       
More facts on alcohol and other drug addiction |
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6.1 Introduction Our goals for this chapter were similar to those in the previous chapter on alcoholism treatments. Based on a review of the extant literature, we hoped to learn the answers to the following questions: (1) What treatments are being used to treat drug abusers? (2) Are these treatments effective? Do they work? (3) Which treatments are the most cost effective? (4) What are the benefit/cost ratios for these treatments? (5) Which treatments are the most effective for the different types of patients? At best, we were only able to find partial answers to these questions. The reason for this is that evaluation of drug abuse treatment effectiveness is very complex, involving an assessment of the nature of treatment provided, the problems and characteristics of clients, and the multiple outcomes attributable to interaction between treatments and clients (Hubbard et al. 1989). Because treatment programs have different goals, they use different outcomes to measure success. All of the programs seek to reduce or eliminate drug use among patients and many seek to lessen criminal activity as well. Some programs attempt to increase their patients’ employment and earning opportunities, while others try to change their patients’ lifestyles, social behavior, and mental health. This review will focus on the program’s ability to reduce drug use and criminality and to improve patients’ employment and earnings. Patients, their families, and health care administrators are particularly interested in the decline in drug use because of the health benefits, the reduction of stress, and the associated decline in diseases such as AIDS, TB, and hepatitis spread by the use of needles (McLellan, Woody, and Metzger 1996). Taxpayers and government officials are, perhaps, more interested in the effects of treatments on criminality, employment and earnings for obvious reasons. Part of the complexity of the study of drug abuse treatment effectiveness arises from the diversity of approaches and settings in which treatment occurs. Drug abuse treatment is provided in a number of modalities by hospitals, community public health agencies, and a variety of independent organizations (Hubbard et al. 1989). Prior to 1990, there were four major modalities (detoxification programs, methadone maintenance programs, residential drug free, and outpatient drug free) and effectiveness results were frequently reported at this level. In the 1990s, a number of new modalities were introduced and some of them have recently been evaluated (NIDA 1999). Comparisons of the relative effectiveness of drug abuse modalities is difficult because they have different goals and outcome measures, they provide different treatment services, and they serve different types of patients (DeLeon 1984, Hubbard et al. 1989, and NIDA 1999). The outline of the chapter is as follows. Section 6.2 discusses the major types of drug abuse treatments and the various types of modalities. In the next section, we outline the major methodological problems involved in estimating the effectiveness of drug abuse treatments. Section 6.4 reviews the literature on the effectiveness of drug abuse treatments. We begin with an overview of the data sources and the overall effectiveness of such treatments. Then we consider modality effectiveness. Studies have shown that the modalities treat different types of clients and that outcomes are sensitive to the problems and characteristics of clients. We shall investigate this literature next. After this, we shall examine the literature on the effects and determinants of length of treatment on program effectiveness. This is followed by a discussion of the effectiveness of individual treatment and program components. We shall also discuss the “MATCHING” hypothesis. The section ends with a discussion of the problems of relapse and readmission. In Section 6.5 we shall review the sparse literature on the cost-effectiveness of drug abuse treatment programs. The few existing benefit/cost studies of drug abuse treatment programs will be considered in the next section. Section 6.6 critically reviews some recent benefit/cost studies of state drug abuse programs from the taxpayer’s point of view. The final section summarizes our findings and conclusions on drug abuse treatment evaluations. 6.2 Drug Abuse Treatments and Modalities According to Anglin and Hser (1990), there is no simple cure for drug dependence. Drug dependence is a chronic condition, and relapse is often the rule. Many biological, socio-cultural, economic, and psychological factors are believed to contribute to drug abuse. For this reason, the treatment of drug abuse is not simply a medical issue; it involves a wide spectrum of social considerations. Because of the complexity of addiction, drug addiction treatment involves many components. Some of those components focus directly on the individual’s drug use, but others focus on restoring the addicted individual to productive membership in the family and society (NIDA 1999). Treatment for drug abuse and addiction is delivered in many different settings, using a variety of behavioral and pharmacological approaches.
6.2.1 Drug Abuse Treatment Modalities Research studies on drug addiction have typically classified treatment programs into several general types or modalities (NIDA 1999). These include the following: (1) Methadone Maintenance Treatment for opiate addicts usually is conducted in outpatient settings. These programs use a long-acting synthetic opiate medication, usually methadone or LAAM, administered orally for a sustained period at a dosage sufficient to prevent opiate withdrawal, block the effects of illicit opiate use, and decrease craving. (2) Narcotic Antagonist Treatment Using Naltrexone for opiate addicts usually is conducted in outpatient settings. Naltrexone is a long-acting synthetic opiate antagonist that blocks the effects of self-administered opiates, including euphoria. (3) Outpatient Drug-Free Treatment programs differ in the types and intensity of services offered, such as drug education and counseling. Such treatment costs less than residential or inpatient treatment and often is more suitable for individuals who are employed or who have extensive social supports. (4) Long-Term Residential Treatment provides care 24 hours per day, generally in non-hospital settings. The best-known residential treatment model is the therapeutic community (TC), which focuses on the “re-socialization” of the individual and uses the program’s entire “community” as active components of treatment. Addiction is viewed in the context of an individual’s social and psychological deficits, and treatment focuses on developing personal accountability and responsibility and socially productive lives. Some residential treatment programs employ other models, such as cognitive-behavioral therapy. (5) Short-Term Residential Programs provide intensive but relatively brief residential treatment based on a modified 12-step approach. These programs were originally designed to treat alcohol patients, but during the cocaine epidemic of the mid-1980’s, many began to treat illicit drug abuse and addiction. (6) Medical Detoxification is a process whereby individuals are systematically withdrawn from addicting drugs in an inpatient or outpatient setting, typically under the care of a physician. Detoxification is sometimes called a distinct treatment modality but is more appropriately considered a precursor of treatment, because it is designed to treat the acute physiological effects of stopping drug use. (7) Prison-Based Treatment Programs Offenders with drug disorders may encounter a number of treatment options while incarcerated, including didactic drug education classes, self-help programs, and treatment based on therapeutic community or residential milieu therapy models. (8) Community-Based Treatment for Criminal Justice Populations A number of criminal justice alternatives to incarceration have been tried with offenders who have drug disorders, including limited diversion programs, pretrial release conditional on entry into treatment, and conditional probation with sanctions. For example, drug courts mandate and arrange for drug addiction treatment, actively monitor progress in treatment, and arrange for other services to drug-involved offenders. The Treatment Accountability and Safer Communities (TASC) program provides an alternative to incarceration by addressing the multiple needs of drug-addicted offenders in a community-based setting. These programs include counseling, medical care, parenting instruction, family counseling, school and job training, and legal and employment services. The key features of TASC include (1) coordination of criminal justice and drug treatment; (2) early identification, assessment, and referral of drug-involved offenders; (3) monitoring offenders through drug testing; and (4) use of legal sanctions as inducements to remain in treatment. 6.2.2 Drug Abuse Treatments Most treatment programs usually provide a combination of service components besides their modality-specific treatment. The following treatment components have been identified by Anglin and Hser (1990) and the National Institute of Drug Abuse (1999). (1) Drug Counseling is the primary support service provided to clients in most drug-treatment programs and is common across all modalities. Drug counseling focuses on assisting the client in practical problem solving for day-to-day living. (2) Drug Education contributes to the client’s understanding of the biological, familial, psychological, and social factors that contribute to drug dependence. (3) Pharmacotherapy interventions with serious drug dependence typically involve a period of detoxification for the purpose of medically managing drug withdrawal systems. Agents such as desiprimine and bromocriptine have been used to treat depression with dysfunctional levels of cocaine use. Long-term use of narcotic antagonists such as naltrexone or clonidine have been used to treat heroin addiction. Methadone substitution for illicit opiate dependence is perhaps the most lengthy pharmacotherapy applied in drug treatment. (4) Psychotherapy components vary widely across the programs. The unit of the intervention may be the client, the client and spouse, or the family. Group counseling is commonly used. (5) Education and Vocational services are often provided because of clients educational, employment, and legal problems. Job skill training can enhance employment and earnings opportunities. (6) Urine testing provides one objective measure of compliance with the treatment goals of reducing primary drug use. Such testing is common in all modalities. (7) Relapse-prevention training can be used to insulate the carefully cultivated attitudes, skills, and intentions derived from the treatment process from individual and community influences. The relapse prevention approach to the treatment of cocaine addiction consists of a collection of strategies intended to enhance self-control (NIDA 1999). (8) Social and Community Support assists recovery from drug dependence during treatment after discharge. This includes self-help or mutual support organizations like Narcotics Anonymous and Cocaine Anonymous. Group homes can provide a useful intermediate step from residential care to community care. (9) The Matrix Model draws heavily from other treatment approaches. It includes relapse prevention training, family and group therapies, drug education and self-help participation. The therapist functions simultaneously as teacher and coach, fostering a positive encouraging relationship with the patient and using that relationship to reinforce positive behavior change. (10) Supportive-Expressive Psychotherapy has two main components: supportive techniques to help patients feel comfortable in discussing their personal experiences and expressive techniques to help patients identify and work through interpersonal relationship issues. Special attention is paid to the role of drugs in relation to problem feelings and behaviors, and how problems may be solved without recourse to drugs. (11) Motivational Enhancement Therapy is a client-centered counseling approach for initiating behavior change by helping clients to resolve ambivalence about engaging in treatment and stopping drug use. This approach employs strategies to evoke rapid and internally motivated change in the client, rather than guiding the client stepwise through the recovery process. 6.3 Methodological Problems in Evaluating Drug Abuse Treatments The number of evaluation studies of drug abuse treatment programs has increased rapidly since the early 1970s. These studies vary in scope and methodology, which makes it difficult to interpret and compare their results (French 1995 and Anglin and Hser 1990). The methodological problems involved in evaluating drug abuse problems are quite similar to those in evaluating alcoholism treatments, which were discussed in Section 5.3. Therefore, only a brief summary of these problems will be presented in this section.
Problem 1. Standardizing Treatment Protocols There is widespread disagreement among clinicians and researchers with respect to the causes of drug addiction and how it should be treated. Therefore, treatments, processes, and procedures vary from program to program. Evaluation studies of drug abuse programs rarely provide detailed information on these components so we are only beginning to learn the relative effectiveness of these components (see Section 6.4.5 below). Recently, the National Institute of Drug Abuse (1999) put out a manual explaining how to measure and improve costs, cost-effectiveness, and cost benefit for substance abuse treatment programs based on a cost-procedure-process-outcome analysis (CPPOA) model. The manual is intended to help program managers understand why their programs are effective and to find the cost-effectiveness of individual processes and procedures so that programs can be improved. Problem 2. Standardized Outcome Measures The primary goal of most drug abuse treatment programs is abstinence or at the very least reduction in drug use. But studies define and measure success with respect to abstinence and reduced drug use in different ways, making it difficult to compare the relative effectiveness of the programs. Drug abuse programs have a number of other goals and associated output measures including: “decreased levels of illegal activities such as drug trafficking, property crime, or prostitution; increased employment and decreased reliance on social service agencies; improved social and family functioning; improved psychological functioning, and decreased mortality and improved physical health” (Anglin and Hser, 1990, pp. 415-416). Because program objectives and output measures are not identical across programs, it is difficult to measure their relative effectiveness. Problem 3. Patient Variation Over time we have learned more about the heterogeneous nature of the drug-dependent population. We have learned that certain types of patients self-select into different types of drug abuse modalities and types of treatments (Anglin and Hser 1990). Some clients respond to treatments better than others and some patient characteristics are significantly correlated with successful outcomes (see Section 6.4.3 below). It is difficult to separate treatment effects from patient variation when comparing the effectiveness of different programs. Problem 4. Costs of Treatments Average costs per patient are typically reported (if at all) at the program level rather than actual individual patient costs. Because most programs tailor treatments to individuals, and individuals remain in treatment for different lengths of time, the average cost per patient is a poor proxy for actual patient cost (NIDA 1999). In addition, most evaluation studies ignore indirect costs such as individual’s transportation expenses, lost work time, donated time and equipment, and care taking (French 1995). The omission of such costs makes it difficult to estimate the cost-effectiveness or the cost-benefits of drug abuse programs. Problem 5. Research Design Like alcoholism treatment evaluations, drug abuse treatment evaluations do not use the experimental design, which randomly assigns patients to experimental patient groups and to a control group which does not receive treatment services, because it is considered unethical to deny services to drug abusers (Anglin and Hser 1990). In the absence of randomly selected “no treatment” control groups, it is impossible to determine the “true” effectiveness of drug abuse treatments. Random assignment reduces or eliminates the problem of patient variation discussed above. There have been a few attempts to randomly assign patients in drug abuse studies, but many patients refuse random assignment and attrition rates have been so high that the results cannot be trusted (Anglin and Hser 1990). Many of the early 1970s evaluation studies of drug abuse programs did not include control groups. For reasons discussed earlier, we have little confidence in these studies’ findings. Later studies have used the pre/post research design with patients serving as their “own” control group. These studies produce results that are favorable biased because of the “ramp up” and “regression-to-the-mean” and “spontaneous recovery” problems discussed earlier. A few studies have used a matched control group drawn from participant dropouts or waiting lists. Unfortunately, we cannot be sure that individuals chosen from these sources have the same motivation to change even if they are matched on other patient characteristics. Finally, there are a few natural experiment studies where the control group seems quite comparable to the treatment group (Anglin and Hser 1990). These studies come closer to measuring the “true” effectiveness of drug abuse treatment programs than the other evaluations. Problem 6. The “Ramp Up Effect” and “Regression-to-the-Mean Problem Anglin and Hser (1990), French (1995), and Estee and Nordlund (2001) have noted that the abnormally high levels of drug use, crime, or both among drug abusers in the period just prior to treatment might cause the observed “improvement” in the post-period to represent no more than a “regression-to-the-mean effect, particularly when the pre-treatment period was short. Also, the crisis resulting from the high levels of drug use and crime might cause the individuals to seek treatment or to change their behavior without treatment (i.e., “spontaneous recovery”). Problem 7. Follow-Up Analysis Problems Drug abuse evaluation follow-up periods tend to be short (6 months or one year). Studies using no control group or “own” control group research designs tend to produce highly favorable results in short follow-up periods because of the “regression-to-the-mean” and “spontaneous recovery effects”. Studies with longer follow-ups (2 years or more) provide a better indication of a program’s effectiveness. Follow-ups also face the problem of sample selection due to high attrition rates in drug abuse programs (which often exceed 50%). Problem 8. The Relapse Issue Drug dependence is a chronic illness and many patients that successfully complete drug abuse treatments will relapse and later re-enter new drug-abuse treatment programs. Most drug abuse evaluations ignore the issue of readmission. They focus on individual treatment episodes. Without tracking patients who return for more treatment, treatment cost and effectiveness measures could be seriously biased (French 1995). Observed differences in abuse treatment effectiveness could represent different mixes of new and readmitted patients rather than “true” treatment effects.
Problem 9. Spontaneous Recovery We know that some drug abusers recover (i.e., lessen their drug use and reduce their health care expenditures) without treatment (Estee and Nordlund 2001) and follow-up studies often show some degree of improvement for drug abusers that receive only minimal treatment (Anglin and Hser 1990). For these reasons, it is difficult to accept at face value the highly favorable results reported by evaluation studies that have no control group or that use an “own-patient” control group. If a spontaneous recovery effect is present, their estimates of success are biased upward by an unknown amount. Problem 10. Statistical Analysis Most research data obtained in drug-treatment evaluation have been analyzed at the descriptive and comparative level. Simple descriptive analysis of means can detect average changes in outcome variables between periods, but it cannot explain or predict the causes of the changes. We need more advanced statistical techniques such as multivariate regression analysis to help explain why a certain result occurred (French 1995). Multivariate analysis can be used to estimate the effects of patient characteristics and program components on post-treatment outcome measures. With advanced statistical techniques, we can begin to learn why programs and individual drug abuse treatments are effective. Over time, drug-treatment evaluations have become more sophisticated in terms of research design and statistical analysis, but there is still a long way to go before we are able to measure the “true” effectiveness of drug abuse treatment programs.
6.4 The Effectiveness of Drug Abuse Treatments A considerable body of evaluative research on the treatment of drug abuse has been generated over the past thirty years, by clinical experience and project research and from three large evaluative studies. The Drug Abuse Reporting Program (DARP) was the first comprehensive, nationally based evaluation of drug abuse treatment effectiveness. DARP examined the admission records of over 44,000 clients in 52 NIDA-supported agencies during the period from 1969 to 1974 (Hubbard et al. 1989). At that time, the drug of choice was opiates. Effectiveness measures were reported in DARP studies based on one, six, and twelve-year follow-ups. The second national evaluation study, Treatment Outcome Prospective Study (TOPS), was also funded by the NIDA. The TOPS study included 11,750 clients in three annual admission cohorts – 1979, 1980, and 1981. This study collected more information about the nature of drug abuse treatment and the characteristics and behavior of abusers prior to treatment. Evaluation reports were conducted during treatment and based on, one, two, three, and five-year follow-ups. Most TOPS studies use the pre/post research design with no separate control group. The studies do report outcomes for patients who received minimal (less than 3 months) treatments. The TOPS research also includes studies of the outcomes for clients involved with the criminal justice system, particularly those referred to treatment by the Treatment Alternatives to Street Crime (TASC) programs (Hubbard, Rochal, Craddock, and Cavanaugh, 1984). The TOPS studies included far more non-opioid drug abusers than did the DARP studies. Finally, the NIDA supported the Drug Abuse Treatment Outcome Study (DATOS) which tracked 10,010 admissions to 96 programs in 11 cities for 1991-1993. This includes 2,774 admissions to long-term residential programs; 2,574 to outpatient drug free programs, 3,122 to short-term inpatient programs, and 1,540 to outpatient methadone treatment (DATOS 2003b). DATOS analysis was limited to clients who had stayed in treatment for at least a month. Evaluations were based on one and five year follow-ups. The DATOS studies did not include a control group. DATOS collected a large amount of data on clients, treatments, and the program environment, which was intended to help us understand how drug abuse treatment works (Franey and Ashton 2002). Literally hundreds of drug abuse treatment effectiveness studies have been published. There was no way to incorporate all of these studies in this review. Our analysis of drug abuse treatment effectiveness draws heavily from seven survey papers (Tims and Ludford 1984, Hubbard et al. 1989, Anglin and Hser (1990), McLelland, Woody, and Metzger 1996, NIDA 1999, Franey and Ashton 2002, and numerous DATOS sources 2003). A number of individual studies were also reviewed and they will be incorporated into the discussion. 6.4.1 The Overall Effectiveness of Drug Abuse Treatments Early in the literature, most researchers concluded that, in general, drug abuse treatments are effective in reducing patient’s drug use and criminal behavior, but somewhat less successful in improving patient’s social behavior, employment opportunities and mental health. For example, see the statements by Joffe, Hubbard et al., Sevay, and Tims and Holland in the NIDA volume edited by Tims and Luford (1984). According to Hubbard et al. (1989), the body of research emerging from the DARP study provides convincing evidence of the effectiveness of drug abuse treatment in community-based settings. Significant reductions in drug use were reported. For example, 82% of DARP clients reported they frequently used heroin in the year before treatment. One year after treatment, only 63% reported any opioid use and 47% reported daily use. Six years after treatment, only 42% reported any use and 25% reported daily use. Between 6 to 12 years after treatment, 23% increased their frequency of opioid use and 23% decreased their frequency of opioid use or stopped entirely. Although fewer in number, cocaine users in the DARP sample also reduced their consumption following treatment. During the pre-treatment period, 38% of their sample of opioid users has used cocaine. One to six years after treatment only 18 to 32% reported using cocaine. However, in the 12 year follow-up, 39% said they used cocaine. Finally, the DARP studies indicated that patient’s use of marijuana and alcohol increased after treatment raising the possibility that these drugs were being substituted for opioids, a troubling prospect. The DARP studies reported a significant decline in criminal activity following treatment. We shall review these findings in our discussion of modality effectiveness presented later. TOPS studies also reported significant declines in drug use and criminal activity following drug abuse treatment (Hubbard et al. 1989). TOPS compared the use of four types of drugs (heroin, cocaine, psychotherapeutic drugs, and marijuana) for the year prior to treatment, during the treatment period, and one and five years after treatment. They reported results for patients who stayed in treatment less than 3 months and for patients who received treatment for more than 3 months. Our current discussion will focus on the latter group. Relative to usage in the pre-period, the TOPS studies reported a significant decline in cocaine, heroine, psychotherapeutic drugs, and marijuana during the treatment and post-treatment periods. The results varied across the different modalities and we shall examine the specific outcomes below. The TOPS studies reported that heavy alcohol use declined significantly during treatments, but it almost returned to pre-period rates shortly after treatment. Based on self-reported data, TOPS found that predatory criminal activity (robbery, burglary, larceny, etc.) declined significantly from pre-treatment levels during and after treatments. The declines varied across the modalities and will be discussed later. One of the goals of drug abuse treatments is to get drug abusers back to work and perhaps increase their earnings. Several TOPS studies examined this issue. Hubbard (1989) examined the effects of treatments on full-time employment defined as working 35 or more hours per week for at least ¾ of the weeks in the period. He reported a small but significant increase in employment between the pre-treatment period and the 5 year follow-up for residential and outpatient drug-free patients, but not for outpatient methadone patients. Several later studies based on TOPS data and using multivariate statistical analysis reported that drug abuse treatments have a small but statistically significant negative effect on illegal earnings and a small positive effect on legal earnings and employment (French, Rachal, Harwood, and Hubbard 1990; French, Zarden, Hubbard, and Rachal 1991; ad. French and Zarkin 1992). After reviewing the existing literature and noting the absence of the “ideal” control group, Anglin and Hser (1990), concluded “research on drug abuse treatment demonstrates significant declines in drug use and criminal behavior by drug-dependent clients as a result of treatment” (p. 443). In their review of the literature, McLellan, Woody, and Metzger (1991) concentrated “on the studies that have used the most rigorous evaluation methods, including random patient assignment, an intent-to-treat design and data collection by independent evaluation, the same standards and methods that are typically applied by the FDA in evaluating new drugs and medical devices” (p. 84). They concluded that substance abuse treatments dramatically reduce alcohol and drug use, improve patient’s medical and psychological function, sometimes improve earnings from employment and reduce utilization of medical and social services, and reduce AIDS risk behaviors and drug-related crime. The authors stress that these outcomes are found both in controlled clinical trials of experimental interventions and in large-scale (i.e., DARP and TOPS) evaluations of standard treatments in “real world” settings (p. 84). The NIDA (1999) echoed these sentiments a few years later. The institute contends that drug addiction treatment is as successful as treatment of other chronic diseases such as diabetes, hypertension, and asthma. According to them, research shows that drug treatment reduces drug use by 40 to 60% and significantly decreases criminal activity during and after treatment by 40% or more. Treatments also reduce the risk of HIV infection and improve the prospects for employment. Finally DATOS (2003) one-year follow-ups indicted that drug abuse treatments reduced drug use, illegal activities, and psychological distress on average by 50%. The success rate varied across the different modalities, which will be discussed below. Some patients also experienced a 10% increase in full-time employment. The results from the DATOS (2003d) 5-Year Outcomes were not quite as promising. Weekly cocaine use was reported by 25% of the sample in the fifth year of follow-up, slightly higher than the 21% for the first year after treatment. Illegal activity was 25% in the fifth year compared to 16% in the first year after treatment, but this is still well below the 40% level at intake. Based on these studies, it must be concluded that some drug abuse treatments are effective and that effectiveness varies across treatment modalities. 6.4.2 The Effectiveness of Treatment Modalities We shall begin with a discussion of the four historically important treatment modalities and then consider the effectiveness of newer modalities. (1) Methadone Maintenance Programs Early on, it was learned that methadone maintenance treatments for opioid addicts led to a significant reduction in the use of those drugs (Cooper et al. 1983). DARP studies confirmed this result. Because DARP considered multiple outcomes, they defined two types of outcomes for purposes of analysis: (1) highly favorable outcomes are defined as no use of illicit drugs (except for less-than-daily marijuana use) and no arrests–or- incarcerations in any one or more months during the year and (2) moderately favorable outcomes are defined as no daily use of illicit drugs and no major criminality (i.e., no more than 30 days collectively in jail or in prison, and no arrests for crimes against persons or crimes of profit) (Simpson 1984). These two outcomes are well below the pre-treatment levels of drug use and criminal activity levels. At the end of the first year after treatment in methadone maintenance programs, it was reported that 27% of white males had a highly favorable outcome and 41% of black males had a moderately favorable outcome. The results for methadone maintenance programs in the TOPS studies were also favorable, as indicated in Table 6.1. The percentage of drug use for each of the four drugs declined significantly for methadone patients from the one-year pre-period to the 4
Table 6.1 Changes in Drug Abuse in the TOPS Study By Modality and Treatment Duration
Source: Hubbard et al. (1989, p. 181).
post-periods. For example, for MM patients having 3 months or more of treatments, the percentage of regular heroin users declined from 63.5% in the pre-treatment period to 16.7% at the one-year follow-up. This represents a 73.7% decrease in drug use. In the 3-to-5 year follow-up, the figure had risen slightly to 17.5%. Even MM patients with less than 3 months of treatment experienced a significant decline in drug use. For this group, the percentage of regular heroin users declined from 65.0% in the pre-period to 31.2% in the one-year follow-up and 24.9 in the 3-to-5 year follow-up. TOPS MM patients with 3 or more months of treatments also experienced a decline in criminal activity in the post-treatment period. In this group, the percentage of patients engaging in predatory crimes was 31% in the pre-period and only about 19% in the one-year follow-up (a 39% decline) and in the 3-to-5 year follow-up it had declined further to about 17% (Hubbard 1989). Employment gains were more modest for the TOPS MM patients with 3 or more months of treatment. This group’s percentage of full-time employment was 24.2 in the pre-period. It declined to 20% in the first year follow-up and then rose to nearly 30% in the second year follow-up. In the 3-5 year follow-up it was 17.7%, which was below the pre-treatment level (Hubbard et al. 1989). Anglin and Hser (1990) were also sold on the effectiveness of methadone maintenance in reducing drug use and criminality. They were particularly impressed by two natural experiment studies that investigated the effects of the termination of two different methadone maintenance programs, which they had conducted. NIDA (1999) reviewed the literature on methadone maintenance programs and narcotic antagonist treatment programs using naltrexone and concluded that naltrexone can help patients hold jobs, avoid crime and violence, and reduce their exposure to HIV. Finally, DATOS (2003b) reported that a one-year follow-up of outpatient methadone treatment showed a 47.6% reduction in cocaine use, a 68.5% reduction in heroin use, a 6.6% increase in heavy alcohol use, a 51.7% reduction in illegal activity, and a 3.5% gain in full-time work compared with pre-treatment levels. (2) Long-Term Residential Drug Free Programs DeLeon (1984) was the first to survey the literature on the effectiveness of therapeutic communities (TCs) or long-term residential drug free programs. He only considered published studies of traditional TC programs that had at least 12 months of planned treatments. He reported that immediate and long-term status of clients in terms of drug use and criminality declined significantly, while measures of employment and/or school involvement increased. DeLeon did not provide any quantitative estimates of the average outcome effects for the programs surveyed. He cautioned, however, that these conclusions should be regarded as tentative because of serious methodological problems. The studies did not include a control group and the follow-up samples may be self-selected to seek, remain in and benefit from TC; or, perhaps, to improve without any treatment. DARP studies also reported favorable outcomes for TCs. At the first year follow-up, 28 percent of adult white male TC patients were reported to have highly favorable outcomes and 40% of adult black males to have moderately favorable outcomes, as defined above (Simpson 1984). The TOPS data also showed that residential programs are highly affected. As shown in Table 6.1, there was a significant decline in residential patients use of all four drugs following treatment. For example, for those patients having 3 or more months of treatment, the percentage of regular heroin users declined from 30.9% in the year prior to treatment to 11.5% at the 1-year follow-up and to 11.8% at the 3-to-5 year follow-up. Even those patients having less than 3 months of treatment reported significant declines in drug use at the 1-year and 3-to-5 year follow-ups. Criminal activity also declined for TOPS residential patients following treatment. A little over 60% of residential patients engaged in predatory crime before treatment. At the first year follow-up, less than 30% reported doing so and in the 3-to-5 year follow-up only 20% reported such activity (Hubbard et al. 1989). TOPS residential patients having more than 3 months in treatments showed significant gains in long-term employment. The percentage of patients working full-time prior to treatment was 15.3%. At the first-year follow-up, it had risen to 25% and in the 3-to-5 year follow-up it was 38%. Subsequent review studies confirm the effectiveness of TCs. Citing DARP, TOPS, and other studies, Anglin and Hser (1990) concluded that TCs reduce patient’s drug use and criminal activity and increase their employment and social behavior. DATOS (2003e) reported favorable outcomes for patients in long-term residential treatment. From the pre-period to the first-year follow-up cocaine use declined 66.7%, heroin use declined 64.7%, heavy alcohol use declined 52.5%, illegal activity fell 60.9% and full-time employment rose 12.5%. (3) Outpatient Drug Free Treatment DARP data indicated favorable outcomes for outpatient drug free treatment. At the first year follow-up, 24% of adult white males had highly favorable outcomes and 33% of adult black males had moderately favorable outcomes (Simpson 1984). TOPS data for patients with 3 months or more treatment in outpatient drug-free treatment also showed favorable outcomes. As reported in Table 6.1, drug use declined for all 4 drugs following treatment. The percentage of regular heroin use declined from 8.6% in the year prior to treatment to 4.9% in the first year follow-up and to 4.6% in the 3-to-5 year follow-up. Table 6.1 also shows that outpatient drug-free patients having less than 3 months of treatment also reported significant declines in drug use in the post-period follow-ups. TOPS data also show a reduction in predatory crime activity for outpatient drug-free patients having more than 3 months of treatment. For this group, the predatory crime rate was 33% in the year before treatment. It declined to 19% in the first year follow-up and to 8% in the 3-to-5 years follow-up (Hubbard et al. 1989). TOPS data showed highly significant gains in employment for this group as well. The percentage of patients in full-time employment rose from a pre-treatment level of 27% to 38% in the first year follow-up and to 49% in the 3-to-5 years follow-up (Hubbard et al. 1989). DATOS data also confirm the effectiveness of outpatient drug-free treatments. From the pre-period to the first year follow-up, DATOS outpatient drug-free treatment patients experienced a 57.1 decrease in cocaine use, a 64.0% decrease in marijuana use, a 51.6% decrease in heavy alcohol use, a 36.4% decrease in illegal activity, and a 7.3% increase in full-time work (DATOS 2003e). (4) Detoxification Programs It was concluded early on that outpatient or inpatient detoxification treatments produce no lasting effects for those addicted to opioids (Cooper et al. 1983). However, this treatment is effective in reducing drug use temporarily and there is a demand for it (Anglin and Hser 1990). Furthermore, as Senay (1984) points out from a clinical point of view, detoxification programs are needed to treat emerging episodes, reduce the length and severity of “runs” and attract addicts into the treatments system generally. A recent NIDA (1999) study echoed these sentiments. (5) Criminal Justice Treatment Programs and Clients Anglin and McGlothlin (1984) summarized the results their research group obtained from evaluations of the California Civil Addict Program (CAP). They used a pre/post time series design with a matched comparison group. They found evidence of positive “ramp up” effects in the pre-period for drug use and criminal activity and negative “ramp-down” effects for employment. They find strong evidence that CAP effectively reduces drug use and crime, and to a lesser extent, increases employment and family responsibility. The strength of their findings was supported by two natural experiment studies that analyzed the effects of closing two methadone maintenance treatment programs. The TOPS study analyzed the effects of drug abuse treatments on clients who were referred to outpatient drug-free or residential treatment programs under the Treatment Alternatives to Street Crimes (TASC) Act. The TOPS data indicated that in terms of reductions in drug use and criminal activity, the criminal justice clients do as well or better than other clients in drug abuse treatment (Hubbard et al. 1989). After reviewing the relevant literature, Anglin and Hser (1990) concluded clients entering treatment under legal coercion do as well by most outcome criteria as volunteer clients and may stay in treatment longer. They specifically referred to the evidence from the evaluations of criminal justice civil commitment programs conducted by Anglin and McGlothlin (1984). Anglin and Hser also reported that research results indicate that correctional drug-treatment programs can have a substantial effect on the behavior of chronic drug-abusing offenders. Along these same lines, NIDA (1999) reported that research has shown that combining criminal justice sanctions with drug treatments can be effective in decreasing drug use and related crime. They also reported that prison-based treatment programs can be effective if patients are separated from the general prison population and if they continue treatment after returning to the community. Finally, NIDA (1999) concluded that individuals who enter treatment under legal pressure have outcomes as favorable as those who enter treatment voluntarily. (6) Short-Term Inpatient (STI) Treatment DATOS data showed that patients receiving short-term inpatient treatments have favorable outcomes. First year follow-ups showed a 69% drop in the number of weekly cocaine users, a 63% reduction in the number of weekly marijuana users, a 58% decline in heavy drinkers, and an insignificant 4.5% increase in full-time work (DATOS 2003e). 6.4.3 The Relative Effectiveness of Treatment Modalities Simpson (1984) noted that the DARP outcome differences reported for methadone maintenance, therapeutic communities, and outpatient drug-free treatment programs were not statistically significant. He noted there were significant differences in the types of clients served and in the dropout rates in the programs. For instance, methadone maintenance frequently deals with older addicts with longer histories of opioid use and criminal involvement and the treatment strategy is designed to deal with these historical entrenched behavioral patterns. Tims and Holland (1984) argued that few meaningful differences are likely to be found in outcomes among treatment modalities that are not either a function of client differences or of time in treatment. They also noted that attempts to randomly assign well-defined homogenous client pools to modalities have been frustrated by clients crossing over to their treatment of choice or withdrawing from treatment (see also Hall 1984). Finally, Anglin and Hser (1990) also concluded that comparisons between modalities are necessarily restricted because no two modalities necessarily have similar client populations. We know that outcomes are correlated with patient’s problems and characteristics. 6.4.4 Patient Characteristics and Outcomes The drug abuse treatment population is heterogeneous; clients are not characterized by a common set of demographics or problems. They vary in age, gender, race, social and economic background, drug-dependence, health status, and psychological well being (Hubbard et al. 1989). They have different criminal and treatment histories. The literature indicates that some of these factors are highly correlated with post-treatment successful outcomes. Jaffe (1984), DeLeon (1984) and McLellan, Woody, and Metzger (1996) concluded in their reviews that a stable family background has a positive affect on drug abuse patients’ favorable outcomes. Anglin and Hser (1990) reported that having an intact marriage also has a positive impact on drug abuse treatment outcomes. They further concluded that having a job was positively correlated with favorable outcomes. Jaffe (1984), Simpson (1984), and DeLeon (1984) reported that drug abuse patients having a more extensive criminal history are likely to report less favorable outcomes. DeLeon (1984) reported that drug abusers with more extensive history of treatment fared as well as other patients, but Franey and Ashton (2002) reported they fared less well. The severity of drug dependence and the extent of drug use are reported to be negatively correlated with drug abuse treatment favorable outcomes (Simpson 1984 and McLellan, Woody, and Metzger (1996). Drug addicts that use alcohol or poly drug use are likely to have less favorable outcomes as well (Anglin and Hser 1990). Finally, a number of studies have reported the greater the severity of the psychiatric disorder at intake, the less favorable the treatment outcomes for drug abusers (Jaffe 1984, DeLeon 1984, Anglin and Hser 1990,McLellan, Woody, and Metzger 1996, and DATOS 2003d). McLellan, Woody, and Metzger (1996) added that treating drug abusers having an antisocial personality diagnosis is particularly problematic. Given these findings, it is important to gather information on the | ||||||||||||||||||||||||||||||||||||||||||||||||
