathology (McLellan et al. 1994). These

dual diagnosis patients usually require more sophisticated supervision and

treatments (including pharmacotherapy) than can be applied by

paraprofessionals atone.

Order Effects

An important point pertains to the order of treatment efforts, that is, which

problem should be addressed first—drug use or associated psychiatric

symptoms. In general (exceptions are patients who are suicidal, homicidal, or

schizophrenic), the drug problem must be stabilized first. Furthermore, it must

be continuously monitored concurrent with any additional psychiatric care that is

administered. Psychiatric care alone is often inappropriate, and sequential and

separate treatments (i.e., drug only followed by psychiatric alone) increase the

chances for patient relapse and dropout. It seems best to integrate both

approaches into a treatment package that is delivered continuously.

SPECIFIC TREATMENTS

Psychotherapy

In a psychotherapy study that was done with methadone-maintained opiate

addicts, it was found that additional professional psychotherapy was a useful

156
adjunct to paraprofessional drug counseling services for methadone-treated

opiate addicts (Woody et al. 1989). In this study, methadone patients who were

entering a new episode of treatment were randomly assigned to one of three

treatment conditions: drug counseling (DC), counseling plus supportiveexpressive psychotherapy (SE), or counseling plus cognitive-behavioral (CB)

psychotherapy. Patients in all groups made gains, but those receiving the

additional psychotherapies showed more positive changes than those who

received DC alone. The data also showed potentially important interactions

between patients and treatments, which are discussed below.

Psychiatric Severity. The first was that between psychiatric severity and

outcome. Previous studies have shown that a global rating of psychiatric

severity is the best predictor of outcome for both opiate addicts and alcoholics

being treated in a range of outpatient and inpatient programs. This work

showed that patients with few additional psychiatric symptoms (termed “lowseverity” patients) generally did well in all programs. Patients with high

symptom levels generally did poorly, and midseverity patients had intermediate

outcomes that were particularly sensitive to patient/program matches (McLellan

et al. 1983).

Accordingly, the data were examined, looking especially for interactions

between psychiatric severity, outcome, and treatment condition. It was found

that there were few differences in outcome between groups in low-severity

patients among the three treatment conditions. However, high-severity patients

who received psychotherapy showed gains, but little progress was made if they

received drug counseling alone. Midseverity patients showed more gains with

psychotherapy than with counseling alone, but patients in each treatment

condition improved in several areas. The conclusion was that the addition of

psychotherapy altered the traditional relationship between high psychiatric

severity and poor outcome and that the extra treatment gave this group of more

disturbed patients a better chance to benefit from methadone (Woody et al.

1984).

This finding pointed toward a possible cost-effective use of psychotherapy in

which high-severity patients can be identified early in treatment, provided

additional therapy, and, thus, given a better chance to improve. In addition to

providing a better chance for these problematic patients to benefit from

treatment, this plan also could reduce the strain and the time demands that

these patients place on program staff (Woody et al. 1986).

Antisocial Personality Disorder. The second interaction examined was that

between antisocial personality disorder (ASP) and outcome. Many opiate

addicts have ASP, and people with this diagnosis typically do not respond well

157
to treatment. However, a literature review indicated that there are probably

many subtypes of ASP and that some patients with this diagnosis may be

“therapy responsive.” With this in mind, we examined those with ASP and

found that approximately half had other Axis I diagnoses—most commonly,

depression. We then examined four groups of patients who received

psychotherapy: (1) those with a diagnosis of opiate dependence only;

(2) those with opiate dependence and depression; (3) those with opiate

dependence, depression, and ASP; and (4) those with opiate dependence and

ASP only.

We found that patients in groups 1 and 2 showed gains in many areas,

especially those in group 2. Patients in group 3 also showed considerable

progress, but not quite as much as those in the first two groups. In contrast,

patients with only opiate dependence and ASP (group 4) showed gains only in

a few measures of drug use, but no significant changes in other areas (Woody

et al. 1985). Thus, this analysis not only confirmed the impression that ASP is a

negative predictor of outcome but also indicated that patients with depression

accompanying their ASP can respond to therapy. One possible explanation is

that those with depression have more capacity to relate to people and events

and to experience such feelings as guilt or loss; another is that depression is a

psychiatric problem that is responsive to psychotherapy and that patients with

ASP and depression responded simply because they happened to have an

associated condition that is amenable to treatment.

Therapist Assignment. The third analysis of patient/therapy interactions

examined outcome according to therapist assignment. Psychotherapy studies

have traditionally examined outcome according to treatment assignment. There

have been attempts to examine the qualities that are associated with successful

outcome, but most studies have paid little attention to examining the interaction

between therapist assignment and outcome within a specific treatment modality.

This study employed 5 SE and 4 CB therapists and 13 counselors, which

provided the opportunity to see if therapist assignment and outcome were

related. From each modality, three therapists and counselors were chosen who

had treated at least seven study patients, and the overall outcomes of these

patients were compared according to therapist assignment.

The data showed that there were significant differences in outcome, as judged

by the average effect size produced by individual therapists. One SE therapist

had a large effect, whereas another had little effect and, in some cases, may

have made patients worse. Similar but less dramatic variability in outcomes

was seen for CB therapists and drug counselors. Variability in outcome

according to therapist assignment also was found by Luborsky and colleagues

(1986) in an analysis of results from other psychotherapy studies and by

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McLellan and coworkers (1988) in a study of outcome according to counselor

assignment. Further analyses indicated that these differences were associated

most strongly with the ability of the therapist to form a “helping relationship” with

the patient and a second but weaker association was that between outcome

and the application of specific techniques (Luborsky et al. 1985).

Throughout all analyses, both the SE and CB therapies generally were

associated with similar amounts of improvement; thus, we found no advantage

for one therapy over the other with this population. The differences in outcome

among SE, CB, and DC patients who were seen at 7 months also were seen at

the 12-month followup, 6 months after therapy ended (Woody et al. 1987).

In brief, our experience with this study showed that the additional therapy could

provide meaningful benefits to opiate-addicted veterans being treated in the

methadone program, particularly those with significant psychiatric symptoms in

addition to the addiction. More detail about the techniques used and the overall

results is available in two recent publications (Woody et al. 1986; Woody 1989).

It is important to emphasize that this work was a combined counseling/

psychotherapy and pharmacotherapy study. All these ingredients were

necessary to achieve the final results. The patients would not have been

available for therapy without the methadone; the concrete services and drugfocused therapy provided by the counselors helped manage the addiction and

many of the associated social problems; and the psychotherapists provided

additional help for those with the more complicated psychiatric problems.

Pharmacotherapy

This is a potentially important adjunct to drug treatment for dually diagnosed

patients, but several issues must be considered if it is to be used.

First is the choice of drugs. Substance abusers often will attempt to “get high”

on anything that is prescribed; thus, special care must be taken in the choice of

drugs. Some psychotropic drugs that have little abuse potential in other

populations have significant abuse liability in this population. The reasons for

these differences are not always clear but may be attributable to drug

interactions that are seen only among substance-abusing patients simply

because they experiment with drugs. An example is the combined use of

benzodiazepines, such as diazepam or alprazolam, with methadone. This

combination appears to produce a clinically significant “high” that is not obtained

when either drug is used alone (Cappell et al. 1986). Another is the use of

pentazocine tripelennamine (“Ts and Blues”) or of glutethimide combined with

159
codeine-containing cough syrups or acetaminophen (Tylenol) with codeine

(“pancakes and syrup,” “combos,” “sets”). In all these cases, the drug

combination is abused to a much greater extent than any single drug that is part

of the combination.

A second issue is that of compliance. Because substance abusers often do not

follow instructions, attention must be given to compliance with the

recommended dosing schedule, especially during the early stages of

pharmacotherapy. One method that has been used successfully in methadone

programs is to prescribe the ancillary psychotropic medication daily along with

the daily dose of methadone.

One pharmacotherapy that has been tested in this population is doxepin for

depressed methadone-maintained opiate addicts. As of this writing, there are

four studies that show that doxepin can be a useful adjunct for these patients

(Woody and O’Brien 1986). The studies do not suggest that doxepin reduces

illicit drug use but rather that it reduces depression and anxiety and thus

contributes to a better overall treatment result. Other pharmacotherepies that

have been used but not studied are oxazepam for anxiety disorders, which,

unlike diazepam, has a low abuse liability with this population (Griffiths et al.

1984); antipsychotics such as haloperidol for addicts with schizophrenia; and

lithium for addicts with bipolar disorder (Kleber 1988).

An important consideration in adjusting doses of adjunctive psychotherapeutic

medications is that some drugs that are abused or taken therapeutically may

alter the metabolic pathways of other psychotropic agents, for example, the

inhibition of metabolic pathways of certain psychotropic agents that can be

produced by methadone. This has been shown recently with desipramine;

blood levels were doubled when patients were maintained on methadone

(Maany et al. 1989). Thus, the doses of some psychotropic agents that are

necessary to produce clinical effects may be lower in methadone patients.

Behavioral Treatments

Behavioral interventions are used in almost all drug programs to suppress

antisocial behavior. These interventions commonly take the form of rules and

regulations about standards of behavior while in treatment and include

sanctions for those who break the rules. These range from loss of privileges

(such as take-home doses of methadone) to outright suspension from treatment

in the case of infractions that jeopardize the integrity or safety of the program.

Examples are forging prescriptions with the program physician’s name, selling

drugs on the premises, making threats, or fighting. The specific content of the

rules varies among programs, but very few have no rules. Rules are especially

160
important because ASP is a common diagnosis among addicts and because

many have developed patterns of antisocial behavior as a consequence of their

addiction. The rules usually are combined with considerable support. The

message to the patient is that staff will try its hardest to help them, but that

certain behaviors will not be tolerated.

AVAILABILITY OF RESOURCES

Necessary components for managing the dually diagnosed substance abuser

include inpatient beds and psychiatrically trained staff members who can

prescribe psychotropic medications. Even under the best circumstances, these

patients occasionally need inpatient treatment, which might be necessary to

detoxify them from a highly dangerous form of addiction such as dependence

on cocaine or sedatives, to protect them from suicidal or homicidal impulses, or

to treat a psychotic episode such as stimulant-induced paranoia or acute

schizophrenia. Most inpatient treatment episodes can be relatively brief (1 to 2

weeks, occasionally even less), but it is sometimes necessary to extend

hospitalization for 3 to 4 weeks.

It is difficult for an outpatient program to assume the responsibility for treating

dually diagnosed patients without knowing that a good inpatient service is

available to support them when symptoms are extremely severe and

unmanageable in an outpatient setting. Similarly, a psychiatrically staffed

outpatient drug treatment program that can prescribe psychotropic medication is

essential for followup after hospital discharge. In many cases, psychiatrically

impaired patients can be treated entirely in the outpatient program by the

combined use of counseling/psychotherapy and pharmacotherapy.

STAFF INPUT AND COORDINATION

As can be seen in the above discussion, the delivery of treatments for dually

diagnosed substance abusers/addicts requires meaningful input and

coordination among professional staff (physicians, nurses, clinical

psychologists, social workers), program management personnel, and

paraprofessional drug counselors. In addition to a decrease in psychiatric

symptoms, effective psychiatric treatments for dually diagnosed patients usually

will produce a reduction in behavioral problems, fewer crises, and an improved

ability of the overall treatment program to provide services to a wider range of

patients. Drug use may also decrease, probably indirectly as a result of the

patients having fewer psychiatric symptoms, which prompt attempts at selfmedication. While delivering these additional treatments, it is important to

remain focused on the drug problems and not be distracted into a singular

161
emphasis on treating the additional psychopathology. These treatments are

combined with counseling and other drug-specific therapies, and they are not

meant to substitute for them, although they may serve to further reduce drug

use and produce additional gains in important areas such as employment.

PRACTICAL CONSIDERATIONS IN TREATING DUAL DIAGNOSIS

PATIENTS

This chapter cannot end without commenting about some of the practical issues

that arise in attempting to use the interventions described above. Any attempt

to treat the dually diagnosed substance-abusing patient, especially in most

publicly funded treatment programs, immediately confronts a series of

problems. One of these is the staffing patterns of many drug treatment

programs; another is the availability of resources.

Staffing Patterns

The following advertisement from the Philadelphia lnquirer demonstrates a

potential staffing problem:

Philadelphia Inquirer

Sunday April 10, 1988

COUNSELOR For D/A Prog.

Full Time. No Experience

Necessary. $12,000 Send

resume to: XXX XXXXX XX

Phila. Pa.

It is obvious that programs staffed with people who have the lack of training

reflected in this advertisement are poorly equipped to effectively treat the more

complex dual diagnosis patients. Problems of diagnosis, appropriate treatment

recommendations, and improper responses to symptomatic affects and

behavior are some of the issues that will be likely to arise when minimally

trained staff interacts with the psychiatrically impaired substance abuser.

An additional problem is that many programs have little physician coverage.

Programs often rely on the local community mental health center to provide

psychiatric services, but in many areas these services are marginal at best.

Thus, even if the programmatic staff makes correct diagnoses and treatment

recommendations, no one is readily available to deliver treatment, especially it it

involves psychopharmacology. In some cases, programs have a “drug-free”

philosophy that totally eliminates the possibility of pharmacotherapy, even if

these services are available at a nearby clinic.

162
Resource Availability

Many programs have no or very restricted access to inpatient beds that accept

substance-abusing patients with accompanying psychiatric disorders. In

addition, many programs are located in places that are unattractive to nurses,

psychologists, physicians, and other personnel who are necessary to deliver the

appropriate treatment services for dually diagnosed patients. Even if funds are

available to supply the additional staffing, many programs have great difficulty in

recruitment on the basis of location alone. Therefore, it is difficult to discuss

management of dual diagnosis patients without including programmatic issues,

which also are discussed in other chapters of this volume.

SUMMARY

Research studies indicate that addressing psychiatric comorbidity can improve

treatment for selected groups of substance-abusing patients. However, the

chances for implementing the necessary techniques on a large scale are

compromised by the absence of professional input and guidance within

programs. This is especially true in public programs, which treat some of the

most disadvantaged, disturbed, and socially destructive individuals in the entire

mental health system.

One starting point for upgrading the level of knowledge and training of staff

members who work in this large treatment system could be to develop a better

and more authoritative information dissemination network. Such a system

exists in medicine; physicians are expected to read appropriate journals and to

guide their treatment decisions using the data contained in the journals.

Standards of practice and methods for modifying current practice are within the

tradition of reading new facts, studying old ones, and comparing treatment

outcome under different conditions with what is actually being done. No such

general system of information-gathering or -sharing exists, particularly in public

treatment programs. One of the most flagrant examples of this “educational

shortfall” can be found among those methadone programs that adamantly insist

on prescribing no more than 30 to 35 mg/day for all patients, in spite of the

overwhelming evidence that these dose levels generally are inadequate. In

some cases, program directors are unaware of studies that have shown the

relationship between dose and outcome. In other cases, they are aware of the

studies but do not modify their practices accordingly. This example of

inadequate dosing is offered as an example of one situation that could be

improved by adherence to a system of authoritative and systematic information

dissemination.

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Many issues in substance abuse treatment do not lend themselves to

information dissemination as readily as that of methadone dosing. However,

the existence of a general information/education system about substance abuse

treatment, combined with adherence to it among care providers, not only would

provide helpful data for treatment staff but also might stimulate their curiosity

and initiative. These latter qualities, along with additions to existing treatment

resources, may in the long run serve as the best guarantee for improvement

and maintenance of quality care.

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195.

AUTHORS

George E. Woody, M.D.

Clinical Professor

A. Thomas McLellan, Ph.D.

Clinical Professor

Charles P. O’Brien, M.D., Ph.D.

Professor

Lester Luborsky, Ph.D.

Clinical Professor

Drug Dependence Treatment and Research Center

University of Pennsylvania

Drug Dependence Treatment Unit

Veterans Affairs Medical Center

Building 7

39th and Woodland Avenues

Philadelphia, PA 19104

166
Are There Minimum Conditions

Necessary for Methadone Maintenance

To Reduce Intravenous Drug Use and

AIDS Risk Behaviors?

Anna Rose Childress, A. Thomas McLellan, George E. Woody,

and Charles P. O’Brien

INTRODUCTION

With the rapid spread of acquired immunodeficiency syndrome (AIDS) among

intravenous (IV) drug users, particularly opiate addicts, the need for an effective

and acceptable form of drug abuse treatment is even more important than in

years past. Methadone maintenance has been an inexpensive and well

accepted (by patients, if not society) form of treatment for opiate dependence,

and many have called for a rapid expansion of methadone programs. How this

expansion should occur is far from decided and is often controversial. Should

rehabilitative services (counseling, medical, psychiatric, and vocational

interventions) be eliminated, using the resulting funds to create more treatment

slots in programs offering “methadone alone”? Or would removal of these

rehabilitative services drastically reduce the effectiveness of the pharmacologic

intervention, rendering it nearly useless in the battle against IV drug use and

AIDS? Furthermore, can it be demonstrated that increased rehabilitative

services would actually result in increased treatment effectiveness and,

therefore, be more cost-effective than minimal (methadone only) treatment?

The first part of this chapter reviews the background and available evidence on

these questions, and the second part introduces a recently begun research

study that directly investigates the minimum conditions necessary for

methadone maintenance to be effective in reducing IV drug use and AIDS risk

behaviors.

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BACKGROUND

Do Patients Improve in Methadone Maintenance Treatment?

The early reports of Dole, Nyswander, Cushman, and others established the

safety and pharmacological efficacy of methadone in the treatment of opiate

dependence (Dole and Nyswander 1968; Gearing and Schweitzer 1974; Dole et

al. 1982). Since that time, the clinical efficacy of methadone maintenance has

been evaluated in more than 300 published reports (Hubbard and Marsden

1986; Sells et al. 1979). Although there has been considerable variability in the

methodology and results of these studies, the weight of evidence clearly

indicates that the majority of opiate addicts remain in methadone maintenance

treatment for a significant period (usually a year or more) and show significant

reductions in opiate use, nonopiate use, and illegal activity during their

treatment (Hubbard and Marsden 1986; Sells et al. 1979). Furthermore, it is

equally clear from the body of published work in this area that the majority of

methadone-maintained patients have a longer and more serious history of

substance abuse (as well as other problems) than patients treated in other

modalities—e.g., drug-free outpatient treatment or inpatient therapeutic

community treatment (Hubbard and Marsden 1986; Sells et al. 1979).

What Is the Most Effective Way To Expand Methadone Treatment

Services?

The recent spread of AIDS in the drug-using population has led to the call for

rapid expansion of funded methadone treatment slots. There are two views

about how such an expansion should occur, based largely on different concepts

of the “active ingredients” in methadone maintenance treatment. The first

perspective holds that methadone alone, as a pharmacologic agent that blocks

opiate withdrawal and (through cross-tolerance) opiate euphoria, is the primary

active ingredient in methadone maintenance treatment and the one directly

responsible for patient improvements. Counseling requirements and rules and

regulations currently associated with this modality are viewed as probably

useful but costly, having the unwelcome “side effect” of reducing the total

number of available patient slots. Proponents of this “methadone alone” view

argue for the elimination of a minimum counselor-patient ratio requirement (now

1 to 50) and for further reduction in the number of urine specimens required by

the treatment programs (now 1 per month). With these more liberalized criteria,

it is argued, more potential clients could be given methadone, and in turn, the

risks for continued drug use, crime, and spread of AIDS could be reduced.

Psychiatric, medical, vocational, and other rehabilitative services (already

scarce or nonexistent in most programs) are not viewed as cost-effective.

Adding such services, it is argued, would cost substantially more than

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methadone alone but would not lead to measurably better performance on

factors closely related to AIDS: reduced IV drug use, reduced needle-sharing,

reduced AIDS risk behaviors, reduced incidence of AIDS, and reduced medical

costs associated with AIDS.

The opposing view argues that methadone alone, despite its pharmacologic

value, is not the only active ingredient in methadone maintenance treatment;

without a context of adequate administrative support, counseling, urine

monitoring, and rehabilitative services, methadone alone is very unlikely to lead

to a reduction in drug use and AIDS-related target behaviors. From this

perspective, the poor performance of many ongoing methadone maintenance

programs (even under current counseling and urine guidelines) can be traced to

lack of adequate staffing and administrative and rehabilitative services. Minimal

service programs do not have the resources needed to reduce the proportion of

patients who loiter, divert their methadone, continue use of illicit drugs, and

even “deal drugs” near the program site—making the programs unwelcome in

most communities (Wrangle 1988) and the treatment modality controversial

(Cummings 1979; Newton 1979) even among many substance abuse

professionals. Adding more methadone-only treatment slots, the argument

goes, would only increase community problems and further tarnish the image of

methadone as a treatment modality. Image concerns aside, a feared outcome

of expanded methadone-only treatment could be a dramatic increase in all the

problems outlined above, with little or no beneficial impact on IV drug use, AIDS

risk behaviors, or AIDS. In this view, methadone should be administered under

close counseling supervision, with urine contingencies and a full program of

supportive services, for it to achieve its full value as a tool for reducing drug use

and AIDS risk.

ARE THERE NECESSARY MINIMAL CONDITIONS FOR METHADONE TO

BE EFFECTIVE?

If methadone is the only active ingredient in reducing IV opiate use, then rates

of opiate use among demographically similar patients across different programs

should be similar. Several pieces of clinical evidence now emphatically suggest

that this is not the case. In the course of performing an evaluation of

professional psychotherapy as an adjunct to methadone maintenance (Woody

et al. 1983) we observed several programs and the patients in them. Despite

relatively small differences in demographics, background, or current status

measures among the patient samples from these different programs, we have

seen dramatic differences in such fundamental outcome measures as

proportion of opiate-positive urines, number of visits to the program, and

average methadone dose. An example of the size of these differences is

shown in figure 1, illustrating the proportion of opiate-positive urines for patients

169
in two community programs as well as in the Veterans Affairs (VA) program. As

can be seen, these differences are quite large and, because of small

differences seen among the patient samples, suggest that there are basic

programmatic differences that account for the observed performance

differences.

FIGURE 1. Rates of opiate-positive urines in the Philadelphia VA methadone

maintenance program and two community methadone

maintenance programs over a 6-month (24-week) study period

These observations are similar to those of Ball in his 3-year evaluation of

methadone treatment in six different programs from three eastern cities (Corty

and Ball 1987; Ball et al. 1988). In general, the patients treated in these

programs were quite similar in terms of their demographic characteristics and

treatment problems at the time of admission to methadone maintenance across

the different geographic sites surveyed. In contrast, the data gathered have

revealed striking differences in patient performance, depending on the program.

Rates of current IV drug use ranged from less than 10 percent to more than 50

170
percent (compare Programs A, E, and F, respectively, in figure 2), and rates of

needle-sharing showed a similar pattern. Although all these programs

administered methadone, the effectiveness of this treatment ranged from

impressive to almost nonexistent. The programs differed widely on such

important parameters as dose (one program had an average methadone dose

of 20 to 25 mg, whereas other programs averaged 45 to 50 mg), medical

coverage, use of ancillary psychotropic medications, uniformity of enforcement

of rules, caseloads of counselors, informed psychiatric input into

decisionmaking processes, quality of inservice training, and quality of the

physical facilities. Importantly, several of these program variables showed a

predictive relationship to treatment outcome.

FIGURE 2. Rates of current IV drug use across six different methadone

maintenance programs, two from each of three U.S. cities

From Ball et al. 1988. Copyright 1988. American Sociological Association

(Washington, DC).

The implications of these data are quite important with regard to the two

previously described views on expanding methadone treatment. Clearly, simply

171
administering methadone does not by itself guarantee clinical improvements or

reduced AIDS risk. On the other hand, when necessary minimum conditions

are met, this treatment modality can lead to dramatic and sustained

improvements, many of which (reduced IV drug use, reduced needle-sharing)

are directly related to the spread of AIDS. Thus, identifying the programmatic

factors and the minimal administrative conditions necessary for effective

methadone treatment are crucial steps in improving methadone maintenance

and in helping to contain the AIDS epidemic.

Determining the “Active Ingredients” in Methadone Maintenance

We have recently begun a set of studies designed to help determine the active

ingredients of methadone maintenance treatment. The full design and

procedures for these studies are described elsewhere (McLellan et al., in

preparation). The basic design compares three different levels of methadone

services (minimum, basic, and enhanced methadone maintenance) within each

of two explicitly different types of methadone programs (a hospital-based,

medically oriented program at the Philadelphia VA Medical Center and a nearby

community-based, social service-oriented program) for both newly admitted and

in-treatment samples. Study participants in each program setting are initially

stabilized on a modal dose of 40 to 45 mg methadone and then randomly

assigned to one of three different levels of methadone treatment services

provided and prospectively evaluated over a 6-month period.

Minimum Methadone Maintenance (MMM). This program setting offers

blocking doses of methadone, plus emergency counseling and referral services,

but no regular counseling, no privilege or service contingencies based on urine

results, and no extra services such as family or employment counseling.

Basic Methadone Maintenance (BMM). This level of methadone services

offers blocking doses of methadone, plus regular, supervised counseling and

referral services using weekly urine screens as the basis for contingency

management of the patient, but no extra services such as family or employment

counseling. A central feature of BMM is drug counseling, shown by Woody and

McLellan (Woody et al. 1987; McLellan et al. 1988) to be a particularly

significant aspect of methadone maintenance treatment, with the ability to

markedly enhance or detract from the other aspects of the program (e.g.,

methadone dose, rules and regulations, etc.).

Enhanced Methadone Maintenance (EMM). This program offers blocking

doses of methadone, plus regular, supervised counseling and referral services

using weekly urine screens as the basis for contingency management of the

patient, plus regular additional services, including medical/psychiatric care,

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social work assistance, family therapy, and employment counseling designed to

develop job-seeking and job-holding skills. The selection of extra services,

such as family therapy and employment counseling, was based on the

recognition that most methadone maintenance patients have multiple problems

that, if untreated, can undermine the effectiveness of the pharmacologic

intervention.

The psychiatric problems (Rounsaville et al. 1982; Khantzian and Treece 1985;

Woody et al. 1983), family problems (Stanton 1979; Stanton et al. 1982), and

poor job-seeking skills (Platt and Metzger 1985; Metzger and Platt, in press) of

methadone maintenance patients have been well documented. Regardless of

the original relation between these problems and the opiate addiction, it is clear

that the presence of these additional problems significantly affects the course

and overall results of treatment (Hubbard and Marsden 1986; Sells et al. 1979;

McLellan et al. 1982, 1986). It is therefore possible that a more enhanced and

expensive program, providing effective treatment for the medical, psychiatric,

family, and employment problems of these patients, may be more cost-effective

than the less expensive programs—particularly if this enhanced treatment is

significantly more effective in reducing AIDS risk behaviors and more capable of

effecting greater social rehabilitation and productivity with corresponding

reductions in crime, welfare claims, and the utilization of expensive medical

care services.

All patients are evaluated using a battery of instruments at the start of

treatment, at 3 months and at 6 months during treatment, and at 6 months

following their intervention (McLellan et al., in preparation). Additional duringtreatment measures include attendance and dropout rates, health care

utilization, and urine screening records. Major posttreatment outcome

measures include drug use (particularly IV drug use), employment, crime,

health care utilization, high-risk-for-AIDS behaviors, and the costs of care

delivered to each patient during treatment.

Of all the outcome measures listed above, perhaps one of the most clinically

significant is the number of patients in each treatment level who require

“protective termination” from the project due to an unacceptable level of illicit

drug use. Ethically, we did not want study patients to be at any greater risk for

human immunodeficiency virus exposure than other patients receiving standard

methadone treatment at our clinic. Therefore, we developed a set of

“safeguards” that, if exceeded, result in the patient’s termination from the

treatment project and referral to “treatment as usual” at the same site. The

safeguards are as follows:

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1.

2.

3.

A total of eight opiate-positive urine reports or four opiate-positive urines in

a row during the 24-week intervention.

A total of 12 cocaine-positive urines or 6 cocaine-positive urines in a row

during the 24-week intervention. Note: Cocaine use is not always

intravenous, even in these patients, and is considered somewhat less

serious than opiate use—thus, the decision to allow slightly more cocaine

use before requiring termination.

Three or more medical or psychiatric emergencies, necessitating inpatient

referral or an intensity of treatment inconsistent with the assigned level of

services.

Termination from the study means, essentially, that the level of methadone

services received by the patient was not sufficient to reduce illicit drug use and

FIGURE 3. Percent of patients requiring protective termination from three

different levels of methadone services across two different

methadone maintenance programs (Total Philadelphia VA and

Community Program Sample [N = 53])

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to offer protection from AIDS. Although data collection is still in the very early

stages, a striking pattern of results has already begun to emerge. Within both

programs, the number of patients requiring “protective termination” from the

study is by far greatest in the MMM group. As shown in figure 3, more than half

the patients in the MMM group have already required protective termination,

whereas none of the patients in the EMM group has exceeded the described

safeguards. Therefore, the level of services in the MMM intervention failed to

meet the minimum conditions necessary for effective methadone maintenance

for more than half of the patient sample. Most of the terminated patients in the

MMM group met criteria for termination within only 8 to 10 weeks of entry into

the study—during which time they continued to use illicit drugs, usually opiates

and cocaine. Finally, these numbers may underestimate the proportion of

patients eventually requiring termination, because some patients included in

these preliminary data have not yet completed 24 treatment weeks and may yet

require protective termination.

SUMMARY

Although methadone maintenance is a treatment modality with the

demonstrated ability to reduce IV drug use and subsequent AIDS risk,

methadone maintenance programs vary widely in their effectiveness:

Demographically similar patient samples show profound improvements in some

programs and little change in others. This suggests that programmatic factors

rather than patient variables or sheer availability of methadone may be

important active ingredients in effective methadone maintenance. The AIDS

epidemic has led to the demand for increased availability of methadone, with

suggested elimination of counseling, urine contingencies, and other

rehabilitative services in an effort to fund additional “methadone-only” treatment

slots. The data reviewed here, including preliminary results from a study

examining the effectiveness of “minimal” methadone services, suggest that

merely increasing the availability of methadone in the absence of administrative,

counseling, and rehabilitative services may not adequately protect the majority

of patients from continued drug use and the risk of AIDS.

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Ball, J.; Lange, W.R.; Myers, C.P.; and Friedman, S.R. Reducing the risk of

AIDS through methadone maintenance treatment. J Health Soc Behav

29:214-216, 1988.

Corty, E., and Ball, J.C. Admissions to methadone maintenance: Comparisons

between programs and implications for treatment. J Subst Abuse Treat

4(3):181-187, 1987.

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Cummings, N. Turning bread into stones: Our modern anti-miracle. Am

Psychol 34:276-339, 1979.

Dole, V.P., and Nyswander, M. Successful treatment of 750 criminal addicts.

JAMA 206:2708-2710, 1968.

Dole, V.P.; Nyswander, M.; and Des Jarlais, D. Performance-based rating of

methadone maintenance programs. N Engl J Med 306:169-172, 1982.

Gearing, F.R., and Schweitzer, M.D. An epidemiological evaluation of longterm methadone maintenance. Am J Epidemiol 100:101-105, 1974.

Hubbard, R.L., and Marsden, M.E. Relapse to use of heroin, cocaine, and

other drugs in the first year after treatment. In: Tims, F.M., and Leukefeld,

C.G., eds. Relapse and Recovery in Drug Abuse. National Institute on Drug

Abuse Research Monograph 72. DHHS Pub. No. (ADM)88-1473.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1986. pp. 157-166.

Khantzian, E.J., and Treece, K. DSM-III psychiatric diagnosis of narcotic

addicts. Arch Gen Psychiatry 42:1067-1071, 1985.

McLellan, A.T.; Luborsky, L.; and O’Brien, C.P. Alcohol and drug abuse in three

different populations: Is there improvement and is it predictable? Am J Drug

Alcohol Abuse 12(2):101-120, 1986.

McLellan, A.T.; Luborsky, L.; Woody, G.E.; O’Brien, C.P.; and Druley, K.A. Is

treatment for substance abuse effective? JAMA 247:1423-1428, 1982.

McLellan, A.T.; Woody, G.E.; Luborsky, L.; and O’Brien, C.P. Is the counselor

an “active ingredient” in substance abuse rehabilitation? An examination of

treatment success among four counselors. J Nerv Ment Dis 176(7):423-430,

1988.

McLellan, A.T.; Woody, G.E.; Metzger, D.; Childress, A.R.; and O’Brien, C.P. A

comparison of three levels of methadone maintenance services, in

preparation.

Metzger, D.S., and Platt, J.J. Solving vocational problems for addicts in

treatment. In: Platt, J.J.; Kaplan, C.D.; and McKim, P.J., eds. Effectiveness

of Drug Abuse Treatment: Dutch and American Perspectives. Malabar, FL:

Krieger Publishing Co., 1990. pp. 101-112.

Newton, J. Methadone promise is unfulfilled. J Drug/Alcohol Abuse, Dec. 1,

1979. pp. 1-2.

Platt, J.J., and Metzger, D. The role of employment in the rehabilitation of

heroin addicts. In: Ashery, R.S., ed. Progress in the Development of CostEffective Treatment for Drug Abusers. National Institute on Drug Abuse

Research Monograph 58. DHHS Pub. No. (ADM)88-1401. Washington,

DC: Supt. of Docs., U.S. Govt. Print. Off., 1985. pp. 111-121.

Rounsaville, B.J.; Weissman, M.M.; and Wilber, C.H. The heterogeneity of

psychiatric diagnosis in treated opiate addicts. Arch Gen Psychiatry 39:161-

166, 1982.

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

Drug Abuse Treatment Modalities, NIDA Services Research Administrative

Report. Rockville, MD: National Institute on Drug Abuse, 1979.

Stanton, M.D. The client as family member. In: Brown, B.S., ed. Addicts and

Aftercare. New York: Sage Publications, 1979.

Stanton, M.D.; Todd, T.; and associates. The Family Therapy of Drug Abuse

and Addiction. New York: Guilford Press, 1982.

Woody, G.E.; Luborsky, L.; McLellan, A.T.; O’Brien, C.P.; Beck, A.T.; Hole, A.;

and Herman, I. Psychotherapy for opiate addicts: Does it help? Arch Gen

Psychiatry 40:639-645, 1983.

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O’Brien, C.P. Psychotherapy

for opiate dependence: A 12-month follow-up. Am J Psychiatry 145:109-

114, 1987.

Wrangle, C. Comments of Representative Charles Wrangle (D-NY). McNeilLehrer News Hour, Public Broadcasting System, February 9, 1988.

ACKNOWLEDGMENTS

This work was supported by National Institute on Drug Abuse grants DA-05789

and DA-05186 and by Merit Review funding from the Veterans Affairs.

AUTHORS

Anna Rose Childress, Ph.D.

Clinical Associate Professor

A. Thomas McLellan, Ph.D.

Clinical Professor

George E. Woody, M.D.

Clinical Professor

Charles P. O’Brien, M.D., Ph.D.

Professor

Department of Psychiatry

University of Pennsylvania

Veterans Affairs Research Center

3900 Chestnut Street

Philadelphia, PA 19104

177
Reducing Illicit Drug Use Among

Methadone Patients

Maxine L. Stitzer and Kimberly C. Kirby

INTRODUCTION

The reduction or elimination of all illicit drug abuse and control of alcoholic

drinking patterns are important secondary goals of methadone treatment. This

chapter presents a brief overview of the most widespread patterns of

supplemental drug use by methadone patients, including use of cocaine,

benzodiazepines, opiates, and alcohol.

A variety of methods are reviewed that may influence supplemental drug use

among methadone maintenance patients, and the evidence for their efficacy is

discussed. The review starts with two examples of pharmacological methods:

(1) increasing the methadone dose and (2) providing adjunct or alternative

medications. The first intervention is designed primarily to influence continuing

illicit opiate use; the second strategy refers to ancillary pharmacotherapies

designed to have an impact on nonopiate drug use. Next, several

nonpharmacological treatment approaches are discussed that could be

implemented in the methadone clinic with the expectation of influencing

polyabuse patients: (1) Incentive programs that reward abstinence constitute

the most systematically researched approach to controlling polyabuse problems

in the methadone clinic and are covered at some length. (2) Social environment

manipulations designed to limit interactions among active polyabusers and

encourage interaction with abstinent role models are discussed.

(3) Improvements in counseling and psychotherapy, including provision of social

skills training, constitute another area of potential impact on polyabuse

problems. (4) A final section addresses the need for generalization and

maintenance of therapeutic gains and suggests a behavioral approach that

involves contracting with employers and family to discourage drug use and

promote abstinence.

Clearly, the division of treatment methods into these designated areas is

arbitrary; in clinical practice there is an overlapping and mixing of approaches.

It is important, however, to understand the effectiveness of treatment elements

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before systematically addressing the even more difficult tasks of selecting,

combining, timing, and perhaps individualizing treatment elements to best

effect. This chapter focuses on the polyabusing methadone patient who

continues to supplement with both licit and illicit drugs during treatment and

considers how various strategies might influence that particular type of patient.

Based on the present knowledge base, we recommend incorporating the most

systematically evaluated interventions—urinalysis-based incentive programs—

into routine methadone maintenance treatment to improve treatment

effectiveness. With regard to other intervention approaches, this chapter

surveys previous research and identifies additional research needs with an

emphasis on effectiveness with polyabuse patients.

PREVALENCE OF SUPPLEMENTAL DRUG USE

Methadone maintenance has proven efficacy for the treatment of illicit opiate

abuse (Ball et al. 1988a, 1988b; Dole et al. 1968; Gunne 1988; Gunne and

Gronbladh 1984; Newman and Whitehill 1979); it promotes a rapid cessation of

opiate use and related drug-seeking behavior. However, opiate abusers do not

necessarily or even typically confine their self-administration to drugs from the

opiate class. In a recent report from drug treatment facilities in the State of

Maryland, 80 percent of all admissions reported problems with more than one

type of drug (Maryland Department of Health and Mental Hygiene 1989). Ball

and associates (1986) found that 60 percent of methadone treatment

admissions typically used one or more illicit or prescription drugs (excluding

alcohol and marijuana) in addition to opiates. Thus, the methadone treatment

clinic, like all drug abuse treatment facilities today, accepts for treatment a

variety of polysubstance abusers with a range of drug use and abuse patterns,

including but not confined to illicit opiates. Cocaine, benzodiazepines, and

alcohol, the three drugs most commonly abused by methadone patients,

typically are the targets for treatment intervention; continuing illicit opiate use is

also a clinically relevant problem for these patients. Use of both marijuana and

tobacco is widely prevalent among methadone patients, but these drugs rarely

form the target for evaluation or clinical intervention. Prevalence estimates for

abuse of cocaine, benzodiazepines, opiates, and alcohol by methadone

patients are discussed before considering interventions designed to reduce or

eliminate these types of supplemental drug use during treatment.

Cocaine

A rising prevalence of cocaine abuse has been documented recently, and

among methadone treatment patients these rates have reached dramatic

proportions (Black et al. 1987; Kaul and Davidow 1981; Kosten et al. 1987a;

Maryland Department of Health and Mental Hygiene 1989). In a recent, large179
sample (N = 617) multiclinic survey (Ball et al. 1988a), 60 percent of methadone

treatment admissions reported regular abuse of cocaine with a mean duration of

5.7 years of use. In our Baltimore clinic, we currently find urinalysis evidence of

cocaine abuse in about 50 percent of maintenance patients and in 70 to 80

percent of those applying for admission to a short-stay, 180-day methadone

treatment program. Thus, cocaine is our most serious and prevalent polyabuse

problem.

Benzodiazepines

Although cocaine is relatively new on the scene, benzodiazepines are well

entrenched in the pharmacopeia of methadone patients (Bigelow et al. 1980;

Kleber and Gold 1978; Stitzer et al. 1981; Wiersum 1974; Woody et al. 1975a,

1975b). In a survey of methadone clinics in New York and Philadelphia, about

40 percent of patients reported recent benzodiazepine use (Iguchi and Griffiths,

personal communication). Patient self-reports suggest that benzodiazepines

sometimes are used as a self-medication for anxiety but more commonly are

taken in abusive dosages and patterns, often to boost methadone effects

(Preston et al. 1984; Stitzer et al. 1981).

Opiates

Although methadone is quite effective for the treatment of illicit opiate use,

clinicians must be alert to evidence of illicit use that may continue during

treatment in individual patients. Both the prevalence and frequency of illicit

opiate use are generally lower than the rates cited above for cocaine and

benzodiazepines. Thus, for example, Ball and colleagues (1988a) found that

23.4 percent of methadone patients in treatment for .5 to 4.5 years reported an

average frequency of heroin use of 6.3 days per month. Illicit opiate use tends

to be associated with programs that use lower methadone doses (Ball et al.

1988b); this implies that low-dose policies may not be optimal for suppressing

illicit opiate use.

Alcohol

Although alcohol is a licit drug, alcoholism among methadone patients is a

serious concern because it is associated with medical problems, particularly

liver disease (Force and Millar 1974; Hartman et al. 1983; Stimmel et al. 1972);

with early treatment termination (Joseph and Appel 1985; Hunt et al. 1986); and

with elevated mortality risk (Concool et al. 1979; Joseph and Appel 1985; Sells

and Simpson 1987). Numerous studies have surveyed the prevalence of

alcoholic drinking patterns among methadone patients; results vary due to

differences in the definition of what constitutes alcohol abuse. In a recent

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multiclinic survey of methadone treatment admissions (Ball et al. 1988a), 50.7

percent of patients reported regular use of alcohol to intoxication. One study

using Research Diagnostic Criteria found 16-percent current and 36-percent

lifetime rates of alcoholism among a sample of opiate addicts (Rounsaville et al.

1983). Other studies generally have estimated the prevalence of this polyabuse

problem to be between 17 and 30 percent (Bickel et al. 1987).

PHARMACOLOGICAL INTERVENTIONS

The methadone clinic is a convenient place to coordinate specific

pharmacological treatments for a variety of abused drugs, to the extent that

such treatments are available. Thus, the treatment of a given patient can be

pharmacologically tailored to the pattern of substance abuse exhibited

historically and/or after treatment entry. Current pharmacological interventions

for the most widely abused substances are briefly reviewed below.

Methadone Dose Increase

The methadone dose level would be expected to primarily reduce illicit opiate

use, because methadone’s pharmacological effects are specific to the opiate

class. The optimal methadone dosage and even the effective dosage range for

controlling illicit opiate use, however, have been hotly debated and oftenstudied topics during the 20-plus years that methadone treatment has been

available. The preponderance of evidence suggests that higher dosage is

associated with less illicit opiate drug use (Hargreaves 1983). Some of these

data come from controlled trials in which patients were randomly assigned to

different methadone dosage levels (Ling et al. 1976; Garbutt and Goldstein

1972), whereas some come from comparisons of patient outcomes across

clinics using different average methadone doses (Ball 1988b; McGlothlin and

Anglin 1981; Siassi et al. 1977). Further, if the methadone dosage is gradually

lowered, the consequence almost invariably is the recurrence of illicit opiate use

(Newman and Whitehill 1979; Senay et al. 1977). The general consensus from

these studies is that doses of 40 mg or less may be associated with noticeably

higher rates of illicit opiate use. However, the research findings concerning

dosage generally pertain to aggregate data from a large number of subjects

stabilized at different methadone doses and thus are less useful as a guide for

determining individual doses.

What constitutes an adequate dosage for a particular individual is not entirely

clear, because individuals metabolize methadone differently and may achieve

very different plasma levels (Horns et al. 1975; Nilsson et al. 1982). Further,

the dosage required to control illicit opiate use may change over time as a

patients drug use history becomes more remote and other factors conducive to

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abstinence change. The clinical symptom that indicates inadequate dosage is

detection of illicit opiates with urinalysis. In this case, raising the methadone

dose is a logical and commonly employed clinical approach. However, the

efficacy of individual dose changes in suppressing illicit drug use has not

received much systematic evaluation. Some of the available data suggest that

dose increases can be effective in suppressing illicit opiate use of individual

maintenance patients but that efficacy is improved if the increase is given

contingent on opiate-free urines rather than noncontingently (Higgins et al.

1986; Stitzer et al. 1985). Thus, it may be more effective to require the patient

to stop using illicit drugs as a condition of receiving the dose increase rather

than to supply the increase as a noncontingent pharmacological intervention.

It is possible that methadone dose increases given either contingently or

noncontingently are also helpful in controlling other types of illicit drug use. For

example, patients who claim they use benzodiazepines to boost methadone

effects might be willing to stop their illicit use if given the chance to obtain

contingent methadone dose increases; however, this idea has not been tested.

Although there is no direct pharmacological interaction between methadone and

cocaine, it is possible that methadone’s mild sedating effects could blunt

cocaine’s acute cardiovascular and subjective effects or relieve in part its

unpleasant side effects (e.g., nervousness, irritability). If this were the case,

dose increases—at least of the noncontingent variety—might be

contraindicated for cocaine abusers.

Adjunct or Alternative Medications

Provision of disulfiram for methadone patients with an alcoholic drinking profile

is a logical extension of a standard alcoholism treatment approach. The

success of this maneuver may depend importantly on the conditions of

implementation, as discussed in a later section. Benzodiazepine antagonists

that have recently been developed ultimately may play a useful role in

controlling benzodiazepine use among methadone patients, but these drugs are

not currently available for this purpose. The development of alternative or

adjunct medications for the treatment of supplemental cocaine abuse is a

current, active area of research. A variety of medications have been tested for

reducing cocaine withdrawal and promoting abstinence (Gawin and Ellinwood

1988; Kleber and Gawin 1986). Several of these medications have appeared

very promising in open trials with primary cocaine abusers, but subsequent

double-blind trials produced equivocal results so that the usefulness of these

medications is not yet clear. Few studies to date have examined the

effectiveness of adjunct medication specifically for methadone maintenance

patients with supplemental cocaine abuse (Gawin et al. 1988; Kosten et al.

1987b). Recently, investigators have begun to examine opioid antagonists and

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partial antagonists, particularly buprenorphine, as alternative medications to

treat opiate addiction and simultaneously block cocaine euphoria, therefore

discouraging both opiate and cocaine self-administration (Kosten et al. 1989;

Mello et al. 1989). These treatments also appear promising.

NONPHARMACOLOGICAL METHODS

Even if more and better pharmacological adjuncts are developed for control of

additional illicit drugs, it is likely that behavioral strategies will be needed to

encourage treatment retention, promote compliance with treatment regimens,

and address the broader range of social, behavioral, and psychiatric problems

that drug abusers bring to treatment. Indeed, nonpharmacological (cognitive

and behavioral) interventions have always been an essential element in the

treatment of drug abusers, forming the backbone of therapeutic practice.

Because they are nondrug specific, cognitive and behavioral interventions

provide a more flexible set of treatment tools that are useful in responding to a

range of specific drug abuse patterns.

The methadone clinic has several specific advantages as a site for

implementing and evaluating nonpharmacological interventions designed to

affect polysubstance abuse. The methadone clinic provides intensive, longterm contact with many polysubstance abusers. Objective urinalysis

assessment of supplemental drug use is built into clinic operations.

Circumstances surrounding the delivery of methadone (e.g., timing, “takehomes”) as well as other features of clinic operation can be used in incentive

programs designed to influence polysubstance abuse. A take-home privilege

allows the subject to carry a methadone dose away from the clinic and selfadminister it at home the following day, thus freeing the patient from the

necessity of a daily clinic visit. Finally, clinic infrastructure (space and staffing)

can be used to support ancillary services (e.g., educational, vocational) that

may improve the chances of maintaining a drug-free lifestyle. Although there

are many interventions that might have an effect on supplemental drug abuse,

incentive programs implemented at the methadone clinic have received the

most extensive evaluation to date.

Incentives at the Clinic

The idea behind urinalysis-based incentive programs is to enhance the

attractiveness of abstinence by providing some external motivation for stopping

illicit drug use during treatment. In essence, choices are offered in which

abstinence incentives such as receiving take-homes or remaining in treatment

with methadone must compete with the very potent and immediate reinforcing

effects of illicit drugs. Studies primarily have evaluated two very different types

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of incentives for their ability to influence supplemental drug use: negative

incentives, usually involving the threat of treatment termination, and positive

incentives, usually involving methadone take-home privileges. Both

approaches have been effective in influencing supplemental drug abuse

behavior.

Negative Incentives. Treatment termination contracting, the most popular

negative incentive, frequently is used by drug abuse counselors to deal with

patients who persist in supplemental drug use or exhibit other uncooperative

behaviors at the clinic. Typically, a contract is written that specifies cessation of

the offending behavior by a specified date with gradual withdrawal of

methadone treatment as the consequence of failure to meet the terms of the

contract. Because the intervention is widely used, it has been the focus of

some explicit evaluation efforts.

McCarthy and Borders (1985) investigated the effects of a structured treatment

program for methadone patients that used continued access to treatment as an

incentive to promote abstinence from illicit drugs. Sixty-nine subjects were

randomly assigned to either a structured or unstructured treatment group upon

admission to a California methadone program with an average maintenance

dose of 40 mg. Structured treatment patients were told that they needed to be

drug free—other than methadone—for 1 of every 4 months. If they had 4

consecutive “drug use months” during any point in the 1 -year study, they

gradually would be withdrawn from methadone treatment. The unstructured

group had no consequences attached to urine test results. Although urines

were screened for opiates, barbiturates, amphetamines, and cocaine, the study

pertained primarily to the control of illicit opiate abuse, because this is what

study patients were primarily abusing. Considering only those who remained in

treatment for 1 year, the study showed a marked contrast in rates of positive

urine tests between structured and unstructured treatment patients, with about

80 percent of structured treatment patients remaining drug free compared with

less than 50 percent of unstructured patients. This study demonstrated that the

threat of treatment discharge could act as an incentive for improved treatment

outcomes at least among patients whose primary supplemental drug of abuse

was an opiate.

Another evaluation of treatment termination contracting was conducted by

Dolan and colleagues (1985, 1986) at a methadone clinic in Dallas, Texas.

Individualized contingency contracts were developed with 21 patients who did

not respond to other treatment modalities offered by the clinic. Patients were

required to give completely drug-free urines for 1 month or undergo treatment

termination via methadone detoxification. About 50 percent (11) of subjects

fulfilled conditions of the contract and successfully achieved abstinence. Drug

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use for these patients remained suppressed during a 60-day postcontract

followup period. Data published in later papers (Black et al. 1987; Dolan et al.

1986) suggest that cocaine was the primary drug of abuse among these study

patients, with some benzodiazepine abuse as well. Thus, these two studies

show that treatment termination contracting can be effective with methadone

patients who abuse a variety of illicit drugs during treatment.

Positive Incentives. In positive incentive programs, clinic privileges are

offered to poorly performing patients to increase the attractiveness of achieving

and maintaining abstinence from supplemental drugs. A variety of positive

incentives are employed, including dose adjustments (Higgins et al. 1986;

Stitzer et al. 1986) monetary payments (McCaul et al. 1984; Stitzer et al. 1982),

and take-home medication privileges (Iguchi et al. 1988; Magura et al. 1988;

McCaul et al. 1984; Milby et al. 1978; Stitzer et al. 1979, 1982). In a survey

conducted in our laboratory, subjects ranked the methadone take-home

privilege as the most desirable of nine different clinic privileges (Stitzer and

Bigelow 1978). This privilege has subsequently proven to be a most effective

approach for reducing supplemental drug use. Although take-homes are

routinely administered at methadone clinics, patients are generally eligible only

under stringent rules that require lengthy periods of drug-free urines while

engaging in productive activity before the awarding of take-home privileges. In

the studies described below, the take-home privilege is used as an immediate

reward for improved performance of patients who ordinarily would not be

eligible under the typical stringent rules.

The original demonstration of utility for urinalysis-contingent take-homes offered

to poorly performing patients involved 10 patients who primarily abused

diazepam (Stitzer et al. 1982). The study used a within-subject design and

showed a marked improvement in urine test results during the time that takehomes or money could be earned for delivering benzodiazepine-free urines. As

a group, fewer than 20 percent of the study patients delivered drug-free urines

both before and after the study. During the 3-month take-home incentive

program, benzodiazepine-free urines increased to about 50 percent. This

intermediate level of drug-free urine results reflects marked individual

differences in treatment response; about half the subjects became

benzodiazepine free, while the other half failed to respond to the intervention

and continued using their supplemental benzodiazepine drug.

More recently, we completed a controlled, between-group study to determine

whether the chance to earn take-homes for drug-free urine test results could

improve treatment outcomes when a wider range of supplemental drugs was

targeted and when the evaluation was continued over a more prolonged period

(Stitzer and lguchi 1989). The subjects were 54 recently admitted methadone

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294-012 0 - 91 - 7
maintenance patients. About 33 percent used cocaine exclusively: 35 percent

used benzodiazepines alone; 17 percent used both; and 15 percent used

opiates or nothing. The high overall prevalence of supplemental use reflects

the fact that our clinic specifically selects patients with polyabuse problems who

have difficulty getting into treatment elsewhere. Patients randomly assigned to

an earned take-home condition had to give 2 consecutive weeks of totally drugfree urines before the first take-home was authorized. They could ultimately

receive as many as three take-homes per week after 6 consecutive weeks of

drug-free urines. Also, these take-homes could be lost if evidence of relapse to

supplemental drug use was detected. The number of take-homes received by

subjects assigned to the chance take-home group was determined in a monthly

drawing held independently for each study patient. Examination of individual

subject performance revealed a clear treatment effect. Within the earned takehome group, 11 of 26 (42 percent) subjects met the criteria for improvement

compared with 3 of 28 (11 percent) subjects who received take-homes on a

chance basis. Thus, there was a 30-percent improvement in treatment

response rate when subjects had to earn take-homes rather than being on the

take-home dole. Within the group of treatment responders, the number of

consecutive drug-free urines was seen as an indication of continuous

abstinence time. The median abstinence time during baseline for treatment

responders was less than 2 weeks, whereas during the earned take-home

program this increased to about 8 weeks. Further, among the treatment

responders, 6 of 11 (55 percent) were abstinent at the end of the 6-month trial:

1 was abstinent at his study termination point (incarcerated in study week 12);

and 4 relapsed during the study.

The results of this study are consistent with another report by Magura and

colleagues (1988), who implemented a urinalysis-based take-home earning

program via contingency contracting with individual problem patients rather than

by initiating a clinic-wide program. Thirty-four percent of patients receiving

contracts responded by giving 1 month of totally drug-free urines. However,

results were not well sustained over time when new contracts were negotiated.

This suggests the need for longer term contracts to avoid the disruptive

influence of contract terminations and renewals. The study also found that

cocaine abusers were less likely to respond to treatment contracts than were

patients abusing other types of drugs. This was not the case in our study, in

which treatment responders were about equally divided between cocaine and

benzodiazepine abusers.

Combined Negative and Positive Incentives: Disulfiram Compliance.

Occasionally contingency programs combine the features of positive and

negative reinforcement to gain control over supplemental drug use among

methadone patients. An interesting example of this approach is a disulfiram

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compliance program that was implemented with alcohol-abusing methadone

maintenance clients (Liebson et al. 1978). Study patients generally were

treatment failures from other methadone clinics who had long histories of

alcoholic drinking and associated behavior problems. Although disulfiram is an

effective medication for preventing ingestion of alcohol, noncompliance with the

disulfiram administration regimen is a common problem. Control subjects in this

study had disulfiram prescribed for home use, and experimental subjects were

required to participate in a monitored disulfiram program, ingesting disulfiram

daily at the clinic before their methadone. With this arrangement, the ingestion

of disulfiram was immediately followed by the presentation of the methadone

dose; refusal to ingest the disulfiram would have resulted in withholding the

methadone dose for that day. Thus, the positive incentive was the immediate

presentation of the methadone dose, whereas the negative incentive was

withholding of the dose with the implied eventual consequence of terminating

methadone treatment. Experimental subjects reliably ingested their disulfiram

under this arrangement, but the control subjects rarely took their medication.

The experimental intervention had a marked positive effect on measures of

drinking and on antisocial behavior. For example, experimental subjects spent

an average of 2 percent of days drinking compared with 21 percent for control

subjects. Monitored ingestion of disulfiram at the methadone clinic is now

standard practice to control alcoholic drinking, with the pressure of treatment

termination probably used at times to obtain cooperation with the program.

Combined Incentives To Improve Efficacy. It is possible that the efficacy of

incentive programs could be improved by combining positive and negative

incentives because a combined incentive might enhance the potency or

salience of consequences attached to drug use versus abstinence. A study

conducted in our laboratory (Iguchi et al. 1988) addressed this question by

examining the separate and combined effects of a positive methadone takehome incentive and a negative treatment termination incentive. Two groups of

patients matched on baseline polydrug abuse patterns were involved; both

could earn take-home incentives during the study for giving totally drug-free

urines, but a randomly assigned one-half of subjects also received methadone

dose reductions leading to eventual treatment termination if they continued to

give drug-positive urine samples, Interestingly, these two programs produced

an identical number of successful cases, with half of the patients in each group

giving drug-free urines during an 18-week evaluation period. This study failed

to support the idea that a more potent incentive combining positive and

negative reinforcement would yield better results. Instead, the study suggested

that an incentive program incorporating only positive reinforcers may be as

effective for producing behavior change in methadone patients as an incentive

package incorporating both positive reinforcement and aversive control

elements.

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Choice of Positive or Negative Incentives. Although both positive and

negative incentives can be effective in curtailing supplemental drug use and

improving treatment effectiveness, each approach has advantages and

disadvantages that should be carefully considered before implementing

treatment incentive strategies. For example, the widespread use of treatment

termination contracting in clinic settings may be due to an advantage that this

approach has over positive incentive procedures. Unlike positive incentive

procedures, treatment termination contracting allows clinic staff to remove

difficult patients from their caseload-an advantage for clinic staff, not for the

patient. For the patient, treatment termination contracting has a substantial and

potentially deadly disadvantage: If it is not successful, the procedure results in

treatment termination and almost certain return to intravenous drug use with its

associated risk of exposure to HIV infection. As such, treatment termination

contracting should not necessarily be advocated, especially not as the

intervention of first choice.

The disadvantages associated with treatment termination contracting do not

necessarily imply that all aversive procedures should be avoided. Negative

incentive procedures can be very effective in producing immediate and longlasting behavior change, provided they are implemented carefully and

appropriately. In general, it is important for effective behavior suppression that

the consequences are sufficiently aversive and are introduced reliably and

quickly following occurrence of the undesirable behavior (e.g., the uncertainty

and delay of criminal justice punishment is often cited as a reason for poor

deterrence efficacy). It is possible that ethically acceptable negative incentive

procedures could be devised for use with methadone patients that produce

desirable effects on client outcomes. An example of an untested but potentially

useful negative intervention might involve delaying receipt of the daily

methadone dose (i.e., rescheduling medication time for later in the day) as a

consequence of drug-positive urine tests. Further research regarding negative

incentive programs is needed to develop a better understanding of the impact of

these procedures and their effectiveness with particular problem areas and

client types.

Recommendation for Use of Positive Incentives. It appears that success

rates of commonly used positive and negative incentive procedures are similar,

particularly when the positive incentive is the methadone take-home privilege

and the negative incentive is treatment termination contracting. One other

study that directly compared a positive incentive (dose increase for drug-free

urines) with a negative incentive (dose decrease for drug-positive urines) also

showed identical success rates for the two procedures and thus supports the

conclusion of similar efficacy (Stitzer et al. 1986). In this case, we strongly

advocate the use of positive incentive programs over treatment termination

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contracting. Procedures that reward success have the advantage of

effectiveness without the disadvantage of expelling patients into situations

where they are potentially at greater risk, and positive procedures are not more

costly or significantly more time consuming to implement compared with

negative incentive programs. Urine testing is mandated and budgeted at all

methadone clinics, so the most expensive aspect of the procedure is already in

place. Studies have shown that urine monitoring alone has little therapeutic

value (Goldstein et al. 1977; Havassy and Hall 1981) so the additional time

required to implement a urinalysis-based incentive program is necessary. The

addition of positive incentive procedures can make urine testing a more

valuable activity and integrate testing into the therapeutic process. An

additional benefit is that these programs ensure that counselors are at least

aware of which patients are using supplemental drugs, which may prompt them

to design systematic interventions beyond the urine-based incentive program.

Limitations of Urinalysis Incentive Programs. Urinalysis-contingent takehome incentives share two limitations with most other drug abuse treatment

strategies. First, although they can be effective in reducing the supplemental

drug use of one-third to one-half of patients, they are not effective for all

patients. Second, even when they are effective, reductions in supplemental

drug use are not always permanent. These limitations are not unique to

contingent-incentive procedures and should not seriously discredit urinalysisbased incentives as a therapeutic technique; however, they should cause

concern and lead to ways to improve and/or add to this technology. For

example, allowing clients to specify which privilege they wish to work for might

increase the number of patients who respond to incentive programs by taking

into account individual differences in reinforcer preferences. Incorporating into

treatment outside sources of motivation such as families, employers, or criminal

justice monitors may lead to more abstinence attempts and/or longer periods of

sustained abstinence. Allowing clients to occasionally choose new privileges or

earn additional ones may be beneficial in improving maintenance. Other types

of interventions that also may improve outcomes on supplemental drug use,

either independently or in combination with incentive programs, are discussed

below.

Social Environment Manipulations

This section presents several strategies designed to limit the interaction among

actively abusing individuals and increase interaction with nonabusers who can

serve as models and encourage abstinence.

Controlled Methadone Medication Times. The methadone clinic at its best is

a therapeutic environment that discourages supplemental drug use.

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Unfortunately, it also can serve to bring together individuals with similar drug

abuse problems. Observation and questioning of methadone patients can

reveal groups of patients who tend to arrive for medication at similar times and

carry their social interactions out of the clinic to a regular meeting place. This

type of socially supportive peer group can be beneficial unless it contains one

or more members who are sliding into increased supplemental use and

encouraging friends to accompany them. If these groups can be identified,

members who are experiencing difficulty in recovery could be separated

temporarily from the group and targeted for more intensive supportive therapy.

On a practical level, this generally means scheduling patients for a medication

time different from that of their regular social group. Although clinics

occasionally use this technique to deal with clients who have behavior

problems, it is not known to have undergone systematic evaluation as a method

for discouraging supplemental drug use. Nonetheless, it may be an effective

procedure in some situations with potentially positive effects on the patient who

is segregated and the remainder of the group. In addition, this procedure can

be combined with urinalysis-based incentive procedures by requiring some

criterion of drug-free urines before allowing clients to return to a preferred

medication time.

Participation in Self-Help Groups. The inclusion of Narcotics Anonymous

(NA), Cocaine Anonymous, or Alcoholics Anonymous groups within the

methadone clinic may confer significant benefits related to interaction with an

abstinence-oriented peer group, including access to successful abstinent role

models, modeling of productive alternative activities to drug use, and social

encouragement of abstinence. Some clinics that sponsor NA meetings have

reported this to be a successful strategy (Fram and Marmo 1988). There

traditionally had been some reluctance on the part of established 12-step

groups to include methadone patients, but this prejudice recently has been

changing (Gordis, this volume). Systematic evaluation of the beneficial effects

of participation in a 12-step program for methadone patients would be useful.

Residence Relocation. Residence relocation is a more extreme example of an

intervention that changes the amount of social contact with active abusers.

Maddux and Desmond (1982) reported on the results of naturally occurring

residence relocation of drug abusers who had previously been treated at the

Public Health Service Hospital in Fort Worth, Texas. They collected information

on 248 San Antonio addicts through treatment records, law enforcement and

correctional agencies, personal interviews, and urine tests. During times of

relocation, subjects engaged in less drug use than when they were in their

hometown of San Antonio. For example, subjects who relocated

(N = 171) were abstinent 54 percent of the time during residence relocation

compared with 12 percent of the time when in San Antonio. Although

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permanent removal from an environment that supports the patient’s drug use

may not always be practical, it is worth exploring as a promising strategy for

some abusers. More research on residence relocation would be useful to

understand the factors that determine better outcomes and to develop

innovative relocation programs.

Improved Psychotherapeutic and Counseling Methods

The interaction between patient and counselor is an essential component of

drug abuse treatment, and there is little doubt that treatment retention and

patient outcomes in a variety of domains can differ as a function of counselor

characteristics and/or counseling content. Somewhat less certain are the

characteristics of a counselor’s background and training or the specific

elements of a counselor’s behavior that may be relevant to improved treatment

of drug abuse patients in general and reduction of ongoing illicit drug use in

particular. This section considers some of the dimensions of counseling

behavior and counseling content that might be relevant. Another study (Hall

1983) also reviewed the roles of counselor training and experience as

determinants of drug abuse treatment outcomes.

Domains of Good Counseling. The domains relevant to good counseling or

psychotherapy are often described in somewhat global terms rather than in

terms of concrete behaviors that counselors might be trained to perform. For

example, a particularly careful study by Luborsky and colleagues (1985)

identified four factors that were positively related to client outcomes during a

controlled comparison of psychotherapy versus standard drug abuse

counseling: (1) the therapist’s personal adjustment, (2) the therapists interest

in helping the patient, (3) the extent to which the therapist established a positive

helping alliance with the patient, and (4) the extent to which a therapist adhered

to manual-guided treatment techniques. Overall, the data from this study

supported the notion that the therapist’s ability to develop a positive, warm,

supportive patient-therapist relationship, as well as the skill level of the therapist

in implementing specific treatment techniques, may be important determinants

of treatment outcome.

To improve the performance of therapists or counselors, it is advantageous to

define these domains in more concrete behavioral terms. For example, Miller

(1985) reviewed several studies that showed improved treatment retention rates

when counselors sent letters or made telephone calls to clients who missed

appointments. Such concrete behaviors are likely to be interpreted as showing

concern, interest, and support on the part of the counselor. Other influential

counselor behaviors may be more complex. McLellan and colleagues (1988)

documented the widely held belief that individual therapists differ in

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effectiveness as measured by the treatment outcomes of their clients. In this

case, between-counselor differences appeared to be associated with, although

not necessarily caused by, the organizational and treatment planning ability of

the therapists. The differential use of effective treatment elements such as

contingency contracting is another potential source of between-counselor

variability in treatment outcomes.

Caseload Size. Another factor that may be relevant to patient outcome and

that should be considered in efforts to improve counseling is the amount and/or

intensity of contact between patient and therapist. In this regard, the tendency

of methadone clinics to increase counselor caseloads in response to funding

constraints is of concern. Caseload size has a logical if not demonstrated

inverse relationship to treatment outcomes simply because less effort and

attention per patient can be devoted by counselors with larger caseloads.

Experimental information about the effect of caseload size on patient outcomes

would be valuable for developing rational policies on this issue.

Professional Psychotherapy. Psychotherapy represents a specialized form of

nonpharmacological intervention that differs from drug abuse counseling

primarily in its focus on the broader range of psychiatric symptoms that are

prominent among drug abusers. Alleviation of psychiatric symptoms may have

a beneficial effect on illicit drug use. Woody and colleagues (1983, 1984)

investigated the effects of psychotherapy delivered to drug abusers by highly

trained professional therapists. The study showed that psychotherapy patients

tended to reduce their methadone doses during the trial more than counseling

control patients and receive fewer prescriptions for psychotropic medications.

Psychotherapy patients also showed greater improvement on addiction severity

index measures of drug use, employment, and psychiatric problems, with the

best results seen in those patients who started the study with mid- to highseverity ratings on psychiatric problems. With regard to urinalysis data on illicit

drug use, psychotherapy patients overall showed lower rates of opiate-positive

test results during the trial than did drug counseling patients. This is notable

because these patients also had lower methadone doses. Unfortunately,

however, the study did not indicate whether psychotherapy could be expected

to specifically benefit polydrug patients who abuse benzodiazepines, an

analysis that was obscured by clinic prescription practices, or cocaine, which

was apparently not in prominent use at the time the study was conducted.

Relapse Prevention Skills Training. Another specialized form of therapy that

could be especially beneficial to drug abusers involves training drug abusers in

the social skills necessary to function effectively as a nondrug abuser.

Programs have been developed to train drug abusers in relapse prevention

skills (Hawkins et al. 1986; McAuliffe and Ch’ien 1986; Zackon et al. 1985) and

192
in skills necessary for finding and obtaining employment (Hall et al. 1981 a,

1981b; Platt and Metzger 1985). These programs are generally successful in

teaching the targeted skills. Relapse prevention, but not employment, programs

have received some controlled evaluation concerning their impact on drug use.

Programs designed to bolster drug-free support systems and to specifically

teach drug abusers how to handle problematic situations that might lead to

relapse have recently received considerable attention. Evaluations have been

conducted with two relapse prevention programs to determine their impact on

drug abuse, although differences in the test populations preclude any

meaningful comparison of the efficacy of the two programs. Hawkins and

colleagues (1986, 1989) delivered relapse prevention and social network

development skills training to therapeutic community patients before their

reentry into the pretreatment natural environment. The program was effective in

enhancing interpersonal and problemsolving skills, as assessed in

posttreatment role-play tests (Hawkins et al. 1986). However, there was little

evidence of treatment effects on relapse rates or on the extent or type of

posttreatment drug use, including use of opiates, cocaine, and alcohol; the one

exception was reported marijuana use among skills training versus control

treatment subjects (Hawkins et al. 1989).

A second trial conducted by McAuliffe and colleagues (1985) evaluated an

aftercare treatment package called Recovery Training and Self-Help that

combined skills training with participation in self-help groups after formal

treatment ended. The package was administered to opiate abusers drawn from

a variety of program types (methadone, drug-free, detoxification, and residential

treatment) in the United States and China. Preliminary outcome evaluation

during a 1-year followup found significantly more good outcomes (abstinent or

using opiates less than once a month) among experimental than among control

group subjects, with a 15 to 17 percent improvement in abstinence rates. The

diversity of study populations makes it difficult to draw conclusions about impact

on any particular group such as methadone patients, and there is no

assessment of treatment impact on nonopiate illicit drug use, including cocaine.

Summary. Overall, the research cited suggests that more emphasis be placed

on identifying the important aspects of counselor behavior, developing methods

for training therapists to incorporate them, and determining how any

improvement in the counseling interaction or counseling content influences

specific treatment outcomes, including supplemental drug abuse.

Psychotherapy continues to be a promising adjunctive treatment, particularly for

psychiatrically disturbed patients. Relapse prevention skills training also is an

appealing therapeutic approach from a conceptual point of view, although there

are few convincing data to support its effectiveness in actually preventing

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relapse to a variety of illicit drugs. It is possible that skills training could be

useful in combination with other motivationally based treatments that enhance

environmental supports for abstinence.

Contingency Contracting Outside the Clinic

Researchers experienced in contingency-based procedures have long

emphasized the need to actively arrange for maintenance of any treatment

gains that are made during the intensive early phases of treatment intervention

(Baer 1982; Kirby and Bickel 1988; Marholin and Seigel 1976; Marholin et al.

1976; Stokes and Baer 1977). One dominant theme has been the importance

of ensuring that treatment gains continue to receive support in the social

environment in which the patient lives during treatment or to which the patient

returns after treatment. Although this approach has stimulated very little

systematic investigation with respect to methadone treatment, it has received

some attention in the treatment of impaired health care professionals (Crowley

1984) and more extensive evaluation in the treatment of chronic alcoholics

(Azrin 1976; Azrin et al. 1982; Hunt and Azrin 1973; Miller 1985).

Employment Contracting. Under some circumstances, employers can be

involved with treatment to monitor drug-abusing employees and deliver

appropriate consequences. For example, partial loss of job privileges such as

wages or vacation time might be arranged as a consequence of drug

intoxication detected at the worksite. Other positive incentives such as

increased vacation time, monetary bonuses, or reduced health care costs also

could be offered based on improvements in work attendance (poor attendance

being one of the most frequent signs of drug or alcohol abuse) or good

cooperation with treatment. If the employer is unaware of the drug abuse

problem and cannot be directly involved with treatment, it may be possible to

use employer notification as an aversive consequence of poor treatment

performance.

Such a program was developed by Crowley (1984) and coworkers to treat

medical practitioners who were abusing opiates or cocaine. At the start of

treatment, each patient provided the therapist with a signed letter to their

licensing board or employer describing the drug abuse problem and voluntarily

relinquishing the license or job because of continued drug abuse. The patient

agreed via a written contract that the letter would be mailed by the therapist if

drug use was detected during routine frequent urine monitoring. Thus, the

license-loss contract functioned to change a likely negative consequence of

long-term continued drug use to an immediate aversive consequence of drug

use relapse. Outcome evaluation based on 17 patients revealed that the

potential loss of a professional license did not totally prevent relapse but did

194
appear to greatly reduce the frequency and severity of relapse incidents and

result in generally favorable outcomes among those who stayed with the

program.

Community Reinforcement. A comprehensive community reinforcement

approach was developed and implemented by Hunt and Azrin (1973) to support

the abstinence of alcoholic individuals who had recently completed inpatient

detoxification. The program may serve as a prototype for a comprehensive

environmental contingency management program with drug-free patients. The

evaluation study was conducted in a small, sparsely populated midwestern

region and involved reconstructing the social environment of chronic alcoholics

to ensure that the environment supported sobriety and did not support alcoholic

drinking. Job placement was an important aspect of the program; job-finding

activities were supported by a Job Club networking program (Azrin and Besalel

1980); and an acceptable job was found for all experimental patients before

they left the hospital. Patients who were married underwent behavioral family

counseling; the spouse was trained explicitly to provide reinforcement to the

patient for maintaining sobriety and to withhold marital benefits (e.g., attention,

shared finances, meal preparation, sexual relations) when the patient drank.

For patients who were not married, surrogate families were identified (and when

necessary, formed), and similar contingencies were arranged. An alcohol-free

social club was developed where clients were encouraged to invite friends as

guests and to participate in social interactions with other members. Access to

the club was restricted whenever a patient was found to be drinking. The

community reinforcement program resulted in substantial improvements in

sobriety, employment, and other socially desirable behaviors compared with a

matched control group who received standard hospital services. A community

reinforcement approach could be applied to methadone patients who have

successfully stopped supplemental drug use to explicitly arrange an

environment in which the patients drug-abstinent behavior would receive

continued support.

SUMMARY/DISCUSSION

Polysubstance abuse among methadone patients may be amenable to several

intervention approaches that might be expected to promote and maintain

abstinence from supplemental drug use during methadone treatment. At this

time, incentive programs at the methadone clinic are the one type of

intervention that has demonstrated efficacy for reducing supplemental drug

abuse. The studies reviewed suggest that urinalysis-based incentives can

improve treatment outcome for individual methadone maintenance patients and

thus are a clinically useful treatment tool that can be readily implemented at the

methadone clinic. As such, we recommend that incentive programs be

195
incorporated whenever possible into individual treatment plans or clinic-wide

operations. Even if effects are not always permanent, incentive programs can

be instrumental in initiating periods of abstinence among chronic polydrug

abusers and in increasing aggregate drug-free time in cases in which there is a

poor prognosis for permanent abstinence. An interesting observation from the

studies reviewed is that the particular features of the incentive program

employed may be less important than that some type of structured program is

implemented. In particular, both positive incentive programs involving takehomes and negative incentive programs involving the threat of treatment

termination have been shown to promote abstinence among some treatment

patients. To the extent that success rates are similar, the use of positive rather

than negative incentive programs is advocated because these avoid the

problem of poor outcomes and increased risk exposures that may be

associated with treatment termination.

A variety of other interventions have also been reviewed that might be expected

to affect polydrug abuse. Some are related to the social environment that

supports or discourages abstinence (e.g., dissociation from drug-using friends,

participation in self-help groups, contingency contracting with family and

employers, contact with more effective therapists). Other interventions are

specifically designed to address the multiple problems of drug abusers (i.e.,

vocational and skills training deficits, psychiatric comorbidity). There is general

consensus within the drug treatment community that a comprehensive

treatment package that includes these types of interventions would be valuable,

and perhaps necessary, in obtaining long-lasting behavior changes in polydrugabusing patients. There is less consensus on what the optimal intensity,

duration, and timing of interventions should be or what criteria should be used in

choosing particular interventions to match individual patient needs. Most of

these more comprehensive interventions are untested at the present time with

regard to their efficacy in improving treatment outcome for polysubstance

abusers. Clearly, more research is needed to determine the conditions under

which various behavioral and environmental interventions can be effective tools

in the treatment of polysubstance-abusing methadone patients.

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ACKNOWLEDGMENTS

This chapter was prepared with support from Public Health Service research

grant DA-04104 and the National Institute on Drug Abuse research training

grant T32 DA-07209.

AUTHORS

Maxine L. Stitzer, Ph.D.

Associate Professor of Behavioral Biology

Kimberly C. Kirby, Ph.D.

Postdoctoral Research Associate

Johns Hopkins University School of Medicine

Francis Scott Key Medical Center

Psychiatry Department, D-5-West

4940 Eastern Avenue

Baltimore, MD 21224

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Improving Client Compliance

in Outpatient Treatment:

Counselor-Targeted Interventions

Mary E. McCaul and Dace S. Svikis

INTRODUCTION

Although abstinence-oriented outpatient treatment programs account for the

majority of treatment slots (U.S. Department of Health and Human Services

1987, 1989) treatment participation and associated outcome in these programs

traditionally have been problematic, with the majority of patients dropping out of

treatment before completion (Hubbard et al. 1964; Polich et al. 1979; Simpson

and Sells 1982). This chapter (1) highlights the need for more effective

strategies to enhance client compliance in abstinence-oriented outpatient

treatment programs, (2) briefly reviews some variables that have been

previously studied in efforts to enhance client participation and retention, and

(3) explores the feasibility and effectiveness of interventions that target the

counselor rather than the client for improving client outcome.

PATIENT PARTICIPATION AND RETENTION: THE PROBLEM

There has been increasing recognition of the prevalence and therapeutic

importance of other drug use by clients in treatment programs that have

traditionally served a primarily alcohol-dependent population (Senay 1984).

Estimates of other drug use by these clients have ranged from one-fifth to

nearly two-thirds of program admissions (Hawkins et al. 1985; Morrissey 1981;

Sokolow et al. 1981). In a study comparing pretreatment and posttreatment

drug use, Sokolow and colleagues (1981) characterized self-reported drug use

by 1,340 patients enrolled in 17 publicly funded alcoholism programs in New

York. In the 30 days preadmission, 46 percent of clients reported use of at

least one drug in addition to alcohol, with 20 percent reporting use of two or

more substances. Although reported drug use decreased postdischarge,

approximately 30 percent of clients still reported use of at least one drug (not

alcohol) in a 30-day period several months posttreatment, and 10 percent

reported use of two or more substances. In a more recent study, 48 percent of

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alcoholic soldiers in Army treatment facilities reported regular use of other

drugs, and 17 percent reported daily drug use (Hawkins et al. 1985). Schuckit

and Bogard (1986) characterized the drug use status of consecutive admissions

into a Veterans Administration alcohol treatment program and found that 9

percent met diagnostic criteria for primary drug abuse and an additional 8

percent used drugs intravenously but did not meet diagnostic criteria for drug

abuse. Finally, admission patterns at Hazelden, a large abstinence-oriented

treatment program in Minnesota, have shown an increasing prevalence of other

drug dependency in its treatment population. Specifically, rates of drug

dependency, either alone or in combination with alcohol, increased from 44

percent to 66 percent of admissions from 1976 to 1985 (Novalany 1988; Patton

1979).

In our own large, publicly funded drug-free treatment program in Baltimore,

current admission data demonstrate even higher rates of drug abuse. From

July 1988 to June 1989, data were collected on 310 program admissions using

family history research diagnostic criteria for alcohol and drug abuse

(Andreasen et al. 1977). Based on client self-report, 21 percent of clients were

diagnosed as alcohol abuse only; 35 percent were diagnosed as drug abuse

only; and 44 percent were diagnosed as alcohol and drug abuse. Opiate and

cocaine abuse each accounted for approximately 40 percent of the combined

cases in the drug only and alcohol and drug abuse groups. These and earlier

data clearly indicate that multiple substance use is a widespread clinical

phenomenon in drug-free treatment settings.

These drug-abusing clients often report greater severity on a variety of

psychosocial variables at admission (McLellan et al. 1986; Schuckit and Bogard

1986), suggesting the need for more intensive treatment interventions to

promote program participation and retention. Yet despite these changing

clinical profiles of program clients, drug-free services have remained largely

unchanged in their treatment service components. Such programs largely

consist of individual counseling, group education and therapy, provision of

ancillary support services, and a 12-step model of recovery (Price, this volume).

These programs generally do not use medications as a primary treatment

method and indeed often oppose the use of adjunct medications in the

treatment of substance abuse. Because the effectiveness of pharmacotherapy

has been well established only in the treatment of opiate dependence (Dole and

Joseph 1978). drug-free treatment is currently the only therapeutic alternative

for the majority of drug-dependent persons.

To date, methadone maintenance has been the only pharmacotherapy to

receive widespread client acceptance and to have demonstrated therapeutic

efficacy in drug abuse treatment. Research comparing patient participation and

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retention in drug-free treatment vs. methadone maintenance has suggested that

it may be more diffiiult to retain clients in drug-free treatment settings. For

example, in a double-blind study Newman and Whitehill (1979) compared

opiate addicts randomly assigned to methadone vs. placebo maintenance in

combination with a range of supportive services. They found a dramatic

between-group difference in retention rates at 32 weeks postadmission, with 76

percent of those receiving methadone still in treatment compared with only 10

percent of controls. The controls also evidenced higher rates of opiate use and

criminal activities. Similarly, Bale and colleagues (1980) compared opiateaddicted male veterans randomly assigned to therapeutic community vs.

methadone maintenance treatment. They found significant between-group

differences in retention rates, with 75 percent of methadone patients compared

with 5 percent of therapeutic community patients still in treatment at 12 months

postadmission. Thus, patient dropout is clearly elevated in drug-free compared

with methadone maintenance programs.

Earlier research across a variety of treatment modalities has demonstrated a

positive correlation between treatment participation and retention and

posttreatment abstinence rates for both alcohol- and opiate-dependent clients

(Edwards and Guthrie 1967; Polich et al. 1979; Simpson and Sells 1982).

Thus, strategies that improve treatment participation and retention can be

expected to improve posttreatment client outcome.

This brief overview highlights the importance of developing new and improving

existing strategies to increase treatment participation and retention in

abstinence-oriented programs. To enhance posttreatment outcome for

addictive disorders, within-treatment performance first must be improved. This

task is particularly challenging in treatment settings where pharmacological

incentives are not available.

CLIENT PARTICIPATION AND RETENTION: CURRENT INTERVENTION

STRATEGIES

There is a widely held belief that motivation is an intrinsic trait of treatment

patients and that this patient trait is a significant determinant of treatment

participation and retention. However, it is clearly more productive in developing

treatment intervention strategies to recognize that there are a variety of factors

that may contribute to motivation and thereby influence treatment participation

and retention and that these factors differ in both their accessibility and

malleability. One conceptual framework for treatment motivation variables has

been described by Miller (1985). This mode consists of four major components

and some specific variables that have been examined in each of these

components:

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Client Characteristics

—psychiatric severity

—cognitive functioning

—self-esteem

Motivational Interventions

—goal-setting and feedback

—continuity of care

—contingency management

—modification of behavior attractiveness

Environmental Variables

—involvement of spouse, parole and

probation, and employer

—clinic availability

Therapist Characteristics

—directive/nondirective style

—professional/peer status

—empathy/supportiveness

—client outcome expectancy (Miller 1985)

For comprehensive reviews of this model, see Annis (1988) and Miller (1985).

A more detailed explication of many of these factors and their role in substance

abuse treatment has been provided elsewhere (see De Leon, McLellan, and

Stitzer, this volume).

Although client and therapist characteristics have been shown to play a role in

determining treatment participation and outcome (Gerstley et al. 1989; Lafferty

et al. 1989; McLellan et al. 1983; Nurco et al. 1987, 1988a, 1988b; Patterson

and Forgatch 1985) many of these variables represent relatively static

characteristics of the individuals being studied (e.g., psychiatric diagnoses,

demographics) and are not readily amenable to change through treatment

interventions. Other treatment motivation factors are more malleable and can

be successfully manipulated to improve treatment outcome (e.g., involvement of

family, clinic accessibility). To date, such intervention strategies have focused

predominantly on client-targeted interventions, with less attention to the role of

treatment program variables as determinants of dient outcome.

207
However, just as behavioral interventions with clients have been shown to

improve their participation and retention (client-targeted interventions), it should

be possible to develop interventions for increasing counselor behaviors that

have a positive impact on client participation and retention (counselor-targeted

interventions). Development of these strategies is based on the premise that

the counselor is an important agent of change on the client’s behavior and, for

better or worse, can influence the length and frequency of client participation in

treatment (McLellan et al. 1988).

CLIENT PARTICIPATION AND RETENTION: AN ALTERNATIVE

STRATEGY

Several studies have demonstrated that within a given treatment program there

can be considerable variability across addiction counselors in their ability to

retain patients in treatment (Rosenburg et al. 1976; Valle 1981). More recently,

McLellan and colleagues (1988) also have reported variability across

counselors for within-treatment client measures such as methadone dose,

employment status, and utilization of supportive medical services in a

methadone maintenance setting. Within our drug-free outpatient treatment

clinic, there is considerable variability across counselors in maintaining patient

participation as measured by treatment duration and discharge status. As

shown in table 1, successful discharge rates across counselors varied from 17

percent to 54 percent of caseload over a 1 -year period (July 1988-June 1989).

Similarly, rapid dropout rates (less than 3 months in treatment) ranged from 14

percent to 61 percent of counselor caseload. This naturally occurring variability

TABLE 1. Variability in client discharge status as a function of counselor

assignment

Discharge Status Counselor

(Percent) ABCDEFG Range

Successful 18 32 33 54 25 30 17 17-54%

Dropouts

< 3 months

3-6 months

> 6 months

50 32 37 14 43 35 61 14-61%

29 32 23 18 14 22 22 14-32%

3 5 7 14 14 13 0 0-14%

208
in client outcomes based on counselor assignment dearly suggests that the

counselor plays an important role in determining dient outcome and, therefore,

can be strategically targeted to improve client compliance.

There are several compelling reasons for considering counselor-targeted

interventions as alternatives and/or adjuncts to client-targeted interventions.

First, the effectiveness of behavioral interventions with substance abuse

treatment clients has been clearly demonstrated (Stitzer and Kirby, this

volume); however, these studies often have been restricted to specialized

research settings with limited numbers of patients. Given the large number and

diversity of clients enrolled in most treatment programs, the ability to effectively

implement and monitor such interventions on a program-wide basis may be

limited (Bigelow et al. 1984). In contrast, there are dramatically fewer

counselors, and they remain readily accessible for extended periods, making

them more practical targets for intervention. Second, there is often resistance

from addiction counselors to the implementation of structured, specific

behavioral interventions, particularly if these interventions are perceived as

aversive (Bigelow et al. 1984). Client-targeted interventions are perceived as

increasing workload and compromising the counselor’s control over the clients

clinical course. In contrast, counselor-targeted interventions are less dependent

on counselor acceptance for their implementation. More importantly, they can

maintain the counselor’s flexibility in how clinical services are delivered because

the intervention specifies the expected patient outcome and not the method for

achieving this result. Third, the menu of incentives for counselors is broader,

more readily available, and less costly than the menu of patient incentives in

drug-free treatment programs where pharmacological reinforcers are not

available (Bigelow et at. 1984). For example, there are a variety of potential

counselor incentives already dispensed in a noncontingent fashion in most

programs, including salary, outside educational training, comp time, access to

clerical services, funds to purchase educational materials, and ability to flex

work hours.

Interventions that target the counselors may operate through several

mechanisms. Given the high rate of counselor burnout in substance abuse

treatment, such interventions may serve to sustain or increase effective

therapeutic behaviors that are already in the counselors repertoire. This may

be particularly critical in dealing with difficult clients, who often are perceived as

treatment failures from the time of admission and, as a consequence, may not

be provided the same type and intensity of treatment services as those clients

perceived to be ‘motivated” for treatment (Miller 1995). Another mechanism

may be to expand counselor skills by encouraging staff to develop and

implement a variety of new strategies for improving client treatment

participation. Finally, these structured behavioral interventions eventually may

209
affect underlying therapist characteristics, particularly outcome expectancy and

empathy. That is, when counselors achieve increased success with clients who

were initially perceived as unlikely to succeed in treatment, this process may

positively influence outcome expectancy and empathy with future patients.

The ultimate goal of a counselor-targeted intervention is the same as the goal of

a client-targeted intervention, that is, improved patient participation and

retention in treatment. The success of either intervention is measured in the

short term by the length of time clients are retained in treatment, the number of

individual and group sessions attended, the number and frequency of negative

urinalysis results, and the number of treatment goals achieved. In the long

term, the efficacy of these approaches is measured by posttreatment

abstinence or moderation in drug use and improvement in psychosocial stability

such as family, employment, and legal status.

CLIENT PARTICIPATION AND RETENTION: TYPES OF COUNSELORTARGETED INTERVENTIONS

Many of the same types of interventions that have been found effective with

clients also may serve as interventions targeted to the counseling staff. For

example, feedback, continuity of care, and behavioral contingencies are all

potentially useful strategies for effecting change in counselor performance.

Feedback and Goal-Settlng

We are currently investigating the impact of goal-setting and regular supervisory

feedback to individual counseling staff members on client participation and

retention in treatment. As part of routine program quality assurance, standards

were established for minimally acceptable levels of routine clinic participation,

including individual counseling sessions, group counseling sessions, and

breathalyzer monitoring visits (i.e., brief program contacts to determine current

blood alcohol level via breath sample). We informed counselors of these

standards and then monitored each counselor’s success in meeting these goals

with clients on their caseload. Following a 4-month baseline period, we

implemented a supervisory feedback system. Data are based on the six

counselors who were employed during both the preintervention and

postintervention periods.

Each counselor was provided with monthly written feedback on the performance

of each client on his or her caseload relative to the standards and to the prior

month’s participation levels. The results of this goal-setting and supervisory

feedback are shown in table 2. Overall, there was improvement in client

participation for each of the three program service components, although there

210
was variability across the goals in the magnitude of change. This increase was

significant for the mean number of individual and group counseling sessions

(Mann-Whitney U test, p < 0.05). This overall increase in the mean number of

client sessions per month also resulted in more clients meeting the minimum

standards postintervention compared with preintervention. For example, before

supervisory feedback, only 35 percent of clients met the minimum requirement

of participation in one group session per month. The percentage of clients in

compliance with the program standard increased to 58 percent postintervention.

TABLE 2. Effects of supervisory feedback to counselors on mean levels of

client outpatient participation per month

Program Component

Condition

Prefeedback

Postfeedback

Individual Group

Counseling Counseling

1.6 0.7

2.3 1.4

Breathalyzer

Visits

6.0

6.6

As shown in table 3, we also analyzed these data as the percentage of

counselors who met each standard based on mean participation levels for their

overall caseload. This was an important analysis to examine whether the

improvement had occurred across all counselors as opposed to having been

isolated in only one or two counseling staff members. As found for client visits,

there was an increase for all three standards in the percentage of counselors

whose clients were in compliance from preintervention to postintervention. The

magnitude of the preintervention to postintervention increase was statistically

significant for group sessions (p < .01) and breathalyzer visits (p < .05), with a

marginal effect for individual sessions (p < .10).

These preliminary findings suggest that counselor-targeted interventions can be

an effective strategy for improving client treatment participation. It is of

particular interest that the intervention was effective not only in increasing the

average number of monthly visits but also in improving the overall percentage of

treatment patients in compliance with program standards. These findings

suggest that the intervention should affect program dropout rates, although

these were not a direct target of the feedback. Furthermore, the success of this

program is striking given the minimal nature of the goal-setting and feedback

intervention.

211
TABLE 3. Percentage of counselors whose clients are in compliance with

program standards prefeedback and postfeedback

Program Component

Condition

Individual Group

Counseling Counseling

Breathalyzer

Visits

Prefeedback

Postfeedback

26% 32% 51%

52% 80% 80%

Manipulation of Counselor Continuity

Another study in our treatment program examined the impact of counselor

continuity on client participation and retention. A variety of earlier studies

examined client-targeted interventions such as letters, phone calls, and

appointment calendars that were designed to promote continuity of care

(Koumans and Muller 1965; Koumans et al. 1967; Nirenberg et al. 1980;

Panepinto and Higgins 1969). In addition, it may be possible to directly

manipulate counselor availability from a program policy basis and thereby affect

client participation. For example, in an earlier study, clients assigned to twiceweekly counseling contacts were more than twice as likely to be active in

treatment and continuously abstinent over the course of an 8-week intervention

compared with patients assigned to once-weekly counseling (Gerrein et al.

1973).

In an earlier study we examined counselor continuity from residential to

outpatient treatment as an important contributor to outpatient treatment

participation and retention. Clients were randomly assigned to either the same

or a different counselor for the residential and subsequent outpatient treatment

periods. All persons admitted to the residential facility over a 2-year period

were eligible for this study. Clients were excluded from the study if they failed

to sign an outpatient treatment contract during their residential stay or were

transferred to another facility for subsequent care. On average, subjects (N =

250) were males in their mid- to late-thirties; single, divorced or separated; and

unemployed and reported approximately 14 years of regular alcohol use. There

were no significant differences between experimental and control groups for any

demographic variables. All subjects participated in the same residential and

outpatient treatment program regardless of group assignment.

212
TABLE 4. Effects of counselor continuity on outpatient treatment participation

Counselor Condition

Same Different p-value

Time in Treatment (weeks)

(SD)*

Number of Visits for:

Abstinence Monitoring

(SD)

Individual Counseling

(SD)

Group Counseling

(SD)

18.6

(22.6)

27.3

(36.9)

6.4

(8.8)

6.2

(8.1)

10.3 <.05

(12.0)

15.8 <.05

(23.1)

2.9

(4.4)

<.01

(7.9)

4.3 **

*Standard Deviation

**No significant difference

As shown in table 4, clients in the “same” counselor condition remained in

outpatient treatment significantly longer than dients in the “different” counselor

condition. Further, clients with the same counselor participated in significantly

more brief breathalyzer monitoring visits and individual counseling sessions

than clients with different counselors. “Group counseling” participation was not

significantly different in the two study groups. These findings suggest that the

ongoing relationship with the primary counselor affects those aspects of

treatment that specifically involve the primary counselor and not on more

general treatment requirements such as group therapy that involve diverse

program staff. Counselor contact generally is assumed to be a positive

reinforcer for patients; thus, interventions that manipulate counselor availability

should affect client treatment compliance positively.

Other Counselor-Targeted Interventions

It will be of interest in future research to examine potentially more potent

counselor-targeted interventions such as use of contingent incentives, including

comp time, continuing education, and financial incentives. An interesting recent

study with therapists in a child behavior management clinic explored the effects

213
of making new case assignments to therapists contingent on patient

participation in counseling visits (Handen et at. 1986). The four therapists who

conducted the most counseling sessions during each 2-week period were

exempted from assignment of new cases, with new admissions equally divided

among the other six therapists. The mean number of patients seen per day by

each therapist doubled during the contingent case assignment period, primarily

as a result of an increase in the number of appointments that therapists

scheduled. These findings demonstrate that routine aspects of program

administration such as assignment of new cases can be used in a contingent

fashion to influence counselor behavior.

SUMMARY

Earlier research has demonstrated the need for more effective strategies to

increase treatment compliance, particularly in drug-free treatment programs.

This need is particularly acute given the increased admissions of patients who

use multiple drugs. Most efforts in this area have utilized client-targeted

interventions to increase participation levels and length of retention. Thus,

based on the studies cited in this chapter, counselor-targeted interventions may

offer a cost-effective and potent alternative or adjunct to client-targeted

interventions that should be the focus of future research.

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AUTHORS

Mary E. McCaul, Ph.D.

Assistant Professor

Dace S. Svikis, Ph.D.

Instructor

Department of Psychiatry and Behavioral Sciences

Johns Hopkins University School of Medicine

Francis Scott Key Medical Center

4940 Eastern Avenue

Baltimore, MD 21224

217

294-012 0 - 91 - 8
Retention in Drug-Free Therapeutic

Communities

George De Leon

INTRODUCTION

The effectiveness of drug abuse treatment is highly correlated with retention.

Almost all studies of treatment outcomes report that posttreatment success and/

or improvement rates are directly related to length of stay in treatment. Figures

1 and 2, for example, show the relationship between retention and

posttreatment outcomes for the three major modalities.

However, dropout is the rule across all drug treatment modalities. Although

absolute levels of retention are higher for methadone maintenance and lower

for drug-free outpatient and residential treatment, too many clients leave

treatment before maximal benefits are presumed to occur.

Despite the obvious importance of retention, research in this area is a relatively

recent development. This chapter provides an overview of the research and the

issues of retention in drug-free residential therapeutic communities (TCs).

Although the material presented is drawn from TC studies, generalizations to

other treatment modalities are evident.

The initial section provides an overview of the main research findings and

conclusions on retention. The following section summarizes a recently

completed experimental attempt to reduce early dropout from TC treatment.

The final section offers a perspective and paradigm for the study of retention

and implications for treatment and research.

OVERVIEW OF MAIN FINDINGS AND CONCLUSIONS

This is not an exhaustive survey nor a critical review of the TC research on

retention. Full reviews and bibliographies of retention that include TCs are in

the drug abuse literature (Allison and Hubbard 1985; Collins and Allison 1983;

Siddiqui 1989; Siddall and Conway 1988; De Leon 1985; De Leon and

Schwartz 1984). Only the material from technical reports and published studies

218
FIGURE 1. One-yearposttreatment outcomes by length of stay in treatment

in three modalities

SOURCE: Simpson and Sells 1982.

219
FIGURE 2. Comparisons between the 1970-1971 and 1974 cohort through 2

years of followup for male opioid abusers—success and

improvement rates by time in program

SOURCE: De Leon 1984.

220
in drug-free TCs is surveyed, although some recent unpublished results are

cited.

Most retention studies were completed in programs that adhere to the traditional

TC model (De Leon and Rosenthal 1989; De Leon 1986a). However, an

unknown percentage of programs in the Client-Oriented Data Acquisition

Program (CODAP) and Treatment Outcome Prospective Study data sets were

shorter term, nontraditional TCs.

There are a fair number of retention studies on drug-free residential alcohol

programs (Baekland and Lundwall 1975) that are not included because

application of the TC model in these settings is absent or unclear. Finally, the

TC literature outside of the United States is excluded except where noted.

Despite these limitations, the material reviewed provides a reasonably accurate

picture of the current status of retention research in U.S. TCs.

The research on retention can be organized around four major questions

concerning retention rates, client characteristics or predictors of dropout, clientstated reasons for dropout, and attempts to enhance retention. Relatively few

studies address the latter two issues, although a fairly substantial literature

reports on the first two. The main findings and conclusions each are

summarized below.

What Are the Retention Characteristics for TCs?

The term “TC” is a generic term applied to a range of drug-free residential

settings, only about a quarter of which are the traditional long-term variety.

Thus, interpretation of dropout and completion rates must consider these

program differences (discussed below in “Why Do Clients Drop Out of TCs?”).

Temporal Pattern of Dropout Is Lawful. Figures 3 and 4 show the

characteristic curve for dropout in several data systems and across several

admission years. Dropout is maximal in the first 30 days, elevates through 90

days, and decreases sharply thereafter. Figure 5 shows the Therapeutic

Communities of America (TCA) retention data corrected for admissions who

have already left treatment (i.e., survivor rates). Continued retention in

treatment increases with length of stay; that is, the likelihood of dropout

decreases with time spent in treatment.

Dropout Rates. Across the data systems the 10-month retention rates are 7 to

15 percent (figure 3). Programs in TCA vary, yielding 10-month rates as high

as 25 percent (figure 4). Actual completion (graduation) rates from 2-year

programs are not formally reported in these data sets, but TCA program records

221
indicate a range of 10 to 15 percent. It should be stressed that the low

graduation rate underestimates the impact of treatment. In long-term TCs

posttreatment success rates are highly correlated with graduation or completion

and also with post-12-month retention (figure 2).

There is some evidence for increased retention in recent admissions to TCs.

Data from 1985 and 1986 entries to a large northeastern TC show that 1 -year

retention exceeds 29 percent compared with less than 20 percent in 1979. A

steady rise in retention through the 1980s is confirmed in a recent survey of

1988 admissions to 15 other TCs, showing an average 30-day retention rate of

75 percent compared with the 60-percent average for 1979 admissions shown

in figure 4. Revised graduation rates are needed, but these correlate highly

with 1 -year retention and should show a corresponding increase.

FIGURE 3. Retention curves for drug-free residential programs in several

data systems

SOURCE: De Leon 1985.

222
FIGURE 4. Pattern of dropout in seven traditional TC programs of TCA

SOURCE: De Leon 1985.

223
FIGURE 5. Likelihood of retention in the TCA consortium based on

successive 3-month survivor rates. More than 70 percent of

admissions stay 14 days. Of these, half remain 90 days, and of

those that remain 90 days, 62 percent continue to 180 days.

Approximately 68 percent of the 6-month survivors continue an

additional 3 months, and 75 percent of the 9-month survivors stay

through 12 months.

SOURCE: De Leon 1985.

224
Although modest, these recent TC retention data are important. They suggest

greater “holding” power in TCs that are now serving admissions who are

predominantly cocaine/crack abusers compared with the early opiate

admissions. This retention trend augurs favorably for the efficacy of the TC for

cocaine abusers given the high correlation between time in program and

success rates.

Why retention shows an increasing trend is less understood. However, informal

surveys of TC program administrators and clinicians cite such factors as aging

opiate addicts who appear to be accepting the necessity of remaining in

treatment, the fear of relapse among cocaine/crack abusers, and improved

managerial and administrative capability in TCs. A frequently reported

interpretation underscores improved treatment based on clinical training and a

broader staffing pattern that integrates traditional mental health with TC

experience. These interpretations and impressions provide hypotheses for

empirical investigation.

Key Conclusion. Overall retention in TCs is low but has been increasing in

recent years. The period of highest dropout is the first 3 months of residential

treatment, particularly the first 30 days. Thereafter, the longer clients remain in

treatment the greater the likelihood of treatment completion. This pattern of

retention is the same in other treatment modalities, although absolute levels of

retention differ (e.g., higher for methadone maintenance).

The quantitative temporal pattern of retention findings agrees with clinical

observations concerning critical transition points in treatment and has significant

implications for research efforts to minimize early dropout. In particular, the

“probability of staying” function highlights the importance of facilitating a clients

adjustment through the early period of high vulnerability to dropout to

significantly enhance an overall treatment impact.

Who Drops Out of Treatment?

Issues of Client Self-Selection and Matching. Those who enter TCs may

differ from those who do not, and those who remain in treatment may differ from

those who leave prematurely. Thus, the relationship between successful

outcome and retention could reflect client self-selection factors rather than

treatment effects.

A related issue is client-treatment matching. Presumably, identification of client

differences, with respect to appropriate treatments (or interventions), would

reduce premature dropout and increase favorable outcomes. Both these issues

have been investigated through prediction studies, which attempt to isolate the

client correlates of outcome and retention.

225
Predicting Treatment Outcomes. The magnitude of predictive effects vanes

across studies and modalities. However, the main domains of client

preadmission factors that have been studied contribute relatively little to

posttreatment outcomes (Simpson and Sells 1982; De Leon 1985, 1986b).

These consist of demography, baseline and lifetime drug and alcohol use

variables, and family and juvenile histories. Severe criminality and psychiatric

history are consistent but small contributors of poorer outcomes in TCs and in

other modalities.

Predicting Retention. The collective set of client variables contribute little to

the variance in TC treatment retention. Client retention correlates have been

weak and sporadic, depending on the study. Again, however, severe criminality

and psychopathology predict shorter retention (e.g., De Leon 1985, 1986b; De

Leon et al. 1973; Foureman et al. 1981; Zuckerman et al. 1975).

Recent efforts have addressed the specific question of predicting early (30-day)

retention because it has the highest dropout period. Little of the retention

variance was explained in regression analyses. However, small but consistent

predictors of early dropout were client perception factors, that is, their readiness

and suitability for TC treatment (De Leon and Jainchill 1986). Notably, clients’

initial estimates of how long they needed treatment were significantly correlated

with their actual length of stay (De Leon 1988a; Siddiqui 1989).

Other Predictors of Retention, Legal referral or legal involvement (e.g., court

cases pending) is the most consistent nonclient, nontreatment predictor of

retention. (A fuller review of legal pressure factors in TCs is contained in De

Leon 1988b.) Clients referred to TCs average significantly more days in

treatment than do “voluntary admissions” (Aron and Daly 1976; Condelli 1986;

De Leon 1988b; Hubbard et al. 1988; Sirotnik and Roffe 1977; Pompi and

Resnick 1987; Samsome 1980; Siddiqui 1989).

Retention may be influenced by differences in program quality (e.g., staff

composition and experience, program resources, administrative and

management expertise). This is suggested in the TCA consortium studies

indicating program differences in absolute level of retention. However, this

hypothesis has not been tested directly in traditional TCs.

Key Conclusion. Overall, typical client profiles in relation to retention (or

outcome) have not been delineated. Although some variables have

consistently correlated with length of stay, their predictive power has not been

large or corroborated in replicational designs. Nonclient correlates of TC

retention are not apparent (with the exception of legal pressure), and program

contributors to dropout are suggested but have not been specifically identified.

226
The research reviewed suggests that there are inherent statistical as well as

substantive limits in prediction studies and in the variables that have been

surveyed. Psychological, motivational, perceptual, and other “dynamic”

variables appear more relevant to retention than do “fixed” variables such as

demography, drug use patterns, and family background.

Why Do Clients Drop Out of TCs?

This question refers to client-stated reasons for leaving treatment prematurely.

Studies that directly survey reasons for dropout are few and understandably are

of limited retrospective designs. These studies have included face-to-face

interviews of dropouts 2 to 6 years after treatment (Wexler and De Leon 1983)

and, more recently, telephone interviews with dropouts within 7 days of leaving

treatment prematurely (i.e., “hot splits”) (De Leon et al. 1987).

Results. Various results have emerged from these studies. (1) Client reasons

for dropout can be reliably classified into two overall categories: personal (e.g.,

want to get high, family, work pressures, do not need treatment, etc.) and

program (cannot tolerate the regimen, do not like staff, need treatment for

nondrug problems, etc). A smaller category consists of both personal and

program reasons. (2) Overall, program and personal reasons are equally

divided, but categories are significantly correlated with time in the program. For

example, later dropouts more often state program reasons for leaving than do

earlier dropouts. (3) Dropout is not necessarily precipitated by negative

incidents. (4) Early dropouts (less than 30 days) more often view their drug

problem as less serious than do later dropouts.

Other Reasons for Dropout. Related but indirect investigations of reasons for

dropout have examined client satisfaction with treatment and their perceptions

of the TC treatment environment (Bell 1983; Simpson 1986; Wexler and De

Leon 1983; Siddall and Conway 1988). The findings from these indicate that

(1) most dropouts and graduates attribute their reductions in drug use to

treatment; (2) most indicate satisfaction with the treatment they received,

although satisfaction levels directly increase with length of stay; and (3)

perception of the TC treatment environment—Community-Oriented Programs

Environmental Scales—changes with length of stay. Earlier dropout correlates

with poorer program perception.

Key Conclusion. The few findings in this area must be viewed as preliminary,

requiring replication in other TCs. Nevertheless, they agree with studies

indicating the importance of client motivation, readiness, and suitability for

treatment in understanding dropout. Moreover, client reasons for dropout offer

considerations for how programs can improve retention.

227
How Can Dropout Be Reduced?

Despite its importance, especially in light of the need to keep high-risk addicts in

treatment, this question has been essentially unaddressed. There is some

evidence that provides inferences about reducing dropout. For example, in

methadone maintenance, higher retention has been related to client-specific

maintenance dose (i.e., flexible dose policy), to clinics with generally better

quality of services and staffing (Brown et al. 1983; Ball and Corty 1988), and to

mandated family involvement (Sorenson et al. 1985).

One published study cites that family involvement in treatment in TCs correlates

with retention (Siddall and Conway 1988), and an unpublished report states that

residential services for female addicts with their children are related to longer

stay in treatment (N. Arbiter, personal communication, 1989). Overall, however,

there is virtually no research literature on experimental attempts to reduce

dropout from drug treatment in general or in drug-free TCs in particular.

STUDY: REDUCING EARLY DROPOUT FROM TCs

The above conclusion provided the general rationale for a large-scale

investigation to enhance treatment retention. A recently completed National

Institute on Drug Abuse-funded study examined the effects of three

interventions on modifying early dropout from a TC with a rigorous experimental

design (De Leon 1988a). Two experimental trials were conducted on

successive yearly cohorts, although the report emphasizes the results of the

initial trial.

Method

Study Cohort. The study cohort consisted of all first-time admissions to

residential treatment from January 1, 1985, to January 31, 1985 (N ± 810).

They were primarily male (78.8 percent), black (55.1 percent), and older than 20

years of age (67.1 percent). Most (81.0 percent) had entered treatment

voluntarily (not legally referred, on probation or parole, or otherwise legally

involved). The cohort reflects a spectrum of drug abusers with pluralities

among those claiming their primary drug to be cocaine (46.3 percent), heroin

(25.6 percent), and marijuana (15.6 percent).1

In addition to substance abuse, psychological profiles revealed a considerable

degree of depression, anxiety, prominence of personality disorder, and poor

self-esteem. These profiles were essentially similar for the experimental and

control groups within the cohort. Overall, the demographic and psychological

226
profiles of treatment admissions during the project period appear to be

characteristic of drug abusers in general and of admissions to TCs in particular.

Experimental Interventions. Three different interventions were implemented

separately for different monthly cohorts. The general objective of all three was

to facilitate client adjustment to the TC in the early days of treatment. Although

briefly summarized here, a fuller description of the specific rationale, goals, and

protocol for each is contained in the full project report (De Leon 1988a).

Senior professor (SP). Four 1-1/2-hour seminars per week were provided by

different senior staff persons through a 2-month experimental period. Seminars

addressed TC philosophy and expectations and problems of staying in

treatment. The experience of these senior staff members addressed the range

of concerns and questions expressed by new admissions. The main objective

of the SP was to facilitate role induction into the TC.

Significant others (SO). Two 2-hour sessions were provided to new

admissions in the first 2 weeks to groups of significant others. In addition, SOs

had one 30-minute session with the staff counselor at the treatment facility.

Orientation for the family was provided by a research associate. The main

objective of the SO was to strengthen the alliance between family and

treatment.

Individual counseling (IC). Six 30- to 40-minute sessions were provided

during the first 14 days of treatment with three additional sessions during days

14-28. Counseling was conducted by a trained research assistant and focused

on issues of client advocacy (resolving “outside” problems—family, legal,

health, children, etc.), adjustment problems (e.g., difficulties with peers, staff,

the daily regimen, loneliness, etc.), and role conditioning (specific instructions to

facilitate the clients understanding and acceptance of the TC). The main

objective of IC was to reduce anxiety about treatment and strengthen

commitment to change through individualized attention to client differences and

needs.

Design and Data Collection. Data were collected on all consecutive treatment

admissions through the 31 months of the project period. lndepth social and

psychological client descriptions were obtained during the first week of

admission through a face-to-face interview and a standard psychological test

battery.

An experimental design was employed in which each intervention was

sequentially implemented for a 2-month period (i.e., “on” months), preceded and

followed by a 2-month period during which the interventions were not

229
implemented (i.e., “off months). Thus, the experimental group consisted of all

admissions who received the interventions within the usual TC 30-day induction

process, and the control group consisted of all treatment admissions who

underwent the usual TC induction process only.

Main Findings

Dropout rates for the experimental group were compared with those of the

control group. Focus was on enhancing 30-day retention, because that is the

period of highest dropout. However, the longer term retention effects (180, 365

days) of each intervention also were assessed.

Early Dropout. The 30-day retention rates for the total “on” experimental group

(i.e., pooled interventions) were significantly higher than for the total “off control

group (70.2 percent vs. 63.4 percent, p < .05). The differential effects of each

intervention at 30 days are not significant, except that retention under the SP

condition was significantly higher than the control and the other intervention

groups.

Shifts In Retention. Figure 6 presents data that further clarify the separate

effects of the interventions. Thirty-day retention is plotted for successive 2-

month segments across the cohort 1 experimental phase (January 1, 1985-

January 31, 1986). A distinct change in retention occurs when interventions are

introduced or removed, although two reversals are seen in the “off periods

(following counseling and in the 2 months before the family intervention).

Nevertheless, the consistent on/off changes in figure 6 display the effect of the

interventions, particularly those of SO and SP.

Longer Term Retention Effects. These are less consistent. Each of the

interventions shows higher retention than the controls, but only the pooled

experimental and SP effects are statistically significant at 6 and 12 months. It

appears that the brevity of the interventions, offered in the first 30 days only,

resulted in a delayed dropout after 30 days. This reduced the impact at 6 and

12 months of the SO and IC interventions, although the SP effects remained

significant throughout the year.

Participation and Intervention Effects. Within each intervention condition

there is a positive association between short-term retention and attendance

level (figures 7 and 8). In the SC condition clients with participant families

showed significantly higher 30-day retention than the controls or the clients with

nonparticipant families. In the IC and SP conditions, the number of sessions

attended is significantly associated with higher short- and long-term retention.2

230
FIGURE 6. Thirty-day retention in the experimental and control months of

cohort 1

SOURCE: De Leon 1988b.

231
FIGURE 7. Retention by participation in the SP condition in cohort 1

SOURCE: De Leon 1988b.

232
FIGURE 8. Retention by participation in the IC condition in cohort 1

SOURCE: De Leon 1988b.

233
Predicting Dropout. A second aim of the study was to ascertain whether the

interventions differentially influenced certain clients to remain longer in

treatment. Regression analyses examined the relationship between client

factors and short- and long-term retention rates under each intervention.

In general, the regression equations were significant, but the variance

accounted for by the model was small. There were no large client predictors of

30-day retention in the experimental or control conditions, and there were no

large client predictors specific to each separate intervention. This pattern of

regression findings was similar for predicting longer term retention. However,

the magnitude of the multiple correlations were smaller than for 30-day

retention.

Notably, client perception factors remained small but significant predictors of

short- and long-term retention. These consisted of client self-reported scaled

items of readiness and suitability for TC treatment and their time estimates of

needed length of stay. Nevertheless, with all client contributors removed, the

interventions remained a significant predictor set of 30-day, 6-month, and 1-

year retention, particularly the SP condition.

Replication. A second experimental trial was carried out on 1986 admissions.

The cohort 2 admission profile contained significantly more females, blacks,

younger clients, cocaine abusers, and first-time and voluntary admissions.

Some profile differences between the cohort 2 experimentals and controls were

also evident, although discussion of these is beyond the purview of this chapter.

The shifts in 30-day effects were striking (figure 9). The largest effect was

obtained with IC, which yielded significantly higher 30-day retention rates

compared with controls and the other two interventions. The longer term effects

in cohort 2 were more unstable than in the initial trial. At 180 and 365 days, for

example, retention rates between experimentals and controls were not

significantly different.

Finally, the cohort 2 regression findings for 30-day retention also replicated

those of cohort 1, although the variance explained for retention was less than

that for cohort 1. The interventions were not consistent predictors of 6-month

and 1-year retention.

Study Conclusions

The interventions significantly reduced early dropout. The experimental effects

were largest at 30 days and persisted through 365 days in the SP condition.

Increased retention was positively associated with number of sessions in the IC

234
and SP conditions. The stability of the 30-day retention effects was replicated

in a second trial of the experiment on a new admission cohort.

FIGURE 9. Thirty-day retention in the experimental and control months of

cohort 2

SOURCE: De Leon 1988b.

235
That longer term retention effects were less consistent is not unexpected given

the focus on brief interventions to modify early dropout. Nevertheless, the

significant increase in 1-year retention for the SP group remains an impressive

finding. In particular, the 30-day findings underscore the need for flexible

program practices affer the initial phase of treatment to offset delayed dropout

and extend long-term retention.

Consistent with the TC literature, there was no typical client profile of dropout in

any condition. Although modest, the regression results did emphasize the

importance of client perceptions as correlates of retention. These variables

must be considered in prediction and client-matching efforts, a conclusion

further elaborated in the last section of this chapter.

RETENTION: BROADER IMPLICATIONS FOR IMPROVING DRUG ABUSE

TREATMENT

Though still developing, the existing knowledge base on retention in drug-free

residential settings can guide efforts to improve treatment quality. This last

section briefly outlines several broad implications for retention research and

treatment planning: a perspective on retention, experimental considerations,

methodological clarifications, and quality assurance.

Perspective on Retention

A paradigm for the study of retention (and outcome) is more fully outlined in

other writings (De Leon 1985, 1988a; De Leon and Jainchill 1986). Retention

can be understood as a continuing interaction between client diversity and

treatment (program) factors. Thus, a constant proportion of dropout is the rule

when homogeneous program procedures are applied to a heterogeneous

population of clients.3 Client diversity, however, is more evident in dynamic

variables (e.g., changing factors such as psychological improvement,

motivation, perceptions of treatment need) rather than fixed variables (e.g.,

background drug use, criminality, demography).

The recovery process reflects dynamic client variables continually interacting

with the treatment experience. For example, initially “low” motivation may result

in a positive treatment “moment,” which in turn increases motivation to remain in

treatment. Thus, the cumulative effects of client-treatment interaction result in a

continually changing status of the client and a changing probability of dropout,

which have practical implications for treatment and research.

Assessment. Spaced, periodic assessments of client change are needed to

surface individual differences with respect to client suitability for treatment. In

236
the first month of treatment, for example, daily evaluations of client adjustment

are needed to detect signs of early dropout. Thereafter, the frequency of

assessment can be guided by the characteristic temporal pattern of retention.

Prediction and Intervention Strategies. The dynamic properties of the

recovery process ensure that long-term prediction of retention (or outcome) may

not be a logical or reasonable expectation. Not surprisingly, the prediction of

program completion or posttreatment success is poor because these outcomes

are points in the recovery process that generally depend on long-term treatment

retention.

Thus, prediction strategies should be short term, based on client change

measures rather than variables at a fixed point such as at admission.

Intervention strategies should focus on identifying efforts that facilitate retention

to the next stage in the recovery or treatment process.

Enhancing Retention In Treatment: Experimental Considerations

Retention and treatment quality are interrelated. Improving treatment quality

can extend retention, which in turn leads to better outcomes. Conversely,

efforts to extend retention can directly affect treatment process and, thus, affect

treatment quality. Clearly, more experimental study is needed to assess

methods for enhancing treatment retention. However, the successful

modification of early dropout reported offers general suggestions for retention

research.

Interventions Within TC Treatment. Although effective in reducing early

dropout, refinement of the interventions could produce even more impressive

results. In particular, they may be adapted for use throughout primary treatment

to facilitate the client’s transition through various stages of the recovery process

in TCs.

Applications. Although requiring replication in other TCs, the experimental

findings are consonant with related studies in other modalities, highlighting the

effects of psychotherapy and family participation on outcomes. Of special note,

however, are the effects of the SP and IC interventions, which clearly have

applicability to drug-free outpatient and methadone maintenance settings.

Design. The experimental design employed a successive cohort procedure

(on/off). While adhering to strict experimental control requirements, this

approach avoids the matching and random assignment problems that often

have impeded treatment research. Thus, the design holds promise for retention

research in particular and for studies of treatment process in general. It is

237
illumination of the latter that, in the last analysis, is necessary for improving drug

treatment.

Some Methodological Clarifications for Retention Research

There are several basic definitions and analytic strategies that could enhance

the efficiency of retention research as well as improve assessments of

treatment delivery. Some of these have been employed in TC retention

investigations but have relevance for all modalities.

Planned Duration of Stay (PDS). Interpretation of dropout rates, or reciprocal

retention, is seriously affected by program and modality differences in PDS.

This parameter refers to the duration of treatment considered as optimal in

producing treatment goals (e.g., successful outcomes). In long-term traditional

TCs, for example, the PDS is 15 to 24 months, most of which is in residence.

Drug-free outpatient centers are less uniform or explicit concerning their

recommended optimal stay. Methadone maintenance clinics generally view 1 to

2 years as the minimum required participation to stabilize treatment effects

(e.g., elimination of illicit drug use). For most methadone clients, continued

tenure in treatment is recommended to minimize relapse and maintain prosocial

behavior.

The importance of the PDS is underscored further by the proliferation of shorter

treatment strategies in both residential and outpatient settings. Many TCs, for

example, have implemented short-term residential components to address

special client populations (e.g., employed addicts, adolescents, and relapsed

readmissions). Increasing numbers of outpatient clinics in both the public and

private sectors have appeared in response to the cocaine/crack epidemic.

Some include an outpatient modality with varying or vague recommended PDS.

Assessments of program quality or comparative effectiveness and cost-benefit

evaluations across programs or modalities as measured through retention must

consider the PDS. For example, 30-percent dropout rates from a 6-month

outpatient program and an 18-month, long-term TC are as dissimilar as

completion rates from 28-day programs and 90-day residential settings.

Without factoring in the PDS, these retention comparisons are invidious.

Retention Ratio (RR). This measure attempts to quantitatively adjust for

differences in the planned duration of treatment to facilitate direct and easy

comparison of programs and modalities with respect to their retention capacity.

The RR is a ratio of the actual average days in treatment (for a given admission

cohort) to the PDS. The RR can vary from 0 to 1.00 providing a quick and

238
easy-to-interpret comparative value (e.g., across years or programs). For

example, in all first quarter 1981 admissions to a large northeastern long-term

TC, the mean days in treatment was 172.4 days, and the PDS was 720 days,

yielding an RR of 0.24 multiplied by 100; this RR is 24 percent. For all 1979

admissions to a consortium of seven TCs, the RR was 0.15, or 15 percent.

Estimates of the RR for drug-free outpatient and methadone maintenance

centers, as well as short-term programs, would rigorously clarify the retention

differences in these modalities.

Retention Potential. A commonly reported RR is based on the entry rates

during the year of study. For example, in the CODAP statistical reports RRs

reflected the percent of all 1979 admissions still in treatment at the end of 1979.

This gross measure overestimates retention because it ignores the shorter

period of risk for dropout among admissions to treatment during the later

months of the year studied. An analogous problem is evident in followup

studies, which often do not adjust for client differences in time out of program or

period at risk.

The retention potential is a term that represents the explicit period of

observation during which an admission cohort is at risk to drop out of treatment.

For example, to determine the correct 10-month retention rates for the 1979

admission cohort shown in figures 3 and 4, the cutoff date of observation had to

be 10 months after the last entry in 1979. Thus, 6-month or 1-year RRs which

are comparable across studies, requires a fixed minimum period for all

admissions during which they are at equal time risk to drop out (e.g., 6 months

or 12 months after each individual admission date).

Survivor Rates. This term has been used mainly to reflect the number or

proportion of all admissions who remain in treatment for specific periods. More

precise estimates of when dropouts leave are obtained if rates are calculated on

a base that excludes those who have already left treatment. These yield RRs

for individuals who are still in treatment and therefore available to drop out. As

shown in figure 5 this corrected survivor rate provides a quantitative measure of

the likelihood or probability of remaining in treatment.

Wayside Rate (WR). Although not strictly a retention measure, this statistic

has been calculated in recently completed TC research. It is the percentage of

those accepted for treatment who actually fail to enter treatment (i.e., those who

get lost along the way to treatment). Estimated at 25 percent of all accepted

admissions, the WR is of obvious importance in determining program service

activity. Considerable front-end costs are involved with admission evaluations,

which are often not reimbursed to programs if clients fail to enter treatment.

239
The WR also may reflect client selection factors because it highlights possible

differences in those who accept and actually enter treatment.

Currently, the WR is of considerable relevance to the issue of waiting lists and

barriers to treatment. Reduction in the WR would clearly reflect improvement in

program quality. Although factors influencing the WR remain to be empirically

clarified, it is reasonable to assume that shorter delays in the treatment entry

process could lower the WR.

Quality Assurance and Retention

Quality assurance implies efforts to both monitor and improve drug treatment.

Two key elements that underscore the relationship between retention and

quality assurance are program validity and training.

Program Validity Effectiveness and Retention. Treatment programs are

valid when they deliver the services that they promise to deliver, and a program

is effective if it achieves treatment objectives. Although not necessarily causally

related, program process effectiveness and validity are highly correlated

because valid programs are more likely to initiate effective treatment. To a

considerable extent, retention reflects the fidelity with which treatment programs

implement their services and interventions. Therefore, retention is highly

related to program validity and quality assurance. Valid programs are

accountable, and accountability (to assess quality assurance) methods can

detect the program, staffing, and client factors that influence retention.

Training and Retention. Training is essential to ensure proper implementation

of program protocol. For TCs in particular, staffing factors are fundamental to

program validity and therefore indirectly influence retention in treatment.

Although not sufficiently documented by research, these factors include unity,

morale, dedication, and (as suggested in the SP findings) experience and

credibility. Thus, ongoing training is necessary for upgrading skills and

sustaining staff motivation.

Moreover, current TC staff composition is changing, which results in a broader

mix of traditional mental health and human services professionals and

nontraditional recovered professionals. Integration of these staff differences is

crucial to maintain consistency in clinical and management practice, which are

factors that contribute to improving retention. This requires an intensive training

to orient all personnel to the perspective, model, and method.

240
NOTES

1.

2.

3.

The study focused on first-time admissions data (i.e., first-time entries to

the program during the project period). Approximately 16 percent of all

admissions were multiple entries during the project period. Readmissions

data were excluded from the main analyses to minimize the variance

arising from previous treatment in intervention and nonintervention periods.

However, for the first-time admissions, the contribution of previous

treatment before the project period in the study program or any drug

treatment modality is assessed in the regression analyses reported in later

Papers.

A caveat in the participation analysis is that the number of sessions

attended in the SP and IC conditions was confounded with days in

treatment. Nevertheless, with time dependency controlled (i.e., the 6-

month and 12-month RRs based on 30-day survivors only), a positive

correlation between attendance and 12-month retention approaches

significance in the IC and SP conditions.

Nontreatment factors may be relevant to retention (e.g., legal, economic,

and family pressures; the community climate of acceptance of drug use).

However, the effect of these on treatment entry and retention also depends

on client perceptions.

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ACKNOWLEDGMENT

Preparation of this chapter was supported by the National Institute on Drug

Abuse grant R01-DA0-3617.

AUTHOR

George De Leon, Ph.D.

Director

Research and Training

Therapeutic Communities of America

1010 Fifth Avenue

New York, NY 10028

244
Using Methadone Effectively:

Achieving Goals by Application of

Laboratory, Clinical, and Evaluation

Research and by Development of

Innovative Programs

Mary Jeanne Kreek

Since the initial studies performed at The Rockefeller University in 1964 and the

early extension of these studies to actual treatment procedures, methadone

maintenance treatment for chronic heroin addiction has been used to manage

more than 150,000 “hard-core” heroin addicts (defined as heroin abusers with

more than 1 year of multiple, daily, self-administered doses of illicit heroin, with

the development of tolerance, physical dependence, and drug-seeking behavior

or addiction) (Dole et al. 1966; Kreek 1973a, 1973b, 1987a; Cooper et al. 1983;

Novick et al. 1986; Gunne and Gronbladh 1984; Blix 1988; Corty and Ball 1987;

Ball and Corty 1988; Ball et al. 1988a, 1988b).

Methadone maintenance treatment has been documented by prospective

studies initiated in 1964 and by numerous other prospective and retrospective

studies to be medically safe and very effective in achieving its targeted primary

treatment goal, that is, significant reduction or cessation of illicit narcotic (opiate,

usually heroin) use. As a result of the effectiveness of methadone maintenance

treatment in significantly reducing or eliminating illicit and regular use of heroin

and other short-acting narcotics and thus reducing or eliminating the regular use

of potentially contaminated needles and other equipment used in the selfadministration of drugs, such treatment also has been successful in significantly

reducing the medical problems and antisocial behaviors associated with the

procurement and self-administration of illicit drugs. Effective methadone

maintenance treatment has resulted in the reduced incidence of new cases of

infectious diseases transmitted by use of contaminated needles, such as

hepatitis B, hepatitis delta, and human immunodeficiency virus (HIV) infection

(Dole et al. 1966; Kreek 1973a, 1973b, 1987a; Cooper et al. 1983; Novick et al.

245
1986; Gunne and Gronbladh 1984; Blix 1988; Corty and Ball 1987; Ball and

Corty 1988; Ball et al. 1988a, 1988b).

Effective methadone maintenance treatment, delivered by good programs that

usually have a broad-based, knowledgeable, and caring staff, has resulted in

fewer criminal acts by those in treatment and therefore in significant reductions

in numbers of arrests and imprisonments. Effective treatment also has resulted

in an increase of social adjustment and productivity of patients (e.g.,

employment, education, and homemaking).

Methadone is an orally effective synthetic opioid that is long acting in humans,

with a plasma half-life of more than 24 hours for the racemic compound used in

therapeutics and a half-life of approximately 48 hours for the active 1 (R)

enantiomer. Thus, methadone may be administered once a day to prevent

opiate withdrawal symptoms as well as “drug hunger” for 24 to 36 hours, and

when administered to tolerant patients, it causes no euphoria or sedation (Kreek

1973c; Dole and Kreek 1973; Kreek et al. 1976a, 1979, 1980, 1983; Hachey et

al. 1977; Nakamura et al. 1982; Pond et al. 1985). This is in contrast to heroin,

which is a short-acting narcotic with a plasma half-life in humans of 1 to 2 hours

and a plasma half-life for its major metabolite morphine of 4 to 6 hours. Thus,

heroin must be self-administered several times each day, either to produce the

desired euphoric “high” effects or to prevent narcotic withdrawal symptoms.

Whereas methadone is orally effective, heroin is not; thus, heroin must be

administered parenterally, usually using needles and other injection equipment

that may be contaminated because of needle-sharing.

Recent studies have shown that the long-acting properties of methadone in

humans, with the resultant steady-state plasma levels achieved during regular

use once each day and steady-state perfusion of opiate receptors (the binding

sites of opiate drugs as well as the endogenous opioids, or so-called

endorphins, which then results in opiate-like actions), result in normalization of

many functions of human physiology that may be profoundly altered by acute or

chronic use of short-acting narcotics such as heroin. This includes

normalization of the neuroendocrine function, including the timing of hormone

release and the levels of hormones of the hypothalamic-pituitary-adrenal axis

and the hypothalamic-pituitary-gonadal axis, which are important in the normal

responses to stress and reproductive behavior, respectively, and also

normalization of many indices of immunological function and normalization of

behaviors (Kreek 1973a, 1973b, 1978, 1987a, 1987b, 1988; Kreek et al. 1972,

1981, 1984; Kosten et al. 1987; Novick et al. 1989).

Long-term methadone maintenance treatment is accepted voluntarily by a high

proportion of “street” heroin addicts, with an estimated 40 to 60 percent of

246
addicts accepting methadone treatment. Voluntary retention rates in methadone

maintenance of 2 years or more range from 45 to 85 percent in different clinics

(Dole et al. 1966; Kreek 1987a; Blix 1988; Corty and Ball 1987; Ball and Corty

1988; Ball et al. 1988a, 1988b). However, long waiting lists, ranging from 1

month to 1 year, now exist for entry into some methadone maintenance

treatment programs, especially those in crowded urban settings and those in

remote areas. Because of social, behavioral, and medical problems and

polydrug abuse problems (including alcohol and cocaine abuse, which

frequently accompany heroin addiction at this time), methadone maintenance

treatment programs that have an enlightened, knowledgeable, expert, and

caring staff that can offer counseling, behavioral, and rehabilitative services and

primary medical care and that have a staff that includes one or more ex-addicts

successfully in treatment are the most effective in achieving both the primary

goal of methadone maintenance treatment (figure 1). The primary goal is (1)

the cessation of illicit narcotic use, and the secondary goals of treatment include

(2) reduction or elimination of other drug or alcohol abuse, (3) decreased

exposure to diseases spread by use of unsterile equipment, (4) a decrease in

antisocial behaviors and criminality of all types, and (5) an increase in

socialization and productivity and improvement in general health status (figure

1). As stated by Drs. Vincent P. Dole and Marie E. Nyswander in 1967, 3 years

after the initiation at The Rockefeller University of research on the use of

methadone in chronic treatment of heroin addiction, “A pharmacological cure is

no more than a beginning. To become a productive and responsible member of

society, the ex-addict needs help from someone who understands the nature of

his struggle” (Dole and Nyswander 1967). (See also Blix 1988; Corty and Ball

1987; Ball et al. 1988a, 1988b; Nyswander 1967; Dole and Joseph 1978; Dole

and Nyswander 1976; Dole et al. 1982.)

Primary Goal

1a. Significant reduction or cessation of illicit narcotic (opiate; heroin) use

(specific pharmacological effect of methadone).

1b. Related goal of voluntary retention in treatment for 1 year, 2 years, or

more.

Secondary Goals

2. Significant reduction or cessation of cocaine, alcohol, and polydrug abuse

(nonspecific treatment program effect).

247
3. Significant reduction of exposure to and infection with diseases transmitted

by use of unsterile injection equipment used in parenteral drug abuse, such

as hepatitis B, hepatitis delta, and HIV infections.

4. Significant reduction in criminality and in antisocial behaviors and,

therefore, reduction in arrests and imprisonments.

5. Significant improvement in socialization and productivity, including

employment, resumption of education, and homemaking.

FIGURE 1. Goals of methadone maintenance treatment

In the early years of methadone maintenance treatment for heroin addiction and

related treatment research, the treatment goals envisioned by many treatment

programs, their staffs the patients, and policymakers was the ultimate

“detoxification” or dose reduction and elimination of the pharmacological

treatment with methadone. However, several different long-term prospective

and retrospective studies have shown that a high percentage of former

methadone-maintained patients will demonstrate recidivism or relapse to illicit

narcotic (opiate, usually heroin) drug use after a relatively short opioid-free

interval (Cooper et al. 1983; Stimmel and Kreek 1975; Rounsaville et al. 1987;

Cushman and Dole 1973; Stimmel and Rabin 1974; Stimmel et al. 1974; Dole

and Joseph 1977; Des Jarlais et al. 1983; Des Jarlais and Joseph 1981; Senay

1985). Between 70 and 80 percent of former methadone-maintained patients

return to illicit narcotic use within 1 to 2 years after leaving methadone

maintenance treatment, according to several studies. This relapse may be

preceded or accompanied by increased abuse of alcohol as well as other drugs.

Thus, clinical experts in the area of treatment of chemical dependency,

especially those involved specifically in the treatment of opiate addiction, along

with scientists and epidemiologists working in this area, are arriving at a

consensus that the most effective treatment for chronic heroin addiction is longterm methadone maintenance treatment for an indefinite period, which may be

essential for the majority, though certainly not all, of such patients. Also, there

is considerable research evidence that increasing the total length of time in

treatment, including from later time points ranging from 1 year to more than 5

years, results in progressive improvement in all primary and secondary goals of

treatment of narcotic addiction (Blix 1988; Corty and Ball 1987; Ball and Corty

1988; Ball et al. 1988a, 1988b; Dole and Nyswander 1967).

However, it is also the consensus that until and unless similarly effective (and

similarly specific) pharmacological treatment approaches become available for

other types of chemical dependencies—such as alcoholism and cocaine abuse,

248
which affect up to 40 to 50 percent and 70 to 90 percent, respectively, of all

street heroin addicts at this time, and thus, all new entrants into methadone

maintenance treatment—drug-free, behavioral, 12-step-oriented, and/or

psychosocial approaches to the management of these additional problems must

be combined with the effective chemotherapy of methadone maintenance for

narcotic addiction in patients with these dual or multiple chemical dependency

problems (Dole 1988). Inpatient or residential treatment may be essential for

the most severely dually addicted alcohol-abusing or cocaine-abusing active or

former heroin addicts, first to be able to completely detoxify them from alcohol

or cocaine and then to initiate abstinence-based treatment for the second

addiction along with methadone treatment for the heroin addiction. This should

occur in a setting removed from the stresses of everyday life of each addict and

away from specific drug cues, both of which may aggravate, increase, or cause

a recrudescence of drug-craving for alcohol or cocaine. Also, it is increasingly

appreciated that medical and psychological as well as social and rehabilitative

efforts must be combined with chemotherapy and that such combined treatment

must be individualized—that is, treatment must be delivered on an individual

patient basis—if the secondary goals of treatment are to be achieved by

effectively addressing problems related to heroin addiction.

Former heroin addicts in chronic methadone maintenance treatment who have

achieved success in the primary and secondary goals of treatment and who

therefore no longer require or further benefit from counseling, rehabilitation, and

psychosocial services have been shown to benefit from continued

chemotherapy in a conventional general medical setting such as that used for

the treatment of any chronic disease. This setting combines general medical

care with pharmacological treatment of using methadone addictive disease

(Novick et al. 1988a. 1988b). Such a “medical maintenance approach” in the

future could provide additional and needed treatment resources for new

patients entering methadone maintenance treatment for illicit heroin addiction

and for patients who have continuing general or specific needs.

The efficacy of chronic treatment for heroin addiction using methadone,

including the most common available form at this time, “chronic methadone

maintenance treatment,” which does not imply or guarantee uniform quality or

spectrum of services, must be judged in terms of the goals that are realistic for

methadone treatment. There is a single primary goal for methadone

maintenance treatment—the cessation of illicit narcotic use; however, significant

retention in treatment is essential if this primary goal is to be achieved.

Therefore, a related essential goal is to retain patients in treatment for periods

sufficient to achieve the primary goal. This is best measured as voluntary

retention in treatment minimally for 1 year or preferably for 2 years or more.

Secondary goals of methadone maintenance treatment include the reduction or

249

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cessation of cocaine, alcohol, and polydrug abuse during methadone

maintenance treatment; reduction of exposure to and infection with diseases

transmitted by use of unsterile injection equipment during parenteral drug abuse

and by exposures related to increased risk behaviors during drug abuse in

general; reduction in antisocial behaviors and criminality and, therefore,

reduction in arrests and imprisonments; and increase in socialization and

productivity (figures 1 and 2).

Primary Goal

1a. Significant reduction or cessation of illicit narcotic (opiate; heroin) use

(specific pharmacological effect of methadone). “Best” programs:

Continued any heroin use 15 percent.

1b. Related goal of voluntary retention in treatment for 1 year, 2 years, or

more. “Best” programs: Voluntary retention 2 years > 65 percent.

Secondary Goals

2. Significant reduction or cessation of cocaine, alcohol, and polydrug abuse

(nonspecific treatment program effect). “Best” programs: e.g., cocaine—30

to 40 percent reduction in numbers of chronic abusers—and alcohol—20 to

30 percent reduction in numbers of chronic abusers.

3. Significant reduction of exposure to and infection with diseases transmitted

by use of unsterile injection equipment used in parenteral drug abuse, such

as hepatitis B, hepatitis delta, and HIV infections. “Best” programs: e.g.,

HIV < 10 percent anti-HIV-1 positive if entered in programs before HIV

epidemic as compared with 50 percent of those using drugs parenterally

during epidemic.

4. Significant reduction in criminality and in antisocial behaviors and,

therefore, reduction in arrests and imprisonments. “Best” programs: > 70

percent reduction in criminal acts and in arrests.

5. Significant improvement in socialization and productivity, including

employment, resumption of education, and homemaking. “Best” programs:

> 60 percent improvement in productivity.

FIGURE 2. Maximum levels of achievement of goals of methadone

maintenance treatment

250
The effectiveness of methadone in achieving these goals has been studied in

numerous different prospective and retrospective research efforts carried out

over the past 25 years and in many less elaborate evaluation procedures (figure

2). However, continued consideration of these goals will be essential in the

context of remodeling or altering the structure of existing programs or in the

development of innovative programs. Also, simiiar or parallel well-defined goals

should form the basis of evaluations carried out to determine the extent of

achievement of these goals when any other drug, such as cocaine or alcohol, is

the primary drug abused and when treatment is focused on this problem.

Defined goals should be considered, and accountability with respect to

achievement or failure to achieve these goals should be ensured by mandatory

evaluation of all drug treatment programs, including all types of pharmacological

programs using methadone or any other pharmacological agent (e.g., LAAM,

buprenorphine, the opiate antagonist naltrexone, or any of the pharmacological

agents currently under study for possible use in treating cocaine dependency).

Similarly, the same articulated goals, as well as accountability, assessed by

ongoing mandatory evaluation should apply to all drug-free residential or

outpatient programs, 12-step-based programs, and any other programs for

which any type of private, Federal, State, or municipal funding is required or for

which any scientific, clinical, or sociological impact claim is to be publicly made.

As a corollary to this, it is essential that all mandatory evaluation efforts use

similar tools in such followup assessments. Of greatest importance in this

context is the need for equivalent application of the use of urine monitoring as

part of the short-term and long-term evaluation of drug abuse treatment of all

types, including all pharmacological and nonpharmacolgoical treatments.

Although some clinicians will correctly argue that careful history-taking can

reveal any changes in patterns of drug abuse or a lapse in the goal to remain

abstinent from illicit use of drugs, nevertheless, it is important both for that

clinician and other members of the clinic staff, as well as especially for the

patient and for society, to document such abstinence. Therefore, a similar

mandatory schedule for urine monitoring at different stages of treatment should

apply equally to all pharmacological and nonpharmacological drug abuse

treatment programs. Otherwise, accountability is lacking and data remain

incomplete, a major problem that pertains today in assessments of all types of

drug abuse treatment programs other than those using methadone. Unless

such equivalent evaluations of diverse treatment are mandated, the potential for

providing the optimal care for each patient and for understanding the potential

needs for groups of patients with different clinical, social, and economical

characteristics will remain unknown. The cost of the failure to evaluate all drug

abuse treatment programs, for each individual patient and for society, will

remain unacceptable.

251
Finally, in a serious consideration of improving the effectiveness of methadone

maintenance treatment, it is important to consider how effective chronic

methadone maintenance treatment has been shown already to be in those

“good” or “best” programs, with knowledgeable and caring staff members and

where general comprehensive and a broad spectrum of services are available

(usually including counseling and social work efforts) but with or without any

onsite or direct access to comprehensive medical and psychiatric care and with

or without any significant indepth onsite rehabilitation programs.

In looking at the primary goal of methadone maintenance treatment, for

instance, it has been shown in several studies that less than 15 percent (and in

other studies less than 10 percent) of heroin addicts stabilized on methadone

maintenance treatment continue to use heroin (figure 2). It should be

underscored, however, that three separate factors have been shown to

positively correlate with such success of methadone maintenance treatment.

First, such good results are seen in programs where there is a staff that is

knowledgeable and caring and that can offer a broad spectrum of services.

Second, such good outcomes have been noted in those programs where there

is a continuity of leadership, either by the medical director or by an administrator

of the clinic, thus allowing staff stability and continuity of individual patient care.

Third, and possibly most important, there has been such a good outcome in

achieving the primary goal when adequate doses of methadone have been

used. When the doses of methadone used in stabilized chronic treatment have

been between 60 and 100 mg a day, a recent study has shown that less than

15 percent of patients will continue to use heroin. Other studies have shown

that an even lower percentage of methadone-maintained patients will continue

to use heroin in that setting.

Conversely, the same recent study found that when less than 35 mg of

methadone per day is used, a high percentage of up to 50 percent or more of

patients may use heroin on an illicit basis (Blix 1988; Corty and Ball 1987; Ball

and Corty 1988; Ball et al. 1988a, 1988b; Tong et al. 1981). Also of great

importance is that many research studies have shown that the methadone dose

must be held stable during chronic treatment and not be used in any type of

“contingency contracting” or otherwise purposely or capriciously increased or

decreased. Dose changes should be made after careful clinical consideration

using medical and scientific information and not be used to “reward” or “punish.”

A stabilized dose, which results in stabilized plasma levels and receptor levels

of methadone, appears to be crucial for the normalization of the heroin-induced

disruption of many physiological functions. Any disruption in such stabilized

plasma levels, which can provide steady-state profusion at receptor sites of

action, can lead to a return of drug hunger and drug-seeking behavior (Kreek

1973c; Dole and Kreek 1973; Kreek et al. 1976a, 1976b, 1979, 1980, 1983a;

Hachey et al. 1977; Nakamura et al. 1982).

252
With respect to the secondary goals, which cannot be considered to be directly

responsive to methadone as a pharmacological agent but which may be

achieved by the therapeutic milieu of a well-established effective methadone

maintenance treatment program of one type or another, varying results have

been obtained. An extremely important secondary goal, that is, reducing

alcohol abuse, cocaine abuse, and polydrug abuse, has been addressed in

many studies with many different results forthcoming to date. With respect to

alcohol abuse, early studies showed that from 25 to 50 percent of heroin

addicts entering methadone maintenance treatment programs were alcohol

abusers (figure 3). These studies also showed that there was only a modest

improvement in alcohol abuse during methadone maintenance treatment, as

measured by the number of persons who decreased or stopped alcohol abuse

during chronic methadone treatment (figure 2). At the same time, these studies

also have shown clearly that there was no significant increase in the number of

persons who initiated alcohol abuse in the setting of methadone maintenance

treatment. However, with the exception of those programs that rigorously

addressed alcohol abuse problems, continuing alcohol abuse was shown to

occur (Beverly et al. 1980; Hartman et al. 1983). This is one of the areas

singled out in 1979 and now again in 1989 where special treatment programs

might be effective in further reducing the alcohol abuse problems (Beverly et al.

1980; Hartman et al. 1983). Similarly, there have been variable reports as to

the reduction or lack thereof of polydrug abuse during methadone maintenance

treatment.

Of special importance at this time is a consideration of the negative impact on

the effectiveness of methadone maintenance treatment of the cocaine abuse

problem, which has been increasing dramatically since about 1978 when a

reduction in price and increased availability of cocaine occurred. Cocaine often

is used by the intravenous (IV) route by active or former heroin addicts.

Sometimes cocaine is used to reduce the symptoms of narcotic withdrawal, and

at other times it is used concomitantly with heroin by the IV route as a

“speedball” to achieve the effects of heroin and of cocaine, with a reduction of

the anxiety-producing facets of cocaine and a reduction of the somnolenceproducing capacity effects of heroin (figure 3). About 1985, a less expensive

freebase form of cocaine, “crack,” was introduced that could be “smoked” by

inhalating cocaine vapor. In the 1980s, large numbers of primary cocaine

abusers were already turning to heroin use in an attempt to self-medicate the

so-called “crash” following bouts of heavy cocaine use and are now seeking

treatment for heroin addiction (figure 3). Many additional cocaine addicts many

go on to become heroin addicts, requiring treatment for that second addiction.

Most recently, a new combined freebase form of cocaine plus heroin, so-called

“crank,” has appeared, which also is “smoked” and inhaled and may in time lead

to many new cases of dual addiction (figure 3).

253
Desired Effect

1.

2.

Heroin plus alcohol Enhance heroin “high” or euphoria

Heroin followed Self-medicate narcotic withdrawal

by alcohol symptoms

3. Heroin followed Self-medicate narcotic withdrawal

by cocaine symptoms

4.

5.

Cocaine plus alcohol Enhance cocaine “high” or euphoria

Cocaine followed

by alcohol

6. Cocaine plus heroin

7. Cocaine followed

by heroin

Combination

Self-medicate anxiety, nervousness,

and overstimulation (“crash”)

followed by cocaine use

Enhance and alter cocaine

“high” or euphoria

Self-medicate anxiety, nervousness,

and overstimulation (“crash”)

followed by cocaine use

FIGURE 3. Patterns of heroin, cocaine, and alcohol use in combination

In a recent published study, it was found in San Francisco that whereas 24

percent of methadone-maintained patients increased or initiated cocaine abuse

during methadone treatment, more than 60 percent decreased or stopped

cocaine abuse during methadone maintenance treatment (Chaisson et al.

1989). Similarly, in our experience in New York, where most recently the

prevalence of cocaine abuse has climbed to almost 90 percent in street heroin

addicts, we have found that a significant reduction of cocaine abuse occurs

during stabilized methadone maintenance treatment in effective programs,

However, even in the most effective programs, it has been found that 15 to 20

percent of patients continue to use cocaine regularly and often by the IV route

and that another 10 to 20 percent continue to use cocaine or crack by other

routes of administration. Thus, 25 to 40 percent of patients in well-staffed,

broad-service programs continue to use significant amounts of cocaine during

what would otherwise be called “effective methadone maintenance treatment”

(figure 4). This clearly is a second very important problem that needs to be

addressed. Continuing drug abuse, as well as special medical problems

254
imposed by HIV and acquired immunodeficiency syndrome (AIDS), may require

the development of specialized treatment programs (figures 4 and 5).

FIGURE 4. Early (1980) modeling of needed methadone maintenance

programs

Early in the 1970s a significant reduction in numbers of new cases of hepatitis

B infection was also documented in methadone-maintained patients, although it

is more difficult to demonstrate such a reduction at this point in time when over

80 percent of all heroin addicts in most studies in the United States already

have markers of hepatitis B infection. It may be possible to use an examination

of the prevalence of hepatitis delta markers to assist in determining the

reduction of ongoing parenteral drug abuse (figure 2).

In addition, HIV infection may be used as a marker to determine changes in

patterns of parenteral drug abuse (Novick et al. 1986; Blix 1988). In some

areas, including most of Europe and in the New York City area, more than 50

percent of street parenteral drug abusers, primarily heroin addicts, are already

anti-HIV-1 seropositive. However, any dramatic increase in these numbers

would suggest an increase in parenteral drug abuse. Similarly, in those areas

255
FIGURE 5. Recent (1989) modeling of needed methadone maintenance

programs

*Research with rigorous evaluation in progress

**Research with rigorous evaluation completed

where the HIV infection rates are much lower, any change in prevalence rates

of anti-HIV-1 seropositivity certainly can be used as a marker of parenteral drug

abuse. From studies carried out with respect to initial infection and the spread

of HIV, it is quite clear that methadone maintenance is highly effective in

reducing exposure to this virus (Novick et al. 1986; Blix 1988). In a study

carried out in New York in 1984-85, it was shown that less than 10 percent of

those heroin addicts who had entered effective methadone maintenance

treatment programs prior to the AIDS epidemic hitting New York City in 1978

were anti-HIV-l positive, as contrasted to more than 50 percent of those

entering treatment after 1982 or on the streets in 1984-85 (Novick et al. 1986).

In a similar study in Sweden in 1987-88, it was shown that less than 5 percent

of those patients who had entered effective methadone maintenance treatment

prior to 1983 were anti-HIV-1 positive, whereas more than 50 percent of those

who had entered after 1986 were anti-HIV-1 positive (Blix 1988). Therefore,

significant reductions of exposure to diseases transmitted in the setting of

parenteral drug abuse, such as hepatitis B virus, hepatitis delta agent, and HIV,

256
can be stated to have been amply documented in effective methadone

maintenance treatment programs (figure 2).

Most studies that have evaluated methadone maintenance treatment have

shown more than an 80-percent reduction in criminality as judged by reduced

numbers of criminal behavior acts, arrests, and incarcerations after stabilization

on methadone maintenance treatment (figure 2) (Corty and Ball 1987; Ball and

Corty 1988; Ball et al. 1988a, 1988b).

With respect to the secondary goal of achieving increased socialization and

productivity, the data in the 1960s and early 1970s were very clear in showing

that more than 80 percent of methadone-maintained patients became

productive as defined by working, running a household, or attending

educational classes on a regular basis. However, with decreased job

opportunities, increased costs of education, and less emphasis on this facet of

secondary success of methadone maintenance treatment in more recent

studies, no specific statement can be made with respect to the productivity of

methadone-maintained patients in the 1980s.

More information is now available about the biological basis of some of the

addictive diseases, and the greatest amount of information now available

provides insights into the biological basis of alcoholism. However, increasing

information is now available concerning the possible biological basis of narcotic

(opiate) addiction. For instance, from our work, which now has been extended

and corroborated by others, it is appreciated that endocrine and neuroendocrine

function, which is profoundly disrupted during periods of heroin addiction,

becomes normalized during periods of methadone maintenance treatment.

There is preliminary information from our research efforts that, following

cessation of pharmacological treatment, abnormalities in neuroendocrine

function reappear, especially that of the hypothalamic-pituitary-adrenal axis as

related to the response to stress. These abnormalities are different from those

that pertain during cycles of heroin addiction and are similar to those that occur

during periods of acute narcotic withdrawal. These abnormalities may persist

for long periods following cessation of methadone treatment (or of heroin use)

and may contribute to drug hunger and drug-seeking behavior and, thus, to the

addictive disease (Kreek 1973a, 1973b 1987a, 1987b; Kreek et al. 1984;

Kosten et al. 1987; Dole and Nyswander 1968). Similarly, studies of

neuroendocrine function have shown that abnormalities are present during

chronic naltrexone maintenance treatment that are similar to those seen during

mild narcotic withdrawal. These abnormalities may explain in part the very low

acceptance rate for naltrexone treatment (less than 20 percent of unselected

heroin addicts will accept voluntarily and stay in treatment for 6 months or

more), the high dropout rates from this mode of treatment, and the types of

257
symptoms complained of by those in treatment next with naltrexone (Kosten et

al. 1986a, 1986b).

Ongoing studies from many laboratories have provided evidence that cocaine

may affect many biological systems, including three or more neurotransmitter

systems (Kreek 1987a). Also, based on recent work from our laboratory, the

endogenous opioid system may be altered significantly during cocaine abuse

(Kreek 1987a). Clearly, more research is needed, both of a laboratory and

basic clinical research type and in treatment research and evaluation research,

to improve not only the effectiveness of methadone maintenance treatment but

also the treatment of other addictive diseases that may confound narcotic

addiction or that may occur as the primary addictive disease.

The very recent findings that normalization may occur during long-term

uncomplicated methadone maintenance of many of the specific indices of

immune function, which are profoundly deranged during heroin addiction and

which are of potential importance with respect to the vulnerability of the heroin

addict to being at risk for becoming infected with certain viruses, also may be of

importance with respect to the possible role of immune disruption in altering the

rate of progression of HIV to AIDS and the possible beneficial effects of

methadone maintenance treatment in this regard. Again, research has played

an important role in achieving a better understanding of these various problems

that arise during heroin addiction and that may be ameliorated significantly

during chronic methadone treatment.

It is now clear that there is a medical emergency with respect to the linkage

between heroin and other parenteral drug abuse (as well as other types of drug

abuse that may predispose abusers to risk behaviors) and infection with HIV

and AIDS. Therefore, it is essential at this time to determine the best

mechanism for providing emergency drug abuse treatment, coupled with

emergency medical care and risk behavior reduction counseling, while heroin

addicts are awaiting entry into full-service, broad-spectrum, comprehensive

methadone maintenance programs, drug-free treatment programs, or special

inpatient residential resources using pharmacological and/or

nonpharmacological approaches for treatment of parenteral drug abuse. It is

not easy to determine what could be the optimal feasible settings and

mechanisms for providing such emergency care. However, full consideration

should be given to the development of emergency treatment programs within

established academic and teaching hospitals as well as all other nonprofit

hospitals and within municipal- or Federal-supported community-based primary

health care stations.

258
Because of the lack of adequate numbers of physicians, nurses, paramedics,

social workers, and counseling staff needed to fully conduct such emergency

needs (as well as for all comprehensive treatment programs), consideration

should be given to officially allowing “moonlighting” by hospital staff in each of

the categories of workers needed to perform additional work in return for

additional pay in emergency drug abuse treatment programs. Also, it should be

mandated that such moonlighting treatment services be performed by staff

within their own hospital and/or clinic to ensure accountability and excellence of

work performed, with oversight by the heads of the appropriate departments.

Existing clinics within hospitals generally are not utilized between 5 p.m. and 8

a.m. These geographic resources, coupled with staff working extra time, should

be able to provide emergency care as needed.

Similarly, emergency care for drug abuse should be made mandatory in all

Federal- and/or State-supported AIDS treatment centers, and close linkages for

long-term drug abuse treatment also should be provided within the spectrum of

activities of these centers. Because, by definition, emergency treatment cannot

be expected to provide all the resources needed and provided (hopefully) in a

comprehensive or special drug abuse treatment program, the time of caring for

any individual patient in such emergency sources should be limited to the

minimum time essential to secure entry for that individual into a full-service

program and should not be allowed to exceed 6 months. Provision of each of

these types of services could be made cost-effective by reducing expensive,

less effective health care costs. For instance, in such clinics, AZT for

symptomatic or asymptomatic anti-HIV seropositive patients with low absolute

numbers of T4 cells (less than 500 cells) could be administered along with

methadone, while other needed services also would be provided there—a major

combined need at this time. In 1979 and again in 1981, before the identification

of AIDS as a specific disease or the isolation and identification of HIV and also

before the current cocaine/crack epidemic during an earlier period of critical

need to expand treatment for narcotic (opioid) addiction (especially as

compounded by polydrug abuse and alcohol abuse), a proposal for a spectrum

of different treatment programs for heroin addicts using methadone as an

important and probably essential pharmacological component was presented at

both the State and Federal levels (figure 4). At that time, there were already

unrealistically low and consistently contracting fiscal resources for treatment of

drug abuse as well as decreasing numbers of available geographic sites for

such treatment because of increasing community resistance—problems that still

pertain today.

In 1989 a spectrum of programs utilizing methadone maintenance was

proposed again but now modified to recognize the negative impact of the AIDS

epidemic and the cocaine/crack epidemic on the previously demonstrated

259
effectiveness of existing methadone maintenance treatment programs (figure

3). This modified scheme of a proposed spectrum of programs is planned with

the goal of using methadone more effectively than in the past or at present by

increasing access to treatment and by expanding the types of programs

available for patients to meet their specific needs. However, because of the

diverse types, the quality of existing programs and the even greater diversity of

proposed programs (despite overall improved quality) and of emotional

resistance of the general public, policymakers, and potential patients, there is a

need to develop specific and novel terms to apply to each of these proposed

programs and not to simply use the words “methadone maintenance treatment”

as now done to refer to all programs. Consideration also should be given to

identifying a new name for the generic agent methadone when it is to be used

on a chronic basis in treatment to decrease the negative and emotional

connotations with this word. Possible use of initials from its chemical name

would be considered, such as “DM DPH” or more simply, “MPH”or “DPH.”

In the past there has been an increasing trend to detach methadone

maintenance treatment and related types of treatment programs using

methadone from the health care system and health care establishment in

general. This detachment frequently is recommended or mandated under the

proclamation of a public health need or in the setting of declaring increasing

fiscal crises with respect to providing both drug abuse treatment and health

care. It is mandatory at this time that this “public health approach” to drug

abuse treatment be reconsidered, especially in light of the multiple medical

ramifications of not only heroin use but also the abuse of many other drugs and

especially with the increasing AIDS epidemic as well as the recrudescence and

increase of epidemics of hepatitis B and hepatitis and the rise in prevalence of

hepatitis delta.

The development of such a spectrum of emergency, comprehensive care, and

specialized treatment programs, each utilizing methadone as currently the only

long-acting opioid that is effective for chronic treatment, but with the possibility

of utilizing the long-acting opioid agonist LAAM or the partial agonist

buprenorphine, should be accompanied by a coupling of such programs with a

computerized network of centralized intake systems to screen and evaluate

persons entering drug abuse treatment. This would better utilize existing

openings for treatment in existing programs and more appropriately match new

patients who have specific needs or problems to programs that potentially will

best meet those needs. Such a network of centralized intake resources

coupled with clinics and other sites where addicts may seek or be referred to

treatment could markedly increase both access to and effectiveness of

methadone as used in treatment of narcotic addiction.

260
Many types of treatment recommended in this spectrum of programs have

already been studied rigorously in various research efforts and have been

proven to be effective when carried out as originally designed and studied.

Other programs may have been tried on a sporadic basis but have not been

fully evaluated. Some special programs suggested here are innovative

programs that therefore would need to be carried out with close evaluation and,

possibly, initially carried out on a research basis (figure 5).

All primary and secondary goals of methadone treatment and the realistic

estimates of the extent to which they may be achieved should be taken into

account in evaluation programs. These evaluation programs should be carried

out on a uniform basis for all pharmacological- and nonpharmacological-based

treatment programs for heroin addiction and for all other treatment programs for

other drug addictions and drug dependencies. In 1982 Dole and colleagues

proposed a performance-based evaluation rating for methadone maintenance

treatment programs. An evaluation program of the type that Dole presented,

modified to include current special needs as well as modified to the extent

needed to reflect realistic levels of achievement of these primary and secondary

goals, would provide a semiquantitative, uniform, general assessment for all

treatment programs. The application of such a uniform evaluation would be

extremely valuable at this time when a variety of different treatment programs—

those with full services and, possibly, those with spare services—may be

developed with the emergency of the cocaine epidemic and the HIV epidemic

and AIDS. However, it is imperative to act on the findings of such evaluation

research and to close inadequate programs as well as to modify borderline

programs so that (1) the patients can benefit maximally; (2) medical and

paramedical and all other staff members can take pride in the work they perform

and the accomplishments they achieve; and (3) society will see that it is served

in a humanitarian and cost-effective fashion and will be encouraged therefore to

continue support of such broad-spectrum programs. Finally, such evaluation

that could ensure good programs also would ensure an appreciation and

continuing support for basic laboratory and clinical research as well as applied

clinical research and would ensure early application of the findings from such

research to human needs.

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Kosten, T.R.; Kreek, M.J.; Ragunath, J.; and Kleber, H.D. A preliminary study

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Kreek, M.J. Medical safety and side effects of methadone in tolerant

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Mass Spectrom 7:385-395, 1980.

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Kreek, M.J.; Garfield, J.W.; Gutjahr, C.L; and Giusti, L.M. Rifampin-induced

methadone withdrawal. N Engl J Med 294:1104-1106, 1976b.

Kreek, M.J.; Gutjahr, C.L.; Garfield, J.W.; Bowen, D.V.; and Field, F.H. Drug

interactions with methadone. Ann N Y Acad Sci 281:350-370, 1976a.

Kreek, M.J.; Hachey, D.L.; and Klein, P.D. Stereoselective disposition of

methadone in man. Life Sci 24:925-932, 1979.

Kreek, M.J.; Ragunath, J.; Plevy, S.; Hamer, D.; Schneider, B.; and Hartman, N.

ACTH, cortisol and beta-endorphin response to metyrapone testing during

chronic methadone maintenance treatment in humans. Neuropeptides

5:277-278, 1984.

Kreek, M.J.; Wardlaw, S.L.; Friedman, J.; Schneider, B.; and Frantz, A.G.

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endogenous opioid (beta-endorphin) in man. In: Simon, E., and Takagi, H.,

eds. Advances in Endogenous and Exogenous Opioids. Tokyo: Kodansha

Ltd. Publishers, 1981. pp. 364-366.

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Quantitation of methadone enantiomers in humans using stable isotopelabeled 2H3

, 

2H5

, 

2H8

, methadone. J Pharm Sci 71:39-43,1982.

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Dole, V.; and Nyswander, M. Medical maintenance: A new model for

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Novick, D.M.; Khan, I.; and Kreek, M.J. Acquired immunodeficiency syndrome

and infection with hepatitis viruses in individuals abusing drugs by injection.

Bull Narc 38:15-25, 1986.

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N.; and Kreek, M.J. Natural killer cell activity and lymphocyte subsets in

parenteral heroin abusers and long-term methadone maintenance patients.

J Pharm Exp Ther 250:1-5, 1989.

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Jarlais, D.C.; Anderson, M.; Dole, V.P.; and Nyswander, M.E. Methadone

maintenance patients in general medical practice. JAMA 259:3299-3302,

1988b.

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2:27-33, 1967.

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methadone pharmacokinetics in methadone-maintained pregnant women.

J Pharmacol Exp Ther 233:1-6, 1985.

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of achieving abstinence in opioid addicts: A 2.5-year follow-up study. Am J

Drug Alcohol Abuse 13:214-229, 1987.

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1985.

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1220, 1974.

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Tong, T.G.; Pond, S.M.; Kreek, M.J.; Jaffery, N.F.; and Benowitz, N.L.

Phenytoin-induced methadone withdrawal. Ann Intern Med 94:349-351,

1981.

AUTHOR

Mary Jeanne Kreek, M.D.

Associate Professor and Physician

The Rockefeller University

1230 York Avenue

New York, NY 10021-6399

266
Using Psychotherapy Effectively in

Drug Abuse Treatment

Lisa Simon Onken

INTRODUCTION

Although there have been numerous clinical opinions expressed about how to

use psychotherapy effectively with drug abusers, very little research exists on

the topic. The purpose of this chapter is to review and discuss the major

research findings in this area, highlight some areas where more research is

needed, and address some of the problems and pitfalls inherent in this

research.

Effective psychotherapy involves the right person using the right therapy at the

right time with the right client. Therefore, any discussion on this topic must

address therapist, therapy, and patient characteristics.

THERAPY CHARACTERISTICS

Only a few well-designed investigations on the relative efficacy of different types

of psychotherapy with drug abusers have been carried out at this point. This

effort at determining the “best” psychotherapeutic strategy has paralleled an

effort in the broader nondrug abuse psychotherapy research arena. In the drug

abuse field, psychodynamic, supportive, and behavioral strategies all have

been the subject of investigation.

As part of the well-known Veterans Administration-University of Pennsylvania

(VA-Penn) Psychotherapy Project, Woody and his coworkers (1933) compared

the relative efficacy of drug counseling alone with two types of therapy offered

in conjunction with drug abuse counseling. In this controlled study, opiatedependent methadone-maintained patients were randomly assigned to one of

three treatment conditions: (1) drug counseling alone, (2) “supportiveexpressive” (SE) therapy plus drug counseling, or (3) cognitive-behavioral (CB)

therapy plus drug counseling. SE therapy is a psychoanalytically based, focal

therapy, and CB therapy emphasizes correcting maladaptive and typically

267
exaggerated and unrealistic thoughts. Although all treatment groups showed

significant improvement, the two psychotherapy groups experienced greater

improvement than the drug counseling alone group, and they also required less

medication. There was no difference in efficacy between the two psychotherapy

groups. The differences in improvement between the psychotherapy groups

and the drug counseling alone group held up at the 7- and 12-month followups

(Woody et al. 1987).

The value of interpersonal psychotherapy (IPT) in the treatment of opiatedependent methadone-maintained clients was the focus of a study published by

a group of researchers at Yale (Rounsaville 1986). As the name suggests, IPT

emphasizes dealing with the interpersonal conflicts of the client that appear to

be related to the commencement or continuation of drug abuse. It is a brief,

focused, exploratory, and supportive type of therapy. Patients were randomly

assigned to an IPT condition or a “low-contact” condition. Subjects in the IPT

condition received one 60-minute session of IPT each week with a doctorallevel psychologist or psychiatrist, additional meetings with “significant others” if

the psychotherapist believed it to be necessary, and a weekly group

psychotherapy meeting. Subjects in the low-contact condition received the

weekly group psychotherapy meeting and one 20-minute session with a

psychiatrist who avoided advice-giving and interpretations. Results indicated

little difference between these two groups, except in attrition patterns. Sixty-two

percent of the subjects in the IPT group and 46 percent in the low-contact

treatment group dropped out of the study. Of the remaining subjects, both

groups showed some clinical improvement. The authors stress the fact that,

because the low-contact condition already provided fairly intensive weekly

group psychotherapy, this was not a test of the efficacy of IPT. Rather, it was a

test of the effect of adding a psychotherapy (IPT) to a psychotherapy (group

therapy). In addition, the authors cite methodological factors that may have

produced a “bias” against the demonstration of an IPT effect. Hence, the

effectiveness of IPT with opiate-dependent individuals is inconclusive from this

study.

Paula Kleinman, in a recent NIDA-sponsored technical review meeting,

described a study comparing the efficacy of individual “low-intensity” SE

psychotherapy, structural strategic family therapy, and treatment as usual

(paraprofessionally run group therapy) in the treatment of cocaine abusers

(Kleinman et al. 1989). Preliminary analyses indicated that the type of therapy

to which a subject was assigned was unrelated to whether he or she stayed in

treatment, although there was a trend toward extended retention in the

individual therapy and family therapy conditions (compared with treatment as

usual). However, neither of these two therapies (e.g., individual or family

therapy) was a sufficient treatment for these patients. Kleinman and colleagues

266
stress that more frequent contact than that offered in their study may be

required for effective treatment.

In another more recent comparative trial, Carroll and colleagues (submitted for

publication) studied the efficacy of two “purely psychotherapeutic treatments,”

IPT and relapse prevention (RP), in a population of ambulatory cocaine

abusers. RP is a cognitive-behavioral strategy that has been adapted to deal

with those problems specific to relapse to drug abuse; in this case, it was

adapted further to deal with cocaine abusers. Half of the patients were

randomly assigned to the RP group, with the remainder receiving IPT. Subjects

in both conditions demonstrated significant (statistical as well as clinical)

improvement from their baseline scores on most outcome measures. There

was a trend toward better retention in the RP group throughout the study, with

67 percent of the subjects in the RP condition completing treatment, compared

with only 38 percent of the subjects in the IPT condition. In addition, although

not statistically significant, the RP group consistently did better on most

measures of outcome (e.g., ability to attain 3 consecutive weeks of

abstinence—classification as “recovered” at the end of treatment). The authors

conclude that purely psychotherapeutic approaches can be effective in the

treatment of cocaine abuse. No statistically significant differences between the

RP and IPT groups were found. Nonetheless, because of the consistent

superiority of the RP condition across outcome measures, the authors believe

there was a clinically significant difference between the RP and IPT groups.

One might tentatively hypothesize from these results that RP might hold more

promise than IPT as an effective treatment.

Research in the broader, nondrug abuse field has generally supported the

notion that patients receiving psychotherapy do better than those in placebo

groups or those in no treatment control groups. However, it has not been

consistently demonstrated that one type of psychotherapy is more effective than

another (Luborsky et al. 1975; Smith and Glass 1977; Lambert et al. 1986;

Stiles et al. 1986). Nor has anything conclusive been determined in the drug

abuse field regarding the superiority of one psychotherapy over another.

Clinicians appear to agree that psychodynamic therapy is contraindicated early

in the treatment of the drug abuser and should not be attempted until after

abstinence is achieved (Washton 1988; Kaufman 1989). To date, researchers

have little to say about which type of psychotherapy is the treatment of choice

following abstinence, Individual behavioral, supportive, psychodynamic, and

family approaches all have been demonstrated to be effective in their own right

or useful as adjuncts to other forms of treatment (Kaufman and Kaufman 1979;

Stanton et al. 1982; Woody et al. 1983; Rounsaville et al. 1983; Rogalski 1984;

Carroll et al., submitted for publication), but none has been demonstrated

consistently to be more effective than another.

269
THERAPIST CHARACTERISTICS

Psychotherapy research was originally focused on the types of psychotherapy

or characteristics thereof that promote positive outcome. The attributes of the

therapist have been, until recently, relatively ignored. However, the qualities of

the therapist have been recognized, of late, as an important determinant of

effective psychotherapy (Luborsky et al. 1985, 1986; Crits-Christoph et al.

1989).

As part of the VA-Penn Psychotherapy Project (Woody et al. 1983) described

earlier, determinants of therapist success were examined (Luborsky et al. 1985)

in nine therapists (three performing CB therapy, three performing SE therapy,

and three performing drug abuse counseling) who worked with a population of

methadone-maintained opiate addicts. They found striking differences among

the success rates of the nine therapists and looked at different variables that

might account for these differences. No differences were found in therapists’

patient caseloads on a number of factors (e.g., drug use, psychiatric diagnosis,

etc.) that could account for these effects. The investigators also examined the

relationship between the therapists’ personal qualities (e.g., adjustment, interest

in helping clients) and successful outcome and found modest, insignificant

positive correlations. A measure of the quality of the early therapist-patient

relationship, the Helping Alliance Questionnaire (Alexander and Luborsky

1984) was found to be highly related to outcome. In addition, it was found that

the greater the degree of adherence to the CB or SE psychotherapy treatment

manuals, that is, the greater the “purity” of the sessions, the better the outcome.

This was not true for adherence to the drug counseling manual.

As McCaul (this volume) has beautifully illustrated, “therapist effects” are not

exclusive to psychotherapists—they also have been found among drug

counselors. A unique opportunity arose for the study of counselor effects for

the VA-Penn group when two staff counselors unexpectedly resigned (McLellan

et al. 1988). It was necessary that the patients of these counselors be

reassigned to new drug abuse counselors in a virtually random manner. That

is, due to time constraints, it was not possible to “match” the patients of these

counselors to new counselors in the usual manner. After 6 months of treatment

with four new counselors, patient status was examined. There were sizable and

consistent differences in patient status between counselors. No clue about why

certain drug abuse counselors performed better than others was evident. The

fact that the more successful counselors also seemed to have more complete

records than the less successful counselors could not explain the observed

differences.

270
Kleinman and colleagues (1989) reported preliminary data that suggested

tremendous variability in retention rate among therapists but not among

therapies. In a comparative study of SE individual psychotherapy, structuralstrategic family therapy, and treatment as usual with a population of cocaine

abusers, Kleinman and coworkers found that the particular therapist to which a

patient was assigned was the most potent predictor of subject attrition. One

therapist retained as few as 14 percent of the patients for four or more sessions,

whereas another therapist retained more than 80 percent. Other outcome data

from this study are not yet available. Preliminary data reported by Woody and

colleagues (1989) in a community-based psychotherapy outcome study with

methadone-maintained opiate addicts also suggest that there are differences

between therapists in the ability to retain a patient in treatment.

Luborsky and colleagues (1986) have reported that not only do therapist effects

exist but also that they also may “overshadow” treatment effects. In an analysis

of four separate comparative studies of psychotherapies (including the VA-Penn

Psychotherapy Project), Luborsky and coworkers found that differences among

therapists were stronger than differences between CB and SE therapies as

performed with drug abusers. In populations not defined as drug abuse

populations, therapist effects outweighed differences among a variety of types

of individual, group, and conjoint therapies.

At the recent National Institute on Drug Abuse technical review meeting

mentioned above, Paul Crits-Christoph elegantly portrayed how therapist

effects, when ignored or improperly analyzed, can affect conclusions about the

efficacy of one psychotherapy as opposed to another in psychotherapy

outcome research (Crits-Christoph et al. 1989). He pointed out that in some

cases, even when statistical tests are done that show that differences among

therapists are not significant (p < .05), results can be significantly affected such

that differences are found among therapies when they do not exist (Martindale

1978). In an analysis of eight psychotherapy outcome studies, great diversity in

therapist effects were found among studies, ranging from no effect to 29

percent of the variance accounted for due to therapist. Crits-Christoph

recommends that therapist effects never be assumed to be nonexistent.

Rather, he emphasizes the importance of treating the therapist as another

variable in psychotherapy outcome research.

The study by Carroll and colleagues (submitted for publication), discussed

earlier, is an example. One might tentatively hypothesize that RP strategies will

be more effective in the treatment of cocaine abuse than IPT in future

comparative studies of the two therapies, based on the consistent “clinical”

superiority of RP. With more careful inspection of the methods used in this

study, however, it is apparent that even a tentative conclusion about the relative

271
efficacy of the two therapies would be premature. Only three therapists

administered the two therapies: One therapist performed RP exclusively;

another performed IPT exclusively; and the third did both RP and IPT (K.

Carroll, personal communication, 1989). With so few therapists, this study may

really have been a test of whether or not RP, as practiced by one particular

therapist, is more effective in the treatment of cocaine abusers than IPT, as

practiced by another particular therapist. Conclusions cannot be drawn about

the relative efficacy of the two therapies.

Not only do therapist effects exist, but they also may create errors in the

conclusions drawn about the relative efficacy of various psychotherapies if

overlooked or inappropriately analyzed. There is very little knowledge currently

available, however, about which characteristics of therapists are most related to

outcome. The ability of the therapist to establish an early, positive therapeutic

alliance, the consistent adherence to a particular method, and the

documentation of relatively complete treatment plans and records all have been

shown to be related to positive outcome in various studies. It is not clear,

however, how or why these characteristics are related to successful treatment,

nor is it clear what other therapist characteristics are important determinants of

outcome.

PATIENT CHARACTERISTICS

Providing psychotherapy to a patient who will not benefit from it is a waste of

time, money, and effort. Not providing psychotherapy to someone who needs it

also can be a waste of time and resources; but more importantly, it can prolong

the suffering and contribute to the relapse of the drug-dependent individual.

The problem is determining who will benefit from psychotherapy and who will

not.

Psychotherapy was developed for the treatment of mental disorders, not for the

treatment of drug dependence. It is reasonable to expect that those drug

abusers with coexisting mental disorders will benefit more from psychotherapy

than those without them. The occurrence of a “dual diagnosis” in a substance

abuse patient is not a rarity. In a study of cocaine abusers, Weiss and Mirin

(1986) found a concurrent DSM-III diagnosis for affective disorder in 53 percent

of their population. Axis II diagnoses were even more common, with 90 percent

of the subjects receiving a diagnosis of personality disorder (predominantly

narcissistic and borderline). Only one of their 30 subjects met the criteria for

antisocial personality (ASP) disorder. Kleinman and coworkers (1989)

however, found a higher (18 percent) ASP disorder rate than was found in the

Weiss and Mirin (1986) study, which may be related to the lower social class of

Kleinman’s population. Opiate addicts also have been found to have a high

272
frequency of mental disorder. Rounsaville and colleagues have found high

rates for affective disorder (Rounsaville et al. 1982a) and have reported the

ASP disorder rate to be elevated (Rounsaville et al. 1982b). In one study on

opiate addicts, the frequency of a current Research Diagnosis Criteria diagnosis

for major depressive disorder was found to be 23.8 percent, and the DSM-III

ASP rate was 54.7 percent (Kosten and Rounsaville 1986).

There has been an increasing recognition that substance abusers with

concurrent mental disorders tend not to be adequately treated in either

traditional programs for the chemically dependent or traditional mental health

facilities (Wallen and Weiner 1989; Carey and Carey, submitted for publication).

It is no surprise that the prognosis for dual-diagnosis patients is poorer than for

those with a diagnosis of substance abuse alone (Hall et al. 1977; McLellan et

al. 1983, 1986; Rounsaville et al. 1986, 1987). Researchers are beginning to

help us better understand how to treat substance abusers with coexisting

mental disorders.

In the study described earlier (Woody et al. 1983), the VA-Penn group looked at

the relationship between “psychiatric severity” and psychotherapy in substance

abusers. Rather than a measure of any particular diagnosis or set of

diagnoses, psychiatric severity is a global measure of the number and degree of

psychiatric problems in an individual. Patients who were classified as low in

psychiatric severity did just as well with paraprofessional drug counseling as

with additional professional psychotherapy (CB or SE). Mid-severity patients

made notable gains with drug abuse counseling but made even more gains with

the added psychotherapy. High-severity patients did not improve much with the

drug counseling alone but improved significantly with the additional

psychotherapy (Woody et al. 1984). Preliminary findings from a communitybased study done by the VA-Penn group were consistent with these findings

(Woody et al. 1989). In this study involving only mid-to-high psychiatric severity

patients, methadone-maintained opiate addicts were assigned to either an SE

psychotherapy plus drug counseling group (SE group) or drug counseling plus

drug counseling group (DC group). Preliminary analyses suggested that

patients in the SE group were progressing better than those in the DC group.

In another study, the VA-Penn group reported findings regarding differential

psychotherapy (SE and CB) outcome in four groups of methadone-maintained

opiate addicts: addicts without a coexisting DSM-III diagnosis, those with a

diagnosis of depression, those with diagnoses of both depression and ASP

disorder, and those with ASP disorder alone (Woody et al. 1985). The opiate

dependence alone and opiate dependence with depression groups both

showed considerable improvement on several outcome measures. The group

that had a diagnosis of ASP but no diagnosis of depression did not make any

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gains with psychotherapy, except in the area of drug use and on a legal factor.

In spite of the fact that the presence of ASP is commonly believed to preclude a

positive response to psychotherapy (Shamsie 1981; Woody et al. 1985) and did

so in this study, the group that had diagnoses for both depression and ASP

showed substantial improvement.

Rounsaville and coworkers (1983) found no differential efficacy for IPT and lowcontact treatment in depressed as opposed to nondepressed methadonemaintained opiate addicts. Once again, however, it must be stressed that all

subjects in both conditions (IPT and low-contact) received group psychotherapy

each week. Conclusions, therefore, cannot be drawn about the efficacy of

either therapy alone in the treatment of depressed versus nondepressed

individuals.

In a recent study comparing the efficacy of two forms of “aftercare group

treatment,” Kadden and coinvestigators (in press) examined the relationship of

psychiatric severity and sociopathy to treatment outcome. Alcoholic patients

were randomly assigned to receive either a coping skills training therapy or an

interactional therapy. Overall, there was no difference in efficacy between the

two treatments during aftercare, and there were no consistent differences in the

efficacy of the two treatments for subjects low in psychiatric severity. However,

contrary to the findings of Woody and colleagues (1984), who did not find

differential efficacy of therapies for patients high in psychiatric severity, high

psychiatric severity patients in the Kadden study did better with the coping skills

treatment than with the interactional treatment. Kadden and coworkers also

found that alcoholics high in sociopathy benefited more from a CB-based

coping skills treatment than from an interactional therapy. Patients low in

sociopathy, however, did better with the interactional therapy. This sociopathy/

psychotherapy interaction existed only when sociopathy was measured with the

California Personality Inventory Socialization Scale and not when measured

according to DSM-III criteria. This highlights the need for the unambiguous

definition of constructs and the valid and reliable measurement of these

constructs.

In summary, patient variables are an important determinant of successful

psychotherapy. There is evidence that patients with moderate-to-high levels of

psychiatric severity benefit from psychotherapy, but those with low levels can

benefit just as much with drug counseling alone. ASP disorder without another

nonsubstance abuse psychiatric diagnosis appears to be an indicator for a poor

response to psychotherapy. However, there is some evidence that patients with

this characteristic may be better helped with a skills training-oriented therapy

than with an interactional therapy. Other patient characteristics that may be

linked to successful psychotherapy outcome have yet to be explored.

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CONCLUSION AND COMMENTS

In a review of the literature on the characteristics of patients, therapists, and

therapies related to successful psychotherapy, some conclusions have

emerged. First of all, no one type of psychotherapy has been consistently

demonstrated to be more effective than another in the treatment of drug

abusers. Second, there are a variety of therapist and patient variables that

seem to be important determinants of successful therapy. But this is not the

whole picture. Psychotherapy does not occur in isolation. Rather, in substance

abuse treatment, it is best administered as part of a comprehensive drug abuse

treatment program, which can play a major role in treatment outcome (Corty

and Ball 1987; Woody et al. 1989). Pharmacological interventions, drug

education and counseling, contingency management, and self-help groups may

all be available to the drug abuser as part of the comprehensive drug abuse

treatment package (Spitz and Rosecan 1987; Millman 1988; Washton 1988).

Research is needed not only in the areas of the best therapies, the most

efficacious components of therapies, the most effective therapists, and the most

suitable patients for psychotherapy but also in the area of how psychotherapy

affects and is affected by the context in which it occurs. We are beginning to

understand the conditions under which successful psychotherapy with

substance abusers can occur. Future research not only must address the

specifics of how to do effective psychotherapy but also must address the

questions of when and how additional interventions potentiate the effectiveness

of psychotherapy with substance abusers and vice versa.

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Am J Psychiatry 141:1172-1177, 1984.

AUTHOR

Lisa Simon Onken, Ph.D.

Research Psychologist

Treatment Research Branch

Division of Clinical Research

National Institute on Drug Abuse

Room 10A-30

5600 Fishers Lane

Rockville, MD 20857

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Relapse Prevention

Sharon M. Hall, David A. Wasserman, and Barbara E. Havassy

INTRODUCTION

Preventing relapse is a challenging enterprise. Usually, relapse takes place

after patients have left our treatment units and laboratories. Thus, the crucial

events leading up to a relapse, and the episode itself, remain outside our arena

of observation and influence. Nevertheless, answers to basic questions about

relapse are crucial if we are to prevent it. Although we have knowledge about

some of the variables that predict and control relapse, many puzzles remain.

What is relapse? Few would disagree with Rounsaville (1986) that relapse is a

“resumption of substance abuse following a period of abstinence . . .” (p. 172).

Yet the extent of drug use that constitutes full-blown relapse is a matter of

debate. To adherents of a strict abstinence model, a single self-administration

of any abusable drug (usually excluding nicotine) would qualify as relapse. A

return to baseline use of one’s problem drug(s) is another common criterion. At

a recent National Heart, Lung, and Blood Institute conference on smoking

(Ossip-Klein et al. 1986) the cutoff adopted for relapse was 7 consecutive days

of use. This definition, however, may be more appropriate to nicotine than to

drugs with highly variable use patterns, for example, cocaine. (There is also no

consensus regarding the length of time an individual must be drug-free before

he or she can be said to have “relapsed.” Forty-eight hours appears to be an

acceptable criterion.)

Whatever level of resumed use is agreed to constitute relapse, three stages in

the relapse process are usually of interest: (1) the first lapse, or “slip,” after a

quit episode; (2) relapse itself, defined as some level of continuing use; and (3)

the transition between the two. Seemingly few individuals, having slipped,

avoid returning to pretreatment levels of drug use, at least temporarily. For

example, in a recent study (Hall et al., in press), we found that 90 percent of a

sample of treated opiate addicts who slipped returned to using at least 4 days a

week by the end of 12 weeks. Similarly, in a study by Brandon and colleagues

(1986), more than 90 percent of ex-smokers who smoked one cigarette

returned to at least 3 consecutive days of smoking during a 2-year followup.

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Fortunately, these setbacks are not necessarily permanent. A study by Gossop

and colleagues (1987) in England indicated that, although 72 percent of a

sample of treated opiate addicts had lapsed within 6 weeks after treatment

termination, 47 percent were abstinent at 6 months.

Many characteristics of the relapse process have been insufficiently studied.

Whether the same or different variables control the first lapse and relapse is

unknown and should be clarified. If the two outcomes are controlled by different

variables, this may explain inconsistent research findings. Changes in risk

factors across time should also be investigated. The variables that cause

relapse should differ as a function of time abstinent. Yet we know little about

which variables are important at which time. Another issue is change over time

in an individual’s level of risk. Clinically, it appears that the risk of drug use for

successful ex-drug users eventually reaches a plateau, becoming similar to the

risk faced by those who have never used drugs. We know little about the

intermediate phases of abstinence, the length of time individuals spend in

various phases, or whether these phenomena differ by drug of abuse.

MODELS OF RELAPSE

Despite lack of an agreed-on marker for relapse and inadequate data on the

relapse process, there are two classes of models for explaining how relapse

occurs: cognitive-behavioral and conditioning models.

Cognitive-Behavioral Models

The cognitive-behavioral model that has received the most attention is that of

Marlatt and Gordon (1986). The model focuses on situations in which there is a

high risk of relapse and on the ex-drug user’s responses to them. Marlatt and

Gordon suggest that the relapse process begins when the ex-drug user

confronts a high-risk situation for which he or she has no effective coping

response. According to the model, high-risk situations can occur for many

reasons, including social pressure to use drugs, negative emotions, and, less

frequently, withdrawal symptoms and positive emotions. The lack of a coping

response, combined with positive expectancies for the initial effects of the drug

in the situation, greatly heighten the risk of a slip.

According to Marlatt and Gordon (1986), a first slip may lead to a full-blown

relapse via the abstinence violation effect (AVE), a core construct in the model.

The AVE is said to occur in individuals who are committed to absolute

abstinence. It has two components: (1) a causal attribution of responsibility for

the slip emphasizing internal, stable, global, and uncontrollable factors and (2) a

negative affective reaction to the attribution. This affective reaction is said to be

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similar to cognitive dissonance: The individual believes that drug use is

unacceptable, yet he or she has just used a drug. This conflict state is

aversive, and individuals may attempt to reduce it as they have customarily

dealt with negative states in the past, that is, by continuing to use the drug.

Alternatively, they may resolve the conflict by redefining themselves as helpless

addicts. This may lead to the cessation of all efforts to control drug use.

Conditioning Models

Conditioning models emphasize craving. In the classical conditioning model

proposed by Wikler (e.g., Wikler 1948) drug-craving is assumed to reflect the

conditioning of withdrawal symptoms and drug effects to both environmental

and interoceptive stimuli. A variant is the opponent-process or compensatory

response model (Solomon 1977; Solomon and Corbit 1974; Siegel 1979). In

this model, responses opposite to the drug effects are conditioned to drug cues

via a homeostatic process. These opposing responses presumably

compensate for the ‘impending pharmacological assault” (Niaura et al. 1988, p.

134) of the drug. For example, a cocaine user might initially use the drug to

increase his or her energy level in social situations. Over time, the presence of

these social stimuli would elicit a compensatory response of decreased arousal.

This withdrawal-like state would be experienced as aversive and interpreted as

craving.

STATUS OF KEY VARIABLES

Models of relapse suggest a plethora of variables that may be important in

relapse prevention. Although only a few have been well explored in empirical

studies, the literature on these does offer some direction for improving relapse

prevention treatment.

Commitment and Motivation

The importance of a strong initial and long-term commitment to abstinence has

been emphasized repeatedly in the addiction literature (e.g., Brownell et al.

1986; Miller 1986). Several dimensions of commitment to abstinence may be

important for preventing relapse. A central one is abstinence goal, the degree

to which one’s aim is total and permanent abstinence versus a less restrictive

goal, for example, periods of abstinence with occasional slips. In our own work

(Hall et al., in press), we found that a goal of absolute abstinence at end of

treatment predicted better short-term outcomes in opiate addicts, smokers, and

alcoholics than did less stringent goals. However, all our subjects were drawn

from programs that endorsed strict abstinence. It is unknown whether our

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findings would be replicated with subjects exposed to other treatment

philosophies and instructed in how to respond to occasional slips.

As with any resolution, enthusiasm for abstinence may decay over time

(Saunders and Allsop 1987). Early in treatment, drug users may be highly

motivated to abstain because of real or threatened aversive consequences of

continued use (e.g., job loss, marital dissolution, or imprisonment). But as

potential negative consequences are averted or forgotten, the positively

reinforcing aspects of drug use may become more salient (e.g., the “euphoric

recall” of heroin and cocaine users). A decision to slip or relapse may be the

ultimate result. This shift in the perceived costs and benefits of habit change

(Hall 1980) suggests that postcessation motivation for abstinence should be

continually monitored and bolstered. A setback may be likely if the perceived

costs of change begin to outweigh the perceived benefits.

Many investigators have studied methods for maintaining motivation during

treatment. One such intervention is contingency management. If motivation is

conceptualized as the arrangement of environmental contingencies for the

purpose of staying drug free, then contingency management studies have much

to contribute to relapse prevention. Contingency management using positive or

negative reinforcement has been demonstrated in many drug-using

populations. Positive reinforcement may involve the provision of monetary

payments or other incentives, including methadone dose changes and takehome doses. Negative contingencies include loss of deposits, forced

contributions to disfavored organizations, and other penalties of special

relevance to the client. Anker and Crowley (1982) used contingency contracts

successfully with cocaine patients. Outcomes were strikingly positive, but

subjects were self-selected and may have been strongly motivated from the

outset. Stitzer and her group (e.g., Stitzer et al. 1982) repeatedly have obtained

positive results from imposing contingencies on illicit drug use in methadone

maintenance and detoxification patients. Our group has reported similar

outcomes with these populations (Hall et al. 1979).

A criticism of contingency contracting has been that it promotes abstinence only

as long as the contingencies are in force. Once they are removed, motivation

wanes. This is not a problem of the interventions per se. Return of responses

to baseline levels when contingencies are stopped is predictable from the model

on which the intervention is based. Given that extinction occurs, however,

longer term interventions using clinic-provided contingencies may be necessary.

Another important direction may be the development of strategies that transfer

contingency management indefinitely to community institutions, including

families and workplaces.

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Coping Skills

Coping skills training for negotiation of high-risk situations has been highly

touted, but the results have been mixed. Skills training has been effective

sometimes with alcoholics (e.g., Chaney et al. 1978; Eriksen et al. 1986) and,

less consistently, with smokers (Hall et al. 1984a, 1985, 1987). Comparable

research with opiate and other illicit drug users is scanty and, so far, not

encouraging (e.g., Hawkins et al. 1989). There are several possible reasons for

the equivocal results of skills training. The skills needed for relapse prevention

may be so elementary that skills training is superfluous. If so, more emphasis

may be needed on a patients motivation to use the skills that he or she has.

Also, the discrete situations in which the drug is available (e.g., being offered a

drug) may be insufficient causes of relapse. The complex, chronic life problems

that predispose ex-users to be in these situations may be more important.

Examples are chronic unemployment and failure to develop drug-free networks,

both of which predict relapse. Skills training oriented toward more complex

targets, like job-seeking, has been shown to be effective (Hall et al. 1984b).

Other relevant skill areas may include job-holding skills, parenting skills, and

general social skills for developing nondrug-using networks. Research is

needed to explicate the role of enhancing these skills in preventing relapse.

Social Support

Social support has been demonstrated to be related to health outcomes and to

mortality. Two major dimensions of social support have been identified (Cohen

and Wills 1985). Structural support concerns the existence of relationships with

others, for example, marital status and group memberships. Functional support

is the degree to which these relationships provide emotional, informational, and

material resources. Recently there has been increased attention to social

support variables in drug treatment research, with general social support being

distinguished from support specific to abstinence.

Across addictions, intriguing correlations have been found between levels of

support (primarily structural) and drug treatment outcomes (e.g., Havassy et al.

1989; Hawkins and Fraser 1987; Mermelstein et al. 1983). Nevertheless,

formal interventions to increase levels of support usually have been ineffective

in preventing relapse (Lichtenstein et al. 1986). One exception to this is the

work of Stanton and colleagues (1979) on family therapy with opiate abusers.

Encouraging results also have been obtained using marital therapy with

alcoholics (O’Farrell 1989). It appears that successful treatment interventions

(compared with those that have failed) have been distinguished by intensive

intimate engagement with the primary social system, compared with less

intensive methods, such as spouse training (e.g., McIntyre-Kingsolver et al.

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1986), or involvement of less intimate systems such as work groups (e.g.,

Malott et al. 1984).

Clinical lore indicates that involvement in nonfamilial social support programs

that emphasize abstinence also helps prevent relapse. Although 12-step selfhelp recovery organizations, such as Narcotics Anonymous, can address this

need, they may not be palatable to substance abusers who find the spiritual

orientation or the meeting content offensive. Development and evaluation of

support programs offering alternative philosophies are crucial. A promising

alternative is Recovery Training and Self Help (McAuliffe and Ch’ien 1986),

created for treated opiate addicts.

Research on social support points to gender differences, and not surprisingly,

correlational evidence primarily from the alcoholism literature suggests that

social support may be particularly important for drug-abusing women.

Investigators have found that alcoholic women have less social support than

nonalcoholic women (McCormack 1985); familial support is important in

successful treatment for women (Billings and Moos 1982); and the number of

supportive relationships predicts treatment outcome (MacDonald 1987). Some

clinical reports indicate that women not only fail to receive active support for

abstinence but also actually may encounter opposition to entering treatment

from family and friends (Amaro and Beckman 1984). Reasons for this include

the shifting of child care responsibilities to other family members and the

spouses’ reliance on the women for meeting their day-to-day needs. The

importance of providing adequate child care to remove this major treatment

barrier has been emphasized (e.g., Blume 1982).

Negative Affect

Drug abusers have high rates of current and historical major depression

(Rounsaville et al. 1982). In treatment research, both negative moods and a

history of depression predict poorer initial treatment outcomes and higher

relapse rates (e.g., Hatsukami and Pickens 1982). Thus, depressed patients in

treatment systems should be identified. For some patients, especially those

with current major depressions, psychoactive medications have been shown to

be useful (e.g., Woody et al. 1982). Many patients who do not have

diagnosable mood disorders may still be dysphoric much of the time, and

psychological interventions to modify and prevent such dysphoria are promising

tools for preventing relapse. The work of Woody and his colleagues (1983,

1987) on psychotherapy lends support to this idea. Our current work with

smokers offers a promising new direction. In collaboration with Ricardo Muñoz,

we have incorporated cognitive-behavioral interventions for depression into our

smoking treatment protocol. Muñoz’s “depression prevention” intervention has

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been shown to decrease negative moods up to 1 year after treatment in

persons at high risk for depression (Muñoz et al. 1989). We expect that these

interventions will be readily adaptable to other drug treatment populations.

Cue Reactivity

Conditioning models suggest that internal responses conditioned to

environmental cues can lead to relapse. Exposure techniques for reducing cue

responsiveness may therefore prolong abstinence. Relevant strategies have

included practicing drug-avoidance in selected real-life situations (e.g., Blakey

and Baker 1980) and administration of priming doses followed by response

prevention (e.g., Hodgson and Rankin 1976). Early findings in this area were

difficult to interpret because of small sample sizes, overreliance on self-reports,

and lack of followup. Recently, conditioned responses to drug-related stimuli

(paraphernalia, audiotapes, and videotapes) have been systematically studied

by Childress and her colleagues (e.g., Childress et al. 1988; McLellan et al.

1986; O’Brien et al. 1988). Although these laboratory procedures have been

shown effective in reducing conditioned responses, it is still unknown whether

better long-term outcomes will result. It is plausible that, although the treatment

model is a good one, successful clinical implementation will require

modifications such as booster sessions and structured implementation in the

natural environment.

The role of other drugs as conditioned cues deserves special mention. For

example, many clinicians believe that alcohol consumption is an important

precursor to cocaine relapse. Also, clinical lore suggests that, for individuals

whose use of a specific drug has been linked to other drugs, total abstinence

from all drugs may be necessary. There is intriguing laboratory research about

the effects of one drug on another (e.g., Roache and Griffiths 1987). Yet we

know little about why, how, or even whether use of one drug causes use of

another in the natural environment. We can improve drug treatment by

obtaining such knowledge.

In addition to the key variables already discussed, two others seem intuitively

important: “stress” and the abstinence violation effect. In contrast to the

previous areas, however, there are as yet insufficient data to suggest potential

interventions.

“Stress”

Stress has long been implicated in drug abuse. The term “stress” has been

applied to objective situations, such as major life events, as well as to chronic

minor irritants (‘hassles”). Relevant research has been largely retrospective, as

285
in studies in which users are asked to describe the events leading to a recent

lapse. Whether the stress-relapse link is real or artifactual is unclear. A critical

question is, To what extent does postlapse retrospection color the perception of

antecedent events? For example, if one has lapsed and seeks to understand or

interpret the lapse, a previously neutral-seeming situation preceding the lapse

may be reinterpreted as stressful. A second issue is the extent to which

observed correlations are illusory. Addicts tend to experience a high level of

stressful events. One of these events may precede a lapse yet still not be

causative. Actual causative variables may be subtle and not easily verbalized.

In our own work with opiate users, alcoholics, and smokers (Hall et al., in

press), retrospective analyses showed stress to be linked significantly to

relapse. Prospective examination of the same data showed no relationship.

Thus, our findings support the belief that the “true” relationship between stress

and relapse may not be strong.

A better understanding of the role of stress in relapse is needed. Additional

prospective research employing a fine-grained approach (i.e., assessing stress

on a day-to-day basis) should help illuminate the stress-relapse relationship.

Without additional knowledge, it is difficult to suggest answers to relevant

treatment questions such as whether stress-reduction training is advisable.

Abstinence Violation Effect

As appealing as Marlatt and Gordon’s (1985) formulation of the AVE is,

empirical evidence of its role in relapse is thus far limited to a study of cigarette

smokers (Curry et al. 1987). The phenomenon and its consequences still await

demonstration across drug-using populations. Still, the AVE remains intriguing.

It would seem worthwhile investing in studies establishing the importance of the

AVE in relapse and then seeking ways to address it in drug treatment.

SUMMARY

Although knowledge about relapse prevention is still at an early stage, the

extant data highlight the importance of several constructs.

1. Motivation for abstinence remains central. The construct itself is often

clouded because of its association with mystical notions such as willpower

and self-control. We know that manipulation of environmental events can

increase motivation. These interventions are effective, however, only as

long as the contingencies are in effect. We need to develop and evaluate

strategies for transferring contingency management to the natural

environment, that is, to institutions and groups that can perpetuate them for

the long term. Also, clarification of the kinds of abstinence goals needed to

prevent relapse is important.

286
2.

3.

4.

5.

Coping skills have been studied by several investigators, but research on

these, except for job-finding skills, is not encouraging. The skills usually

taught may be too basic. Skills training oriented to complex targets, such

as building nondrug-using networks, may be useful and should be further

explored.

Social support is clearly important, yet we do not know how best to use it to

promote abstinence. The little research available suggests that both

familial and nonfamilial systems should be mobilized. We need to define

abstinence-promoting supportive behaviors, identify and engage important

support systems in treatment, and help patients expand their nondrug-using

contacts.

Negative affect may be causally related to relapse. We need to continue

efforts to identify dysphoric patients and develop interventions to ameliorate.

dysphoria concurrent with drug abuse treatment (cf. Zweben and Smith

1989).

Drug cue reactivity and extinction to drug cues have been demonstrated in

the laboratory. What is needed in this promising line of research are (1)

investigation of cues and cue-reactivity phenomena in the natural

environment or in conditions closely mimicking that environment and (2)

extinction methods that transfer from the treatment setting to the outside

world.

Other phenomena are not well understood but seem intuitively important.

Maladaptive ways of responding to lapses, such as the AVE, are included here.

Another is stress, which our patients and our clinical intuition tell us must play a

role in relapse. Its exact role is far from clear.

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ACKNOWLEDGMENTS

Preparation of this article was supported in part by National Institute on Drug

Abuse grants DA-00065, DA-02538, DA-03082, and DA-05582; BRSG grant

S07-RR0575; and a Veterans Administration Merit Review grant to the first

author.

AUTHORS

Sharon M. Hall, Ph.D.

Professor

University of California-San Francisco

Psychiatry Service (116A)

San Francisco Veterans Administration Medical Center

4150 Clement Street

San Francisco, CA 94121

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David A. Wasserman, Ph.D.

Assistant Professor

University of California-San Francisco

Center for Social and Behavioral Sciences

1350 Seventh Avenue, Room 207

San Francisco, CA 94122

Barbara E. Havassy, Ph.D.

Assistant Professor

University of California-San Francisco

Department of Psychiatry

San Francisco General Hospital

1001 Potrero Avenue, Suite 7M

San Francisco, CA 94110

292
Conditioning Factors May Help To

Understand and Prevent Relapse in

Patients Who Are Recovering From

Drug Dependence

Charles P. O’Brien, Anna Rose Childress, and

A. Thomas McLellan

INTRODUCTION

There is general agreement that drug dependence is a chronic relapsing

disorder, but there are many aspects of relapse that remain unexplained. In

some cases the treated, drug-free former addict reports an occasional, sudden

compulsion to obtain the drug. In these instances the relapse may appear

paradoxical. For example, the patient has been through a rehabilitation

program; he has returned to his job; he is reunited with his family; and he can

present an apparently genuine and logical argument that he never intends to

touch the drug again. And then, as one patient said recently, “I bumped into a

guy that I used to do “coke” with, and my heart started pounding and I started

shaking. Then I went on automatic pilot.” Although it is possible that some of

these patients are trying to evade responsibility for the relapse, they appear

sincere, and there is a consistency to their stories. It appears that there are

many involuntary aspects to relapse and that the mechanisms of relapse

demand further study.

One of the first people to study relapse was Abraham Wikler in the 1940s. He

noted the similarity of certain relapse phenomena to conditioned responses.

Wikler observed withdrawal-like signs in opiate addicts who were participating in

group therapy sessions in the Public Health Service Hospital in Lexington,

Kentucky. These patients had not taken opiates for at least several months;

they had been completely detoxified; and, thus, they should have had no signs

of opiate withdrawal. However, when they started talking about drugs in group

therapy, they would suddenly start yawning or tearing and appear as though

they were experiencing an opiate abstinence syndrome. Wikler was aware of

some of the studies from Pavlov’s lab in the 1920s showing that the effects of

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morphine could be conditioned. Wikler suggested that some of the withdrawal

signs observed in addicts might be conditioned responses (Wikler 1948).

Wikler labeled this phenomenon “conditioned withdrawal,” speculating that

environmental stimuli, through classical conditioning, can elicit many of the

signs and symptoms of pharmacological withdrawal. He further hypothesized

that cues formerly associated with drug effects or drug withdrawal symptoms

might play an important role in triggering relapse to drug use in the abstinent

opioid abuser. Wikler also pointed out that the adaptation to drugs could be

conditioned (Wikler 1973), a phenomenon later explored in a series of elegant

studies by Siegel on conditioning of tolerance (Siegel 1976). Wikler developed

a rat model for studying morphine withdrawal, and in subsequent experiments

(Wikler 1965; Wikler and Pescor 1967) he demonstrated that withdrawal signs

in rats could be conditioned. Goldberg and Schuster (1970) Davis and Smith

(1974) Siegel (1976), and others confirmed that many drugs from different

pharmacological classes can produce conditioned responses. Conditioned

opioid withdrawal responses also have been experimentally produced in human

subjects (O’Brien 1975; O’Brien et al. 1977) (see Grabowski and O’Brien [1981]

for a review of both animal and human demonstrations of classical conditioning

experimentally produced by drugs).

RELAPSE

Before discussing the conditioning mechanisms that may be involved with

clinical relapse, it is important to place the phenomenon of relapse in

perspective. Relapse to drug use in a formerly dependent person is one of the

core features of addiction. The typical addict may continue drug use for years

before seriously trying to break the habit by entering a treatment program.

Although the length of time before requesting treatment varies, the addict is

likely to have been changed by a long period of exposure to compulsive drug

use. These changes probably involve both physiological and social areas. The

repetitive behaviors reinforced by drug effects become ingrained, perhaps by a

process that includes classical conditioning. Thus, it is not surprising that the

reasons for relapse after treatment may be totally different from the reasons that

led to the initial drug use (O’Brien et al. 1986). Both psychosocial and biological

factors probably contribute to the phenomenon of relapse. A critical aspect of

treatment is the analysis of those factors that increase the likelihood of relapse

after a period of abstinence; this allows the treatment team to develop ways to

reduce relapses and prolong periods of abstinence.

Substance Dependence: A Chronic Disorder

Our studies focus on methods to achieve the long-term rehabilitation of drugdependent persons. Treatment success is measured by the function of patients

294
over the weeks, months, and years after an initial course of treatment. Shortterm treatment, including detoxification and 28-day rehabilitation, is not

meaningful unless there is a program to continue treatment on an outpatient

basis and prevent relapse. Like arthritis, the condition is one that has a

proclivity to recur repeatedly, even after apparently successful short-term

therapy. In followup studies, we attempt to analyze the factors that precipitate a

return to the use of drugs and those that seem to be responsible for a

prolonged drug-free period. For drug dependence disorders in general,

researchers have found that multiple factors influence the likelihood of relapse.

Four classes of relapse factors are:

Psychiatric disorders, including depression and anxiety disorders

Social factors, including employment opportunities and social support

network

Protracted abstinence syndrome varies with the drug. Acute abstinence

symptoms for opioids may last 5 to 7 days. Protracted opioid abstinence

may persist for 6 months or more. Protracted abstinence symptoms also

appear to exist for alcohol and cocaine, but there are only clinical data.

Conditioned responses

Treatment outcome studies show that the presence of psychiatric disorders is

the most critical factor influencing success or failure in treatment. Psychiatric

disorders greatly influence the prognosis of the entire substance dependence

syndrome and, thus, must be specifically addressed and treated. Clinical data

also suggest that social factors such as employment opportunities and the

availability of social supports play a major role in influencing treatment outcome.

Psychiatric variables often are not addressed in traditional treatment programs;

it is even less common to find programs that deal directly with protracted

abstinence syndrome and conditioned responses. Protracted abstinence

symptoms may persist for months after detoxification and probably represent

prolonged derangements in homeostatic regulation produced by chronic drug

use. The patient interprets these abstinence symptoms as “need” for the drug.

The state of autonomic nervous system irritability found in the protracted

abstinence syndrome probably makes the patient more reactive to classically

conditioned phenomena (see below) as well.

Conditioned Responses in Substance Dependence

Although our research center is engaged in treatment studies aimed at each of

the four relapse factors cited above, this chapter focuses on Pavlovian

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conditioned responses produced by repeated drug administration in the

presence of specific stimuli. Conditioned responses produced by drug

administration were first reported from Pavlov’s laboratory (Pavlov 1927). Since

then, such conditioned responses have been reported in association with the

administration or the withdrawal of several classes of drugs in animals and

humans (Grabowski and O’Brien 1981). These conditioned responses may be

classified as drug-like or drug-opposite. Drug-opposite responses can mimic

the drug withdrawal syndrome. If drug-opposite responses are elicited just

before a dose of the drug is administered, the conditioned responses produce

attenuation of drug effects. This attenuation of drug effects produced by

conditioned responses can be called “tolerance,” and it may form a partial

explanation for the diminished drug effects commonly seen with repeated

administration of the same dose of a drug (Siegel 1976).

There is also extensive literature on conditioned drug-like responses (Lynch et

al. 1976; Grabowski and O’Brien 1981). Drug-like conditioned responses have

been produced experimentally in animals by pairing distinct stimuli with drug

administration. After repeated pairing, the stimuli themselves can produce

drug-like effects. Drug-like responses also have been described in human

subjects exposed to drug-related stimuli or in addicts who self-inject saline

when they are expecting opioid (O’Brien 1975). Thus, a conditioning

mechanism may form a partial explanation for what are known as the “placebo

effects” of drugs. This presumes that drug-like or placebo effects have been

conditioned by past exposure to the drugs under similar circumstances to the

placebo exposure. Our research over the years has provided clues as to which

conditioning paradigms are most likely to produce either drug-like conditioned

responses or drug-opposite conditioned responses. Both animal and human

data suggest that stimulants such as amphetamine and cocaine are more likely

to produce conditioned responses that are drug like, whereas typical opioid use

in human subjects produces more prominent drug-opposite responses. There

also appear to be influences of timing of the conditioning stimulus and

unconditioned stimulus. For example, in opioid users, drug-opposite responses

are likely to occur when the subject is presented with preinjection stimuli, but

postinjection stimuli more often produce drug-like responses (O’Brien et al.

1986). Much more research will be required to sort out the factors that

influence the type and robustness of the conditioned response.

In animal experiments drug-naive subjects can be trained by exposing them to

drug effects in association with specific environmental stimuli. Thus, we can

control the subject’s conditioning paradigm and carefully describe unconditioned

and conditioned responses. Of course, in studies of drug-dependent patients

there is no direct information about the subject’s conditioning history. In most

cases the patients have repeatedly self-administered the addicting substance

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thousands of times over the years and under similar conditions. We can test for

the presence of presumed conditioned responses by observing the patient’s

subjective and physiological reactions to drug-related stimuli in a test situation

and then compare the patient’s reactions, both subjective and physiological, to

neutral stimuli and drug-associated cues. A particularly interesting group of

patients are those who have been drug free in an inpatient program for 28 days

before being studied. These patients are detoxified and then treated in a

protective environment such as a hospital or a therapeutic community. During

the 28-day rehabilitation program, the patients are not exposed to the situations

that previously were associated with drug use and are given intensive group

and individual counseling. Before discharge, the patients are usually confident

that they want to refrain from further drug use and despite previous relapses

say, “This time will be different.”

The test procedure consists of exposing the patient to stimuli previously

associated with obtaining and administering drugs and comparing the patients

reactions with the responses produced by control, nondrug-related stimuli. The

drug-related stimuli are produced by filming or taping addict volunteers planning

a drug purchase, making the purchase, and administering the drugs. The

stimuli are specific to the type of drug so that crack users are exposed to crack

stimuli. However, the stimuli are not personalized to the individual patient and

his or her specific drug-using environments. In other words, all heroin users

view the same materials. The current protocol consists of sequential exposure

to audiotapes, to videotapes, and then to objects related to the acquisition,

preparation, administration, and use of the drug on which the patient has been

dependent.

The patients come to the experimental sessions feeling well and confident.

They are often surprised by the intensity of their reactions to these artificial

stimuli even in the laboratory setting. Opiate addicts studied in this way report

dysphoria and other withdrawal-like symptoms and/or signs when exposed to

opiate-related stimuli (Teasdale 1973; O’Brien 1975; Ternes et al. 1980;

Sideroff and Jarvik 1980; McLellan et al. 1986). We assume that these

responses were conditioned during the course of the patient’s addiction before

coming to the treatment program. Opiate addicts often show such drugopposite responses when presented with the videos and other materials

associated with heroin use. Such drug-opposite responses in opiate addicts

are similar to those produced in the laboratory when opiate withdrawal is paired

with a novel stimulus to demonstrate that the withdrawal syndrome could be

conditioned in humans (O’Brien et al. 1977).

Patients who have been addicted to cocaine show arousal, craving and urges to

go out and obtain cocaine when exposed to cocaine-related stimuli in the

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laboratory (figure 1). Although the reactions in opioid addicts can be classified

as conditioned drug-like or drug-opposite effects with a fair degree of certainty

based on experimental evidence, responses in drug-free former cocaine addicts

are difficult to classify. We lack experimental evidence from studies of

unconditioned and conditioned cocaine effects in human subjects. Perhaps the

arousal seen in former cocaine addicts presented with cocaine-related stimuli is

a conditioned drug-like response similar to the increased activity that rats show

when placed in a cage where they have previously received cocaine. This mild

conditioned cocaine-like response could act as a primer for the production of

craving and drug-seeking behavior. However, one must remember that nonspecific arousal can involve sympathetic nervous system stimulation and thus

resemble a mild cocaine-like response. However, we believe that many of the

responses to cocaine-related stimuli that we have observed are too severe to

be classed as non-specific arousal. Moreover, lacking direct experimental data

on cocaine conditioning in humans, we cannot be confident about the

classification of the responses to cocaine-related stimuli.

Whatever the origin of these responses, former cocaine-dependent patients

frequently show striking responses to cocaine-related stimuli. The patients are

typically surprised by the intensity of their own responses and by their strong

urge to leave the hospital and buy cocaine. Some express confusion because

they thought that they had decided never to use cocaine again. The stimuli

shown in the test situation are likely to be encountered in “real life” after the

patient leaves the hospital; by discovering this continuing aspect of their

dependence, patients can be forewarned about their reactions outside of the

hospital. Also, there is the possibility that these conditioned reactions can be

modified or diminished via an extinction procedure.

Clinical Significance of Conditioned Responses

Given the evidence from animal and human studies, the existence of

conditioned responses in drug- dependent patients is generally accepted, but

the clinical significance of these responses remains uncertain. One way of

assessing clinical importance is to determine whether modification of

conditioned responses can influence the course of addiction. This is a

particularly difficult criterion because there are multiple factors that influence

clinical course (see relapse factors above). Improvement in one area could be

overridden by lack of improvement in another. For best results, therefore, a

treatment that addresses conditioned responses should be embedded in a

comprehensive treatment program, which should address all of the major issues

confronting recovering drug addicts. However, such a combined approach

means that clinically significant increments in treatment efficacy will be difficult

to detect. In a combined treatment approach in which each treatment element

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contributes 10 percent to the patient’s overall improvement, that contribution

may be extremely important, but very difficult, to distinguish from the

contributions of the other treatment elements. For the past several years our

research group has conducted studies combining efforts to extinguish

conditioned responses with use of naltrexone (O’Brien et al. 1980). We also

have studied the combination of methadone, psychotherapy, and extinction

(McLellan et al. 1986). Currently we are studying the effects of extinction in

drug-free patients formerly dependent on cocaine and another group recovering

from dependence on heroin. Because it is not ethical or practical to compare

the results with patients receiving no treatment, we have tried to measure the

effects of adding extinction to another treatment already shown to have efficacy.

The responses targeted in our extinction program include subjective responses

such as “craving” and feelings of “high” and drug withdrawal. We also have

studied the effects of the extinction program on autonomic responses such as

changes in pulse, blood pressure, skin resistance, and skin temperature. The

procedure for modifying these responses is based on systematic, gradual

exposure to drug-associated cues. The general approach in most of these

projects has been first to select conditioned “trigger” stimuli (e.g., sight of

syringe, drug talk, “cookup” paraphernalia) that reliably elicit conditioned drug

responses in the target population and then to attempt to reduce these

responses through repeated, nonreinforced exposure (extinction).

Opioid Dependence

Our research group has studied the conditioned responses associated with

chronic opioid use, speculating that some of these responses (particularly

conditioned craving and withdrawal) could lead to drug use and relapse in the

abstinent patient (O’Brien 1975; O’Brien et al. 1977; Ternes et al. 1980;

McLellan et al. 1986). We have found that the opioid-like responses can be

easily extinguished in most patients, but the drug-opposite responses in former

opioid addicts are very persistent despite repeated efforts at extinction. We

began by studying conditioned responses in patients receiving the narcotic

antagonist naltrexone (O’Brien et al. 1980). We attempted to extinguish the

conditioned responses we observed. by administering a course of nonreinforced

exposure to drug-related cues and self-injection rituals. The drug-opposite

responses in these patients proved very resistant to extinction. Our extinction

methods have improved, and we have more recently conducted a large-scale

treatment/outcome study employing random assignment of extinction trials in

methadone patients (McLellan et al. 1986). We found that drug-related stimuli

were reliable elicitors of conditioned responses, particularly conditioned craving

and conditioned withdrawal. In about a third of these methadone-maintained

subjects, the effects were quite marked. With 20 or more extinction sessions,

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conditioned craving was significantly reduced, but conditioned withdrawal was

still in evidence despite the patients being maintained on methadone.

Currently, we are conducting a treatment study in drug-free patients who

recently have been detoxified from opioid dependence.

Cocaine Dependence

The recent upsurge of cocaine use among our patients has given us the

opportunity to study and document the kinds of conditioned responses that may

occur in chronic cocaine abusers (Childress et al. 1987). Cocaine use tends to

be episodic: Whether the user has stopped taking cocaine because of toxicity,

incarceration, or admission to a hospital for detoxification, there is a strong

tendency to resume taking cocaine after a short abstinence period. Detoxified

cocaine users report cocaine craving in certain situations despite their

determination to refrain from returning to drug use. Some report intense

craving, arousal, and palpitations when they encounter objects as diverse as

grains of white sugar in a bowl or talcum powder while changing a child’s

diaper, or being with a friend with whom they had used cocaine. Many of these

situations involve a white substance that–because of the patient’s repeated

experience with white, crystalline cocaine–now signals cocaine to the former

user. Detoxified former cocaine-dependent patients also experience similar

responses to cocaine-using friends, drug-buying locations, a pharmaceutical

odor–almost anything that has been repeatedly associated with getting and

using cocaine. The stimulus acts as a trigger for arousal and craving. By the

time he or she enters treatment, most of a patient’s environment consists of

reminders of cocaine use.

Use of cocaine can produce complex conditioned responses because the

unconditioned responses themselves are quite complex. When smoked or

injected, cocaine results in a rapid onset of euphoria and pleasurable

sensations, often followed in as little as 10 minutes by dysphoria, nervousness,

and extreme drug-craving. These biphasic effects are further complicated by

the appearance of toxic symptoms (suspiciousness, paranoia, etc.) after high

doses, long binges, or even a long history of less frequent use. Finally, after

ceasing continued use, patients may complain of “crash” feelings, including

depression, irritability, and fatigue. Because the same environmental stimuli

may be linked to several different phases of cocaine’s actions, there can be

several different kinds of responses to the same cocaine reminder.

Although many different factors may contribute to the extremely high rate of

relapse among cocaine users, conditioned cues can play a significant role.

Traditional treatment approaches intuitively have recognized the power of

cocaine reminders. Thus, abstinent patients are warned to avoid “people,

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places, and things” associated with prior cocaine use (Marlatt 1982). In reality,

complete avoidance is very unlikely, even in a well-motivated patient; patients

need additional tools for coping with or reducing drug-craving.

Our cocaine studies have four goals: (1) better characterization of the

responses conditioned by cocaine use in humans (Are these indeed drug-like

responses?), (2) development of ways to measure the intensity of these

responses, (3) development of ways to reduce these responses to cocainerelated stimuli, and (4) determination of the effect on clinical outcome of

diminishing or extinguishing these conditioned responses.

Integration of Cue Exposure Within A Comprehensive Treatment Program

Relapse to drug use after detoxification is influenced by several factors both

internal and external to the patient. To prevent relapse, all categories of

relapse-producing factors should be addressed, including pharmacological,

social, occupational, medical, legal, and family issues. If conditioning factors

play a role in relapse, the influence of conditioning probably varies with the

individual patient, depending on the relative importance of other relapseproducing factors. Thus, we have integrated the extinction procedure within the

context of a treatment program that addresses a range of issues thought to be

important to the recovering addict.

Although individual patients seem to benefit from systematic cue exposure or

extinction, the only way to determine whether any technique adds significantly

to the treatment of an illness is to obtain a relatively homogeneous sample of

patients and randomly assign them to the experimental treatment or to a control

condition. We have studied more than 50 cocaine-dependent patients, and

preliminary data are presented here. All subjects were male veterans who had

entered the Substance Abuse Treatment Unit of the Philadelphia Veterans

Affairs Medical Center with a primary problem of cocaine dependence. These

patients ranged in age from 28 to 53 and averaged 3 years of cocaine use.

Although several patients also had histories of alcohol and marijuana use, those

with a significant history of opiate dependence were specifically excluded. In

general, these relatively “pure” cocaine abusers tended to have significantly

shorter addiction histories and fewer previous treatment episodes than recent

admissions for treatment of opiate or polydrug dependence.

All patients were detoxified before entering the study. The exposure of the

patients to cocaine-related stimuli initially took place while the patient was

hospitalized so that the protective therapeutic setting would minimize the

possibility that the patient would be stimulated to actually acquire and use

cocaine in response to any craving/arousal triggered by the cocaine reminders.

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Cocaine-related stimuli were tied as closely as possible to the patient’s cocaine

history, particularly to the preferred mode of cocaine administration (intranasal,

intravenous, or smoked). Patients in a pilot study reported that seeing or

hearing tapes of cocaine use in a nonpreferred modality generally did not

stimulate craving or arousal.

Laboratory Measurement Sessions. Before extinction or other treatments, all

patients were tested for their initial responsivity to cocaine-related stimuli in a

90-minute laboratory measurement session. These laboratory test sessions are

conducted in an environmentally controlled, electrically shielded recording

chamber. Both physiological and subjective measures are obtained.

Physiological measures include peripheral skin temperature, galvanic skin

resistance (GSR), general arousal index, heart rate, and respiration. These

physiological measures are simultaneously recorded on a polygraph and a

computer database for later analyses. Subjective measures are obtained by

asking each abstinent patient to rate, on a 1 to 10 scale, the degree of

subjective cocaine “high,” ‘craving,” or ‘crash” (withdrawal) experienced under

each set of stimulus conditions. The following stimulus components are used:

(1) neutral baseline, (2) neutral videotape (a nature story), (3) neutral activity

(video motor skill game), (4) drug baseline, (5) drug-related videotape (buy-sell

and cocaine administration rituals), (6) drug-related activity (handling drug

paraphernalia and performing a simulated cocaine administration) and (7)

recovery baseline. Both neutral and drug-related stimuli were developed

through our work with pilot patients. Each patient’s drug-related videotapes and

paraphernalia were linked to the preferred (usually the most recent) mode of

using cocaine.

Treatment Assignment. After pretreatment testing, patients were randomly

assigned to one of four treatment conditions: (1) supportive-expressive

psychotherapy + extinction (SE-X); (2) supportive-expressive psychotherapy +

activities to control for the extra attention received by patients assigned to the

extinction condition (SE-C); (3) standard drug counseling + extinction (DC-X),

and (4) standard drug counseling + control activities (DC-C). Control activities

consist of sessions (equal in length and number to extinction sessions) with

self-help tapes featuring suggestions for developing a healthy lifestyle and

better relationships. Drug counseling is administered by experienced

counselors according to a treatment manual and represents good standard

treatment for substance abuse. Supportive-expressive psychotherapy is

administered by experienced doctoral-level psychologists and has been found

to be significantly more effective than drug counseling for opioid-dependent

patients (Woody et al. 1963). The efficacy of psychotherapy for cocaine

dependence has not been previously examined in a controlled study.

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Treatment Sessions. Inpatients assigned to extinction groups received 15

hourlong sessions of repeated, nonreinforced exposure to cocaine “reminders”

during the 2-week period of hospitalization following initial detoxification from

cocaine. (Therapy or counseling sessions were administered on a three-timesper-week basis during this 2-week period). The 2-week inpatient treatment

phase was followed by a 2-month outpatient phase offering eight additional

weekly sessions of extinction or control activities (as well as weekly therapy or

counseling, depending on group assignment). All these treatment sessions

were added to basic treatment for cocaine dependence at our clinic. Outpatient

treatment and followup evaluations are still in progress; therefore, the data

presented here focus primarily on the 15 inpatient extinction sessions.

Each hourlong cocaine extinction session contains three 5-minute audiotape

segments, three 5-minute exposures to a cocaine-related videotape, and three

simulated cocaine administration rituals. The presentation sequence of these

drug-related stimuli is audio/video activity, repeated three times. This

procedure provides nine drug-related stimulus exposures per session, for a total

of 135 exposures over the course of 15 sessions.

Although most inpatient extinction sessions are conducted on the treatment

ward, sessions 1,8, and 15 are conducted in the laboratory chamber to allow

for monitoring of physiological responses over the course of extinction. For

both laboratory and hospital ward extinction sessions, subjective data are

based on the Within Session Rating Scale for cocaine symptoms (WSRS-C)

(Childress et al. 1987) a quantified report that assesses both the type and

intensity of conditioned responses that a patient may experience on exposure to

cocaine-related stimuli (CSs). With this instrument, the patient first is asked to

rate the overall intensity of high, craving, and crash (withdrawal) using a 1-to-10

scale for each. The type and intensity of symptoms then are probed through an

accompanying list of 50 responses associated with early high (euphoria), toxic

(e.g., paranoia), and crash phases of cocaine use. The entire WSRS-C is

administered at the beginning and again at the end of each hourlong extinction

session.

RESULTS OF PREEXTINCTION TESTING

The following interim results illustrate the conditioning phenomena and provide

a progress report on the status of our ongoing treatment study.

Pretreatment Laboratory Testing (N = 30)

Data from the laboratory pretest before treatment confirm our preliminary finding

that cocaine abusers respond differentially to neutral vs. drug (cocaine)-related

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stimuli. A two-way analysis of variance (ANOVA) performed on the skin

temperature data yielded significant main effects of stimulus type (neutral vs.

drug (cocaine)-related, p < .000) and mode (video vs. activity, p < .000) on

peripheral skin temperature, with no significant interaction effect. These

temperature data, presented graphically in figure 1, show that reductions in

peripheral skin temperature (an index of arousal) were greater to drug

(cocaine)-related stimuli than to neutral stimuli (p < .000) and were generally

greater in response to activities than to video stimuli.

FIGURE 1. Skin temperature response in cocaine abusers to neutral vs.

cocaine-related stimuli (N = 30)

The average temperature reduction to cocaine-related stimuli (including

“nonresponders”) was approximately 4°F. Among those classified as

“responders,” however, dramatic reductions of 8 to 12°F (in response to

cocaine-related stimuli) were not uncommon. The magnitude and pattern of

these temperature changes in response to cocaine-related stimuli are very

similar to the changes that occur in former opioid addicts in response to opioidrelated stimuli, frequently reported by our laboratory (Childress et al. 1984;

Childress et al. 1987).

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For the physiological variable of GSR, a two-way ANOVA similarly revealed

significant main effects of both stimulus type (neutral vs. drug (cocaine)-related,

p < .04) and stimulus mode (video vs. activity, p < .001). There was a

significant type x mode interaction effect (p < .008): GSR values were

significantly different between neutral vs. drug-related video stimuli, but not

between neutral vs. drug-related activities. Analyses of heart rate data showed

trends similar to those for GSR but fell just short of statistical significance.

Subjective Responses (N = 26)

An overall ANOVA (with stimulus condition as the repeated measure) was

performed on each of the subjective variables of self-rated high, craving, and

withdrawal. For each variable, four difference scores were derived to represent

the change in subjective response under each stimulus condition: neutral video

(neutral video-baseline), neutral activity (neutral activity-baseline), drug video

(drug video-baseline) and drug activity (drug activity-baseline). These overall

analyses revealed a significant effect of stimulus condition on cocaine craving

(p < 0.0000), cocaine high (p < .01), and withdrawal/crash (p < .01). Of these

responses, craving was clearly the most prevalent, being reported two to three

times as often as either high or withdrawal/crash responses.

At least one-third of these patients were adamant nonresponders, insisting the

pretest stimuli triggered no craving, arousal, or other response(s). For these

patients, physiological arousal (as reflected in either decreased skin

temperature or a fall in GSR) was sometimes present, even though subjective

arousal was denied; these patients are included in the above analyses.

EXTINCTION SESSIONS

Subjective Responses

A one-way ANOVA with repeated measures was performed for each of the

subjective variables of craving, high, and withdrawal/crash, using sessions as

the repeated measure. These analyses revealed a significant effect of sessions

on all three subjective variables: craving (p < .0000), high (p < .0001), and

withdrawal/crash (p < .0000). Of these responses, craving was the most

prevalent and persistent, reducing gradually over the course of 15 extinction

sessions. Reports of high and withdrawal/crash were less common and were

largely extinguished by the sixth hour of extinction. Figure 2 shows the

reduction in three subjective responses: craving, high, and withdrawal/crash as

a function of extinction trials.

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FIGURE 2. Reduction in subjective responses to cocaine-related stimuli as a

function of extinction sessions by abstinent cocaine abusers

(N = 25)

Physiological Responses

Measures of skin temperature and GSR show significant reductions as a

function of extinction trials. Figure 3 compares the change in temperature

responsivity from extinction session 1 to session 15 (the final inpatient session).

Though the skin temperature and GSR responses were reduced as a function

of extinction trials, their relative persistence is underscored by the fact that

some arousal is still in evidence even after 15 hourlong exposure sessions.

TREATMENT OUTCOME

The study is still in progress, and outcome results are not yet available. In

general, the outcome of treatment for cocaine dependence is not good after

patients leave the hospital. The majority of patients drop out of outpatient

treatment quickly and commonly return to using cocaine. For this study, the

outpatient phase involves 8 weeks of treatment after discharge from the

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FIGURE 3. Reduction in skin temperature response to cocaine-related stimuli

as a function of extinction by abstinent cocaine abusers (N = 26)

hospital. Dropout is a serious problem for all treatment groups, and those

patients who remain in treatment in any group seem to be those who have

developed a good working relationship with a counselor or therapist. Thus far,

retention rates in the four treatment groups have varied over the course of the

study, but at the present time no group is significantly better than the others.

The critical measure of outcome is cocaine use. The goal is complete

abstinence, but during the course of treatment, some cocaine use typically

occurs even in successfully treated patients. Thus, a quantitative measure of

cocaine use would be desirable so that relative use could be compared;

however, this presents problems in measurement. Cocaine metabolites can be

detected in urine for at least 3 days (and occasionally for 6 to 10 days) after

use. Thus, a positive urine test may not readily distinguish whether cocaine use

has decreased. Patient self-reports may be distorted, but they can add

significantly to the quantitative information (Gawin et al. 1989a). We are

experimenting with outcome measures that combine patient self-reports of

amount and frequency of cocaine use given to an independent followup

technician and quantitative urine assays of the cocaine metabolite

307
benzoylecgonine in an effort to improve our comparisons of cocaine use among

outpatients.

Clearly, detoxified cocaine abusers can experience conditioned craving and

arousal to cocaine reminder stimuli. These responses can be both intense and

persistent, meaning that the abstinent cocaine abuser may be vulnerable long

after detoxification is complete. Although the program of extinction described

here is effective in reducing craving to cocaine-related stimuli presented in the

context of the laboratory or clinic, patients often report craving in the natural

environment. We are currently considering two approaches to improve

generalization from the lab to the street:

1.

2.

Use of even more realistic stimuli (e.g., the sight of real cocaine) and

individualized stimulus contexts (e.g., in vivo repeated exposures).

Previously we have been reluctant to employ in vivo exposures near

“copping” corners or shooting galleries because of possible risk to both

patients and clinical staff. Somewhat less dangerous stimuli could involve

the patient’s own home or the use of neighborhood videos taped from a

moving car.

A second approach would explore the effectiveness of several other

techniques in actively countering or reducing the conditioned craving and

arousal that occur in response to reminder stimuli. These techniques could

include training of alternative behaviors (competing responses), aversive

imagery, and cognitive techniques.

Our upcoming treatment protocols will feature elements from both these

approaches, including the use of more individualized cocaine reminders and the

training of active techniques for dealing with the powerful responses to these

stimuli.

Although data collection is still in progress, several significant findings are

already apparent from our study of cocaine reminders:

1. Detoxified cocaine abusers show a differential responsivity to drug-related

cocaine reminders compared with neutral stimuli. In our laboratory setting,

patients responded to cocaine reminders with strong signs of physiological

arousal, including dramatic reduction in peripheral skin temperature and a

fall in GSR. Subjectively, patients experienced increased cocaine craving

and, with lesser frequency, feelings of a cocaine-like high and cocaine

crash or withdrawal.

308
2.

3.

4.

In extinction sessions, repeated, nonreinforced exposure to cocaine

reminders led to a complete reduction in craving to these stimuli by the 15th

hourlong session in most patients. High and crash responses were virtually

eliminated by the sixth hour of extinction.

Physiological arousal to cocaine reminders was often still in evidence after

15 hours of extinction.

Even after completing the current extinction protocol, cocaine abusers may

crave and use cocaine when experiencing drug reminders in the natural

environment.

CONCLUSIONS

There is an extensive literature from animal and human experiments showing

that drugs from several pharmacological classes can readily act as

unconditioned stimuli in the production of conditioned responses. Further,

patients in treatment for opioid or cocaine dependence show subjective and

physiological responses when presented with drug-associated stimuli. These

responses can be assumed to have been conditioned during the course of

becoming drug dependent. Patients who already have been treated in the

traditional manner may continue to show dramatic responses to drug-related

stimuli despite a strong conscious motivation to avoid drug use in the future.

There are multiple factors that influence the probability that recovering drug

addicts will sample drugs again and eventually relapse to a state of

dependence. Although one can produce anecdotes suggesting that conditioned

responses play an important role in a given patient’s relapse, this is not

adequate evidence. Controlled studies are required, but the design of such

studies is a problem. One can show that repeated unreinforced exposure to

drug-related stimuli can extinguish or diminish conditioned responses, but

demonstrating that extinction significantly adds to treatment efficacy is difficult.

Treatment of a complex medicopsychosocial problem such as addiction

requires a multimodal approach. In this situation it is difficult to assess the

value of any single element.

We have made progress in the integration of graded cue exposure or extinction

into a comprehensive substance abuse treatment program. The technique is

acceptable to patients, and the theoretical framework makes sense to both

patients and staff. One possibility that we intend to explore is to take advantage

of the short-term benefits afforded to recovering cocaine addicts by medication

such as desipramine (Gawin et al. 1989a) or flupenthixol (Gawin et al. 1989b)

combined with behavior therapy in the form of extinction and other psychosocial

309
methods for the prevention of relapse. The brief period of abstinence induced

by the medication could be used to initiate efforts at long-term behavior change.

Such a combination will be even more difficult to study in a prospective

controlled fashion, but considering the complex blend of pharmacological and

psychosocial problems represented by substance abuse, such a combined

approach seems reasonable.

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ACKNOWLEDGMENT

This work was supported by National Institute on Drug Abuse grants P-50 DA5186 and DA-3008.

AUTHORS

Charles P. O’Brien, M.D., Ph.D.

Professor

Anna Rose Childress, Ph.D.

Clinical Associate Professor

A. Thomas McLellan, Ph.D.

Clinical Professor

Department of Psychiatry

University of Pennsylvania

Veterans Affairs Medical Center

3900 Chestnut Street

Philadelphia, PA 19104

312
Some Special Considerations for

Treatment of Drug Abuse and

Dependence in Women

Jack H. Mendelson, Roger Weiss, Margaret Griffin,

Steven M. Mirin, Siew K. Teoh, Nancy K. Mello, and

Barbara W. Lex

INTRODUCTION

During the past decade there has been a considerable increase in the

prevalence of drug abuse problems in women. A survey of metropolitan areas

carried out under the aegis of the National Institute of Mental Health revealed

that drug abuse and dependence was the second most common psychiatric

disorder among women ages 18 to 24 (Robins et al. 1984). This finding

highlighted the need for safe and effective therapeutic interventions for women

who abuse drugs during their early reproductive years. Although treatment

programs for women may be similar or identical to those that have been

developed for male substance abusers, there are gender-related factors that

merit special attention. This chapter focuses on three areas that may be

important for substance abuse treatment program development for women: (1)

special considerations for pharmacotherapeutic treatment of drug abuse and

dependence for women and development of new medications for women who

abuse drugs, (2) polydrug abuse in association with alcohol abuse by women

and their unique needs, and (3) new findings concerning gender-related

differences that are both antecedent to and consequent on cocaine abuse

(Griffin et al. 1989).

PHARMACOTHERAPY FOR DRUG-DEPENDENT WOMEN OF

REPRODUCTIVE AGE

Women who abuse or are dependent on opiates or cocaine may become

pregnant, and perpetuation of drug abuse during pregnancy may compromise

growth and development of the fetus. There have been numerous reports of

opioid abstinence syndromes in the newborn of opiate-dependent women

(Finnegan 1979) and serious disorders of neonatal health may occur in the

313

294-012 0 - 91 - 11
newborn of women who abuse cocaine (Chasnoff et al. 1985). Because

women who abuse drugs also may be lax in applying birth control procedures,

their risk for pregnancy may be significantly enhanced. Thus, rational

development of pharmacotherapies for women who abuse drugs and are at

high risk for pregnancy should meet several special requirements. First,

pharmacotherapy for women who are of reproductive age should not increase

risk for fetal malformation or disorders if the woman becomes pregnant while

receiving medication. Second, pharmacotherapy for drug abuse should not

increase risk for pregnancy, especially if the patient does not employ

contraceptive measures on a regular basis. Although this second

consideration may appear to be speculative, there is evidence that one of the

most effective pharmacotherapies for opioid abuse and dependence may

increase risk for unwanted pregnancy.

Naltrexone is a potent long-acting opioid antagonist that is prescribed for the

treatment of opioid dependence. Although the drug has been shown to be safe

and effective in controlled laboratory studies (Meyer and Mirin 1979) clinical

effectiveness may be diminished as a consequence of poor patient compliance.

At present, there are no restrictions for administering naltrexone to women,

although the drug may enhance risk for unwanted pregnancy.

Naltrexone has major effects on the hypothalamic pituitary-gonadal-axis in both

men and women (Mendelson et al. 1986; Teoh et al. 1988). Figure 1 shows

luteinizing hormone (LH) values for two subjects (1 and 2) studied during the

early follicular phase of the menstrual cycle (top panel) and two subjects (3 and

4) studied during the mid- and late-follicular phases (bottom panel).

Baseline LH levels before naltrexone administration for subjects (1 and 2)

studied during the early follicular phase ranged between 8 to 18 ng/mL. Peak

LH values were detected 210 minutes following naltrexone intake. Peak LH

increments above mean baseline levels were 63 ng/mL for subject 1 and 72

ng/mL for subject 2.

Subject 3 was studied during the mid-follicular phase and had baseline LH

values averaging 30 ng/mL. Peak LH values were detected 180 minutes

following naltrexone administration. The peak increment in LH values for this

subject was 33 ng/mL (95-percent increase above baseline values).

Subject 4, studied during the late-follicular phase of the menstrual cycle, had

baseline LH levels averaging 90 ng/mL. Peak LH levels following naltrexone

administration were detected at 210 minutes. LH levels increased by 55 ng/mL

(50-percent increase above baseline values).

314
FIGURE 1. Luteinizing hormone levels prior to and following naltrexone

administration at 0 time. Top panel shows LH values for two

subjects (S-1, S-2) studied during the ear/y follicular phase of the

menstrual cycle. Bottom panel shows LH values for two subjects

(S-3, S-4) studied during the mid- and late-follicuiar phases of the

menstrual cycle.

From Mendelson et al. 1986. Copyright 1989 by Pergamon Press (Elmsford, NY).

315
Naltrexone-induced LH stimulation observed in women studied during the early

follicular phase of the menstrual cycle was of greater magnitude than LH

increments reported following administration of the standard dose of synthetic

luteinizing hormone releasing hormone (LH-RH). Administration of 100 m IV

LH-RH induces a peak increment in LH levels in women ranging between 100

percent and 500 percent above baseline values (Ayerst Laboratories, Inc.

1982).

Induction of ovulation in patients with secondary hypothalamic amenorrhea has

been reported following chronic administration of naltrexone (Wildt and

Leyendecker 1987). Secondary hypothalamic amenorrhea may be caused by

opiate abuse as well as cocaine abuse. Paradoxically, women who receive

naltrexone therapy for attenuation of opioid abuse may be at higher risk for

unwanted pregnancy because of the effects of naltrexone on stimulating

hypothalamic LH-RH secretory activity.

The effects of the opioid antagonist naltrexone on reproductive function in

women have been emphasized to highlight an important factor that should be

considered in medication development for drug-dependent women. It is

obvious that medications that would adversely affect pregnancy should not be

administered, but it is also important to consider drug actions that may increase

risk for unwanted pregnancy.

SPECIAL CONSIDERATIONS FOR TREATMENT OF WOMEN WITH

POLYDRUG AND POLYDRUG PLUS ALCOHOL ABUSE PROBLEMS

As a consequence of increased public concern about morbidity and mortality

associated with alcohol-impaired driving, an increasing number of women who

abuse alcohol and drugs have been referred for treatment through the criminal

justice system. Many of these women require more extensive resources for

therapy than their male counterparts because they lack equivalent social and

economic support.

A specialized program for alcoholism treatment for men confined by the

Criminal Justice System in the Commonwealth of Massachusetts has been

available for more than 10 years, but a similar program was not available for

women until 1987. Staff members of the Alcohol and Drug Abuse Research

Center of Harvard Medical School-McLean Hospital have collaborated with the

Massachusetts Departments of Public Health and Corrections for evaluating the

needs and resources of women who are mandated for treatment (Lex et al., in

press). Many of these women have polydrug abuse or dependence problems in

addition to alcohol abuse and dependence.

316
Women polydrug abuse patients were significantly younger (mean age 26.8

years) than those who had a primary diagnosis of alcohol abuse or dependence

(mean age 41.9 years). Their level of educational attainment was significantly

lower (10.8 years vs. 13.0 years of education). Women with polydrug abuse

and dependence problems reported regular alcohol use at a significantly

younger age (15.8 years) than did patients with alcohol abuse and dependence

(24.8 years). Women with polydrug abuse disorders sought treatment at a

significantly younger age than did women with alcohol problems (21.1 years vs.

34.5 years). The average cost of drugs per week for polydrug abuse patients

was $170, and surprisingly, they spent more on alcohol ($49) per week than did

alcohol-dependent women ($24). Polydrug abuse by women also was

associated with earlier and more frequent heterosexual behavior. For example,

women with alcohol abuse and dependence problems had first intercourse at

age 18, whereas those with polydrug abuse problems had first intercourse at

age 15.

Cocaine abuse and dependence was the predominant problem of women with

polydrug abuse disorders; abuse of tranquilizers and sedatives, marijuana,

amphetamines, and opiates also was common. Alcohol consumption by

women with polydrug abuse problems ranged from 84 to 832 grams per day,

and their years of regular drinking ranged from 7 to 18 years. Menstrual cycle

function was normal for virtually all of the polydrug abusers, and approximately

50 percent had one or more therapeutic abortions before their admission to

treatment.

These observations highlight concern about development of specialized

programs for women who are polydrug abusers and also at high risk for

unwanted pregnancy. These data also underline the need to develop more

effective treatment programs for young women who are polydrug and

intravenous drug abusers in light of recent evidence that indicates that women

who are drug abusers are at high risk for human immunodeficiency virus

infection.

GENDER DIFFERENCES IN COCAINE ABUSERS

The dramatic increase in cocaine use and dependence during the past 15 years

has led clinicians and researchers to seek effective treatment strategies for this

burgeoning patient population. One area of investigation that has flourished as

a part of this effort has been an attempt to classify cocaine abusers into clinical

subgroups to develop specific treatment strategies for more homogeneous

patient populations (Weiss and Mirin 1986). Although these studies have

grouped cocaine abusers by age (White 1988), route of cocaine administration

(Verebey and Gold 1988), and psychiatric status (Gawin and Kleber 1986;

317
Weiss et al. 1986, 1989), relatively little research has focused on differences

between men and women who use cocaine (Griffin et al. 1989; Erickson and

Murray 1989). This relative lack of attention to gender differences in cocaine

abusers reflects an unfortunate trend in much of the substance abuse literature

(Davidson and Bemko 1978), as men and women cocaine abusers may differ in

some important respects, including their response to treatment. As previous

studies have shown that women alcoholics may suffer a higher mortality rate

than men (Hill 1986), and women opioid addicts experience poorer long-term

adjustment than their male counterparts (Cuskey et al. 1977; Marsh and

Simpson 1986; Reed 1978), elucidating sex differences in cocaine abusers

assumes potentially great clinical importance.

Although the popular media have paid some attention to the female cocaine

abuser, little scientific research has been published on the subject. Erickson

and Murray (1989) examined sex differences in patterns and practices of

cocaine use in 75 men and 36 women from Ontario. Their study sample was

not in treatment, and most subjects used cocaine quite infrequently (less than

once a month during the previous year). Erickson and Murray found relatively

few differences between men and women in their responses to cocaine,

although more women than men (37 percent vs. 14 percent) reported that

cocaine made them feel sociable and confident and men were more likely (42

percent vs. 26 percent) to enjoy the sense of a controlled high and increased

physical energy while on cocaine. In general, however, men and women

experienced quite similar physiological and psychological effects from cocaine.

Because this was a nontreatment sample of infrequent cocaine users, the

findings may not reflect potential gender differences in a cocaine-dependent

population. For example, few of the study sample had experienced significant

adverse consequences from cocaine use. It is possible that adverse reactions

to cocaine may differ according to gender; these potential differences may have

important clinical and treatment implications.

In an attempt to delineate gender-related differences in cocaine abusers, a

study was carried out with 129 patients hospitalized because of cocaine abuse

at the Drug Dependence Treatment Unit of McLean Hospital, Belmont,

Massachusetts (Griffin et al. 1989). The patient sample included 95 men and

34 women admitted between 1980 and 1986. Several major research

questions were addressed, including whether men and women reported

different reasons for cocaine use, because women alcoholics (Beckman 1975;

Curlee 1970; Lisansky 1957) and women who use other drugs (Suffet and

Brotman 1976) more frequently cite situational or emotional disturbances as

precipitants for substance use. Second, perceived differences in cocaine

effects between men and women were evaluated. Studies of therapeutic drugs

generally have shown more adverse effects in women (Bottiger et al. 1979;

318
Domecq et al. 1980; Hurwitz 1969), and animal studies have revealed sex

differences in drug response (Finnegan 1979). Finally, evaluation of psychiatric

comorbidity in men and women was carried out. Gender-related differences in

the prevalence and nature of depression were studied because this has been

found to be an important prognostic indicator in other substance abusers

(McLellan et al. 1983; Rounsaville et al. 1982a, 1987). Severity of depression

and level of overall psychological distress have been shown in other substance

abuse populations to be higher in women (Blume 1986; Colten 1980; Ross and

Berzins 1974), whereas antisocial personality disorder generally has been more

common in men (Hesselbrock et al. 1985; Rounsaville et al. 1982b; Weissman

and Klerman 1977). Because the study followed patients over the course of a

4-week hospital stay, it was possible to compare the initial response with

treatment among men and women.

Study instruments included a 287-item self-report sociodemographic and

substance abuse history questionnaire. The questionnaire also asked about

reasons for cocaine use and drug effects. The Social Adjustment Scale (SAS)

(Weissman and Bothwell 1976) was used to measure overall social functioning.

The 24-item Hamilton Depression Rating Scale (HDRS) (Hamilton 1960) was

completed at admission and at the end of the second and fourth weeks of

hospitalization. DSM-Ill diagnoses made at discharge reflected a consensus of

two psychiatrists who had conducted repeated clinical interviews with the

patients throughout the course of a 4-week hospital stay. Patients received an

Axis I diagnosis other than substance abuse only if they were currently ill and

had previously fulfilled DSM-III criteria for that diagnosis while drug free.

Further details of the methods and procedure used in the study have been

described elsewhere (Griffin et al. 1989).

There were several significant differences between men and women. Women

were significantly younger when hospitalized (mean age 26.6 years vs. 30.5

years, p < .001). Men were more likely to be employed (78 percent vs. 50

percent, p < .005) and held jobs with significantly higher status; 61 percent of

the men and only 20 percent of the women held executive, professional, or

sales jobs (p < .0001). SAS scores revealed significantly better overall social

functioning in men than women (2.2 ± 0.5 for men vs. 2.5 ± 0.6 for women, p <

.05). Furthermore, women were more likely than men to live with a drugdependent partner (36 percent vs. 21 percent).

As shown in table 1, women began drug use at an earlier age than men and

also were younger when they initially entered drug treatment. Because this

finding is unusual and contradicts the usual trend for opioid addicts (Levy and

Doyle 1976; Moise et al. 1982), a similar analysis for men and women opiate

addicts admitted to our facility during the same period revealed that, unlike the

319
TABLE 1. Substance abuse histories in cocaine abusers by sex

W omen

(N=34)

Mean S.D.

Men

(N=95)

Mean S.D.

Age of First Drug Usea

Years of Drug Use

Years of Heavy Drug Use

Age at Initial Treatmentb

Number of Different Drugs

Used During Past 30 Days

Years of Cocaine Usec

Grams of Cocaine Used

During Past 6 Months

Money Spent on Cocaine During

Past 6 Months ($)d

15.6 3.5 18.5 7.3

9.0 4.7 10.2 5.4

4.3 3.2 5.2 4.2

24.6 4.7 29.1 7.7

4.4 2.7 3.5 2.8

3.7 2.2 5.4 3.2

107.5

3,050 3,382 9,375 10,778

148.2 106.3 177.5

a

t=2.99,df=109.61,p<.005

b

t=3.02,df=114,p<.005

c

t=2.19,df=30.16,p<.05

d

t=3.03,df=43.13,p<.005

From Griffin et al. 1969. Copyright 1989 by American Medical Association (Chicago).

cocaine abusers, women opiate addicts were older than men and had begun

drug use at a later age. Men had used cocaine significantly longer before

admission, supporting the idea that women may have experienced a more rapid

onset of addiction to cocaine.

Diagnostically, 47 percent of the women and 40 percent of the men met DSM-III

criteria for an Axis I diagnosis other than substance abuse. Major depression

was significantly more common among women (24 percent vs. 4 percent, p <

.005). Conversely, antisocial personality disorder was found in 22 percent of

the men but was not present in any of the women (p < .01).

When asked about reasons for drug use, there were no statistically significant

differences between men and women on any single item. However, women

cited using cocaine in response to “depression, feeling unsociable, family and

job pressures, and health problems” more frequently than did men, who cited no

reasons for drug use more often than women. Regarding cocaine effects, men

were more likely to report a decreased ability to have sex (67 percent vs. 38

percent, p < .05), although no significant gender differences were reported

regarding the effects of cocaine on sexual desire, anxiety, mood, aggression, or

320
appetite. One interesting difference regarding drug effects was that women

were more likely to report decreased guilt during cocaine intoxication (47

percent vs. 23 percent), whereas men were more likely to feel more guilty (56

percent vs. 34 percent) while intoxicated (p < .05).

As shown in figure 2, serial administration of the HDRS revealed substantial

depressive symptoms in both groups, with consequent improvement during their

hospitalization. One notable difference between the sexes, however, was that

HDRS scores in women improved significantly between admission and 2

weeks, (p < .001) but not between 2 weeks and 4 weeks. Men, on the other

hand, improved significantly between admission and 2 weeks (p < .001) and

between 2 weeks and 4 weeks (p < .001). We subsequently eliminated patients

with major depression from our analysis (figure 3) and found the same trend,

with HDRS scores improving for men throughout the hospital stay (p < .001

between admission and 2 weeks, p < .001 during the subsequent 2 weeks),

whereas women improved only during the first 2 weeks (p < .01), but not over

the next 2 weeks.

FIGURE 2. Mean Hamilton Depression Rating Scale scores over time in all

cocaine abusers

From Griffin et al. 1989. Copyright 1989 by American Medical Association (Chicago).

321
FIGURE 3. Mean Hamilton Depression Rating Scale scores over time in

cocaine abusers without a diagnosis of major depression

From Griffin et al. 1989. Copyright 1989 by American Medical Association (Chicago).

This study of hospitalized cocaine abusers revealed several notable differences

between men and women. Women began using cocaine earlier than men and

entered treatment at a younger age after having used cocaine for a shorter

period. Men had better overall social adjustment, including better employment

and living situations. Cocaine was more likely to make men feel more guilty and

to reduce guilt in women. Men had a higher incidence of antisocial personality

disorder, and women were more likely to have major depression. Although men

and women were almost equally depressed at admission, men improved more

rapidly, with peak differences in HDRS scores at 4 weeks.

These findings suggest that the natural history of cocaine abuse in men and

women may be somewhat different; the differential effect on guilt may make

cocaine somewhat more reinforcing for some women, thus speeding up the

process of their addiction. It also is possible that the cocaine withdrawal

322
syndrome, which has recently been the subject of some research (Brower et al.

1988; Gawin and Kleber 1986), may be different in men and women. The

slower recovery from depressive symptoms may be a function of a sex-related

difference in the cocaine withdrawal syndrome, or it may reflect that the overall

social adjustment of the women in the study was less satisfying; this suggests

that a comprehensive approach to such issues as vocational adjustment, living

situation, and relationships with other substance abusers should be thoroughly

evaluated in all cocaine abusers, particularly women.

The generalizability of these findings is limited in part by the nature of the study

sample (inpatients admitted to a private psychiatric hospital) and the relatively

short-term nature of the study. It also is not clear, for example, whether

remaining more depressed 1 month after attaining abstinence is a good or a

bad prognostic sign. Recent research by Carroll (1989) suggests that

depression may be a favorable sign in cocaine abusers, as has been found

previously in alcoholic women (Rounsaville et al. 1987). We also must

emphasize that women cocaine abusers, like women alcoholics (Martin and

Casswell 1988), are not a homogeneous group but must be evaluated and

treated individually. However, our findings do suggest that some general

differences between men and women cocaine abusers may exist, and these

may have important treatment implications.

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ACKNOWLEDGMENTS

Preparation of this chapter was supported in part by National Institute on Drug

Abuse grants DA-04059, DA-00064, DA-00101, and DA-05944 and by a grant

from the Engelhard Foundation.

Portions of this chapter were originally published in the Archives of General

Psychiatry and Pharmacology Biochemistry and Behavior and are reprinted with

permission.

AUTHORS

Jack H. Mendelson, M.D.

Professor and Codirector

Roger Weiss, M.D.

Associate Psychiatrist

Margaret Griffin, Ph.D.

Medical Sociologist

Steven M. Mirin, M.D.

Acting General Director/Psychiatrist in Chief

Siew K. Teoh, M.D.

Clinical and Research Fellow

Nancy K. Mello, Ph.D.

Professor

326
Barbara W. Lex, Ph.D.

Associate Anthropologist

Alcohol and Drug Abuse Research Center

Harvard Medical School-McLean Hospital

115 Mill Street

Belmont, MA 02178

327
Opportunities for Enhancing Drug

Abuse Treatment With Criminal Justice

Authority

Carl G. Leukefeld

INTRODUCTION

Drug abuse treatment has a traditional relationship with the criminal justice

system (Maddux 1967, 1978). After briefly reviewing that relationship, this

chapter presents an overview of the high number of drug users who come into

contact with the criminal justice system and presents opportunities for

enhancing drug abuse treatment with criminal justice authority.

From one point of view, drug abuse treatment began in the United States with

two Public Health Service (PHS) farms–one at Lexington, Kentucky, in 1935

and the other at Fort Worth, Texas, in 1938. As drug abuse treatment matured,

these facilities were called PHS hospitals and, later, clinical research centers.

Treatment at these facilities was designed primarily for Federal prisoners, but

voluntary patients with no Federal court pressure could also receive treatment.

However, after withdrawal from drugs, most voluntary patients did not stay, and,

with no community followup, there was a high relapse rate (Pescor 1943;

Vaillant 1966).

With that high relapse rate and using the California and New York civil

commitment programs as models, Congress passed the Narcotic Addict

Rehabilitation Act (NARA; Public Law 89-793) in 1966 as a Federal civil

commitment program. NARA established court-ordered treatment initially at

Lexington and Fort Worth as an alternative to incarceration. NARA’s purpose

was to keep opiate addicts in treatment after detoxification and provide

community aftercare. NARA inpatient treatment facilities were also developed

in several cities and served as the foundation for community-based drug abuse

treatment (Leukefeld 1985). The NARA community “seed money” and NARAsponsored training for drug abuse counselors and professionals permitted a

foundation for local drug treatment expertise and established a close working

relationship between community criminal justice activities and health care.

328
When NARA title I (treatment in lieu of prosecution) and title Ill (treatment with

no formal charges), with no sentencing, were phased out as civil commitment

responsibilities of narcotic addicts by the PHS in the mid-1970s, the Lexington

and Fort Worth Clinical Research Centers were transferred to the Federal

Bureau of Prisons, and they are now Federal correctional facilities. It is

important to note that NARA titles I and Ill (no conviction) must be separated

from title II, which provides for the treatment of narcotic addicts convicted of

Federal crimes; before enactment of title II, this group was the responsibility of

the Department of Justice.

Another milestone in the area of linking drug abuse treatment with the criminal

justice system is Treatment Alternatives to Street Crime (TASC), which was

initially established by the Special Action Office for Drug Abuse Prevention in

1972. TASC can be described as a diversion program and as case

management and helps bridge the gap between the criminal justice system and

the drug abuse treatment system (Cook and Weinman 1988). TASC provides

identification, assessment, referral, case management, and monitoring services

for drug- and alcohol-dependent offenders accused or convicted of nonviolent

crimes (Bureau of Justice Assistance 1988).

Case management is used with other groups, including the elderly and in

mental health populations, as l . . . an approach to service delivery that attempts

to ensure that clients with complex, multiple problems and disabilities receive all

the services they need in a timely and appropriate fashion” (Rubin 1987, p.

212). TASC has implemented this case management approach in 128

communities (Beth Weinman, personal communication, August 6, 1989).

The use of court authority and coercion derived from the criminal justice system

has not been without controversy. In October 1977 Robert L. Du Pont, then

Director of the National Institute on Drug Abuse, presented a paper titled

“Operation Trip-Wire: A New Proposal Focused on Criminal Heroin Addicts” to

the Federal Bar Association Convention (Du Pont 1977). Using the findings of

McGlothlin and colleagues (1977). he proposed setting up a “tripwire” in the

form of urine testing that would identify daily heroin users who were on

probation and parole. If an addicted probationer or parolee did not stop his or

her daily drug use, the user would be referred to compulsory drug abuse

treatment; if treatment was refused or daily heroin use maintained, the addict

would be reincarcerated. Even though the proposal was changed to a research

study called Paroled Addicts in Treatment for Heroin (PATH), the study never

got under way because of the controversy. Criticism focused on three areas:

(1) the image problem created when a health agency proposed a mechanism

for behavioral control using the criminal justice system, (2) the violation of

probationers’ civil rights when tested, and (3) the inadequacy of the urine testing

technology (Leukefeld 1985). However, in spite of the controversy, practitioners

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and researchers interested in the relationship between drugs and crime

supported the PATH concept, not only because of their clinical experience but

also because of the large number of crimes committed by addicts (Ball et al.

1981; Nurco et al. 1986).

DRUG USE AND CRIMINAL JUSTICE

The criminal justice system has a large number of drug abusers. Both adults

and juveniles report that they are using drugs at the time of their arrest. This

high level of use is substantiated with early data from Eckerman and coworkers

(1971) who found, in a sample of arrestees from six major cities, that 49

percent were drug users and 64 percent had used drugs at some time. Another

early study (Barton 1976) reported that 30 percent of State correctional facility

inmates had used heroin before they were arrested, 21 percent had used it

daily, and 14 percent were using heroin daily at the time of their incarceration.

A 1975 State survey by the New York Department of Corrections found higher

rates, with 58 percent of State prison inmates reporting drug abuse before

incarceration (Joseph 1988).

Recent studies support these earlier findings. Data from 22 cities participating

in the Drug Use Forecasting (DUF) system indicate that about 60 percent of

arrestees were using drugs other than alcohol-confirmed with urine tests–at

the time of their arrest (National Institute of Justice 1988). In another study,

State prison inmates’ self-reports showed that 43 percent were using drugs

daily or almost daily in the month before their offense; 35 percent also said they

were under the influence of a drug at the time they committed their offense–up

from 32 percent in 1979 (Bureau of Justice Statistics 1987).

A survey of institutionalized juveniles in State-operated institutions (Bureau of

Justice Statistics 1988) details the drug abuse among youth. Sixty-three

percent used illegal drugs regularly (once a week or more for at least a month);

82 percent reported “any” illegal drug use; 46 percent reported cocaine use;

and almost 40 percent were under the influence of a drug at the time of their

offense. As expected, these juveniles used more drugs than did high school

seniors. For example, 81 percent of youth in custody reported that they had

used marijuana compared with 51 percent of high school seniors (National

Institute on Drug Abuse 1987). And 13 percent of institutionalized youth

reported that they had used heroin, while 1 percent of seniors reported use of

heroin.

On the other side of the coin, drug abusers in treatment are involved with the

criminal justice system. They are frequently on probation, parole, or mandatory

release. Early data from the Client Oriented Data Acquisition Process (CODAP)

330
revealed that 17 percent of clients who entered drug abuse treatment were on

probation, parole, or mandatory release (National Institute on Drug Abuse

1974). By 1982 CODAP reported a 4-percent increase of criminal justice

involvement for persons in drug abuse treatment to 27 percent for males and 15

percent for females (National Institute on Drug Abuse 1982).

OPPORTUNlTlES FOR ENHANCING DRUG ABUSE TREATMENT

In keeping with the overall purpose of this volume (which is to develop

recommendations for improving drug abuse treatment), the following

opportunities for improvement, using authority derived from the criminal justice

system, are presented for consideration and application by drug treatment

programs.

The Criminal Justice System Provides an Environment for ldentifying

Potential Drug Abuse Clients

As suggested by the previously cited studies and underscored by the recent

findings from the DUF system, there are a large number of adult drug abusers–

about 60 percent–and juvenile drug abusers–more than 60 percent–(Bureau

of Justice Statistics 1988) who come into contact with the criminal justice

system. From a system’s point of view, jails and lockups could serve as natural

entry points to provide early intervention, information, and drug abuse treatment

referral. More than 1 1/2 percent of the U.S. adult population (2.6 million adults)

were under correctional supervision in 1985, with more than 1.8 million persons

on probation (up 18 percent from 1983) more than 250,000 in jail (up 14

percent from 1983), more than 500,000 in prison (up 15 percent from 1983),

and more than 277,000 on parole (up 12 percent since 1985) (Bureau of Justice

Statistics 1988).

One example of an identification and referral program, called KEEP (Key

Extended Entry Process), was developed by Charles Laporte in New York City

(Joseph 1988). Patients recruited into KEEP at Rikers Island are voluntarily

maintained on methadone while in jail and are referred to methadone

maintenance programs for immediate outpatient treatment within 24 hours.

Early data indicate that 70 percent of the released KEEP inmates reported to

methadone programs when they were released.

Probation and Parole Can Enhance Behavioral Contingencies

Drug testing, treatment exposures, and incarceration as well as other court

sanctions can be used to keep drug abusers in treatment and reduce drug use.

Several studies support the importance of parole in reducing drug abuse

331
(Diskind and Klonsky 1964; Diskind 1967). Brill and Lieberman (1969) reported

that rational authority (i.e., involuntary rehabilitation of addicts with court

coercion) was the most important factor in the treatment of narcotic addiction.

McGlothlin and coworkers (1977) found that close supervision of parolees,

including urine testing, resulted in lower daily narcotic use and less criminal

activity than supervision without testing. However, the effectiveness of criminal

justice referral to drug abuse treatment is not consistent. For example, Stitzer

and McCaul (1987), after reviewing selected alcohol and other drug abuse

studies, suggested that the treatment studies they examined did not

demonstrate effectiveness. However, they added that community supervision

programs combined with substance use monitoring and possible incarceration

may reduce substance abuse.

Drug Abuse Treatment Programs Can Capitalize on Establishing a

Working Relationship With the Criminal Justice System To Enhance

Treatment

However, capitalizing on referrals to treatment from the criminal justice system

is not a simple matter. The dilemma is highlighted by Hubbard and colleagues

(1988) who reported, in a 3-year followup study, that less than 3 percent of

clients in outpatient methadone maintenance treatment were referred to

treatment by the criminal justice system compared with about 30 percent of

residential and outpatient drug-free clients. Thus, methadone maintenance

treatment, which appears to be the most effective drug abuse treatment

modality, is least used by the criminal justice system. Anglin (1988) reported

that methadone maintenance combined with civil commitment was a powerful

combination for decreasing drug abuse and enhancing positive behaviors.

Finally, probation and parole officers have considerable information about

individuals on their caseloads. This information can be useful for augmenting

treatment planning and carrying out drug abuse treatment.

Compulsory Treatment In the Form of Civil Commitment Can Reduce

Intravenous Drug Abuse but Should Not Be Considered a Panacea

Reporting on the results of the California Addict Program followup study, Anglin

(1988) maintains that parole should be used to monitor addicts against relapse

to addiction. After reviewing the followup studies from the PHS hospitals,

Maddux (1988) suggests that treatment with legal coercion, when combined

with compulsory community followup, produced better outcomes but not vastly

different from those for voluntary patients.

Civil commitment also has serious limitations (Maddux 1988), including the

following: It cannot overcome service deficits; coercion can bring a person into

332
treatment, but it cannot force participation; and civil commitment operates within

constitutional guarantees of civil liberties. Civil commitment is also

administratively cumbersome and expensive. If it is effectively implemented,

appropriate sanctions must be available, including incarceration.

Court Referral to Drug Abuse Treatment Generally Increases the Length of

Time Drug Abusers Remain In Treatment

Several studies-including Levine and Monroe (1964), McGlothlin and

colleagues (1977), Leukefeid (1978), and Collins and Allison (1983)–found that

patients involved with the criminal justice system remained in treatment longer

than those not involved with the criminal justice system. As previously

indicated, retention in treatment was a major force behind the enactment of the

NARA civil commitment legislation. However, the findings are not uniform for

prisoner addicts. For prisoner addicts committed under NARA title II, Friedman

and colleagues (1982) reported that NARA did not accomplish all that was

intended but may have contributed to reduced drug use. Englin (1986) found

that prison treatment followed by purchased community treatment did not

reduce drug use for prisoners civilly committed under NARA title II.

Linking Drug Abuse Treatment and the Criminal Justice System Can Help

Disrupt the Addiction Life Cycle and Decrease Drug Abuse

TASC serves as an example of an effective case management approach (Lazar

Institute 1976; System Sciences, Inc. 1978; Hubbard et al. 1988) that bridges

drug abuse treatment programs and the criminal justice system. TASC does

this by increasing communication as well as coordinating more effective drug

abuse treatment. For TASC clients, drug abuse treatment is used as an

alternative or supplement to criminal justice sanctions and procedures.

CONCLUSION

The use of compulsion, coercion, court authority, mandatory treatment, civil

commitment, and referral to drug abuse treatment has a tradition in the United

States. In general, although the literature is mixed, it seems that the use of

court authority and compulsory treatment should not be ignored by treatment

programs and treatment program staff. Perhaps, if more widely used, casemanaged care and coordinated care focused on the addiction career and

reducing the time spent using drugs could make drug abuse treatment more

effective in reducing drug abuse.

333
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Ball, J.C.; Rosen, L.; Flurck, J.A.; and Nurco, D.N. The criminality of heroin

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Barton, W.I. Drug Histories of Prisoners: Survey of Inmates of State Correction

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Brill, L., and Lieberman, L. Authority and Addiction. Boston: Little, Brown,

1969.

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Collins, J.J., and Allison, M. Legal coercion and retention in drug abuse

treatment. Hosp Community Psychiatry 34(120):1145-1149, 1983.

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Diskind, M. The role of the parole officer or the use of the authoritative

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Diskind, M., and Klonsky, G. New Approaches in the Treatment of Paroled

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Du Pont, R.C. “Operation Trip-Wire: A New Proposal Focused on Criminal

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Eckerman, W.C.; Bates, J.D.; Rachal, J.V.; and Poole, W.K. Drug Usage and

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Contract No. J-70-35). Washington, DC: U.S. Department of Justice, 1971.

Englin, J. The Impact of Federal Drug Aftercare Program. Washington, DC:

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Friedman, S.B.; Horvat, G.L.; and Levinson, R.B. The Narcotic Addict

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Print. Off., 1978. pp. 217-250.

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Maddux, J.F. Clinical experience with civil commitment. In: Leukefeld, C.G.,

and Tims, F.M., eds. Compulsory Treatment of Drug Abuse: Research and

Clinical Practice. National institute on Drug Abuse Research Monograph 86.

DHHS Pub. No. (ADM)88-1578. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1988. pp. 35-56.

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comparison by ethnic group and city of the criminal activities of narcotic

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170[Suppl]:1-18, 1943.

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Work. Vol. I. Silver Spring, MD: National Association of Social Workers,

1987. pp. 212-222.

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Handbook of Application, Research, and Concepts. New York: Plenum

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social and psychiatric characteristics. Arch Gen Psychiatry 15(6):599-609,

1966.

AUTHOR

Carl G. Leukefeld, D.S.W.

Director

Multidisciplinary Center on Drug and Alcohol Abuse

Department of Psychiatry

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University of Kentucky Medical Center

Room 210

800 Rose Street

Lexington, KY 40536

337
Contemporary Issues in Drug Abuse

Treatment Linkage With Self-Help

Groups

David N. NurCO, Philip Stephenson, and Thomas E. Hanlon

INTRODUCTION

The primary purpose of this chapter is to discuss the linkage between self-help,

as a viable aftercare modality, and methadone treatment. A particular focus is

placed on the relevance of self-help as a vehicle for (1) improving the quality

and effectiveness of treatment, (2) reducing the demand for drugs, and (3)

reducing the spread of acquired immunodeficiency syndrome (AIDS).

Because this chapter presents a general overview of self-help and related

issues, self-help as an aftercare modality is discussed in a broad conceptual

context. Specific experiences and research findings are alluded to, but not

presented as formal or documented results. This is partly due to a desire to

maintain consistency in the amount of material presented as well as the need to

adhere to the originally stated purpose of providing a vehicle to stimulate

thought rather than present research findings.

SELF-HELP AND HEALTH CARE SYSTEMS

The past 25 years have witnessed increased interest in self-help as an adjunct

to formal health care services. This has been the result of several factors.

Traditionally, self-help has represented a “grassroots” response to perceived

failure in health care delivery and a natural inclination of those affected by an

ailment to band together for mutual support. Health care providers often are

perceived as insensitive or as having inadequate resources to effectively treat

certain disorders, which has compelled those afflicted to seek alternative forms

of treatment.

The gulf that sometimes separates patients and clinicians is exemplified by the

current AIDS epidemic. AIDS patients frequently find themselves in conflict with

the medical community and, consequently, seek independent means of dealing

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with the disorder because already overburdened health services personnel

have neither the time nor the resources to adequately inform patients about the

progression and consequences of AIDS. Applied within this context, self-help

procedures permit those afflicted to share experiences, information, and

resources. This mutual assistance is not only informative and educational but

also provides a means by which participants can better understand and come to

terms with their circumstances. Self-help group support has been particularly

effective in relieving the isolation and stigmatization that accompany AIDS.

As spontaneously evolving grassroots organizations demonstrated the capacity

to provide effective and responsible services, health care systems took notice

and eventually began to use them as a referral resource. Service delivery at

times has been changed to reflect innovations introduced by self-help

organizations.

The impact of self-help groups on service delivery is perhaps best exemplified

by the experience of Alcoholics Anonymous (AA). The basic precepts

embodied in the 12 steps and 12 traditions of AA have been incorporated

(either partially or intact) into the regimen of many professionally sponsored

alcoholism treatment programs. AA also is used widely as an aftercare referral

for discharged clients. (It might well be argued that AA is the primary treatment

modality for those who seek its fellowship, even when imbedded in a

professionally sponsored treatment program.) Senior members of AA, with

proven abstinence, also have been hired as professional service providers

within alcoholism treatment programs. Moreover, AA’s demonstrated

effectiveness has spawned a range of “anonymous” groups such as Overeaters

Anonymous, Gamblers Anonymous, and Narcotics Anonymous (NA), all using

AA’s steps and traditions.

A second impetus to the growth of self-help as an accepted intervention is

found in the changing pattern of health care problems. Gartner and Riessman

note, “. . . the major health problems are not those of acute illness, in which the

doctor plays a crucial, curative role, but rather those of chronic illness, in which

the patient plays the strategic role” (Gartner and Riessman 1977). Self-help

has emerged in response to the needs of those with chronic health problems

(e.g., diabetes, heart disease, arthritis, and now AIDS) as well as those

recovering from or coping with long-term disorders (e.g., stroke, cancer, and

heart attack). Here, self-help provides information and support to facilitate

recovery, understand the consequences of the disorder, and better manage

illness-related problems over time.

These factors have contributed to a rapid increase in the number of self-help

groups in recent decades, along with the development of widespread interest in

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professionally sponsored self-help groups as a complementary process. This

has been evidenced not only in the health care arena but also in the broader

realm of human services and in what Saragin (1969) described as “societies of

deviants.”

SELF-HELP IN ADDICTIONS

In the field of narcotic addiction (i.e., addictions to opium and its derivatives and

synthetics), there also has been considerable interest in self-help. Yet, the

employment of self-help procedures has not kept pace with other segments of

the health care system.

There are major exceptions. The therapeutic community (TC) movement is

strongly immersed in the self-help tradition, although it has gone far beyond the

self-help concept (Nurco et al. 1986). Furthermore, the contributions of NA and

Cocaine Anonymous have been significant. Currently, NA is the largest selfhelp group available to drug abusers (Ashery 1979; Peyrot 1985).

Although these self-help initiatives are significant, methadone maintenance

remains the primary treatment modality sought by narcotic addicts. Attitudes

generally associated with this type of treatment among both methadone

maintenance staff and clients have serious implications with regard to the

utilization of self-help concepts. Methadone treatment evolved from a ‘medical”

model and, consequently, does not share the grassroots and self-help tradition

of TCs. In fact, the two modalities are at considerable variance in their basic

approach to treatment. In very general terms, the object of methadone is to

enable the addict to control addiction by chemically reducing the craving/need

for illicit narcotics and, thus, allow him or her to assume a more adaptive and

productive lifestyle. On the other hand, TCs aim at a basic reorientation of the

individual and operate by removing the addict from the community until such

time as the addictive behavior has been replaced with more socially acceptable

and adaptive skills. Whereas individual counseling is an integral aspect of

methadone maintenance, group intervention techniques traditionally have been

associated with the TC approach, as its name implies.

It would appear that NA’s fellowship, steps, and traditions have much to offer

methadone clients. Unfortunately, it has been our experience that methadone

clients often feel out of place when attending NA meetings. Also, the

methadone programs with which we have worked have been unsuccessful in

attempts at sponsoring NA meetings within their clinics (Nurco et al., in press),

which is largely due to the philosophy of total abstinence espoused by NA.

Methadone clients who attend NA meetings are inclined to hide their chemically

dependent status, thereby creating an atmosphere of deception. This is not to

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say that methadone dients have not participated in and actually benefited from

NA. To the contrary, there are probably numerous examples of methadone

clients—particularly those receiving either short-term maintenance or

detoxification services—successfully engaging the fellowship of NA. Likewise,

there are, no doubt, examples of methadone programs having successfully

sponsored NA groups. By and large, however, methadone clients and

programs have been unable to resolve the conflict between the maintenance of

a methadone status—especially over the long term—and NA’s avowed stance

with regard to the requirement of total abstinence.

Despite only limited documented attempts to adapt self-help concepts to the

treatment of narcotic addiction, it should be readily evident that self-help has

much to offer. Self-help concepts appear to be particularly relevant for longterm, stabilized, methadone clients who no longer require intensive primary

care. For these clients, self-help offers a “common sense” approach to

providing aftercare services. There are some compelling and practical reasons

for this.

Methadone treatment services currently are operating in a crisis state. Faced

with ever-increasing demands, most programs are understaffed and

underfunded. As a consequence, there has been an erosion in the quality of

services offered. The concurrent epidemics of cocaine abuse and AIDS are two

major events that have contributed substantially to the increased demand for

methadone services. Cocaine abuse is widespread in many communities and

has had an impact on otherwise stable methadone clients. Programs we work

with in the northeastern section of the Nation report positive urinalysis results in

excess of 40 percent, most of which are for cocaine. At the same time,

methadone programs are on the front line of the AIDS epidemic, which

especially has affected the intravenous (IV) drug-using population.

IV drug use is the second most common risk behavior associated with AIDS in

the United States; in the Northeast, the AIDS epidemic has reached crisis

proportions within the IV drug-using population. Even those who have ceased

their narcotic abuse remain at risk. Des Jarlais and Friedman (1988) have

reported that the States of New York, New Jersey, and Connecticut account for

approximately three-fourths of the AIDS cases in the United States in which IV

drug use is the primary risk factor. Furthermore, their studies show

seroprevalence rates of 50 percent or higher among IV drug users in these

states.

Throughout the Nation, methadone programs have been asked to provide

additional treatment slots to reduce IV drug use and thereby reduce the risk of

HIV infection. Additionally, methadone treatment staffs have been requested to

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provide information and counseling to clients seeking to reduce risk behavior, to

address the concerns of those who fear they might be infected, and to respond

to the specialized needs of those who are seropositive or have become

symptomatic with AIDS. Yet, the funding of the additional positions required to

carry out these responsibilities has not always kept pace with the demands for

service.

The cocaine- and AIDS-generated demands on methadone treatment are in

addition to those associated with secondary substance abuse (methadone

programs are confronted with high rates of alcohol abuse and abuse of

tranquilizers) and with client psychopathology, program dependence, and

complex interpersonal and social needs (e.g., family, employment, education,

and housing).

Given the increased demands for service, self-help procedures have much to

offer methadone programs. As previously noted, self-help concepts offer a

common sense approach to providing aftercare services for long-term,

stabilized clients who no longer require intensive, one-to-one, primary care.

Utilization of self-help concepts would enable such clients to assume more

responsibility for their own care and treatment, thus freeing staff to devote

greater resources to clients who are in more acute need. Self-help also offers a

vehicle by which aftercare services can complement primary care, thereby

reducing client dependency on the program. An added feature is that a

successful self-help venture has the potential for generating a positive client

constituency whose activities would tend to counter the generally negative

assessment that the surrounding community has of methadone programs.

Successfully engaged individuals also would serve as role models for insecure

or less advanced clients. Leaders in the groups could even be brought into the

treatment process, serving as cotherapists with trained staff to run groups or to

assist with outreach and referral services.

THE SELF-HELP EXPERIENCE

We at the Social Research Center in Baltimore have developed an experimental

self-help model, clinically guided self-help (CGSH), with specific applicability for

long-term, stabilized methadone clients. We have described CGSH in several

publications (Nurco et al. 1983). Although fieldwork concerned with its

evaluation will not be concluded until 1991, experiences to date strongly

suggest that this model is a viable and cost-effective adjunct to primary

treatment.

We have five operational self-help groups and are in the final stages of

implementing four additional groups. Groups are small, consisting of 5 to 12

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members. Several groups have experienced little attrition, whereas several

others have experienced rapid turnover. Attrition appears to correlate directly

with the degree of program and staff support for the self-help concept as well as

with the general attrition rate of the program as a whole. On the basis of

process evidence to date, the groups have supported our original expectation

that self-help would provide stabilized clients with a positive peer support

network; constructive, nondrug-oriented social and recreational activities; a

means of reinforcing the growth achieved by primary treatment; and an

opportunity to engage in outreach and advocacy projects to help others. In

determining the risk-benefit of the procedure, preliminary assessment suggests

that those participating in the self-help process have a lower rate of relapse, as

reflected by urinalysis testing, and have greater retention in treatment than their

controls. Risks, which primarily involve confidentiality, are minimal and easily

addressed.

The CGSH model is founded in the self-help tradition. Participation is voluntary

and draws on clients’ motivation to assume greater responsibility and control of

their lives. It stems from the humanistic social work tradition in that it promotes

a nurturing and nonjudgmental environment and draws on the abilities of clients

themselves to recognize and act on their needs. CGSH is clinically based in

that it is initially dependent on program staff to facilitate the process and

ultimately to lead the group to self-sufficiency.

CGSH offers clients the opportunity to develop individual purposes and goals

and places responsibility for this development, along with the subsequent

attainment of objectives, largely in their hands. Staff members provide the

information and skills-training necessary to enable clients to run their groups

and maintain responsibility for determining basic standards for group behavior

(i.e., only one person speaks at a time, what is said within the group stays

there, no aggressive or assaultive behavior is permitted). Staff members also

assist in establishing basic criteria for belonging to the group and foster the

recognition that success in treatment–especially sustained abstinence from

illicit drugs–is an essential characteristic that should be the hallmark of

membership in the self-help group. Over time, staff members may disengage

from the group and serve only in an advisory or liaison capacity, which is in

marked contrast to traditional forms of group therapy, in which program staff

predetermine treatment techniques and objectives.

Experiences with our version of self-help generally have been positive. We

have found that even long-term, stabilized clients are willing to voluntarily

participate in the approach. From these clients, we have learned that even

those who are self-motivated and stable in treatment–a few for a decade or

longer–present needs that can be effectively addressed by a self-help,

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aftercare modality. For some, this may be nothing more than the fellowship

offered by a peer support group; for others, it may be the opportunity to

participate in social and recreational activities and to engage in leisure activities

without drugs. Some experience self-help as an opportunity to acquire or refine

life skills, whereas others engage in community outreach projects.

We have found that participants are especially interested in acquiring or refining

life skills. Many methadone programs measure treatment success solely in

terms of abstinence from illicit narcotic drugs, employment, and family

relationships. Little opportunity exists to focus on other issues that might enable

the former addict to live a more self-sufficient and fulfilling lifestyle. With

respect to this general area of concern, group time is devoted to discussion of a

variety of specific issues and topics. These include the following: relationships

with spouses, children, siblings, and/or parents; handling work-related stress;

how to handle job interviews and improve one’s employment opportunities;

following through on commitments and obligations (e.g., taking care of aging

parents or returning to school); ongoing conflict with local police; budgeting and

financial problems; lingering self-doubt associated with their perceived stigma

as addicts; concerns about the long-term consequences of methadone

maintenance and conflicts arising from their methadone status; guilt

surrounding their previous misdeeds toward family and community; how to say

“no” when confronted with drugs in the home, community, or workplace; and

fear of relapse.

Care is taken to ensure that group time is not wasted on “war stories” or

complaints about the clinic. It is equally important that groups not be used as

therapy groups to address issues that are more appropriately the target of

primary treatment. It was and remains our position that self-help groups should

not replace primary treatment and should not become psychotherapy/social

work groups. At times, the group developmental process has been slowed by

clients who have attempted to use the self-help group as a psychotherapeutic

regimen and the group facilitator as a therapist. Such inappropriate demands

have been counterproductive and have thwarted the development of group

cohesiveness and sense of purpose. Where this has happened, it appears to

have been a product of poor client selection and, at least partially, a reflection

on the lack of therapeutic services within specific clinics. The most salient

issues expressed by clients seeking therapeutic intervention have centered on

their depression, dependency, anomie, and/or poor self-esteem. Such clients

present an inordinate demand on the time and resources of staff and other

group members that was not envisioned in the approach and that should not be

part of the focus of a self-help group.

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POLICY AND ADMINISTRATIVE ISSUES

In spite of its potential benefits, implementation of self-help within methadone

maintenance programs is not without its difficulties. Because many of the

proposed benefits are long range, it is difficult for programs to identify and

allocate the resources to implement a self-help approach. Program

administrators fear that such an endeavor will interfere with normal program

operations and further disrupt already strained services. Concern also has

been expressed that State and Federal funding might be reduced for those

clients in self-help who no longer receive intensive primary care or that

treatment slots might be further increased without a corresponding increase in

funding. In addition, program administrators have expressed logistical concerns

that need to be addressed before self-help procedures can be implemented.

Some programs lack adequate space and accommodations for group meetings;

many are located in neighborhoods that are not conducive to evening meetings;

and some lack convenient public transportation. Also, security concerns

confound the process of scheduling meetings during other than regular clinic

hours.

Line staffs are equally hesitant about a self-help approach. Counselors and

social workers view the endeavor as an unwarranted intrusion on their already

difficult workload, and because self-help is directed at those clients who are

least demanding and problematic in treatment, staff members are reluctant to

relinquish these clients. Often, staff members express the belief that clients will

not be receptive to CGSH and cite other group failures as evidence. They are

also quick to declare that the segment of the treatment population targeted for

self-help will not return to the clinic for the required meetings because this

would conflict with employment and family commitments.

Clients, like staff, have been hesitant to become involved with self-help. When

queried about participation, clients have raised a variety of issues. Concerns

have been expressed about the added time and travel required to return to the

program for group meetings; the motives of the researchers, other participating

clients, and/or the program; potential conflicts with other responsibilities (e.g.,

work, family, or school); the negative (i.e., punitive) connotation of group

placement within methadone programs because this generally is prescribed for

clients with specific problems (e.g., cocaine or alcohol abuse, marital,

employment, and so forth); their fear that self-help might be a mechanism to

force them to detoxify; and their own impression that they are not doing as well

as others and do not deserve to be in the self-help group.

By meeting with candidates individually, we generally have been able to

respond to their fears and concerns. Often, they are resolved by taking the time

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to correct any misunderstanding the clients have about the purpose and goals

of self-help and any false impressions they might have about participation

requirements (e.g., forced detoxification). We have found that once they are

furnished accurate and concise information about the self-help process, the

majority of the clients have agreed to participate. Few clients have rejected our

efforts to meet with them or have otherwise become uncooperative or hostile.

In our own recruitment to date, 50 percent of the eligible clients have agreed to

participate. This figure has far exceeded the expectations of program staff, who

believed favorable response to recruitment would be minimal. It is the interest

of the clients that often provides the impetus to overcome administrative and

staff reluctance.

BENCHMARKS/CONCLUSIONS

Self-help procedures offer overburdened methadone programs a way of

providing aftercare services for long-term stabilized clients who no longer

require intensive primary care services and for whom a regimen of regular

doses of methadone is the only necessary prescriptive treatment. Application of

self-help procedures to this segment of the treatment population would permit

the programs to devote greater time and resources to other clients, who have

not as yet acquired the motivation and/or skills to curb their addictive behavior.

In the long term, self-help concepts afford methadone programs a strategy for

expanding treatment services into the realm of aftercare. Expansion and

intensification of treatment services would permit programs to more effectively

reduce the demand for drugs and thereby reduce the risk of client exposure to

AIDS.

Clearly, however, implementation of self-help concepts must be carefully

planned and coordinated. The intervention must be tailored to reflect the

specific circumstances of each program, taking into account the expectations of

both staff and clients. Despite the fact that adjustments will be made in

response to individual program requirements, several key policy-related

considerations should be recognized to ensure successful implementation of

self-help procedures:

1. Self-help is not for everyone. Only those self-motivated clients with

demonstrated stability should be recruited. Clients who still require primary

care (e.g., those with ongoing substance abuse or psychopathology) are

not suitable candidates.

2. Self-help is not a substitute for primary care. It is intended more for

ancillary treatment and for aftercare. In this way, it complements primary

care.

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3.

4.

5.

Implementation of self-help procedures requires staff involvement and

commitment as well as some clinic resources (e.g., moderators and

meeting area). Unfortunately, the benefits of the approach are not

immediately obvious to program personnel.

Self-help procedures necessitate that clients voluntarily attend meetings

onsite more often. This is contrary to the reinforcement policy in many

methadone programs that rewards adherence to rules by reducing

reporting requirements (i.e., granting take-home privileges).

Because methadone maintenance program group sessions generally are

prescribed only for those clients who are problematic, a negative impact on

self-help recruitment is likely.

REFERENCES

Ashery, R.S. Self-help groups serving drug users. In: Brown, B., ed. Addicts

and Aftercare. Beverly Hills: Sage, 1979. pp. 135-154.

Des Jarlais, D.C., and Friedman, S.R. HIV infection among persons who inject

illicit drugs: Problems and prospects. J AlDS 3(1):267-273, 1988.

Gartner, A., and Riessman, F. Self-Help in the Human Services. San

Francisco: Jossey-Bass Publishers, 1977. p. 69.

Nurco, D.N.; Stephenson, P.E.; and Hanlon, T.E. Aftercare/relapse prevention

and the self-help movement. Int J Addict, in press.

Nurco, D.N.; Wegner, N.; Stephenson, P.; Makofsky, A.; and Shaffer, J.W. ExAddicts’ Self-Help Groups: Potentials and Pitfalls. New York: Praeger,

1983. p. 15.

Peyrot, M. Narcotics Anonymous: Its history, structure, and approach. Int J

Addict 20(10):1509-1522, 1985.

Saragin, E. Odd Man In: Societies of Deviants in America. New York:

Quadrangle Books, 1969.

ACKNOWLEDGMENT

This research was supported by National Institute on Drug Abuse grant DA03925 and was administered by Friends Medical Science Research Center, Inc.

AUTHORS

David N. Nurco, D.S.W.

Research Professor

347
Thomas E. Hanlon, Ph.D.

Research Associate Professor

Department of Psychiatry

University of Maryland

School of Medicine

Philip Stephenson

Research Associate

Friends Medical Science Research Center, Inc.

1229 West Mount Royal Avenue

Baltimore, MD 21217

348
Primary Care and Intravenous Drug

Abuse Treatment

Richard J. Russo

What is primary care?

Why primary care in drug treatment?

Does not drug treatment have enough to do without adding this new service?

Will primary care break the back of the drug treatment system?

This chapter touches on these and other issues of primary care in drug abuse

treatment, but it does not supply answers–only insights into the issues.

Primary care is coordinated, comprehensive, and personal care, available on

both a first-contact and a continual basis. It incorporates several tasks:

medical diagnosis and treatment, psychological assessment and management,

personal support, communication of information about illness, prevention, and

health maintenance.

The clinical problems encountered by primary care physicians include

responsibilities and tasks beyond the narrow technological confines of medical

diagnosis and treatment. Although great effort must be focused on accurate

diagnosis and technically sound therapy, the other clinical tasks that complete

the definition of primary care also assume major importance.

Alongside this clinical definition of primary care stands a plethora of other

definitions. For example, policy planners have defined primary care as a level

of medical services, one that is provided outside the hospital. Presumably,

primary care (community-based services) is a less technical practice compared

with secondary care (consultant or specialty services) and tertiary care (hospital

services).

From the standpoint of professionalism, primary care has been defined as a

specialty concentrating on humanistic medicine practiced outside the hospital

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but devoid of the special procedures and technology that typically characterize

medical specialization. From the university comes another definition of primary

care as an academic discipline concerned with the expansion of knowledge

unique to primary practice and to personal care, a definition that contains the

promise of a departmental position for primary care in the medical school.

Although each of these definitions presents a particular perspective of the

doctors practice, primary care can be defined by several tasks: (1) medical

diagnosis and treatment; (2) psychological diagnosis and treatment; (3)

personal support of patients of all backgrounds in all stages of illness; (4)

communication of information about diagnosis, treatment, prevention, and

prognosis; (5) maintenance of patients with chronic illness; and (6) prevention of

disability and disease through detection, education, persuasion, and preventive

treatment. These tasks comprise the clinical work of doctors providing primary

care.

Drug dependence often compels people to take drugs in spite of severe legal

penalties and threats to their health and is a chronic medical disorder, not a

temporary condition. Thus, it is more similar to other chronic medical diseases,

such as diabetes, hypertension, and emphysema, than to acute conditions that

respond rapidly to treatment.

Intravenous (IV) drug abuse has been identified as a major vector for the

spread of the human immunodeficiency virus (HIV). Twenty-seven percent of

all adult cases of acquired immunodeficiency syndrome (AIDS) report IV drug

use. Among IV drug abusers (IVDAs), HIV infection is spread primarily by

needle-sharing, a pervasive practice of IV drug abuse that fulfills both practical

and social functions. HIV also can be transmitted between IVDAs and others,

either sexually or perinatally. HIV contracted through IV drug abuse has been

particularly devastating to minority populations.

Successfully combating HIV requires curbing the spread of the virus among

IVDAs, their sexual partners, and their families. Treatment of the IVDA

presents many challenges, from the entrenched behavior of needle-sharing and

multiple drug use to economic, geographic, cultural, and ethnic factors.

Medical complications for drug abusers, in addition to infectious diseases such

as HIV, tuberculosis (TB), and sexually transmitted diseases, include bacterial

endocarditis, which is life threatening. Heart valve replacement with

subsequent intensive care is usually necessary for patient survival, but the

problem is not as easily managed as it once was, due to changes over time in

the type of organisms infecting IVDAs. Other serious infectious complications

350
include skin and subcutaneous infections, osteomyelitis, and viral hepatitis

types B and non-A, non-B.

Noninfectious complications in IVDAs are generally due to organ insult

secondary to injection of foreign material. These include renal failure and

attendant amyloidosis, chronic interstitial lung disease, hematologic problems

related to vascular damage that can involve aneurysms and false aneurysms,

anemia, and thrombocytopenia. Heart failure, secondary to valve damage, also

can occur. Cardiomyopathy and chronic liver diseases are frequent

complications among alcoholics. Embolic phenomena, secondary to vascular

disease, may lead to thrombophlebitis. Malnutrition is common in substance

abusers and increases their risk of infections. Cocaine abusers may develop

sudden, unpredictable, life-threatening cardiac arrhythmias as well as damage

to the nasal septum and mucosa that require a variety of medical interventions.

Acute psychiatric complications also are seen with cocaine, amphetamines,

alcohol, and psychedelics. Medical care providers perceive this population as

presenting special problems: lack of compliance with medical regimens,

inability to keep scheduled appointments, lack of transportation and child care,

homelessness, and poor coping skills. These patients often have feelings of

stigmatization and, therefore, frequently display hostility, which makes receiving

adequate care in the existing medical system virtually impossible and taxes the

emergency rooms of area hospitals.

Dually diagnosed drug abusers, who may be suffering from major psychiatric

disorders as well as the concomitant severe depression that is present in as

much as 70 percent of all drug treatment clients, are rarely the recipients of an

integrated care program designed to deal with both problems together. Current

treatment programs do not offer any of the specialized, short-term, talking

therapies that can be valuable for focused anxieties, stress, affective or

attention-related disorders, and suicidal ideation. Chemotherapeutic

approaches to joint drug dependency and mental health problems have been

neglected, as have innovative uses of family dynamics in facilitating behavior

change.

The spectrum of care required by HIV-infected IVDAs ranges from

hospitalization in acute care facilities through nursing home care to various

forms of ambulatory care. The latter includes primary care, medical outpatient

specialties, personal care services, home and hospice care, and community

services. These services must be coordinated effectively if they are to be

delivered in such a way as to improve quality of life. Coordination of these

services presents a particular challenge in an AIDS population, where cases

have been historically concentrated in the racial and ethnic minority groups in

which IV drug use is most widespread. In addition, because of sexual

351
transmission of HIV from drug users, a disproportionate number of women and

infants have AIDS or AIDS-related complex (ARC).

Because of the illegality of their activity, most IVDAs lead marginal existences

and rarely seek medical services. Those with AIDS usually first come to the

attention of medical professionals in hospital emergency departments relatively

late in the course of the illness. Therefore, they have more severe medical

complications and shorter lifespans than other AIDS patients.

The emerging continuum of care for persons with HIV infection is a necessary

step toward the provision of humane and accessible care. National and private

reports and demonstration projects have pursued a model of patient care

comprising appropriate inpatient services for those most acutely ill and

comprehensive outpatient care in hospitals and community-based agencies.

The guiding principle of this model has been that health services should be

delivered, if clinically appropriate, in community-based agencies.

A primary care medical unit would consist of physicians with expertise in

substance abuse, infectious diseases, general adult and pediatric medicine,

and obstetrics and gynecology. Nurse practitioners and nurses are also a

necessary component. The medical unit would provide initial medical

assessments and acute and ongoing primary medical care for patients and their

families. Practitioners would work in close liaison with outside medical

treatment providers. Physicians would prescribe appropriate medications;

nursing staff, in conjunction with case management staff, should provide

supervision over compliance for all medications, including those prescribed by

outside or consulting treatment providers, (e.g., AZT, medications for TB).

Counseling and testing for HIV antibody should be routine in all drug treatment

programs.

The primary care medical unit would function somewhat as a health

maintenance organization for substance abusers and their families. Each client

(or family member) accepted into the program would be assigned a primary

care physician who would perform a thorough intake and an annual physical

examination and provide primary care. Along with other health professionals in

the unit, primary care physicians also would treat the physical complications of

substance abuse, coordinate specialist care, determine whether drug

interactions might be harmful, and assist specialists with compliance with their

treatment recommendations. This unit would provide the referral physician for

those clients tested at admission and found to be seropositive for HIV. The

medical unit would take major responsibility for determining whether the client’s

family or significant others might be at risk for HIV or other infection and would

encourage the client to bring family members into the program, or the unit staff

could arrange for an appointment.

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A mental health services unit would provide psychiatric and psychological

services when indicated, including prescriptions for psychotropic medications

and ongoing psychotherapy services (individual, family, and group).

Patients with major psychoses, schizophrenia, or manic-depressive psychosis

who require psychiatric hospitalization should be referred; however, a small

proportion of drug abusers have an underlying affective disorder that might be

managed with psychotropics, allowing the client to participate in other

ambulatory substance abuse treatment programs. In conventional drug-free

outpatient care, this approach generally would not be employed by a single

provider. Patients whose mental health problems consisted solely of AIDS

dementia or psychiatric symptoms related to substance abuse should be cared

for by the program.

Psychological services to be offered to clients and/or family members could

include testing for early signs of neurologic impairment due to HIV infection,

short-term behavior therapies such as cognitive therapy that have been shown

to be effective with depressed drug abusers in treatment, stress management

for those suffering from anxiety reactions to information regarding their HIV

status, parenting skills for parents of juvenile or adolescent substance abusers,

and assertiveness training to assist female sex partners of HIV-infected drug

abusers in resisting pressures to engage in unsafe sex practices.

Family therapy and counseling for the identified population should place great

emphasis on treating the primary drug abuser conjointly with these significant

others. Its aim would be to intervene in the negative and destructive patterns of

all group members to destroy addiction-maintaining behaviors and substitute

positive, abstinence-maintaining ones.

Adequate care for persons with HIV infection requires the development of an

integrated, managed network providing a continuum of care and services for

patients and for their families and children. This should be the overall goal of a

primary care medical unit.

The continuum of care concept for persons with HIV infection is indispensable

to the provision of comprehensive, humane, and accessible care. National and

private reports and demonstration projects have pursued a model of patient

care comprising appropriate inpatient services for those most acutely ill and

comprehensive outpatient care in drug treatment agencies. The guiding

principle of this model has been that health services should be delivered to the

extent possible and clinically appropriate through a case-managed system of

care.

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The United States has seen a rapid increase in HIV caseloads at many innercity hospital-based and freestanding outpatient clinics. There are several

reasons for this, each of which will continue to contribute to this upward spiral:

high rates of infection among high-risk groups in inner-city areas, the demand

for increased counseling and testing resources in many health care settings, the

changing clinical nature of HIV disease progression to a more chronic pattern

demanding aggressive and continuous ambulatory care, and the relative lack of

private physician resources to render primary health care.

Recent Federal Centers for Disease Control recommendations for widespread

HIV testing and subsequent CD4 testing of all HIV-positive individuals every 6

months, and for prophylaxis of those with specified cell counts, offer an exciting

and challenging opportunity for drug treatment primary care units. The Public

Health Service recommends that–unless contraindications exist–physicians

should initiate prophylaxis against phencyclidine (PCP) for any HIV-infected

adult patient who has already had an episode of PCP, even if the patient has

been receiving AZT. Unless contraindicated, prophylaxis also should be

initiated for HIV-infected patients who have never had an episode of PCP if their

CD4+ cell count is < 200/mm3 or if their CD4+ cells are < 20% of total

lymphocytes. Patients with CD4+ cell counts of < 100/mm3 or CD4+ cells

< 10% and patients with oral thrush or persistent fever (temperature of > 100°F)

are at particularly high risk. From a prevention perspective, drug treatment

units can have contact on a regular and repeated basis with asymptomatic HIVinfected people–while they are most likely to spread their infection. From a

therapeutic perspective, there is now a standardized approach to the detection

of early HIV-related disease and the prospect of extending the life and

prolonging the onset of acute symptoms among infected persons.

A recent Federal study indicates that AZT not only can be crucial for those

suffering from AIDS but also can help delay the onset of the deadly disease.

AZT may become the drug of choice for all HIV-infected people with a T-cell

count between 200 and 400.

Every drug treatment unit should develop a program plan for implementation of

this primary care, prophylaxis initiative, which signifies the first step toward a

chronic care HIV disease model with significant opportunities for intensive

clinical intervention and behavior modification. Until recently, the major focus of

effort had been on epidemiology, clinical research, and preventive education.

This new public health initiative compares with previous historical public health

campaigns to control tuberculosis, cholera, and typhoid.

Clinically, although there may be life-threatening crises, most persons with

AIDS are chronically affected with a slow relentless decline in level of

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functioning reminiscent of such familiar chronic diseases as certain cancers and

cardiovascular disease. The neurologic manifestations of HIV infection are now

acknowledged to be a frequent and important aspect of the AIDS epidemic.

Patients may require a low level of supportive care with medical monitoring for

substantial periods before they progress to life-threatening disease. This has

significance for ambulatory/primary care strategies with respect to the epidemic.

Due to the nature of the IVDA/AIDS population and the resultant stresses of

poverty and discrimination, the majority of affected persons are without primary

health care. Experience suggests that drug treatment centers can serve as

major providers of AIDS services for infected IVDAs, and some centers are

accepting more responsibility as AIDS primary care centers.

The ambulatory care needs of chemically dependent persons infected with HIV

can be enormously varied. Stages of the clinical spectrum of AIDS will affect

the patients attitude toward and ability to respond to substance abuse

treatment, both physically and motivationally. Some IVDA/AIDS patients are

symptomatic and require residential treatment with medical services; some are

symptomatic but only minimally debilitated and can be treated for their

addictions with ongoing medical monitoring for their AIDS or ARC diagnoses.

Asymptomatic HIV-infected persons can be treated in inpatient or outpatient

chemical dependency programs or detoxification units, but they should be

followed and counseled on an ongoing basis. It is apparent that services for

both AIDS and substance abuse should be provided simultaneously in a

coordinated manner in drug treatment units.

Drug abuse treatment and primary health care are historically two separate

systems of care that, without serious collaboration, negatively affect service

provision for drug users with AIDS. There is thus a strong role for case

management for this population to help integrate the two systems on behalf of

the client.

Case management and primary care coordination for IVDAs with AIDS will help

address major issues of importance to the substance abuse treatment system,

including:

Identification of a broader range of health and social service needs than

may be otherwise apparent

Health care personnel who do not understand the substance abuse

treatment system and thus provide medical treatment that does not

consider a person’s substance abuse problem

355
Homelessness

Patient compliance with medical visits

Black market for AIDS therapeutics

Lack of community/political support for services

Lack of volunteer networks (which addicts may not want to use even if they

did exist)

Coordination of home-based services-methadone home delivery and

home health care

Dependence on public entitlements for services

Realization that AIDS represents a disease of the family (where there is

one) and that services may need to evolve that are family focused

An anticipated benefit of pursuing a case management function through

substance abuse treatment centers is that, out of necessity, these centers

would become an active participant in an emerging continuum of care. This

would propel the drug treatment primary care unit into a highly respected

partner in the continuum of care health care delivery system.

An effective continuum of care network for those HIV-infected or those with

AIDS should be centrally accessible. Because of the geographic distribution of

AIDS cases, many areas of the country are hard pressed to deal with current

caseloads of symptomatic persons. Outpatient clinic care is already overloaded

and is nonexistent in some areas. Drug treatment programs’ average

enrollments far exceed their capacity. Systems that were strained even before

the advent of AIDS are near collapse due to the epidemic. Serious health care

personnel shortages exist, as do barriers in the ability of HIV-infected drug

users to obtain access to primary health care services. Unfortunately, the

current lack of outpatient services only feeds the more costly inpatient system,

further burdening individual institutions and public systems that pay for the

majority of such care, much of which is unnecessary.

We must work with clinical care providers to develop a practical, short-term plan

that will address the availability of comprehensive HIV outpatient clinic/

ambulatory care and include the appropriate management and organizational

elements at both State and local levels. One of the most important components

of this plan is to develop strong linkages with drug treatment systems.

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In conclusion, States should develop and implement a program plan for a

primary care component in our drug treatment system. This primary care

component will be the first step toward a chronic care HIV disease model with

significant opportunities for intensive clinical intervention, HIV prophylaxis

initiatives, and behavior modification. We in drug treatment must seize the

opportunity to develop the necessary linkages and creative methodologies to

provide enhanced access to primary care for HIV-infected substance abusers

and, thus, build on the existing drug treatment national network.

If we in drug treatment can integrate primary care services into the system, we

not only will “improve our treatment effectiveness” but also will “save lives.”

AUTHOR

Richard J. Russo, M.S.P.H.

Acting Assistant Commissioner

Division of Alcoholism and Drug Abuse

New Jersey State Department of Health

129 East Hanover Street, CN362

Trenton, NJ 08625

357
Establishing a Methadone Quality

Assurance System: Rationale and

Objectives

James R. Cooper

The National Institute on Drug Abuse (NIDA) and the Food and Drug

Administration (FDA) recently announced plans to study the feasibility of

establishing a methadone maintenance quality assurance system to monitor

methadone programs (Federal Register 1989). The motivation for such a study

is the growing concern about the existing quality of treatment programs and the

resultant impact on patients, especially in times of increasing prevalence of

human immunodeficiency virus infection among intravenous drug abusers (Ball

et al. 1986, 1988; Cooper 1989). Currently, the Federal methadone regulations

are the minimum standards of care used to measure the competence of most

methadone programs. Some critics argue that these standards are not a valid

measure of quality. Others suggest that monitoring for compliance by

nonclinical staff makes interpretation of compliance unreliable or impossible. A

major objective of this feasibility study is to determine to what extent patient intreatment performance correlates with program quality and program compliance

to existing Federal methadone regulations. NIDA also will examine whether a

system built on program performance standards can complement or supplant

parts or all of the existing Federal regulations governing the use of methadone.

To better understand the current NIDA study, a general understanding is

required of the evolution of the Federal methadone regulations as a minimum

measure of quality and other approaches designed to measure treatment

quality in other health care delivery systems. The history of the development of

methadone treatment and the unique use of the Federal statute since 1974 to

regulate this medical treatment have been described in detail elsewhere

(Cooper 1988). Relevant to the discussion, however, are several important

factors. For approximately 50 years, U.S. policy gradually evolved from one of

strict prohibition of narcotic maintenance treatment for narcotic addicts before

1965 to one of qualified acceptance with conditions. The primary impetus for

the shift in policy was the growing narcotics abuse problem in the United States

and Vietnam and subsequent rapid proliferation of methadone programs after

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the initial promising report that narcotic maintenance was an effective treatment

(Dole and Nyswander 1965). Many of these new methadone programs were

funded with Public Health Service grants.

With the expansion of methadone programs, a growing concern emerged as

reports appeared of methadone diversion and of primary addiction to

methadone, resulting from either street abuse or inappropriate treatment

admissions of nondependent persons. In 1974 Congress, recognizing both the

potential benefits of methadone maintenance and the risk of diversion and

iatrogenic addiction, legally sanctioned narcotic maintenance treatment with

certain provisions for use (Narcotic Addict Treatment Act of 1974). In essence,

these provisions for use require a separate Federal registration with the

Department of Justice (DOJ) of all practitioners using narcotics for this

indication in this population. DOJ registration is contingent on certification/

recertification by the Department of Health and Human Services (HHS) that the

practitioner/program is qualified under standards established by the Secretary

to engage in narcotic maintenance and treatment. Although the legislative

history clearly indicated congressional intent to mitigate methadone diversion

and to limit registration to only those practitioners capable of rendering

appropriate medical treatment, no congressional guidance was provided with

regard to defining appropriate medical standards.

HHS authority to develop the Secretary’s standards was jointly delegated to

NIDA and FDA. NIDA was delegated the authority to determine the

appropriate standards of medical treatment; FDA was delegated the authority to

determine the safety and efficacy of new drugs and to approve them for this

indication. In 1975 the Director of NIDA and the Commissioner of FDA agreed

that NIDA would take the lead in drafting these standards and FDA would

eventually publish these standards as regulations and monitor for compliance.

Subsequently, there were discussions between NIDA and FDA as to what

credentials or standards would be required in determining appropriate

practitioner certification. The methadone regulations in 1975 were similar to the

original FDA Investigational New Drug protocol. Also in existence were NIDA

Federal Funding Criteria, generic treatment standards required as a condition

for NIDA funding. The decision was made to incorporate some of the process

standards embodied in the existing Federal Funding Criteria and to retain some

of the structural standards in the existing FDA regulations. These draft

standards were further refined after consultation with a group of clinicians and

researchers in narcotic addiction treatment. The standards finally were

proposed as regulations in 1977 and, after public comment, were revised and

finalized as FDA/NIDA regulations in 1980. It is beyond the scope of this

chapter to describe the individual standards. However, for purposes of

subsequent discussion, these regulations include primarily structural and

359
process standards such as admission criteria, diagnostic assessment, initial

treatment plans with periodic review, periodic urine testing, requirements for

take-home privileges, and the availability of a range of ancillary treatment

services for those with a diagnosed need.

Although it was clearly HHS’s intent that the methadone regulations should

embody a minimum standard of care, no subsequent research studies have

ever attempted to determine if any correlation exists between regulatory

compliance, quality of services rendered, or in-treatment performance

measures. This lack of evidence exists in other fields of medicine, in part due to

methodological limitations. Moreover, monitoring for compliance has evolved to

become a managerial/administrative function. Compliance is determined in

large part by the adequacy of the medical record. Interpretation of incomplete

or discordant medical record findings is further complicated by the use of

inspectors/investigators without clinical training or experience. At best,

inspections discover the most noncompliant programs and, hopefully, motivate

most program staff to perform better.

There has been a growing body of literature pertaining to the measurement of

the quality of health care. Donabedian and others proffer three domains for

investigation when assessing quality of care: structure, process, and outcome

(Donabedian 1982, 1985; Lohr et al. 1988; McGlynn et al. 1988; Rutstein et al.

1976; Williamson 1971). Various authors have debated the advantages and

limitations of each domain (Lohr 1988; Donabedian 1988). Most believe that

none has yet been determined superior and that more research is needed to

better determine the extent to which correlations exist among the three

domains. Historically, most assessments of quality have evaluated the

structure and process of treatment by relying heavily on the medical record as a

data instrument for making judgments of quality. In the past decade, concerns

about health cost containment have focused more interest on developing more

precise clinical indicators to measure outcome as a means for judging quality of

care. Dole first suggested the use of performance standards as a means for

measuring quality methadone programs in 1982 (Dole et al. 1982). More recent

concern about acquired immunodeficiency syndrome prevention, the existing

quality of drug treatment programs, and renewed congressional interest in

program accountability and concomitant increased funding for such research

have provided the impetus and resources to develop additional reliable

methods to measure program quality by assessing patient in-treatment

performance and to compare these methods with the existing process/structure

standards.

Designing and implementing a quality assurance system for methadone

programs may be less complicated than in some other areas of health care.

360
Methadone has undergone exhaustive evaluation studies; its effectiveness is

well documented as are some of the effective components of treatment, for

example, methadone dose, program staffing and structure, and case

management (Cooper 1989). A growing body of literature suggests that

individual addiction severity or the presence of psychiatric comorbidity influence

both in-treatment and posttreatment outcome (Woody et al. 1984, 1987;

Rounsaville et al. 1983). Measures of in-treatment performance, for example,

illicit drug use, criminality, and social productivity, are well-accepted indicators.

Large posttreatment evaluation studies have demonstrated the importance of

program retention, suggesting tenure to be another important in-treatment

performance measure (Simpson 1979, 1981). Thus, there exists a body of

research data from which to operationally define some process and structure

parameters of quality and existing reliable performance indicators for measuring

outcome, suggesting that some comparison among three domains as measures

of program quality is feasible.

In view of the above, NIDA will study the feasibility of establishing a quality

assurance system for methadone programs. Plans are under way to develop

an ongoing program monitoring system that will assess individual addiction

severity and collect in-treatment performance data from a stratified random

sample of methadone programs. Selected programs will evaluate each

patient’s addiction severity using the revised Addiction Severity Index (ASI).

This revised instrument will provide a means to categorize programs by the

addiction severity of their patients (case mix). Dr. Thomas McLellan (University

of Pennsylvania) is currently revising the ASI to include additional questions

relating to contemporary drug use and psychiatric diagnosis, is conducting

additional reliability and validity testing, and will propose classification strategies

that can be used for stratifying program populations. In addition, he will

produce an abbreviated instruction manual to assist programs in using the ASI.

Instruments will be developed capable of providing reliable, valid, and ongoing

measures of patient in-treatment performance. Once program staff is trained,

these instruments will be incorporated into randomly selected programs as part

of a 2-year data collection and analysis process.

As a result of the study, we hope to learn more about the following:

1. Additional information on the extent to which the addiction severity predicts

in-treatment performance

2. The reliability and validity of the revised ASI and its utility in classifying the

methadone maintenance population

3. A reliable method for scoring outcome measures

361
4. The reliability of urinalysis results from local laboratories and the utility of

those results as a measure of illicit drug use in the quality assurance

system

5. The reliability of this monitoring system to differentiate program quality by

case mix and weighted performance standards

6. The linkages between process and outcome standards

7. The extent to which existing process standards (methadone regulations)

can be eliminated without affecting the quality of care

Although cognizant of the complexity of the tasks, the author is optimistic that

such a system can be designed and implemented and can be a useful method

for differentiating program quality. In addition to existing diagnostic instruments

and treatment evaluation information data, NIDA will have available the

expertise of research consultants knowledgeable in both drug abuse treatment

and quality health care evaluation methodologies. If our expectations are

realized, such a system might serve as a means for identifying programs in

need of technical assistance. In addition, the information generated will provide

ongoing documentation with regard to the effectiveness of existing programs to

retain patients and to reduce their illicit drug use and improve their social

productivity.

The Narcotic Addict Treatment Act has put in place an administrative process

and structure whose primary objective is to establish and maintain program

accountability. Should this study demonstrate its utility in differentiating

program quality, it is plausible that such a quality assurance system could be

established nationwide. Such a system is conceptually and legally consistent

with the existing statutory framework governing methadone program

accountability. Perhaps existing FDA/NIDA regulations could be eliminated. In

place of the regulations, continued DOJ registration of methadone programs

could be contingent on their routinely providing information to such a quality

assurance system and demonstrating a certain level of performance.

REFERENCES

Ball, J.C.; Corty, E.; and Graff, H. Medical services provided to 2,394 patients

at methadone programs in three States. J Subst Abuse Treat 3:203-209,

1986.

Ball, J.C.; Lange, W.R.; Meyers, C.P.; and Friedman, S.R. Reducing the risk of

AIDS through methadone maintenance treatment. J Health Soc Behav

29:214-226, 1988.

362
Cooper, J.R. Methadone treatment in the United States. In: Arif, A., and

Westermeyer, J., eds. Methadone in the Management of Opioid

Dependence: Program and Policies Around the World. Minneapolis, MN:

University of Minnesota, 1988. pp. 139-153.

Cooper, J.R. Methadone treatment and acquired immunodeficiency disease.

JAMA 262:1664-1668,1989.

Dote, V.P., and Nyswander, M.E. A medical treatment of diacetylmorphine

(heroin) addiction. JAMA 193:647-650, 1965.

Dote, V.P.; Nyswander, M.E.; and Des Jarlais, D. Performance-based rating of

methadone maintenance programs. N Engl J Med 306:169-171, 1982.

Donabedian, A. Explorations in Quality Assessment and Monitoring: The

Criteria and Standards of Quality. Ann Arbor, Ml: Health Administration

Press, 1982.

Donabedian, A. The Methods and Findings of Quality Assessment and

Monitoring. An Illustrated Analysis. Ann Arbor, Ml: Health Administration

Press, 1985.

Donabedian, A. The quality of care: How can it be assessed? JAMA

260:1743-1748, 1988.

Federal Register. Vol. 54. March 2, 1989. pp. 8976-8979.

Lohr, K.N. Outcome measurement: Concepts and questions. lnquiry 25:37-50,

1988.

Lohr, K.N.; Yordy, K.D.; and Thier, S.O. Current issues in quality of care.

Health Aff (Millwood) 7:5-18, 1988.

McGlynn, E.A.; Norquist, G.S.; Wells, K.B.; Sullivan, G.; and Liberman, R.P.

Quality-of-care research in mental health: Responding to the challenge.

Inquiry 25:157-170, 1988.

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 39:161-166, 1983.

Rutstein, D.D.; Berenberg, W.; Chalmers, T.C. Measuring the quality of medical

care: A clinical method. N Engl J Med 294:582-588, 1976.

Simpson, D.D. The relation of time spent in drug abuse treatment to posttreatment outcome. Am J Psychiatry 136(11):1449-1453, 1979.

Simpson, D.D. Treatment for drug abuse: Follow-up outcomes and length of

time spent. Arch Gen Psychiatry 38:875-880, 1981.

Williamson, J.W. Evaluating quality of patient care: A strategy relating outcome

and process assessment. JAMA 218:564-569, 1971.

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O’Brien, C.P. Severity of

psychiatric symptoms as a predictor of benefits from Psychotherapy: The

Veterans Administration-Penn Study. Am J Psychiatry 141(10):1172-1177,

1984.

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O’Brien, C.P. Twelve-month

follow-up of psychotherapy for opiate dependence. Am J Psychiatry 5:590-

596, 1987.

363
AUTHOR

James R. Cooper, M.D.

Assistant Director

Medical and International Affairs

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, MD 20657

364
Methadone Maintenance and Patients

in Alcoholism Treatment

Enoch Gordis

INTRODUCTION

Alcoholic ex-heroin addicts who are in methadone-maintenance treatment can

be treated for their alcoholism without first withdrawing them from methadone,

according to the results of clinical research.

Alcoholism treatment programs have frequently had a policy of first taking the

ex-heroin addicts off methadone. This policy now has important public health

implications.

Intravenous (IV) drug abusers are the second largest risk group for AIDS, after

homosexual and bisexual men. With the recent reduction in the rate of new

human immunodeficiency virus (HIV) infection among homosexuals and

bisexuals, IV drug abusers have become the primary target for intervention to

halt the spread of the disease.

About 25 percent of the almost 1 million chronic IV drug abusers in the United

States are HIV seropositive, and approximately 26 percent of all reported

acquired immunodefiiiency syndrome (AIDS) cases in the United States have

occurred among this risk group (Dondero et al. 1987; Novick et al. 1986a). IV

drug abuse also is considered to be the direct or indirect source of most of the

AIDS cases among mothers and their newborns (Des Jarlais et al. 1985;

Dondero et al. 1987). Prompt intervention among this risk group will protect

seronegative IV drug abusers and their sexual partners as well as pregnant

mothers and their children.

METHADONE MAINTENANCE EFFECTIVE

Successful intervention strategies among IV drug abusers, however, must

overcome the problem of narcotic addiction. Since 1965 methadone

maintenance programs have proved to be the most effective treatment for IV

365
opiate (e.g., heroin) addiction. When properly supervised, a daily dose of 60 to

100 mg of methadone prevents withdrawal symptoms and drug “hunger,”

produces no euphoria, and enables patients to return to a normal lifestyle. The

effectiveness of methadone treatment has been demonstrated by reductions in

criminal arrests, increases in employment, and stability of social relationships

(Dole and Joseph 1978; Dole and Nyswander 1976). (Methadone maintenance

has no role, nor was it designed to have a role, in the treatment of any addiction

other than opiate addiction.)

More than 150,000 heroin addicts have been treated with methadone, and

almost 100,000 are currently enrolled in programs in the United States (Kreek,

in press). Between 55 and 80 percent of addicts remain voluntarily enrolled in

methadone maintenance programs for at least 2 years; fewer than 10 percent of

these patients continue to abuse heroin while in treatment (Dole and Joseph

1978; Kreek, in press).

REDUCING THE RISK OF AIDS

The observed 90-percent reduction of IV heroin use among methadonemaintained patients can substantially reduce the risk of HIV infection and AIDS.

A study conducted in 1984 of methadone-maintained patients in New York City

compared patients who had been in continuous treatment before 1978 (the year

HIV infection became apparent in New York) with patients who had not been in

continuous treatment since 1978. Results indicated that fewer than 10 percent

of the patients who had been in continuous treatment before 1978 were

seropositive for HIV, compared with 47 percent of the patients who had not

been in continuous treatment since 1978 (Novick et al. 1986b).

SIDE EFFECTS NOT SERIOUS

An early concern with methadone maintenance treatment was whether it was

harmful to various organ systems. Since then several studies have indicated

that high daily oral doses of methadone are safe, although there are a few side

effects such as increased sweating, chronic constipation, sexual dysfunction,

and sleep abnormalities. These side effects are not considered serious, and

they often disappear after the first 6 months of treatment (Kreek 1973, 1978,

1983). Studies of methadone’s effect on the liver have shown that methadone

is not toxic to this organ, even in patients with severe chronic liver disease

(Beverley et al. 1979; Kreek 1973).

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IMMUNOLOGIC REACTIONS

It also has been suggested that methadone reduces the effectiveness of the

body’s immune system, a critical complication that, if true, could have serious

consequences for contracting AIDS. Although immunologic alterations are

common among methadone-maintained patients, these alterations are largely

attributable to preexisting chronic liver disease (caused by hepatitis or alcohol

abuse), an illness common among IV drug abusers, and not attributable to

methadone (Kreek 1978; Kreek et al. 1986).

At least one study has shown an improvement, over time, in the immunologic

status of methadone-maintained patients (Kreek et al. 1986). Laboratory

studies of the toxic effects of morphine vs. methadone on cells derived from the

immune systems of animals and humans have found that methadone either was

not toxic or displayed a much lower toxic potentiality than morphine (Tubaro et

al. 1985, 1987).

COMMON PROBLEM OF ALCOHOLISM

Alcoholism is a common problem among people in methadone programs,

affecting as many as half of such patients (Birhari 1974; Kreek, in press, 1978;

Stimmel et al. 1972). Consequently, many methadone-maintained patients

need to be treated simultaneously for alcoholism. Methadone-maintained

patients enter alcohol treatment for the same reasons as other alcoholics. In

addition to the benefits that all alcoholics derive from treatment, methadonemaintained patients, because of their high rate of chronic liver disease, receive

an extra benefit: prevention of further damage to the liver.

HIGH RELAPSE RATE WHEN METHADONE STOPPED

Once a patient is admitted to a methadone maintenance program, it is important

that treatment be continuous and long term. When treatment is suspended, it is

estimated that from 55 to 60 percent of patients relapse to illicit IV drug use

within 2 years (Dole and Nyswander 1976). The result of this high relapse rate

is an increase in the risk of hepatitis and HIV infection (and ultimately AIDS) and

the spread of these diseases.

MINIMAL TREATMENT INTERACTIONS

Questions have been raised concerning methadone maintenance in

combination with alcoholism treatment. First, some concern exists over the

possible adverse interaction between methadone and sedatives during

detoxification and between methadone and disulfiram (Antabuse) during long367
term treatment. However, to date, research indicates that interactions between

methadone and these other drugs are minimal and that no modifications in

dosage have to be made to any of the drugs, although more research is needed

on the long-term effects of these interactions (Kreek et al. 1976; Liebson et al.

1973, 1978; Tong et al. 1980).

Second, it has been suggested that methadone-maintained patients are not

suitable for long-term support such as that offered by Alcoholics Anonymous

(AA). However, researchers have concluded that, based on studies of alcoholic

methadone-maintained patients, “treatment for alcoholism in methadone

patients should follow the time-tested approaches of the alcoholism field” (Khuri

et al. 1984).

CHALLENGE AND OPPORTUNITY

AIDS is a major public health threat–arguably the most urgent health threat

facing our Nation through the end of the century, if not beyond. To date, the

contribution of the alcohol field to the national AIDS effort has focused

principally on how to treat alcohol abusers and alcoholics who are HIV infected

or who suffer from AIDS-related complex or AIDS. In fact, the speed with which

this guidance was provided by alcohol-related organizations is impressive and

commendable.

Now the alcoholism field, particularly the treatment community, has an

opportunity to demonstrate once more its ability to meet new challenges in a

prompt and decisive fashion by confronting and resolving an issue with

significant implications for preventing the spread of HIV infection. That issue is

treating methadone-maintained alcoholics in alcohol treatment programs.

NEED FOR ALCOHOLISM TREATMENT

Despite the ongoing philosophical debate surrounding the use of methadone

maintenance in drug abuse treatment, the fact remains that many former heroin

addicts have been able to return to normal functioning due to methadone

maintenance. We know that there is a great need for alcoholism treatment in

this population; the prevalence of alcoholism among individuals on methadone

maintenance is approximately 50 percent. We also know that relapse rates are

high—70 to 80 percent—among addicts who discontinue methadone

maintenance. AIDS is spreading most rapidly now among IV drug users, their

sexual partners, and the children of women who are HIV infected. Preventing

relapse to IV drug use, therefore, is a significant step toward containing the

spread of AIDS.

368
This, then, is the problem facing the alcohol field. Many alcohol treatment

programs require patients to terminate their use of methadone as a condition of

admittance for treatment, forcing alcoholics who are methadone maintained to

choose between two equally untenable options: They may choose to continue

with methadone maintenance and risk disability and death from the chronic

health problems of untreated alcoholism, or they may choose to discontinue

methadone maintenance and risk drug use relapse and the development and

spread of HIV infection.

SUCCESSFUL OUTCOME

For many years I directed a large alcohol treatment program in which

methadone-maintained individuals, while continuing on methadone, were

successfully detoxified from alcohol and treated within the framework of existing

alcoholism treatment modalities, including chemotherapeutic treatments and

long-term support through AA. I do not believe that alcohol treatment providers

need fear or be reluctant to do likewise. Based on my experience, I would

argue that even if AIDS prevention were not an issue, there is no justifiable

reason to deny treatment in an alcohol treatment program to alcoholics who are

well stabilized on a program of methadone maintenance.

PHARMACOLOGY OF METHADONE MAINTENANCE

Once the pharmacology of methadone maintenance is understood, it becomes

clear that treating methadone-maintained individuals is compatible with good

clinical management of alcoholism. Methadone, as used in a methadone

maintenance program, is pharmacologically different from heroin and alcohol. It

eliminates the body’s physical craving for heroin without producing euphoria,

allowing former heroin users to stabilize their lives and return to normal patterns

of living. There also is little adverse interaction between methadone and other

chemotherapeutic agents (e.g., disulfiram) used in alcoholism treatment. Nor

does methadone maintenance interfere with the successful utilization of longterm alcoholism treatment, including participation in AA (Obuschowsky and

Zweben 1987; Zweben 1987). Perhaps it is best stated by Vincent P. Dole,

M.D., a nonalcoholic trustee of AA and cooriginator of methadone maintenance

treatment: “It would be more reasonable to consider heroin addiction as a

medical problem separate from alcoholism just as a person with both heart

disease and alcoholism could receive digitalis from his doctor and still be

welcomed into an AA group” (Dole 1972).

369

294-012 0 - 91 - 13
RATIONALE FOR TREATMENT

When the data are examined on the effectiveness of methadone maintenance

in preventing IV heroin use, on the degree of alcoholism among former IV

heroin users in methadone maintenance programs, and on the alcoholic’s risk

for deteriorating health conditions such as chronic liver damage, it becomes

clear that requiring individuals to terminate methadone maintenance as a

condition of acceptance into alcoholism treatment should be rejected as a

standard practice by alcohol treatment service providers.

REFERENCES

Beverley, C.L.; Kreek, M.J.; Wells, A.O.; and Curtis, J.L. Effects of alcohol

abuse on progression of liver disease in methadone-maintained patients. In:

Harris, L.S., ed. Problems of Drug Dependence. 1979: Proceedings of the

41st Annual Scientific Meeting, The Committee on Problems of Drug

Dependence, Inc. National Institute on Drug Abuse Research Monograph

27. DHHS Pub. No. (ADM)80-901. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1979. pp. 399-401.

Birhari, B. Alcoholism and methadone maintenance. Am J Drug Alcohol Abuse

1:79-87, 1974.

Des Jarlais, D.C.; Friedman, S.R.; and Hopkins, W. Risk reduction for acquired

immunodeficiency syndrome among intravenous drug users. Ann Intern Med

103:755-759, 1985.

Dole, V.P. AA, drug addiction, and pills. AA Grapevine October 1972.

Dole, V.P., and Joseph, H. Long-term outcome of patients treated with

methadone maintenance. Ann N Y Acad Sci 311:181-189, 1978.

Dole, V.P., and Nyswander, M.E. Methadone maintenance treatment: A tenyear perspective. JAMA 235:2117-2119, 1976.

Dondero, T.J., and the HIV Data Analysis Team. Human immunodeficiency

virus infection in the United States: A review of current knowledge. MMWR

Suppl. Centers for Disease Control, U.S. Department of Health and Human

Services, 36(S-6), 1987.

Khuri, E.T.; Millman, R.B.; Hartman, N.; and Kreek, M.J. Clinical issues

concerning alcoholic youthful narcotic abusers. Adv Alcohol Subst Abuse

34:69-86, 1984.

Kreek, M.J. Medical safety and side effects of methadone in tolerant

individuals. JAMA 223:665-668, 1973.

Kreek, M.J. Medical complications in methadone patients. Ann N Y Acad Sci

311:110-134, 1978.

Kreek, M.J. Health consequences associated with the use of methadone. In:

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

370
on the Treatment of Narcotic Addiction. National Institute on Drug Abuse

Treatment Research Monograph Series. DHHS Pub. No. (ADM)83-1281.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1983.

Kreek, M.J. Opiate-ethanol interactions: Implications for the biological basis

and treatment of combined addictive diseases. In: Harris, L.S., ed.

Problems of Drug Dependence, 1987: Proceedings of the 49th Annual

Scientific Meeting, The Committee on Problems of Drug Dependence, Inc.

National Institute on Drug Abuse Research Monograph 81. DHHS Pub. No.

(ADM)88-1564. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1988.

Kreek, M.J.; Gutjahr, C.L.; Garfield, J.W.; Bowen, D.V.; and Field, F.H. Drug

interactions with methadone. Ann N Y Acad Sci 281:350-370, 1976.

Kreek, M.J.; Khuri, E.; Fahey, L.; Miescher, A.; Arns, P.; Spagnoli, D.; Craig, J.;

Millman, R.; and Harte, E.H. Long-term followup studies of the medical

status of adolescent former heroin addicts in chronic methadone

maintenance treatment: Liver disease and immune status. In: Harris, L.S.,

ed. Problems of Drug Dependence, 1986: Proceedings of the 47th Annual

Scientific Meeting, The Committee on Problems of Drug Dependence, inc.

National Institute on Drug Abuse Research Monograph 67. DHHS Pub. No.

(ADM)86-1448. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1986. pp. 307-309.

Liebson, I.; Bigelow, G.; and Flamer, R. Alcoholism among methadone

patients: A specific treatment method. Am J Psychiatry 130:483-485, 1973.

Liebson, I.; Tommasello, A.; and Bigelow, G. A behavioral treatment of

alcoholic methadone patients, Ann Intern Med 89:342-344, 1978.

Novick, D.M.; Khan, I.; and Kreek, M.J. Acquired immunodeficiency syndrome

and infection with hepatitis viruses in individuals abusing drugs by injection.

Bull Narc 30(1-2):15-25, 1986a.

Novick, D.M.; Kreek, M.J.; Des Jarlais, D.C.; Spira, T.J.; Khuri, E.T.; Ragunath,

J.; Kalyanaraman, V.S.; Gelb, A.M.; and Miescher, A. Antibody to LAV, the

putative agent of AIDS, in parenteral drug abusers and methadonemaintained patients. In: Harris, L.S., ed. Problems of Drug Dependence,

1986: Proceedings of the 47th Annual Scientific Meeting, The Committee on

Problems of Drug Dependence, Inc. National Institute on Drug Abuse

Research Monograph 67. DHHS Pub. No. (ADM)86-1448. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1986b. pp. 318-320.

Obuschowsky, M.A., and Zweben, J.E. Bridging the gap: The methadone

client in 12-step programs. J Psychoactive Drugs 19(3):301-302, 1987.

Stimmel, B.; Vernace, S.; and Tobias, H. Hepatic dysfunction in heroin addicts:

The role of alcohol. JAMA 222:811-812, 1972.

Tong, T.G.; Benowitz, N.L.; and Kreek, M.J. Methadone-disulfiram interaction

during methadone maintenance. J Clin Pharmacol 20:506-513, 1980.

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Tubaro, E.; Avico, U.; Santiangeli, C.; Zuccaro. P.; Cavallo, G.; Pacifici, R.;

Croce, C.; and Borelli, G. Morphine and methadone impact on human

phagocytic physiology. Int J lmmunopharmacol 7(8):865-874, 1985.

Tubaro, E.; Santiangeli, C.; Belogi, L.; Borelli, G.; Cavallo, G.; and Croce, C.

Methadone vs. morphine: Comparison of their effect on phagocytic

functions. Int J Immunopharmacol 9(1):79-88, 1987.

Zweben, J.E. Can the patient on medication be sent to 12-step programs? J

Psychoactive Drugs 19(3):299-300, 1987.

AUTHOR

Enoch Gordis, M.D.

Director

National Institute on Alcohol Abuse and Alcoholism

5600 Fishers Lane

Rockville, MD 20857

372
Community Resistance to Drug

Treatment Program Placement

Chauncey L. Veatch Ill

INTRODUCTION

In the fiscal year 1990 U.S. budget, the Bush administration provided for a 49-

percent increase in Federal funding for drug abuse treatment, resulting in an

unprecedented total of $925 million. This increase is a sign of the magnitude of

the drug problem in the United States and also reflects a recognition of the

effectiveness of drug abuse treatment. With this increase in funds, the drug

treatment community will have a renewed opportunity to ease human suffering

and reduce crime by weaning larger numbers of addicts from their expensive

and crime-stimulating habits.

Such funding increases have brought into focus one of the keenest challenges

to face the drug treatment system: finding new sites for community treatment

facilities. Too often drug rehabilitation groups throughout the country are finding

proposals for new facilities blocked by indignant citizens who argue vehemently:

“Not in my backyard!” (NIMBY). Local community leaders, government officials,

and even members of law enforcement who are, or should be, aware of the

need for more treatment centers contribute to the so-called NIMBY syndrome

(Veatch 1987).

Drug abuse centers are not alone in confronting the NIMBY syndrome. Halfway

houses for convicts, juvenile homes, landfills, recycling centers, toxic waste

dumps, and nuclear waste repositories are just a few of the facilities that are

encountering strong and growing community resistance to placement.

Nationwide, no large metropolitan airport has been sited since 1961; no major

hazardous waste dumps have been established since 1980 (Hornblower 1988).

No new methadone maintenance facilities have been sited in New York City in

the past 15 years, even though the city has approximately a quarter of a million

heroin addicts and only 40,000 treatment slots (J. Gustafson, personal

communication, 1989). California also has limited methadone capacity: 14,631

licensed treatment slots to serve an estimated 291,000 drug abusers.

Currently, 1,077 addicts seeking methadone treatment are on waiting lists.

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They may waft for 200 days or longer (H. Goldstein, personal communication,

1989).

In some ways, siting community drug rehabilitation centers is even more difficult

than siting other facilities because addicts are stigmatized. One 1983 survey,

for example, showed that respondents viewed drug addicts as skid row habitues

(Dean and Poremba 1983). A 1984 survey found that “the overwhelming image

was of a disoriented, unhealthy, thin, low-class, male “hippie” with behavioral

and skin problems who suffered from a disease” (Dean and Rud 1984). The

prevailing image has not improved since then, particularly given the image of

drug users and pushers portrayed on television and in the movies. That this

image is demonstrably false is of little consequence in the outcry that

accompanies proposed placement of drug treatment centers.

Methadone maintenance clinics may be even more disliked than other types of

drug therapy facilities because they are viewed by the public as a form of social

control (Ruiz et al. 1976), as a new form of addiction substituted for an old one

(Genevie et al. 1988), or as a less desirable form of treatment that does not

deal with the presumed underlying problems of the addict (Ball and Corty 1988;

Genevie et al. 1988).

One example of the image problem in drug treatment: The citizens of the

Hudson River community of Rhinebeck, NY, successfully resisted the

placement of a landfill in their community only to be confronted with the

possibility that a drug treatment facility would be located there instead. Their

response: “Bring back the dump!” (Rimer 1987).

Despite the overwhelming need for more treatment facilities, there are no easy

answers to the problem of siting additional programs. The image of the drug

abuser will not change overnight, nor will the fears and misperceptions of

community residents.

THE PROBLEM

Opposition to the placement of new treatment facilities can be either overt,

involving zoning processes, licensing requirements, and lobbying by neighbors

and local businesses, or covert, involving opposition by local public officials.

Remarkably little information about these problems can be found in the scientific

literature. Most information that is available is anecdotal and comes directly

from those who have been involved in the process of siting new drug treatment

facilities or other types of social service programs. Because many of these

people are still engaged in trying to site facilities, some have chosen to remain

anonymous in the case histories cited below.

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Covert Opposition

According to Maurice Weiner of the Tarzana Treatment Center in California,

zoning is “the single most difficult problem” his group encountered in trying to

find a site for a new satellite center to be funded by Los Angeles County (M.

Weiner, personal communication, 1989). Potential facilities that had an

acceptable price and location did not have the proper zoning for a treatment

center, whereas those that had the proper zoning were too expensive or

required too many repairs at too great a cost before they could be used.

In Los Angeles County, for example, the typical zoning category for residential

drug treatment centers is commercial, a category that includes street corners,

shopping centers, and malls, which generally are not appropriate locations for

drug treatment centers or would require expensive alterations (M. Weiner,

personal communication, 1989). The types of places that are most appropriate

for drug treatment centers, such as abandoned convalescent homes, retirement

homes, and hospitals, are usually located in the residential communities from

which drug treatment clients will come and have the appropriate bedrooms,

plumbing, and other necessary qualities. Such in-place housing facilities

typically have a waiver or variance from the local zoning requirements that is

specific to their current or prior use. Unfortunately, obtaining a variance to use

a site as a drug treatment facility requires public hearings, where neighbors

have the opportunity to make their objections known. Weiner notes that his

group has been intensively but unsuccessfully searching for a residential facility

site for 2 years, because they have not been able to obtain the necessary site

variance.

Abandoned hospitals present a different challenge. Typically, they have the

requisite zoning, so licensing is not a problem. Unfortunately, hospitals have

other facilities associated with them, such as surgical operating suites or

radiology units, that make their purchase prohibitively expensive for a group

wishing to operate a drug treatment center.

Robert Bright, who helped run halfway houses for the Illinois Department of

Corrections, has described his experiences with one halfway house that was set

up in an inner-city neighborhood of Chicago despite community and political

opposition (Krajick 1980). Shortly after it was opened, inspectors from city

departments showed up almost weekly to search for violations. In time,

corrections officials grew tired of the constant visits and closed the facility.

Although licensing and building codes are important safeguards, their rigid

application must not be used to block the creation of or harass new centers

once they are established (Lippincott 1979). Public officials, especially city

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council members, can play behind-the-scenes key roles in blocking new

facilities. Henry Templeton, a former director of work release programs in the

Chicago area, has noted that approval had to be obtained from the local

alderman before a halfway house could be sited in his ward (Krajick 1980).

Templeton noted one instance in which an abandoned nursing home had been

selected as a potential site. Templeton called the alderman, who asked, “How

many jobs can you guarantee me?” Templeton could not guarantee any jobs,

and that was the end of the conversation.

Even staff members of agencies that regulate drug abuse programs have

sabotaged the placement of new facilities. Sometimes such individuals

disagree with the agency’s official views and let material that must pass through

their hands languish for long periods. Others actively sabotage proposals.

Many of these individuals believe that treatment does not work and that the best

social policy is enforcement and incarceration: others are not eager to provide

public funds to this stigmatized group of people, arguing that the funds could be

more appropriately spent elsewhere.

Conflicting positions taken by officials in the same jurisdiction also can hamper

efforts to provide treatment. San Joaquin is one of three counties in California

that still provide methadone maintenance directly to clients. The county needs

new treatment centers but has no funds to create or maintain new programs.

Some local county authorities would like to attract private, for-profit or nonprofit

agencies into the county to provide treatment without drawing from scarce

public funds, but other county officials have resisted these efforts, concerned

that such private endeavors may shortchange clients by becoming “juicebars”

that give out methadone without any other form of therapy (H. Goldstein,

personal communication, 1989).

Some public and government officials take positions that often are based on

emotion winning out over the larger responsibility to the community.

Unfortunately, drug abuse deals with very emotional issues, including, Should

addicted mothers be prosecuted? Should their babies be taken from them? Do

we give addictive opiates (methadone) to some heroin addicts for the rest of

their lives? These are issues that, like abortion, have most Americans

searching for the definitive answer. Most researchers are searching for rational

solutions, but those people who have formed an opinion, either pro or con, are

very adamant and are swaying elected boards and community leaders across

the country.

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Overt Opposition

Perhaps the most troubling stumbling block to new treatment centers is the

resistance of homeowners in the affected communities–the ultimate expression

of the NIMBY syndrome. Goldstein surveyed the directors of the 79 methadone

maintenance clinics in California and asked them to rate various difficulties in

siting new facilities. “Community resistance” was by far the most commonly

cited problem, followed by obstruction by “local officials” (H. Goldstein, personal

communication, 1989).

The National Institute on Drug Abuse (NIDA) conducted a major study entitled

“Overcoming Barriers to Drug Abuse Treatment in the Community.” In a study

of community resistance associated with that project, researchers found that

two concerns were most frequently cited by individuals opposed to drug

treatment centers: security and property values (Technical Assistance and

Training Corporation 1989). Residents feared that crime would rise in the

community as a result of the influx of drug users. Furthermore, property owners

feared that property values would decline because of the center’s presence.

Other concerns included increases in traffic and fear that children would be

exposed to undesirable influences. Ultimately, however, all rationales boil down

to one problem: fear of the unknown. The drug treatment community’s role is

to dispel these unfounded fears.

Resistance to treatment centers encompasses all types of neighborhoods and

all socioeconomic groups. The residents of rustic Lake View Terrace,

approximately 20 miles from downtown Los Angeles, objected vehemently to

the Nancy Reagan Center for Drug Rehabilitation proposed for their community

by Phoenix House (De Atley 1989). Mrs. Reagan ultimately withdrew her

support for the project in deference to the residents, who objected that the

center would bring crime to the neighborhood and traffic jams when Mrs.

Reagan visited. Phoenix House is still searching for another site.

Residents of inner-city neighborhoods are also vehement in their objections to

the location of drug treatment facilities, even when the majority of the facility’s

clients will come from that neighborhood. Consider the example of Beth Israel

Hospital in New York City, which operates 23 community-based drug treatment

centers. The hospital has been trying for 2 years without success to relocate

two existing facilities and to open a new one (N. Peyser, personal

communication, 1989).

In one case, the hospital lost its lease in one building and is trying to buy

another office building on the same block of West 125th Street in a

semicommercial section of Harlem. Community leaders argued that the

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neighborhood was marked for renaissance and that taking one of its few good

office buildings was a disservice to the community (N. Peyser, personal

communication, 1989). Race and religion also became an issue (N. Peyser,

personal communication, 1989). Meanwhile, nobody else has had the money

to buy the building and renovate it. Today, it stands empty, but perhaps it also

stands as a monument to NIMBY.

As an alternative location, Beth Israel has been looking at a site over a

supermarket on a Harlem commercial block of West 116th Street, in a

neighborhood needing additional local drug treatment services. The site is near

subway stations and is virtually ideal, but community leaders have opposed it,

giving all the usual arguments plus raising such unexplainable issues as the

location “was next to a post office.” In late 1989 the city said that it would not

approve the site over community objections.

Community resistance to drug treatment centers and other facilities does not

necessarily end when a facility is finally approved. In April 1987 white residents

of Gladwin Avenue in the Borough of Queens burned down a two-story home

that was being used as a foster home for black children (Hornblower 1988).

Homes for the mentally handicapped also have been burned in middle-class

neighborhoods in Hewlett, NY, and Ventura, CA (Hornblower 1988).

POTENTIAL SOLUTIONS

Potential solutions to the problems of siting drug treatment programs and other

necessary community facilities are difficult, primarily because so few methods

have worked. Some lessons can be learned from the few successes. Overall,

perhaps the greatest efforts of the treatment community must be directed to

reeducating the public about the need for drug treatment facilities, their positive

impact on and value to the communities, and the importance of everyone

sharing societal burdens. According to ethicist Willard Gaylin of the Hastings

Center, “One of the few things we deprive our middle classes of is the

opportunity to serve” (Hornblower 1988). Sociologist Richard Taub from the

University of Chicago adds, “Community spirit says “Take care of your own.”

The ethical challenge is to make people see that the world is their community”

(Hornblower 1988). The community at large must come to view the clients of

drug treatment facilities not as “them,” but as “us.”

A critical factor in increasing drug treatment facilities acceptance is educating

the public about the effectiveness of such treatment in halting addiction,

decreasing drug-seeking behavior, and lowering crime rates and the human

immunodeficiency virus transmission rate. “The programs that have been

successful almost uniformly have shown the ability to educate people about

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program management, what they are doing, and how they are doing it,” notes

Karst Besteman (K. Besteman, personal communication, 1989).

Reflecting the importance of this approach, NIDA has initiated a study of

barriers to drug abuse treatment that suggests that public relations programs

can be useful in persuading communities to accept such facilities (Technical

Assistance and Training Corporation 1989). Pilot public relations programs are

being implemented in four eastern communities. After evaluating those results,

NIDA plans to move west and conduct further studies in 20 sites throughout the

country over the next 2 years. It is not clear, however, that such a public

relations approach will always be successful. In one study of 43 community

residences for the mentally retarded in Metropolitan Boston, Seltzer (1984)

found that about half had encountered opposition. Significantly, the centers that

had conducted extensive public relations campaigns–including open houses,

media campaigns, and community meetings–were more likely to encounter

opposition than those that had not. It may be that conducting such a campaign

too far in advance of a planned opening allows opponents too much time to

mobilize opposition (Krajick 1980).

Generally, nontraditional neighborhoods, transitional communities, and

commercial zones are the easiest places to site drug treatment facilities

(Technical Assistance and Training Corporation 1989). Within those

neighborhoods, key support for establishing a treatment center comes most

often from two broad groups: those faced with the impact of drug addiction on

society, such as elected officials, law enforcement, others in the criminal justice

system, and those familiar with the impact of drug addiction on individuals, such

as health care professionals, recovering addicts and their families, and the staff

and board of directors of the facility (Technical Assistance and Training

Corporation 1989).

Fear that property values will decrease and crime will increase in the vicinity of

centers are major residential concerns. More research documentation is

needed related to the effects of drug treatment centers on both property values

and crime. Perhaps the only study of the effects of drug treatment facilities on

property values is an old case study of a Phoenix House facility in Brooklyn,

which found that property values in the neighborhood continued to rise for a

year after the drug treatment center opened (Nash 1969).

The experience of other types of facilities is instructive. The few studies of

property values around facilities for retarded or mentally ill persons in several

cities and states, for example, have shown no adverse effects from the siting of

the facilities (Sigelman et at. 1979; Kappel 1986). “On the contrary, the property

values often seem to go up because of superior care given to the building and

its environment,” according to J.K. Thomas (Sigelman et al. 1979).

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Fears that property values around such shelters would fall because neighbors

would rush to sell their properties also proved to be unfounded; one study

showed, for example, that neighbors often were not even aware of the

existence of a group home (Kappel 1986). Another study, conducted by the

Green Bay Planning Commission, found that the percentage of homes sold

following the establishment of a group home decreased in the immediate block

(Knowles and Baba, cited by Lauber and Bangs 1974).

Even fewer studies of crime rates around group facilities are available, and

none specifically devoted to drug treatment centers (Technical Assistance and

Training Corporation 1989). A 1979 literature survey, however, showed no

increase in crime rates around facilities for developmentally disabled persons,

ex-convicts, or juvenile delinquents (Sigelman et al. 1979). A more recent study

of paired neighborhoods in Toronto–four with halfway houses for ex-convicts

and four without such facilities–found no difference in crime rates in the paired

neighborhoods (Kappel 1988).

Crime rates in the immediate vicinity of such facilities decrease. An appropriate

response to document these impressions would be to initiate and fund studies

of both crime rates and property values in areas surrounding treatment

programs. The findings could be of significant public relations benefit in the

attempt to site new centers.

In the absence of such studies, a few alternatives exist. One possibility is the

“tour guide” approach, in which elected officials, community advisory board

members, and other influential community residents are invited to tour a

potential facility or visit existing facilities. Local realty boards should be able to

demonstrate that the existing centers presence has had no effect on property

values, and local police-may be able to give at least an impression of changes

in crime patterns (J. Gustafson, personal communication, 1989).

Such visits to established facilities have an additional benefit. Most facility

operators keep their buildings in good shape and their yards neat and clean and

participate in the life of the community. In other words, they are good

neighbors. After a drug treatment center has been in a neighborhood for a

while, most community members no longer consider it a threat; some even

consider it a bengfit.

Weiner notes that one of his group’s facilities was established in a

neighborhood several years ago at a time when a zoning hearing was

unnecessary–community residents did not know that drug treatment was being

carried out at the site. About 4 or 5 years later, when a few members of the

community discovered that it was a drug treatment facility and decided to

380
organize an effort to keep such “undesirables” out of the community, they were

unable to gamer any support from other community members (M. Weiner,

personal communication, 1989). Similarly, a Brooklyn neighborhood survey

about a Phoenix House drug treatment center showed that only 21 percent of

the neighbors supported the facility when it was established, but 67 percent

supported it a year later (Nash 1969).

Drug treatment facilities can become valuable to a community by providing a

community service in addition to drug treatment (Technical Assistance and

Training Corporation 1989). For example, a facility might offer free counseling

or drug education programs to community organizations or citizens.

Legislative solutions also should be considered. In California and other States,

local zoning ordinances can be superseded for periods ranging from 1 to 5

years if the State legislature or other bodies declare an emergency need for

such a facility. Weiner and others are convinced that such short-term

exemptions allow property owners near the site to become acquainted with the

facility and its management and eliminate the fear of the unknown that causes

so many potential sites to be rejected.

Another legislative approach is an innovative Wisconsin law, Chapter 205 of the

Wisconsin State Code, that prohibits local zoning boards from denying permits

to organizations that want to start halfway houses (Krajick 1980). Although the

bill arose in 1978 as a result of pressures from lobbyists for handicapped,

mentally ill, elderly, and retarded persons, the bill applies specifically to

parolees and drug and alcohol abusers. By 1980 the Ohio and Minnesota

Legislatures had passed similar statutes (Krajick 1980). In Massachusetts,

halfway houses are designated as educational facilities and thus cannot be

excluded by local zoning boards (Krajick 1980); State law preempts all local

codes except those in Boston. In recent years, at least 37 States have passed

laws removing zoning restrictions on group homes in single-family

neighborhoods (Hornblower 1988).

Other legislative solutions are possible. Urban planner Perry Norton of New

York University advocates tax abatements for homeowners who live near an

undesirable public facility or a public guarantee on the resale value of their

homes (Hornblower 1988).

Benjamin Miller of the New York City Office of Resource Recovery has cited an

alternative, albeit more expensive way, of winning public support for an

undesirable facility (B. Miller, personal communication, 1989). His agency

spent 4 years trying to site a waste recycling facility. As part of the effort, the

agency granted a local citizens advisory committee $85,000 with which to hire

381
its own experts to critique the proposed center, suggest improvements, and

examine alternatives. Both sides thus gained confidence in the accuracy of the

agency’s plans and estimates of the project’s impact. Equally important, Miller

said, “The substantive issues were separated from the bogus, grandstanding,

white-noise issues” (B. Miller, personal communication, 1989). Although the

expense in this particular instance was high, the same idea could be carried out

on a smaller scale. In addition to public relations measures, legislation and

other means also must be used to convince communities of the need to accept

some type of facility, be it drug treatment centers, recycling facilities, halfway

houses, or other facilities that are affected by the NIMBY syndrome. The New

Jersey Supreme Court broke new ground in this area in 1975 when it ruled that

wealthy suburbs must share the burden of low-cost housing (Hornblower 1988).

In a similar vein, Arkansas officials have proposed that any county that refuses

to have a prison within its boundaries must pay to have its prisoners housed in

other counties (Hornblower 1988). California has passed legislation designed

to spread prisons around the State so that they are not disproportionately

concentrated in only a few areas.

A final approach involves what has been called a “community pain index” (J.

Meyer, personal communication, 1989), in which the State would assign a set of

point values to different types of installations. A nuclear waste dump, for

example, might be worth 20,000 points, a prison 2,000 points, a halfway house

1,000 points, and a drug abuse treatment center 500 points. After a

consideration of the total needs of the State, each community then would be

required to accept facilities totaling a certain number of points. Of course,

communities would be given a certain amount of flexibility in the nature of the

facilities they would accept to reach that total.

CONCLUSION

Covert and overt resistance to siting drug treatment programs must be

overcome to salvage drug-dependent citizens. The emotional furor surrounding

siting issues can be reduced by public education and other coordinated

approaches. Some progress is being made, but the recently released report on

the National Drug Control Strategy (Office of National Drug Control Policy 1990)

calls for more aggressive treatment efforts. Public policymakers can achieve a

more equitable solution to this battle in the “war on drugs” by reasoned,

persistent, and constructive efforts.

REFERENCES

Ball, J.C., and Corty, E. Basic issues pertaining to the effectiveness of

methadone maintenance treatment. In: Leukefeld, C.G., and Tims, F.M.,

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eds. Compulsory Treatment of Drug Abuse: Research and Clinical Practice.

National Institute on Drug Abuse Research Monograph 86. DHHS Pub. No.

(ADM)89-1578. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1988. pp. 178-191.

De Atley, R. Nancy Reagan just says no to plans for drug center. Los Angeles

Times May 27, 1989.

Dean, J.C., and Poremba, G. The alcoholic stigma and the disease concept.

Int J Addict 18:739-751, 1983.

Dean, J.C., and Rud, F. The drug addict and the stigma of addiction. Int J

Addict 19:859-869, 1984.

Genevie, L.; Struening, E.; Kallos, J.; and Geiler, I. Urban community reaction

to health facilities in a residential area: Lessons from the placement of

methadone facilities in New York City. Int J Addict 23:603-616, 1988.

Hornblower, M. Not in my backyard, you don’t: Too often, that’s the answer to

a community in need. Time June 27, 1988.

Kappel, B. Community Impact Study: The Effect of locating Correctional

Group Homes in Residential Neighborhoods. Toronto: Canadian Training

Institute, 1986.

Krajick, K. Not on my block: Local opposition impedes the search for

alternatives. Corrections October:15, 1980.

Lauber, D., and Bangs, F.S., Jr. Zoning for Family and Group Care Facilities.

Planning Advisory Service Report No. 300. Chicago: American Society of

Planning Officials, 1974.

Lippincott, M.K. “A sanctuary for people”: Strategies for overcoming zoning

restrictions on community homes for retarded persons. Stanford Law Rev

31:767-783, 1979.

Nash, G. Community Response to a Narcotic Addiction Treatment Facility: The

Case of Prospect Place. New York: Columbia University, Bureau of Applied

Social Research, 1969.

Office of National Drug Control Policy. Understanding Drug Treatment. Office

of National Drug Control Policy White Paper, June 1!990.

Rimer, S. Unwelcome guests from New York City. New York Times January

24, 1987.

Ruiz, P.; Langrod, J.; and Lewinson, J. Community Acceptance of Addiction

Treatment Programs: A Contemporary Perspective. Proceedings, Third

National Drug Abuse Conference, 1976.

Seltzer, M.M. Correlates of community opposition to community residences for

mentally retarded persons. Am J Ment Defic 89:1-8, 1984.

Sigelman, C.K.; Spanhel, C.; and Lorenzen, C. Community reactions to

deinstitutionalization. J Rehabil 45(1):52-54, 1979.

Technical Assistance and Training Corporation. Overcoming Barriers to Drug

Abuse Treatment: Market Research Report. National Institute on Drug

Abuse, 1989.

383
Veatch, C. “The Response of State Agencies to AIDS, Alcoholism, and

Addiction.” Paper presented at the American Medical Society on Alcoholism

and Other Drug Dependencies Forum on AIDS and Chemical Dependency,

Fort Lauderdale, FL, February 1987. UCLA Drug Abuse Research Group.

ACKNOWLEDGMENT

The California Drug Abuse Information and Monitoring Project compiled

materials for the preparation of this report.

AUTHOR

Chauncey L. Veatch Ill, J.D.

Director

California Department of Alcohol and Drug Programs

1700 K Street

Sacramento, CA 95814

384
The Impact of AIDS on Drug Abuse

Treatment

Lawrence S. Brown, Jr.

INTRODUCTION

Amid the changing epidemiology of the acquired immunodeficiency syndrome

(AIDS) in the United States, the importance of persons with the risk behavior of

intravenous (IV) drug use has increased considerably. Although IV drug use is

the second most frequent behavior reported among AIDS cases registered by

the Centers for Disease Control (U.S. Department of Health and Human

Services 1990) IV drug use is the most pivotal factor in AIDS case reports

among women, children, ethnic/racial minorities, and individuals who contract

human immunodeficiency virus (HIV) infection via heterosexual contact. AIDS

case reports, mortality data, and HIV seroprevalence studies provide invaluable

information. Yet, as the first decade ends since the identification of the first

AIDS case, the awful morbidity and mortality statistics still do not provide the full

dimensions of the human toll associated with HIV infection and disease. An

exhaustive analysis of these issues is beyond the scope of this chapter;

however, a brief explanation is important to the focus of the present

discussion–the impact of the HIV pandemic on the drug-dependent patient, the

personnel who provide drug abuse treatment, and drug abuse treatment

programs.

The concurrent rise in case reports of Mycobacterium tuberculosis (TB),

pneumonia, and syphilis and other sexually transmitted diseases (STDs) with

the steady rise in AIDS case reports is receiving considerable attention in many

discussions of HIV-related medical consequences (Stoneburner et al. 1988;

Centers for Disease Control 1987a, 1988). These reports are particularly

alarming because these increases are overrepresented among ethnic/racial

minorities and IV drug users (Brown and Primm 1988; Centers for Disease

Control 1987b). This is attributed in part to the fact that IV drug users are a

sexually active population (with a mean age of 35 years of those enrolled in

drug treatment in New York City) and that many characteristics of poverty (i.e.,

poor housing, poor hygiene, unemployment) occur with a greater frequency

among IV drug users, especially those in the inner cities of the northeastern

385

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United States. Sexual activity (particularly unprotected) and poverty,

respectively, have been demonstrated to be risks for STDs and TB. These

extensions of the HIV epidemic represent many of the challenges for drug

abuse treatment in the 1990s.

Only in the past several years have the many socioeconomic manifestations of

the HIV epidemic become evident. Given the propensity of HIV infection and

disease to strike individuals between the ages of 20 and 40 years, there is a

considerable increase in demand on health care resources from an age group

that required less such utilization before the HIV epidemic (Drucker 1986;

Weinberg and Murray 1987). Simultaneously, many inner-city health systems

are experiencing an increase in drug abuse in perinatal women and in children

who are orphaned (boarder babies). This increased demand is particularly

devastating because it occurs in many areas in which there was already a thin

fabric of health care resources. The loss of these young men and women also

means further deterioration in the economic base of selected communities. In

the northeastern United States these communities tend to be areas where drug

abuse is prevalent and where the economic base is also weak. This represents

further misery to communities in which an injurious state previously existed. As

discussed below, this state of affairs is a significant aspect of the background of

drug abuse treatment in the HIV era.

Drug abuse treatment plays an important role in preventing HIV transmission

and has public health benefits by indirectly dampening the spread of HIV

infection (Brown et al. 1988; Hubbard et al. 1988; Cooper 1989) in several

ways. First, individuals enrolled in effective drug abuse treatment participate in

drug abuse-associated behaviors that place them at risk of HIV infection and/or

transmission. Second, as new “recruits” to drug abuse are introduced to

psychoactive drug use by individuals with previous such experience, effective

drug abuse treatment programs reduce the number of “recruiters” available to

introduce new individuals to drug abuse behaviors. Unfortunately, there is not

enough drug abuse treatment to maximally achieve these HIV-associated

benefits. Also, the impact of the HIV epidemic in many ways may undermine

the delivery of drug abuse treatment services.

PATIENT PERSPECTIVE

After all the noble pronouncements about the benefits of various public policy

approaches and the focus on health care and social service systems, the

impact on the patient/client is the real litmus test. Although there have been

several investigations focusing on the cost-effectiveness of drug abuse

treatment (i.e., avoidance of crime and incarceration), studies on the impact of

chemical dependency on the individual largely have been limited to the

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physiological and pharmacological effects of the drug(s) and the psychological

aspects of drug dependence. However, the scope of available community drug

abuse services is associated strongly with that community’s attitude toward

drug abusers and drug treatment services. Unfortunately, there are great

obstacles impeding effective community responses to drug abuse-associated

HIV transmission (Brown 1990).

Even within the subculture of chemically dependent persons, there have been

many anecdotal accounts of discrimination, including accounts of parenteral

drug users refusing to use drugs with anyone perceived to be infected with the

HIV virus, which in part represents the effectiveness of dissemination of HIVrelated information among drug abusers. Although this behavior modification is

not the desired outcome of prevention efforts, it signals potential changes in the

social networks of drug abusers. Unfortunately, these changes also have

occurred within drug abuse treatment. Despite the increasing prevalence of

patients with symptomatic HIV disease in many drug treatment programs in

New York City, there has been no noticeable response of compassion by their

fellow patients. To the contrary, once a patient is suspected of having HIV

disease, there is often the accompanying ostracism.

Along similar lines, there have been unfortunate accounts of a patient’s HIV

serostatus limiting his or her admission to drug abuse treatment. There is also

the discrimination felt by drug-dependent patients/clients when they attempt to

seek medical and social services. Although the stigma against drug abusers in

most medical and social service institutions is legendary, it has increased with

HIV. Yet, because of the now commonly recognized association between HIV

disease and drug abuse, fewer human services providers are willing to extend

care to drug abusers.

Besides the discrimination experienced in their previous social networks and in

health and social service delivery systems, the HIV-infected drug abuser also

may sustain further deterioration in family support. Even without HIV infection,

chemically dependent families experience considerable challenges to their

integrity; the additional effect of HIV infection often produces family collapse.

For drug abusers, this means the unwillingness of family members to provide

emotional or physical help or to maintain communications. The stigma against

the HIV-infected drug abuser by their friends, their families, and health and

social service providers (in addition to some drug abuse treatment providers)

makes the challenges to drug abuse treatment monumental.

387
DRUG ABUSE PERSONNEL PERSPECTIVE

Understanding the impact of the AIDS pandemic requires a brief description of

the provider group. Providers can be categorized as former, recovered drug

abusers and professionally trained staff. Drug treatment personnel who have

had personal past experiences with psychoactive drug use tend to have an

inherent understanding of the drug abuse subculture. However, because of the

complexities involved in developing effective responses to the consequences of

drug dependency, there is an increasing demand for technical knowledge and

expertise in a range of disciplines. Both sources of drug treatment personnel

are insufficient to meet demand. For professional staff, institutions of higher

education do not see the field of drug dependency as an important career path.

All too often drug treatment professional personnel are on “temporary leave”

from their formal, academic career paths. Universities and other institutions

reflect society’s general prejudice against most aspects of drug addiction.

Drug abuse treatment personnel report many different types of experiences in

the midst of the HIV epidemic. They express a need to strengthen community

health and social service supports as a way to augment drug abuse treatment

services; the inadequacy of these resources in many communities is frustrating

for treatment staff. An emotional challenge to many treatment personnel is the

growing number of patients/clients who become symptomatic and disabled

secondary to HIV disease. The alarming frequency of this phenomenon has

been the chief complaint of many staff members working with drug-dependent

persons.

Another source of confusion for many who provide drug abuse treatment

services is reconciling drug abuse rehabilitation with current efforts to prevent

further IV drug use associated with HIV transmission. Although arguments for

and against needle-exchange efforts are not within the scope of this chapter,

many drug treatment professionals find the provision of sterile needles contrary

to the principles of drug abuse treatment. Needle-exchange discussions have

had important implications regarding the proper role of drug abuse and public

health interventions. One implication is whether drug abuse personnel should

support total discontinuance of parenteral drug use in concert with drug abuse

rehabilitation goals or agree to the provision of sterile needles in concert with

the public health goats of impeding the spread of needle-associated HIV. The

resulting decision has a major impact on how drug abuse treatment personnel

counsel and provide services to their clients.

Another concern for drug treatment personnel in dealing with the AIDS

pandemic is learning how to coexist with the range of scientific investigations

occurring in many drug treatment settings. Drug abuse treatment clinics

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represent logistically important points of contact with persons dependent on

illicit substances. Consequently, research efforts involving drug abusers in drug

treatment tend to have a greater probability of continued access. Investigators

recognize the need to maintain the integrity of the science and the

confidentiality of the participants (i.e., using only summary information and not

information with any personal identifiers). On the other hand, many drug

treatment staff members argue that information gained through research may

alert them to impending stresses in their patients’ lives and may indicate a need

for counseling and other interventions.

In addition to the issue of information-sharing, there is the continuing concern

for limited physical space. In New York City, drug abuse treatment clinics tend

to be located in unsightly buildings; conducting research in these institutions

often is met with resentment by drug abuse treatment staff. This resentment is

based on the concern that the limited available space must be shared with

nontreatment research staff members who cannot provide direct assistance.

Although the number of drug abuse treatment programs nationwide that

participate in such behavioral research is probably still in the minority, in the

epicenters of IV drug-associated HIV disease (e.g., New York, New Jersey, and

Florida), inadequate space has become an increasing concern.

PROGRAM OPERATION PERSPECTIVE

The HIV epidemic offers many challenges for drug abuse treatment clinics and,

ironically, many opportunities as well. For example, several factors influence

methadone treatment prugrams. The Federal regulations that provide

guidelines for the operation of drug abuse treatment facilities may be modified

further by State regulations. State regulations, promulgated by single-state

drug abuse service agencies, also address maximum patient capacity. If

methadone is provided as a pharmacological intervention, then compliance also

is required of the Drug Enforcement Administration, State health departments,

and State agencies that oversee controlled substances. Thus, for

administrators of drug abuse treatment programs, there is a continuing need to

establish systems that ensure compliance with Federal and State regulatory

bodies.

During the HIV pandemic, there have been occasions in which Federal and

State regulations opposed each other. For example, in some States HIV

serostatus is reportable–as are other communicable diseases–to the local

public health authority. However, the reporting of such information by drug

treatment staff is a violation of Federal regulations governing the confidentiality

of persons enrolled in drug abuse treatment. Such circumstances represent

administrative challenges in the AIDS era. Drug abuse treatment administrators

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must respond to these challenges while also ensuring that revenues are

sufficient to meet expenses for maintaining compliance and delivery of drug

abuse treatment services.

Even before the HIV epidemic there were disincentives to delivering effective

drug abuse treatment services. The lack of a truly effective marketing approach

is one such drawback. Because of the societal attitude against drug abuse,

providing care to those who are drug dependent has received a low priority.

There is no private or public agency (similar to the American Cancer Society or

the American Diabetes Association) that could mount an aggressive public

relations campaign about the virtues of drug abuse treatment. It is no wonder

that the opening of a drug abuse treatment clinic is met with extensive

community opposition.

The same issues that influence recruitment of drug abuse treatment personnel

affected staff retention and continuing competency before the HIV epidemic.

For most drug abuse treatment programs, AIDS has signaled further difficulties.

Many employment candidates inquire about the prevalence of HIV disease in

the patient population, and in some cases candidates withdraw their

applications when they discover that the population consists of drug-dependent

persons, chiefly because they perceive that the prospect of working with HIVinfected patients is considerable. For whatever reason, staff shortages are a

way of life in most drug abuse treatment programs.

Persistent staff shortages prohibit administrators from sparing their limited staff

to obtain important new information, even though this new information may be

helpful. Because of AIDS. the need to provide drug abuse treatment staff with

up-to-date HIV-related knowledge is paramount. However, as a result,

administrators must face the prospects of decreased revenues (by temporarily

limiting the delivery of some services) or more aggravating and stressful staff

working conditions (by having the remaining staff temporarily accommodate the

workload of their absent fellow employees).

In the area of financing most States license drug abuse treatment programs and

provide funding based on the number of patients (slots) served. Although there

is some indirect and often distant relationship to the breadth of services

delivered, reimbursement is not influenced by the types of services required by

many patients. This dilemma has stimulated discussions among administrative

staff about the composition and mix of services (e.g., serving pregnant, addicted

women at the exclusion of other patients). Many drug abuse treatment

administrators admit the benefits of enhancing service delivery by adding

primary medical care and enhanced counseling services. Simultaneously,

many drug abuse treatment programs quickly discover that current systems of

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remuneration require difficult decisions about the scope of service delivery. In

other words, financing is the force driving drug abuse treatment in the midst of

the HIV epidemic.

CONCLUSION

At the threshold of the 20th century’s last decade, drug dependency has taken

on even greater importance in this country. A large part of this is due to the

pivotal role that illicit drug abuse occupies in HIV transmission and in the

prevalence of HIV-related morbidity and mortality. These consequences of drug

dependency have stimulated interest in finding effective responses to intervene

in the natural history of addiction. Drug abuse treatment is one response with

proven efficacy (Tims, this volume) to slow the spread of drug abuse-associated

HIV. Despite this benefit, however, drug abuse treatment is experiencing

considerable challenges.

These challenges can be traced to the increasing medical and social service

needs of HIV-infected drug abusers at a time when they are experiencing

discrimination in their social networks, in health care and social service delivery

systems, and by their families. The challenges to drug abuse treatment also

include the increasing frustration experienced by drug abuse treatment staff

related to limited social and rehabilitation services, accompanied by the stress

of living with the morbidity and mortality of their patients in increasing numbers.

Finally, there are challenges related to the operation of drug abuse treatment

facilities. Although many disincentives to the provision of effective drug abuse

treatment services predated HIV, many of these obstacles have become even

more imposing. For administrators, this means complying with an array of

Federal and State regulations, which often may be contradictory. This is

supplemented by the difficulties in recruiting and retaining staff and reevaluating

the role of drug abuse treatment. This reassessment is occurring in an

environment of increasing patient care needs without changes in financing or

reimbursement mechanisms.

Ironically, the HIV epidemic also has provided drug abuse treatment programs

with the mandate to reflect on their purpose. Hopefully, as discussions such as

these proceed, there will be opportunities to address long-standing as well as

HIV-related disincentives to the provision of quality drug abuse treatment

services. Clearly, the challenges raised in this discussion are monumental, but

not insurmountable. The significance of developing effective solutions is

important to the drug abuse treatment delivery system; there are also benefits

to drug abusers, their families, and many communities across this country

where drug abuse and HIV-associated consequences of drug abuse are

prevalent.

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REFERENCES

Brown, L.S. Black intravenous drug users: Prospects for intervening in the

transmission of human immunodeficiency virus infection. In: Leukefeld,

C.G.; Battjes, R.J.; and Amsel, Z., eds. AlDS and Intravenous Use: Future

Directions for Community-Based Prevention Research. National Institute on

Drug Abuse Research Monograph 93. DHHS Pub. No. (ADM)89-1627.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1990. pp. 53-67.

Brown, L.S.; Burkett W.; and Primm, B.J. Drug treatment and HIV

seropositivity. N Y State J Med 88:156, 1988.

Brown, L.S., and Primm, B.J. Intravenous drug abuse and AIDS in minorities.

AIDS Public Policy 3:5-15, 1988.

Centers for Disease Control. Tuberculosis and acquired immunodeficiency

syndrome-New York. MMWR 36:785-795, 1987a.

Centers for Disease Control. Tuberculosis in minorities-United States. MMWR

36:77-80, 1987b.

Centers for Disease Control. Increase in pneumonia mortality among young

adults and the HIV epidemic-New York City. MMWR 37:593-496, 1988.

Cooper, J.R. Methadone treatment and acquired immunodeficiency syndrome.

JAMA 262:1664-1668, 1989.

Drucker, E. AIDS and addiction in New York City. Am J Drug Alcohol Abuse

12:165-181, 1986.

Hubbard, R.L.; Marsden, M.E.; Cavanaugh, E.; Rachal, J.V.; and Ginzburg,

H.M. Role of drug-abuse treatment in limiting the spread of AIDS. Rev Infect

Dis 10:377-384, 1988.

Stoneburner, R.L.; Des Jarlais, D.C.; Benezra, D.; Gorelkin, L.; Sotheran, J.L.;

Friedman, S.R.; Schultz, S.; Marmor, M.; Mildvan, D.; and Maslansky, R. A

larger spectrum of severe HIV-1-related disease in intravenous drug users in

New York City. Science 242:916-919, 1988.

U.S. Department of Health and Human Services. HIV/AIDS Surveillance–

Year-End Edition. January 1990.

Weinberg, D.S., and Murray, H.W. Coping with AIDS. The special problems of

New York City. N Engl J Med 317:1469-1473,1987.

AUTHOR

Lawrence S. Brown, Jr., M.D., M.P.H.

Senior Vice President

Medical Services, Evaluation & Research

Addiction Research and Treatment Corporation

22 Chapel Street

Brooklyn, NY 11201

392
Department of Medicine

Harlem Hospital Medical Center

Columbia University College of Physicians and Surgeons

New York, NY 10037

393
Improving Drug Abuse Treatment:

Recommendations for Research

and Practice

Carl G. Leukefeld, Roy W. Pickens, and Charles R. Schuster

INTRODUCTION

Drug abuse treatment is effective, but many of us forget that drug abuse is often

a chronic and relapsing condition. That recognition and efforts to make drug

abuse treatment more effective are the emphasis of this monograph, Improving

Drug Abuse Treatment. Authors were asked to comment on specific

recommendations they could make to improve drug abuse treatment,

recognizing the importance of the issue. A 1989 Gallup survey (Gallup

International Foundation 1989) reinforced that importance by reporting that drug

abuse topped the public’s list as the Nation’s most important problem, which is

virtually unprecedented for any social issue.

To help meet the concern about drug abuse and to coordinate Federal drug

efforts, the Office of National Drug Control Policy (ONDCP) was established in

the Executive Office of the President. As part of the challenge, ONDCP (1989,

1990) developed and updated the National Drug Control Strategy, which

focuses both on supply reduction and demand reduction activities, including

treatment. It also specifically recognizes that the Nation’s emphasis on

enforcement during the past decade must be supplemented with expanded

activities for treating drug abusers.

As part of emphasizing treatment to reduce the demand for drugs, the Office of

Treatment Improvement (OTI) was established in the Alcohol, Drug Abuse, and

Mental Health Administration. OTI, among other things, is charged with

providing an organizational home and with funding research programs for drug

abuse treatment; its principal function is to improve treatment services for

individuals who suffer from drug abuse and other problems associated with drug

abuse, including alcoholism and physical as well as mental illness. In addition,

OTI is staffed with individuals who have firsthand knowledge of and experience

with drug abuse treatment.

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The importance of drug abuse treatment may be driven partially by the spread

of acquired immunodeficiency syndrome (AIDS) and the human

immunodeficiency virus (HIV) epidemic among intravenous (IV) drug abusers.

IV drug abusers currently represent a high proportion of persons with AIDS,

almost 30 percent of adult AIDS cases (Centers for Disease Control 1990). IV

drug abusers also account for many AIDS cases among minorities and present

a major vector for the spread of HIV to the heterosexual community.

Until recently, drug abuse treatment had not been emphasized or received an

increase in revenues at the Federal level since the 1970s when President Nixon

declared a “war on drugs.” The National Institute on Drug Abuse (NIDA) was

created in 1974 during that period. That drug war expanded drug abuse

treatment by focusing on the connection between street crime and heroin

addiction and expanded and institutionalized the public drug abuse treatment

system. From at least one point of view, the publicly funded drug abuse

treatment field has matured, but new treatment approaches have not recently

evolved.

Along with the recent attention given to drug abuse treatment and treatment

effectiveness is the important recognition that treatment providers can and

should improve drug abuse treatment by applying the results of existing clinical

research. Unfortunately, the findings from clinical and other studies are not

readily transferred from journals and other publications to clinical practice.

Therefore, the recommendations at the end of this chapter, based on the most

current research results and clinical practice, are made to facilitate improvement

of drug abuse clinical practice. These recommendations form the core of this

chapter and incorporate administrative as well as fiscal suggestions to help

improve drug abuse treatment.

This technical review meeting was structured around specific areas that were

perceived as important for a better understanding of drug abuse treatment.

Chapter authors were asked to stress practical things that could be done, based

on available data and clinical experiences, to improve drug abuse treatment.

Many of the participants emphasized the effectiveness of drug abuse treatment

in modifying drug-abusing behaviors. In addition, it was suggested that this

monograph be dedicated to those drug abuse treatment staffs that have

provided treatment over many years–at times, in difficult circumstances.

Chapter authors voiced their concerns that the existing status of publicly funded

drug abuse treatment has been shaped by available funding, which until

recently has not kept up with inflation. These limitations have had a dramatic

influence on drug abuse treatment in the public sector. However, these

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resource limitations do not detract from the importance or the efficiency of most

drug treatment programs.

This monograph is anchored on the following areas, which serve as an

overview of drug abuse treatment and as an outline for this chapter’s

recommendations: current status of drug abuse treatment, clinical issues, and

program/policy issues. There was agreement among meeting participants,

bordering on total consensus, on improving drug abuse treatment, which is

reflected by the recommendations. There was an underlying sense of urgency

to move forward as quickly as possible, not only with the publication of this

volume but also, and more importantly, with action steps to improve drug abuse

treatment. The following sections present an overview of author contributions to

this monograph.

CURRENT STATUS OF DRUG ABUSE TREATMENT

Pickens and Fletcher provide an overview of issues related to improving drug

abuse treatment with a confirmation that drug abuse treatment is effective.

They also trace early drug abuse treatment efforts and link those early efforts

with contemporary treatment issues, including therapeutic community treatment

and methadone maintenance treatment. They emphasize the following areas

for improving drug abuse treatment: attracting drug abusers to treatment,

decreasing drug use rates for those in treatment, matching clients to treatment

programs, increasing treatment retention, preventing relapse, applying research

findings to clinical practice, increasing staff morale, and changing the reliance

on methadone maintenance programs.

Gustafson suggests that drug abuse treatment programs are straining to do

more and do it better. He highlights staffing issues as a major area for

improving drug abuse treatment and presents specific suggestions in such

areas as recruitment and retention, credentialing, facility improvement, staff

morale, AIDS and HIV services, and staff training and development.

Price and colleagues present findings from a survey of 569 methadone and

drug-free outpatient treatment programs. Multiple drug abuse is the major

presenting problem with young males, the predominant group receiving

services. Self-referrals and courts are the major treatment referral sources, with

self-referral the major source to methadone treatment. Staff members with

master’s and bachelor’s degrees provide the bulk of outpatient treatment

services, particularly in drug-free programs. Methadone treatment programs

reported more involvement with licensing and program certification. Finally,

only two-thirds of outpatient treatment units report any followup or relapse

prevention efforts, a major point of emphasis for improving treatment.

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Drug abuse treatment programs recently have reported that treatment is not

available in certain geographic areas and that treatment waiting lists exist,

largely in methadone treatment programs and therapeutic communities (TCs).

Butynski reports that there are about 1,600 drug abuse treatment units in the

United States in addition to 3,500 combined alcohol and drug abuse treatment

units. It is estimated that about 834,000 individuals received drug treatment in

1987 at these units, which have a treatment capacity of about 260,000 at any

one time. It is also estimated that 4 million persons had serious drug problems

in 1988 and that 2 million of these could benefit from drug abuse treatment

(Office of National Drug Control Policy 1989).

Butynski also emphasizes the diversity of publicly funded drug abuse treatment,

which is important in meeting treatment needs reflected by the variety and

severity of drug abuse. Drug treatment now incorporates the following:

detoxification programs, which have the goal of stopping the immediate physical

addiction to drugs; chemical dependency units, which offer 3 to 4 weeks of

private residential and inpatient treatment followed by outpatient treatment; TC

treatment involving 9 to 12 months of structured residential treatment; outpatient

treatment, the most common form of community drug abuse treatment offering

counseling and support, including psychotherapy; pharmacotherapy treatment,

including maintenance treatment with methadone, a prescribed medication to

block heroin withdrawal and craving; and self-help groups, which generally

apply Narcotics Anonymous (NA) and Alcoholics Anonymous approaches. In

addition to methadone, another pharmacotherapy uses naltrexone, which has

been approved by the Food and Drug Administration, in addition to methadone,

for treating illicit heroin addiction. Naltrexone is a synthetic narcotic antagonist

that blocks the “high” experienced from injecting heroin and reduces the craving

for heroin without opiate-like effects.

Tims and colleagues emphasize that both controlled and large cohort research

studies have reported that drug abuse treatment is effective in reducing drug

abuse and related behaviors (Hubbard et al. 1989; Simpson and Sells 1982).

An important additional point is that drug abuse treatment appears to be

effective in preventing the spread of HIV among IV drug abusers (Battjes et al.

1988; Hubbard et al. 1988; Novick et al. 1990).

Tims and colleagues also reference Hubbard and coworkers’ Treatment

Outcome Perspective Study (TOPS) as the most recent research that has

validated the effectiveness of drug abuse treatment. Subjects for this

longitudinal study included more than 11,000 individuals who received drug

abuse treatment from 1979 to 1981 from 41 different publicly supported

programs in 10 cities. Four treatment approaches were examined: methadone

detoxification, methadone maintenance treatment, TC treatment, and outpatient

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drug abuse treatment. A sample of three cohorts was followed for up to 3

years. Substantial decreases in heroin use and reduced cocaine use with

decreased severity of drug use were reported during and after treatment for

those who remained in treatment for at least 3 months. The benefits of

treatment matched or exceeded the costs of treatment. The average length of

stay was 159 days for residential treatment with an average total cost of $2,942

per patient, 267 days for outpatient methadone treatment with an average cost

of $1,602, and 101 days for outpatient treatment with an average cost of $606.

CLINICAL ISSUES

Clinical treatment skills can, and in some cases must, be changed to improve

drug abuse treatment. Clearly, there are multiple clinical issues associated with

the changing dient population. McLellan and Alterman point out the need to

develop valid and reliable assessment and diagnostic indicators to match clients

to treatment. The Addiction Severity Index has become a standard to collect

assessment information, including past and present symptoms, and to estimate

the level of discomfort along seven problem areas: alcohol use, medical

condition, drug use, employment/support, illegal activity, family/social relations,

and psychiatric function. Additional instrumentation is being developed to focus

on varied populations and provide clarity for clinical interventions. NIDA, along

with the National Institute of Mental Health and the National Institute on Alcohol

Abuse and Alcoholism, is collaborating with the World Health Organization and

the American Psychiatric Association to develop reliable and validated clinical

and research diagnostic criteria for drug abuse and dependence. Reliable

instruments are being developed to measure these criteria and have exciting

possibilities for both clinical practice and research in both domestic and crosscultural settings.

Kosten reports that enhanced diagnostic and clinical skills are necessary to

treat the more complex client issues related to multiple drug use, and Woody

and colleagues support this claim for use with comorbidity or dually diagnosed

clients. Kosten also suggests that most current multiple drug abuse involves

the use of cocaine, alcohol, opiates, and benzodiazepines and that using drugs

in combinations is often more severe than single drug use. Dually diagnosed

clients-individuals who have both drug abuse/dependence and a mental

disorder such as major depression or schizophrenia–often present special

management problems and seem to be increasing in drug abuse treatment

programs. Woody and colleagues suggest that addressing psychiatric

comorbidity can improve treatment but that implementing the necessary

protocols in publicly funded treatment programs is compromised without

qualified staff. A theme stressed throughout the presentations was that specific

treatments should be mixed and matched to individualize client treatment.

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Thus, it is suggested that “talking” therapies such as counseling and

psychotherapy could be combined with pharmacotherapy, relapse prevention,

and self-help activities to match clients to treatment.

Ongoing research is adding to our knowledge about counseling and

psychotherapy. Specifically, Onken presents research showing that therapists

differ in their effectiveness, and McCaul and Svikis show that the most effective

therapists/counselors should be retained and rewarded for their effectiveness.

However, although psychotherapy is effective in treating clients with severe or

moderate psychopathology, Onken’s data show that clients in methadone

treatment with low levels of psychopathology do as well with drug counseling as

with counseling plus psychotherapy.

An important and persistent finding is that drug abusers should be educated

about measures they can take to prevent relapse. Relapse prevention is

challenging, and although knowledge about relapse exists, Hall and colleagues

reveal that many puzzles remain. To better understand relapse, O’Brien and

colleagues identify four factors: psychiatric disorders, including depression and

anxiety disorders; social factors such as employment opportunities and social

supports; protracted abstinence syndrome, which may persist for 6 months or

more; and conditioned responses that “recall” drug experiences.

Practical considerations to decrease relapse and enhance recovery include a

recommendation from a previous NIDA review that clinicians can make

aftercare contacts at specific times following treatment: first week, first month,

third month, and first year (Leukefeld and Tims 1989). Nurco and colleagues

report that self-help groups are cost-effective for maintaining changes and can

help prevent relapse. Self-help groups such as NA help individuals cope with

life stressors as well as the discontinued dependency on substances.

A consistent research finding reported by Kreek is that methadone maintenance

is effective in significantly reducing or eliminating illicit and regular use of heroin

and other short-acting narcotics when appropriate doses of methadone are

prescribed. Several authors report on the large amount of research carried out

in methadone maintenance treatment clinics in several areas: efficacy of

treatment (Kreek), provision of rehabilitation services (Childress and

colleagues), approaches to reduce illicit drug use (Stitzer and Kirby), alcohol

use (Gordis), and HIV (Brown). Cooper presents NIDA’s plan to study the

feasibility of establishing a methadone maintenance treatment quality

assurance program with the aim of defining appropriate medical standards.

Research is currently proceeding to develop medications that normalize those

brain systems that are not regulated by drugs of abuse. For example, possible

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medications for cocaine include a painkiller called buprenorphine; an

antidepressant called desipramine; flupenthixol, an antipsychotic; an antiseizure

drug called carbamazepine; gepirone, an anxiety drug; bromocriptine and

mazindol, dopamine antagonists; and bupropion (Holden 1989). This emphasis

on medications development activities has been called the “Manhattan Project”

for chemists in the war on drugs (Time 1989).

TREATMENT PROGRAM AND POLICY ISSUES

The recent events that have helped focus the Nation’s increased drug abuse

activities on treatment programs and treatment policies are a result of various

perceptions and activities, including consistent media attention; the violence

associated with drug abuse; babies born addicted; the use of crack and

associated behaviors; and the relationship between needle use, sexual

behaviors, and AIDS.

Because the length of time in treatment consistently has been related to

positive drug abuse treatment outcomes, shown by Tims and colleagues, it

seems desirable to examine policies that enhance treatment retention. McCaul

and Svikis point to improving program compliance and De Leon to improving

retention as issues related to increasing the length of time in treatment that can

supplement relapse prevention activities reported by Hall and coworkers.

Mendelson and colleagues highlight the special needs of women with regard to

special treatment considerations for pharmacotherapeutic treatments and

issues related to polydrug abuse, alcohol abuse, and cocaine use.

There are also linkage issues related to the provision of community drug abuse

treatment. Linking community patient care and continuity of care recently has

been expanded due to the spread of HIV in large, urban communities.

Accounts (presented by Russo) of the overburdened primary care system along

with special needs of the IV drug abuser highlight difficulties. There is also a

high level of drug use by those who come into contact with the criminal justice

system. Leukefeld shows how the justice system provides opportunities for

using its authority to enhance drug abuse treatment.

Other policy issues also deserve special attention. First, program accountability

for publicly funded treatment providers is an area that will receive additional

emphasis. A second policy issue that currently has a direct impact on

community drug abuse treatment is community resistance to the neighborhood

placement of drug abuse treatment programs. Veatch refers to the NIMBY

(“Not In My Backyard”) syndrome as the overriding attitude of community

residents–the fear of increased crime and decreased property values. Clearly,

there is a need for expansion in this area, including technical assistance,

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videotapes, hands-on experiences, staff exchanges, and a variety of media, all

of which hold promise.

AREAS OF AGREEMENT RELATED TO IMPROVING DRUG ABUSE

TREATMENT

The following statements represent the major areas of agreement reached by

those researchers and practitioners who attended the NIDA meeting on

“Improving Drug Abuse Treatment.” As further introduction and for emphasis,

the editors would like to stress that the chapter authors as well as other meeting

participants agreed that drug abuse treatment is effective. To put it more boldly,

participants wanted to go on record that drug abuse treatment saves lives,

prevents and reduces criminal activities, improves quality of life, and when

compared with the alternative of incarceration without drug abuse treatment, is

cost-effective. The following statements represent areas of specific agreement.

Funding for Drug Abuse Treatment

1. The effectiveness of drug abuse treatment in some programs has been

compromised by limited funding and enormous demands on services.

2. Treatment program staffs should receive technical assistance and funding

to help them review the quality of their clinical services, with the goal of

improving their effectiveness.

3. Additional treatment funding should include support for essential

administrative and related services such as staff training, staff salaries,

enhanced data collection, evaluation activities, vocational services, new

facility construction, and new treatment slots.

Evaluating Drug Abuse Treatment

1. Additional data should be collected and new studies designed to allow for

more concise characterization of patients, programs, and outcome results.

2. Due to the chronic relapsing nature of drug dependence, evaluations of

treatment effectiveness should be based on client performance while in

treatment and after leaving treatment.

3. Accountability should be a necessary component of drug abuse treatment,

with the provision of fiscal and staff resources to support regular reporting

on client characteristics, program characteristics, services provided, fees,

and performance measures.

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4. Quality assurance components are needed in drug abuse treatment

programs to ensure the highest quality of patient care.

Clinical Aspects of Drug Abuse Treatment

1.

2.

3.

4.

5.

6.

7.

8.

Special attention should be paid to improving the clinical skills of treatment

staff because staff members now are required to intervene with more

complex clinical issues (e.g., comorbidity, psychopathology, infectious

diseases related to HIV, sexually transmitted diseases, tuberculosis, and

medications).

Research shows that counselors and therapists differ considerably in their

effectiveness, even with the same level of training and experience.

Increased efforts should be made to identify and to retain them by providing

the most effective counselors and therapists with higher salaries and other

inducements.

After treatment capacity is expanded, more emphasis should be placed on

enhancing outreach activities and recruiting patients into treatment,

because evidence suggests that ethnic and cultural matching of clients to

treatment may affect compliance with treatment.

Psychiatric and medical comorbidity and multiple drug use, including

alcohol problems and cocaine/crack use, are becoming increasingly

common among clients entering drug abuse treatment; treatment programs

must be able to recognize and treat such conditions.

Additional emphasis should be placed on matching clients to treatment

because evidence suggests that clients with moderate to severe

psychopathology do better in programs that provide psychotherapy and/or

pharmacotherapy.

Although psychotherapy has been effective in treating clients with severe

and moderate levels of psychopathology, clients in methadone treatment

with low levels of psychopathology do as well with drug counseling as with

drug counseling plus psychotherapy.

Preliminary evidence indicates that involving senior staff in initial client

contacts during the intake process may improve retention rates for TCs.

Relapse prevention strategies have been shown to reduce drug use

following treatment. Educating drug abusers about these strategies during

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9.

10.

11.

treatment and placing greater emphasis on provision of followup services

may improve treatment outcomes.

Conditioning to drug-related stimuli develops during chronic drug use and

continues into relapse after treatment. Although research evidence is not

complete, preliminary evidence suggests that exposing drug abusers to

these stimuli in a supportive treatment environment may result in extinction

and help to eliminate the stimuli as factors that contribute to relapse.

Self-help groups are cost-effective for maintaining behavioral changes

following drug abuse treatment and for teaching appropriate role behaviors

to clients in methadone treatment. Self-help groups are also beneficial for

drug abusers who do not require intense treatment.

Appropriate medical use of psychotropic medications should not be

prohibited in drug treatment programs; their appropriate use has been

shown to be beneficial for many drug-dependent persons.

Methadone Maintenance Treatment

1.

2.

3.

4.

Adequate doses of methadone should be prescribed in maintenance

treatment because evidence indicates that low doses of methadone are

associated with higher rates of illicit drug use, premature treatment

termination, and failure to comply with treatment goals.

Methadone maintenance programs should be funded and staffed to provide

supportive services to those with an assessed need in addition to

methadone; preliminary evidence suggests that such clients function better

in programs that provide counseling and other needed services.

Allowing methadone take-home privileges that are contingent on “clean”

urines may be effective in reducing illicit drug use during methadone

treatment. However, additional research is needed to determine the

durability of such approaches.

Methadone-maintained patients should not be prohibited from also entering

abstinence-oriented programs for the management of other dependencies,

including alcohol.

Linking Drug Abuse Treatment With Other Community Institutions

1. A stronger linkage must be established by drug abuse treatment programs

with the criminal justice system because the justice system has a high

403
proportion of individuals with drug problems and offers motivation (i.e.,

probation and parole) for drug abusers to enter and comply with treatment

goals.

2. Stronger linkages are needed between drug abuse treatment and primary

medical care and mental health care services to provide a continuum of

care for drug-dependent persons, especially those with AIDS and other

infectious diseases.

Minority Involvement in Drug Abuse Treatment

1. The special needs of minorities and women must be recognized by drug

treatment programs along with expanded resources to train existing staff

and hire new staff members who are culturally and racially sensitive and

who speak the primary language of their clients.

Community Barriers to Drug Abuse Treatment

1. Community obstacles and barriers to identifying and establishing new

treatment program sites must be overcome to maximize the use of

treatment as an effective strategy for reducing drug abuse and HIV.

National, State, and local policymakers must become involved in this

process.

Transferring Proven Drug Abuse Treatment Technologies

1. Technology transfer should be improved to ensure rapid communication of

research findings so that they can be incorporated into clinical skillsbuilding and practice.

2. Treatment programs and providers must be encouraged to adopt new

knowledge based on research into their clinical practice. Such knowledge

should be transferred through more intensive direct contacts among

researchers and practitioners and through the provision of technical

assistance and training to practitioners.

Research Focused on Improving Drug Abuse Treatment

1. Treatment programs should support research efforts that focus on

improving the effectiveness and efficiency of drug abuse treatment,

including medications development, improved counseling and

psychotherapy techniques, psychiatric and medical comorbidity, and

quality assurance issues.

404
2. Research programs should support and incorporate practitioner insights

directed to improving treatment.

3. Treatment research should address areas of system improvements to

better understand the dynamics of underlying biological and behavioral

factors. Specific areas include recruitment, retention, illicit drug use and

alcohol problems during treatment, and relapse following treatment.

4. Drug abuse treatment programs should be encouraged to participate in

both drug abuse clinical research and evaluation studies.

Training

1. Training should be expanded to develop and refine clinical skills for

physicians, nurses, social workers, clinical psychologists, counselors, and

case managers.

REFERENCES

Battjes, R.J.; Leukefeld, C.G.; Pickens, R.W.; and Haverkos, H.W. The

acquired immunodefciency syndrome and intravenous drug abuse. Bull

Narc 40(1):21-34, 1988.

Can drugs cure drug addiction? Time December 11, 1989. pp. 104.

Centers for Disease Control. HIV/AIDS Surveillance Report. Atlanta, GA:

Centers for Disease Control, February 1990.

Gallup international Foundation. “Surveys of the Attitudes of American Adults

and Teen-Agers Towards the Drug Crisis and Drug Policy.” Press briefing

presented at the Old Executive Office Building, Washington, DC, August 4,

1989.

Holden, C. Street-wise crack research. Science 246:1376-1381, 1989.

Hubbard, R.L.; Marsden, M.E.; Cavanaugh, E.; Rachal, J.V.; and Ginzburg,

H.M. Role of drug abuse treatment in limiting the spread of AIDS. Rev Infect

Dis 10(2):377-384, 1988.

Hubbard, R.L.; Marsden, M.E.; Rachal, J.V.; Harwood, H.J.; Cavanaugh, E.R.;

and Ginzburg, H.M. Drug Abuse Treatment National Study of

Effectiveness. Chapel Hill, NC: University of North Carolina Press, 1989.

Leukefeld, C.G., and Tims, F.M. Relapse and recovery in drug abuse:

Research and practice. Int J Addict 24(3):189-201, 1989.

Novick, D.M.; Herman, J.; Croxon, T.S.; Salsitz, E.A.; Wang, G.; Richman, B.L.;

Poretsky, L.; Keefe, J.B.; and Whimbet, E. Absence of antibody to human

immunodeficiency virus on long-term, socially rehabilitated methadone

maintenance patients. Arch Intern Med 150:97-99, 1990.

405
Office of National Drug Control Policy. National Drug Control Strategy. S/N

040-000-00542-1 Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

September 1989.

Office of National Drug Control Policy. National Drug Control Strategy. S/N

040-000-00543-9 Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

January 1990.

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

Effectiveness: Summary of the DARP followup Research. DHHS Pub. No.

(ADM)82-1209. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1982.

AUTHORS

Carl G. Leukefeld, D.S.W.

Director

Multidisciplinary Center on Drug and Alcohol Abuse

Department of Psychiatry

University of Kentucky Medical Center

Room 210

800 Rose Street

Lexington, KY 40536

Charles R. Schuster, Ph.D.

Director

National Institute on Drug Abuse

Room 10-05

5600 Fishers Lane

Rockville, Maryland 20857

Roy W. Pickens, Ph.D.

Acting Director

Addiction Research Center

National Institute on Drug Abuse

4940 Eastern Avenue

Baltimore, MD 21224

406
monograph series

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; add $3 handling charge for each order.

Microfiche copies 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, MD 20852

(301) 468-2600

(800) 729-6686

GPO

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NTIS

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For information on availability of NIDA Research Monographs 1 through 24

(1975-1979) and others not listed, write to NIDA, Community and Professional

Education Branch, Room 10A-54,5600 Fishers Lane, Rockville, MD 20857.

407
25 BEHAVIORAL ANALYSIS AND TREATMENT OF SUBSTANCE ABUSE.

Norman A. Krasnegor, Ph.D., ed.

GPO out of stock NCADI out of stock

NTIS PB #80-112428/AS $31

26 THE BEHAVIORAL ASPECTS OF SMOKING. Norman A. Krasnegor,

Ph.D., ed. (reprint from 1979 Surgeon General’s Report on Smoking and

Health)

GPO out of stock NTIS PB #80-118755/AS $23

30 THEORIES ON DRUG ABUSE: SELECTED CONTEMPORARY

PERSPECTIVES. Dan J. Lettieri, Ph.D.; Mollie Sayers; and Helen W. Pearson,

eds.

GPO out of stock NCADI out of stock

Not available from NTIS

31 MARIJUANA RESEARCH FINDINGS: 1980. Robert C. Petersen, Ph.D.,

ed.

GPO out of stock NTIS PB #80-215171/AS $31

32 GC/MS ASSAYS FOR ABUSED DRUGS IN BODY FLUIDS. Rodger L.

Foltz, Ph.D.; Allison F. Fentiman, Jr., Ph.D.; and Ruth B. Foltz, eds.

GPO out of stock NCADI out of stock

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36 NEW APPROACHES TO TREATMENT OF CHRONIC PAIN: A REVIEW

OF MULTIDISCIPLINARY PAIN CLINICS AND PAIN CENTERS. Lorenz K.Y.

Ng, M.D., ed.

GPO out of stock NCADI out of stock

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37 BEHAVIORAL PHARMACOLOGY OF HUMAN DRUG DEPENDENCE.

Travis Thompson, Ph.D., and Chris E. Johanson, Ph.D., eds.

GPO out of stock NCADI out of stock

NTIS PB #82-136961/AS $39

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/AS $23

408
40 ADOLESCENT MARIJUANA ABUSERS AND THEIR FAMILIES. Herbert

Hendin, M.D; Ann Pollinger, Ph.D.; Richard Ulman, Ph.D.; and Arthur Carr,

Ph.D., eds.

GPO out of stock NCADI out of stock

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42 THE ANALYSIS OF CANNABINOIDS IN BIOLOGICAL FLUIDS. Richard

L. Hawks, Ph.D., ed.

GPO out of stock NTIS PB #83-136044/AS $23

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.

GPO out of stock NCADI out of stock

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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.

GPO out of stock NCADI out of stock

NTIS PB #84-184670/AS $17

46 BEHAVIORAL INTERVENTION TECHNIQUES IN DRUG ABUSE

TREATMENT. John Grabowski, Ph.D.; Maxine L. Stitzer, Ph.D.; and Jack E.

Henningfield, Ph.D., eds.

GPO out of stock NCADI out of stock

NTIS PB #84-184688/AS $23

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 out of stock NCADI out of stock

NTIS PB #85-159663/AS $31

48 MEASUREMENT IN THE ANALYSIS AND TREATMENT OF SMOKING

BEHAVIOR. John Grabowski, Ph.D., and Catherine Bell, M.S., eds.

GPO out of stock NCADI out of stock

NTIS PB #84-145184/AS $23

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 $23

409
51 DRUG ABUSE TREATMENT EVALUATION: STRATEGIES, PROGRESS,

AND PROSPECTS. Frank M. Tims, Ph.D., ed.

GPO out of stock NTIS PB #85-150365/AS $23

52 TESTING DRUGS FOR PHYSICAL DEPENDENCE POTENTIAL AND

ABUSE LIABILITY. Joseph V. Brady, Ph.D., and Scott E. Lukas, Ph.D., eds.

GPO out of stock NTIS PB #85-150373/AS $23

53 PHARMACOLOGICAL ADJUNCTS IN SMOKING CESSATION. John

Grabowski, Ph.D., and Sharon M. Hall, Ph.D., eds.

GPO out of stock NCADI out of stock

NTIS PB #89-123186/AS $23

54 MECHANISMS OF TOLERANCE AND DEPENDENCE. Charles Wm.

Sharp, Ph.D., ed.

GPO out of stock NCADI out of stock

NTIS PB #89-103279/AS $39

55 PROBLEMS OF DRUG DEPENDENCE, 1984: PROCEEDINGS OF THE

46TH ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS

OF DRUG DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

GPO out of stock NCADI out of stock

NTIS PB #89-123194/AS $45

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 NTIS PB #89-123160/AS $31

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 out of stock NTIS PB #88-248083/AS $23

58 PROGRESS IN THE DEVELOPMENT OF COST-EFFECTIVE

TREATMENT FOR DRUG ABUSERS. Rebecca S. Ashery, D.S.W., ed.

GPO out of stock NTIS PB #89-125017/AS $23

59 CURRENT RESEARCH ON THE CONSEQUENCES OF MATERNAL

DRUG ABUSE. Theodore M. Pinkert, M.D., J.D., ed.

GPO out of stock NTIS PB #89-125025/AS $23

410
60 PRENATAL DRUG EXPOSURE: KINETICS AND DYNAMICS. C. Nora

Chiang, Ph.D., and Charles C. Lee, Ph.D., eds.

GPO out of stock NTIS PB #89-124564/AS $23

61 COCAINE USE IN AMREICA: EPIDEMIOLOGIC AND CLINICAL

PERSPECTIVES. Nicholas J. Kozel, M.S., and Edgar H. Adams, M.S., eds.

GPO out of stock NTIS PB #89-131866/AS $31

62 NEUROSCIENCE METHODS IN DRUG ABUSE RESEARCH. Roger M.

Brown, Ph.D.; David P. Friedman, Ph.D.; and Yuth Nimit, Ph.D., eds.

GPO out of stock NCADI out of stock

NTIS PB #89-130660/AS $23

63 PREVENTION RESEARCH: DETERRING DRUG ABUSE AMONG

CHILDREN AND ADOLESCENTS. Catherine S. Bell, M.S., and Robert Battjes,

D.S.W., eds.

GPO out of stock NTIS PB #89-103267/AS $31

64 PHENCYCLIDINE: AN UPDATE. Doris H. Clouet. Ph.D., ed.

GPO out of stock NTIS PB #89-131858/AS $31

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 $3.50 NTIS PB #89-130637/AS $23

66 GENETIC AND BIOLOGICAL MARKERS IN DRUG ABUSE AND

ALCOHOLISM. Monique C. Braude, Ph.D., and Helen M. Chao, Ph.D., eds.

GPO out of stock NCADI out of stock

NTIS PB #89-134423/AS $23

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 out of stock NCADI out of stock

NTIS PB #89-134936/AS $31

69 OPIOID PEPTIDES: MEDICINAL CHEMISTRY. Rao S. Rapaka, Ph.D.;

Gene Barnett, Ph.D.; and Richard L. Hawks, Ph.D., eds.

GPO out of stock NTIS PB #89-158422/AS $39

70 OPIOID PEPTIDES: MOLECULAR PHARMACOLOGY, BIOSYNTHESIS,

AND ANALYSIS. Rao S. Rapaka, Ph.D., and Richard L. Hawks, Ph.D., eds.

GPO out of stock NTIS PB #89-158430/AS $45

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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 out of stock NTIS PB #89-151955/AS $31

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 NTIS PB #89-151963/AS $31

73 URINE TESTING FOR DRUGS OF ABUSE. Richard L. Hawks, Ph.D., and

C. Nora Chiang, Ph.D., eds.

GPO Stock #017-024-01313-7 $3.75 NTIS PB #89-151971/AS $23

74 NEUROBIOLOGY OF BEHAVIORAL CONTROL IN DRUG ABUSE.

Stephen I. Szara, M.D., DSc., ed.

GPO Stock #017-024-01314-5 63.75 NTIS PB #89-151989/AS $23

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 out of stock NCADI out of stock

Not available from NTIS

76 PROBLEMS OF DRUG DEPENDENCE, 1986: PROCEEDINGS OF THE

48TH ANNUAL SCIENTIFIC MEETING, THE COMMlTTEE ON PROBLEMS

OF DRUG DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

GPO out of stock NCADI out of stock

NTIS PB #88-208111/AS $53

77 ADOLESCENT DRUG ABUSE: ANALYSES OF TREATMENT

RESEARCH. Elizabeth R. Rahdert, Ph.D., and John Grabowski, Ph.D., eds.

GPO Stock #017-024-01348-0 $4 NCADI out of stock

NTIS PB #89-125488/AS $23

78 THE ROLE OF NEUROPLASTICITY IN THE RESPONSE TO DRUGS.

David P. Friedman, Ph.D., and Doris H. Clouet, Ph.D., eds.

GPO out of stock NTIS PB #88-245683/AS $31

79 STRUCTURE-ACTIVITY RELATIONSHIPS OF THE CANNABINOIDS.

Rao S. Rapaka, Ph.D., and Alexandros Makriyannis, Ph.D., eds.

GPO out of stock NTIS PB #89-109201/AS $31

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80 NEEDLE SHARING AMONG INTRAVENOUS DRUG ABUSERS:

NATIONAL AND INTERNATIONAL PERSPECTIVES. Robert J. Battjes,

D.S.W., and Roy W. Pickens, Ph.D., eds.

GPO out of stock NTIS PB #88-2361381/AS $31

81 PROBLEMS OF DRUG DEPENDENCE, 1987: PROCEEDINGS OF THE

49TH ANNUAL SCIENTIFIC MEETING, THE COMMllTEE ON PROBLEMS

OF DRUG DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

GPO Stock #017-024-01354-4 $17 NTIS PB #89-109227/AS

Contact NTIS for price

82 OPIOIDS IN THE HIPPOCAMPUS. Jacqueline F. McGinty, Ph.D., and

David P. Friedman, Ph.D., eds.

GPO out of stock NTIS PB #88-245691/AS $23

83 HEALTH HAZARDS OF NITRITE INHALANTS. Harry W. Haverkos, M.D.,

and John A. Dougherty, Ph.D., eds.

GPO out of stock NTIS PB #89-125496/AS $23

84 LEARNING FACTORS IN SUBSTANCE ABUSE. Barbara A. Ray, Ph.D.,

ed.

GPO Stock #017-024-01353-6 $6 NTIS PB #89-125504/AS $31

85 EPIDEMIOLOGY OF INHALANT ABUSE: AN UPDATE. Raquel A. Crider,

Ph.D., and Beatrice A. Rouse, Ph.D., eds.

GPO Stock #017-024-01360-9 $5.50 NTIS PB #89-123178/AS $31

86 COMPULSORY TREATMENT OF DRUG ABUSE: RESEARCH AND

CLINICAL PRACTICE. Carl G. Leukefeld, D.S.W., and Frank M. Tims, Ph.D.,

eds.

GPO Stock #017-024-01352-8 $7.50 NTIS PB #89-151997/AS $31

87 OPIOID PEPTIDES: AN UPDATE. Rao S. Rapaka, Ph.D., and Bhola N.

Dhawan, M.D., eds.

GPO Stock #017-024-01366-8 $7 NTIS PB #89-158430/AS $45

88 MECHANISMS OF COCAINE ABUSE AND TOXICITY. Doris H. Clouet,

Ph.D.; Khursheed Asghar, Ph.D.; and Roger M. Brown, Ph.D., eds.

GPO Stock #017-024-01359-5 $11 NTIS PB #89-125512/AS $39

89 BIOLOGICAL VULNERABILTY TO DRUG ABUSE. Roy W. Pickens,

Ph.D., and Dace S. Svikis. B.A., eds.

GPO Stock #017-022-01054-2 $5 NTIS PB #89-125520/AS $23

413
90 PROBLEMS OF DRUG DEPENDENCE, 1988: PROCEEDINGS OF THE

50TH ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS

OF DRUG DEPENDENCE. INC. Louis S. Harris, Ph.D., ed.

GPO Stock #017-024-01362-5 $17

91 DRUGS IN THE WORKPLACE: RESEARCH AND EVALUATION DATA.

Steven W. Gust, Ph.D., and J. Michael Walsh, Ph.D., eds.

GPO Stock #017-024-01384-6 $10 NTIS PB #90-147257/AS $39

92 TESTING FOR ABUSE LIABILITY OF DRUGS IN HUMANS. Marian W.

Fischman, Ph.D., and Nancy K. Mello, Ph.D., eds.

GPO Stock #017-024-01379-0 $12 NTIS PB #90-148933/AS $45

93 AIDS AND INTRAVENOUS DRUG USE: FUTURE DIRECTIONS FOR

COMMUNITY-BASED PREVENTION RESEARCH. C.G. Leukefeld, D.S.W.;

R.J. Battjes, D.S.W.; and Z. Amsel, D.Sc., eds.

GPO Stock #017-024-01388-9 $10 NTIS PB #90-148941/AS $39

94 PHARMACOLOGY AND TOXICOLOGY OF AMPHETAMINE AND

RELATED DESIGNER DRUGS. Khursheed Asghar, Ph.D., and Errol De

Souza, Ph.D., eds.

GPO Stock #017-024-01386-2 $11 NTIS PB #90-148958/AS $39

95 PROBLEMS OF DRUG DEPENDENCE, 1989: PROCEEDINGS OF THE

51ST ANNUAL SCIENTIFIC MEETING. THE COMMITTEE ON PROBLEMS

OF DRUG DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

GPO Stock #017-024-01399-4 $21 NTIS PB #90-237660/AS $67

96 DRUGS OF ABUSE: CHEMISTRY, PHARMACOLOGY, IMMUNOLOGY,

AND AIDS. Phuong Thi Kim Pham. Ph.D., and Kenner Rice, Ph.D., eds.

GPO Stock #017-024-01403-6 $8 NTIS PB #90-237678/AS $31

97 NEUROBIOLOGY OF DRUG ABUSE: LEARNING AND MEMORY. Lynda

Erinoff, Ph.D., ed.

GPO Stock #017-024-01404-4 $8 NTIS PB #90-237686/AS $31

98 THE COLLECTION AND INTERPRETATION OF DATA FROM HIDDEN

POPULATIONS. Elizabeth Y. Lambert. M.S., ed.

GPO Stock #017-024-01407-9 64.75 NTIS PB #90-237694/AS $23

99 RESEARCH FINDINGS ON SMOKING OF ABUSED SUBSTANCES,

C. Nora Chiang, Ph.D., and Richard L. Hawks, Ph.D. eds.

GPO Stock #017-024-01412-5 $5

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100 DRUGS IN THE WORKPLACE: RESEARCH AND EVALUATION DATA.

VOL. II. Steven W. Gust, Ph.D., and J. Michael Walsh, Ph.D., eds.

101 RESIDUAL EFFECTS OF ABUSED DRUGS ON BEHAVIOR. John W.

Spencer, Ph.D., and John J. Boren, Ph.D., eds.

GPO Stock #017-024-01426-5 $6

102 ANABOLIC STEROID ABUSE. Geraline C. Lin, Ph.D., and Lynda Erinoff,

Ph.D., eds.

GPO Stock #017-024-01425-7 $6

103 DRUGS AND VIOLENCE: CAUSES, CORRELATES, AND

CONSEQUENCES. Mario De La Rosa, Ph.D.; Elizabeth Y. Lambert, M.S.;

and Bernard Gropper, Ph.D., eds.

GPO Stock #017-024-01427-3 $9

104 PSYCHOTHERAPY AND COUNSELING IN THE TREATMENT OF

DRUG ABUSE. Lisa Simon Onken, Ph.D., and Jack D. Blaine, M.D., eds.

GPO Stock #017-024-01429-0 $4

105 PROBLEMS OF DRUG DEPENDENCE, 1990: PROCEEDINGS OF THE

52ND ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS

OF DRUG DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

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