Recommendation A: Improve drug rehab and substance abuse outcomes by delivering effective, evidence-based substance abuse services.
A tremendous volume of research today supports the efficacy and cost-effectiveness of substance abuse treatment, especially for people under the supervision of the criminal justice system. Yet not all treatment is equally effective, and ensuring that drug dependent individuals are treated according to evidence-based practices and treatment modalities is critical to improving outcomes, maximizing investment, and building support for further expansion of services.
What are Evidence-Based Practices?
Evidence-based practices are interventions and treatment approaches that have been proven effective through a rigorous scientific process. Policymakers are increasingly looking to fund and implement programs and interventions that have been tested and found to produce positive results. Although evidence-based practices are being promoted in diverse public policy fields such as education, substance-abuse prevention, and health care, in the context of re-entry, this concept often refers to a practice which has had a demonstrable, positive outcome in terms of lowering recidivism, increasing victim satisfaction, or decreasing expenditures. (See Policy Statement 6, Measuring Outcomes and Evaluating the Impact of a Re-Entry Initiative for more on systematically evaluating program effectiveness.)
Source: National Institute of Drug Abuse, Principles of Drug Abuse Treatment: A Research-Based Guide, NIH Pub No. 99-4180, Rockville, MD, 2003.
The effectiveness of substance abuse treatment depends on a range of factors at both program and system levels. The National Institute on Drug Abuse, the federal government’s research agency, has identified key components of successful treatment (see sidebar, “13 Basic Principles of Effective Treatment”). While any approved provider can apply for and receive the Substance Abuse Prevention and Treatment (SAPT) Block Grant funding, state and local policymakers and agencies should engage and contract with only those treatment providers who consistently use evidence-based practices and adhere to evidence-based principles. [1]
13 Basic Principles of Effective Treatment
Source: National Institute of Drug Abuse, Principles of Drug Abuse Treatment: A Research-Based Guide, NIH Pub No. 99-4180, Rockville, MD, 2003.
- Treatment needs to be readily available, on demand.
- Treatment needs to focus on the multiple needs of the person, not just drug use.
- Treatment needs to be continually monitored and modified to meet changing needs.
- Length of time in treatment is crucial.
- Individual and group counseling approaches are both effective.
- Medications, when combined with counseling, increase the chance of success.
- Detoxification is only the first step and is not effective by itself.
- Treatment does not have to be voluntary to work.
- No single treatment is appropriate for all individuals.
- Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated.
- Treatment programs should provide assessment for infectious disease.
- Possible drug use during treatment must be continuously monitored.
- Recovery from drug abuse can be a long-term process with multiple episodes of treatment necessary.
Source: National Institute of Drug Abuse, Principles of Drug Abuse Treatment: A Research-Based Guide, NIH Pub No. 99-4180, Rockville, MD, 2003.
At the system level, the following functions are fundamental to a high-quality treatment delivery system: [2]
- Provide ready access to high-quality treatment for everyone who needs it.
- Match people with the right treatment programs for their specific needs.
- Make sure that clients transition smoothly from one program to another as their needs change.
- Connect recovering people with addictions with the other types of help and support they need, such as employment, housing, and mental health services.
- Provide performance incentives both to people with addictions and treatment programs to get the best results.
As indicated in the “Key Problems” section above, three elements which are critical to establishing effective programs and systems are missing in many treatment systems across the country: adequate duration of care; adequate variety of treatment intensities or “modalities”; and appropriate, science-based care strategies. Addressing them would dramatically improve treatment outcomes.
Duration of Care
Research is clear that treatment achieves the best results when clients are engaged in it at least 90 days. Yet many programs offer treatment that lasts 90 days or less, which is far too short a period for drug-dependent individuals to make lasting changes in their behavior. Some health insurance policies, including both private insurance and, depending on the state, Medicaid, limit treatment coverage, a policy which further encourages shorter lengths of stay in treatment. Longer courses of treatment must be made available both through new resources and shifting of current dollars. Behavioral health problems should be addressed with the same urgency as physical health problems. In addition, treatment programs must employ research-proven strategies to retain more voluntarily referred clients in treatment for longer periods, including the use of motivational interviewing techniques and providing performance incentives to clients who stay.
Variety of Treatment Intensities
In addition to a sufficient duration in treatment, it is essential for clients to receive the right intensity of treatment for their needs. The primary treatment modalities are outpatient, intensive outpatient, residential (short- and long-term), and medication-assisted, such as methadone. More severely addicted individuals tend to need more intensive services and more structure in their lives, often away from the people, places, and things that tempt them to abuse substances. But the vast majority of treatment services in the nation, about 85 percent, are basic outpatient services, which typically consist of one counseling session per week. In creating new services or redistributing existing ones, systems must offer more intensive outpatient services (several sessions per week) and residential placements. This will allow clients to receive the right intensity of treatment and to “step up” or “step down” to another level of care as they progress or fail.
Effective Treatment Strategies
Studies have shown that certain types of treatment are more successful at changing behavior than others. Unfortunately, at present, there is a tremendous gap between evidence-based treatment modalities and the actual practices implemented by some treatment agencies and providers. For instance, research has shown that treatment is most effective when individual counseling is combined with group counseling, but in reality, most clients receive only group counseling.
Several proven treatment strategies have gained acceptance in the field: Cognitive-Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET) are the two best known. CBT is based on the “social learning” theory and focuses on interpersonal skill building, stress management, relapse prevention, and cognitive restructuring of maladaptive beliefs. (See Policy Statement 14, Behaviors and Attitudes, for more on cognitive-behavioral treatment programs.) MET is based on principles from cognitive and social psychology. It attempts to overcome any ambivalence an individual may have toward treatment and motivate them to change. MET has been proven effective in both inpatient and outpatient settings and found particularly successful with alcohol-addicted and marijuana-dependent clients.
New Yorkers interested in this type of treatment or in need of it can contact http://nycats.net for more information.
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