Not everyone who tries drugs or regularly uses drugs
becomes addicted; however, those who do become
addicted find that not only does the compulsion to take
drugs take over their life, but these compulsive behaviors
come with a wide range of dysfunctional behaviors that
can interfere with normal functioning in the family, the
workplace, and the broader community. Addiction also
can place people at increased risk for a wide variety of
other illnesses. These illnesses can be brought on by
behaviors, such as poor living and health habits, that
often accompany life as an addict, or because of toxic
effects of the drugs themselves. Because addiction has so
many dimensions and disrupts so many aspects of an
individual’s life, treatment for this illness is never simple.
Drug treatment must help the individual stop using drugs
and maintain a drug-free lifestyle, while achieving productive
functioning in the family, at work, and in society.
Effective drug abuse and addiction treatment programs
typically incorporate many components, each directed to
a particular aspect of the illness and its consequences.
Drug Addiction Treatment is Effective
Overall, treatment of addiction is as successful as treatment
of other chronic diseases, such as diabetes,
hypertension, and asthma. Drug treatment reduces drug
use by 40 to 60 percent and significantly decreases criminal
activity during and after treatment. Research shows
that drug addiction treatment reduces the risk of HIV
infection and that interventions to prevent HIV are much
less costly than treating HIV-related illnesses. Drug injectors
who do not enter treatment are up to six times more
likely to become infected with HIV than injectors who
enter and remain in treatment. Treatment can improve
the prospects for employment, with gains of up to 40 percent after a single treatment episode. Although these effectiveness rates hold in general, individual treatment
outcomes depend on the extent and nature of the patient’s
presenting problems, the appropriateness of the treatment
components and related services used to address those
problems, and the degree of active engagement of the
patient in the treatment process.
Research on Addiction19
Scientific research and clinical experience have
increased our understanding of addiction, which is characterized
by compulsive drug-seeking and use—even in
the face of negative consequences. Virtually all drugs of
abuse affect a single pathway deep within the brain: the
mesolimbic reward system. Activation of this system
appears to be what motivates substance abusers to keep
taking drugs. Not only does acute drug use modify brain
function in important ways, but prolonged drug use
causes pervasive changes in the brain that persist long
after the individual stops taking a drug. Significant effects
of chronic use have been identified for many drugs at all
levels: molecular, cellular, structural, and functional.
The addicted brain is distinctly different from the non-addicted
brain, as manifested by changes in metabolic
activity, receptor availability, gene expression, and responsiveness
to environmental cues. Some of these long-lasting
changes are unique to specific drugs whereas others are
common to many substances. We can actually see these
changes through use of imaging technologies, like
positron emission tomography. Understanding that
addiction is, at its core, a consequence of fundamental
changes in brain function means that a major goal of
treatment must be to compensate for brain changes
through medication or behavior modification.
Addiction is not just a brain disease. The social context
in which drug dependence expresses itself is critically
important. The case of thousands of returning Vietnam
veterans who were addicted to heroin illustrates this point.
In contrast to addicts on the streets of America, many of
the veterans were relatively easy to treat. American soldiers
in Vietnam who became addicted did so in a totally different
setting from the one to which they returned. At home
in the United States, veterans were exposed to very few of
the conditioned environmental cues that had been associated
with drug use in Southeast Asia. Conditioned cues
can be a major factor in causing recurrent drug cravings
and relapse even after successful treatment.
Addiction is rarely an acute illness. For most people, it
is a chronic illness with a significant volitional dimension.
Total abstinence for the rest of one’s life is relatively rare
following a single experience in treatment. Relapses are
not unusual. Thus, addiction must be approached like
other chronic illnesses—such as diabetes and hypertension—rather than acute conditions, like a bacterial
infection or broken bone. This approach has serious
implications for how we evaluate treatment. Viewing
addiction as a chronic illness means that a good treatment
outcome may be a sizeable decrease in drug use and long
periods of abstinence.
Status of Drug Treatment
A significant treatment gap—defined as the difference
between individuals who would benefit from treatment
and those receiving it — exists. According to recent estimates
drawn from the National Household Survey on
Drug Abuse (NHSDA), the Uniform Facility Data Set
(UFDS), and other sources, approximately five million
drug users needed immediate treatment in 1998 while 2.1
million received it. The NIAAA report, Improving the
Delivery of Alcohol Treatment and Prevention Services, estimates
that there are fourteen million alcohol abusers
whereas the 1998 NHSDA found approximately ten million
dependent on alcohol. Certain parts of the country
have little treatment capacity of any sort. Likewise, some
populations—adolescents, women with small children,
and racial as well as ethnic minorities—are woefully
under-served. According to the Child Welfare League of
America, in 1997 only 10 percent of child welfare agencies
were able to locate treatment within a month for
clients who needed it.16 According to SAMHSA, 37 percent
of substance-abusing mothers of minors received
treatment in 1997.17 Some modalities—namely
methadone—fall short of needed capacity; 179,000
patients were in methadone treatment at the close of
1998. Furthermore, while treatment should be available
to those who request it, society also has a strong interest
in helping populations that need treatment but will not
seek it. Drug-dependent criminal offenders and addicts
engaging in high-risk behavior are important candidates
for treatment, whether they want it or not.
Ultimately, calculations of the treatment gap should
include both actual demand and populations that society
has a special interest in treating due to the high social cost
associated with their drug abuse. Starting in 2000, a new
methodology—based on clinical criteria—will be
employed in the NHSDA. This approach will provide
improved national estimates by August 2001. More precise
numbers will be helpful in determining the
magnitude of the treatment gap and targeting resources to
the areas where the gap is greatest.
Limited funding for substance-abuse treatment is a
major factor that restricts the availability of treatment.
Over the last decade, spending on substance-abuse prevention
and treatment rose to an estimated annual level of
$12.6 billion. Of this amount, public spending is estimated
at $7.6 billion. The public sector includes
Medicaid, Medicare, federal agencies like the Veterans
Administration, the Substance Abuse Prevention and
Treatment (SAPT) Block Grant, and other state and local
government expenditures. Private spending is estimated at
$4.7 billion and includes individual out-of-pocket payment,
insurance, and other non-public sources. One of
the main reasons for the higher outlay in public spending
is the frequently limited coverage by private insurers. The
lack of coverage and recent changes in payment structures
affect attitudes, resources, treatment plans, and the quality
of treatment. Private and public insurers are not
working collaboratively; thus, more public resources are
utilized, and government funds—which were intended
to be a safety net—have become a primary option for
many individuals.
In addition to resource limitations, other factors limit
treatment, including restrictive policies and regulations,
incomplete knowledge of best practices, resistance to
treatment on the part of certain populations in need, and
limited information on treatment at the state and local
level. Action in the following areas can make treatment
more available:
- Increase SAPT Block Grant funding to close the
treatment gap. Increase funding for NIDA’s National
Drug Abuse Treatment Clinical Trials Network
(CTN) program to improve the quality of drug abuse
treatment throughout the country and to ensure the
delivery of effective therapies in community-based
treatment programs.
- Use funding under SAMHSA’s Targeted Capacity
Expansion program; expansion of services to vulnerable
and underserved populations; more outreach
programs for those at risk of HIV/AIDS; and
increased community options for sanctions among
criminal and juvenile justice clients.
- Use regulatory change to make proven modalities
more accessible: reform regulation of methadone/LAAM treatment, maintain and improve program
quality; train treatment professionals and physicians
to employ the proper administration of opiate agonists
and emerging pharmacotherapies; conduct
demonstrations of administration by doctors of opiate
agonists; and provide comprehensive evaluation
of the impact of regulatory reform on treatment
access, quality, and cost.
- Continue examining possible changes in policy to
remove barriers, such as lack of parity in insurance
coverage. For example, the President recently
announced that the federal Employees Health Benefits
Plan (FEHB) would provide parity for both
substance abuse and mental health services.
- Review policies, practices, and federal statutory
requirements, such as the statutory exclusion of Medicaid
funding for Institutes for Mental Disease
(IMD), which may affect access to residential treatment
services for substance abuse.
- Prioritize research, evaluation, and dissemination—including state-by-state estimates of drug-treatment need, demand, and treatment resources; dissemination
of best treatment practices; guidance on ways to
increase retention and reduce relapse; and foster
progress from external coercion to internal motivation.
- Reduce stigma associated with drug treatment.
To improve treatment accountability, ONDCP is piloting
an information system with treatment programs
around the country that will be expanded by DHHS into
the National Treatment Outcome Monitoring System
(NTOMS). Under NTOMS, treatment performance will
be measured and compared. In addition, an agreement
has been negotiated with the states to establish a common
set of outcome measures to be applied to programs receiving
federal funding.
Treatment services are being fostered through manuals
created by NIDA, Treatment Improvement Protocols and
addiction curricula by CSAT, clinical guidelines by the
Department of Veterans Affairs (VA), and a comprehensive
curriculum for treatment by the Federal Bureau of
Prisons (BOP). State and local treatment programs with
promising results are applying these resources. CSAT has
joined with the Certification Board for Addiction Professionals
of Florida and a number of national stakeholder
organizations to develop core competencies for substance-abuse
counselors. Ultimately, these efforts will lead to a
body of certified professionals equipped with manuals
reflecting the most advanced approaches to treatment.
Adolescents with alcohol and drug problems are not
adequately served in most existing drug-treatment programs
designed for adults. Adolescents rarely seek help for
problems related to drug and alcohol use. Referrals by
juvenile courts are too often the first intervention. By this
time, substance abuse has contributed to delinquent
behavior, violence, and high-risk activities. There is also a
paucity of research-based information about juvenile
treatment. SAMHSA/CSAT, in collaboration with
NIAAA, is supporting a five-year research grant, titled
Treatment for Adolescent Alcohol Abuse and Alcoholism,
which will contribute to the development of good
programs for adolescents.
Providing state-of-the-art treatment services that are scientifically
validated for adolescents is a work in progress.
The Substance Abuse and Mental Health Services Administration
(SAMHSA), Center for Substance Abuse Treatment
(CSAT), is a the forefront of advancing these services.
The questions regarding what works, for whom, and
when, are among the great unknowns in adolescent treatment.
However, it is first important to understand the
need for services. Is there really a large group of adolescents
in need of treatment who are not receiving services?
Official estimates indicate that only one in five of every
adolescent in need of treatment services actually receives
treatment. Other estimates indicate that only one of every
10 adolescents in need of treatment, currently in school
(grades 6-12), received treatment services. Most state estimates
are problematic from a methodological perspective,
but taken at face value, their most recent reports show a
much higher rate of treatment need, with only one in 35
adolescents in need of treatment actually receiving services.
However, it is important to note that since 1992,
admissions for adolescents have increased by 45 percent.
To identify effective treatment approaches, CSAT began
in 1997 with the Cannabis Youth Treatment (CYT) program
to test new models of treatment that were theory
based. They announced preliminary findings in September
of 2000 that validated five different models of treatment. It
was reported that six months after intake to treatment these
programs were able to increase the percentage of adolescents
with no past month use 8 fold (from 4 percent to 34 percent)
and the percent reporting no past-month abuse or
dependence symptoms by 3 fold (from 19 percent to 61
percent). Treatment reduced days of use by 36 percent, and
reduced the number of adolescents with past month substance
related problems by 61 percent. The decrease in rate
of use is better than all prior studies of adolescent outpatient
treatment in community settings.
The Adolescent Treatment Models (ATM) program (initiated
in 1999) is in the process of evaluating 10 potentially
exemplary programs to determine the most effective, looking
at individual client outcomes and cost-effectiveness.
Results from the earliest of the ATM projects will be available
in 2001. Each of these programs is also developing a
manual that will allow for replication of the intervention.
No Wrong Door
The development of an interactive system that matches
care to need regardless of the point of entry is crucial in
establishing inter-system linkages. In developing its treatment
plan, CSAT has drawn upon research like that of
Connie Weisner, Ph.D. a senior scientist with the Alcohol
Research Group. Dr. Weisner discusses the prevalence of
weekly drug users among new admissions across population
and community agency systems. Dr. Weisner’s
estimates of cross system drug users included: 12.7 percent
in the public primary health care; 27.1 percent in the welfare
system; 27.1 percent in the mental health system; and
43.6 percent in the criminal justice system.
Services for Women
Although women use alcohol and illegal drugs at lower
rates than men, the consequences of women’s substance
abuse is greater than their lower consumption levels would
imply. These adverse effects range from increased mortality
related to cardiovascular and liver disease to increased incidence
and prevalence of HIV/AIDS. Children born to
substance abusing women are at risk for Fetal Alcohol Syndrome,
Fetal Alcohol Effects, infant mortality, attention
deficit disorder and other health problems.
Women experience substance abuse differently than men
and need access to quality gender specific substance abuse
treatment. The barriers to treatment for women include: the
stigma and shame associated with a women’s substance
abuse, the lack of early identification by professionals, the
lack of child care, the lack of residential treatment programs
that can accommodate mothers with children and the lack
of transportation to and from treatment sessions. SAMHSA
is addressing the lack of quality treatment for women
through the “Grants to Expand Substance Abuse Treatment
Capacity in Targeted Areas of Need.” This program is
designed to address gaps in treatment capacity by supporting
rapid and strategic responses to demands for substance
abuse treatment services.
Women in recovery report histories of elevated rates of
childhood physical and sexual abuse. Consequently, the
trauma caused by the abuse must be addressed in treatment.
SAMHSA’s Women, Co-occurring Disorders, and Violence
Study seeks to discover ways to improve treatment outcomes
for women and their children. This study is developing a
comprehensive integrated services delivery system.
Substance Abuse and Co-occurring
Mental Disorders
According to the National Comorbidity Survey, more
than 40 percent of persons with addictive disorders also
have co-occurring mental disorders. Data suggests that
mental disorders precede substance abuse more than 80
percent of the time, generally by five to ten years.18 We
must take advantage of this window of opportunity to predict
drug-abuse and prevent it. In addition, treatment
providers must recognize co-occurring mental disorders
and addiction in order to prevent relapse and improve the
likelihood of recovery.
Roughly ten million people in the United States have co-occurring
substance abuse and mental disorders. These
individuals experience more severe symptoms and greater
functional impairment than persons with a single disorder,
have multiple health and social problems, and require more
care. In addition, dual disorders are often associated with
unemployment, homelessness, contact with law enforcement,
and other medical problems like HIV/ AIDS.
According to the Department of Veterans Affairs, about a
third of adult homeless people once served their country in
the armed services. On any given day, as many as 250,000
veterans (male and female) are living on the streets or in
shelters, and perhaps twice as many experience homelessness
at some point during the course of a year. About 45
percent of homeless veterans suffer from mental illness, and
70 percent have alcohol or other drug abuse problems.
Considerable overlap exists between these two categories.
Treatment of co-occurring substance-abuse and mental-health
disorders have has historically been provided by
multiple service delivery systems, which at times have
been at odds with one another organizationally, philosophically,
and financially—often to the detriment of
the people in need. A new paradigm is necessary to provide
services for a spectrum of co-occurring disorders.
Early intervention, integrated treatment, cross-training of
staff, licensing of medical personnel (psychiatrists, psychologists,
etc.), consistent qualifications for other
mental-health and addiction personnel, and sufficient
funding are among the areas where innovative solutions
are badly needed. Long-term studies of co-occurring
disorders can help identify the best courses of treatment.
Moving Addiction Treatment into the
Mainstream of Healthcare
For the past forty years, the addiction treatment system
has evolved largely outside the larger health care system. In
many cases, treatment approaches and treatment programs
were created by individuals and groups that had overcome
their own addiction, and built a system to help others. For
example, recovering persons played an important in creating
the 12-step oriented “Minnesota model” programs that are
common in many public and private treatment settings, and
recovering drug addicts were key to the development of
therapeutic communities. Because of their history in the
recovering community, many of these programs have
remained outside the mainstream of the health care system.
In addition, stigma against substance abuse has resulted in
the isolation of providers who provide such treatment. For
example, it has been difficult to site new methadone programs,
despite the documents effectiveness of this form of
treatment for opiate addiction.
This history of isolation has resulted in a lack of integration
with other health care services and providers. This
isolation is problematic because many substance abusers
have co-occurring physical or mental health disorders; not
addressing these issues can limit the effectiveness of treatment,
and undermine recovery. The problem is
particularly acute for vulnerable populations that do not
have the ability to negotiate an often fragmented health
care delivery system and that lack access to health insurance
and transportation. Bringing substance abuse
treatment into the mainstream, and integrating services
when appropriate would improve outcomes for individuals
in treatment, as well as improving the public health.
Parity for Substance-Abuse
Treatment
From a scientific standpoint, management of addiction
is similar to treating other chronic illnesses. Were insurance
parity in place, substance-abuse treatment would be
subject to the same benefits and limitations as other comparable
disorders. Unfortunately, most employer-provided
insurance policies currently place greater burdens on
patients in terms of cost-sharing, co-payment, and
deductibles while offering less coverage for the number of
visits or days of coverage and annual dollar expenditures
for treatment. Many health insurance companies impose
lower lifetime limits on amounts that can be expended for
drug and alcohol treatment than for other illnesses. Parity
for substance-abuse treatment would correct these unfair
practices and expand the amount of available treatment.
Parity is affordable. According to the SAMHSA report
The Costs and Effects of Parity for Mental Health and Substance
Abuse Insurance Benefits, the average premium
increase due to full parity would be 0.2 percent—just a
dollar per month for most families. Furthermore, other
medical expenses incurred by treated patients are less than
for untreated clients. Therefore, substance-abuse prevention
and intervention saves employers money in both the
short and long term. Documentation and validation of
best practices for health-service providers are currently
being prepared. These figures will include added cost offset,
cost benefit, and cost utility incentives for both
private- and public-sector employers.
Ending the disparity between drug abuse and other diseases
through legislation would reduce the treatment gap.
Such action could be particularly useful for adolescents who
are covered by parents’ insurance plans. Parity legislation
will help lessen demands by people with private insurance
on publicly funded treatment. Parity and the ensuing privatization
of treatment would encourage more effective
interventions. Indeed, the lack of private insurance for drug-abuse
treatment discourages the development of new
therapies.19 Legislation supporting parity will move drug
treatment further into the mainstream of health care and
reduce the stigma associated with addiction.
The federal government has taken an historic step with
regard to drug abuse and is serving as a model for other
employers. In June 1999, the President announced that
the Federal Employee Health Benefit Program (FEHB)
would offer parity for mental-health and substance-abuse
coverage by 2001. This unprecedented initiative will provide
access to treatment for nine million people including
federal employees, retirees, and their families. This move
underscores the federal government’s commitment to
quality coverage for mental illness, substance abuse, and
physical illness. In December, the FEHB began working
with small businesses to provide these benefits.
Medications for Drug Addiction
Given that the development of new and effective treatments
for addiction is both a national need and a NIDA
priority, it is imperative that we capitalize on recent
research advances to rapidly bring new treatments to the
clinical tool boxes of front-line clinicians who are treating
addiction. Just like other chronic diseases such as hypertension,
diabetes, and cancer, for which medications have
been developed, drug addiction is a disease that merits
medication for its treatment. NIDA has already made
great progress in bringing useful medications to drug
abuse professionals to treat addicted individuals, such as:
the readily available nicotine addiction therapies; the
most effective medications to date for heroin addiction,
methadone and LAAM (levo-alpha-acetyl-methadol,
trademark ORLAAM); in addition, buprenorphine, a
new treatment option for heroin addiction, is pending
approval by the Food and Drug Administration (FDA).
A substantial body of NIDA-funded research has laid
out the neurochemical details of how opiates, including
heroin, produce their analgesic and behavioral effects, and
perhaps important work in this area has characterized the
receptors that opiate drugs bind to in various parts of the
brain. This endeavor has led directly to the development
of buprenorphine, which may soon become the latest
pharmacological treatment for opiate addiction. For
example, NIDA-supported research has shown that the
so-called “mu” opiate receptor is responsible for the effects
associated with morphine: analgesia, euphoria, sedation,
and respiratory depression. Buprenorphine has the ability
to bind to this particular receptor, but does not activate
the receptor to the same extent as the opiates do. Thus it
is classed as a partial agonist. As a partial agonist,
buprenorphine does not produce the same high as heroin,
for example, and is less likely to cause respiratory depression,
the major toxic effect of opiate drugs. At the same
time, buprenorphine leaves the mu receptor unusually
slowly, so its effects last much longer than those of other
opiates (methadone, for example).
NIDA and its private sector partners are also developing
a buprenorphine-naloxone may combination tablet. As a
partial mu agonist, buprenorphine has some potential for
misuse, but, combination of buprenorphine with the opiate
antagonist naloxone would significantly reduce the
potential of this medication for abuse. If a heroin addict,
for example, attempted to abuse the combination product
by dissolving and intravenously injecting it, the individual
would experience unpleasant withdrawal effects induced
by the naloxone. The safety and effectiveness profiles for
buprenorphine and the buprenorphine-naloxone combination
suggest they may be valuable new tools for the
treatment of opiate addiction.
NIDA is also engaged in clinical trials with lofexedine
as a non-opioid medication to reduce or alleviate symptoms
encountered in opiate detoxification, and
dextromethorphan (a non-opioid NMDA receptor antagonist)
given in combination with oral methadone to
prevent relapse to injection opiate use. NIDA has produced
a dosage form of the narcotic antagonist naltrexone
in a long-lasting (30 days or more) depot formulation. In
the area of cocaine dependence, NIDA is currently
engaged in advanced clinical testing of selegiline, in both
immediate release and a new transdermal patch formulation.
Additionally, NIDA continues to test a variety of
new agents to test various hypotheses concerning stimulant
(cocaine and methamphetamine) abuse and
dependence. NIDA has also seen encouraging results
from three clinical trials of disulfiram as a potential treatment
agent for cocaine addiction. Each of these trials was
conducted at Yale University and indicated that disulfiram
appears to reduce the use of cocaine. Larger trials,
and trials in different locations and settings, will be conducted
to further delineate the scope of these findings.
NIDA has also supported several groups in their efforts to
develop immunotherapies (vaccines) that would either
prevent the use of cocaine or be useful as antidotes to
overdose.
A medications development effort aimed specifically at
the growing prevalence of methamphetamine dependence
is now underway. After consultation with experts in the
field, NIDA has assembled both an internal preclinical
discovery program and an external set of clinical trials
sites dedicated to the testing of potential treatment agents
for methamphetamine addiction. Additionally, NIDA
recently initiated its new National Drug Abuse Treatment
Clinical Trials Network to encourage community treatment
providers to become involved in the clinical testing
of new and existing pharmacological and behavioral treatments.
The program is designed to rapidly infuse the
developments of academic research into actual practice at
the point of treatment delivery. Treatment providers will
be actively involved in developing protocols and demonstrating
and developing best practices within the context
of their own unique community populations, settings,
and service delivery systems. NIDA will continue funding
a multi-faceted approach aimed at developing medications
to treat addiction, withdrawal, and prevention of
relapse.
SAMHSA’s Center for Substance Abuse Treatment’s
Methadone Accreditation Study continues with 165 participating
opioid agonist treatment programs (OTPs). To
date, the Commission for Accreditation of Rehabilitation
Facilities (CARF) has surveyed 50 OTPs; 44 have received
accreditation decisions; only one of the CARF-surveyed
programs was unable to attain accreditation. Seven OTPs
have been surveyed by the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) and have
received accreditation. CSAT has provided considerable
technical assistance to OTPs seeking accreditation.
Behavioral Treatment Initiative
Behavioral therapies have proven to be effective treatments
for many drug problems, including cocaine
addiction. Behavioral treatments, such as cognitive behavioral
therapies, for example, have been shown in a wide
variety of studies to treat addiction disorders. Behavioral
interventions are especially beneficial when pharmacological
treatments are being used. An explosion of knowledge
in the behavioral sciences is ready to be translated into
new therapies. NIDA is especially interested in taking
what is learned from small-scale studies and translating
the findings into real life settings through the new
National Drug Addiction Clinical Trials Network. NIDA
is encouraging research in this area to determine why particular
interventions are effective, develop interventions
that could reduce AIDS-risk behavior, and disseminate
new interventions to practitioners in the field. More specifically,
this initiative will focus on finding effective
treatments to reducing adolescent drug use.
National Drug Abuse Treatment
Clinical Trials Network
NIDA has declared the improvement of drug abuse
treatment nationwide as one of its major goals. Behavioral
and neuroscience research have provided substantial evidence
in support of the concept that drug addiction is a
chronic and, for many people, a recurring disease. As is
the case for other chronic disorders, effective treatments
for addiction do exist. However, the efficacy of these new
treatments has been demonstrated primarily in specialized
treatment research settings, with somewhat restricted
patient populations. As a consequence, not enough of
these new treatments are being applied on a wide-scale
basis in real-life practice settings. In response, NIDA
established the National Drug Abuse Treatment Clinical
Trials Network (CTN),to provide a research infrastructure
to test whether new and improved treatment
components are effective in real-life settings with diverse
patient populations.
Since its inception in September 1999, NIDA has made
11 CTN grant awards. Each of these centers will link with
at least five community treatment programs in their
region. When complete, the network will consist of 20 to
30 regional research treatment centers (RRTC). At the
local level, each center will be linked with 10 to 15 community-
based treatment programs (CTP) that represent a
variety of treatment settings and patient populations
available in that particular region of the country. Each
RRTC will work in concert to conduct multi-site clinical
trials research. They will deliver and test an array of
behavioral and pharmacological treatments and determine
conditions under which novel treatments are
successfully adopted. Most studies to be conducted will
span multiple sites, populations and geographic regions.
Through this growing network, NIDA hopes to transport
promising science-based behavioral and pharmacological
treatments to communities across the Nation.
Science-based therapies that are ready for testing in the
CTN include new cognitive behavioral therapies, operant
therapies, family therapies, brief motivational enhancement
therapy, individual and group drug counseling,
aftercare behavior therapy and science based treatment
with a court-diverted patient population. One behavioral
study, for example, will develop and evaluate in a community
treatment setting, motivational incentive procedures
that have been shown to be effective in small scale
research settings. The study will determine if these
incentives coupled with standard care therapy are more
effective than standard care therapy alone in treating
addiction. To address the real problem of relapse following
residential treatment, another study will compare
focused aftercare interventions to standard aftercare
planning on longer-term outcomes.
Among the medications to be studied are: naltrexone,
LAAM, buprenorphine for heroin addiction, and the new
buprenorphine/naloxone combination coupled with psychosocial
treatment in an adolescent population. New
methods to treat adolescents dependent on heroin are
sorely needed; the new buprenorphine/naloxone combination
offers the possibility of a significant new treatment
option for this group. A study will be undertaken to compare
treatment retention, drug use outcome, psychosocial,
and high risk behaviors among adolescent heroin addicts
treated with the usual psychosocial treatment with or
without daily buprenorphine/naloxone.
As the CTN grows over the next 5 years, its goal will be
to bring researchers and practitioners together as partners
to conduct full-scale testing of promising new medications
and behavioral treatments in a wide range of
community drug abuse treatment clinics with patients
from a variety of ethnic and social backgrounds. The program
is designed to rapidly infuse the developments of
academic research into actual practice at the point of
treatment delivery. Treatment providers will be actively
involved in developing protocols and demonstrating and
developing best practices within the context of their own
unique community populations, settings, and services
delivery systems.
The CTN also will be useful to other aspects of NIDA’s
research portfolio. For example, multi-site clinical trials
with diverse patient populations could provide a valuable
resource to researchers interested in elucidating genetic
and environmental determinants of vulnerability. Ultimately,
increased understanding of the roles played by
genetics, environment, and their interaction in shaping an
individual’s susceptibility to drug addiction will lead to a
variety of more targeted drug abuse prevention and
treatment approaches.
Practice Research Collaboratives
Program (PRC)
This SAMHSA/CSAT-supported initiative was undertaken
to support and promote effective, efficient, and
accessible community-based treatment. The goals of the
program are to: Increase the usefulness of substance abuse
treatment research to community-based treatment organizations,
and Increase the capability of community-based
treatment organizations to adopt evidence-based clinical
and service delivery practices.
Through this program, community-based treatment
organizations partner with researchers, policy-makers, and
other stakeholders to implement evidence-based practices
that are responsive to the needs of local providers and consumers
of substance abuse services. Together, the PRC
stakeholders assess community service delivery needs, identify
evidence-based practices that are relevant and feasible
to implement, and, conduct studies to evaluate the most
effective methods of implementing these practices in community-
based treatment settings. The PRC program will
reduce the isolation of treatment providers, researchers, and
policymakers and provide needed support to community-based
organizations that serve as the primary sources of
substance abuse treatment for underserved populations.
CSAT has awarded eleven PRC grants, including four
developmental and seven implementation phase programs.
During the one-year developmental phase, PRC
grantees: develop an organizational stricture that provides
a forum for diverse stakeholders to come together and
work collaboratively toward the goal of implementing evidence-based practices in local community-based
treatment organizations; conduct a community needs
assessment, and, develop a knowledge adoption
agenda that is endorsed by the PRC governing body of
community stakeholders.
During the three-year implementation phase, the PRC
grantees: Conduct network enhancement activities to
promote researcher/practitioner collaborations, e.g. clearinghouses,
mentoring programs, conferences, workshops,
and technical consultation and liaison activities, and,
involve PRC stakeholders in the design and conduct of
community-based knowledge adoption studies responsive
to locally defined needs.
PRC grantees include a mix of Statewide, metropolitan,
and rural programs. PRC stakeholders include and diverse
range of community-based treatment programs including
programs serving ethnic and cultural minorities, clients
involved with the criminal justice system, and clients with
co-occurring mental health and substance abuse disorders
and HIV/AIDS.
Treatment Research and Evaluation
Recent studies of pharmacotherapies and behavioral
therapies for abuse of cocaine/crack, marijuana, opiates,
and stimulants (including methamphetamine) will
improve the likelihood of successfully treating substance
abuse. In addition, a comprehensive epidemiological system
needs to be developed to measure the success of new
therapies. NIDA will conduct clinical and epidemiological
research to improve the understanding of drug abuse
among children and adolescents. These findings will be
widely disseminated to assist in finding more effective
approaches to prevention. ONDCP/CTAC will complete
the development of the Drug Evaluation Network System
(DENS) which can monitor and evaluate substance-abuse
programs by tracking patients entering treatment, their
characteristics and discharge status. The system software
architecture is designed to host a wide variety of trends
and treatment effectiveness methodologies. DENS is
being transitioned to the SAMHSA/CSAT’s National
Treatment Outcome Measurement System (NTOMS)
this year.
To ensure that basic research is put to good use,
SAMHSA supports and evaluates applied research. For
example, SAMHSA/CSAT’s Methamphetamine Treatment
Project (http://www.methamphetamine.org) is
funding evaluations of sixteen-week methamphetamine
interventions in non-residential (outpatient) psychosocial
settings in California, Hawaii, and Montana. The objective
is to determine whether promising results from
stimulant treatment attained by the MATRIX Center in
Los Angeles can be replicated.
Research into the Mechanisms of
Addiction
In conjunction with the National Institute on Drug
Abuse (NIDA), ONDCP/CTAC examines addiction
research and the application of technology to expand the
effectiveness or availability of drug treatment. These
efforts seek to answer basic questions, such as:
- UnderWhy do some drug users become addicted
while others do not?
- What changes occur in the brain that result in addiction
and what can be done to reverse or mitigate the process?
For the past five years, brain imaging technology development
projects that exploit advancements in Positron
Emission Tomography (PET), functional Magnetic Resonance
Imaging (fMRI) and Magnetic Resonance
Spectrometry for drug abuse research have been developed
with institutions such as NIDA’s Intramural
Research Program, Brookhaven National Laboratory,
Massachusetts General Hospital, Emory University, University
of Pennsylvania, University of California at Los
Angeles and Harvard University/McLean Hospital. Each
of these institutions have world-class medical research
teams that have agreed to conduct leading edge research
on drug abuse and addiction with the new equipment.
They also have agreed to train other professionals with a
concentration on drug abuse research to advance the
current base of knowledge and understanding.
Last year, a 7 Tesla magnet was delivered to the Nuclear
Magnetic Resonance Research Center at Massachusetts
General Hospital. When the facility is completed this
year, the new 7 Tesla fMRI system will serve as the cornerstone
for a collaborative effort between Massachusetts
Institute of Technology and Massachusetts General Hospital
to conduct research on the brain circuitry. Research
scientists will use this sophisticated brain imaging equipment
to map brain reward circuitry, blood volume and
flow associated with drug metabolism, and interactions
with potential therapeutic medicines. They will be able to
localize the brain circuitry that mediates drug addiction
and characterize its temporal dynamics. This premier
neuro-imaging facility also will support research to determine
the extended circuitry of human motivation and its
modification by functional illness. Using these findings,
research scientists will be able to develop neuro-imaging
tools for diagnosis and prognostic determination of treatment
for substance abuse disorders.
Scientists at Yerkes Regional Primate Research Center at
Emory University are seeking to find a medication to serve
as a “front line” initial step in normalizing addicts for further
treatment. This year they plan to demonstrate two to four
compounds that help reduce cocaine intake in animals.
Researchers from the Research Triangle Institute, using
PET brain scanning equipment located at the NIDA
Intramural Research Program, are assessing the role of
impaired cognitive functioning and looking for vulnerability
factors or markers for specialized treatment
regimens. In order to link rigorous experimentation done
in non-human primates with clinical populations, a
“micro” PET brain scanning capability is being developed
with NIDA to resolve the small brain structures in non-human
primates and rodents.
Reducing Infectious Disease Among
Injecting Drug Users
Although the number of new AIDS cases has declined
dramatically during the past two years because of the introduction
of combination therapies, HIV infection rates have
remained relatively constant. CDC estimates that 650,000
to 900,000 Americans are now living with HIV, and at least
forty-thousand new infections occur each year. HIV rates
among African Americans and Hispanics are much higher
than among whites. Exposure to HIV through injection
drug use practices accounts for 22 percent of cumulative
AIDS cases among men, but higher percentages of African
Americans (34 percent) and Hispanics (36 percent) have
contracted HIV directly through this mode of transmission.
Studies of HIV prevalence among patients in drug-treatment
centers and women of child-bearing age demonstrate
that the heterosexual spread of HIV in women closely parallels
HIV among injection drug users (IDUs), with 42
percent of cumulative AIDS cases among women being
attributable to injection drug use. The highest prevalence
rate in both groups has been observed along the East Coast
and in the South. Hepatitis B and C are also spreading
among IDUs. IDUs represent a major public-health challenge.
Addicted IDUs frequently have multiple health,
psychological, and social problems that must be overcome
in order to address their addiction, criminal recidivism, and
disease transmission.
NIDA has created a center on AIDS and Other Medical
Consequences of Drug Abuse to coordinate a comprehensive,
multi-disciplinary research program that will
improve the knowledge base about drug abuse and its
relationship to other illnesses through biomedical and
behavioral research. This work will incorporate a range of
scientific investigation from basic molecular and behavioral
research to epidemiology, prevention, and treatment.
Information from each of these areas is essential for
understanding the links between drug abuse and AIDS,
TB, and hepatitis and for developing strategies for stemming
infectious diseases spread through injection drug
users. NIDA is conducting public-health campaigns to
increase awareness of infectious diseases. If we are to make
progress in addressing the dual problems of HIV/AIDS
and substance abuse, it will be necessary to create linkages
between addictions treatment, primary care, and mental
health services for those with HIV.
SAMHSA will continue its support of early intervention
services for HIV through the SAPT Block Grant.
Under the Congressional Black Caucus Initiative aimed at
reducing the disproportionate impact of HIV/AIDS on
racial and ethnic minorities, SAMHSA awarded over $60
million to fund outreach, substance abuse prevention and
treatment, and prevention services for women and youth
in communities of color in FY 2000. The grants from
SAMHSA’s Targeted Capacity Expansion and Outreach
Programs will improve substance-abuse treatment and
prevention services in minority communities highly
affected by the twin epidemics of substance abuse and
HIV/AIDS. In addition, SAMHSA is working to foster
collaboration regarding HIV/AIDS and substance abuse
among a variety of federal agencies including the Health
Resources and Services Administration, the Centers for
Disease Control and Prevention, and the Office of
Minority Health.
Training for Substance-Abuse
Professionals
In spite of their rigorous educational and licensing
requirements, most health care professionals lack the training
to identify the symptoms of substance abuse.
A survey by the National Center on Addiction and
Substance Abuse at Columbia University (CASA) demonstrated
that 94 percent of primary care physicians (excluding
pediatricians) failed to identify substance abuse in their
patients.20 Forty percent of physicians who treat teens
missed an illegal drug abuse diagnosis in teens. Health care
providers are simply not being trained to ask the right questions.
The majority of health professionals can graduate
from their basic and graduate educational programs without
ever having to take a course in addictions. However, there is
evidence to suggest that interactive learning sessions can
greatly increase the ability of medical professionals to screen
patients for signs of substance abuse. For example, Boston
University Medical School researchers designed and conducted
a seminar on detection and brief intervention of
substance abuse for doctors, nurses, physician’s assistants,
social workers and psychologists. When asked the usefulness
of the information, 91 percent of the clinicians say that they
are still using the techniques 1-5 years later.21
At present, the Health Resources and Services Administration
(HRSA), the Center for Substance Abuse
Treatment (CSAT), National Institute on Drug Abuse
(NIDA), National Institute of Mental Health (NIMH)
and Center for Substance Abuse Prevention (CSAP) are
actively engaged in increasing health care professional’s
knowledge and ability to recognize and treat substance
abuse. HRSA, for example, is engaged in the “HRSA-AMERSA
Interdisciplinary Project to Improve Health
Professional Education in Substance Abuse.” CSAT supports
Addiction Technology Transfer Centers (ATTCs)
and CSAT’s counselor training programs. NIDA’s oversees
a Clinical Training Program that prepares clinicians
to be researchers. CSAP conducts a Faculty Development
Program, and NIMH a Clinical Training Program.
ONDCP supports efforts to increase funding for these
agencies in order that the substance abuse education of
health care professionals be expanded. By increasing this
targeted funding for the education of health professionals,
more clinicians from diverse specialties will be able to recognize,
refer and/or treat addictions. Increased funding
would mainstream addiction prevention and treatment
into various medical disciplines. It would have the ancillary
effect of reducing substance abuse treatment costs in
the future, as early intervention by a primary care practitioner
will decrease the level of care needed to diagnose
and treat the addiction.
Providing Services for Vulnerable
Populations
For prevention and treatment to be effective, we must
address the unique needs of different populations. As a
result of managed care and changes in the welfare and
health-care system, much-needed services may be less
available to vulnerable populations, including racial and
ethnic minorities like African-Americans, Native Americans,
Alaskans, Hispanics, Asian American/Pacific
Islanders; children of substance-abusing parents; the
disabled; the poor; the homeless; and people with co-occurring
substance abuse and mental disorders.
SAMHSA/CSAT is addressing this problem in the
Targeted Capacity Expansion Program, which responds to
the treatment needs of serves these vulnerable populations.
Our overall challenge is to help chronic drug
abusers overcome dependency and lead healthy, productive
lives. In addition, SAMHSA/Center for Mental
Health Service’s PATH program supports services to
individuals who are homeless or at risk of homelessness,
including homeless families. Three out of every five clients
served through this program also have a co-occurring
substance abuse disorder.
Family Drug Treatment Courts
CSAT’s Family Drug Treatment Court initiative is
designed to stop the cycle of substance abuse and child
neglect or abuse that occurs in many families, providing
appropriate services to each family member so that families
can be reunited, or children can be adopted when families
cannot be reunited. In Family Drug Treatment Courts,
alcohol and other drug treatment, combined with intervention
and support services for the child and the family, are
integrated with the legal processing of the family’s case. To
be effective these courts are a true three-way partnership
between the child welfare, substance abuse treatment, and
court systems.
Key components of Family Drug Treatment Courts
include the following: screening and assessment using a
non-adversarial approach; providing a continuum of
alcohol and drug treatment with accompanying wrap-around
rehabilitative and logistic services that support
families and recovery; alcohol and other drug testing; and
the judge, child welfare, and substance abuse treatment
personnel work as a team to closely monitor participants’
compliance with treatment through a system of rewards
and sanctions administered during frequent court hearings.
One of the key benefits of Family Drug Treatment Courts
is helping states comply with the Adoption and Safe Families
Adoption Act of 1997, P.L. 105-89. Early indications are
that using family drug treatment courts reduces the time
taken for final disposition of abuse and neglect cases, and
also increase the percentage of family reunification.
The National Treatment Plan
Initiative
The problem of substance abuse and dependence has
long troubled the nation, reflecting conflicting concerns
for public safety, moral values, and health. SAMHSA’s
Center for Substance Abuse Treatment (CSAT) believes
that further progress in the treatment of substance abuse
and dependence will require a sustained and coherent
approach that can address the whole range of issues associated
with alcohol and drug problems. This approach is
the purpose for initiating Changing the Conversation:
Improving Substance Abuse Treatment: The National
Treatment Plan Initiative (NTP).
To organize thinking about such a broad set of concerns,
CSAT in collaboration with the NTP Steering
Group selected five domains that can encompass the
whole array while highlighting strategic issues central for
the field: (1) Closing the Treatment Gap; (2) Reducing
Stigma and Changing Attitudes; (3) Improving and
Strengthening Treatment Systems; (4) Connecting Services
and Research; and (5) Addressing Workforce Issues.
For each domain, CSAT, with input from the field, chose
a panel of experts including consumers, providers of services,
researchers and policy makers who represented diverse
knowledge, experience, and views. Panel members were
charged with considering and building on the work of previous
reports and studies. Rather than duplicating prior work,
the panels focused on what should be done in the future.
CSAT also sponsored a series of six public hearings to obtain
additional information and views, particularly from front-line
providers, policymakers, and people in recovery and
their families.
The NTP combines the recommendations of the five
Expert Panels into a five-point strategy: (1) Invest for
Results; (2) No Wrong Door to Treatment; (3) Commit
to Quality; (4) Change Attitudes; and (5) Build Partnerships.
The recommendations represent the collective
vision of the participants in the NTP “conversation” over
the past year. The goal of these recommendations is to
ensure that an individual needing treatment—regardless of
the door or system through which he or she enters—will be
identified and assessed and will receive treatment either
directly or through appropriate referral. Systems must
make every door the right door.
