Drug Treatment - How Effective Is Treatment?

The first major study of drug-treatment effectiveness was the Drug Abuse Reporting Program (DARP), which studied more than forty-four thousand clients in more than fifty treatment centers from 1969 to 1973. Program staff then studied a smaller group of these clients six and twelve years after their treatment. A second important study was the Treatment Outcome Prospective Study (TOPS) taken during the 1980s. Both DARP and TOPS found major reductions in both drug abuse and criminal activity after treatment.

The Services Research Outcomes Study (SROS)

The Services Research Outcomes Study, or SROS (SAMHSA, 1998), confirmed that both drug use and criminal behavior are reduced after drug treatment. With its extended time frame, the SROS provides the best nationally representative data to answer the question, "Does treatment work?" This study, although now several years old and reporting on even older data, has not been repeated and is the most recent assessment available based on a national sample.

During 1995 and 1996 the SROS interviewed 1,799 persons (of a sample of 3,047). The individuals had undergone drug treatment in 1989 and 1990, and the SROS survey was a follow-up. Individuals were not only interviewed but also provided urine samples. The interviews dealt with drug use five years before and five years after the individuals had received drug treatment; other questions established the respondents' criminal behavior and lifestyle changes. A national sample of ninety-nine drug treatment facilities (rural, suburban, and urban) provided the initial list of individuals sampled and also furnished administrative data on their treatment and its duration.

The outcome of the study is shown in Figure 8.4. The number of those reporting using alcohol or a drug is shown for a five-year period before treatment and a five-year period after treatment. Decrease in drug use after treatment as a percent change from before to after is shown as a diamond for each category (measured by the right-hand scale).

TABLE 8.5
Admissions by primary substance of abuse and type of treatment, 2002
SOURCE: "Table 3.4. Admissions by Primary Substance of Abuse, according to Type of Service, Treatment Referral Source, and Planned Use of Methadone: TEDS 2002 Percent Distribution," in Treatment Episode Data Sets (TEDS) 1992-2002, Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, September 2004, http://www.dasis.samhsa.gov/teds02/2002_teds_rpt.pdf (accessed March 31, 2005)

		Primary substance at admission
		Alcohol		Opiates		Cocaine			Stimulants
Type of service, treatment referral source, and planned use of methadone	All admissions	Alcohol only	With secondary drug	Heroin	Other opiates	Smoked cocaine	Other route	Marijuana/ hashish	Methamphetamine/ amphetamine	Other stimulants	Tranquilizers	Sedatives	Hallucinogens	PCP	Inhalants	Other/ specified
Total	1,882,584	444,781	363,158	285,667	45,605	176,014	65,685	283,527	124,755	1,308	8,209	4,493	2,795	3,854	1,199	71,534
Type of service
Ambulatory	60.6	56.5	55.5	52.7	54.2	50.3	60.3	82.9	65.0	62.9	48.5	52.9	62.8	64.9	62.9	79.0
Outpatient	49.0	47.4	46.2	37.7	40.6	37.5	47.2	68.0	53.1	53.5	37.7	42.2	52.6	52.3	48.6	73.3
Intensive outpatient	9.3	8.3	8.9	3.9	9.9	12.1	12.5	14.2	11.8	9.3	9.6	9.6	9.7	12.0	13.6	4.9
Detoxification	2.3	0.8	0.4	11.1	3.7	0.7	0.5	0.7	0.1	0.2	1.1	1.2	0.6	0.5	0.7	0.8
Residential/rehabilitation	16.9	11.3	20.0	12.3	16.1	28.9	25.6	14.5	25.8	18.8	16.3	26.6	26.4	25.3	23.1	11.3
Short-term (< 31 days)	8.1	6.4	11.8	5.0	9.4	12.4	10.7	5.9	9.6	4.4	8.6	13.8	9.7	7.9	11.7	3.2
Long-term (31 + days)	8.0	3.9	7.4	6.7	5.6	16.1	13.3	8.0	15.6	11.6	5.7	8.1	15.9	16.7	9.5	4.2
Hospital (non-detox)	0.9	1.0	0.8	0.5	1.2	0.4	1.6	0.6	0.5	2.8	2.0	4.7	0.7	0.7	1.9	3.9
Detoxification (24-hour ser vice)	22.4	32.2	24.5	35.0	29.6	20.9	14.1	2.6	9.2	18.3	35.2	20.5	10.8	9.8	14.0	9.6
Free-standing residential	17.9	27.4	18.7	24.7	23.9	19.0	11.8	2.4	8.9	17.0	21.4	13.8	9.6	9.3	12.9	3.7
Hospital inpatient	4.6	4.9	5.8	10.3	5.7	1.9	2.3	0.2	0.3	1.2	13.8	6.7	1.2	0.5	1.1	6.0
Total	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0
No. of admissions	1,882,584	444,781	363,158	285,667	45,605	176,014	65,685	283,527	124,755	1,308	8,209	4,493	2,795	3,854	1,199	71,534
Treatment referral source
Individual	35.1	30.9	31.4	63.3	51.5	40.7	33.8	16.6	24.0	27.8	37.0	38.4	27.0	29.0	30.0	34.3
Criminal justice/DUI	35.9	40.4	34.0	13.0	14.9	26.1	34.1	58.1	52.6	39.2	18.1	23.1	44.1	50.4	33.3	36.0
Substance abuse provider	10.6	10.0	14.7	12.8	14.4	13.9	12.1	5.4	5.0	6.9	15.6	13.5	11.4	6.1	7.0	3.0
Other health care provider	6.8	8.4	7.5	4.5	10.4	7.6	6.9	4.7	4.6	7.2	14.6	12.4	6.9	4.2	12.1	8.7
School (educational)	1.2	0.5	0.8	0.1	0.2	0.1	0.3	4.2	0.4	3.9	0.7	0.7	1.9	0.2	4.7	4.6
Employer/EAP	0.9	1.1	1.0	0.3	1.2	0.7	1.7	1.2	0.5	0.8	0.8	0.9	0.6	0.7	0.5	0.7
Other community referral	9.5	8.6	10.5	6.0	7.5	10.9	11.1	9.8	12.9	14.1	13.1	11.0	8.1	9.4	12.4	12.7
Total	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0	100.0
No. of admissions	516	430,015	352,264	281,525	44,343	170,979	63,013	274,174	120,689	1,272	8,008	4,362	2,688	3,759	1,147	64,659
Methadone use planned as part of treatment
Yes	6.3	0.1	0.3	35.2	19.2	0.4	0.6	0.4	0.1	0.8	1.3	1.1	1.6	0.8	0.9	0.9
No	93.7	99.9	99.7	64.8	80.8	99.6	99.4	99.6	99.9	99.2	98.7	98.9	98.4	99.2	99.1	99.1
Total	17.4	18.4	22.2	17.3	24.8	21.5	18.9	10.2	9.6	14.2	30.2	26.0	18.3	10.3	19.1	11.7
No. of admissions	13	423,950	343,284	279,973	43,721	170,409	63,528	268,370	112,023	1,298	7,430	3,826	2,547	3,806	1,138	60,131

FIGURE 8.4
Change in drug/alcohol use by those receiving treatment, 1989-90, from SROS study 1995-96
SOURCE: Adapted from "Table B-2. Percentage Who Used Drugs and Alcohol during the Five Years before and after Treatment," in Services Research Outcomes Study, Substance Abuse and Mental Health Services Administration, 1998, http://www.oas.samhsa.gov/Sros/httoc.htm (accessed March 31, 2005)

In this nationally representative sample, alcohol use decreased 14.4% and drug use 21.4%, leading to the following conclusion in SAMHSA's SROS report (Executive Summary, SROS, 1998, http://oas.samhsa.gov/Sros/httoc.htm): "A nationally representative survey of 1,799 persons confirms that both drug use and criminal behavior are reduced following inpatient, outpatient and residential treatment for drug abuse."

Decreases varied from drug to drug as shown in the graphic, with heroin use decreasing the least. It went down 13.2%, suggesting that heroin use continued for just under 87% of users. Crack use declined 16.4%, but those treated for snorting cocaine powder did better: 45.4% had abandoned the drug after treatment and continued to do so five years later—but 54.6% were still snorting cocaine. Among marijuana users, 28% had given up the drug, while 72% continued. In all the other drug categories, results were better, but, as the graphic shows, these are also the drugs of limited use by the sample (and the population at large).

Treatment or Time?

SROS did not include a control group of persons using drugs who had not received treatment—which might have been helpful in determining how much of the results achieved were due to treatment and how much to the passage of time and the aging of the respondents. SROS, however, reported data showing decreases (or increases) in drug use by age groups, suggesting that (among the major drugs at least) success of treatment is higher when users are older. The exception was crack cocaine.

These results are shown in Figure 8.5. Beginning with all illicit drugs tracked by SROS (first set of bars on the left), it is clear that as the age of those interviewed rises, results are better. The first item, marked NS, is for those less than eighteen years of age, where results were "not statistically significant," meaning that changes were small and may have been due to chance. The same pattern is visible for marijuana and for cocaine. In the case of crack, the youngest age group actually increased its drug use after treatment by 202%. In both of the next two age groups, 20% had stopped using crack. The oldest age group (forty years and older) turned in statistically insignificant results. For heroin, finally, the two youngest age groups had NS results, but of the two oldest, those forty and older did better than those aged thirty to thirty-nine.

Type and Length of Treatment

Results by type of treatment have been variable. (See Figure 8.6.) Overall results for any illicit drug show that best results (25% decrease in drug use) were obtained by inpatient (hospital) treatment, followed by residential treatment. Outpatient methadone treatment had less favorable results (10% decrease) than outpatient drugfree treatment (19%). Outpatient methadone treatment consists of receiving methadone during visits to a treatment center; the center may also provide other services, such as counseling. Outpatient "drug-free" treatment consists of counseling, group therapy, and other services, but individuals receive no pharmaceutical support.

Marijuana users who were treated in impatient facilities had better results (35% stopped using the drug) than those in residential (32%) and in methadone treatment (33%). Drug-free outpatient treatment had the lowest success rate (19%). Those using powdered cocaine, on the other hand, benefited almost as much from drug-free outpatient treatment (42% decrease) as from inpatient treatment (47%) and did best in residential settings (55% decrease). Crack users also did best with residential treatment (32% decrease) but had a low response to inpatient care and showed no significant decrease in use from outpatient treatment, whether with methadone or free of drugs. Heroin users responded only to methadone treatment in statistically significant numbers; 27% of those surveyed had stopped using the drug as a consequence of outpatient methadone treatment.

Figure 8.7 shows results based on the length of the treatment received. The same general pattern, with slight FIGURE 8.5
Percentage change in drug use by age, from SROS study 1990-96
SOURCE: "Figure 3.5. Percentage Change in Drug Use by Age," in Services Research Outcomes Study, Substance Abuse and Mental Health Services Administration, 1998, http://www.oas.samhsa.gov/Sros/httoc.htm (accessed March 31, 2005) FIGURE 8.6
Percentage change in drug use by type of treatment, from SROS study 1990-96
SOURCE: "Figure 3.6. Percentage Change in Drug Use by Type of Treatment," in Services Research Outcomes Study, Substance Abuse and Mental Health Services Administration, 1998, http://www.oas.samhsa.gov/Sros/httoc.htm (accessed March 31, 2005) FIGURE 8.7
Percentage change in drug use by length of stay in treatment, from SROS study 1990-96
SOURCE: "Figure 3.7. Percentage Change in Drug Use by Length of Stay," in Services Research Outcomes Study, Substance Abuse and Mental Health Services Administration, 1998. http://www.oas.samhsa.gov/Sros/httoc.htm (accessed March 31, 2005) variations, is shown for all drugs, marijuana, and powdered cocaine. Best results for all drugs and cocaine were achieved with treatment that lasted six months or more; this length of treatment was also nearly the top category for marijuana use, missing by one percentage point. The second length with good results (and with the best result for marijuana) was treatment lasting at least one week but less than a month. Results for crack cocaine show statistically significant results only for the "1 week to less than 1 month category." For heroin, only the "6 months or more" treatment duration produced significant decrease in use. Most heroin addicts require long-term methadone treatment (or treatment with a similar prescription drug) to control their habits.

Gender and Racial/Ethnic Differences

Females showed a greater decrease than males in post-treatment substance abuse for any illicit drug and for each of the most frequently used illicit drugs—marijuana, cocaine, crack, and heroin. Figure 8.8 shows the differences. For males, the difference in heroin use before and after treatment was not statistically significant. The total SROS sample was 28.6% female.

Treatment reduced illicit drug use among African-American, white, and Hispanic individuals, although only African-American respondents reduced their crack and heroin use to a statistically significant extent (23% and 18%, respectively). African-Americans were more likely to have used crack and heroin before treatment than whites and Hispanics. The SROS sample was 60.1% white, 28.4% African-American, 8.2% Hispanic of any race, and 3.3% of all other racial categories.

High Death Rates

SROS reported that about 9% of the sample died during the post-treatment phase of the study. Using adjustments for age, sex, and race of the total sample, the investigators calculated, using the overall U.S. death rate, what the expected death rate of the sample would have been and then compared it to the actual observed death rate. The results are shown in Figure 8.9. Each gender and race group within the sample had experienced a substantially higher death rate than expected of a matching group in the population as a whole. The white male death rate was eight times higher than expected, the white female rate eighteen times higher, the African-American male rate five times higher, and the African-American female rate seven times higher than expected—once more documenting the fact that drugs (or more broadly, lifestyles/living conditions that include drug use) are hazardous to health.

FIGURE 8.8
Percentage change in drug use by sex, from SROS study 1990-96
SOURCE: "Figure 3-4. Percentage Change in Drug Use by Sex," in Services Research Outcomes Study, Substance Abuse and Mental Health Services Administration, 1998, http://www.oas.samhsa.gov/Sros/httoc.htm (accessed March 31, 2005)

Criminal Behavior

The SROS, like previous studies, showed that treatment for substance abuse can significantly reduce crime. Criminal activities such as breaking and entering, drug sales, prostitution, driving under the influence, and theft/larceny decreased between 23 and 38% after drug treatment. However, incarceration and parole/probation violations actually increased, by 17 and 26%, respectively. (See Figure 8.10.) Data in the study on those incarcerated or detained were less reliable than other data because of nonresponse to the survey.

How Is Success Measured?

Abstinence is usually the measure of success when treatment providers conduct patient follow-up studies. However, Hazelden Foundation, a nonprofit organization that provides chemical-dependency treatment and education, maintains that abstinence is not the only indicator of successful outcome and suggests that as long as individuals are moving toward abstinence, progress is being made. Other important indicators include the frequency and amount of alcohol/drug use before and after treatment; the patient's quality of life; and decreases in legal, health FIGURE 8.9
Expected and observed death rates of those who underwent substance abuse treatment, from SROS study 1990-96
SOURCE: Adapted from "Table 3.13. Comparison of Expected and Observed Death Rates in the SROS Client Sample," in Services Research Outcomes Study, Substance Abuse and Mental Health Services Administration, 1998, http://www.oas.samhsa.gov/Sros/httoc.htm (accessed March 31, 2005) care, and job problems. Hazelden measures success by using data self-reported by patients and verified by relatives, friends, and/or laboratory tests (e.g., urinalysis).

Hazelden uses the Minnesota Model of treatment, a program that integrates behavioral treatment concepts with traditional Twelve Step treatment based on Alcoholics Anonymous (AA). A 1998 study (Randy Stinchfield and Patricia Owen, "Hazelden's Model of Treatment and Its Outcome," Addictive Behaviors, vol. 23, no. 5) of 1,083 clients using this model found that 53% maintained abstinence during the year after treatment, and an additional 35% reduced their use. Before treatment, 76% of Hazelden's patients used alcohol or drugs daily; one year after treatment, less than 1% used them daily. Between 70 and 80% reported an improved quality of life in such areas as family relationships, job performance, and ability to handle problems. Hazelden considers these findings a treatment success.

Many studies have shown a strong correlation between high abstinence rates and compliance with after-care and/or participation in Twelve Step programs. These findings confirm that addiction needs to be treated as a chronic illness. In the Stinchfield and Owen study, 72% attended AA or other Twelve Step groups after treatment. FIGURE 8.10
Percentage who reported criminal activity during the five years before and after treatment, from SROS study 1990-96
SOURCE: Adapted from "Table 3-12. Percentage Who Reported Criminal Activity during the Five Years before and after Treatment," in Services Research Outcomes Study, Substance Abuse and Mental Health Services Administration, 1998, http://www.oas.samhsa.gov/Sros/httoc.htm (accessed March 31, 2005) Of the 28% who did not, only 18% remained abstinent, while 57% of those who did attend AA stayed abstinent.

A. Thomas McLellan et al. (Training about Alcohol and Substance Abuse for All Primary Care Physicians, New York: Josiah Macy, Jr. Foundation, 1995) maintain that "substance abuse is a real medical disorder. It is a recurring disorder much like diabetes, hypertension, or asthma, with profound and expensive public health and safety implications." These are chronic diseases that have serious consequences for the patient, including death. When substance abuse is treated as a chronic disease, they note that success is similar to that of treatment of other chronic illnesses.

For example, despite the real dangers, less than 50% of diabetics take their medicine properly, and fewer than 30% follow their diet. Within twelve months, 30-50% have to be retreated. Similarly, fewer than 30% of hypertension patients take their medicine properly, and fewer than 30% follow their diet. Within a year, 50-60% must be retreated. Finally, fewer than 30% of asthma sufferers take their medicine properly, and 60-80% must be retreated within twelve months.

Along the same lines, McLellan et al. note that:

Studies of treatment response have shown that patients who comply with the recommended regimen of education, counseling, and medication, which characterizes most contemporary forms of treatment, typically have favorable outcomes during treatment and longer-lasting benefits after treatment. Thus, it is discouraging to those in the treatment field that so many substancedependent patients fail to comply with the recommended course of treatment and subsequently resume substance use. Factors such as low socioeconomic class, co-morbid psychiatric conditions, and lack of family or social supports for continuing abstinence are among the most important variables associated with lack of treatment compliance, and ultimately, to reoccurrence of the disorder following treatment.