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III. Report on Programs and Initiatives

2. TREATING ADDICTED INDIVIDUALS

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.