175
Drug and Alcohol Dependence, 25 (1990) 175- 177 Elsevier Scientific Publishers Ireland Ltd.
Treatment outcome: a neglected area of drug abuse research Leo E. Hollister Harris County Psychiatric
Center and Department
of Psychiatry. The University KJ.S.A.I
Scientific
Publishers
Texas
other than the more troubled the individual, in whichever ways, the more vulnerable they are. We do much better in predicting which drugs have the potential for creating dependence, usually long after this phenomenon has been demonstrated by experience in the street. We have little idea of how to prevent drug abuse through biologic mechanisms. We have some clues for its sociological prevention. Despite intensive research efforts at great cost for most of the past two decades, the estimated number of drug abusers has changed very little. For every drug abuser who becomes clean, or who ‘burns out’ or who dies prematurely as a consequence of drug use, another is recruited as a replacement. Both in the past, as well as the present, much of the research effort has been directed at areas that are tangential to actual drug use.
Although I have been engaged in research on drugs of abuse for almost 30 years, I never paid a great deal of attention before to the outcome of treatment programs. Three years ago, I became Medical Director of a 250-bed psychiatric hospital which had 48 beds dedicated to the treatment of substance abuse. Our treatment programs were modelled after those considered to be the best in the country. We estimate that we spend about $3 million on them with about 500 patients each year graduating from them. And we have no idea about the results of our efforts. Curiously, not many other treatment programs do. Thus, rather than taking the position that more research should be done in the areas in which I have been involved, I prefer to call attention to what seems to me to be a notable omission in drug abuse research. The benefits of scientific research have been so obvious and so overwhelming, even in one’s lifetime, that we have come to believe that any problem can be solved by research. Although I have been both an arbiter in, consultant to, and grantee of the drug abuse research establishment, I am sometimes disturbed to think how little impact we have had. Superb fundamental discoveries have been made (the opiate receptor-endorphins saga first comes to mind). We have learned a tremendous amount about the biological and social pharmacology of many drugs of abuse. We have, however, made relatively little progress in understanding the psychobiology of the compulsion to use drugs. We cannot predict who is at increased risk, 0376~8716/90/$03.50 0 1990 Elsevier Printed and Published in Ireland
of Texas Medical School, Houston,
Research on treatment Enormous amounts of money are spent on treatment programs. The most recent estimate is $3 billion yearly in the U.S. Yet we have virtually no idea of their success rates. Certainly, many persons are ultimately able to rid themselves of the use of drugs, but often the way this benefit is accomplished is idiosyncratic. The ‘anonymous’ programs, modeled after Alcoholics Anonymous, are probably the most successful, but they deal with self-selected samples of ‘clients’, have tremendous attrition rates and, by virtue of anonymity, provide no statistics about outcome. Most other treatment Ireland
Ltd.
176
programs suffer from the same deficiencies. Methadone maintenance programs for opiatedependence have been most amenable to data collection. While some construe the substitution of one drug of abuse for another as a dubious treatment, the outcome of methadone maintenance in terms of function has been more than acceptable. Motivation has been the key factor leading to success, whatever the program. The most successful programs have been those within industry or the military. The loss of current and future benefits is a strong motivator. It is not nearly so easy to motivate an unemployed ghetto youth who sees little hope. Most research efforts regarding treatment have been in the area of heroin abuse. Even though the original observation that methadone could act as a satisfactory replacement for heroin, with much less morbidity, was not funded from drug abuse research funds, its further development, certainly was. In addition, the development of longer a&ing methadone compounds, such as L-acetylmethadyl, or the narcotic antagonist naltrexone, have been liberally funded. Acetylmethadyl is not yet available for general use and naltrexone has only a very limited acceptability among the drug-using population. Both speak to the difficulty in establishing new treatments. Yet drug abuse programs have proliferated faster than any other special treatments in psychiatry. Paradoxically, twenty years ago it was a rare psychiatrist who treated alcoholics or drug abusers. Now treatment programs have sprung up in almost every hospital. We probably have more private practice slots for drug abuse treatment that can be filled. On the other hand, publicly funded programs have only limited resources and consequently have large numbers of potential patients waiting for available treatment slots. Most programs offer a mix of therapeutic approaches and services. Education about the health aspects of drug use, group therapy, psychodrama, family therapy and virtually every possible othep therapy are offered. Social and vocational rehabilitation is available for
those who need these services. Therapeutic programs seem to have been derived empirically with no more than a strong belief that the treatments offered are likely to be successful. Almost all programs are closely allied with ‘anonymous’ programs. The problem is that we don’t have much idea of how effective all this treatment is. We have overlooked the need to evaluate what is being done, to ask questions which challenge dogma and to learn the longterm outcome of these efforts. Some unanswered questions about treatment The first piece of information that would be useful would be to determine the longterm success rate of various treatment programs. It would be essential that a variety of programs be studied, as one would expect success rates to be highly variable. Success rate might be defined as being drug-free for one year following treatment, recognizing the fact that relapse tends to diminish after that time and that it is difficult to keep contact much longer with a representative sample of patients. From such data one should be able to derive some idea of which factors augur for a favorable response. Another useful type of information would be to determine the optimal site for treatment. Hospitals are most often used, simply because they have instituted programs. The prevailing idea is that isolation of the patient from access to drugs and from the drug-taking environment justifies in-patient treatment. But does it have to be in hospital rather than in a residential center, which might be considerably less expensive? Or even with patients living in nearby hotels? If a patient is gainfully employed, could they be managed by some sort of night hospital program? Such comparisons could easily be set up and would provide useful information about the most cost-effective way to render treatment. Assuming that some sort of inpatient treatment might be required for some patients, what is the optimal period? Most inpatient programs are based on a %-day stay. Just how this dura-
177
tion was selected is unclear; it was probably determined by the maximum time allotted by third party payers for payment for services. How would 28-day programs compare with shorter programs, say 14 days or 7 days, given the same type of follow-up care? One might devise a treatment sequence of initial hospitalization followed by residential care followed by outpatient care. What would be the optimal time periods for each phase? Aftercare is especially important in treating drug abuse. How intensive should it be? What are the retention rates in such programs? Is retention in aftercare essential for a good outcome? A number of drug treatments have been proposed for managing dependence on particular substances. It is somewhat sad that twenty years after lithium was first proposed as a treatment for alcoholism, its status remains unclear. Two recent studies have come to opposite conclusions. Will we remain in the dark for as long in regard to the use of serotonin uptake inhibitors? A large-scale controlled trial should be planned without delay to determine the worth of this type of drug treatment. Methadone maintenance for opiate-dependent persons has been extensively studied and the verdict is that it has been valuable. Even so, one is hesitant to believe that it should be maintained indefinitely. One might test a
sequence of treatment in which methadone was replaced by some mixed agonist-antagonist opiate, such as buprenorphine, with a later switch to a pure antagonist, such as naltrexone, and finally to a drug-free state. It would be nice to know how many persons who enter such a course might see it through to the drug-free state and whether they could be maintained in that condition without further drug treatment. Recently a flurry of interest has developed regarding several drugs which have been alleged to decrease craving in cocaine users. Desipramine, carbamazepine and flupenthixol have been said to achieve this desirable goal. Surely it should be possible to assess such claims in a comparative controlled study without much delay. If any or all of these drugs worked, it would be a major step forward in managing cocaine dependence. The fact that each drug seems to work by a different mechanism is puzzling but inquiry might add some knowledge about the biological basis of cocaine dependence. Conclusions Research on treatment outcomes in drug abuse has fallen behind other, far less pertinent areas of inquiry. We need to know whether the vast amounts of money spent on treatment are being used wisely and effectively. It is about time that we directed our inquiry to these important questions.
Drug and Alcohol Dependence, 25 (1990) 175- 177 Elsevier Scientific Publishers Ireland Ltd.
Treatment outcome: a neglected area of drug abuse research Leo E. Hollister Harris County Psychiatric
Center and Department
of Psychiatry. The University KJ.S.A.I
Scientific
Publishers
Texas
other than the more troubled the individual, in whichever ways, the more vulnerable they are. We do much better in predicting which drugs have the potential for creating dependence, usually long after this phenomenon has been demonstrated by experience in the street. We have little idea of how to prevent drug abuse through biologic mechanisms. We have some clues for its sociological prevention. Despite intensive research efforts at great cost for most of the past two decades, the estimated number of drug abusers has changed very little. For every drug abuser who becomes clean, or who ‘burns out’ or who dies prematurely as a consequence of drug use, another is recruited as a replacement. Both in the past, as well as the present, much of the research effort has been directed at areas that are tangential to actual drug use.
Although I have been engaged in research on drugs of abuse for almost 30 years, I never paid a great deal of attention before to the outcome of treatment programs. Three years ago, I became Medical Director of a 250-bed psychiatric hospital which had 48 beds dedicated to the treatment of substance abuse. Our treatment programs were modelled after those considered to be the best in the country. We estimate that we spend about $3 million on them with about 500 patients each year graduating from them. And we have no idea about the results of our efforts. Curiously, not many other treatment programs do. Thus, rather than taking the position that more research should be done in the areas in which I have been involved, I prefer to call attention to what seems to me to be a notable omission in drug abuse research. The benefits of scientific research have been so obvious and so overwhelming, even in one’s lifetime, that we have come to believe that any problem can be solved by research. Although I have been both an arbiter in, consultant to, and grantee of the drug abuse research establishment, I am sometimes disturbed to think how little impact we have had. Superb fundamental discoveries have been made (the opiate receptor-endorphins saga first comes to mind). We have learned a tremendous amount about the biological and social pharmacology of many drugs of abuse. We have, however, made relatively little progress in understanding the psychobiology of the compulsion to use drugs. We cannot predict who is at increased risk, 0376~8716/90/$03.50 0 1990 Elsevier Printed and Published in Ireland
of Texas Medical School, Houston,
Research on treatment Enormous amounts of money are spent on treatment programs. The most recent estimate is $3 billion yearly in the U.S. Yet we have virtually no idea of their success rates. Certainly, many persons are ultimately able to rid themselves of the use of drugs, but often the way this benefit is accomplished is idiosyncratic. The ‘anonymous’ programs, modeled after Alcoholics Anonymous, are probably the most successful, but they deal with self-selected samples of ‘clients’, have tremendous attrition rates and, by virtue of anonymity, provide no statistics about outcome. Most other treatment Ireland
Ltd.
176
programs suffer from the same deficiencies. Methadone maintenance programs for opiatedependence have been most amenable to data collection. While some construe the substitution of one drug of abuse for another as a dubious treatment, the outcome of methadone maintenance in terms of function has been more than acceptable. Motivation has been the key factor leading to success, whatever the program. The most successful programs have been those within industry or the military. The loss of current and future benefits is a strong motivator. It is not nearly so easy to motivate an unemployed ghetto youth who sees little hope. Most research efforts regarding treatment have been in the area of heroin abuse. Even though the original observation that methadone could act as a satisfactory replacement for heroin, with much less morbidity, was not funded from drug abuse research funds, its further development, certainly was. In addition, the development of longer a&ing methadone compounds, such as L-acetylmethadyl, or the narcotic antagonist naltrexone, have been liberally funded. Acetylmethadyl is not yet available for general use and naltrexone has only a very limited acceptability among the drug-using population. Both speak to the difficulty in establishing new treatments. Yet drug abuse programs have proliferated faster than any other special treatments in psychiatry. Paradoxically, twenty years ago it was a rare psychiatrist who treated alcoholics or drug abusers. Now treatment programs have sprung up in almost every hospital. We probably have more private practice slots for drug abuse treatment that can be filled. On the other hand, publicly funded programs have only limited resources and consequently have large numbers of potential patients waiting for available treatment slots. Most programs offer a mix of therapeutic approaches and services. Education about the health aspects of drug use, group therapy, psychodrama, family therapy and virtually every possible othep therapy are offered. Social and vocational rehabilitation is available for
those who need these services. Therapeutic programs seem to have been derived empirically with no more than a strong belief that the treatments offered are likely to be successful. Almost all programs are closely allied with ‘anonymous’ programs. The problem is that we don’t have much idea of how effective all this treatment is. We have overlooked the need to evaluate what is being done, to ask questions which challenge dogma and to learn the longterm outcome of these efforts. Some unanswered questions about treatment The first piece of information that would be useful would be to determine the longterm success rate of various treatment programs. It would be essential that a variety of programs be studied, as one would expect success rates to be highly variable. Success rate might be defined as being drug-free for one year following treatment, recognizing the fact that relapse tends to diminish after that time and that it is difficult to keep contact much longer with a representative sample of patients. From such data one should be able to derive some idea of which factors augur for a favorable response. Another useful type of information would be to determine the optimal site for treatment. Hospitals are most often used, simply because they have instituted programs. The prevailing idea is that isolation of the patient from access to drugs and from the drug-taking environment justifies in-patient treatment. But does it have to be in hospital rather than in a residential center, which might be considerably less expensive? Or even with patients living in nearby hotels? If a patient is gainfully employed, could they be managed by some sort of night hospital program? Such comparisons could easily be set up and would provide useful information about the most cost-effective way to render treatment. Assuming that some sort of inpatient treatment might be required for some patients, what is the optimal period? Most inpatient programs are based on a %-day stay. Just how this dura-
177
tion was selected is unclear; it was probably determined by the maximum time allotted by third party payers for payment for services. How would 28-day programs compare with shorter programs, say 14 days or 7 days, given the same type of follow-up care? One might devise a treatment sequence of initial hospitalization followed by residential care followed by outpatient care. What would be the optimal time periods for each phase? Aftercare is especially important in treating drug abuse. How intensive should it be? What are the retention rates in such programs? Is retention in aftercare essential for a good outcome? A number of drug treatments have been proposed for managing dependence on particular substances. It is somewhat sad that twenty years after lithium was first proposed as a treatment for alcoholism, its status remains unclear. Two recent studies have come to opposite conclusions. Will we remain in the dark for as long in regard to the use of serotonin uptake inhibitors? A large-scale controlled trial should be planned without delay to determine the worth of this type of drug treatment. Methadone maintenance for opiate-dependent persons has been extensively studied and the verdict is that it has been valuable. Even so, one is hesitant to believe that it should be maintained indefinitely. One might test a
sequence of treatment in which methadone was replaced by some mixed agonist-antagonist opiate, such as buprenorphine, with a later switch to a pure antagonist, such as naltrexone, and finally to a drug-free state. It would be nice to know how many persons who enter such a course might see it through to the drug-free state and whether they could be maintained in that condition without further drug treatment. Recently a flurry of interest has developed regarding several drugs which have been alleged to decrease craving in cocaine users. Desipramine, carbamazepine and flupenthixol have been said to achieve this desirable goal. Surely it should be possible to assess such claims in a comparative controlled study without much delay. If any or all of these drugs worked, it would be a major step forward in managing cocaine dependence. The fact that each drug seems to work by a different mechanism is puzzling but inquiry might add some knowledge about the biological basis of cocaine dependence. Conclusions Research on treatment outcomes in drug abuse has fallen behind other, far less pertinent areas of inquiry. We need to know whether the vast amounts of money spent on treatment are being used wisely and effectively. It is about time that we directed our inquiry to these important questions.
