Recommendations for improving drug treatment.

Subst Use Misuse Downloaded from informahealthcare.com by University of Melbourne on 11/23/14 For personal use only.

The International Journal of the Addictions, 27( 10). 1223- 1239, 1992

Recommendations for Improving Drug Treatment Carl Leukefeld,' Roy W. Pickens: and Charles R. Schuster2

' Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky National Institute on Drug Abuse, Baltimore and Rockville, Maryland

ABSTRACT Recognizing that drug use is both chronic and relapsing once an individual is addicted, and that treatment is effective in reducing drug use/misuse, improving drug misuse treatment is examined and research as well as practice recommendations are presented. Drug misuse treatment is now recognized in the United States to meet the expanding drug use problem and for reducing the spread of HIV. With that background, the current status of drug misuse treatment is reviewed, clinical issues are emphasized, and policy issues are noted. Recommendations include the need for uniform funding, linkage with community agencies, technology transfer, training, and expanding research and evaluation efforts. Key words. Drug treatment; Treatment improvement; Treatment recommendations

INTRODUCTION Drug treatment is effective, but many of us forget that drug use is chronic and relapsing. That is to say, drug use is chronic for many who become addicted and frequently persists throughout the life cycle, which is apparent by the relapsing nature of the disorder. That recognition and efforts to make drug I223 Copyright 01992 by Marcel Dekker, Inc.


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misuse treatment more effective is the emphasis of this paper. Specific recommendations are made to improve drug treatment, recognizing the importance of the issue. In fact, a 1989 Gallup survey reinforced that importance by reporting that drug misuse topped the public’s list as the nation’s most important problem-which is virtually unprecedented for any social issue in the United States. In order to help meet the concern about drug use and to coordinate federal drug efforts in the United States, the Office of National Drug Control Policy was established in the Executive Office of the President. As part of the challenge, the Office of National Drug Control Policy developed and updated the National Drug Control Strategy (1989 and 1990). The strategy focuses on supply reduction as well as demand reduction activities including treatment. It also specifically recognizes that the nation’s emphasis on enforcement during the past decade must be supplemented with expanded activities for treating drug users. As part of emphasizing treatment to reduce the demand for drugs and to improve treatment, the Office of Treatment Improvement (OTI) was created in 1988 within the U.S. Alcohol, Drug Abuse, and Mental Health Administration. OTI provides technical assistance to states and local programs with planning, financing, and management needs. In other words, OTI has been charged with providing an organizational home and funding responsibilities for drug treatment. The principal function of the Office of Treatment Improvement is to improve treatment services for individuals who suffer from drug use and other problems associated with drug use, including alcoholism, and physical as well as mental illness. In addition, OTI is staffed with individuals who have first-hand knowledge of and experience with drug misuse treatment. The importance of drug treatment may partially be driven by the spread of AIDS and the HIV epidemic among intravenous drug users. Intravenous drug users currently represent almost 30% of adult AIDS cases (Centers for Disease Control, 1990). Intravenous drug users also account for a large number of AIDS cases among minorities (Battjes et al., 1988), and they present a major vector for the spread of HIV to the heterosexual community. By 1988, AIDS associated with intravenous drug use accounted for over half of all AIDS cases among Blacks and Hispanics (Centers for Disease Control, 1989). The federal AIDS budget has grown in parallel with the numbers of individuals infected. For example, in 1985 the National Institutes of Health were spending $64 million a year on AIDS research, and this grew to $800 million in 1991. Associated with that budgetary growth has been the expansion of outreach workers to intravenous drug users, training for drug treatment staff, and expanded research opportunities. Until recently, drug treatment had not been emphasized or received increase revenues at the federal level in the United States since the 1970s when President Nixon declared a “War on Drugs.” The National Institute on Drug


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Abuse was created during that period in 1974. That drug war expanded drug treatment by focusing on the connection between street crime and heroin addiction. It also expanded and institutionalized the public drug misuse treatment system. And from at least one point-of-view the publicly funded drug treatment field has matured, but new treatment approaches have not recently evolved. Currently there are about 1,600 drug treatment units in the United States in addition to 3,500 combined alcohol and drug treatment units (Butynski, 1991). It is esimated that about 834,000 individuals received drug treatment in 1987, with treatment capacity of about 260,000 at any one time. It is also estimated that four million persons had serious drug problems in 1988 and that two million of these could benefit from drug treatment (National Drug Control Strutegy, 1989). The effectiveness of treatment in reducing drug use and enhancing positive indicators has been reported in multisite evaluation projects (Sells, 1974; Hubbard et al., 1989) and reductions in crime and improvements in social functioning and employment (Simpson and Sells, 1986) have also been reported. Along with the recent attention given to drug treatment and treatment effectiveness comes the important recognition that treatment providers can, and should, improve drug treatment by applying the results of existing clinical research. Unfortunately, the findings from clinical and other studies are not readily transferred from journals and other publications to clinical practice. Therefore, the recommendations at the end of this paper, based on the most current research results and clinical practice, are made to facilitate improvement of clinical practice. In fact, these recommendations form the core of this presentation and incorporate administrative as well as fiscal suggestions to help improve drug treatment. This article is based on a meeting sponsored by the National Institute on Drug Abuse on August 28-30, 1989. The dual purpose of the meeting was to: 1) Examine problems which currently exist with drug treatment, and 2) Propose strategies to improve treatment effectiveness. To be more specific, and as further background, this paper is structured around specific areas which were perceived as important for better understanding drug treatment. Meeting participants were asked to stress practical things which could be done, based on available data and clinical experiences, to improve drug treatment. Emphasis is placed on the effectiveness of drug treatment in modifying drug using and related behaviors as well as examining employment and other positive treatment outcomes. In addition, it is suggested by the meeting participants that the proceedings and this paper be dedicated to those treatment staff who have provided treatment over many years, at times in difficult circumstances. In keeping with that line of thinking, participants voiced their concerns that the existing status of publicly funded drug treatment has been shaped by available funding (Butynski, 1991) which, until recently, has not kept up with


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inflation. These limitations have drastically influenced drug treatment in the public sector. However, these resource limitations do not detract from the importance or the efficiency of most drug treatmenl programs. As a final introductory note, this paper is anchored on the following areas which serve as an overview of drug treatment and as an outline for the recommendations: Current status of drug treatment, clinical issues, and program/ policy issues. It is important to note that there was agreement among the meeting participants, bordering on total consensus, for improving drug treatment, which is reflected by the recommendations. In fact, there was an underlying sense of urgency to move forward as quickly as possible with action steps to improve drug treatment.

CURRENT STATUS OF DRUG TREATMENT Pickens and Fletcher (1991) overview issues related to improving drug treatment with a confirmation that drug treatment is effective. They also trace early drug treatment efforts and link those early efforts with contemporary treatment issues including therapeutic community treatment and methadone maintenance treatment. They emphasize the following areas for improving drug treatment: Attracting drug users to treatment, decreasing drug use rates for those in treatment, matching clients to treatment programs, increasing treatment retention, preventing relapse, applying research findings into clinical practice, increasing staff morale, and changing the reliance on methadone maintenance programs. Gustafson (1991) suggests that drug treatment programs are straining to do more and to do it better. He highlights staffing issues as a major area for improving drug treatment, and presents specific suggestions. Suggestions include recruitment and retention, credentialing, facility improvement, staff morale, AIDS and HIV services, and staff trainingldevelopment. Data related to staffing are limited. In addition to unacceptably low salaries, Gustafson (1991), citing a New York survey, suggests that the following areas of remediation should be addressed by communities and treatment programs to retain qualified staff Inadequate fringe benefits, reluctance of persons to work with drug misusers, location of many drug treatment facilities in less than desirable areas, shortage of job candidates, and fear of AIDS. Credentialing, licensure, and accreditation of facilities have all been applied inconsistently as criteria in the United States for ongoing criteria to be used in assessments of staffing standards, Clearly, there is a long way to go in establishing standards for many publicly funded treatment programs as well as ongoing and outcome assessments. Price et al. (1991) present findings from a survey of 569 methadone and drug-free outpatient treatment programs. Multiple drug use is the major



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presenting problem with young males, the predominate group receiving services. Self-referrals and courts are the major treatment referral sources, with self-referral the major source to methadone treatment. Individuals with masters and bachelor’s degrees provide the bulk of outpatient treatment services, particularly in drug-free programs. Methadone treatment programs reported more involvement with licensing and program certification. Finally, it is important to note that only two-thirds of outpatient treatment units report any follow up or relapse prevention efforts, a major point of emphasis for improving treatment. Butynski (1991) emphasizes the diversity of publicly funded drug treatment. That diversity is important in order to meet treatment needs reflected by the variety and severity of drug misuse. Drug treatment now incorporates: Detoxification programs which have the goal of stopping the immediate physical addiction to drugs; Chemical dependency units which offer 3 to 4 weeks of private residential and inpatient treatment followed by outpatient treatment; nerapeutic community treatment involving 9 to 12 months of structured residential treatment; Outpatient treatment, which is the most common form of community drug misuse treatment, offering counseling and support, including psychotherapy; Pharmacotherapy treatment including methadone maintenance treatment which is a prescribed medication to block heroin withdrawal and craving; and.Self-help groups which generally apply Narcotics Anonymous and Alcoholics Anonymous approaches. There is one other pharmacotherapy, naltrexone, which has been approved by the Food and Drug Administration, in addition to methadone, for treating illicit heroin addiction. Naltrexone is a synthetic narcotic antagonist that blocks the “high” experienced from injecting heroin and reduces the craving for heroin without opiate-like effects. Tims et al. (1991) emphasize that both controlled and large cohort research studies have reported that drug treatment is effective in reducing drug misuse and related behaviors (Hubbard et al., 1989; Simpson and Sells, 1982). An important additional point is that drug treatment appears to be effective in preventing the spread of HIV among intravenous drug rnisusers (Battjes et al., 1989; Hubbard et al., 1988; Novick et al., 1990). Treatment outcome has traditionally been measured using the amount drug and alcohol used, the level of criminal activity including arrests and crimes, employment, and/or days involved in educational activities. Based on two treatment studies (DARP and TOPS), treatment has been effective in reducing drug use which is dependent upon the amount of time an individual remains in treatment. Clearly there are limitations to treatment, and further research is needed to better understand these limitations. Tims et al. (1991) reference Hubbard et al.’s (1989) Treatment Outcome Perspective Study (TOPS) as the most recent research which has validated the effectiveness of drug treatment. Subjects for this longitudinal study included more than 11,OOO individuals in drug treatment from 41 different publicly sup-


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ported programs in 10 cities who were in treatment during 1979 to 1981. Clients from the 1979 admissions were followed and interviewed in 1980 and 1981. Clients in the 1980 admissions group were interviewed at 3 months after treatment and in 1981. 1981 admissions were interviewed in 1984 to 1987. Four treatment approaches were examined: methadone detoxification, methadone maintenance treatment, therapeutic community treatment, and outpatient drug treatment. A sample of three cohorts were followed for up to 3 years. Substantial decreases in heroin use and reduced cocaine use with decreased severity of drug use were reported during and after treatment for those who remained in treatment for at least 3 months. The benefits of treatment matched or exceeded the costs of treatment. The average length of stay was 159 days for residential treatment with an average total cost of $2,942, 267 days for outpatient methadone treatment with an average cost of $1,602, and 101 days for outpatient treatment with an average cost of $606.

CLINICAL ISSUES Clinical treatment skills can, and in some cases must, be modified to improve drug treatment. Clearly, there are multiple clinical issues associated with the changing client population. An important issue, now receiving more emphasis, is the need to develop valid and reliable assessment and diagnositic indicators to match clients to treatment. McLellan (1991) has developed the Addiction Severity Index which has become a standard to collect assessment information including past and present symptoms and to estimate the level of discomfort along seven problem areas: alcohol use, medical condition, drug use, employment/support, illegal activity, family/social relations, and psychiatric function. Additional instrumentation is being developed to focus on varied populations and provide clarity for clinical interventions. The National Institute on Drug Abuse, along with the National Institute of Mental Health and the National Institute on Alcohol Abuse and Alcoholism, is collaborating with the World Health Organization and The American Psychiatric Association to develop reliable and validated clinical and research diagnostic criteria for drug use and drug dependence. Reliable instruments are being developed to measure these diagnoses which have exciting possibilities for both clinical practice and research in both domestic and cross-cultural research. Enhanced diagnostic and clinical skills are necessary to treat the more complex client issues related to multiple drug use (Kosten, 1991) and comorbidity or dually diagnosed clients (Woody et al., 1991). Kosten (1991) also suggests that enhanced clinical skills must shift beyond immediate behavioral aspects and focus on the dynamics of personality to target alcohol and drug use. Kosten (1991) indicates that most current multiple drug use involves cocaine, alcohol, opiates, and benzodiazepines, and that using drugs in combi-



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nations is often more severe than single drug use. Dually diagnosed clients, individuals who have both drug misuse/dependence and another mental disorder such as major depression or schizophrenia, often present special management problems and seem to be increasing in drug misuse treatment programs. Woody et al. (1991) suggest that addressing psychiatric comorbidity can improve treatment, but implementing the necessary protocols in publicly funded treatment programs is compromised without qualified staff. A theme stressed was that specific treatments should be mixed and matched to individualize client treatment. Thus, it is suggested that talking therapies such as counseling and psychotherapy could be combined with pharmacotherapy and relapse prevention as well as self-help activities to match clients with the most appropriate treatment. Ongoing research is adding to our knowledge about counseling and psychotherapy. The therapeutic role can vary considerably, depending upon diagnosis and the intervention. More emphasis is being placed on the importance of initial treatment engagement, planned termination, follow up, and relapse prevention. Specifically, research is showing that therapists differ in their effectiveness (Onken, 1991) and point to possibilities that the most effective therapists/counselors should be retained and rewarded for their effectiveness (McCaul and Svikis, 1991). Onken (1991) suggests that there are few indicators of therapist characteristics which are related to success. But Onken suggests the following are related to enhanced outcomes: the ability of the therapist to establish an early and positive therapeutic alliance, the consistent adherence to a particular method, and documentation of relatively complete treatment plans and records. However, while psychotherapy is effective in treating clients with severe or moderate psychopathology, clients in methadone treatment with low levels of psychopathology do as well with drug counseling as with counseling plus psychotherapy (Onken, 1991). An important and persistent finding is that drug users should be educated about things they can do to prevent their relapse. Relapse prevention is challenging and, although knowledge about relapse exists, many puzzles remain (Hall et al., 1991). In order to better understand relapse, O’Brien et al. (1991) identify four factors: psychiatric disorders including depression and anxiety disorders, social factors such as employment opportunities and social supports, protracted abstinence syndrome which may persist for 6 months or more, and conditioned responses that “recall” drug experiences. Practical considerations to decrease relapse and enhance recovery include a recommendation from a previous NIDA review that clinicians can make aftercare contacts at specific times following treatment: first week, first month, third month, and first year (Leukefeld and T i m , 1989). Self-help groups are cost effective for maintaining changes (Nurco et al., 1991) and can help prevent relapse. Self-help groups such as Alcoholics and Narcotics Anonymous


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help individuals cope with life stressors as well as the discontinued dependency on substances. A consistent research finding is that methadone maintenance is effective in significantly reducing or eliminating illicit and regular use of heroin and other short-acting narcotics when appropriate doses of methadone are prescribed (Kreek, 1991). In fact, there has been a great deal of research carried out in methadone maintenance treatment clinics which examine efficacy (Kreek 1991), provision of rehabilitation services (Childress et al., 1991), approaches to reduce illicit drug use (Stitzer et al., 1991), alcohol use (Gordis, 1991), and HIV (Brown, 1991). Research is currently proceeding to develop medications that normalize the brain systems which are not regulated by drugs of misuse. For example, possible medications for cocaine include: a painkiller called buprenorphine, an antidepressant called desipramine, an antipsychotic called flupenthixol, an antiseizure drug called carbamazapine, an anxiety drug called gepirone, bromocriptine and mazindol, dopamine antagonists, and buproion (Holden, 1989). In fact, medications development activities have been called the “Manhattan Project” for chemists in the war on drugs (Time, 1989).

TREATMENT PROGRAM AND POLICY ISSUES As suggested above, recent events helped focus the nation’s increased drug activities on treatment programs and treatment policies. These events are a result of various perceptions and activities, including consistent media attention, the violence associated with drug use, babies born addicted, the use of crack and associated behaviors, and the relationship between needle use, sexual behaviors, and AIDS. Since the length of time in treatment has consistently been related to positive drug misuse treatment outcomes ( T i m and Fletcher, 1991), it seems desirable to examine policies that enhance treatment retention. Improving program compliance (McCaul and Svikis, 1991) and improving retention (DeLeon, 1991) are issues for increasing the length of time in treatment and can supplement relapse prevention activities (Hall et al., 1991). Clients in drug treatment also have special needs. Mendelson (199 1) highlights the special needs of women which point to special treatment considerations for pharmacotherapeutic treatments and issues related to polydrug use, alcohol use, and cocaine use. Clearly, there are other special treatment needs related to gender, HIV, minority status, employment, vocational rehabilitation, and community status. There are also linkage issues related to the provision of community drug treatment. Linking community patient care and continuity of care have recently been driven by HIV in large, urban communities. Accounts of the overbur-



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dened primary care system along with special needs of the intravenous drug abuser highlight difficulties (Russo, 1991). There is also a high level of drug use by those who come into contact with the criminal justice system. The criminal justice system provides opportunities for using its authority to enhance drug treatment (Leukefeld, 1991). A policy issue which currently has a direct impact on community drug treatment is community resistance to the neighborhood placement of drug treatment programs. Community resistance is not new and has been a continuous barrier for treatment planning and program implementation. Veatch (199 1) refers to the NIMBY syndrome or “Not In My Back Yard” as the overriding attitude of community residents. In other words, there is fear of increased crime and decreased property values.

AREAS OF AGREEMENT RELATED TO IMPROVING DRUG TREATMENT The following statements represent the major areas of agreement reached by those researchers and practitioners who attended the National Institute on Drug Abuse meeting on Improving Drug Treatment. As further introduction and for emphasis, it should be stressed that the participants agreed that drug treatment is effective. To put it more boldly, participants wanted to go on record as saying that drug treatment does save lives, prevent and reduce criminal activities, improve quality of life and, when compared to the alternative of incarceration without drug treatment, is cost effective. An issue considered is meshing the drug user’s personal goals with treatment goals. Most important is the development of treatment plans along with accepted treatment goals and outcome. The following statements represent areas of specific agreement reached.

Funding Drug Treatment The effectiveness of drug treatment in some programs has been compromised by limited funding and enormous demands on services. Treatment programs should receive technical assistance and funding to help them review the quality of their clinical services with the goal of improving their effectiveness. Additional treatment funding should include support for essential administrative and related services such as staff training, staff salaries, enhanced data collection, evaluation activities, vocational services, and new facility construction as well as support for new treatment slots.


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Evaluating Drug Treatment Additional data should be collected and new studies designed to allow more concise characterization of patients, programs, and outcome results. Due to the chronic relapsing nature of drug dependence, evaluations of treatment effectiveness should be based on client performance while in treatment, as well as after leaving treatment. Accountability should be a necessary component of drug treatment with the provision of fiscal and staff resources to support regular reporting on client characteristics, program characteristics, services provided, fees, and performance measures. Quality assurance components are needed in drug treatment programs to assure the highest quality of patient care.

Clinical Aspects of Drug Treatment Special attention should be paid to improving clinical skills related to treatment interventions. Therapists should receive general training related to assessment, diagnoses, and specific treatment protocols and interventions which are focused on behavior change. In addition, staff are now required to intervene with more complex clinical issues (e.g., comorbidity , psychopathology, infectious diseases related to HIV, sexually transmitted diseases, tuberculosis, and medications) which suggests further training. Research is showing that counselors and therapists differ considerably in their effectiveness, even with the same level of training and experience. Increased efforts should be made to identify and retain the most effective counselors and therapists with higher salaries and other inducements. After treatment capacity is expanded, more emphasis should be placed on outreach and recruiting patients into treatment since evidence suggests that ethnic and cultural matching of clients to treatment may affect engagement and compliance with treatment. Psychiatric and medical comorbidity as well as multiple drug use, including alcohol problems and cocainekrack use, are becoming increasingly common among clients entering drug misuse treatment, and treatment programs must be able to recognize and treat such conditions. Additional emphasis should be placed on matching clients to treatment since evidence suggests that clients with moderate to severe psychopathology do better in programs that provide psychotherapy and/or pharmacotherapy. While psychotherapy has been effective in treating clients with severe and moderate levels of psychopathology, clients in methadone treatment with low levels of psychopathology do as well with drug counseling as with drug counseling plus psychotherapy.



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Preliminary evidence indicates that involving senior staff in initial client contacts during the intake process may improve retention rates for therapeutic communities. Relapse prevention strategies have been shown to reduce drug use following treatment. Educating drug users about these strategies during treatment, and greater emphasis on providing follow-up services, may improve treatment outcomes. Conditioning to drug-related stimuli develops during chronic drug use and continuity to relapse after treatment. Although research evidence is not complete, preliminary evidence suggests that exposing drug users to these stimuli in a supportive treatment environment may result in extinction and help to eliminate the stimuli as factors which contribute to relapse. Self-help groups are cost effective for maintaining behavioral changes following drug treatment and for clients in methadone treatment to teach appropriate role behaviors. Self-help groups are also beneficial for drug misusers who do not require intense treatment. Appropriate medical use of psychotropic medications should not be prohibited in drug treatment programs since their appropriate use has been shown to be beneficial for many drug-dependent persons.

Methadone Maintenance Treatment Adequate doses of methadone should be prescribed in maintenance treatment since evidence indicates that low doses of methadone are associated with higher rates of illicit drug use, premature treatment termination, and failure to comply with treatment goals. Methadone maintenance programs should be funded and staffed to provide supportive services to those with an assessed need in addition to methadone since preliminary evidence suggests that such clients function better in programs that provide counseling and other needed services. Allowing methadone take-home privileges which are contingent on clean urines may be effective in reducing illicit drug use during methadone treatment. However, additional research is needed to determine the durability of such approaches. Methadone maintained patients should not be prohibited from also entering abstinence-oriented programs for the management of other dependencies including alcohol.

Linking Drug Treatment with Other Community Institutions Stronger linkage must be established by drug treatment programs with the criminal justice system since the justice system has a high proportion of individuals with drug problems, and it offers motivation (i.e., probation and

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parole) for encouraging drug users to enter and comply with treatment goals. Stronger linkages are needed between drug treatment and primary medical care and mental health care services to provide a continuum of care for drug-dependent persons, especially those with AIDS and other infectious diseases.

Minority Involvement in Drug Treatment The special needs of minorities and women must be recognized by drug treatment programs along with expanded resources to train existing staff and hire new staff who are culturally and racially sensitive and who speak the primary language of their clients.

Community Barriers to Drug Treatment Community obstacles and barriers to identifying and establishing new treatment programs sites must be overcome to maximize the use of treatment as an effective strategy for reducing drug abuse and HIV.National, state, and local policymakers must become involved in this process.

Transferring Proven Drug Treatment Technologies Technology transfer should be improved to ensure rapid communication of research findings so that they can be incorporated into clinical skills building and practice. Treatment staff have core responsibilities for engaging and motivating clients to change, and their relationships with clients are critical in the change process. Understanding this critical role and infusing motivation to change their own style and work priorities is critical. Treatment programs and providers must adopt new knowledge based on research into their clinical practice. Using the most effective and efficient available interventions is a practitioner’s responsibility for both accountability and to provide the best scientifically based treatment available. Such knowledge should be transferred through more intensive direct contacts among researchers and practitioners, and through the provision of technical assistance and training to practitioners.

Research Focused on Improving Drug Treatment Treatment programs should support research efforts that are focused on improving the effectiveness and efficiency of drug treatment including: medications development, improved counseling and psychotherapy



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techniques, psychiatric and medical comorbidity , and quality assurance issues. Research programs should support and incorporate practitioner insights directed to improving treatment into their studies. Treatment research should address areas of system improvements in order to better understand the dynamics of underlying biological and behavioral factors. Specific areas include: recruitment, retention, illicit drug use and alcohol problems during treatment, and relapse following treatment. Research should also focus on broader policy issues which can affect drug treatment including: social, economic, political, religious, geographic, and media. Drug treatment programs should participate in both drug misuse clinical research and evaluation studies. Accountability for both expenditures of funds as well as treatment effectiveness should be an integral part of public and private treatment programs.

Training Training should be expanded to develop and refine clinical skills for physicians, nurses, social workers, clinical psychologists, counselors, and case managers. Training should focus on intake, assessment (both initial screening and comprehensive assessment), treatment planning, goal development, urine testing, service coordination, case management, use of community resources and services, termination and discharge, self-help groups, aftercare, and relapse prevention. In conclusion, it is important to note that there are formal and informal institutional barriers which have hindered planning, implementation, and assessments in the dynamically changing treatment situation. These barriers include budget limitations and other policy-driven factors which have historically impinged upon drug treatment in the United States. However, there have been changes in the drug treatment situation overall, largely orchestrated by the Office of Treatment Improvement and based upon research funded by the National Institute on Drug Abuse. However, policies and standard setting are within the domain of each state and are currently directed to incremental treatment gains, largely inspired with additional state and federal resources.

REFERENCES BATTJES, R. J . , LEUKEFELD, C. G . , PICKENS, R. W., and HAVERKOS, H . W. (1988). The acquired immunodeficiency syndrome and intravenous drug abuse. Bull. Narc. SO( I ) : 2 1-34, BROWN, L. (1991). The impact of AIDS on drug abuse treatment. In R . W. Pickens, C . G .


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Leukefeld, and C. R. Schuster (eds.), Improving Drug Abuse Treatment. Washington, D.C.: U.S. Government Printing Office. BUTYNSKI, W. (1991). Drug treatment services: Funding and admissions. In R. W. Pickens, C. G. Leukefeld. and C. R. Schuster (eds.), Inproving Drug Abuse Treatment. Washington, D.C.: U S . Government Printing Otfice. CENTERS FOR DISEASE CONTROL (1989). Update: Acquired immunodeficiency syndrome aesociated with intravenous drug use-United States, 1988. Morbid. Mortal. Wkly. Rep. 38(10): 165-170, March 17. CENTERS FOR DISEASE CONTROL (19%). HIV/AIDS Surveillance Report. Atlanta, Georgia, February. CHILDRESS, A. R., McLELLAN, A. T., WOODY, G. E., and O'BRIEN, C. P. (1991). Are there minimum conditions necessary for methadone maintenance to reduce intravenous drug use and AIDS-risk behaviors? In R. W. Pickens, C. G. Leukefeld, and C. R. Schuster (eds.), Improving Drug Abuse Treatment. Washington, D.C.: U.S. Government Printing Office. DELEON, G. (1991). Retention in drug free therapeutic communities. In R. W. Pickens. C. G. Leukefeld, and C. R. Schuster (eds.), Improving Drug Abuse Treatmenr. Washington, D.C.: U.S. Government Printing Office. GALLUP INTERNATIONAL FOUNDATION (1989). Surveys of the Attitudes of American Adults and Teen-Agers towards the Drug Crisis and Drug Policy. Press Briefing Presented at the Old Executive Office Building, Washington, D.C., August 4. GORDIS, E. (1991). Methadone maintenance and patients in alcoholism treatment. In R. W. Pickens, C. G. Leukefeld, and C. R. Schuster (eds.), Improdng Drug Abuse Treatment. Washington, D.C.: U S . Government Printing Office. GUSTAFSON, J. S. (1991). Do more. . . and do it better: Staff related issues in the drug treatment field which impact on the quality and effectiveness of services. In R. W. Pickens, C. G. Leukefeld, and C. R. Schuster (eds.), Improving Drug Abuse Treatment. Washington, D.C.: U.S. Government Printing Office. HALL, S. M., WASSERMAN, D. A., and HAVASSY, B. E. (1991). Relapse prevention. In R. W. Pickens, C. G. Leukefeld, and C. R. Schuster (eds.), Improving Drug Abuse Treatment. Washington, D.C.: U.S. Government Printing Office. HOLDEN, C. (1969). Street-wise crack research. Science 246: 1376-1381. HUBBARD, R. L., MARSDEN, M. E., CAVANAUGH, E., RACHAL, J. V.. and GINZBURG, H. M. (1988). Role of drug abuse treatment in limiting the spread of AIDS. Rev. Infect. Dis. IO(2): 377-384. HUBBARD, R. L., MARSDEN, M. E., RACHAL. J. V.,HARWOOD, H. J., CAVANAUGH, E. R., and GINZBURG, H. M. (1989). Drug Abuse Treatment: National Study of Effectiveness. Chapel Hill, North Carolim: The University of North Carolina Press. KREEK, M. J. (1991). Using methadone effectively: Achieving goals by application of laboratory clinical and evaluation research and by development of innovative programs. In R. W. Pickens, C. G. Leukefeld, and C. R. Schuster (eds.), Improving Drug Abuse Treahent. Washington. D.C.: U.S. Government Printing Office. KOSTEN. T. R. (1991). Client issues in drug abuse treatment: Assessing multiple drug use. In R. W. Pickens, C. G.Leukefeld, and C. R. Schuster (4s.). Improving Drug Abuse Treatment. Washington. D.C.: U S . Government Printing Office. LEUKEFELD, C. G.(in press). Opportunities for enhancing drug abuse treatment with criminal justice authority. In R. W. Pickens, C. G.Leukefeld, and C. R. Schuster (eds.), Improving Drug Abuse Treatment. Washington, D.C.: U.S. Government Printing Office. LEUKEFELD, C. G.,and TIMS, F. M. (1989). Relapse and recovery in drug abuse: Research and practice. Int. J . Addict. 24(3): 189-201. McCAUL. B., and SVIKIS, D. (1991). Improving client capliance in outpatient treatment: Counselor-targeted interventions. In R. W. Pickens, C. G . Leukefeld, and C. R. Schuster



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(eds.), Improving Drug Abuse Treatment. Washington. D.C.: U S . Government Printing Office. McLELLAN, A. T., and ALTERMAN, A. 1. (1991). Patient treatment matching: A conceptual and methodological review with suggestions for future research. In R. W. Pickens, C. G. Leukefeld, and C . R. Schuster (eds.), Improving Drug Abuse Treatment. Washington, D. C.: U.S. Government Printing Office. MENDELSON, J. (1991). Some special considerations for treatment of drug and dependence in women. In R. W. Pickens, C. G. Leukefeld. and C. R. Schuster (eds.), Improving Drug Abuse Treatment. Washington, D.C.: U.S. Government Printing Office. NATIONAL DRUG CONTROL STRATEGY (1989). Washington, D.C.: U.S. Government Printing Office, September. NATIONAL DRUG CONTROL STRATEGY (1990). Washington, D.C.: U.S. Government Printing Office, January. NOVICK, D. M., HERMAN, J., CROXON, T. S., SALSITZ, E. A., WANG, G., RICHMAN. B. L., PORETSKY, L., KEEFE, J. B., and WHIMBET, E. (1990). Absence of antibody to human immunodeficiency virus on long-term, socially rehabilitated methadone maintenance patients. Arch. Intern. Med. 150: 97-99. NURCO, D. N., STEPHENSON, P., and HANLON, T. E. (1991). Contemporary issues in drug abuse treatment linkage with self-help groups. In R. W. Pickens, C. G.Leukefeld, and C. R. Schuster (eds.). Improving Drug Abuse Treatment. Washington. D.C.: U S . Government Printing Office. O'BRIEN. C . P., CHILDRESS, A. R., and McLELLAN, A. T. (1991).Conditioning factors may help understand and prevent relapse in patients who are recovering from drug dependence. In R. W. Pickens, C . G. Leukefeld, and C. R. Schuster (eds.), Improving Drug Abuse Treatment. Washington. D.C.: U.S. Government Printing Office. ONKEN, L. S. (1991). Using psychotherapy effectively in drug abuse treatment. In R. W. Pickens, C. G. Leukefeld, and C. R. Schuster (eds.). Improving Drug Abuse Treatment. Washington, D.C.: U.S. Government Printing Office. PICKENS, R. W.. and FLETCHER, B. W. (1991). Overview of treatment issues. In R. W. Pickens, C. G. Leukefeld, and C. R. Schuster (eds.), Improving Drug Abuse Treatment. Washington, D.C.: U S . Government Printing Otfce. PRICE, R. H., BURKE, A. C.. D'ANNO. T. A,, KLINGEL, D. M.. McCAUGHRIN, W. C., RAFFERTY, J. A., and VAUGHN, J. A. (1991). Outpatient drug abuse treatment services, 1988: Results of a national survey. In R. W. Pickens, C. G. Leukefeld, and C. R. Schuster (eds.), Improving Drug Abuse Treatment. Washington, D.C.: U.S. Government Printing Office. RUSSO, R. J. (1991). Primary care and intravenous drug abuse treatment. In R. W. Pickens, C. G. Leukefeld. and C . R. Schuster (eds.), Improving Drug Abuse Treatment. Washington, D.C.: U.S. Government Printing Office. SELLS. S. B. (1974). Evaluation of Treatments, Vol 1. Cambridge, Massachusetts: Ballanger. SIMPSON, D. D., and SELLS, S . 8 . (1982). Evaluation of Drug Abuse Treatment Effectiveness: Summary of the DARP Followup Research (DHHS Publication ADM 82-1209). Washington, D.C.: U.S. Government Printing Office. STITZER, M. L., and KIRBY, K. C. (1991). Reducing illicit drug use among methadone patients. In R. W. Pickens, C. G. Leukefeld, and C. R. Schuster (eds.), Improving Drug Abuse Treatment. Washington, D.C.: US. Government Printing Office. TIME (1989). Can drugs cure drug addiction? December 11, p. 104. TIMS, F. M., FLETCHER, B., and HUBBARD, R. L. (1991). Treatment outcomes for drug abuse clients. In R. W. Pickens, C. G. Leukefeld, and C. R. Schuster (eds.). Improving Drug Abuse Treatment. Washington, D.C.: US.Government Printing Office. VEATCH, C. (1991). Community resistance to drug treatment program placement. In R. W. Pick-

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ens, C . G . Leukefeld, and C. R. Schuster (eds.), Improving Drug Abuse Treatment. Washington, D.C.: US. Government Printing Office. WOODY, G. E., McLELLAN, A. T., O'BRIEN, C. P., and LUBORSKY, L. (1991). Addressing psychiatric co-morbidity. In R. W. Pickens, C. G. Leukefeld, and C. R. Schuster (eds.), improving Drug Abuse Treatmenr. Washington, D.C.: U.S. Government Printing Ofice.


THE AUTHORS Carl Leukefeld, D.S.W., is Director of the Drug and Alcohol Abuse Research Center at the University of Kentucky (UK). He received his Doctorate at the Catholic University of America in 1975 and his masters degree at the University of Michigan. His current research interests include the use of judicial sanctions, drug abuse treatment, and the impact of HIV on the drug abuser. He has coedited eight books and is currently working on one: Frontiers of Cocaine Treatment. Roy W. Pickens, Ph.D., is the Director of the National Institute on Drug Abuse (NIDA) Addiction Research Center, which is located in Baltimore, Maryland. His research has spanned a wide range of areas, from basic pharmacological to human genetics, and has yielded findings of basic and clinical importance. In addition, he has published widely with multiple articles and several books.



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Charles R. Schuster, Ph.D., is an internationally recognized researcher on the psychopharmacology of drugs of abuse. He received his Ph.D. from the University of Maryland, his M.S. from the University of New Mexico, and a B.A. from Gettysburg College, Pennsylvania. He has authored or coauthored over 150 scientific journal articles, as well as numerous book chapters and several books.

Drug therapy for nocturnal enuresis. Current treatment recommendations.

Recommendations for selecting drug-drug interactions for clinical decision support.

Recommendations for improving safety practices with short peripheral catheters.

FVE seeks views on recommendations for improving aquatic animal health.

Current treatment recommendations for leishmaniasis.

Improving vocational placement in drug treatment clients: a pilot study.

Miltefosine for visceral and cutaneous leishmaniasis: drug characteristics and evidence-based treatment recommendations.

HIV and chemically dependent women: recommendations for appropriate health care and drug treatment services.

Strategies for improving mucosal drug delivery.

Improving data mining strategies for drug design.

[Treatment of a silent addiction- current treatment recommendations to drug dependence].

Current treatment recommendations for lupus nephritis.

Tick Bite Granuloma: Recommendations for Surgical Treatment.

Formulation of treatment recommendations for statins.

Formulation of treatment recommendations for statins.

Current treatment recommendations for topical burn therapy.

Recommendations for the treatment of osteomyelitis.

Lyme disease: recommendations for diagnosis and treatment.

Optimizing non-invasive radiofrequency hyperthermia treatment for improving drug delivery in 4T1 mouse breast cancer model.

[Malignant insulinoma: recommendations for workup and treatment].

Treatment recommendations for chronic myeloid leukemia.

Consensus recommendations for systematic evaluation of drug-drug interaction evidence for clinical decision support.

Geographic information system for improving maternal and newborn health: recommendations for policy and programs.

Bioerodable PLGA-Based Microparticles for Producing Sustained-Release Drug Formulations and Strategies for Improving Drug Loading.