Informing America's Policy on Illegal Drugs What We Don't Know Keeps Hurting Us (2001) / Chapter Skim
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8 Treatment of Drug Users
8 Treatment of Drug Users
Pages 241-270
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From page 241... ...
And the Center for Substance Abuse Treatment now distributes Treatment Improvement Protocols, providing best-practice guidelines for drug abuse treatment (see http://www.treatment.org/Externals/tips.html)
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From page 242... ...
Policy makers and treatment funders need guidance as to the most cost-effective strategies or combinations of strategies. Second, a very large fraction of the most heavily involved drug users come into contact with the criminal justice system, and many are incarcerated or under the supervision of probation or parole officers.
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From page 243... ...
With these points in mind, we offer in this chapter recommendations for continuous improvement of the science of drug treatment, but also for improved estimation of drug treatment effect sizes to support cost-effectiveness and benefit-cost analyses that can inform policy makers. Both goals require increased attention to potential threats to the validity of inferences from treatment outcome studies.
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From page 244... ...
At present, there is little firm basis for estimating the benefit-cost ratio or relative cost-effectiveness of drug treatment. We begin by articulating a philosophy of constant treatment improvement through the use of successive randomized controlled clinical trials.
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From page 245... ...
CONSTANT IMPROVEMENT OF TREATMENT EFFECTIVENESS VIA A PROGRESSION OF RANDOMIZED TRIALS In modern medicine, treatments intended to benefit human subjects are evaluated in randomized controlled trials (Peso et al. 1977a, 1977b; Freidman et al., 1985; Meinert, 1986; Piantadosi, 1997; Pocock, 1996~.
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From page 246... ...
for a survey of this literature. Randomized trials are typically ethical when there is no clearly effective treatment, or when there is genuine and realistic uncertainty, reflected in a lack of scientific consensus and limited evidence, as to which of two treatments confers greater benefits with fewer harms.
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From page 247... ...
They were evaluated at a 12-month follow-up using a battery of assessment instruments, including the Addiction Severity Index and several psychiatric diagnostic instruments. Though all three groups showed improvement at follow-up, the two groups receiving professional psychotherapy showed greater improvement by various criteria.
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From page 248... ...
Both trials compared traditional drug abuse counseling to a community reinforcement approach involving spouses, friends, or relatives and employment and other counseling services, and an incentive voucher system in which participants earned retail vouchers of modest monetary value for each negative urinalysis over a 24-week period. The first trial compared traditional counseling and the community reinforcement approach + vouchers; the second compared the community reinforcement approach alone to community reinforcement approach + vouchers.
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From page 249... ...
Because they lacked randomized assignment to condition, DARP, TOPS, and DATOS could not provide rigorous evidence on the relative effectiveness or efficacy of particular drug-by-treatment combinations, or for estimating the absolute effect size, cost-effectiveness, or benefit-cost ratio of treatment. The committee recommends that priorities for the funding of treatment evaluation research should be changed; large-scale, national treatment inventory studies should not be conducted at the expense of greater funding for randomized controlled clinical trials.
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From page 250... ...
Here, we emphasize the various processes that can differentially bias selection into, or attrition out of, the treatment and control conditions of the study. When other factors are confounded with the treatment variations under study e.g., addiction severity, motivation to change, life stresses and resources it is not possible to directly estimate treatment effects by simply examining the difference between mean outcomes in each condition.
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From page 251... ...
Note that the treatment estimate from a single study may reflect biases in both directions, and the relative effect of each bias may differ across studies. Randomized clinical trials of the type illustrated in the previous section go a long way toward eliminating concerns about the biasing effects of regression to the mean, biased selection to treatment, and biased attrition.
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From page 252... ...
The cocaine-dependence treatment field would be well served by careful consideration of what additional experimental or quasi-experimental control conditions might be ethically and practically possible in future efficacy and effectiveness studies to help strengthen the validity of causal inferences and permit more precise estimates of the contribution of treatment to any changes observed. The almost complete lack of no-treatment control groups in drug treatment research is striking.
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From page 253... ...
review evidence on the effects of two methadone clinic closings a Bakersfield methadone maintenance clinic that was closed by local officials for budgetary and political reasons, and the discharge of clients from the California civil commitment program due to "relatively random legal errors." They argue that in both cases, clients who abruptly ceased treat
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Situations in which data collection is ongoing when such shocks occur are rare; we know of no examples involving cocaine treatment or modalities for heroin other than methadone maintenance. Another line of relevant evidence comes from statistical comparisons of voluntary versus coerced treatment clients.
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Finding the answer would require a control in the community randomized to no treatment whatsoever. The meta-analytic data do suggest that nonrandomized trials don't invariably inflate effect sizes.
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OPPORTUNITIES FOR RANDOMIZATION WITH NO-TREATMENT CONTROL CONDITIONS When a pharmaceutical manufacturer makes claims about the efficacy or effectiveness of a new drug product, the U.S. Food and Drug Administration advisory committees looks to the evidence from randomized controlled trials in which eligible participants have been assigned at random to different conditions (e.g., new drug regimen versus usual and customary regimen, new drug regimen versus placebo regimen)
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From page 257... ...
Situations of this type, especially those of preemployment drug testing, represent some missed opportunities for randomized controlled trials to compare drug dependence intervention strategies with no-treatment alternatives. The no-treatment alternative meets most ethical standards because current practice is to provide no treatment to these individuals, but simply to advise them that they have lost the privilege to be hired into the job for which they have applied.
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We have outlined some of the missed opportunities for randomization designs with no-treatment conditions that are created because, at present, many drug users are identified without any formal treatment response. The committee recommends greater scientific attention to nowmissed opportunities to conduct randomized trials of drug treatments with no-treatment control conditions.
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From page 259... ...
In thinking about linkages between drug treatment and criminal sanctions, it is important to distinguish between questions of effectiveness and fairness. Supporters of using the criminal justice system for therapeutic leverage typically view treatment participation offered to offenders as an ameliorative device an opportunity for mitigating the sentence that they would otherwise receive (i.e., probation with treatment is offered in lieu of incarceration, using the threat of incarceration for noncompliance)
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From page 260... ...
Yet the existing literature on probationary drug treatment fails to compare the effectiveness of linking probation to treatment conditions with other community-based criminal justice dispositions or with no intervention at all. The need for such comparisons between those on probation and a no-supervision control group becomes more relevant as the net is widened to include drug users who would not have been arrested or put on probation in previous years.
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From page 261... ...
Building on the TASC model, hundreds of jurisdictions have established drug courts (usually specialized dockets rather than separate courts) to identify drug users in the criminal justice system, refer them to treatment programs and monitor their progress (Belenko, 1998, U.S.
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From page 262... ...
While many of these studies report reductions in drug use or criminal recidivism, it is notable that neither result clearly emerged in a rigorous study using random assignment to either drug courts or standard probation (Deschenes et al., 1995~. A Proposed Example There is a clear need for more rigorous experiments on the effects of drug treatment as an alternative or adjunct to criminal justice sanctions.
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From page 263... ...
The criminal justice component of this design raises complex analytic, legal, and ethical issues above and beyond those in an ordinary treatment experiment. Based on the view that drug dependence is a chronic relapsing disorder, many experts believe that abstinence is inappropriate as a sole or primary evaluative criterion.
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From page 264... ...
In this light, the committee applauds the recent National Drug Addiction Treatment Clinical Trials Network of the National Institute on Drug Abuse that is now conducting large-scale randomized, controlled trials in average treatment programs in communities across the country. These studies should provide a more accurate picture of treatment effectiveness for the nation as a whole.
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Turner 1999 Treatment alternatives to street crime: An evaluation of five programs. Criminal Justice ~ Behavior 26:168-195.
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Gfroerer 1995 A Method for Estimating Substance Abuse Treatment Need from a National Household Survey. Paper presented at the 37th International Congress on Alcohol and Drug Dependence, August 20-25, 1995, University of California, San Diego.
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Cavanaugh 1988 The Criminal Justice Client in Drug Abuse Treatment. National Institute on Drug Abuse: Research Monograph Series 86: 57-80.
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Office of National Drug Control Policy 1998 Breaking the Cycle with Science Based Policy: Conference Proceedings, Consensus Meeting on Drug Treatment in the Criminal Justice System. Washington, DC: U.S.
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Preston 1996 Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Archives of General Psychiatry 53:409415.
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Curry 1997 Special issue: Drug Abuse Treatment Outcome Study (DATOS)
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