Treatment Approaches and Outcomes

Another major focus of addiction research is on the development and measurement of effective psychosocial treatment and follow-up studies of the long-term outcomes of different approaches. The Drug Abuse Treatment Outcome Studies project was initiated by NIDA in the early 1990s. This project involves four centers - the National Development and Research Institutes in North Carolina, Texas Christian University in Ft. Worth, Texas, the University of California at Los Angeles, and the NIDA Services Research Branch in Maryland.

Data on over ten thousand addicts who received treatment in four types of settings has been collected with long-term follow-up planned over the next four years on roughly a third of the original sample. These settings include outpatient methadone clinics, long-term residential treatment, drug-free outpatient programs, and short-term inpatient treatment. Data from the study is available from the Substance Abuse and Mental Health Data Archive (SAMHDA) at the University of Michigan.

The Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services makes available a number of services for treatment providers and also coordinates nationwide treatment-outcome studies. The Center for Substance Abuse Treatment (CSAT) is a division of SAMHSA that collects and disseminates state-of-the-art information concerning all aspects of addiction treatment. The National Treatment Improvement Evaluation Study (NTIES) is a recent treatment-outcome survey that looked at patient characteristics and types of treatment settings to determine factors that favored a positive outcome. Completion of the entire treatment program, higher intensity of treatment, and longer treatment were associated with better outcomes. The specific characteristics of the treatment unit did not explain much of the variation, nor did more severe addiction at the time of admission.

SAMHSA also supports an ongoing study called TOPPS, which stands for Treatment Outcomes and Performance Pilot Studies. This nationwide study, involving participants in fourteen states, is based in publicly supported treatment programs administered at the state level. Each state has identified target areas for study within the populations that they serve. The findings of the TOPPS project will be a compilation of a number of studies covering different outcome and treatment issues. Some areas of interest include the effect of managed care on treatment outcomes and the assessment of approaches used with various ethnic and cultural groups.

Contingency management is a recently studied therapeutic technique used in the treatment of cocaine addiction. In this approach behavioral reinforcement is based on the addict’s performance in treatment. The intention is to help counteract the classical conditioning that results in cravings for cocaine when the addict is exposed to an environment where drugs are being used. Vouchers that can be redeemed for retail merchandise are given to addicts in outpatient treatment who have negative urine drug screens. In one randomized trial, addicts assigned to the voucher program showed better treatment retention rates and longer periods of abstinence than those in standard treatment.

Cognitive behavioral therapy involves a supportive and educative approach that teaches the addict to identify core beliefs underlying problem behaviors and to make better choices about drug use. Cognitive behavioral theory is also the basis of relapse prevention protocols which have been added to most treatment programs, and has been applied to couples and family therapy strategies. The addition of cognitive behavioral treatment to traditional treatment approaches has been shown to enhance treatment outcome.

Harm reduction is another treatment approach that has been found to work well with addicts who also have a diagnosis of severe mental illness. This is a treatment paradigm that diverges from the previous belief that total abstinence is the definition of positive outcome. Harm reduction measures such elements as the length of time between using and abstaining and the degree of negative consequences associated with the addiction. The eventual goal of a harm reduction protocol is still abstinence, but it allows for gradual progress as the addict with mental illness becomes more engaged over time in the treatment process.

In summary, research on addiction is varied and plentiful, which, considering the immense complexity of the condition, is not surprising. Much more material is available than what I have discussed here. Interested readers can contact NIAAA, NIDA, SAMHSA, and the NIH directly by mail or phone or by accessing the Web sites provided in

appendix B.

The American Journal on Addictions (only one of several journals featuring articles on addiction) is published quarterly by the American Psychiatric Association Press and includes new research on many different topics.

As we explore the intricacies of the addicted brain, perhaps we will unlock some of the secrets of how that organ functions and how it integrates thoughts, memories, feelings, hopes, aspirations, and spirituality to form the essence of what we call human nature.

A quotation from Alcoholics Anonymous seems appropriate here: “Physicians who are familiar with alcoholism agree there is no such thing as making a normal drinker out of an alcoholic. Science may one day accomplish this, but it hasn’t done so yet.” Actually, anyone who has attained true sobriety and along with it a sense of contentment and serenity doesn’t really care if science ever accomplishes that. Such a person no longer feels the need to be a normal drinker.

Elizabeth Connell Henderson, M.D.



Appendix A: Regulation of Addictive Substances

Appendix B: Sources of Additional Information

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