Solutions to a Public Health Problem

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February 20, 2001 10:42 Annual Reviews AR124-15

Annu. Rev. Public Health 2001. 22:249–72Copyright c© 2001 by Annual Reviews. All rights reserved

INNOVATIONS IN TREATMENT FOR DRUG ABUSE:Solutions to a Public Health Problem

Jody L Sindelar1 and David A Fiellin21Yale University School of Public Health, New Haven, Connecticut 06520;e-mail: [email protected] University School of Medicine, New Haven, Connecticut 06520;e-mail: [email protected]

Key Words treatment of illicit drug use

■ Abstract Illicit drug use is an important public health problem with broad socialcosts. The low effectiveness of prevention efforts leaves treatment of drug dependenceas one of the most powerful means of fighting illicit drug use. Treatment reduces druguse and crime and increases individuals’ functioning. However, programs that treat drugdependence have high dropout rates and low completion rates. In addition, some indi-viduals continue to use drugs while in treatment, and relapse is common. Furthermore,only a fraction of those who need treatment receive it. Recently, there have been im-portant innovations that reduce barriers and increase effectiveness of treatment. Theseinnovations include new pharmacological agents, novel counseling strategies, promis-ing ways to motivate, and treatment in new settings. This paper describes standardtreatments and recent innovations designed to increase (a) effectiveness of treatment,(b) motivation to seek care, (c) access, (d) retention, and (e) cost-effectiveness. We pro-vide criteria on how these innovations should be evaluated in order to determine whichshould be adopted, funded, and transferred to existing and future treatment programs.

INTRODUCTION

Use of illicit drugs and, in particular, dependence on drugs are important publichealth problems. Drug use harms society by reducing user’s physical and mentalhealth and productivity, by reducing family and social functioning and by increas-ing crime. Illicit drug use contributes to the spread of contagious diseases, includ-ing HIV/AIDS, hepatitis B and C, and tuberculosis. Furthermore, illicit drug usecontributes to the disintegration of families and of inner city communities and hasresulted in a huge growth in the prison population, especially of African-Americanmales (83).

Popular prevention programs such as DARE are ineffective (61). High ratesof incarceration based on drug-related crimes have not had a major impact ondrug use (94, 95). Thus, treatment may be the most powerful means of fighting

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250 SINDELAR ¥ FIELLIN

the ills of illicit drugs usage. Treatment reduces costs to society and, in terms ofsocietal costs averted, largely in savings from the criminal justice system, evenpays for itself (34). Despite this, only a small percentage of those who use illicitdrugs receive treatment (46). This treatment gap occurs because of low motivationto seek treatment and limited funding. Limited funding may occur both becauseof negative attitudes about inner city illicit drug users and because of skepticismabout the effectiveness of treatment as a cure. Although drug abuse treatment canreduce drug use and crime and increase social functioning (5), it is not a cure. Inaddition, drug treatment programs have been plagued by poor retention and highrelapse.

This paper discusses recent advances in pharmacotherapy and psychosocialtreatments that are designed to increase motivation to seek treatment, access totreatment, retention of those being treated, and effectiveness of treatment pro-grams. We first discuss the three types of standard care: methadone maintenance,outpatient counseling-based treatment, and therapeutic communities. We then dis-cuss innovations in (a) pharmacotherapy (buprenorphine), (b) treatment settings(methadone in physicians’ offices and treatment in prison), (c) new maintenancetherapies for treatment refractory heroin users (heroin maintenance), (d) promis-ing incentives to seek care (treatment as an alternative to prison), (e) providinggreater incentives to reduce illicit drug use through novel counseling methods(contingency management), and (f ) targeting treatment to those who impose thegreatest costs on society (the incarcerated).

BACKGROUND

Use of illicit drugs is of critical concern to citizens, parents, and policy makers. It isa major public health concern. Roughly 56% of the US population reports that drugabuse is one of the most serious domestic problems (94). Approximately 6% of theUS population older than 12 years old, roughly 14 million people, self-reporteduse of illicit drugs in a single month in 1997 (94).

In 1996, about 9 million people, over half of them opioid dependent, wereestimated to need treatment for drug use. Of these, only 37% received treat-ment (80), mostly for cocaine (38%), heroin (25%), and marijuana (19%) use(75). Of 800,000 heroin-dependent individuals, only 180,000 were able to accesstreatment in narcotic treatment programs with medications such as methadone(80). This treatment gap likely occurs for multiple reasons, including lack of ge-ographic access to appropriate care, cost of care, lack of insurance, lack of desirefor treatment, skepticism about the effectiveness of treatment, and stigma attachedto treatment.

Treatment could reduce costs to society and enhance the overall functioning ofindividuals and families. Substance abuse increases morbidity and mortality, re-duces overall mental and physical health, engenders use of medical resources, leadsto missed opportunities in life, disrupts neighborhoods, and reduces productivity.

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INNOVATIVE DRUG ABUSE TREATMENTS 251

Even those who are not drug users are affected. Externalities include drug-relatedcrimes, spread of contagious diseases, and the risk of adolescents’ use of drugs(40, 46). Illicit drug use is responsible for over 25,000 deaths annually. In 1992,total costs, including health care expenditures, lost productivity, crime-associatedcosts, and other factors, were estimated to be 97 billion dollars (39). The category“lost productivity,” the largest at 69 billion dollars, includes the value of time lostdue to premature death, institutionalization, incarceration, and victimization bycrime. Crime-related cost is the second biggest cost category, at almost 18 bil-lion dollars. Health care expenses constitute the third major category, which isestimated to cost society about 10 billion dollars (39).

There are also many hard-to-quantify costs that do not get measured in cost-of-illness studies. These include reduced self-esteem of drug users, disruption offamilies, poor parenting, abandoned children, fear in the general population ofdrugs and drug-related crime, and disrupted neighborhoods. There are a few equallydifficult to measure potential benefits of illicit drug use, e.g. brief euphoria andrelief from physical or psychic pain.

The important negative externalities make paying for substance abuse treatmentan important role for the government. The federal, state, and local governmentspay for most of drug treatment. In 1998, the Uniform Facility Data Set (111)reported that 70% of all treatment at substance abuse facilities was paid for bythe government. Even though the government is by far the largest overall payer,Medicare and Medicaid offered relatively little in treatment coverage. Medicarepaid only 3% and Medicaid paid just over 16%. A large portion of the treatmentsis funded by federal block grants to states; states then allocate these funds tolocal levels, where the care is provided. Roughly 11% comes from patient fees, andprivate health insurance pays for only 15% (111).

STANDARD TREATMENT MODALITIES

We describe three drug treatment modalities that in the United States have becomekey: methadone maintenance; outpatient counseling-based care, which is the mostcommon; and therapeutic communities. We do not consider detoxification or in-patient care. Detoxification is not a stand-alone treatment, and because of fundingcuts, managed care, and studies that suggest that it is not as cost-effective as out-patient care, inpatient care has become much less prevalent than in the past (6).

Methadone Maintenance and Other Pharmacotherapies

Methadone Maintenance The publication in the late 1960s of a set of influentialarticles by Dole & Nyswander (23, 24) brought about an expansion in methadonemaintenance programs. Methadone, a synthetic narcotic analgesic, is an effec-tive treatment for heroin and other opiates (5). It prevents opioid withdrawal(e.g. muscle cramping, abdominal pain, irritability, and agitation) and blocks the

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high of heroin. Used on a maintenance basis, methadone produces neither euphorianor sedation, allowing the individual to proceed to live a productive life. Patientstypically obtain their oral medication at a clinic on a daily basis; successful patientsmay earn the right to obtain take-home dosages.

Methadone maintenance has been one of the most studied modalities of treat-ment for drug dependence (20, 21). Evaluations repeatedly demonstrate that despitedifficulties with retention and relapse, methadone maintenance results in reductionin crime and drug use for those in treatment (5, 17, 18, 78). Studies show that higherdoses of methadone (e.g. 60–100 mg) are more effective in reducing illicit druguse than are lower dosages (e.g. 20–40 mg) (106, 108). Higher levels of adjuvantpsychosocial counseling also produce improved treatment retention and decreasedillicit drug use (66, 68).

The use of prescribed opiates to treat opiate dependence has engendered somecontroversy. In response, federal and state governments have strictly regulatedmethadone maintenance to ensure quality care and to limit the diversion of metha-done to non-medical uses of opioid agonist medications (5, 18, 91, 112). Currentfederal regulations result from legislative efforts, such as the Harrison Act of 1914and the Narcotic Addict Treatment Act of 1974. These regulations detail licens-ing requirements and specify staffing obligations, frequency of program contact,duration of treatment, frequency of urine toxicology testing, and frequency ofcounseling.

In the United States, methadone maintenance is delivered through approxi-mately 900 narcotic treatment programs. These dedicated narcotic clinics can re-duce the per-treatment administrative costs of providing methadone and adheringto the regulations. They have developed primarily in inner city locations, makingit difficult, if not impossible, for geographically distant users to benefit from them.Clinics are typically supported by government block grants and primarily servethe indigent. Some clinics have substantial waiting lists, but the number of slotscannot be quickly increased to respond to the need in part because of federal andstate regulations. In some states, even an existing facility may need approval of a“certificate of need” to expand.

Other PharmacotherapiesLAAM. Levo-alpha acetylmethadol (LAAM) is a derivative of methadone thatwas approved by the US Food and Drug Administration for maintenance treatmentin 1993. Because it is a long-acting medication, LAAM can be used on a thrice-weekly schedule from the outset of treatment. The relatively fewer clinic visitsoffer the possibility of decreased clinic costs compared with methadone, whichmust be provided on a daily basis for the first 2 years of treatment. However,new regulatory processes, clinic acceptance, and insurance reimbursement haverestricted the use of LAAM (90), despite its effectiveness, which is similar tomethadone (57, 58).

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Naltrexone. Naltrexone is a fast-acting (good oral bioavailability), long-actingopioid antagonist that is safe and effective for treatment of opioid dependence.Naltrexone blocks the euphoric effect of opioids. The major disadvantage of nal-trexone is that individuals must be off opioids at least a week prior to use. Opioidssuch as heroin in an individual’s system precipitate an immediate withdrawal syn-drome, such as nausea, sweating, and muscle aches with the use of naltrexone.Thus, naltrexone, which has demonstrated short-term (4 weeks) retention ratesof less than 40%, is appropriate for only highly motivated individuals (36). Mostheroin addicts on methadone still take some heroin and therefore are not candi-dates for naltrexone. Furthermore, in routine clinical care, naltrexone maintenanceresults in large dropout rates (36). Thus, despite the fact that naltrexone has de-sirable pharmacological properties (71), it has not gained widespread acceptance.A new “depot” version of naltrexone is being developed that will have a 30-dayimpact from a single dosage (16). This development may lead to more widespreadusage, possibly in the criminal justice system.

Issues to Address in Pharmacotherapies.Despite the clinical effectiveness ofmethadone and LAAM, many heroin users still do not get treatment and otherssuffer from low retention in programs and from high relapse (5, 79). There aremany potential reasons for the limited use, e.g. stigma, location, funding, andmotivation. Several major national reports have suggested that a restructuring ofthe regulatory process may help to expand access (74, 82, 91). Problems may alsobe addressed by new medications to increase effectiveness and utilization.

Outpatient Counseling-Based Treatment

Description Outpatient counseling programs, the most common method of treat-ing drug abuse and dependence, range from professional psychotherapy to peercounseling and 12-step meetings. In fact, counseling strategies (e.g. 12-step faci-litation) that are designed to be supplemented by attendance at such self-helpgroups as Narcotics Anonymous and Alcoholics Anonymous are among the moreprevalent. Counseling can occur in individual, family, or group sessions. Theseprograms are heterogeneous in length of stay, philosophy, training of staff, degreeof professionalism, funding, clientele, and other characteristics. Programs mayvary from a few sessions to many weeks. Even more variation is introduced bypatient adherence to scheduled sessions and retention. Thus it can be hard togeneralize about the effectiveness of the programs.

Some programs are abstinence based and their philosophy rejects the use ofany pharmacological treatments. Other programs are primarily counseling basedbut supplement with pharmacotherapy as needed. Counseling programs can bebased in psychology, social work, the 12-step creed, or other approaches. The12-step or Minnesota Model (Hazelden program) is a well-known and commonlyused abstinence-based program. Treatment begins with detoxification and proceeds

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through several of the 12 steps. Attendance can range from one to two sessionsper week for 7–12 weeks to “90 meetings in 90 days.”

There has been some interest in matching treatments to patient needs to increasethe effectiveness of treatment. The results have been mixed (21, 67, 70, 88). In thefield of alcohol research, Project MATCH tested the hypothesis that matching pa-tients according to certain characteristics, such as gender, motivation, psychiatricdisorder, and severity, to specific treatment modalities, such as cognitive behavioraltherapy, motivational enhancement therapy, or 12-step facilitation, can lead to im-proved outcomes. The results of this large-scale clinical trial demonstrated similarpatient outcomes with all three treatment modalities irrespective of baseline clini-cal variables, indicating that treatment matching may not be very productive (88).

One advantage of counseling programs is that they can be suitable for treatinga variety of drugs individually or jointly. Statistics show that most patients inoutpatient drug counseling programs are not opiate users. They more typicallyare abusers who are not dependent nor are involved with the criminal justicesystem (33). Thus, this population comprises a different group of drug abuserthan those in methadone maintenance or other treatment modalities. Success ratesacross treatment modalities should be interpreted with these severity differences inmind.

Issues to Address in Outpatient CounselingEffectiveness of treatment is thou-ght to be a function of retention in treatment. However, many patients drop out priorto the prescribed length of stay in treatment. Thus, both retention and effectivenessare problems with outpatient treatment. New methods are being developed tomotivate individuals to seek and remain in care.

Therapeutic Community

Description Therapeutic communities (TC) are often long-term residential pro-grams that emphasize socialization, lifestyle, and behavioral change. TCs do notuse pharmacologic treatment. Typically, those in a TC have tried other treatmentmodalities and have failed. The TC is an intensive, highly structured residen-tial, communal treatment that operates according to a somewhat distinct, but notcodified, philosophy. The philosophy is aimed toward self-help and a structuredreward system and has a reality-based approach. The person is considered theproblem, not the drug per se. Those in TCs usually have major personality prob-lems, have little education, have poor interpersonal skills, are socially maladjusted,and have little in the way of employment experience or marketable skills. Groupmeetings, psychological counseling, and reality-oriented group sessions are usedto reduce negative thinking and promote prosocial behavior (22). A reward andpunishment system also promotes responsibility and prosocial behavior. Patientsin recovery initiated the first TCs and currently the majority of the staff are “gra-duates” of a TC. Most programs supplement this staff with professionals, such aspsychologists.

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Those in treatment live in a communal, largely self-sufficient setting and mustfollow prescribed and proscribed rules of behavior with sanctions for transgres-sions. Goals of treatment are not only the reduction of drug use but also the adoptionof more socially acceptable norms and behaviors. Anticipated lengths of stay canrange from 4 months to 2 years, with gradual reentry into regular life. However,patients frequently drop out prior to a year and relapse is high. One study of multi-ple facilities indicated that retention at 3 months ranged from 21% to 65%, with amedian length of stay of 3 months (46). Effectiveness increases with length of stay,as is typical of most treatment modalities. Drug use in TCs is reduced for thosewho stay in treatment the recommended length of stay, e.g. a reduction in weeklyheroin use from 17% at baseline to 6% at 1-year follow-up (46). However, many ofthe studies of effectiveness have been flawed by the fact that they compared thosewho “graduate” (e.g. stay in the program for say a year) with those who drop out(46).

Issues to Address with TCsParticipation in a TC can be difficult. The dropoutrate is high because it is a tough, long program. Furthermore, relatively few of thoseappropriate for this type of care are motivated to enter. Thus, although those whocomplete the program have demonstrated success, few enter and many dropout.One relatively new development is the growth of TCs in prison. The provision ofTCs and other types of treatment in prison is discussed below.

INNOVATIONS

We discuss some the recent innovations in treatment that are designed to increaseeffectiveness, including new pharmacological (buprenorphine and cocaine vac-cine) agents, psychosocial approaches (contingency management), and heroinmaintenance for refractory individuals. In addition, we discuss new settings, suchas methadone in a primary care physician’s office and treatment in prison, thatincrease access to care. Other innovations, such as treatment in lieu of prison, mayincrease motivation to seek care.

Buprenorphine Maintenance

Buprenorphine is a pharmacotherapy for the treatment of opioid dependence thatis currently pending approval by the Food and Drug Administration. Comparedwith methadone, LAAM, and naltrexone, it has several unique properties. It hasshown an effectiveness similar to (9, 59, 60, 107), more effective than (51), orslightly less effective than (54) methadone in treating those dependent on heroin.Like methadone, it has opioid agonist properties, which means it will block thehigh of heroin, thus reducing the desire to take it. Unlike methadone, however,buprenorphine is a partial (not complete) agonist and has a relatively low ceiling

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effect, which means that increasing dosages do not increase euphoria and do notcause respiratory depression (52). This reduces the potential for overdose withbuprenorphine.

Buprenorphine is taken orally in a sublingual tablet. In the United States, itis being combined with naloxone in a single tablet so that if individuals try todissolve the tablet and inject it, they will precipitate opioid withdrawal. Thus,there is less of a risk of diversion of buprenorphine/naloxone for abuse or sale.Another advantage of buprenorphine over methadone is its longer duration ofaction. This property allows patients to come to a clinic less frequently, perhapsthree times per week, which saves both patients’ time (e.g. less travel and waittime) and program expenses.

A key potential advantage of buprenorphine over methadone is the possibility ofmore-lenient federal and state regulations compared with methadone. The more-lenient regulations for the combination tablet would result from the reduced likeli-hood of diversion and potential for overdose. The increased safety makes it likelythat the combination medication will be approved as a controlled substance withoutrequiring special Drug Enforcement Agency registration. Therefore, buprenor-phine/naloxone could be available from physician offices, and providers wouldnot have the licensing, staffing, and other restrictions required for dispensingmethadone.

More-lenient regulation (including provision in a primary care setting) com-bined with less frequent administration could greatly increase access. One studyhas already indicated that buprenorphine is cost-effective in reducing the spreadof HIV (115). Buprenorphine has gained relatively widespread use in France totreat opioid dependence but is not yet available in the United States. Pricing hasnot been established but may be a determining factor in adoption of this treatmentbecause the primary alternative medication, methadone, only costs about $0.50–$0.80 per dosage.

Cocaine Vaccine

Cocaine dependence has been difficult to treat. Prior attempts using dopamineagonist medication (e.g. bromocriptine and amantadine), antidepressants (e.g. de-sipramine), and serotonin reuptake inhibitors have not had the same success againstcocaine as methadone has for heroin (5) or naltrexone for alcohol (83). Currentlyunder development is a vaccine that would block the neurotoxicity and reinforcingproperties of cocaine. The fundamental principle is the use of a vaccine to createantibodies against the cocaine molecule that would bind cocaine in the blood-stream. Early development has been promising, but there are concerns about theduration of efficacy and tolerance to repeated administration.

Methadone Maintenance in Physician’s Offices

Methadone and LAAM are currently restricted to use in narcotic treatment pro-grams. Provision of treatment in a physician’s office would expand access and have

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appeal for some drug users who are not in treatment. Interest in using physicians’offices as sites for coordinating methadone services (a concept often referred toas medical maintenance) has been growing because of the need to (a) expand ac-cess, (b) allocate the counseling resources of traditional drug treatment programsto those who need them most, (c) provide treatment in a setting with less stigma,and (d) limit contact of patients with those who are actively using drugs and,thus, may impede the success of treatment. Federal agencies, such as the Officeof National Drug Policy (82), support expansion of physician office–based treat-ment. A recent survey found that 30 state methadone authorities favored off-sitephysician linkages with methadone programs (84). Two published studies havereported successful medical maintenance programs in which stabilized (e.g. noevidence of active drug use for 1 or more years) methadone-maintained patientswere transferred from care in narcotic treatment programs to medical maintenancesettings (76, 77, 96). These programs have reported retention rates of 73%–85%for up to 3 years in some patients (77, 96). These favorable statistics suggest thatmedical maintenance programs may be used to expand access to methadone main-tenance and reduce overcrowding in narcotic treatment programs. The provision oftreatment in a primary care setting may draw new patients into treatment, expandaccess, and reduce overcrowding.

Several important decisions must be made about treatment in a primary care set-ting. These include the following: Should only stabilized clients be treated in thissetting; should stability in treatment be the sole criterion; should the physician’soffice have a base clinic; what is the acceptable level of professional trainingof providers; and how should such a relationship be organized? A key issue iswhether medication dispensing should occur at the physician’s office or at thepharmacy; the pharmacy offers longer hours but does not offer clinical backup.Insurance coverage and reimbursement rates will affect the success of theseendeavors.

Pilot medical maintenance programs are under way or have recently beencompleted in Connecticut, Maryland, New York, and Washington. Results fromthese studies may provide evidence to determine the effectiveness, the impacton access, and the cost-effectiveness of methadone maintenance in physicians’offices.

Heroin Maintenance

Some heroin users, especially those with severe and refractory comorbid psychi-atric disease, are unable to benefit from methadone maintenance (11). This ledthe Swiss government, in 1994, to conduct trials of heroin maintenance in citiesthroughout Switzerland. The goal was to determine whether heroin, morphine,or injectable methadone could reduce dependency, disease, and crime (110). Themore than 1000 participants were those who had tried alternative treatment ap-proaches on several different occasions without success. They were followed overthe course of 2 years. The studies, carried out in outpatient clinics and one penal

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institution, were either double blind, randomized, or based upon the clinician’s dis-cretion. The use of injectable heroin, rather than the other opiate substitutes, provedto be more effective in recruiting, retaining, and fostering compliance among thestudy participants.

One trial demonstrated improvements in participants’ physical and mentalhealth and social functioning and decreases in the use of illicit heroin, cocaine,homelessness, income from illegal and semi-legal activities, and criminal activity(110). For instance, the proportion of those with permanent, gainful employmentincreased from 14% to 32%, whereas the proportion of those unemployed fell from44% to 20%. However, use of other substances, such as alcohol, cannabis, andbenzodiazepines, remained relatively constant.

Although this study was fairly large, it did not have a control group. Anotherstudy was smaller but had a control group (85). This study also found significantbenefits to heroin maintenance. There were significant improvements in the ex-perimental group relative to the control group in physical health, drug expenses,crime committed, and social functioning. There were, however, no gains in work,housing situation, and use of other drugs.

There are several concerns regarding a heroin maintenance program. One isdiversion of clinical supplies of heroin to an illicit market. Another is neighborhooddisturbances due to clientele of the clinics and overdosing among participants dueto their use of other drugs. Despite these concerns, analysis of the outpatienttreatment programs suggests a net benefit of $30 per patient per day due largely tosavings in criminal investigations, prison terms, and improvements in participants’health (110). Netherlands has also begun similar initiatives, with a focus on addictswho have had several prior failed treatment attempts or have poor physical, mental,or social health status (110).

Contingency Management

Contingency management (CM) is a relatively new method of research-basedtreatments for substance abuse and dependence (10, 41–45, 93, 97, 104, 105). It hasbeen used successfully to treat alcohol dependence, and it is particularly important,as it has been successful in treating dependence on cocaine whereas other methodshave not. A central tenet of CM is abstinence from illicit drugs. CM uses anescalating reward system so that violations are punished both by denying theimmediate reward and taking away the benefits of an escalated payment. CM hasbeen implemented with several different types of rewards including monetary andvouchers.

CM using vouchers as the reward would be conducted as follows. Cocaine-dependent individuals who are in treatment would typically receive drug abusecounseling. In addition, with CM, they are tested frequently for drug use. If theirurine tests for drug use are “clean,” i.e. no evidence of drug use via the test,then they are given a “reward,” i.e. a voucher. Attention is paid to the prosocialnature of the voucher or reward, as there is a desire to steer clients toward socially

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beneficial activities (such as developing vocational skills, seeking employment,developing social support system of non–drug users, etc) (86). The vouchers mightbe for bus tokens, food, or sporting goods. If the first test is negative (e.g. nodrug use), then each subsequent drug-free test results in an escalating payment invouchers. If the urine test detects drug use, the payment schedule is set back tozero.

CM has been shown to be effective in reducing drug use during the treatmentperiod, but there are several disadvantages. Payments in a voucher system canbe relatively high. Between the monetary and the administrative costs (e.g. drugdesign and running the program), CM can become an expensive treatment method.Each client can earn up to $1000 and the average payment in some trials has been$600 (10, 41–43, 100). Another potential problem with CM is the politics of givingdrug abusers payments for being clean, which is not palatable when the typicalindividual in the United States is drug free and receives no payment.

The so-called fish bowl technique was designed to reduce the overall cost of CM(87). In the fish bowl technique, clients who test drug free are rewarded with theopportunity to select a piece of paper from the fish bowl. On most papers is writtena prize. Although some have no prize, the majority have small prizes (e.g. bustokens, food items), a smaller percentage has midrange prizes (e.g. electronics),and a few have larger prizes (e.g. hand held televisions). The treatment program canvary the percentages of no, small, and larger prizes, thereby affecting the overallcost. All prizes are to be compatible with a drug-free lifestyle. The clients makesuggestions as to what prizes will motivate them and others. The pecuniary costof running such a fish bowl can vary, as does the expected payment to drug-freeclients. It is interesting that although one study suggested giving the same expectedpayments to clients, the escalating payment system was more effective in reducingdrug use.

CM has been shown to be effective in reducing drug use and increasing re-tention in treatment programs. A weakness of CM programs as they have beenimplemented is that rewards have been based on abstaining from only the drugthat is the focus of the program. Thus, if the program is designed to reduce co-caine use, then a drug test revealing no use of cocaine is rewarded, even if otherdrugs have been used. Another concern is that when the program is completedand the reward structure disappears, individuals may revert to their old drug usepatterns.

CM has been studied in multiple clinical trials and found to be effective. How-ever, it has yet to be used in a community setting. A current national multiple site“research to practice” effort funded by the National Institute on Drug Addiction isbeing initiated to determine the feasibility of use in a community setting. An advan-tage of CM is that it can be added to any type of treatment modality, e.g. counseling,TC, or methadone. Because it can increase retention, it may help the overall effec-tiveness of the initial modality in reducing drugs. The cost-effectiveness of addingCM to existing programs has not been evaluated. It may enhance effectiveness,but is the extra expense worth it?

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Alternative Sanctions Used by the Criminal Justice System

The increasing number of individuals arrested on drug-related charges has over-crowded existing prison facilities and prompted expenditures to build new prisons.The overcrowding and toll on government revenues has spurred a search for moreeffective and cost-effective alternatives. “Alternative sanctions” have been growingin type and number. Drug courts are a rapidly growing response to these problems.The first drug court started in 1989, and by 1996 there were 140 drug courts na-tionally (8). Drug courts provide an opportunity for those arrested primarily fordrug possession to receive a court-supervised alternative to prison. Usually onlynonviolent offenders are eligible because public safety is a key concern. The al-ternative usually involves attending an outpatient drug treatment program, weeklymeetings with the court, and testing for drug use. Graduated sanctions are usedfor infractions of the protocol for behavior set by the courts, and the threat ofincarceration as the ultimate sanction is real. These programs have been viewed assuccessful in reducing overcrowding of prisons, reducing government expenditure,and helping drug-dependent individuals seek treatment and avoid all the disrup-tions and negatives aspects of prison. Early analyses of drug courts suggest thatthey increase retention in treatment and substantially reduce drug use and crimeduring participation. There is some evidence that longer-term outcomes, such asreduced recidivism to crime, are also improved; however, extant studies have somedesign flaws and are suggestive but not conclusive (8).

The motivation to seek treatment and remain in treatment is strong because itis court mandated, there is judicial follow-up on attendance, and the alternative isprison. Thus, drug courts represent one method of getting individuals who needtreatment into appropriate programs and of keeping retention high. Retention in atreatment program has been found to increase the success of the individual. Pre-viously, it was thought that individuals had to be self-motivated to seek treatmentor it would not be as effective. Studies have shown that retention in a program isimportant even if the motivation to stay in care is compulsory and comes from thecriminal justice system.

In addition to drug courts, there are other alternative sanction programs. Theseprograms tend to have the same fundamental approach of using the real threat ofprison to motivate people to seek treatment for their drug problems and of moni-toring the individual for compliance. For instance, there are “coerced abstinence”programs that allow early release of some drug-abusing, nonviolent prisoners to aprobation program that frequently tests for drug abuse. Although treatment is nottypically mandated in these programs, abstinence is and individuals may be morehighly motivated to seek treatment to comply with their parole. Enrollment in aTC instead of prisons is used for selected, nonviolent, drug-addicted prisoners.

Thus, the criminal justice system can be used to motivate drug-abusing felonsto seek treatment. Furthermore, evidence supports the effectiveness of compulsorytreatment. There are no formal economic studies of the alternative sanctions as op-posed to incarceration, and thus statements about relative cost-effectiveness cannot

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be made. However, there is promise that this route will be both effective and cost-effective.

Treatment in Prison

Treatment in state and federal prisons as well as discharge and post-dischargetreatment planning are being increasingly viewed as an “innovation” in treat-ment. Treatment in prison has occurred in the past (56), but growth in the numberof those in the prison population who have drug-addiction problems has sparkedrenewed interest in drug treatments in prisons. Most prison inmates are seri-ously involved with drugs and alcohol, even while in prison. About 80% of the1.4 million people in jail or prison in 1996 (a) were involved with alcohol ordrugs through possession of drugs, (b) were under the influence at the time oftheir crime, (c) stole to support a drug habit, or (d) had a history of drug andalcohol addiction (15). The increasing number of individuals in prison for drugpossession has contributed to the large percentage of the prison population with adrug problem. Thus, the prison and jail populations may be helped by treatmentfor drug dependence and abuse. Treatment in prison may provide an effective andpossibly cost-effective intervention (49, 63). Despite the apparent need for treat-ment, only 10%–20% of state and federal prisoners were receiving treatment whileincarcerated (19).

Historically, prison was seen as an opportunity for rehabilitation. More recently,incarceration has been viewed as a way to stop crime through captivity and de-terrence. There are relatively few treatment programs in prison. The Rikers Islandmethadone maintenance program is one of the few prison methadone programs. Itis offered only to those who will be in prison less than a year or to those who aresoon to be released. There is a concern about security issues of storing methadonein the prison, but use of methadone has been thought to make the prisoners lessdisruptive and less likely to return to prison. Although Rikers has been viewed asa successful program, it is not being replicated in many prisons. The reasons mayinclude the security risk and the desire to be tough on crime.

Therapeutic communities have had a growing presence in prisons (50). Prisondrug treatment programs have been found to reduce reincarceration, and prelim-inary evidence suggests that they are cost-effective (114). The effectiveness ofthese residential programs is enhanced by additional social services, such as aid inobtaining housing and assisting with establishing a treatment program on releasefrom jail. Delaware is significantly expanding its offering of TCs in dedicatedprison units and also expanding transitional programs to halfway houses.

Several programs offering treatment in prison have been developed and evalu-ated (81). Breaking the Cycle is a research demonstration effort to test the effec-tiveness of a state-wide criminal justice intervention for drug-addicted offendersand involving judicial supervision, drug treatment, graduated sanctions, and drugtesting. Stay’n Out, started in 1977 by recovered addicts, is a prison-based thera-peutic community that serves as national model for prison-based TC. KEEP is an

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in-jail methadone maintenance program designed to foster transition to communitymethadone maintenance when released (62).

Debates about treatment in prison remain. One debate is whether treatmentshould occur just prior to release or at the entrance to prison. Another is whetherpharmacotherapies should be used or whether to rely on drug-free counseling andTCs, where there is less of a security risk due to medication being on site.

ARE TREATMENTS EFFECTIVE?

Some of these innovations in treatment will likely flourish by obtaining accep-tance and substantial funding, whereas others may not. In part, their acceptanceand funding will be based on findings from studies that evaluate the innovations’effectiveness and cost-effectiveness. However, there is conflict even as to whatcriteria to use in evaluating outcomes. The extant literature and policy debateshighlight some of the conflict. Standard substance abuse treatments have beenconsidered to be very successful, and at the same time their effectiveness has beenquestioned. At least part of this conflict may be due to the fact that there aremultiple outcomes from treatment and that these outcomes are valued differently,depending on one’s perspective.

On the negative side, there are many dropouts from programs and even thosein the programs may continue to use drugs. Sometimes the specific drug beingtargeted gets eliminated or reduced, but other drugs may continue to be used,e.g. if a person is being treated and tested for heroin, he/she may still be us-ing cocaine. Furthermore, ongoing but reduced drug use can occur. In addition,some individuals often reenter treatment and receive several rounds of treat-ment because substance abuse is a chronic and relapsing condition. Thus, oneview of treatment is that the overall “cure rate” is low and that long-term absti-nence is not typical. This is a viewpoint that plagues support for substance abusetreatment.

However, by other perspectives, treatment can be seen as quite successful andon par in effectiveness with other chronic medical conditions. Treatment reducesdrug use, reduces crime, enhances employment opportunities, and pays for itself insavings (34, 48, 101). Furthermore, if drug reduction not abstinence is the goal, thentreatment can be viewed as successful. Harm reduction may be another criteria; ifdrugs are being used in safer ways, then the spread of AIDS, for example, may bemitigated.

How outcomes are evaluated and the relative preference for different outcomeshas implications for funding of treatment. For example, if reduced crime is theprimary goal, then the recent increase in incarceration of drug users may be seenas an effective approach. If, on the other hand, disintegration of communities or re-habilitation of parents are top priorities, then this trend toward incarceration wouldbe alarming. If cost-effective approaches to reducing crime are of paramount im-portance, then alternative sanctions specifying treatment as a condition of staying

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out of jail may be the top choice. If long-term abstinence is considered to be theonly legitimate goal, then government funding for treatment could be jeopardized,as treatment may seem ineffective. If, on the other hand, reduced drug use, im-provements in individual functioning, reduced crime, and savings are the primarygoals, then treatment may be able to attract even greater funding.

Society may be more concerned about drug use mainly as it affects externali-ties, such as crime, and government expenditures, such as welfare programs andcriminal justice expenses. Some portion of society cares about the welfare of drugabusers. Many care about the many ways in which they and their families suffer.There is little survey data on what drug-dependent individuals seek in terms ofoutcomes from treatment. It is reasonable to suppose that those in treatment careabout all the outcomes that directly pertain to themselves, e.g. reduced drug use,better family functioning, and better mental health (100). However, drug usersmay sometimes want to continue to use drugs but not suffer some of the associatedharms and pains, such as withdrawal, e.g. they could be happy with relatively lowlevels of methadone that keep them from withdrawal while allowing them to enjoythe euphoria from other opioids.

Assessments of current treatments and innovations must be based on appro-priate and carefully developed and implemented criteria. Public policy decisionsshould be made based on the many social costs and benefits of treatments. Mul-tiple outcomes and differing perspectives of the relevant importance of outcomesare important issues to contend with in evaluating the success of treatments andinnovations (13, 71, 102). The answer to the question of to what extent is drugtreatment effective depends on whose perspective is used and, thus, the factorsconsidered and how they are measured.

ARE TREATMENTS COST-BENEFICIALAND COST-EFFECTIVE?

There is increased interest in the degree to which drug abuse treatment is not onlyeffective but cost-effective or cost-beneficial. The focus on economic evaluationsreflects an interest in the question of whether society is getting its moneys’ worthfrom treatment. New treatment methods will likely have to meet the standard ofcost-effectiveness analysis in order to gain acceptance. There are several forms ofeconomic analysis of substance abuse treatment, each taking a different vantagepoint on outcomes. These are discussed below. Much of the focus of the discussionbelow is on outcomes; however, measurement of costs is also a critical area in whichadvances have been made (2, 22, 23, 26).

Cost Offset

Cost offset takes a fairly narrow range of outcomes: It includes only those thatcan readily be measured in pecuniary terms. It asks, does treatment pay for itself

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in terms of society’s resources saved? These studies take society’s perspective.They tend to focus on (a) government and other well-defined expenditures ascosts and (b) relatively easy-to-quantify but sometimes difficult-to-attribute out-comes, e.g. reduced crime, medical expenses averted, and lives saved by drugtreatment. The line of literature is sparse as applied to substance abuse, and thestudies suffer from a variety of methodological problems (92). However, inter-pretation of findings may be an even greater problem. If treatments are found topay for themselves, there still may be better uses of scarce funds. Furthermore,this does not necessarily mean that the government will actually save money,only that there are benefits that accrue to parts of society that offset treatmentcosts. On the other hand, even if the measured expenses do not offset the costs,treatment may be socially desirable when considering the omitted, unmeasuredbenefits.

An often-quoted number is that for every dollar spent on drug treatment, so-ciety saves seven dollars (33). Despite potential methodological problems, theconclusion that treatment costs are fully offset by benefits to society is borne outin other studies (32). One early and interesting study took advantage of a naturalexperiment offered by the closing of a methadone maintenance program in an iso-lated region of California, leaving patients without treatment (3, 65). Savings fromclosing the program were nearly offset by the additional expenses in the criminaljustice system and other government expenditures (109).

CEA

Most economic evaluations of drug treatment use cost-effectiveness analysis(CEA). Such CEAs have addressed the question of what is the most cost-effectivemethod or level of services of treating drug-dependent individuals (98, 99). Com-parisons across treatment modalities is difficult; thus, many of the studies havecompared some form of “standard” versus “enhanced” care within a single treat-ment modality (for reviews of CEA and cost-benefit analysis in substance abusetreatment, see 14, 29). For example, Alterman et al (1) analyzed both the costs andthe outcomes of inpatient versus day hospital treatment for cocaine dependence.They found that outcomes were similar across the two groups but that the costs ofday hospitalization were substantially higher. Kraft et al (55) examined the cost-effectiveness of three different levels of provision of counseling in a methadonemaintenance program. Using the criteria of reduced drug use as the outcome, theyfound that the most intensive level of counseling produced the highest level ofbenefits, but that the midlevel of counseling was the most cost-effective.

Asking a somewhat similar question, Avants et al (4) compared “standard”methadone maintenance versus that enhanced by a considerably higher level ofcounseling. They found that the standard and the enhanced levels of counselingproduced results that were insignificantly different from each other. Obviously,standard care was more cost-effective. Kraft et al found that the midlevel care

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was the most cost-effective, whereas Avants et al found that the standard care wasmore cost-effective. It is important to note, however, that what was referred to as“standard” in the Avants study was more similar to the midlevel of counseling inthe Kraft study.

An analysis of the Philadelphia Target City study reported increased effective-ness of adding a case manager and financial access to additional social servicesin both outpatient and methadone programs (69). A further study indicated thatthey were cost-effective (102). Cost surveys were also conducted on the treatmentprograms (27).

Few CEA studies have been conducted on the innovations in treatment dis-cussed above. One study, however, found that buprenorphine was a cost-effectivetreatment in preventing the spread of AIDS (P Barnett, C Zaric & M Brandeau,unpublished data). Another study analyzed the cost-effectiveness of a prison TC.Using recidivism to crime as the determining outcome (37, 38), they found thatthe TC was most cost-effective for those at high risk.

The CEA literature in substance abuse is nascent. As such, there are some areasthat deserve further development (12). One area is the measurement of outcomes.In CEAs, a single outcome is compared across alternative treatments or differentlevels of treatment (25, 35). Thus, multiple treatments are compared using a singleoutcome. In evaluating substance abuse treatment, the single outcome used tends tobe something along the lines of “days drug free.” One problem with this approachis that there are many other outcomes of concern. One might imagine that reduceddrug use would be a good predictor of the other outcomes. However, one studyhas shown that the multiple outcomes are not highly correlated with abstinence orreduced drug use (102). Thus, use of a single outcome does not capture the entireset of outcomes.

Quality adjusted life years would be a potential single outcome to use, but it, too,has several drawbacks. Because a quality adjusted life year is typically developedfrom the perspective of suffering from a disease, it does not include the importantexternalities, such as reduced crime and spread of AIDS, that are key to evaluatingsubstance abuse treatments. Society’s perspective should be taken into accountwhen evaluating ways to spend society’s resources. On the other hand, the clients’perspective would be a reasonable one to use in evaluating the effectiveness ofprograms in meeting clients needs.

CBA

In cost-benefit analysis (CBA), all the potential societal benefits (including costsaverted) should be included (47). Benefits could include all the aspects mentionedpreviously: increased employment, reduced crime, better family functioning, re-duced spread of AIDS, etc. In theory, a CBA should include all benefits and costs,including those that are difficult to quantify and value (28, 31, 89, 103, 116). ThatCBAs should include all possible costs and benefits makes it a superior method

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of evaluation in theory (53), but on a practical basis, only the more easily quan-tifiable outcomes are included. Some outcomes are relatively easy to quantifybut difficult to value, e.g. reduced crime (89), whereas others defy quantification,e.g. stabilization of a community or better parenting. The latter are typically ig-nored in evaluations, whereas there are attempts to better quantify the former (30).

Several studies have set up the conceptual framework to conduct such studies(32, 47, 89, 103, 116). Relatively few thorough CBAs of substance abuse treatmenthave been conducted based on a clinical trial of a standard treatment or an inno-vation (40). One study (63), however, analyzed three pilot projects designed todivert criminals into treatment instead of jail using a case management model.Focusing on criminal justice costs, productivity, and medical care costs, this studyconcluded that the benefits outweighed the costs. Another study conducted a CBAof the Philadelphia Target City project, finding that the benefits to treatment faroutweighed the costs (32). Yet anther study indicates that heroin maintenanceprograms are cost-beneficial (38).

CONCLUSION

Advances in treatment are likely to help drug users and society by reducing theoverall negative impacts of illicit drug use. Innovations are being designed to in-crease access to care, increase effectiveness, and provide choices of treatment.These innovations need to be evaluated not just for their ability to reduce druguse but also for their impact on the multiple outcomes that are affected. Further-more, we need to know not only whether they are effective but also whetherthey are cost-effective. Economic evaluations tend to find current drug treat-ments to be cost-effective. However, there are few studies that have calculated thecost-effectiveness of the recent innovations. Such future studies will be plaguedby the problems currently encountered in evaluating standard treatments. It is dif-ficult to measure and aggregate into common units the multiple, disparate, andsometimes hard-to-quantify outcomes, thus hindering evaluations. Furthermore,drug users, society at large, payers, and others may vary in what they consider tobe high-priority outcomes. We need additional information to know which innova-tions should be broadly accepted, fully funded, and widely spread throughout thetreatment system. Some treatments may be suitable only for a select population ofdrug users while others may merit widespread usage.

ACKNOWLEDGMENTS

We would like to thank Rebecca Dodge for her research assistance and Marie Youngfor her editorial assistance. This investigation was supported in part by NIAAAResearch Scientist Development Award (K02 AA00164) to Yale University(Dr. Sindelar) and in part by the National Institute on Drug Abuse PhysicianScientist Award (NIDA K12 DA00167) to Yale (Dr. Fiellin).

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