D

The Treatment of Addiction: What Can Research Offer Practice?

A. Thomas McLellan and James R. McKay

Penn-VA Center for Studies of Addiction and The Treatment Research Institute at the University of Pennsylvania

INTRODUCTION

Problems of substance dependence produce dramatic costs to society in terms of lost productivity, social disorder and of course health care utilization (NIDA, 1991; Merrill, 1993). Over the past twenty years many of the traditional forms of substance abuse treatment (e.g., methadone maintenance, therapeutic communities, outpatient drug free and others) have been evaluated multiple times and shown to be effective (Ball and Ross, 1991; DATOS, 1992; Hubbard et al., 1986, 1997; IOM, 1989, 1990b; McLellan et al., 1980; Simpson, 1981, 1997; Simpson et al., 1997a,b). Importantly, this research has shown that the benefits obtained from addiction treatments typically extend beyond the reduction of substance use, to areas that are important to society such as reduced crime, reduced risk of infectious diseases, and improved social function (Ball and Ross, 1991; Institute of Medicine, 1989, 1990b; McLellan et al., 1980). Finally, research findings indicate that the costs associated with the provision of substance abuse treatment provide 3- to 7-fold returns to the employer, the health insurer, and to society within approximately three years following treatment (Everingham and Rydell, 1994; Gerstein et al., 1994; Holder et al., 1991; IOM, 1990b; OTA, 1983; State of Oregon, 1996).

Supported by grants from the National Institute on Drug Abuse, the Center for Substance Abuse Treatment, and the Robert Wood Johnson Foundation. Parts of this paper appear in McKay and McLellan, 1997 and an earlier IOM report on Managing Managed Care, 1997.



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D The Treatment of Addiction: What Can Research Offer Practice? A. Thomas McLellan and James R. McKay Penn-VA Center for Studies of Addiction and The Treatment Research Institute at the University of Pennsylvania INTRODUCTION Problems of substance dependence produce dramatic costs to society in terms of lost productivity, social disorder and of course health care utilization (NIDA, 1991; Merrill, 1993). Over the past twenty years many of the traditional forms of substance abuse treatment (e.g., methadone maintenance, therapeutic communities, outpatient drug free and others) have been evaluated multiple times and shown to be effective (Ball and Ross, 1991; DATOS, 1992; Hubbard et al., 1986, 1997; IOM, 1989, 1990b; McLellan et al., 1980; Simpson, 1981, 1997; Simpson et al., 1997a,b). Importantly, this research has shown that the benefits obtained from addiction treatments typically extend beyond the reduction of substance use, to areas that are important to society such as reduced crime, reduced risk of infectious diseases, and improved social function (Ball and Ross, 1991; Institute of Medicine, 1989, 1990b; McLellan et al., 1980). Finally, research findings indicate that the costs associated with the provision of substance abuse treatment provide 3- to 7-fold returns to the employer, the health insurer, and to society within approximately three years following treatment (Everingham and Rydell, 1994; Gerstein et al., 1994; Holder et al., 1991; IOM, 1990b; OTA, 1983; State of Oregon, 1996). Supported by grants from the National Institute on Drug Abuse, the Center for Substance Abuse Treatment, and the Robert Wood Johnson Foundation. Parts of this paper appear in McKay and McLellan, 1997 and an earlier IOM report on Managing Managed Care, 1997.

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How Do These Research Results Translate into Recommendations that Can Be Useful for Treatment Providers?—Although the conclusions from reviews of the recent treatment research literature are important and gratifying, they are not adequate to inform important clinical questions regarding the delivery of substance abuse treatment services. Simply knowing that those who stay in treatment longer have better outcomes does not help when the funding and duration of treatment in ''real world" settings is regularly reduced (McLellan et al., 1996a). Further, research demonstrating that highly specialized and resource-intensive treatments "work" with highly selected samples of patients may not be helpful to "real world" treatment providers who have no prospects of accessing those treatments and whose caseloads contain very few of the patients on whom the specialized treatment was tested. This is particularly true at the level of the "community-based" public sector treatment programs that have been forced to operate under limited budgets with little access to sophisticated services. How can research in the treatment setting inform these providers? How can these providers use information from research studies to upgrade or expand their treatment efforts—within the practical constraints of budget and personnel available? Parameters of the Literature Review—In response to these questions, we have reviewed the existing treatment outcome literature to summarize the available knowledge regarding the important patient and treatment factors that have been shown to influence the outcomes of addiction rehabilitation treatments. We felt this was an important first step in recognizing and recommending proven, practical, and cost-effective treatment strategies that can be implemented by community behavioral treatment programs. In this regard, we have elected not to review literature on detoxification methods in order to better focus on standard rehabilitation treatments for drug and alcohol dependence—typically following detoxification. Our review does not include the adolescent drug abuse treatment literature since it is still a developing field and there is a paucity of pertinent outcome studies in this area. In addition, we elected not to include a review of the smoking cessation literature as there have been excellent recent reviews of this entire field (see Fiore et al., 1996). From a methodological perspective, we included only those clinical trials, treatment matching, or health services studies where the patients were alcohol or drug dependent by contemporary criteria (e.g., DSM); where the treatment provided was a conventional form of rehabilitation (any setting or modality); and where there were measures of either treatment processes or patient change during the course of treatment as well as posttreatment measures of outcome as defined later in the chapter. We have elected to include methadone maintenance (as well as its long acting form,

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levo-alpha-acetylmethadol [LAAM) as part of the general category of outpatient rehabilitation treatments, rather than create a special category. In the review that follows we first discuss some of the basic assumptions underlying rehabilitation forms of addiction treatment since they set the stage for the clinical methods currently in use and for the types of studies that are in the research literature. Next we discuss some of our considerations regarding definitions of "outcome." With these assumptions and considerations in mind, we then review the most significant patient and treatment process contributors to the outcomes of addiction treatment. REHABILITATION TREATMENTS IN ADDICTION: WHO ARE THEY FOR, WHAT SHOULD THEY DO? What Is Addiction Rehabilitation Designed to Do?—In contrast to "detoxification," which is a relatively brief, usually medical procedure designed to stabilize the acute physical and emotional distress and instability caused by recent termination of heavy alcohol and/or drug use, "rehabilitation" is a much longer process, usually involving multiple types of medical and social services, that is designed to help recently stabilized patients achieve sustained periods of drug-free living and stable personal and social function. There are clear physical signs and symptoms associated with the cessation of most addictive substances and there are standard medications and withdrawal procedures that are very effective in ameliorating these acute "detoxification" symptoms and restoring physiological and emotional stability. Despite the efficacy of these detoxification methods, there is uniform agreement among professionals that detoxification by itself—regardless of the type or the duration—is rarely associated with sustained periods of abstinence or even improved function. Well after the return of physiological and emotional stability, most patients continue to experience regular periods of intense craving for alcohol and drugs and this can lead to "loss of control" in situations where these drugs of abuse are (or have been) present. There has been substantial research showing that among former addicts who have been abstinent for up to a year, even the sight or sound of stimuli associated with former periods of drug use can produce (through learned association) measurable changes in brain chemistry that mimic the actual use of the drug and the withdrawal symptoms produced by those drugs (see Childress et al., 1985, 1986, 1992; O'Brien et al., 1991). Rehabilitation Methods—While there is universal agreement that some form of rehabilitation is necessary, there has been a very wide range of professional opinion regarding the nature or amount of rehabilitation nec-

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essary to produce sustained benefits. In part this is due to disagreement regarding the etiology and course of the addiction syndrome. These etiological theories include a genetic predisposition, an acquired metabolic abnormality, learned negative behavioral patterns, self medication of underlying psychiatric or physical medical problems, and lack of family and community support for positive function. For this reason, there is an equally wide range of treatment methods that have been applied to address these etiological and predisposing factors and to provide continuing support for the targeted behavioral changes. These have included such diverse elements as psychotropic medications to relieve underlying psychiatric problems, "anti-craving" medications to relieve alcohol and drug craving, acupuncture to correct acquired metabolic imbalances, educational seminars, films and group sessions to correct false impressions about alcohol and drug use, group and individual counseling and therapy sessions to provide insight, guidance and support for behavioral changes, and peer help groups (AA/ NA/CA) to provide continued support for the behavioral changes thought to be important for sustaining improvement. These rehabilitation methods have been traditionally provided in two types of settings—inpatient and outpatient. At this writing, inpatient rehabilitation programs can be divided into three general categories (Hubbard et al., 1989, 1997): 1.   Inpatient hospital-based treatment (now very rare)—from 7 to 11 days. 2.   Nonhospital "residential rehabilitation"—from 30 to 90 days. 3.   Therapeutic Communities—from 6 months to 2 years. Outpatient forms of treatment (at least abstinence oriented treatments) range from 30 to 120 days (Hubbard et al., 1989, 1997). Many of the more intensive forms of outpatient treatment (Intensive Outpatient, Day-Hospital) begin with full or half-day sessions, five or more times per week for approximately one month. As the rehabilitation progresses the intensity of the treatment reduces to shorter duration sessions (one to two hours) delivered twice weekly to semi-monthly. Regardless of whether the rehabilitation process is initiated in an inpatient or outpatient setting, most rehabilitation programs recognize the need for some level of continuing involvement with the rehabilitation process. Thus the final part of outpatient rehabilitation is typically called "Continuing Care" or "Aftercare" and includes weekly to monthly group support meetings continuing (in association with parallel activity in self-help groups) for as long as two years (McKay et al., 1998).

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A Special Note on Maintenance Forms of Treatment. The opiate dependence treatment field has had the availability of orally administered, long-acting agonist medications. Three forms of opiate maintenance medications are currently available, Methadone, Levo-alpha-acetyl methadol (LAAM) and Buprenorphine. While each is different in nature and duration of action, they provide 24-72 hours of continuing relief from opiate withdrawal and craving; and serve as the basis for adjunctive social supportive therapy and medical care. This maintenance modality is quite similar in purpose and practice to the combined regimens of pharmacotherapy and supportive therapy now provided for depressed, diabetic, hypertensive, asthmatic, and other chronic illness patients. Like most forms of pharmacotherapy for patients with chronic illnesses, opiate maintenance treatments are designed with an indeterminate length—possibly continuing throughout the life of the patient. Outcomes Expected from Addiction Rehabilitation Treatments—We have argued in earlier work (McLellan et al., 1996b, 1997a) that outcome expectations for substance abuse treatment should not be confined simply to reduction of alcohol and drug use since the public, the payers of treatment, and even the patients themselves are interested in a broader definition of "rehabilitation." Further, we have argued that for substance abuse treatments to be "worth it" to the multiple stakeholders who are involved in treatment, the positive effects of addiction treatment should be sustained beyond the end of the treatment period and carry on at least six to twelve months. Most researchers in the addiction field have taken a similar, broad view of outcome expectations in the addiction treatment field (See Anglin et al., 1989; Babor et al., 1988; Ball and Ross, 1991; De Leon, 1984; Hubbard et al., 1989, 1997; Simpson, 1981, 1997; Simpson et al., 1997a,b). Thus in the review that follows we have given greater attention to studies where multiple outcomes were measured six to twelve months following inpatient discharge or at the same points during the course of the outpatient period of care. Further, we have considered three domains that we feel are relevant to the rehabilitative goals of the patient and to the public health and safety goals of those societal stakeholders that support treatment: 1.   Sustained reduction of alcohol and drug use. This is the foremost goal of substance dependence treatments and we consider it as the primary outcome domain. Within the review, we accepted as operational evidence for improvement in this domain both objective data from urinalysis and breathalyzer readings as well as patients' self reports of alcohol and drug use when those reports were recorded by independent interviewers under conditions of privacy and impartiality.

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2.   Sustained increases in personal health and social function. Improvements in the medical/psychiatric health and social function of addicted patients are important from a societal perspective in that these improvements reduce the problems and expenses produced by the addiction. In addition, improvements in these areas are important for maintaining reductions in substance use. Within the review, we accepted evidence from measures such as general health status inventories, psychological symptom inventories, family function measures, and simple measures of days worked and dollars earned, collected either directly from the patient via confidential self report or from independent medical/psychiatric evaluations and employment records. 3.   Sustained reductions in public health and public safety threats. The threats to public health and safety from substance abusing individuals come from behaviors that spread infectious diseases and from behaviors associated with personal and property crimes. With regard to infectious disease, the sharing of needles, unprotected sex, and trading sex for drugs are serious behaviors that have clearly been linked to addiction and are significant threats to public health. Within the review, we accepted evidence of improved public health from confidential self reporting techniques or (rarely) through laboratory tests. Public safety threats were measured in the studies reviewed either by confidential interviews and questionnaires or by objective records of arrests and incarcerations. In our view, the first two domains are quite consistent with the "primary and secondary measures of effectiveness" typically used by the Food and Drug Administration to evaluate new drug or device applications in controlled clinical trials (FDA) and quite consistent with the mainstream of thought regarding the evaluation of other forms of health care (Stewart and Ware, 1989). The final outcome dimension we believe is more specific to the treatment of substance use disorders since it acknowledges the significant public health and public safety concerns associated with addiction. RESEARCH ON PATIENT FACTORS RELATED TO TREATMENT OUTCOME Demographic Factors—While demographic factors are typically important predictors of the development of drug abuse problems (IOM, 1990b; Wilsnack and Wilsnack, 1993) there is little evidence that race, gender, age, or educational level are consistent predictors of treatment outcome—among those who begin a treatment episode. An inspection of a wide range of treatment outcome studies in the substance abuse rehabilitation field suggests that demographic factors such as age, education, race, and even treatment history are relatively poorly related to the three out-

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come domains defined above in any of the major rehabilitation modalities (see Ball and Ross, 1991; Finney and Moos, 1992; McLellan et al., 1994; Rounsaville et al., 1987). For example, a study of 649 patients entering 22 treatment programs (seven inpatient, eight outpatient, seven methadone maintenance) for treatment of primary alcohol, opiate, or cocaine dependence evaluated the contribution of demographic variables including age, ethnicity, gender, marital status, years of education, and years of problematic substance abuse (McLellan et al., 1994). Results showed that none of the demographic measures was a significant predictor of either posttreatment substance use or posttreatment social adjustment. Similarly, studies by Simpson and Savage (1980) showed no significant effect of demographic and social indicators in predicting multiple outcome domains among heroin addicts treated in methadone maintenance and outpatient drug free treatment. Though less studied at this time, there may be some important exceptions to this conclusion. For example, pregnant and parenting women are an important subgroup of the larger patient population who require different features to permit access to treatment as well as different constellations of treatment to address their often significant treatment problems (see Gomberg and Nirenberg, 1993; Wilsnack and Wilsnack, 1993). There has been indication that these patients have been reluctant to get into "standard" treatments because of stigma and because of the absence of services for their children. There have been experimental programs created to meet the needs of this important subgroup—and some excellent evaluations have followed these groups posttreatment (see Hagan et al., 1994). There have been very few longer term outcome studies of specialized treatments for pregnant and parenting women and only the most obvious conclusions can be drawn regarding the factors that appear to be important for attraction, retention, and improved outcomes for these patients. These factors would include but not be restricted to: 1.   The availability of care for children—and sometimes a residence that will accommodate the patients and their children. Many of the addicted women who could benefit from treatment are responsible for the care of children and facilities that will provide respite care are likely to be necessary for these women to be able to enter outpatient treatment. Other women will not have the resources to be self supporting and may need temporary accommodations for themselves and their children. Still others may require a facility that will offer protection from aggressive and/or drug involved partners. Problems of safety from physical and sexual abuse and separation from drug involved relationships are common in a large proportion of these women (Hagan et al., 1994; Wilsnack and Wilsnack, 1993;

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    Schmidt and Weisner, 1995; Weisner and Schmidt, 1992). Residential settings are potentially important to address these problems. 2.   The availability of general medical, OB/GYN, and psychiatric services. Disproportionately high numbers of these women have shown significant medical and psychiatric problems (Finnegan, 1991; Hagan et al., 1994; Schmidt and Weisner, 1995; Weisner and Schmidt, 1992; Wilsnack and Wilsnack, 1993). Therefore, it is important for programs that treat women substance abusers to provide adjunctive services in these areas. Severity of Substance Use—Various measures of higher levels of severity and greater chronicity of patients' substance use patterns have been reliably associated with poorer retention in treatment and more rapid relapse to substance use following treatment. This has been true of both alcohol dependent patients (Babor et al., 1988; Finney and Moos, 1992); opiate dependent patients in therapeutic communities and in methadone maintenance (Ball and Ross, 1991; De Leon et al., 1984, 1994; Simpson, 1981, 1997a); and cocaine dependent patients treated in outpatient and inpatient settings (Alterman et al., 1994; Carroll et al., 1991; McLellan et al., 1994). The uniform nature of these predictive relationships across different types of drug dependence and treatment modalities suggests a pervasive trend toward poorer performance across all forms of treatment among those with longer durations and/or more intensive use patterns. This relationship is strongest between severity of substance use at treatment admission and posttreatment substance use. It is less clear whether the severity of alcohol and drug use at treatment admission is predictive of the other domains of personal health and social function, or public health and safety (McLellan et al., 1981b, 1992b, 1994). Thus, while the severity of substance use prior to treatment admission (measured in terms of amount, duration, and intensity of alcohol and drug use) is negatively related to posttreatment substance use—accounting for perhaps 10%-15% of outcome variance in that measure—it is less related to outcome in the other outcome domains (Babor et al., 1988; McLellan et al., 1994). Severity of Psychiatric Problems—After the severity of the substance abuse problem, perhaps the most robust general patient variable predicting treatment response and posttreatment outcome has been the chronicity and severity of the psychiatric problems presented by the patient at the start of treatment (Carroll et al., 1993; Kadden et al., 1990; McLellan et al., 1983a,b, 1994; Powell et al., 1982; Project MATCH, 1997; Rounsaville et al., 1987; Woody et al., 1984, 1987). It is important to note that psychiatric problems have been measured using many scales and interviews in these studies, and all have attempted to distinguish more enduring or chronic psychiatric symptoms from the acute and temporary effects of alcohol and

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drug withdrawal. In the case of methadone maintained, opiate dependent patients, studies by McLellan and colleagues (1983a,b) indicated that the psychiatric severity scale from the Addiction Severity Index was the single best predictor of six month substance use, personal health, and social adjustment. Similar findings have been shown by Ball and Ross (1991) and by Kosten and colleagues (1987) and Rounsaville and colleagues (1983, 1987) with methadone maintained patients. Measures of psychiatric severity have also been shown to be predictive of outcome in studies of opiate and multiple drug dependent patients entering an inpatient therapeutic community setting. For example, De Leon (1984) showed that opiate and non-opiate dependent patients with MMPI profiles indicative of high levels of psychopathology entering a therapeutic community were more likely to drop out of treatment and showed significantly less improvement on all outcome measures at discharge and at subsequent twelve month follow-up evaluations. In an earlier study of mixed opiate and non-opiate dependent male veterans entering into a therapeutic community McLellan and colleagues (1984) found that patients with the highest scores on the ASI psychiatric severity scale were most likely to drop out prematurely and actually showed 20%-40% less improvement than other patients who entered treatment at the same time. In that study, the "high psychiatric severity" patients who stayed in treatment longest actually showed the worst posttreatment status—suggesting that the therapeutic environment that had been demonstrably effective for patients with lower levels of psychiatric severity, was actually counter therapeutic for the high severity patients. In the case of cocaine dependent patients, Carroll et al. (1991) also found poorer outcomes for patients with greater psychiatric pathology, as defined by scores on the Addiction Severity Index (ASI) psychiatric problem scale. Her findings were obtained in an outpatient rehabilitation setting. Similar results were found among cocaine dependent patients by Alterman et al. (1994) for patients treated in both a day-hospital and an inpatient rehabilitation setting. Finally, there has been a great deal of evidence for the predictive power of general psychiatric symptomatology among alcohol dependent patients. Rounsaville and colleagues showed that psychiatric severity as measured by the ASI psychiatric scale was the best predictor of overall adjustment among previously treated alcohol dependent patients at a 2.5 year posttreatment follow-up (Rounsaville et al., 1987). Other authors have found that severity of depression (Powell et al., 1982; Schuckit et al., 1990) and anxiety (Brown et al., 1991; Schuckit et al., 1990) have been predictive of posttreatment drinking and posttreatment social adjustment among various samples of alcohol dependent patients. More recently, findings from the NIAAA sponsored, multisite study of patient treatment matching (Project MATCH,

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1997) showed that the ASI psychiatric scale was a significant general predictor of posttreatment drinking and posttreatment social adjustment in a sample of more than 1200 alcohol dependent patients in three types of outpatient treatment. Note: While there are a number of studies relating severity of psychopathology to posttreatment outcome, it should be noted that Schuckit and his colleagues have argued cogently against "over diagnosing" psychiatric symptoms, especially among alcohol dependent patients (Brown et al., 1991; Schuckit and Monteiro, 1988). These authors have shown that much of the serious psychopathology seen among alcohol dependent patients at treatment admission is reduced following even four weeks of abstinence. There is also evidence for rapid dissipation of psychiatric symptoms following abstinence from cocaine (Satel et al., 1991; Weddington, 1992). This proviso suggests that care should be taken to distinguish acute alcohol and/or drug related psychopathology from more enduring and chronic psychiatric symptoms. Patient Motivation and Stage of Change—Evidence for patient "motivation for treatment" has traditionally been measured as the extent to which patients have freely entered into treatment. Conversely, patients who have been coerced into treatment based on pressure from legal, family, or employment sources, have been considered "treatment resistant." While this is a face valid measure of motivation—and presumably a good predictor of patient performance during and following treatment—the large literature on coerced treatment indicates the opposite of what would be expected. That is, patients who have been forced to enter a substance abuse treatment have shown during and posttreatment results that are quite similar to those shown by supposedly "internally motivated" patients (Inciardi, 1988; Lawental et al., 1996; Roman, 1988). This rather broad literature has led to the conclusion that when "motivation" is conceptualized and measured in terms of the degree to which the patient has been coerced into treatment, it is not an important predictor of treatment response. However, there is rapidly growing body of research indicating that when motivation is defined as "readiness for change" and is conceptualized and measured in stages as suggested by Prochaska, DiClemente and their associates (e.g., Prochaska and DiClemente, 1984; Prochaska et al., 1992), "stage of change" motivation can be a very important predictor of treatment response and treatment outcome. According to the stage of change model, the process of behavior change occurs in a progression of five distinct stages, each characterized by a different constellation of attitudes and behaviors. An individual in the "precontemplation stage" has no awareness of a problem and no desire to change. A patient in the "preparation stage" has made the decision to change and is already taking steps to do so. A

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patient in the "maintenance stage" has shown change and is maintaining the changed behavior (see Prochaska and DiClemente, 1984). The power of the model comes from two sets of findings. First, a relatively simple measure of stage of change such as the University of Rhode Island Change Assessment (URICA) (Prochaska and DiClemente, 1984; Prochaska et al., 1992) can apparently identify individuals in the precontemplation stage of change for whom traditional forms of rehabilitation treatment (most of which assume desire and ability to change as a precondition of admission) will not be effective. Specifically, there are several studies showing failure of traditional forms of counseling and therapy in patients identified as "precontemplators" on the URICA (DiClemente et al., 1991; Heather et al., 1993; Marlatt, 1988). The second important finding from work with this measure is that the "stage of change" is apparently an important predictor of treatment response and treatment outcome across all types of substance dependent patient samples (especially alcohol and nicotine dependent patients, but it is less studied among cocaine and opiate dependent patients), even those who are not in treatment (DiClemente et al., 1991). The model provides a way of identifying patients with different levels of motivation and outlines a way of tailoring interventions to match their stage of change. It makes sense that those patients who consciously intend to change are more likely to succeed in treatment than those who do not. In this regard, the majority of the predictive power of the stage of change model has been the identification of precontemplators. Additional research is warranted to determine the extent to which the remaining stages of change can predict response to standard rehabilitation treatments. Employment—There is ample indication from research with methadone maintained patients that employment, employability, and self support skills are a significant problem for this population; and that unemployed patients are more likely to drop out of treatment prematurely and to relapse to substance use early following treatment (Dennis et al., 1993; Hubbard et al., 1989; Platt, 1995). This was illustrated in a study of male veterans in methadone maintenance treatment by McLellan and colleagues (1981a). These authors found that patients who derived most of their income from employment showed more improvement and better six-month outcomes in several outcome domains including drug use, legal, and psychiatric problems and of course employment, than similar patients who derived the majority of their income from unemployment or welfare. Hubbard and his colleagues (1989) showed that the development of employable skills and the capacity for self support were among the most important requirements for sustained reductions in drug use among a large cohort of drug dependent patients in treatment. Similar findings were shown

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    following patient and treatment process factors have been significantly and repeatedly related to favorable outcomes.     Patient variables associated with better outcome from rehabilitation included: a.   low severity of dependence, b.   few psychiatric symptoms at admission, c.   motivation beyond the precontemplation stage of change, d.   being employed or self supporting, and e.   having family and social supports for sobriety.     Treatment variables associated with better outcome from rehabilitation included: a.   staying longer in/ being more compliant with treatment—especially through behavioral contracting for positive reinforcement; b.   having an individual counselor or therapist; c.   having specialized services provided for associated medical, psychiatric, and/or family problem; d.   receiving proper medications—both for psychiatric conditions and anticraving medications; and e.   participating in AA or NA following treatment.     In contrast to the above findings, it was surprising that some of the treatment elements that are most widely provided in substance abuse treatment have not been associated with better outcome. For example, our review of the literature has shown little indication that any of the following lead to better or longer lasting outcomes following treatment: a.   alcohol/drug education sessions; b.   general group therapy sessions, especially "confrontation" sessions; c.   acupuncture sessions; d.   patient relaxation techniques; and e.   treatment program accreditation or professional practice certification criteria.     For the sake of brevity, studies of these five interventions were not described above. These findings are generally in accordance with a review of the alcohol rehabilitation field by Miller and Holder (1994), which concluded that there are a number of therapeutic practices and procedures that remain prevalent in the field that have not yet shown indication of success. It is important to note that "the absence of evidence" does not

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    prove a treatment element is ineffective. Some of the treatment practices or conventions cited may actually have benefits for some patients or under some circumstances but we have found little support for these in the existing literature. 3.   A reviewer of this field will get substantially different views about the "outcome" of an addiction treatment depending upon the perspective taken regarding what "outcome" is; and when, how, and by whom it is measured. Consider three common perspectives on the evaluation of an outpatient addiction treatment program. A quality assurance or service delivery evaluation of that treatment might conclude that the program "had very good outcomes" since there was no waiting for treatment entry and at discharge, more than 80% of the patients were "highly satisfied'' with their counselor and physician. A clinical researcher, having interviewed a sample of patients at admission to the program, and again six months following discharge, might conclude that the program "had mixed outcomes" since at the follow-up point, only 50% of the patients were abstinent (the intended goal of the program) but there was a 70% reduction in frequency of drinking and a 50% reduction in medical and psychiatric symptoms. Meanwhile, an economist or health policy analyst might have used Medicaid data tapes to compare the health services utilization rates of a sample of discharged patients, two years prior to their treatment admission and two years following their discharge. The conclusion here might be that "treatment had very poor outcome" since there had been no decrease in health care utilization from the pre- to the posttreatment period, hence no "cost-offset" to the public. This example illustrates two points. First, that these three common perspectives on outcome have different purposes for their evaluations and different expectations regarding treatment, they measure different elements of the treatment process and the patient population, and at different points in time. Following from the first point, these different measures of outcome are not well related to each other; and it has been the case that clinical research has often focused upon a rather narrow set of outcomes (e.g., abstinence from alcohol or drugs) to evaluate treatments while interventions delivered at community treatment organizations are being evaluated on a different and often broader set of outcomes (e.g., reduction of crime, reincarceration, reduction of family violence, reduction of Medicaid claims, etc.). If research is to be able to inform clinical practice, there should be efforts made to agree upon and adopt common expectations and measures.

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