“blocked” substances may get different degrees of (attenuated) psychoactive effects. Consequently, variations in effectiveness across patients—and why, as well as how, this can be optimized—and different patient’s responses to different levels of effectiveness may be important to examine (National Research Council, 2001). As noted above, it is known that the effectiveness of immunotherapies to block psychoactive effects decreases over time.

In an economic sense, a therapy with low to modest ability to attenuate psychoactive effects could be modeled and thought of as a price increase for the drug in question (see Kleiman, this volume). Absent psychosocial or other interventions (such as testing and sanctions) the effectiveness of the immunotherapy or sustained-release formulation might be comparable in magnitude to an increase in the retail (or street) price of the drug.

Cigarette smokers who use low nicotine products have been observed to increase their consumption (use more cigarettes per day or inhale more deeply) to maintain their dosage of nicotine (and as an unintended consequence, quite possibly their intake of tar and other cigarette byproducts) (Kozlowski et al., 1996). Users of illicit drugs are known to be highly sensitive to the “quality” (e.g., purity or concentration of the active ingredient) of the drug consumed and adjust their consumption of the drug in a manner that regulates the dosage received. Thus, it is quite possible that a low efficacy medication may see continued use and even increased use by some patients, with possible adverse consequences for the individual (e.g., from harms such as HIV/HCV infection that are associated with administration not intoxication) and for society (e.g., from increased demand that stimulates increases in drug-related crime) (Kleiman, this volume).

Cost Effectiveness

The central economic fact of all health care is that resources are scarce and potential demands are virtually unlimited. Consumers, society, and the health system confront the fundamental economic question of how to optimize well-being in the face of scarce resources (Gold et al., 1996). The publicly subsidized substance abuse treatment system is well known to face limited financing, leading to waiting lists for clients and competition between providers and different types of care for resources (Center for Substance Abuse Treatment, 2000). Private and public insurance plans generally have limited coverage for substance abuse treatment therapies and medications. Cost effectiveness analysis can offer insights on the relative value of alternative health interventions.

Public and private purchasers of treatment will need to carefully consider how the benefits and costs of immunotherapies and depot medica-



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