The objective of this White Paper is to report the state of the science of
measurement of drug abuse treatment services outcome and to guide future
research efforts, after carefully considering relevant clinical and health
services research experience. To this end, the Office of National Drug Control
Policy convened a panel of clinicians, researchers, and administrators to
guide the review of past research and experience and to recommend appropriate,
reliable measures of treatment effectiveness.
The talent, dedication, and thoughtful participation of the panel members,
the Treatment Outcome Working Group, has provided a foundation upon which
clinicians, administrators, and researchers can build future research and
demonstrate the benefits of effective treatment approaches. ONDCP gratefully
acknowledges all those individuals who served this effort.
Table of Contents
TREATMENT PROTOCOL EFFECTIVENESS STUDY
EVALUATING THE EFFECTIVENESS OF DRUG ABUSE TREATMENT
Considerations for Treatment Evaluation
Defining Effective Drug Abuse Treatment
Recommendations for Improving Drug Abuse Treatment
EVIDENCE FOR TREATMENT EFFECTIVENESS
Drug Abuse Reporting Program
Treatment Outcome Prospective Study
Drug Abuse Treatment Outcome Study
California Drug and Alcohol Treatment Assessment
A REVIEW OF WHAT IS KNOWN ABOUT TREATMENT MODELS THAT WORK
Measures of TC Treatment Effectiveness
Treatment of Opioid Dependence
Treatment of Cocaine Dependence
Measures of Pharmacological Treatment Outcome
Outpatient Drug-Free Treatment
Measures of Outpatient Treatment Effectiveness
Measures of Inpatient Treatment Effectiveness
INTEGRATING SERVICES FOR SUCCESSFUL OUTCOME
TREATMENT OUTCOME WORKING GROUP
SIDEBAR: Substance-Abusing Population in Treatment
TREATMENT PROTOCOL EFFECTIVENESS STUDY
Drug dependence is a chronic, relapsing disorder requiring specialized treatment.
Breaking the cycle of dependence is difficult at best, and hardcore drug
users often suffer extreme physical, psychological, emotional, economic,
and social pain. In many ways, hardcore drug users are isolated from society.
Their addiction affects not only them but also their families and friends
as well as the larger community (Office of National Drug Control Policy [ONDCP],
Drug abuse treatment is the process of breaking an individual's dependence
on illicit drugs (e.g., heroin and cocaine) or licit drugs (e.g., alcohol
and prescription medications). Although the term "drug abuse treatment" implies
a single entity, in fact it is a complex and variable network of services
tailored to meet the multiple needs of the individual. Drug abuse treatment
can take place in hospitals; long-term residential treatment programs; walk-in
clinics; and counseling centers, psychotherapists' offices, and church basements.
The choice of setting and the type of treatment selected by or mandated for
the individual depends on such factors as the drug of addiction, history
of drug use and previous drug treatment, social needs, criminal record, economic
status, and personality characteristics.
In both the drug treatment and in the treatment research communities, there
is broad consensus that drug abuse treatment works. However, identifying
the most effective type of treatment and for whom it is most effective continues
to be a difficult task. In this climate of managed care, it is more important
than ever to determine which treatment will work best for which patient.
The surest way to make this determination is through rigorous evaluation
of treatment modalities, treatment programs, and patient outcomes.
EVALUATING THE EFFECTIVENESS OF DRUG ABUSE TREATMENT
Evaluating drug abuse treatment effectiveness begins with an understanding
of a number of other factors related to the drug treatment modality or program
itself. These include knowing the array of social, medical, and other services
needed and available to the drug user; understanding the extent of drug use
in a community; and understanding the nature and progression of drug addiction.
The following sections discuss the considerations for treatment evaluation,
definitions of effective drug abuse treatment, and recommendations for improving
drug abuse treatment.
Considerations for Treatment Evaluation
For most drug users, treatment includes a variety of social and medical services
necessary to aid recovery. For hardcore drug users (i.e., those suffering
from continuing and increasing use, those suffering from significant social
and health consequences, and those with a preoccupation with obtaining drugs),
drug treatment occurs within a cluster of legal, social, and medical services
functioning in the community. Knowledge of the ways in which these services
are integrated and delivered is important to determine what can be expected
from treatment and how to evaluate the treatment provided.
Interventions required by the hardcore drug user typically involve the criminal
justice system, the health care system, and the welfare and educational systems.
These, together with the drug abuse treatment system, serve the drug user
in the process of treatment and recovery. These services sometimes, but not
always, are delivered in a coordinated, supportive, and integrated fashion.
The greater the support given the drug user throughout the process of treatment
and long-term recovery, the greater the likelihood of treatment success.
In reality, few communities claim fully functional provision of services
for all persons in need, especially drug users. It is the degree of function
or dysfunction of the treatment and service environment that must be understood
to formulate expectations and accurately evaluate drug treatment effectiveness.
The extent and types of drug abuse in a community also must be gauged accurately
to evaluate the array of required services. Ideally, the drug use patterns,
medical and social consequences, and costs of drug abuse should be understood.
In addition, understanding the nature of addiction is important to structuring
and evaluating appropriate treatment services.
Defining Effective Drug Abuse Treatment
Given what is known about the many social, medical, and legal consequences
of drug abuse, effective drug abuse treatment should, at a minimum, be integrated
with criminal justice, social, and medical services and lead to the following
results or outcomes:1
Reduced use of the primary drug. -- Definitions of treatment effectiveness
include abstinence, reduced time to relapse, reduced frequency of drug use,
and the reduced amount of the drug used in total and during each episode
Improved functioning of drug users in terms of employment. -- This includes
increased number of days worked and enrollment in training programs or school,
Improved educational status. -- This includes increased school attendance
and improved grades and overall performance.
Improved interpersonal relationships. -- This includes relationships with
family, friends, and employers.
Improved medical status and general improvement in health. -- This is indicated
by fewer hospitalizations, doctor visits, and emergency room visits.
Improved legal status. -- This is indicated by improvements in current legal
status (e.g., probation, parole, or incarceration); fewer arrests; fewer
convictions; reductions in crimes committed against self or others; and
reductions in property crimes committed.
Improved mental health status. -- This includes improved mood and cognition,
reduced psychotic states, improved personality traits, and reduced need for
mental health treatment.
Improved noncriminal public safety factors. -- This includes reduced incidence
of drug-related fires, motor vehicle crashes, accidents, trauma to self and
others, and emergency room visits.
Among the indicators of treatment effectiveness cited above, the following
are frequently cited as particularly important when determining treatment
effectiveness among hardcore drug users, regardless of treatment model or
Reduced drug use;
Reduced domestic violence;
Reduced behavior at risk for HIV (human immunodeficiency virus) infection;
Increased days of employment; and
Positive changes in social values and networks.
Recommendations for Improving Drug Abuse Treatment
Effective drug abuse treatment requires a thorough assessment and integration
of the needs of every individual entering treatment. Matching client needs
to the treatments and services available is an essential component of treatment
success. In the short term, tailoring and integrating treatment and related
services to the needs and characteristics of the individual and the specific
drug that is abused may be time-consuming and costly, but the reduction of
drug use and therefore the need for further treatment will provide the biggest
payoff in the long term.
The following are areas in which many programs need to improve to reach the
goal of treatment success for drug-abusing clients, including hardcore drug
Integration of services;
Efforts to engage clients in treatment;
Intensity of services;
Cultural sensitivity in treatment programs;
Staff training and retention;
Data collection and management services; and
Stable sources of funding.
In addition, the following elements of a national-level program evaluation
system would allow thorough monitoring of treatment goals:
A series of demonstration programs that closely monitor service delivery
over a specified period of time;
Selective, regionalized data collection to identify changes in drug abuse
patterns, such as reductions in drug-related crimes and violence; and
Development of nationwide policy indicators that policymakers and treatment
professionals will agree represent minimum standards for treatment services.
Evaluation of drug abuse treatment must focus on the effects of treatment,
not on the drug problem itself. Treatment goals must be realistic and reflect
what is possible, as opposed to what is desirable, in treating a particular
Treatment research should focus on rates of improvement as a result of drug
abuse treatment, rather than on simply documenting a "cure." The degree of
change expected should be realistic and take into consideration the resources
that are available to an individual client.
Treatment evaluation should assess and document (1) whether patients receive
the treatment they need, (2) whether (and which) other improvements are needed
in treatment, (3) whether the array of consequences of drug abuse are reduced
because of the quality of treatment and other services provided, and (4)
whether the benefits outweigh the costs of investing in the treatment system.
Future research efforts should focus on evaluating these areas and on monitoring
the ongoing needs of the drug-using population.
The remainder of this review will present and describe (1) what is known
about effective treatment, (2) what research reveals about which treatments
work best and for whom, and (3) how treatment effectiveness is measured and
the limitations of such measurement. Although broad research literature has
been reviewed to prepare this report, the emphasis is on treatment for the
hardcore drug user (i.e., those with criminal histories and those with chronic,
heavy use of heroin and cocaine).
EVIDENCE FOR TREATMENT EFFECTIVENESS
Determining treatment effectiveness is a complex endeavor that hinges on
the interplay among many client, program, and environmental factors. After
more than 25 years of evaluations of various types of treatment programs,
there are surprisingly few national longitudinal or multisite studies that
offer universal, definitive "truths." However, three national multiprogram
studies and one statewide study represent rigorous analysis of the effectiveness
of the major treatment modalities (i.e., pharmacotherapies and the therapeutic
communities, inpatient treatment settings, and outpatient treatment
settings.)2 These studies are known as the Drug Abuse Reporting
Program (DARP), the Treatment Outcome Prospective Study (TOPS), the Drug
Abuse Treatment Outcome Study (DATOS), and the California Drug and Alcohol
Treatment Assessment (CALDATA). Although other studies of treatment effectiveness
have been conducted and reviewed in preparation for this report, to date,
these four studies are the broadest in scope. They were conducted with the
largest populations in treatment, representing the widest variety of treatment
programs, over the longest period of time. These studies and their findings
in support of treatment effectiveness are described below.
Drug Abuse Reporting Program
DARP was conducted between 1969 and 1973 with individuals admitted into publicly
funded drug treatment and for the first time provided a nationwide, comprehensive
assessment of treatment effectiveness with a large client sample. It was
the first national followup study to assess treatment effectiveness based
on clients' outcomes 1 year after treatment. Major findings from the DARP
study include the following: (1) the three major modalities -- outpatient
drug-free, methadone maintenance, and therapeutic communities -- produced
an equal level of positive outcomes and (2) clients in detoxification (i.e.,
inpatient) programs or those who dropped out of treatment within 3 months
did not demonstrate positive outcomes.
Treatment Outcome Prospective Study
Building on the methodology and findings of DARP, from 1979 to 1981 the TOPS
examined client characteristics, treatment, and outcomes for more than 11,000
clients in 41 methadone, residential, detoxification, and outpatient drug-free
programs. Clients were assessed after 1 month in treatment; at 3-month intervals
during treatment; and at intervals of 3 months, 1 year, 2 years, and 3 to
5 years after leaving treatment. Researchers in this study claimed that
determining treatment effectiveness requires a consideration of both behavioral
and psychological factors of those in treatment and an assessment of treatment
success in terms of both drug use and improvement in related behaviors and
attitudes. Consequently, the TOPS study concluded that effectiveness should
be measured by changes in a client's antisocial (e.g., criminal) behavior,
evidence of socially productive behavior (e.g., employment or school attendance),
and cessation of drug use. The TOPS study found that 95 percent of individuals
in residential treatment and 80 percent of individuals in methadone programs
reported more than minimal drug use before entering treatment and a substantial
reduction in use after 3 months of treatment. For example, of patients in
residential programs for more than 13 weeks, 22.2 percent reported more than
minimal use of heroin (not narcotics) before treatment. After 13 weeks of
treatment, only 7.3 percent of the same population reported more than minimal
use (Hubbard et al., 1989). Of those reporting illegal activity before drug
treatment, 97 percent reported cessation of that activity during treatment.
Furthermore, more than one-third of clients (across all programs) reported
total abstinence from their primary drug during the followup period. Finally,
a 50- to 57-percent decrease in indicators of depression was found in clients
across all treatment modalities.
Drug Abuse Treatment Outcome Study
DATOS was conducted with groups of patients admitted to drug treatment between
1991 and 1993, and results are not yet available. DATOS is a multiyear,
longitudinal study of 12,000 adult clients in more than 50 treatment programs
(e.g., methadone maintenance, inpatient, long-term residential and therapeutic
community, and outpatient drug-free programs) in 12 cities, with followup
of 4,500 clients. One of the largest longitudinal prospective studies of
treatment outcome ever conducted, DATOS will attempt not only to determine
which treatments work but also to conduct a more indepth analysis of why
various treatments work and for which patients. Preliminary data from this
important study already are beginning to provide further insight into the
most critical needs of patients entering treatment, who is and who is not
entering treatment, and some of the barriers to successful treatment. For
example, in a recent study comparing support services needed by TOPS and
DATOS clients (based on self-reports), Etheridge and colleagues (1995) found
a decline from "...TOPS to DATOS in the percentage of clients who reported
having received and of the seven services [i.e., medical, psychological,
family, legal, educational, vocational, and financial services] during the
first 3 months of treatment." Furthermore, this trend was particularly evident
for the DATOS methadone and outpatient treatment clients.
California Drug and Alcohol Treatment Assessment
In 1992 the California Department of Alcohol and Drug Programs launched a
large-scale study of the effectiveness, benefits, and costs of alcohol and
drug treatment in California. The purpose of CALDATA was to study the effects
of treatment on participant behavior, the costs of treatment, and the economic
value of treatment to society. CALDATA's key findings demonstrate that treatment
is a good investment for taxpayers and saves money in terms of real costs
attributed to drug-related crime, illness, and lost productivity. The specific
findings are summarized as follows:
The cost of treating the approximately 150,000 participants represented by
the CALDATA study sample in 1992 was $209 million, while the benefits received
during treatment and in the first year and thereafter were worth approximately
$1.5 billion in savings to taxpaying citizens, due mostly to a reduction
Treatment for problems with crack-cocaine and powdered cocaine was found
to be just as effective as treatment for alcohol problems and somewhat more
effective than treatment for heroin problems.
The level of criminal activity declined by two-thirds from before treatment
to after treatment. The greater the time spent in treatment, the greater
the percent reduction in criminal activity.
Alcohol and other drug use declined by approximately two-fifths from before
to after treatment.
Hospitalizations were reduced by approximately one-third from before to after
treatment. There were corresponding significant improvements in other health
For each type of treatment studied, there were slight or no differences in
effectiveness between men and women; younger and older participants; or among
African-Americans, Hispanics, and whites.
Overall, treatment did not have a positive effect on the economic situation
of the participants during the study period. However, the data indicate that
longer lengths of stay in treatment have a positive effect on employment.
This finding is greater for those in residential programs than for those
in other treatment types. The largest gains in employment occur with those
individuals staying in treatment beyond the first month.
These noteworthy large-scale studies of drug abuse treatment effectiveness
conclude that treatment works. But which treatments are most effective, and
for whom are they most effective? The answers to these questions remain elusive.
Although treatment programs have been studied for decades, many studies produce
isolated, anecdotal evidence of success for individual treatment programs.
However, if standardized research methodologies with comparable outcome measures
had been used, the research may have provided definitive information regarding
treatment effectiveness for specific types of problems or clients. What we
do know, gathered from the programs that have been thoughtfully evaluated,
demonstrates that most treatments are effective under particular conditions
and for some people. More rigorous studies using comparable measures of success
will help us to answer these questions more definitively.
A REVIEW OF WHAT IS KNOWN ABOUT TREATMENT MODELS THAT WORK
This section reviews information about the following drug abuse treatment
models that have been proven effective: therapeutic communities (TCs),
pharmacological treatment, outpatient drug-free treatment, and inpatient
TCs are intensive, long-term, self-help, highly structured residential treatment
modalities for chronic, hardcore drug users who have failed at other forms
of drug abuse treatment. More than one-third of all admissions (including
dropouts) to TCs demonstrate long-term, successful outcomes 1 to 2 years
after treatment. In addition, approximately 60 percent of all admissions
show significant improvement on specific outcome variables 1 to 2 years after
treatment. However, clients remaining in treatment longer than 12 months
have the greatest likelihood of successful outcomes.
The following is known about TC treatment:
Length of stay in treatment is predictive of outcome;
Treatment is effective, although relapse is the rule; and
Treatment is effective, although dropout is the rule.
TCs view drug use as a symptom of profound problems of personality, social
maladjustment, inadequate interpersonal skills, little or no education, and
few (if any) marketable job skills. In other words, the problem is the person,
not the drug.
The environment of the TC, in supportive and confrontational aspects, serves
to make clients aware of the role that their problems play in contributing
to drug use. Elements of TCs (e.g., encounter groups, rule-setting and rule
enforcement, rewards, and work) allow the client to learn -- often for the
first time -- interpersonal, educational, and vocational skills and to develop
psychological, moral, and social strengths that are fundamental to living
a drug-free life, which is the common goal of all TCs.
The concept-based TC, often referred to as the "traditional" TC, is a departure
from traditional psychiatric care (i.e., care in which the doctors are in
control of treatment, rather than a modality in which patients exert control
over their own recoveries). It is a self-help modality developed by recovering
addicts. This modality has become widely accepted as an effective treatment
approach for drug addiction and antisocial problems. Examples of TCs are
San Francisco's Delancey Street Foundation and New York's Phoenix House,
where the length of the residential stay ranges from 9 to 24 months and where
residents move through explicit stages of treatment over time.
The TC atmosphere is informal and communal. TC staff comprise primarily recovered
addicts and a limited number of professionals, such as psychologists. Staff
and resident roles in all TCs are hierarchical in structure, with an explicit
chain of command. New residents are assigned to work teams with the lowest
status and are responsible for the most menial tasks, such as washing floors.
As residents demonstrate increased competency and emotional growth, they
are moved up the hierarchy, earning positions with improved status and
privileges. These rewards are highly reinforcing. Group meetings are central
to TC operations and treatment.
TCs provide an orderly environment for many who have lived in chaotic or
disruptive settings, reduce boredom and distracts from negative preoccupations
that in the past had been associated with drug use, and offer an opportunity
to achieve satisfaction from a busy schedule and the completion of daily
chores. However, because TCs are physically and psychologically demanding,
the dropout rate is high, especially in the first 3 months. Only one in four
voluntary clients remains longer than 3 months, while fewer than one in six
complete the 1- to 2-year course of treatment. For those who do complete
the program, the possibility of living a life free from drugs is greater
than for those who drop out early.
Measures of TC Treatment Effectiveness
The goal of all TCs, and the way they define clinical effectiveness, is the
promotion of a drug-free lifestyle through psychological habilitation and
rehabilitation. Additional issues become important in TC treatment for specific
populations. Drug-addicted pregnant women or women with children need to
develop self-esteem, parenting skills, and ways to cope without drugs in
an environment that nurtures both them and their children. Adolescent drug
users need approaches to treatment that take into account their sense of
denial and invulnerability. Drug-addicted incarcerated offenders need an
environment in which they will be respected so that the dual goals of reduced
recidivism to both prison and drug use will be met.
Good programs can be distinguished on the basis of well-defined treatment
protocols, adequate staffing patterns and experience, explicit program goals,
reasonable and consistent funding, and comprehensive management information
As with other types of settings, several factors govern the effectiveness
of programs that use pharmacotherapy primarily:
The intake population (i.e., substantial selection occurs during the screening
The length of time an individual waits for treatment;
The dropout frequency of those on the waiting list;
The point at which the individual is in the treatment process;
The client's environment;
The points at which success is monitored;
The services integrated into the overall service package; and
The treatment process, including dosages, pattern and duration of treatment,
training of providers, funding, and program demand constraints.
In addition, as with other treatment modalities, programs that provide
pharmacological treatment consider retention in treatment a measure of positive
treatment outcome. Understanding who is retained and the referral history
of clients can help programs prevent relapse and attrition.
The success of pharmacotherapy programs is well documented. A variety of
pharmacological treatments for drug dependence and evidence of their
effectiveness are described below.
Treatment of Opioid Dependence
Pharmacological treatments for opioid dependence frequently use one of two
general approaches. The first approach is long-term treatment in which the
addict is maintained with a legally sanctioned narcotic such as methadone.
The second approach is short-term treatment in which the addict is intended
to be detoxified to a drug-free state. This review will focus on long-term
Pharmacological maintenance programs involve the long-term administration
of a medication that either replaces the illicit drug or blocks its actions.
The medication is administered for at least 1 month and can be administered
for as long as several years. The goal of some programs is lifetime maintenance
on medication. Lifetime maintenance may be warranted as patient needs and
preferences dictate. For a discussion paper on Opioid Agonist Treatment, click below:
Methadone is a narcotic analgesic that is an effective substitute for heroin,
morphine, codeine, and other opiate derivatives. Opiates act quickly and
wear off within a few hours of administration, producing withdrawal symptoms
such as sleep disturbance, agitation, and mild depression. Long-lasting methadone
doses are substituted for illicit opiates to suppress withdrawal symptoms.
Methadone may be prescribed to assist in detoxification or to reduce the
use of illicit drugs and the related criminal, social, and psychological
problems associated with them.
Methadone is used to suppress opioid withdrawal symptoms for the entire 24-hour
period between doses without producing euphoria or sedation. This treatment
eliminates a major source of pressure to use illicit opioids (i.e., the
discomfort of withdrawal). The use of methadone typically renders concurrent
use of other opioids ineffective for purposes of producing euphoria.
Detoxification using methadone takes between 3 weeks and 6 months. The process
begins with increasing the dosage of methadone and decreasing illicit opiate
use without producing symptoms of withdrawal. Methadone doses eventually
may be tapered down to zero. Attrition is reported to be high during the
second week of 3-week programs, and patients show a rate of relapse greater
than 90 percent.
Methadone maintenance programs frequently are long term, often lasting 12
months or longer. Participation in methadone maintenance programs enables
recovering addicts to focus on their social and vocational rehabilitation
and to become reintegrated into society, although they still are addicted
to an opioid. Reducing the use of illicit drugs and reducing the commission
of other crimes to finance the drug habit are the primary goals of methadone
maintenance. Improved physical and psychological well-being and social
productivity also are objectives.
A 1991 study sponsored by the National Institute on Drug Abuse focused on
six established methadone maintenance programs in New York, New York;
Philadelphia, Pennsylvania; and Baltimore, Maryland. Comprehensive data about
the structure and operations of these programs were collected during a 3-year
period. For example, the study found that the experience and education of
counselors at these facilities varied. Each clinic had its own philosophy
of treatment, which appeared to be strongly conditioned by the director's
personal philosophy. Unfortunately, the criteria that constituted a successful
outcome were often unclear to the counselors who were providing treatment.
The only services applied consistently were case management and individual
counseling sessions. Initial assessment by a counselor was consistently available
at only one program. This study found that although opioid use declined markedly
after admission, 82 percent of subjects who left treatment rapidly relapsed
to intravenous drug use within 1 year. Crime was reduced substantially at
all six programs.
Naltrexone, an opioid antagonist, blocks the effects of opioids such as heroin,
thereby discouraging their use. Naltrexone can be administered in small daily
doses or in larger doses three times per week. To avoid intensified withdrawal
symptoms, patients must be completely detoxified from opioids before naltrexone
can be used. Detoxification can be accomplished with the aid of buprenorphine
Naltrexone is typically an adjunct to individual, group, or family therapy.
In general, naltrexone is thought to work best for highly motivated patients,
especially those with social supports. Consequently, the retention rate appears
to be greatest for health professionals and others with high social and economic
status. Patients with appropriate external motivations, such as fear of job
loss or return to prison, may also find success using naltrexone if they
have family support.
In 1986 researchers reported on the success of naltrexone programs serving
three general types of patients. The key findings of this study are summarized
The Veterans' Administration in Philadelphia treated 327 outpatient addicts
for an average of 9 years. At the 6-month followup, 32 percent of patients
receiving naltrexone for more than 30 days remained opioid free.
Middle-class suburban subjects who had been using opioids for an average
of 10.5 years were studied in 13 California clinics. Included in this study
were 42 former heroin addicts who had been maintained with methadone,
levo-alpha-acetylmethadol (LAAM), or other medications prior to naltrexone
treatment. Most of these subjects were employed. Outcomes studied were drug
use and treatment retention. Retention averaged only a few weeks but was
clearly helped by counseling. It was concluded that the use of naltrexone
appears to promote long periods of opioid abstinence but does not prevent
Of the 114 business executives treated at Regent Hospital in New York City
and at Fair Oaks Hospital in Summit, New Jersey, all had been addicted for
at least 2 years and had entered treatment under serious threat of losing
their jobs. The initial phase of the programs, lasting 4 to 10 weeks, consisted
of treatment with clonidine detoxification, group therapy, peer group meetings,
family meetings, individual therapy, educational sessions, and physical exercise.
The second phase consisted of outpatient naltrexone treatment for at least
6 months in conjunction with group and/or individual therapy, self-help groups,
and urine monitoring. Outcomes reported were drug use, employment, and retention
in treatment. At 12- to 18-month followup, 64 percent of subjects were still
opioid free. Patients who completed at least 6 months of treatment were more
likely to be opioid free, employed, and continuing therapy or participating
in a self-help group than those who discontinued treatment shortly before
Buprenorphine, a medication still in the experimental stage, exhibits mixed
opioid-like and opioid-antagonist properties. It causes dependence in those
not already taking opioids but acts as an antagonist to precipitate withdrawal
in those who are opioid dependent. Maintenance buprenorphine treatment, like
methadone, seems to reduce craving, enhance treatment retention, and block
the effects of illicit opioids. Buprenorphine is more frequently used as
an aid to detoxification.
Long-acting opioid maintenance compounds, such as LAAM, are being developed
to overcome the need for daily clinic attendance required by methadone
maintenance. LAAM has been shown to suppress withdrawal symptoms in
opioid-dependent subjects for 72 to 96 hours. Its delayed onset results in
fewer sedative effects and less euphoria than methadone.
Clinical trials of LAAM suggest that it is comparable to methadone maintenance
in clinical safety and efficacy but offers a number of advantages. First,
its long duration of action allows clinic attendance to be reduced from daily
attendance to attendance three times per week. The need for take-home doses
that may be diverted to street use is eliminated. LAAM also increases the
clinics' treatment capacity since fewer clinic visits per patient are required.
Fewer clinic visits further reduces the patient's feelings of dependence
on the clinic. Second, slower onset and more sustained action reduce feelings
of sedation and decrease its attractiveness to street addicts as a potential
drug of abuse.
Treatment of Cocaine Dependence
Both short-term and long-term medications have been studied for their potential
to treat addiction to cocaine and its derivatives. None of these medications
has been accepted for widespread use. Short-term medications (e.g., amantadine
and bromocriptine) have been shown to reduce symptoms of cocaine withdrawal
(e.g., cocaine craving, lack of energy, depression, and insomnia). Long-term
agents have a delayed onset of action in reducing cocaine craving. For example,
desipramine's onset of action is usually delayed for 10 to 20 days.
Fluphenthixol decanoate has both antidepressant and antipsychotic properties.
Preliminary research on this medication has shown it to be effective in
ameliorating cocaine withdrawal symptoms. In experimental research, fluphenthixol
has been found to decrease cocaine use markedly, resulting in a 260-percent
increase in the average time a patient was retained in treatment compared
with their longest previous stays.
Measures of Pharmacological Treatment Outcome
Outcome measures used for evaluating pharmacological treatments depend on
the philosophy of the individual program and the goals of the researchers.
Short-term pharmacological treatment generally implies detoxification.
Medications for detoxification are usually evaluated in terms of immediate
pharmacological effects and retention in treatment for the several days that
detoxification requires. These medications are intended to subdue physical
Medications for long-term or maintenance treatment (e.g., methadone or
naltrexone) are usually evaluated for overall effectiveness and are measured
by such factors as retention in treatment as part of specific programs. Outcome
measures have included the following (separately or in various
intravenous drugs, depressants, marijuana, or alcohol.
Criminality. -- This is expressed by number of arrests or convictions, time
spent in jail, number of days involved in crime, percent of income derived
from crime, or dollar amount derived from crime.
Productivity. -- This is defined by employment, school, or homemaking.
Medical problems. -- This includes days having medical problems, time physically
disabled, and reduction of intravenous-related risk factors such as AIDS
(acquired immune deficiency syndrome) and hepatitis.
Psychological functioning. -- This is usually measured with standard instruments,
such as the Beck Depression Inventory.
Social functioning. -- This is usually measured as the number of days having
family or other interpersonal problems.
Many researchers use the Addiction Severity Index (ASI) for all measurements.
The ASI is a structured clinical interview that can be administered in 30
minutes. It produces 10-point problem severity ratings in each of 6 areas
commonly affected by addiction: drug abuse, physical health, employment,
family/social supports, the law, and psychological health. "Current functioning"
combines ASI measures of employment, drug use, family, and psychological
problems for the past month. In addition, the ASI has proven to be extremely
useful as a set of relevant measurement outcomes in clinical trials examining
Outpatient Drug-Free Treatment
Some researchers consider outpatient drug-free treatment to be the "backbone"
of treatment efforts in most parts of the United States. Outpatient drug-free
treatment includes a range of protocols, from highly professional psychotherapy
to informal peer discussions. Counseling services vary considerably and include
individual, group, or family counseling; peer group support; vocational therapy;
marital therapy; and cognitive therapy. Aftercare, considered necessary to
prevent relapse, typically consists of 12-step meetings, periodic group or
individual counseling, recovery training or self-help and relapse prevention
strategies, and/or vocational counseling.
The National Drug Abuse Treatment System Survey, conducted in 1988, indicated
that outpatient drug-free programs have an average of 9 staff members, compared
with 13 in methadone maintenance programs, and tend to have more staff members
with advanced academic degrees and with drug abuse treatment certification
or training than do methadone maintenance programs. TOPS found that outpatient
drug-free programs are more likely than other modalities to employ psychologists
and social workers.
Measures of Outpatient Treatment Effectiveness
While abstinence appears to be the ideal goal of outpatient drug-free treatment
programs, reduced drug use is commonly viewed as a more realistic objective
and also is considered a sign of treatment efficacy. The clinical measures
of effectiveness are particularly difficult to discern due to the enormous
diversity within the modality and the relative scarcity of available outcome
studies. Like the other major modalities, outpatient drug-free programs most
often focus on clients' drug use when assessing treatment effectiveness.
Studies indicate that outpatient drug-free programs are more likely than
outpatient methadone programs to stress abstinence as an outcome. Even so,
relapse is common and is not considered a sign of treatment failure. Other
common measures of effectiveness, depending on the intensity and range of
services offered by particular programs, are improved employment status,
reduced criminal activity, and a wide variety of psychosocial factors. Programs
specifically for women consider other outcomes, such as improved perinatal
outcomes and parenting skills, as significant signs of treatment effectiveness.
Outpatient drug-free treatment programs continue to grow in number and diversity.
As more and more people turn to outpatient treatment as a cost-effective
treatment modality, a clearer understanding will be needed regarding the
effects that these treatments have on overall long-term outcomes.
Inpatient treatment refers to the treatment of drug dependence in a hospital
and includes medical supervision of detoxification. Inpatient drug treatment
programs traditionally lasted for 28 days, although this duration has changed
considerably since the emergence of managed care models in substance abuse
services and currently range from as little as 3 days to longer, more traditional
lengths of stay. Criteria for hospitalization of the cocaine abuser are as
Users whose drug compulsions are uncontrollable, especially heavy
freebasers3 and intravenous drug users;
Users with physical dependence on other drugs or alcohol;
Users with severe medical or psychiatric complications;
Users with severe psychosocial impairments; and
Users who have failed in outpatient treatment.
Admission to inpatient programs to treat dependence on drugs other than cocaine
is equally stringent, often using the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition criteria for drug use disorders.
The primary objective of inpatient drug-free treatment is to help the patient
achieve and maintain a drug-free lifestyle. Additional objectives include
the following: decreased involvement in illegal activities; increased
productivity in work or school settings; improved social, family, and
psychological functioning; and improved physical health. Improved psychological
and family functioning facilitates improvement in other areas as well. There
are different types of inpatient programs, serving different types of clientele.
Those discussed below are therapy-based programs, 12-step programs, and
Therapy-based programs, also referred to as psychiatric inpatient programs,
tend to serve older or middle-class patients, adolescents whose drug use
has not yet developed the secondary characteristic of drug addiction, and
patients who have a specific psychiatric problem in addition to drug use.
Psychiatric programs require a 4- to 12-week length of stay, although adolescent
treatment may be longer. Programs generally begin with detoxification, followed
by a variety of services, including individual, group, and family therapy;
education; and training in behavioral techniques, such as relaxation and
exercise. Participation in Alcoholics Anonymous (AA) or Narcotics Anonymous
(NA) is required. Psychiatric inpatient programs are described as more useful
for older, middle-class, or blue-collar patients. Addicted health professionals
constitute a specific patient population that appears to benefit from psychiatric
Twelve-step programs, such as the Minnesota Model (patterned after the Hazelden
program in Minnesota), are based on a model of total abstinence. Certified
counselors (often recovering addicts) conduct most of the group and individual
counseling, with program staff providing consulting and resource backup as
needed. Counseling is focused on family and other interpersonal relationships.
Patients work on at least the first four steps of the AA model while in the
treatment program, with progression through the remaining eight steps expected
through subsequent involvement with AA or NA. Detoxification and health
assessment also are included in 12-step programs.
Patients in 12-step programs generally are middle-class or working-class
males with a high school education who do not have co-occurring psychiatric
disorders. Lower rates of abstinence were reported for clients under age
25. Twelve-step treatment is reportedly more effective for middle-age
participants than for those in other age groups.
Multimodality programs, pioneered by Jaffe (1973) and Kleber (1985), offer
a variety of services, including inpatient treatment, medical care, outpatient
brief treatment, vocational training, educational enhancement for adolescents,
family therapy, adult or adolescent TCs, methadone maintenance, group
psychotherapy, individual psychotherapy, drug education, and stress-coping
techniques. Multimodality programs require coordination among noncompetitive
treatment programs. These options often exist within a single community.
Treatment options differ from program to program. A case manager or client
representative assists patients in selecting appropriate treatment options.
Inpatient treatment generally is required at some point in the multimodal
treatment process. Patients may be transferred into or out of different treatment
modalities based on progress, which is assessed by evaluation staff and the
case manager. Criteria for transfer include the following: level of compulsion
or severity of drug use, psychiatric or psychological impairment, compliance
with program requirements, and improvement in psychological functioning.
Inpatient treatment is not an option for everyone, including many drug-using
women with children. Few programs provide childcare services; foster care
may be the only option for women who require inpatient treatment, especially
for low-income families and single women. Many women avoid treatment for
fear that they will be unable to regain custody of their children after
completing treatment. Pregnant women may risk criminal charges for drug use
during pregnancy and may therefore refrain from seeking treatment.
Measures of Inpatient Treatment Effectiveness
Abstinence is the most common goal of inpatient treatment programs and the
most widely used measure of clinical effectiveness. Abstinence, by most
definitions, means refraining from use of all drugs, including the primary
drug of dependence (generally cocaine or heroin), alcohol, marijuana, and
all other mood-altering drugs. Measures of abstinence, however, may be divided
into separate measures for abstinence from the primary drug of dependence,
alcohol, marijuana, and other drugs. Alternately, abstinence may be measured
by the length of time the patient remains drug free during the followup period
or by the frequency of subsequent drug use.
Measures of clinical effectiveness focus on continuance of a drug-free lifestyle
and evidence of improved psychological functioning and social skills for
all inpatient programs reviewed. All programs measured total abstinence,
although some included data on levels of use for nonabstainers and an indication
as to whether data were self-reported or verified objectively. Participation
in aftercare, another measure of treatment effectiveness, is an important
factor in preventing relapse and continued development of coping skills.
Intake data are benchmarks against which posttreatment lifestyle measures
are compared. The CATOR (the Chemical Abuse/Addiction Treatment Outcome Registry)
methodology and studies using the ASI are examples of pretreatment and
posttreatment measures of outcome variables.
INTEGRATING SERVICES FOR SUCCESSFUL OUTCOME
Regardless of the setting (e.g., inpatient, outpatient, or residential),
a successful course of treatment will combine therapies, services, and methods
that produce favorable outcomes. Since drug users, especially hardcore drug
users, face many related problems (e.g., high-risk environment, unemployment,
lack of education, and physical and sexual abuse), effective treatment requires
several critical elements, including the following:
Complete and ongoing assessment of the client;
A comprehensive range of services, including pharmacological treatment, if
necessary; counseling, either individual or group, in either structured or
unstructured settings; and HIV-risk reduction education;
A continuum of treatment interventions;
Case management and monitoring to engage clients in an appropriate intensity
of services; and
Provision and integration of continuing social supports.
These elements, rather than the specific treatment models, determine whether
a program will be successful in treating individual clients and affecting
the broader social or community problems that exist because of drug abuse.
In conclusion, drug addiction is a complex disorder involving a range of
biological, psychological, and often environmental factors. Often a chronic,
relapsing disorder, treatment works when those who abuse drugs can be engaged
and retained in treatment and when other needed services can be integrated
with drug treatment itself and delivered to help clients resolve the range
of problems that accompany their drug use.
1 SOURCE: Treatment Outcome Working Group, a meeting
of treatment and evaluation experts in 1993 that was sponsored by ONDCP.
The meeting's goal was to provide recommendations to improve treatment outcome
research. Recommendations throughout this report are based on findings of
the group and on research conducted with this study.
2 Treatment programs have evolved over time from
this traditional categorization, which is the categorization used in research
literature. Today many programs combine elements from more than one modality.
3"Freebase," a concentrated form of cocaine that
is smoked, is prepared by extracting (freeing) the alkaloid (base) from the
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TREATMENT OUTCOME WORKING GROUP
Douglas Anglin, Ph.D.
Drug Abuse Research Center
University of California, Los Angeles
Los Angeles, California
New Jersey Department of Health Division of Alcohol, Drug Abuse, and Addiction
Trenton, New Jersey
Sam di Menza
Rehabilitation Systems Incorporated
George DeLeon, Ph.D.
Center for Therapeutic Research
New York, New York
Frank Gawin, M.D.
Addiction Research Consortium
University of California, Los Angeles
Los Angeles, California
Barbara Havassey, Ph.D.
Treatment Outcome Research
University of California, San Francisco
San Francisco, California
Norman Hoffman, Ph.D.
New Standards Institute
St. Paul, Minnesota
Robert Hubbard, Ph.D.
Research Triangle Institute
Research Triangle, North Carolina
James Inciardi, Ph.D.
Center for Alcohol Studies
University of Delaware
Duane McBride, Ph.D.
Behavioral Sciences Department
Berrgin Springs, Minnesota
Thomas McClellan, Ph.D.
Drug Dependence Treatment and Research Center
Veterans Administration Medical Center
Native American Rehabilitation Association of the Northwest
Norman Miller, M.D.
Department of Psychiatry
University of Illinois at Chicago
Dwayne Simpson, Ph.D.
Institute of Behavioral Research
Texas Christian University
Fort Worth, Texas
Substance-Abusing Population in Treatment
NATIONAL DRUG AND ALCOHOLISM TREATMENT UNIT SURVEY
When discussing treatment protocols and effectiveness, it is helpful to know
the number of people in the United States currently involved in treatment
for substance abuse and to understand the characteristics of the population
in treatment. The National Drug and Alcoholism Treatment Unit Survey (NDATUS)
is a primary source of national data on specialty substance abuse treatment
and the population seeking such treatment; therefore, NDATUS is used to provide
a representative point of reference in this report.
NDATUS collects services data for 1 day out of the year. This "snapshot"
provides an indication of the scope and costs of annual treatment services,
albeit, to the extent that flow of admissions, duration of treatment episodes,
and nature of treatment services are stable throughout the year. Although
treatment services are changing in light of the development of the services
environment and the introduction of managed care, NDATUS is believed to be
the most representative source of information on treatment nature, type,
CLIENTS IN TREATMENT
On September 30, 1992, approximately 945,000 individuals were undergoing
specialty substance abuse treatment. This represents an average of 432 clients
ages 12 and older per 100,000 in the general population. However, the number
of clients varies across the Nation. Of the four census regions, the highest
rate of specialty treatment clients was found in the West (656 per 100,000).
The Northeast had a rate of 539 clients per 100,000, the Midwest was below
the national average with a rate of 361 clients per 100,000, and the South
had the lowest rate average of 293 per 100,000.
SUBSTANCES OF ABUSE
Since 1991 NDATUS has classified clients by whether they were being treated
for drugs only, alcohol only, or both alcohol and drugs. Besides identifying
the actual substances abused by clients, this classification might also reflect
treatment service provider expectations. For example, if a provider is oriented
toward alcohol abuse, the provider is more likely to report that its clients
abuse alcohol. State funding, licensing, and reporting practices also may
influence the reporting of clients' problems.
Among clients in treatment, simultaneous abuse of illicit drugs (e.g., cocaine,
opiates, and marijuana) and alcohol was the most common pattern of substance
abuse (38 percent). Thirty-seven percent abused only alcohol, while 25 percent
abused only drugs.
The demographic data for clients has been collected by NDATUS since 1980.
Actual numbers of clients cannot be compared over time because of fluctuations
in survey coverage; therefore, the proportion of clients in each demographic
category are compared. Comparing the proportion of clients as opposed to
the number of clients in each category allows an assessment of how the mix
of clients may have changed over time, highlighting potential survey
An analysis of the demographic data revealed the following information:
In 1992, 72 percent of clients in specialty substance abuse treatment were
male. This percentage represents a slow decline in the proportion of men
in treatment, who comprised 75 percent of the total in 1980.
The age pattern of clients has changed. The proportion of clients ages 21
to 44 rose from 62 percent in 1980 to 75 percent in 1992, while the proportion
of clients under age 21 or over age 44 declined substantially.
In 1992 white clients represented the largest proportion of clients in treatment
(60 percent). Blacks, Hispanics, and Native Americans were overrepresented
when compared with their proportions of the general population. Blacks comprised
22 percent of treatment clients, compared with 12 percent of the general
population; Hispanics represented 15 percent of treatment clients, compared
with 10 percent of the general population; and Native Americans comprised
1.3 percent of treatment clients, compared with 0.7 percent of the general
Analysis of the demographic data revealed the following information on treatment
In 1992, 87 percent of daily clients1 were enrolled in outpatient
rehabilitation. The remaining 13 percent were in 24-hour treatment.
The proportion of outpatient rehabilitation clients increased steadily from
1982 to 1992. The proportion of outpatient methadone clients remained between
12 and 15 percent of all clients.
In 1992 the proportion of clients in 24-hour detoxification treatment was
less than 6 percent in all States and 3 percent or less in 40 States. However,
States varied widely in their proportion of clients in outpatient versus
24-hour rehabilitation and in their proportion of outpatient methadone clients.
When States are ranked by number of clients per 100,000 in the general
population, there appears to be a positive correlation between clients per
100,000 and the proportion of clients in outpatient treatment. That is, the
larger the rate of clients in treatment, the greater the proportion of clients
in outpatient care.
The predominance of outpatient services over 24-hour rehabilitation has two
caveats. First, it is more difficult for providers to accurately count the
number of outpatient clients than 24-hour rehabilitation clients because
the definition is more complicated, more records must be reviewed, and many
"actively enrolled" clients who scheduled appointments during the past month
may not return. As a result, many respondents may estimate the number of
active outpatient clients without any detailed review of clinical records.
Second, because 24-hour treatment clients typically have shorter lengths
of stay, more clients are admitted to 24-hour slots than outpatient slots
during a year. Consequently, the proportion of 24-hour clients measured on
this 1-day census is lower than it would be if clients were reported on an
MATCHING CLIENTS TO TREATMENT
As stated earlier, for each treatment type, NDATUS enumerates the number
of clients being treated for alcohol only, drugs only, or both alcohol and
drugs. Although it is difficult to classify problem severity with only these
three categories of substance abuse, clients who use both drugs and alcohol
are more likely to have severe dependency problems.
Clients with both alcohol and drug problems also receive the most intensive
treatment. In 1992, 20 percent of clients using both substances were in 24-hour
treatment versus 10 percent of clients using only drugs and 8 percent using
only alcohol. In 1991, 19 percent of clients using both substances were in
24-hour treament versus 12 percent using only drugs and 8 percent using only
Two possible reasons explain why clients with polysubstance abuse are more
often treated in 24-hour programs: (1) They may be more disabled by their
substance abuse, thereby requiring round-the-clock care or (2) they may need
to be taken out of environments that perpetuate substance abuse.
-- Jason M. Novak
1 The reader is referred to the NDATUS report for precise definitions
of treatment categories.