Alaska Substance Abuse Prevention and Treatment System Effectiveness Study Working Paper #2

A Brief Summary of the Evolution of Substance Abuse Treatment and Prevention Services and the Approaches to Measuring their Effectiveness

Alaska Mental Health Trust Authority

William Herman, Program Manager Jeff Jessee, Director

Institute for Circumpolar Health Studies

Bernard Segal, PhD Brian Saylor, PhD, MPH, Director

Institute for Circumpolar Health Studies University of Alaska Anchorage 3211 Providence Drive Anchorage, Alaska 99508

April 2003

This project was supported by a contract from the Alaska Mental Health Trust Authority TABLE OF CONTENTS

TABLE OF CONTENTS ...... i

I. The Evolution of Substance Abuse Treatment and Prevention ...... 1 A. Introduction...... 1 B. Paper Summary ...... 1 C. Alcoholism: The Nature of the Problem ...... 3 D. The Extent of the Problem ...... 3 II. Alcohol Treatment: Theory and Practice ...... 5 A. Early Concepts of Alcoholism: The Pre-Prohibition Period ...... 5 B. The Post-Prohibition Period: AA and Alcoholism as a Disease...... 7 C. The "Disease Concept" of Alcoholism...... 9 D. Adoption of the Disease Concept of Alcoholism ...... 13 E. Unitary Disease Concept Changes ...... 14 F. Dual Diagnosis/Comorbidity ...... 25 G. Multidimensional Concepts of Drinking-Related Problems ...... 27 H. Examples of Alternative Approaches to Substance Abuse Treatment...... 29 III. Treatment Settings...... 33 A. Inpatient/Residential Treatment ...... 33 B. Transitional Care ...... 35 C. Outpatient Treatment ...... 35 IV. Treatment Approaches...... 37 A. Alcoholics Anonymous (AA) ...... 37 B. Other Self-Help Groups...... 40 C. Patient-Treatment Matching...... 40 D. Counseling or Psychotherapeutic Approaches ...... 42 E. Marital Counseling...... 46 F. Adjunctive Treatments...... 46 G. Behavioral Approaches to Alcoholism...... 49 H. Aversion Techniques...... 49 I. Controlled Drinking (Moderation) Theory...... 51

Evolution of Substance Abuse Treatment i April 2003 Institute for Circumpolar Health Studies J. Relapse Prevention...... 57 V. Treatment of Drug-Related Problems ...... 59 A. Historical/Philosophical Perspective on Drug Treatment...... 59 B. The Changing Role of the Federal Government...... 62 C. Approaches to Drug Treatment...... 64 VI. Measuring Treatment Success ...... 74 A. Effectiveness of Treatment Settings...... 74 B. Measuring Drug Treatment Effectiveness ...... 77 C. General Findings of Treatment Effectiveness ...... 78 D. Research Findings on the Value of Treatment...... 80 E. Concluding Remarks ...... 82 VII. Science-Based or Best Practice Treatment...... 84

VIII. Substance Abuse Prevention...... 87 A. Issues and Concerns Common to Both Alcohol and Drug Prevention ...... 88 B. Prevention of Alcoholism...... 91 C. National Prevention Policies...... 94 D. Alcohol Prevention Programs...... 95 E. Prevention of Drug Abuse ...... 99 IX. Conclusions...... 103

Evolution of Substance Abuse Treatment ii April 2003 Institute for Circumpolar Health Studies I. The Evolution of Substance Abuse Treatment and Prevention

A. Introduction

Of our current social issues, few have as many different and competing perspectives as the issue of alcoholism and other forms of drug addiction and how we deal with them. The intent of this section is to review alcohol ism in America from the historical and current contexts of medical, psychological, and sociocultural knowledge and understanding.

This purpose of this section is to provide background information about alcoholism, related disorders, and prevention of such addiction problems. The information synthesized here is intended to provide a larger context for understanding the problem of alcoholism and alcohol abuse and the impacts the conditions have on our social fabric. It also presents new thinking about the treatment and prevention of these serious problems which may influence our ability to amend current practices based on new knowledge.

B. Paper Summary

There is currently a serious rethinking taking place in the United States about the nature of alcoholism. Until recently, it has generally been accepted that "most alcohol-use problems are well characterized as representing one stage or another in the development of a single disease of alcoholism and] that a single-disease concept of alcoholism is the "officially correct view."

This view has fostered a universal belief about alcoholism that can be summarized in the six following statements:

1. There is a unitary phenomenon that can be identified as alcoholism. 2. Alcoholics and pre-alcoholics are essentially different from non-alcoholics. 3. Alcoholics may sometimes experience a seemingly irresistible craving for alcohol or a strong psychological compulsion to drink. 4. Alcoholics gradually develop a process called "loss of control" over drinking, and possibly even an inability to stop. 5. Alcoholism is a permanent and irreversible condition. 6. Alcoholism is a progressive disease that follows an inexorable development through a distinct series of phases.

The concept of a disease model, however, is being challenged by new and different approaches that offer an alternative to traditional beliefs about alcoholism. This alternate approach is reflected in the following statements:

1. Alcohol dependence summarizes a variety of syndromes defined by drinking patterns and the adverse physical, psychological, and/or social consequences

Evolution of Substance Abuse Treatment 1 April 2003 Institute for Circumpolar Health Studies of such drinking. These syndromes, jointly denoted as alcohol dependence, are best considered as a serious health problem. 2. An individual's pattern of use of alcohol can be considered as lying on a continuum, ranging from to severely pathological. 3. Any person who uses alcohol can develop a syndrome of alcohol dependence. 4. The development of alcohol problems follows variable pattern over time and does not necessarily proceed inexorably to severe fatal stages. 5. Recovery from alcohol dependence bears no necessary relation to abstinence, although such a concurrence is frequently the case. 6. The consumption of a small amount of alcohol by an individual once labeled as "alcoholic" does not initiate either physical dependence or a physiological need for more alcohol by that individual. 7. Continued drinking of large doses of alcohol over an extended period of time is likely to initiate a process of physical dependence that will eventually be manifested as an alcohol withdrawal syndrome. 8. The population of persons with alcohol problems is multivariate. 9. Alcohol problems are typically interrelated with other life problems, especially when alcohol dependence is established. 10. An emphasis should be placed on dealing with alcohol problems in the environment in which they occur. 11. Treatment services should be designed to provide for a continuum of care throughout the lengthy process of recovery from alcohol problems.

Based on these principles, alternatives to the disease concept, in the form of multidimensional theories, are being developed. These approaches reflect a synthesis of biomedical, psychological, and sociological principles or knowledge combined into a comprehensive system that takes into account that alcoholism or other types of problem drinking not only vary with respect to drinking behavior, but also with different personalities, and that there are multiple combinations of adverse consequences that require different types of treatment interventions.

A multidimensional approach allows more flexibility in thinking about alcoholism, and it address better the diagnostic and treatment needs of specialized populations who man- ifest drinking problems. The traditional disease concept of alcoholism, for example, has not generally allowed for the specialized intervention strategies that address the needs of women, children, and older persons, among other groups needing more individualized attention, such as Alaskan Natives, American Indians, and members of other minority groups. Their drinking behavior requires that an understanding of their special problems be developed, and that any approach to alcoholism must be sensitive to differences between men and women, especially recognizing the biological differences between genders. Nor has the disease concept been particularly sensitive to cultural differences. Multidimensional theory can not only account for some of the needs of special population groups, but it may also provide a stronger theoretical base for studying cultural variations in drinking and drinking-related problems.

Evolution of Substance Abuse Treatment 2 April 2003 Institute for Circumpolar Health Studies C. Alcoholism: The Nature of the Problem

Drugs and drug-taking behavior have become well embedded in our society. The problems they create present a formidable challenge. But these problems are not new - - alcohol, tobacco, opium and other drugs have been in use since the nation was founded. The current period in our history, however, is marked by a new dimension of drug activity characterized by the widespread use, particularly among Alaskan youth and young adults, of numerous kinds of powerful mind-altering substances, many of which are dependency-producing. Never before have so many been exposed to a variety of potent drugs, both legal (licit) or illegal (illicit).

The concern about drugs1, however, has resulted in severe misconceptions about the nature and extent of the problem. Stephens (1992) described these misperceptions as follows:

First, there is much misunderstanding concerning this "epidemic." One would almost believe from our mass media messages that huge segments of American society regularly abuse drugs like crack. Second, there appears to be enormous confusion among both the general public and our decision makers about what psychoactive drugs are. Most simply want to lump all types of psychoactive drugs into one category called "dope" or "drugs." The implication is "one type of problem, one type of solution." Third, there is a great deal of hypocrisy concerning drug usage. The use of addictive substances like tobacco products and alcohol is condoned -- indeed in some cases even subsidized by the state. . . . Fourth, Americans tend to ignore . . . social and cultural contexts in which drug use occurs when searching for an answer to the question, "Why do people use drugs?" Most often, drug users are believed to suffer from mental, emotional or possibly even physiological "diseases." Because of this disease state, they have difficulty coping with stress and the problems of living. They take drugs to escape and to ameliorate the anxiety and depression they feel. Finally, Americans are perplexed about how to deal with the drug problem. Some feel that a "get tough" approach is the only solution while others maintain that the ultimate solution lies in decriminalization or outright legalization of all psychoactive substances. (pp. 1-2)

D. The Extent of the Problem

Across the United States, over 85 percent (more than 169 million people) have consumed alcohol. Alcohol-related problems have a significant impact on the nation's health and welfare. Economic estimates of this impact indicate that alcoholism and alcohol abuse cost about $100 billion annually.

Approximately 14 million Americans -- about 7 percent of the adult population -- meet the diagnostic criteria for alcohol abuse and/or alcoholism. About 40 percent of Americans report having a direct family experience with alcohol abuse or alcoholism. The misuse of alcohol is involved in approximately 30 percent of suicides, 50 percent of

1 This is intended to mean alcohol, tobacco, opium and other drugs.

Evolution of Substance Abuse Treatment 3 April 2003 Institute for Circumpolar Health Studies homicides, 52 percent of rapes and other sexual assaults, 48 percent of robberies, 62 percent of assaults, and 49 percent of all other violent crimes. Alcohol is also a factor in 30 percent of all accidental deaths, including up to 50 percent of motor vehicle deaths. In fact, more than 100,000 Americans die each year from alcohol-related causes, which, if it were ranked independently, would make alcohol-related problems the third leading cause of death in the United States.

Americans annually spend over $35 billion on alcoholic beverages, consuming over 23.5 gallons of beer and 2 gallons of distilled wine and spirits per person annually. Cigarette smoking, though tending to decline among males, is increasing among women and adolescents, particularly among female adolescents. The use of smokeless tobacco has also increased among adolescent males.

The economic cost of substance abuse to health and social institutions is significant, estimated as $246 billion in 1992 (Harwood et al., 1998). Alcohol-related costs are estimated at $148 billion, while other forms of drug abuse are estimated to cost $98 billion. These costs have increased considerably since 1985 -- 42% higher for alcohol and 50% higher for drugs over and above the increase in population growth and inflation (Harwood et al., 1998).

Harwood et al. (1998) also estimated that the costs of crime-related substance abuse amounted to $59.1 billion for alcohol-related crimes and $19.7 billion for drug-related crimes. These costs include reduced earnings due to incarceration, crime careers, criminal victimization and the costs of criminal justice and drug interdiction. Drug abuse was estimated to contribute to 25-30% of income-generating crime; alcohol abuse was estimated as being involved in violent crimes, especially domestic violence, sexual assaults against women and child abuse.

The economic burden of these expenses falls on the non-abusing taxpaying population of our society. The U.S. government, through tax revenue, spent $57.2 billion in 1992 for alcohol-related problems, compared with $15.1 billion for private insurance, $9 billion for victims, and $66.8 billion for alcohol abusers and members of their households. Concerning drug abuse, the government spent about $45.1 billion (46.2%); private insurance spent $3.1 billion, victims, about $6.5 billion, and abusers and their families about $42.9 billion (Harwood et al., 1998).

The costs imposed on the non-abusing part of society include drug- and alcohol-relate crimes and trauma, such as motor vehicle crashes, government services, and various social insurance mechanisms. The costs related to the abusers include lost legitimate earnings, encompassing lost tax revenue.

Evolution of Substance Abuse Treatment 4 April 2003 Institute for Circumpolar Health Studies

II. Alcohol Treatment: Theory and Practice

Excessive consumption of alcohol can result in serious adverse consequences that must be addressed at both national and local levels. While there is universal agreement that alcohol produces a wide range of effects and consequences, there is no similar agreement on how to define "alcoholism." As George Gallup, Jr., noted:

Despite the fact that alcoholism is common, not only in the US., but in many other nations, and the fact that incredible numbers of people are adversely affected by alcohol, we know relatively little about alcoholism and alcohol abuse: what alcoholism is, how to define it, how to recognize its symptoms and its impact, why some people can control their drinking and others cannot, why some alcoholics can recover, but others cannot. (cited in Diames, 1984, p.55)

The lack of uniformity in defining alcoholism exists because of disparate views held by professionals in different disciplines regarding how they define alcoholism. Thus medical practitioners, the legal profession, alcohol counselors, the clergy and biomedical, behavioral and social scientists, as well as recovering alcoholics, all differ with respect to how they define alcoholism; and each definition has important implications for public policy concerning alcoholism and its treatment and prevention. With respect to treatment, for example, if alcoholism is defined as having a physiological basis, such as metabolic changes in the structure of certain brain cells, then treatment would mainly consist of a pharmacological approach that would seek to correct the physiological imbalance. In contrast, if an accepted definition of alcoholism is that it results from a lack of will power, then a moral approach would be stressed as the appropriate treatment method.

Because of this lack of specificity in defining alcoholism, a very complex situation exists in which there is significant controversy over what is effective treatment for it . To understand how this situation arouse, and to be able to place it in a proper perspective, it is helpful to trace the history of some of the recent definitions of alcoholism. Part of this unit will examine some of the origins of traditional and contemporary concepts of alcoholism; it also contains a discussion of new approaches in the field. The intent is to provide a comprehensive perspective on alcoholism, and to illustrate how certain views have come to prevail.

A. Early Concepts of Alcoholism: The Pre-Prohibition Period

The belief that continued excessive consumption of alcohol can result in illness or in a chronic disorder dates back to early history, but the term "alcoholism" is thought to be of more recent origin. The earliest documented usage of the term is attributed to Magnus Huss, a Swedish scientist who, in 1849, described a condition resulting from the abuse of alcohol and labeled it "alkoholismus chronicus" ("chronic alcohol disease").

The belief that chronic drinking is a special disease was expressed earlier by Benjamin Rush, a prominent physician in colonial America. After having observed what happened

Evolution of Substance Abuse Treatment 5 April 2003 Institute for Circumpolar Health Studies to people who drunk continuously, Rush, in 1814, concluded that drunkards were "addicted" to spirituous liquors and that they became addicted gradually and progressively. Rush characterized bouts of drunkenness as an inability to refrain from drinking, a condition he designated as a "disease of the will," which could only be cured by total abstinence. Rush's ideas about habitual drunkenness provided nearly all the fundamental principles on which most of today's thinking is based:

1. The cause of habitual drunkenness is alcohol; 2. The drunkard's condition is due to a loss of control over drinking - it is a compulsive activity; 3. This condition is a disease; and 4. The only cure is abstinence.

Rush's beliefs concerning chronic drinking were readily adopted by the Temperance Movement in the United States. The Temperance Movement’s aim was in its formative stage, was to help drunkards and prevent drunkenness. The Temperance Movement, prior to the Civil War, maintained that inebriety, intemperance, or habitual drunkenness was a disease and a natural consequence of the consumption of alcoholic beverages and believed that:

Intoxicating liquors are dangerous articles; that multitudes of persons are so susceptible to the narcotic influence of alcohol that, whatever their accomplishments or station, if they drink at all they drink to drunkenness; and that the confirmed inebriate is a diseased [emphasis added] individual undergoing the tortures of a living death, manifesting symptoms characteristic of the operation of an irritant narcotic poison (Palmer, 1986, p. 21).

In its early years the Temperance Movement thus directed most of its efforts toward helping drunkards to achieve sobriety. Because drunkenness was perceived as a disease resulting from addiction to alcohol, emphasis was placed on persuading people to abstain from alcohol so as to not become afflicted with the disease.

The basic philosophy of the Temperance Movement changed after the Civil War, when it re-emerged as a widespread movement to invoke discipline and to create a society of predictable individuals devoted to self-improvement. Alcohol was to be combated because it contributed to crime, drunkenness, poverty and moral degeneracy.

With this alteration in its philosophy, the Temperance Movement shifted away from advocating temperance to supporting prohibition. Alcohol became a symbol that represented a decline in morality brought about by drinking behavior and the lifestyles of the working class. In its quest for reform the temperance movement changed its earlier position that inebriety is a disease, now insisting that the fault always lies with the drunkard, never in the drink, and that only evilly disposed persons and fools fall victims to alcoholic excess (Palmer, 1986). The efforts of the prohibition movement ultimately culminated in national prohibition.

Evolution of Substance Abuse Treatment 6 April 2003 Institute for Circumpolar Health Studies While prohibition, as history shows, did not eradicate drinking, it succeeded in shifting efforts away from perceiving alcoholism as an addiction or specific disease. Attention was given instead to the evil effects of alcohol and to eliminating it from American society. "Demon rum" was now the enemy. One result of this change was a weakening of the sympathetic attitude toward habitual drunkards long held by reformist movements. "The drunkard came to be viewed less and less as a victim and increasingly more as simply a pest and menace" (Levine, 1978, p. 161).

What is important to understand about this period in American history is that it established attitudes about alcohol and alcoholism that continue to affect how alcoholism is defined, treated, and prevented. One of the major effects of prohibition was that it significantly distracted attention away from efforts to differentiate between different types of drinking behavior and the short- and long term effects of drinking. That is, it direct efforts away from developing an understanding of what alcoholism is and is not, and from identifying what factors might serve to maintain drinking by alcoholics and what factors differentiate alcoholics from non-alcoholics. Instead, as a result of the temperance and prohibitionist movements’ views, alcoholism or drunkenness was perceived as a "moral failing" rather than as an illness. The cause of the moral failure was a lack of will to overcome drunkenness, and the only way to combat this behavior was to make alcohol unavailable. The fact that the chronic or problem drinker may feel guilty after a drinking episode helped to characterize drinking as "sinful," and as socially undesirable. This "moral" approach is reflected in contemporary efforts to limit the sale of alcohol and in the desire to maintain a public appearance of abstinence. Nevertheless, when the major target of public action is focused on limiting the amount of alcohol consumed, and on changing the individual's decision to consume alcohol, drunkenness or alcoholism contains elements of a moral failing.

It should be noted that beliefs expressed by those in the Temperance Movement, and by other groups that advocated the prohibition of alcohol, also influenced attitudes toward drugs in the United States, many of which continue to prevail. Around the turn of the century, and afterward, there was a dramatic increase in drug use in the United States. Morphine, later taken as heroin, and marijuana were special targets of adverse public opinion. In general, the attitudes and opinions about alcohol and other drugs espoused by the anti-alcohol movements in the first half of this century contributed directly to the division of attitudes in the 1950s through the 1970s concerning drug use in America. These beliefs also provided the basis for the strategies adopted by federal, state, and local governments concerning the use of mood-altering drugs. Thus, as White (1979) noted, the prohibitionist beliefs were integrated into the social fabric of American culture, and this integration became so complete that it has prevented the formation of national policies for the social control of mood-altering drugs.

B. The Post-Prohibition Period: AA and Alcoholism as a Disease

The end of prohibition rekindled interest in developing an understanding of alcoholism, one that did not specifically focus on alcohol itself as the source of addiction. After having faced 12 years of prohibition, and a longer period of temperance and prohi-

Evolution of Substance Abuse Treatment 7 April 2003 Institute for Circumpolar Health Studies bitionist philosophy, the public was unwilling to deal with the fact that alcohol may be an inherently addicting substance. In this atmosphere the notion that alcoholism is a disease flourished, and the impetus that gave added emphasis to this notion came from a new philosophy espoused by Alcoholics Anonymous (AA), an organization founded in 1935 to assist alcoholics to obtain sobriety.

AA was established on the basis of the belief that alcoholism is a disease, one that could only be dealt with by admitting "one's powerlessness over alcohol," and by accepting responsibility for this problem. This creed, advocated by Bill Wilson, the founder of AA, along with Dr. Robert (Bob) Holbrook Smith, who assisted Bill W., as he came to be known, was derived from a definition of alcoholism by Dr. Robert Silkworth, a physician whose ideas greatly influenced Bill W. Silkworth (1946) defined alcoholism as a disease, one represented by an "obsession of the mind that compels us to drink and the allergy of the body that condemns us to go mad or die" (p.1).

While AA did not accept this specific definition of alcoholism, the conceptualization advanced by Silkworth provided the framework for AA's definition. The AA approach defined alcoholism as a disease resulting from long-term drinking. Because of either an inherited predisposition or a physiological response to the effects of chronic drinking, an allergic-type reaction to alcohol occurs that causes susceptibility to alcoholism. Also involved in this disease process is an obsession with alcohol and its effects, that is, a craving for alcohol to the extent that one loses control over one's drinking. Stated differently, alcoholism, as conceptualized by AA, is a disease represented by a craving for alcohol resulting from a loss of control over drinking that is attributable to an underlying physiological anomaly. The underlying physiological anomaly, or pre- disposition, and loss of control over drinking, are the essence of the disease model of alcoholism, leading to the premise that the only treatment for this disease is complete abstinence from alcohol.

Based on this approach, Bill W. advocated that one could only start to recover from the compulsion to drink by first admitting powerlessness over alcohol, and by accepting that help is needed to abstain. AA provides the support for a conversion from drinking to sobriety, and for maintaining sobriety. The philosophy of AA was expressed in a publication entitled "Alcoholics Anonymous" (1939), which came to be known as the "Big Book." In it Bill W. developed the "Twelve Steps" to recovery that have become AA's basic principles for overcoming alcoholism.

Since its inception in the mid-1930s, "AA has come to serve as a major vehicle for defining alcoholism in this country, and members of AA have become perhaps the most important lobby advocating the now generally accepted disease concept of alcoholism" (Tournier, 1979, p. 230). Peele (1989) stated that by the 1970s "AA had become the model for all treatment groups and a linchpin in the provision of services for drinking problems in the United States" (p. 24). Additionally the widespread acceptance of AA led to its being involved as an adjunct to the outpatient treatment of alcoholics, and frequently as part of inpatient programs, as well (Blumberg, 1977).

Evolution of Substance Abuse Treatment 8 April 2003 Institute for Circumpolar Health Studies The major question that needs to be asked is: Why did the disease concept of alcoholism, championed by AA, achieve such widespread acceptance? To answer this question it is first necessary to take three things into consideration:

1. The end of prohibition gave rise to a rapid increase in various kinds of drinking problems; 2. The divisiveness generated by the Prohibitionist Movement made it essential that if problem drinking were to be addressed, it had to be accomplished in a way that made it necessary to distinguish interest in dealing with alcohol problems from interest in prohibition and temperance movements; and 3. If progress were to be made, it was essential to remove the stigma of intemperance and immorality from the drinker.

With these three conditions in mind, the stage was set for a movement that could distinguish its response to drinking problems from moralistic action against alcohol. Shaw et al. (1976) noted that:

The AA philosophy not only allowed this differentiation, but also managed to achieve it without blaming the individual drinker. By promoting the idea that a particular group of drinkers were unable to cope with alcohol, and by labeling their inability an illness, AA facilitated a response to drinking problems which blamed neither alcohol itself nor the drinker as a person. (p. 47)

Two important results of the establishment of AA were: (a) it convinced the public to regard alcoholism as a progressive disease, and (b) it helped to establish alcoholism re- search as a legitimate area of inquiry in the various fields of scientific research in American universities. Thus the very research that AA helped initiate furthered an understanding of alcoholism, but much it was also directed at verifying AA's basic tenets.

C. The "Disease Concept" of Alcoholism

The major tenet held by AA was that alcoholism is a special disease characterized by a loss of control over drinking, which requires sobriety as the cure because of the alcoholic’s underlying vulnerability to alcohol. A single drink, after stopping, is likely to lead the person back to uncontrolled drinking. Alcoholism is a lifetime condition that necessitates ongoing abstinence and a lifetime of recovery. This notion is expressed by AA members self-description of “recovering” as opposed to “recovered” (Peele, 1989). Elvin Jellinek, a proponent of the disease concept of alcoholism described different classifications or typologies representative of problem drinking.

1. Early Classification Schemes for Alcoholism

One of the earliest and most important alcohol research centers was the Yale Laboratory of Applied Physiology, established at Yale University in the mid-1930s. The research that was carried out by physiologists and biochemists there led to two

Evolution of Substance Abuse Treatment 9 April 2003 Institute for Circumpolar Health Studies significant events: (a) the founding, in 1940, of the Quarterly Journal of Studies on Alcohol to publish the extensive research findings that were generated in the research laboratory; and (b) the realization that research into the causes and nature of alcoholism required more than laboratory research alone. The latter problem was solved by changing the original research center into the "Yale Center of Alcohol Studies," dedicated to a multidisciplinary approach to alcoholism. The establishment of this multidisciplinary center, which was later to move to Rutgers University, was particularly important because it heralded a recognition within the scientific community that alcoholism is a disease that requires a comprehensive, interdisciplinary approach.

The first director of the Yale center, E.M. Jellinek, was particularly influential in helping to promulgate the disease concept of alcoholism. As a result of his study of AA members who were "recovering alcoholics," Jellinek proposed several classifications of problem drinking, but singled out only one type, gamma alcoholism, to be representative of the disease of alcoholism. Jellinek's (1960) typologies follow. a. Alpha Alcoholism: Alpha alcoholism represents a purely psychological continual dependence or reliance upon the effect of alcohol to relieve bodily or emotional pain. The drinking is undisciplined in the sense that it contravenes such rules as society tacitly agrees upon - such as time, occasion, locale, amount, and effect of drinking - but does not lead to loss of control or inability to abstain. The damage caused by this species of alcoholism may be restricted to the disturbance of interpersonal relations. There may also be interference with the family budget, occasional absenteeism from work and decreased productivity, and some of the nutritional deficiencies of alcoholism, but not the disturbances due to withdrawal of alcohol. Nor are there any signs of a progressive process. b. Beta Alcoholism: This species of alcoholism is one in which such alcoholic complications as polyneuropathy, gastritis, and cirrhosis of the liver may occur without either physical or psychological dependence on alcohol. The incentive to the heavy drinking that leads to such complications may be the customs of certain social groups in conjunction with poor nutritional habits. The damage in this instance is nutritional deficiency diseases, impaired family budget, lowered productivity, as well as a curtailed life span. Withdrawal symptoms, on the other hand, do not emerge. Beta alcoholism is progressive, and may develop into gamma or delta alcoholism. c. Gamma Alcoholism: Gamma Alcoholism is that type of alcoholism in which the drinker acquires an increase in tissue tolerance to alcohol resulting in an adaptation in cell metabolism. Withdrawal symptoms and "craving" (i.e., physical dependence) and loss of control are also involved. In gamma alcoholism there is a definite progression from psychological to physical dependence and marked behavioral changes. Gamma alcoholism produces the greatest and most serious kinds of damage. The loss of control impairs interpersonal relations to the highest degree. The damage to health in general, and to financial and social standing, is also more prominent than in any other type of alcoholism. Gamma alcoholism is what alcoholic members of AA recognize as alcoholism to the exclusion of all other species.

Evolution of Substance Abuse Treatment 10 April 2003 Institute for Circumpolar Health Studies d. Delta Alcoholism: This form shows the first three characteristics of gamma alco- holism as well as a less marked form of the fourth characteristic - that is, instead of loss of control, there is inability to abstain.

Jellinek also described three other types of problem drinking: (a) Pseudo periodic alcoholism, represented by the gamma or AA alcoholic who slips every three, six, or 12 months and then goes back to sobriety; (b) Excessive weekend or spree drinker - the epsilon alcoholic or binge drinker; and (c) The occasional drinker, who causes accidents.

Jellinek's classifications represented an attempt to provide a description of different types of alcoholism, only one of which was designated as a disease - the gamma alcoholic. Although these typologies were established by Jellinek as working hypotheses, and lacked demonstrated empirical support (they were based on a study of only 98 self-reported cases), those working in the field of alcoholism quickly adopted them as different representations of the course and consequences of the disease of alcoholism. That is, the different alcoholic categories identified by Jellinek were interpreted as representing different stages or points on a single continuum and not as separate, or different diagnostic categories of alcoholism.

Jellinek's categories thus led to the belief that alcoholism is a progressive disease, which, if unchecked, could kill directly or through secondary medical complications. In this model, environmental factors and an individual's characteristics only determine the pace of progression. Interestingly, despite the widespread acceptance of Jellinek's theory, " . . . the typology stimulated little empirical research, nor did it inspire attempts to develop comprehensive diagnostic measurements or to match subtypes to specific therapeutic interventions" (Barbor, 1996, p. 10).

The interpretation of Jellinek's categories as points on a continuum resulted in the formation of what is called the unitary concept of alcoholism. This concept proposed that there is a unitary phenomenon called alcoholism, in which all persons so afflicted are substantially the same, experience a similar progressive deterioration, and will respond to a singular treatment, resulting in one specific outcome - abstinence (Pattison, 1980).

The problem with the unitary concept is not only the misrepresentation or misinterpretation of Jellinek’s categories, but that this concept, when linked to the disease concept of alcoholism, is used to categorize all people who experience an alcohol-related problem as being an “alcoholic,” regardless of the individualized nature of the drinking-related problem.

Vaillant (1995), in a comprehensive study of the course and consequences of alcoholism among college students, reported that he found a very different pattern of the life course of alcohol abusers from that suggested by Jellinek's model of alcoholism as a progressive disease. Rather than progression, Vaillant indicated alcohol abusers, from age 45 to 70, "got neither better nor worse." He also reported that "alcohol abuse

Evolution of Substance Abuse Treatment 11 April 2003 Institute for Circumpolar Health Studies could continue for decades without remission or progression of symptoms (Vaillant, 1996, p. 243). Consequently, it may be advantageous to replace Jellinek's categories with the concept of "Drinking Careers" (Vaillant, 1995), which refers to how individuals use alcohol and respond to the consequences of abuse in an idiosyncratic manner. Drinking careers are thus influenced by the individual’s culture and social milieu, which shape and encourage certain behaviors and constrain others, and by the individuality of the drinker, by the perceptions and reactions around him/her, by society’s definition of the drinker’s condition, and by individual and social processes of the most diverse kinds. Thus many people who experience drinking-related problems may be alcoholics, but not all drinking-related problems are a representation of alcoholism.

2. Description of the Progression of Alcoholism

In addition to the categorization of alcoholic types, Jellinek (1946, 1952) also formulated a specific description of the natural history or course of the addiction process leading to alcoholism. He described four phases – pre-alcoholic symptomatic, prodromal, crucial, and chronic -- each with a characteristic set of symptoms. Although Jellinek noted that neither the phases, nor their symptoms, nor their order, is universal or consistent, his scheme has been adopted as invariant and as representing a natural progression of the transition of problem drinking into alcoholism. Jellinek's four phases of are. a. Pre-alcoholic Symptomatic Phase: This phase is characterized by occasional drinking in a social context, marked by strong tendencies to drink to seek relief from tension, leading to continued (daily) social use of alcohol to reduce tension. The continued drinking, over time (several months or years), results in a tolerance to alcohol. b. Prodromal Phase: In this phase one experiences the beginning of alcoholism, with such symptoms as alcoholic palimpsests (amnesia not associated with loss of consciousness, but with part of the events that occurred during or immediately after a drinking bout), surreptitious drinking, preoccupation with alcohol and guilt over drinking. c. Crucial Phase: Involved in this phase are loss of control over drinking and alternating periods of abstinence and heavy drinking. This phase represents the "full blown" symptoms of alcoholism, involving denial, personal and family disruptions, attempts to receive treatment, personal and social decline, physical disorders, diminished sex drive, and the like. d. Chronic Phase: Here the drinker experiences prolonged bouts of intoxication leading to severe personal deterioration. Alcoholic psychosis and physical disorders are common, and reverse tolerance may occur. The drinker may drop out of society and assume a skid-row life-style.

Evolution of Substance Abuse Treatment 12 April 2003 Institute for Circumpolar Health Studies D. Adoption of the Disease Concept of Alcoholism

Jellinek's research contributed significantly to advance the disease concept of alcoholism. The notion that alcoholism is a disease became firmly established, and most of the definitions of alcoholism that were to follow contained elements of Jellinek's work. Conrad and Schneider (1980) emphasized the fact that the National Council on Alcoholism (NCA), when developing its criteria for the diagnosis of alcoholism, adopted Jellinek's thinking when the concepts of "early," "middle," and "late" stages of alcoholism were used to describe manifestations of the disease. Conrad and Schneider (1980) indicated further that Jellinek’s work significantly impacted the medical community’s thinking about alcoholism, exemplified by the views of Max Glatt, a prominent physician interested in alcoholism who Conrad and Schneider describes as: "specifically incorporated Jellinek's phases into his own description of alcohol addiction and recovery. He proposed a U-shaped chart, with the base of the U representing the familiar AA view of having to "hit bottom" before starting on the road to "rehabilitation." This chart has become an almost universal tool in alcoholism treatment centers throughout the world to describe the 'natural history' of the disease" (p. 91).

Mark Keller (1960), a disciple of Jellinek, defined alcoholism as follows: "Alcoholism is a chronic disease or disorder of behavior characterized by the repeated drinking of alcoholic beverages to an extent that exceeds customary dietary use, or ordinary compliance with the social drinking customs of the community, and which interferes with the drinker's health, interpersonal relations, or economic functioning" (p. 9).

Although Keller advocated the disease concept, his definition represented a departure from more traditional thinking because it attempted to account for the health and social consequences related to excessive drinking, and it did not explicitly stress "loss of control" as a key element. Nevertheless, Keller was keenly aware that loss of control was an important element in alcoholism, and there is little doubt that his phrase "repeated drinking" implied "loss of control."

The theory of the disease concept of alcoholism achieved significant acceptance when it was endorsed by the American Medical Association (AMA) in 1956. Over ten years later, in its 1977 "Manual on Alcoholism," the AMA, defined alcoholism as "an illness [emphasis added] characterized by significant impairment that is directly associated with persistent and excessive use of alcohol. Impairment may involve physiological, psychological or social dysfunction" (AMA, 1977, p. 3).

In 1972 the National Council on Alcoholism (NCA), a voluntary health organization concerned with the prevention and treatment of alcoholism, and a strong advocate of the disease concept, established specific diagnostic criteria to help physicians and other practitioners diagnose alcoholism (NCA, 1972). The diagnostic criteria consisted of 86 items that represented a wide range of behaviors that are commonly associated with alcoholism drawn from autopsy findings, laboratory tests, surveys of drinking behaviors, and information from family and friends of alcoholics.

Evolution of Substance Abuse Treatment 13 April 2003 Institute for Circumpolar Health Studies The diagnostic criteria were followed in 1976 by a definition of alcoholism prepared by the NCA and the then American Medical Society on Alcoholism (Morse & Flavin, 1992): “Alcoholism is a chronic, progressive, and potentially fatal disease. It is characterized by tolerance and physical dependency or pathologic organ changes or both - all the direct or indirect consequences of the alcohol ingested” (p. 1012).

E. Unitary Disease Concept Changes

Pattison and Kaufman (1982) stated that the questions that arouse from these sets of criteria were manifold and illustrated the problem with diagnosis based only on common signs or symptoms associated with alcoholism. Moreover, this definition did not account for biobehavioral factors, nor address the influence that environmental factors may have in contributing to drinking behavior. Pattison and Kaufman (1982, p. 20) presented four specific criticisms of the early NCA criteria:

1. Emphasis on late adverse consequences of drinking in the items skews the diagnosis toward late stages of alcoholism, and fails to provide diagnostic markers of early or prodromal stages. 2. The emphasis of the criteria is on the indirect consequences of drinking (e.g., marital fighting), which are nonspecific and not unique to or diagnostic of alcoholism. 3. Major emphasis on physical consequences of drinking minimizes diagnostic detection of alcoholics without such physical signs and symptoms. 4. Lack of discriminate validity of items (e.g., odor of alcohol on breath) weakens diagnosis, since an alcoholic may not have been drinking at an interview while a nonalcoholic may have been.

The imprecision of the NCA criteria resulted in further attempts to develop other diagnostic criteria. Many instruments were then introduced to assess the nature and ex- tent of alcoholic drinking, with their item content designed to represent the signs and symptoms of the disease of alcoholism, but many of these scales were inexact and lead to too many false-positive diagnoses of alcoholism. A number of them were constructed on the assumption or premise that alcoholism is a unitary phenomenon, and that its diagnosis involves determining whether one is or is not an alcoholic. Such measurement or diagnostic instruments seek to make a binary type of diagnosis, that is, an either/or decision - either one is an alcoholic or one is not. But, as Pattison and Kaufman (1982) noted: "A binary diagnosis is based on the assumption that there is a discrete entity termed 'alcoholism.' The diagnostic goal is simply to find an effective means to discriminate between those who suffer from alcoholism and those who do not. . . . However, the research data of the past 20 years clearly demonstrate that the unitary concept of alcoholism is incorrect. There is no one entity to which a binary diagnostic method can be applied" (p. 13).

The inexact definition and criteria of alcoholism established by NCA, and the lack of a clear definition within the field of alcoholism, resulted in a revised definition which explicitly specifies the genetic, psychosocial and environmental components of the disease of Alcoholism. This new definition, introduced by the American Society of

Evolution of Substance Abuse Treatment 14 April 2003 Institute for Circumpolar Health Studies Addiction Medicine (ASAM) and the National Council on Alcoholism and Drug Dependence (NCADD), in August, 1992, attempted to keep up with advances in alcohol research. The modified definition follows: "Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic" (Morse & Flavin, 1992, p. 1013).

The following meaning was given to the key words in this definition (Morse & Flavin, 1992, p. 1013):

Primary, refers to the nature of alcoholism as a disease entity in addition to and separate from other pathophysiologic states that may be associated with it. It suggests that as an addiction, alcoholism is not a symptom of an underlying physical disease state.

Disease, means an involuntary disability. Use of the term “involuntary” in defining disease is descriptive of this state as a discrete entity that is not deliberately pursued. It does not suggest passivity in the recovery process. Similarly, use of this term does not imply the abrogation of responsibility in the legal sense. Disease represents the sum of the abnormal phenomenon displayed by the group of individuals. These phenomenon are associated with a specific common set of characteristics by which certain individuals differ from the norm and places them at a disadvantage.

Often progressive and fatal, means that the disease persists over time and that physical, emotional, and social changes are often cumulative and may progress as drinking continues. Alcoholism causes premature death through overdose, through organic complications involving the brain, liver, heart and other organs, and by contributing to suicide, homicide, motor vehicle crashes, and other traumatic events.

Impaired control, means the inability to consistently limit on drinking occasion the duration of the drinking episode, the quantity of alcohol consumed, and/or the behavioral consequences.

Preoccupation, used in association with alcohol use indicates excessive, focused attention given to the drug alcohol, and to its effects or its use (or both). The relative the person assigns to alcohol often leads to energy being diverted from important life concerns.

Adverse consequences, are alcohol-related problems, disabilities, or impairments in such areas as physical health (e.g. alcohol withdrawal syndromes, liver disease, gastritis, anemia, and neurological disorders); psychological functioning (e.g., cognition and changes in mood and behavior), interpersonal functioning (e.g. marital problems, child abuse, and troubled social relationships) occupational functioning (e.g., scholastic or job problems), and legal, financial, or spiritual problems. Although the alcoholic dependency syndrome may theoretically occur in the absence of ad-

Evolution of Substance Abuse Treatment 15 April 2003 Institute for Circumpolar Health Studies verse consequences, it is believed that the latter are evident in virtually all clinical cases.

Denial, is used in the definition not only in the psychoanalytic sense of a single psychological defense mechanism disavowing the significance of events but more broadly to include a range of psychological maneuvers that decrease awareness of the fact that alcohol use is the cause of a person’s problems rather than a solution to those problems. Denial becomes an integral part of the disease and is nearly always a major obstacle to recovery. Denial in alcoholism is a complex phenomenon determined by multiple psychological and physiologic mechanisms. These include the pharmacologic effects of alcohol on memory, the influence of euphoric recall on perception and insight, the role of suppression and repression as psychological defense mechanisms, and the impact of social and cultural behavior.

What this new approach accomplishes, however, is a perpetuation of the disease concept, but one which has been modified to form a broad-based definition to account for some of the biological and psychosocial factors that are believed to be involved in alcoholism. This definition nevertheless stresses an inability to control drinking as an essential element of the disease, and also defines alcoholism in terms of its devastating life-long effects.

These revised definitions, nevertheless, continue to promulgate the core belief about alcoholism that are the fundamental doctrine of AA and its version of the disease concept. Peele (1989) described these beliefs as follows:

1. Alcoholics don’t drink too much because they intend to, but only because they can’t control their drinking. 2. Alcoholics inherit their alcoholism and thus are born as alcoholics. 3. Alcoholism always grows worse without treatment, so that alcoholics can never cut back or quit drinking on their own. 4. Alcoholism as a disease can strike any individual - it is an "equal opportunity destroyer" - and respects no social, religious, ethnic or sexual bounds. 5. Treatment based on AA principles is the only effective treatment for alcoholism - in the words of one proponent, a modern medical "miracle" - without which no one can hope to arrest a drinking problem. 6. Those who reject the AA approach for their drinking problems, or observers who contradict any of the contentions about alcoholism listed here, are practicing a special denial that means death for alcoholics. (pp. 55-56)

Fingarette (1990) presented a more critical analysis of the implication of the disease concept, noting that it had "Embodied four scientifically baseless propositions," (p.48) which are:

1. Heavy problem drinkers show a single distinctive pattern of ever greater alcohol use leading to greater bodily, mental, and social deterioration.

Evolution of Substance Abuse Treatment 16 April 2003 Institute for Circumpolar Health Studies 2. The condition, once it appears, persists involuntarily: the craving is irresistible and the drinking is uncontrollable once it has begun. 3. Medical expertise is needed to understand and relieve the condition (“cure the disease”) or a least ameliorate its symptoms. 4. Alcoholics are no more responsible legally or morally for their drinking and its consequences than ecliptics are responsible for the consequences of their movements during seizures. (p. 48)

Both Peele and Fingarette maintain a fundamental belief that alcoholism is not a unitary phenomena, nor a disease following a prescribed course. Rather, drinking and drinking- related-problems are perceived as variable phenomena, and the idea of a single disease obscures the development of new approaches. The revised definition proliferated by the NCA and the American Society of Addiction Medicine, continues to perpetuate an approach that leaves no alternative but to believe that alcoholism is a lifelong disease, a contention "that is not supported by clinical knowledge and empirical findings" (Grant & Towle, 1991, p. 291).

The disease model gives no possible consideration to the idea that some people can moderate their own drinking, even after drinking excessively over time, and that many others who drink too much may not be alcoholics, even when they do not recognize overindulgence. This orthodoxy, as Peele (1989) commented, achieves a new level of "Catch 22" when it describes a drinker as being in denial because he/she is incapable of rational thought concerning self-reflection about one’s drinking because of a drinking- related impairment of one’s behavioral and biological functioning (e.g., memory, perception, insight, psychological defense mechanisms, ability to interact with one’s social and cultural environment, and the adverse physiological effects of euphoria on the brain). Thus, this approach appears to infer that drinking engenders dysfunctioning which spawns denial as part of the disease. What is wrong with this approach, as Peele (1989) indicated, is that it is a tautology. It simply declares that the activities that go into or result from drinking to be the disease, especially denial. Thus if one denies that they are an alcoholic the very act of denial infers that they are one. The disease model also precludes any alternate theories, and places the alcoholic in a position that declares s/he to be afflicted with a life-long "incurable condition in which they are continuously threatened with "falling off the wagon." If they do relapse, then this happening is a reminder that one is powerless over alcohol. The relapse is also interpreted as reinforcing the disease model.

What is interesting is that despite the assertions of the diseases model that "once an alcoholic always an alcoholic," people do move from heavy drinking to more moderate drinking after they recognize that here is a need to change their drinking behavior. They either do this spontaneously or after a short period of abstinence following a treatment intervention. Early research by Davies (1962), partly in response to Jellinek’s work, reported that out of a sample of 93 alcoholics who were studied, 7 had returned to drinking quite normally after a brief intervention. This disclosure contradicted the disease model because it implied that alcoholism, in some cases, is a transitory condition. Shaw et al. (1978) remarked that Davies’ findings were "not merely a

Evolution of Substance Abuse Treatment 17 April 2003 Institute for Circumpolar Health Studies challenge to the belief that alcoholism could only be arrested by total abstinence, rather it was a challenge to the whole Gestalt of how alcoholism was conceptualized" (pp. 51- 42).

Despite continuing evidence since Davies’ report that people can recover from drinking alcoholically to drinking normally, the disease proponents have not altered their position, claiming that patients who appeared to have recovered were not really alcoholics in the first place. Shaw et al. (1978) summed up the disease model’s position: "…the bulk of the criticism…was based on genuine fears that it might induce abstinent alcoholics to return to drinking in the forlorn belief that they might not necessarily revert to uncontrolled alcoholism" (p. 52). Disease model advocates believed that this new way of thinking about alcoholism would undermine the existing model, which aimed to influence drinkers to accept the identity of being an alcoholic and to embrace what this meant because their only hope of recovery lay in lifelong total abstinence. To people who genuinely held this view, a slogan like "don’t tell me I’m not an alcoholic" was not meant facetiously, and the publication of reports purporting to show that some alcoholics could return to normal drinking only seemed to make their task of education and treatment more difficult than it already was. Those who did not believe a true alcoholic could ever regain control over his drinking became all the more vehement in their claims that the alcoholic had a permanent illness for which there was no cure. An alcoholic who has not touched liquor for 20 years is just as much an alcoholic as he ever was. To tell such a person that he does not have an incurable disease is absolute madness.

Historically, however, the theory of alcoholism as a disease advanced an understanding of alcoholism, and helped to improve its treatment. Primarily, the disease concept helped to remove the moral stigma associated with chronic drinking, making it possible to provide medical and psychological treatment instead of punitive measures. Indeed, "following World War II, public opinion polls indicated a continuous increase in the belief that alcoholism is a disease…[and], in August 1982, a Gallup poll…found that 79 percent of Americans accepted alcoholism as a disease requiring medical treatment" (Peele, 1984, p. 1339). It also effected a change in public opinion that led to a proliferation of treatment facilities and support for research. Room (1980) estimated that there was a 20-fold increase in the number of alcoholics in treatment between 1942 and 1976. As Peele (1984) remarked, "The disease concept has modified our basic conceptions about the nature and prevalence of drinking problems and about the proper type of treatment, and the efficacy of treatment for alcoholism" (1984, p. 1339). But, as Babor (1995), indicated, Jellinek’s conclusions about alcoholism have been accepted uncritically, but he nevertheless credits Jellinek with having made a contribution to the field of alcoholism: "Jellinek’s seminal ideas about the nature and varieties of alcoholism have been accepted by dogma by many students of alcohol problems, ignored as irrelevant by others. Few have attempted to test these ideas empirically, and those who have tried have sometimes lacked the broad historical, cultural and clinical framework that is so characteristic of Jellinek’s work” (p. 1037).

Evolution of Substance Abuse Treatment 18 April 2003 Institute for Circumpolar Health Studies The net effect of perceiving alcoholism as a disease entity, however, has not been entirely positive. The basic assumption involved in the disease concept of alcoholism, that the cause is within the person, conveys the false impression that alcoholism has an agreed-on etiology, for which treatment can be provided. Additionally the disease concept is thought by some to have had a deleterious effect in that it created a self- fulfilling prophecy (Roman, 1968; Roman & Trice, 1967), and that it also succeeded in frightening problem drinkers away from early treatment because of the dictum "once an alcoholic, always an alcoholic" (Reinert, 1968).

Additionally, the impression that alcoholism is a disease that warrants a standardized approach has also fostered the belief that alcoholism is an "all or none" phenomenon, that is, either one has it or one does not - much like cancer or tuberculosis. The problem with this approach is that it runs the risk of obscuring the fact that alcoholism may be a symptom of a number of quite separate conditions.

Roman and Trice (1983), in a further review of the implications of the effects of labeling a person "alcoholic," noted that: "The medico-disease concept of alcoholism and deviant drinking has led to the assignment of the labeling function to medical authorities which in turn has led to the placement of alcoholics and deviant drinkers in 'sick roles.' The expectations surrounding these sick roles serve to further develop, legitimize, and in some cases even perpetuate the abnormal use of alcohol (p. 231)."

Two basic mechanisms were identified by Roman and Trice (1983) through which the labeling process, based on the "disease model of deviant drinking," serves to reinforce deviant drinking behavior. The first is assignment to a sick role, as noted above, as a consequence of being labeled by a physician as manifesting an illness. An implication of this phenomenon is that assignment to a sick role may legitimize deviant drinking behavior because these patterns have been labeled results of pathology rather than as inappropriate behavior, thereby removing the individual's responsibility for his or her drinking behavior.

The second mechanism described by Roman and Trice (1983) that serves to reinforce deviant drinking occurs because "the labeling process may lead to secondary deviance through a change in an individual's self-concept as well as a change in the image or social definition of him by the significant others in his social life space" (p. 232). In this context the drinker occupies a social status that has accompanying role expectations, the principal expectation being involved in deviant drinking behavior. These authors, in addressing the implications of their concerns about the adverse effects of labeling, stated that:

A curious "double-bind" results from this dual operation of these mechanisms. Deviant drinking behavior is legitimized through the disease label in the sense that the individual is no longer held responsible for this behavior and this behavior is very rewarding to him. He is also assigned a social role which invidiously surrounds him with expectations for deviance as well as resulting changes in self-concept. Simultaneously he is expected by significant others in his life space to "shape up,"

Evolution of Substance Abuse Treatment 19 April 2003 Institute for Circumpolar Health Studies seek treatment, and above all, stop drinking. Both this message and the message of his being "sick" appear legitimate but are contradictory. This double-bind may be an invidious cause of his mobility and differential association with those like himself, these behaviors representing the "escape from the field" that is postulated as a solution to a double-bind situation. This double-bind is very reflective of society's ambivalence toward the labeled alcoholic, a sort of half-acceptance of the sick role notion of problem drinking as well as half-acceptance of the criminal, immoral or "enemy" label of this behavior. (p. 232)

Thus, as Roman and Trice remarked, the process of labeling and assignment of a sick role to the problem drinker may serve to "aggravate" and "perpetuate" a condition that was initially under the person's control. Once the disease label is applied, however, the consequences are such that the individual no longer has to maintain control and begins to live up to the role of problem drinker, resulting in increased drinking and more severe adverse consequences.

An alternative to the labeling process is an emphasis on individual responsibility for one's behavior, which involves confronting individuals with their drinking behavior and making the individual responsible for correcting any form of deviant drinking. Roman and Trice call this approach "constructive coercion," and point out that it is best suited in an occupational setting where job-related coercion can be utilized to confront an employee who is a problem drinker.

Peele (1989), in a critical review of the disease model of alcoholism, questions two of the fundamental concepts of the disease model - loss of control and denial. Loss of control over drinking, which is perceived as being synonymous with alcoholism, is represented by an inability to control drinking because the individual is "powerless over alcohol." Due to this loss of control, the alcoholic can never drink again because once he or she starts, they will soon “lose control” and revert to their previous drinking status. The first step of recovery is admitting this powerlessness over alcohol.

Some research findings, however, have questioned the efficacy of the concept of loss of control. Marlatt & Gordon (1985), for example, found that relapsed alcoholics drinking heavy flavored beverages did not drink excessive amounts -- as long as they thought the drinks were nonalcoholic. "Subjects who were led to believe that they were sampling an alcoholic beverage drank significantly more…than did subjects who expected tonic water -- regardless of the actual presence or absence of alcohol in the drinks they consumed" (Marlatt & Gordon, 1985, p. 150). Fingarette (1989) also found that alcoholics "do not ‘lack control’ in the ordinary sense of those words (p. 50)." They have been found to limit their drinking in response to appeals and arguments or rules and regulations. "In experiments they will reduce or eliminate drinking in return for money, social privileges, or exemption from boring tasks" (Fingarette, 1990, p. 50). It may be, as Segal (1991) noted, that rather than a loss of control, many drinkers may drink to maintain or prolong a specific level of intoxication, a phenomenon Segal called "maintenance drinking."

Evolution of Substance Abuse Treatment 20 April 2003 Institute for Circumpolar Health Studies Denial, the refusal or inability of an alcoholic to recognize their alcoholism or loss of control over their drinking behavior, is also an important factor in being an alcoholic, in accordance with the disease concept of alcoholism. The implication of the use of the concept of "denial" is that once an individual is characterized as having the disease of alcoholism, the individual’s refusal or failure to agree with this characterization automatically renders the person as an “alcoholic,” because he/she is denying their drinking problem.

This belief is transformed into the following dialogue given by an AA member to new affiliates: "If you think you have a problem, or if you think you are an alcoholic, I assure you that you are. You wouldn’t be thinking about it and you wouldn’t be here if you weren’t an alcoholic" (cited in Peele, 1985, p. 90). Based on this philosophy it can be concluded that "if you think you have a drinking problem, you have one."

One implication of this approach is that denial, whatever the nature of the drinker’s condition or pattern of drinking, is used as evidence that they are really alcoholic or addicted. Denial has to be overcome if treatment is to be successful. A second implication is that alcoholics may learn their role or develop their symptom picture based on how the disease model characterizes the alcoholic.

Another limitation of the disease model is its conception of the unitary concept of alcoholism; that is, that there is one discrete disease entity that can be defined as the disease of alcoholism. Fingarette (1990) stated that: "The idea of a single disease obscures the scientific consensus that no single cause has ever been established, nor has any biological causal factor ever been shown to be decisive. Heavy drinking has many causes which vary from drinker to drinker, from one drinking pattern to another. Character, motivation, family environment, personal history, ethnic and culture all play a role. As these change, so do patterns of drinking, heavy drinking, and 'alcoholism' ” (p. 50).

A further implication of the disease concept, as described above, is that it does not hold the individual responsible for his/her behavior while the person is/was drinking. The validity of this belief, and by definition the concept of alcoholism as a disease, was recently tested before the Supreme Court in a case concerning a regulation by the Veterans Administration (VA), which labeled alcoholism -- separate from the physical problems it causes -- as willful misconduct (Powell vs. Texas, 1968; Traynor vs. Turnage, 1988).

The case combined suits brought by two veterans, both recovering alcoholics, who sought extensions of their eligibility for educational benefits on the grounds they had been unable to use these benefits because they were disabled by alcoholism. Their claim was upheld in federal district court in 1985, but the case was appealed by the VA and reversed by higher courts. The case was ultimately submitted to the Supreme Court.

Evolution of Substance Abuse Treatment 21 April 2003 Institute for Circumpolar Health Studies Their suite claimed that the VA violated Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination on the basis of handicaps, including a history of alcoholism. The VA contended that the Veteran’s Benefit Law precludes federal review of the agency’s position.

The VA, in its treatment of alcoholism, defines alcoholism as "primary" or "secondary." Primary alcoholism is alcoholism unaccompanied by physical or mental disorders, and thus represents "willful misconduct." In other words, the behavioral concomitants of alcoholism -- compulsive drinking and alcohol-induced behavior -- are not regarded as components of the disease, but represent physical sequelae. This form of alcoholism qualifies as a disability. Secondary alcoholism is defined as alcoholism secondary to and a manifestation of an acquired psychiatric disorder, and does not qualify as a disability.

The United States Supreme Court, rendering its decision in April, 1988, (Traynor vs. Turnage, 1988) found for the VA. In its decision the Court stated that alcoholics are responsible for their drinking, and that medical evidence does not demonstrate their drinking to be involuntary.

The implications of this decision concerning the treatment of alcoholism were not to be experienced. Congress, responding to pressure from the National Council on Alcoholism (NCA), quickly initiated legislation in October, 1988, which provided that the disabling effects of chronic alcoholism shall not be considered to be the result of willful misconduct.

A voice of reasonableness in this "either/or" debate over the nature of alcoholism is that of Vaillant (1983, 1995), who has been affiliated with a collaborative study of alcoholics that has continued for over 45 years. Based on a longitudinal (or prospective) study of drinking and its effect in a sample followed from adolescents into late middle life, Vaillant raised seven questions that he believes need to be answered if any understanding of alcoholism is to evolve. They are:

• Is alcoholism a symptom or a disease? • If alcoholism is a disease, is it progressive? • Are alcoholics premorbidly different from other people? • Are alcoholics when abstinent often worse than they were when drinking? • Is return to asymptomatic drinking possible for alcoholics? • How does clinical intervention alter the natural history of alcoholism? • In treating alcoholism, what is the relevance of Alcoholics anonymous?

Vaillant's answer to the first question is that "no single set of traits invariable defines alcoholics" (p. 376)l it is the number and the frequency of alcohol-related problems, rather than the specificity of such problems, best defines the clinical phenomenon known as alcoholism. He stated that:

Evolution of Substance Abuse Treatment 22 April 2003 Institute for Circumpolar Health Studies Just as light can consist of both waves and particles, just so alcoholism can exist both as one end of a continuum of drinking problems and as a specific disorder. Alcoholism can simultaneously reflect both a conditioned habit and a disease; and the disease of alcoholism can be as well defined by a sociological model as by a medical model. This alcoholism is a construct of a higher order complexity than, say, pregnancy or measles. Where along the continuum of alcohol-related problems one makes their cutting-off point for the diagnosis of alcoholism is obviously arbitrary.

While it is probably true that loss of control over the ingestion of alcohol is neither a necessary or sufficient criteria for diagnosing alcoholism, it is true that once individuals experience many alcohol-related problems, they may perceive themselves and others perceive them as no longer in control of their use of alcohol Patterns of alcohol use vary enormously, but the further along the continuum of alcohol-related problems individuals find themselves, the more they resemble other alcoholics. (pp. 376-377)

The answer to the question of whether alcoholism is a progressive disease, according to Vaillant, is that it gives all the appearance of being so, but some individuals can abuse alcohol without exhibiting gross progression. Nevertheless, Vaillant notes that:

Once it develops, alcoholism is a chronic disorder. Insidious, fulminating, and intermittent courses are all common; so is recovery…[and] alcoholism can e conceived as broadly comprising three linked stages. The first stage is heavy "social" drinking - frequent ingestion of two to three ounces of ethanol (three to five drinks) a day for several years. This stage can continue asymptomatically for a lifetime; or because of a change of circumstances or peer group, it can reverse to a more moderate pattern of drinking; or it can "progress" into a pattern of alcohol abuse (multiple medical, legal, social, and occupational complications), usually associated with frequent ingestion of more than four ounces of ethanol (eight or more drinks) a day. At some point in their lives, perhaps 10-15 percent of American men reach this second stage. Perhaps half of such alcohol abusers either return to asymptomatic (controlled) drinking or achieve stable abstinence. In a small number of cases…such alcohol abuse can persist intermittently for decades with minor morbidity and even become milder with time…The last stage is much less plastic than the earlier stage and most commonly ends either in abstinence or in social incapacity or death. (p.379)

In response to the question, are alcoholics premorbidly different from other people? Vaillant indicates that although there does not seem to be evidence identifying an "alcoholic personality," his research revealed three areas in which alcoholics appeared to be premorbidly different from asymptomatic drinkers: (a) Alcoholics are more likely to come from ethnic groups that tolerate drunkenness and discourage children and adolescents from learning safe drinking practices; (b) Alcoholics are more likely to be related to other alcoholics; and (c) Alcoholics, compared to asymptomatic drinkers, are more likely to be premorbidly antisocial, perhaps more extroverted, but not more dependent. Vaillant summarizes the situation as follows:

Evolution of Substance Abuse Treatment 23 April 2003 Institute for Circumpolar Health Studies …alcoholics often come from broken homes because their parents abused alcohol, not because broken homes cause alcoholism; and alcoholics are selectively personality disorder as a consequence, not as a cause of their alcohol abuse. Although the conscience may be soluble in alcohol, heavy alcohol use does not relieve anxiety and depression as much as alcohol abuse induces depression and anxiety' (p. 381).

The question of whether abstinence is beneficial or not in the treatment of alcoholism is that abstinence is appropriate and advantageous when heavy drinking was involved, and that without sobriety there is little chance that psychological recovery will occur while people continue to drink abusively.

The reply to the question can alcoholics return to asymptomatic drinking, as answered by Vaillant, is "yes," but only in the form of "controlled drinking," and not in the manner of drinkers who have never experienced subjective loss of control. Vaillant added that:

when young alcohol abusers without dependence altered their peer group, they often returned to asymptomatic drinking, whereas when middle-aged alcoholics who had required detoxification attempted to return to asymptomatic drinking, their situation was analogous to driving a car without a spare tire - disaster was usually only a matter of time. In other words . . . by the time an alcoholic is ill enough to require clinical treatment, return to asymptomatic drinking is the exception, not the rule. (p. 383)

Vaillant's answer to the question: "How does clinical intervention alter the natural history of alcoholism?" has profound implications. He states that:

…alcoholics recover not because we treat them but because they heal themselves. Staying sober is not a process of simply becoming detoxified but often becomes the work of several years or in a few cases even a lifetime. Our task is to provide emergency medical care, shelter detoxification, and understanding until self-healing takes place. In any treatment cohort of alcoholics patients, I have found that 10-20 percent never relapse after their first serious request for help; and that thereafter, depending upon the characteristics of the sample, 3-3 percent will achieve stable recovery each year. (p. 384)

Vaillant goes on to state that:

Neither the efforts of dedicated clinicians nor the individual's own willpower appear to be able to cure an alcoholic's conditioned habit at a given time. This should not be a cause for despair but should spur the clinician to redirect therapeutic attention toward the individual's own powers of resistance. Not only is the patient's social stability (at the time of seeking treatment) important to sustained abstinence, but so are four other factors…Namely, recovery is associated with the alcoholic discovering: (1) a substitute dependency; (2) external reminders (such as disulfiram ingestion or a painful ulcer) that drinking is aversive; (3) increased sources of

Evolution of Substance Abuse Treatment 24 April 2003 Institute for Circumpolar Health Studies unambivalently offered social support; and (4) a source of inspiration, hope, and enhanced self-esteem (such as religious activity) …Alcoholics Anonymous, or any reasonable facsimile, appears to be an effective means of bringing all these four factors together. (p. 385)

Finally, the answer to the question of whether Alcoholics Anonymous is relevant in treating alcoholism, is "yes," according to Vaillant. "…a great many severely alcohol- dependent Americans, regardless of their social or psycho-logical makeup, find help for their alcoholism through Alcoholics Anonymous" (p. 388), which assists them to achieve and maintain stable abstinence.

In conclusion, the disease model of alcoholism has generated significant controversy, and its adherence to the unitary concept of alcoholism is pervasive. Stockwell (1995), however, conveys that "It is important to be reminded on a regular basis that several influential schools of thought flourish in different parts of the world; which have fundamentally different things to say about the nature of alcohol problems [than the disease concept]" (p. 1039). Thus, the net result of this ongoing debate is a general uncertainty or confusion about the role and function of alcohol, particularly in American society, and the nature of alcoholism and its treatment. Anderson (1967) described of the current dilemma in the following terms: Americans are anxious, confused, ambivalent, and guilt ridden in their attitudes toward beverage alcohol. Clinicians, theoreticians and practitioners are divided among opposing viewpoints, sparking controversy. We tend to be confused about our reasons for drinking and those for not drinking, and the methods with which we address alcohol-related problems. We tend to communicate this conflict to the public, and it only creates more confusion, which is reflected in local option laws, legal controls, and cultural inconsistencies and ambiva- lence. Thus despite the fact that beverage alcohol has been rooted in different cultures since the beginning of history, there is little evidence that our contemporary attitudes towards its functions and use are consistently reasonable and practical.

F. Dual Diagnosis/Comorbidity

Dual diagnosis, also known as co-morbidity, refers to the occurrence of two separate diagnostic disorders in a single person. Concerning drug-taking behavior, co-morbidity (or dual diagnosis) refers to a substance abuse disorder together with a psychiatric disorder. Research has shown that it is common for certain psychiatric disorders to occur more frequently in alcoholics and drug abusers than among the general population (Woody, 1996).

Attia (1988) reported that 60% of the patients in both inpatient and outpatient mental health facilities presented alcohol- or drug-related problems. Sobell (1991) indicated that: (a) 30 percent of adults who had a mental disorder also had an alcohol or drug problem or both; (b) 53 percent of adults who had a drug abuse problem also had one or more mental disorders, and 37 percent of adults who had been alcohol abusers also had one or more mental disorders. It was also reported by Sobell that: (a) 64 percent of a sample who sought outpatient treatment for a drug abuse problem also had a mental

Evolution of Substance Abuse Treatment 25 April 2003 Institute for Circumpolar Health Studies health problem during the previous 6 months; (b) 55 percent of the sample who sought treatment for an alcohol abuse problem had a mental disorder in the past six months; (c) 20 percent of the patients at a mental health clinic also had a substance abuse problem during the past 6 months; and (d) 72 percent of institutionalized adults had both mental health and substance abuse disorders. Findings from a large epidemiological study of the general population (cf. Woody, 1996) reported that lifetime prevalence for any psychiatric or alcohol- or other drug-related disorder was 34 percent among people with an alcohol disorder 44 percent also had a psychiatric disorder; among people with drug-use disorders, 64.4 percent also experienced a psychiatric condition. Kessler et al. (1996) also found a high prevalence rate for mental disorders among persons with a current or lifetime alcohol or drug (AOD) diagnosis than among those who had never experienced AOD problems.

Attia (1988) noted that "dual diagnosis patients -- those exhibiting symptoms of psychiatric illness and addictive disease -- have been misdiagnosed and mistreated" (p. 53). This finding has important implications for mental health and alcohol and drug treatment programs. If dual diagnosed cases are not identified, this oversight offers an explanation for why some treatments may not be working. Additionally, although an alcoholic or drug user may be detoxed and achieve sobriety, failure to recognize an underlying depression, for example, is likely to increase the chances of a relapse. Conversely, if treatment is provided while a person is actively experiencing a mental disorder, such as a schizophrenia or a mood disorder, while still drinking or using drugs, a successful outcome in unlikely.

An important issue involved in dual diagnosis is whether the dually diagnosed problem is a function of being an alcoholic or addict (a correlational relationship), an antecedent of drinking or drug use (an etiological relationship), or a consequence of the substance- abusing behavior (a correlational relationship). Moreover, one illness may be active, the other inactive, both may be active, or both may be inactive. Stated differently, does one condition, such as alcoholism, account for the onset, for example, of depression? Or are both alcoholism and an inherent propensity to depression necessary before depression manifests itself in an alcoholic? Additionally, given the high occurrence of depression and alcoholism, does their coexistence represent a predisposition to both illnesses within the same individual? These latter questions point to genetic factors as a strong influence on dual diagnosis, but these is "insufficient data available to seek consensus on the genetics of dual diagnosis" (Coryell, 1991, p. 37).

There are five possible conditions that exist regarding the relationship between addictive behavior and coexisting psychopathology:

1. Psychopathology may serve as a risk factor for addictive disorders. Research has shown that there is a relationship, between trauma-related experiences in childhood and the development of socially deviant behaviors involving substance abuse, particularly in young people, which leads to the notion that use of psychoactive substances may represent an attempt at self-medication. This self-medication hypotheses suggests that substance use provides relief from some aspect of one's

Evolution of Substance Abuse Treatment 26 April 2003 Institute for Circumpolar Health Studies pathology, which may be viewed from psychopharmacological, behavioral, or psychodynamic perspectives.

2. Psychopathology may modify the course of an addictive disorder in terms of rapidity of onset, response to treatment, symptom picture, and long-term outcome.

3. Psychiatric symptoms may develop in the course of chronic intoxications.

4. Some psychiatric disorders emerge as a consequence of use and persist into the period of remission. Certain street drugs may activate part or parts of a disorder which in turn may exacerbate the substance abuse, each feeding the other in a complex, counterproductive manner. For example, amphetamines, PCP, or alcohol, alone or in combination, can induce paranoia. What happens when such paranoia is induced in a person who is actively schizophrenic? It can result in more substance use to anesthetize the unwanted fears, which then leads greater paranoia, resulting in greater fears, and so on.

5. Substance-using behavior and psychopathological symptoms (whether antecedent or consequence) will become meaningfully linked over the course of time.

Two other considerations are: (a) drinking or alcohol withdrawal can produce symptoms that mimic those of an independent disorder, and (b) both alcoholism and a psychiatric disorder may be caused by a separate (third) condition.

There are several types of psychopathology found in patients with addictive disorders. The recognition that people with drinking-related problems may also experience psychiatric conditions has resulted in the development of more specialized screening and diagnostic procedures to identify dual-diagnosed patients, and in the emergence of specialized treatment approaches to address their needs. The principal issue in treating dual diagnosed individuals, however, is whether to treat the disorders sequentially or concurrently. Research (c.f., Woody, 1996), suggests that the best type of treatment is an integrated approach that combines elements of psychiatry and alcohol or drug treatment in a single program.

G. Multidimensional Concepts of Drinking-Related Problems

The multidimensional approach, in contrast to single-process theories, postulates that drinking can result in a broad range of different effects that are interrelated with other problems of life functioning. This approach, also referred to as a multivariate concept of alcoholism, does not discount the fact that there can be a progression of the severity of one's drinking problem.

Rather than advancing the concept a unitary course of alcoholism, the multivariate concept stresses that "significant symptoms associated with alcohol use will vary with each person in accord with his/her own life history" (Pattison, 1980, p. 186). The finding by researchers that there are different or distinct types of common clinical syndromes associated with problem drinking (Morey et al. 1984; Nerviano, 1976) attested to the notion that there is significant variability in the sequential ordering of the signs and

Evolution of Substance Abuse Treatment 27 April 2003 Institute for Circumpolar Health Studies symptoms of alcoholism. Additionally the inability to identify a single dimension representative of an alcohol-dependence syndrome attested further to the need for an alternative to the unitary or single-process model of alcoholism (Chick, 1980).

The multidimensional approach, as an alternative to the disease concept, emphasizes that: "There are multiple patterns of dysfunctional alcohol use that occur in multiple types of personalities, with multiple combinations of adverse consequences with multiple prognosis, that may require different types of treatment interventions" (Pattison & Kaufman, 1982, p. 13). The multivariate approach would utilize a multivariate assessment (see above) to determine the nature of the drinking (or drug-related) problem, to derive an appropriate diagnostics category, and to determine the type of intervention needed.

This strategy differs from the traditional disease model way of thinking because it advocates against placing heterogeneous patients in unidimensional treatment programs. Rather, the multidimensional approach stresses the need for specific and efficient interventions that match client needs, and recognizes that different outcomes may be associated with different treatment strategies. The NIAAA, after reviewing the status of alcohol treatment, noted that:

The traditional concept of alcoholism as a unitary disease has been challenged. Over the past decade, researchers and clinicians have come to realize that multiple patters of alcohol use may result in multiple forms of disability. Accordingly, a new emerging model of treatment stresses that the heterogeneous nature of the client population, the need for more specific and efficient treatments, and the importance of maintaining gains after treatment. This model differentiates among alcoholics (e.g., depressed vs. nondepressed) and attempts to match each type with the most appropriate combination and configuration of treatments. (NIAAA, 1983, p. 116.)

In 1997 the NIAAA restated its earlier call for advancement in treatment of alcoholism by advocating that there is "a need to develop comprehensive models of the varied elements of alcohol treatment and explain the relationships, structures, incentives, integration, and interaction at work in these components" (p. 21). Pattison and Kaufman (1982, pp. 13-14), in their early work on the development of a multivariate model of alcoholism, attempted to address such needs through the assumptions inherent in their multidimensional model:

1. There are multiple patterns of use, misuse, and abuse that may be denoted as a pattern of alcoholism. 2. There are multiple interactive etiological variables that may combine to produce a pattern of alcoholism. 3. All persons are vulnerable to the development of some type of alcoholism problem. 4. Treatment interventions must be multimodal to correspond to the particular pattern of alcoholism in a specific person.

Evolution of Substance Abuse Treatment 28 April 2003 Institute for Circumpolar Health Studies 5. Treatment outcomes will vary in accordance with specific alcoholism patterns, persons, and social contexts. 6. Preventive interventions must be multiple and diverse to address diverse etiologic factors.

The findings from a study by the Institute of Medicine that reviewed the status of alcohol problems in the nation (Institute, 1990), indicated that a shift to a multi-dimensional approach would be advantageous. The study concluded that:

Although it is convenient to use a single term to designate the focus of treatment efforts, the committee places string emphasis on the heterogeneity of the target population. In many crucial respects alcohol problems, as well as the individuals who manifest them, are quite different from one another. Present knowledge sug- gests that the cause of alcohol problems are multiple and diverse, and long experience indicates that alcohol problems present for treatment in many different forms and guises and follow a variety of courses.

The…differences among alcohol problems and among individuals are viewed as potentially relevant to treatment. Hence, they must be comprehensively assessed on an individual basis prior to treatment and taken into account in selecting that treatment or treatments that are most likely to associated with a favorable outcome. Treatment so conceived is a more complex matter than is sometimes recognized. Nevertheless, considering the complexity of the problems themselves and of the individuals who manifest them, the committee believes that effective approaches to treatment for alcohol problems must be able to cope with these complexities. (Institute, 1990, pp. 37-38)

The multivariate approach has not totally replaced the disease concept of alcoholism, but it is beginning to be recognized by the scientific community, medical practitioners, and treatment professionals as an alternative to the disease concept. As research con- tinues to develop the concept of a multidimensional approach, its utility should be more applicable for the diagnosis, treatment, and prevention of alcohol- and drug-related problems. Until such models are utilized, as Hilton et al. (2001) noted, we can only offer little in the way of advancement in the delivery of alcohol treatment services.

H. Examples of Alternative Approaches to Substance Abuse Treatment

1. Cognitive Social Learning Theory Approaches to Alcoholism

The cognitive social learning approach differs from more traditional theories with respect to assumptions about the nature of drinking and the development of alcohol- related problems. Problem drinking, within the context of this approach, is perceived as a multiply determined, learned phenomenon, that can best be understood through the empirically derived principles of social learning theory, cognitive psychology, and behavior therapies. The approach focuses on (a) the observable aspects of drinking behavior, including the frequency, quantity and duration of drinking and problems linked to excessive drinking, with an emphasis on situational and environmental antecedents;

Evolution of Substance Abuse Treatment 29 April 2003 Institute for Circumpolar Health Studies (b) the person's past learning history, prior experience with alcohol; (c)cognitive processes and expectations about drinking itself and the effects of alcohol; (d) on the consequences of drinking; and (e) on the social and interpersonal reactions experienced while drinking. Particular significance is given to identification of the factors that reinforce drinking behavior.

All drinking behavior is assumed to be governed by principles of learning and reinforcement. Drinking is perceived to be on a continuum ranging from social drinking to problem drinking. A problem drinker is one whose drinking negatively effects one's social and emotional functioning, occupation, physiological process and mental functioning. The frequency of the problems related to drinking is indicative of the seriousness of the drinking problem.

The expectancies that the person has about drinking and its effects, the nature of one's adaptive skills, the extent of one's perception of self-efficacy, and the degree to which one believes that they are in control of their behavior, all interact to influence drinking behavior. A lowered sense of control is associated with higher stress levels, which contributed to drinking as means of reducing stress. Helping the person to reduce stress, through gaining a sense of control, both perceived and experienced, will contribute to eliminate or reduce excessive drinking. Treatment, or intervention, focuses on helping the person change cognitive structures to achieve a sense of self-efficacy and to enhance one's perception of personal control.

In summary, the cognitive social learning model provides a direct contrast to the disease concept. It suggests that drinkers are capable of controlling drinking behavior, which can be attained by concentrating treatment on developing social skills, both generalized and specific to high-risk drinking situations, perceived control, enhanced self-efficacy and relapse prevention techniques.

2. Alcoholism and Drug Addiction as a Brain Disease: From Research to Practice

Addiction begins when an individual makes a conscious choice to use drugs (alcohol and other psychoactive substances), but addiction is not just "a lot of drug use." Recent scientific research provides over-whelming evidence that not only do drugs interfere with normal brain functioning creating powerful feelings of pleasure, but they also have long-term effects on brain metabolism and activity. At some point, changes occur in the brain that can turn drug abuse into addiction, a chronic, relapsing illness. Those addicted to drugs suffer from a compulsive drug craving and usage and cannot quit by themselves. Treatment is necessary to end this compulsive behavior, but such treatment has to develop improved strategies that incorporate new knowledge about the nature and course of addiction as a function of a disruption of the brain's normal ability to control the body's movements, balance, coordination, memory and judgment abilities, sensations and cognitive functions.

In almost all instances psychoactive drugs achieve their effects because the molecular structure of the drug is similar to the molecular structure of one or more

Evolution of Substance Abuse Treatment 30 April 2003 Institute for Circumpolar Health Studies neurotransmitters in the CNS. Because of this structural similarity, drug molecules interact with one or more of the stages in the process of neurotransmission. Repeated use of a drug results in chemical and molecular alterations in the brain, and such changes have become equated with drug dependence. Although a person can be introduced into using drugs because of genetic, psychological or sociocultural factors, once a drug (or drugs) is (are) taken, the drug-taking behavior itself can promote continued drug-seeking behavior by acting directly on the brain.

Continuous drug use leads to a cascade of intracellular events that changes the excitability of cells and ultimately alters neuronal circuit activity. These alterations are believed to elicit changes that provoke acute positive reinforcing effects because of drug interactions with individual transmitter systems within the general reward circuitry of the brain. The rewarding or reinforcing properties of drug(s) used are what contributed to continued drug-taking behavior, which can lead to further changes in other neural processes, encompassing neurobiological processes related to long-term drug effects that consequently lead to tolerance, sensitization, dependence and withdrawal.

Drug-taking behavior, over a period of time, can thus result in neuroadaptations in the brain's reward system, accompanied by the onset of addictive behaviors that can involve the same systems underlying acute drug reinforcement systems. These changes in the reward circuitry promote compulsive drug use in part by increasing a drug's positive (e.g., sensitization) and negative (e.g., counter-adaptation) reinforcing effects. These chemical changes are the basis for defining drug addiction as a "brain disease."

Current research reports show that prolonged drug use changes the brain in fundamental and long lasting ways, and that these long-lasting brain changes are a major component of the addiction itself. It is as if there is a "switch" in the brain that turns on at some point during a person's drug-taking career. This switch "flips on" at different points for different drugs and different individuals, but once it is on, it fundamentally changes the user from a drug user/abuser to a drug addict. Hence, the problem has become that of a 'brain disease."

Although the precise molecular structure of "the switch" is not known, there is nevertheless an understanding of some of the mechanisms that are involved when brain changes occur. For example, researchers have implicated activation of the brain's mesolimbic dopamine system as a common dominator in at least the acute effects of all drugs of abuse.

Some of these long-Iasting brain changes are idiosyncratic to specific drugs, whereas others are common to many different drugs. These changes have been observed through the use of recently developed technologies, such as positron emission tomography. The common brain effects of addicting substances suggest common brain mechanisms underlying all addictions.

Evolution of Substance Abuse Treatment 31 April 2003 Institute for Circumpolar Health Studies Very recent research has reported that a single use of cocaine can modify neural connection in the brain. Scientists found that a single injection of cocaine induced a long-lasting (between 5 and 10 days) increase in excitatory synaptic transmission in the ventral tegmental area of the brain in rats and mice. The increase in synaptic currents that were activated by cocaine had many similarities to the changes in neural activity involved in learning and memory processes in many areas of the brain. These immediate effects may help explain cocaine’s ability to take of incentive-motivational systems in the brain and produce compulsive drug-seeking behavior.

Researchers have also found that repeated exposure to cocaine causes a genetic change that leads to altered levels of a specific brain protein called cyclin-dependent kinase (Cdk5). Cdk5 has been found to regulate the chemical action of dopamine. Dopamine is the neurotransmitter associated with cocaine’s pleasurable “rush” and with addiction to cocaine and other drugs. Changes in Cdk5 levels alters dopamine functioning, leading to adaptive changes in the brain related to cocaine addiction.

Understanding that addiction, at its core, is a consequence of fundamental changes in brain function does not mean that an addict cannot stop using -- only that doing so is difficult and often requires treatment and major lifestyle changes. Addicts can learn to change their behavior. Treatment of and recovery from addiction are possible. Steven Hyman, former director of the National Institute of Mental Health, compares the disease of addiction to heart disease, which may also necessitate major lifestyle changes. He said "we don't blame them for having heart disease, but we ask them to follow a certain diet, to exercise, to comply with medication regimes. So it is with the addicted person -- we shouldn't blame them for the disease, but they should be treated as having responsibility for their recovery." The easiest way of avoiding such a situation, however, is to not become involved in using drugs.

In summary, that addiction is so clearly tied to changes in brain structure and function is what makes it, fundamentally, a brain disease. A metaphorical switch in the brain seems to be thrown following prolonged drug use. Initially, drug use is a voluntary behavior but as that switch is thrown, the individual moves into the state of addiction, characterized by compulsive drug seeking and use.

Understanding that addiction is, at its core, a consequence of fundamental changes in brain function means that a major goal of treatment must be either to reverse or to compensate for those brain changes. This could be accomplished through either medications or behavioral treatments (behavioral treatments alter brain function in other psychobiological disorders).

Evolution of Substance Abuse Treatment 32 April 2003 Institute for Circumpolar Health Studies

III. Treatment Settings

Treatment for alcoholism involves a wide array of settings that utilize many different program formats. Such settings can generally be classified into three major categories: (1) inpatient or residential, consisting of intermediate- and long-term programs; (2) tran- sitional care; and (3) outpatient programs.

A. Inpatient/Residential Treatment

Inpatient/residential treatment involves care for periods of up to 30 days, but some programs may retain clients for longer or shorter periods of time. A residential or inpatient program generally provides medical and supportive services for patients requiring 24-hour supervision in a hospital or other suitably equipped and licensed facility for the treatment of alcohol problems. Patients may be admitted directly into such programs following detoxification, or may be referred by physicians, the courts, or health and social agencies, or they may be self-referred. These programs are sometimes called intermediate care programs, in that patients have traditionally been admitted subsequent to detoxification and, upon completion of the program, may be referred to a long-term program, a residential center, or outpatient treatment. Inpatient programs may be part of a unit in a public or private general hospital, a private specialized hospital, or a specialized residential program.

Residential treatment involves participation in a highly structured program in a supportive environment designed to help patients deal with their drinking behavior. Such treatment is utilized for persons who require intensive intervention and who need to be separated from their day-to-day environment to overcome their abusive drinking. It also allows supervised medical treatment to be undertaken, if warranted. Inpatient programs provide individual, group, and family counseling, as well as other therapeutic activities to assist in rehabilitation.

Extended- or long-term- care programs provide inpatient or residential treatment for periods that extend beyond 30 days. Such program, to which patients are referred after discharge from intermediate care, are designed to provide supportive treatment for up to an additional 60-, 90- or 120-day period for patients who need more time to recuperate. The extended treatment program, in addition to continuing to provide counseling, usually focuses on helping patients develop life skills that will help to prepare them to assume a responsible role when they return to the community. New job skills, or updates on old ones, are taught, and vocational rehabilitation training helps the clients to prepare themselves for competing in the job market. The extended care also provides patients with sufficient time to restructure family lives or, in cases where they are without a support system, to begin to work on developing a nonalcoholic support group.

Three examples of inpatient programs, based on a disease model approach, are described below. These programs, which have incorporated medical, social and

Evolution of Substance Abuse Treatment 33 April 2003 Institute for Circumpolar Health Studies psychological components, have emerged as prototypes in the field of alcoholism treatment.

1. The Minnesota Model

The Minnesota Model or treatment approach combines the traditional disease model of alcoholism, reflected in the beliefs espoused by AA, with “professional diagnostic and treatment activities” (Institute, 1990, p. 58). The four-week inpatient program consists of detoxification, education (based on the disease concept), confrontation, participation in AA, and antabuse. This approach places strong emphasis on the use of recovering alcoholics as primary counselors, who guide the person through a multidisciplinary program that attempts to merge the medical, psychological, and sociocultural models (Institute, 1990, p. 58). Also incorporated into the Minnesota model is diagnostic and referral services, extended care, halfway houses, outpatient care, aftercare and a family program.

2. The Hazelden Model

The Hazelden model involves detoxification, lasting between 2 to 7 days and highly structured and intensive primary care that can last up to 60 days. The treatment encompasses a psychological evaluation and two treatment tracks, a general and individualized programs. The essence of the general track is frequent meetings of small task-oriented groups and daily lectures. The individualized program involves meeting with a primary counselor, work assignments, and referral for medical, psychiatric or social services, if necessary.

3. The Johnson Institute Model

The premise of the Johnson Institute’s model, which is similar to Hazelden’s, is that alcoholism or drug abuse are major disorders that require treatment in their own right because they represent an expression of an underlying psychiatric disorder. Treatment involves an intensive inpatient program lasting about four weeks, followed by prolonged outpatient aftercare, lasting up to two years. Inpatient treatment, which takes place in a general hospital setting, involves observation and detoxification, followed by rehabilitation. The outpatient treatment phase involves group therapy, consultation and counseling, weekly AA meetings, and family participation in Al-Anon and Alateen. Recovery involves full participation in the two year program.

Residential (or inpatient) programs have undergone substantial transformations during the past few years, largely attributable to changes in hospitalization benefits provide by health insurers. Due to increased costs, and questions about treatment effectiveness (given the large number of readmissions by insurees), health insurers reduced the number of days covered and limited hospitalization to 21 days or less. Thus, length of stay has decreased dramatically (in some cases to less than a week), and emphasis has shifted to less costly outpatient services. Additionally, younger, polydrug using

Evolution of Substance Abuse Treatment 34 April 2003 Institute for Circumpolar Health Studies clients, has resulted in the necessity for more innovative approaches to address the needs of this substance abusing group.

B. Transitional Care

In many instances patients, after discharge from an intermediate care program, or even after a long-term-care program, are not ready to return to the community. A gradual reentry process is needed, and transitional care helps individuals to reestablish themselves slowly in the community. Many persons who require such programs have no roots in the community and are in need of continued support to make it on their own after discharge from a long-term residential program.

One form of intermediate care is day care (partial hospitalization), in which the client spends the day in a structured program, and returns home, or to a halfway house, during evenings and weekends. A variation of the day hospital is a weekend program, in which clients return over the weekend to engage in supportive activities. Another type of intermediate care is a night program, in which participants return to the program after work, or after being at home during the day, to sleep; clients are engaged in counseling activities in the evening.

The major method of providing transitional care, however, is by means of halfway houses, which serve as temporary group live-in facilities for those who have been discharged from residential programs. Halfway houses offer a supportive environment to assist clients to maintain sobriety and to work toward establishing independent living. A variety of rehabilitative services are available, ranging from individual and group counseling to vocational and educational training.

C. Outpatient Treatment

Outpatient treatment, provided by either private or publicly funded programs, has become the type of treatment most often employed for individuals experiencing alcohol- related problems. Outpatient services may be delivered by units in a general hospital, veteran's hospitals, psychiatric clinics, specialized alcohol treatment facilities, or community mental health centers, or by self-help groups. Of the last, Alcoholics Anonymous (AA) handles the largest share of individuals seeking help for drinking problems outside of a professional setting. The major benefit of outpatient treatment is that it allows people to maintain their daily life while receiving help.

McCaul and Furst (1994) described two types of outpatient settings:

(a) Intensive Outpatient Care, which provide service ranging from 8 hours a day, seven days a week, to three hours daily, several days per week. The advantage of intensive outpatient treatment is that it provides a secure setting in which clients can be provided comprehensive services, and can serve a larger number of clients compared to an inpatient program, thereby resulting in greater cost effectiveness, a concern, as noted above, expressed by health insurers.

Evolution of Substance Abuse Treatment 35 April 2003 Institute for Circumpolar Health Studies (b) Regular Outpatient Care, in which services are provided after discharge from a residential or intensive outpatient program, usually involving clients in weekly group sessions and in individual counseling once or twice weekly. Participation in AA meeting is often involved, and family therapy may be offered when appropriate.

The length of stay in either form of outpatient care is related to the accomplishment of treatment objectives established by the counselor in consultation with the client.

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IV. Treatment Approaches

Although different approaches for treating alcoholism have developed over the years, and interest in alternatives to the abstinence model has evolved, the clinical treatment of alcoholism has largely proceeded on the assumption that alcoholism is a disease and, as a result of the widespread acceptance of the disease model, "the ways in which treatment services are developed and implemented are related to assumptions made about their intended clientele" (Rossi & Filstead, 1976, p. 193). Thus, as Pattison et al. (1977) stated, "many 'alcoholism' programs have only offered one treatment approach - their approach" (p. 212). Such approaches have primarily focused on separating the drinkers from the alcohol, educating them about the disease, and conveying the message that recovery can only be attained when total abstinence is achieved. Within this context, it is only appropriate that Alcoholics Anonymous, which advocates and provides support for the practice of abstinence from alcohol, has been the major approach or philosophy employed in the treatment of alcoholism.

A. Alcoholics Anonymous (AA)

While it may be argued that AA is not a treatment method but a philosophy of recovery, it is so often used as a treatment mode that the distinction is academic. With AA chapters in more than 90 countries, and an estimated worldwide membership of over 1.5 million in over 73,000 groups (of which over 670,000 members are in the United States in more than 20,000 groups) (AA World Services, 1987), AA is the dominant treatment emphasis in alcohol programs, and for many, as Tonigan and Hiller- Sturmhofel (1994) state, “…self-help through AA is the only alcoholism treatment they receive” (p. 308).

Thus while alcohol treatment programs provide a broad level of services such as diagnosis, referral, and follow-up, and conduct individual, group, and family therapies, many programs undertake these activities primarily to support the client's transition to abstinence, achieved largely through participation in AA. It is not surprising, therefore, that a study that inquired about AA activities in alcohol treatment programs found that 96 percent of the programs reported the use of some type of AA activity (Boscarino, 1980a). The kinds of activities found clearly suggests that AA has a significant influence on the nature and content of treatment: “Having AA meetings on the premises (64%); having outside AA speakers coming in (48%); having patients attend AA outside AA meetings while patients at facility (66%); recommending families attend Al-Non or Al- Teen meetings (8%); having AA counselors coming in (50%); and other activities (16%)” (Boscarino, 1980a p. 65).

In accordance with this significant influence of AA, many counselors working in traditional treatment settings are themselves recovering alcoholics who maintain active AA membership. The belief is that only an alcoholic is capable of working with another alcoholic because only such a person is knowledgeable about alcoholism and has the experience to deal with the denial and resistance that the client will demonstrate while in treatment. Babow (1975) described this situation as a "treatment monopoly in

Evolution of Substance Abuse Treatment 37 April 2003 Institute for Circumpolar Health Studies alcoholism that has arisen because of the assumption that only a person who has been alcoholic can understand, relate to, and help other alcoholics…" (p. 120). Babow also noted that an assumption often made in defense of this position is that one's experience as an alcoholic in itself provides the expertise required for treatment.

Treatment representing an AA approach largely tends to be a supportive process. It guides the person to AA and helps to maintain him or her in AA until the person identifies with AA and begins to follow the "Twelve Steps to Recovery." These 12 steps avow faith in a Supreme Being, disavowal of personal responsibility (for drinking), confession of wrongdoing, and a need to proselytize other alcoholics about AA. The first step reflects one's inability to control his or her drinking and a breakdown of denial concerning alcohol. The next steps convey the idea of hope, followed by a shifting of responsibility to God, forming a union to keep oneself sober. The other steps involve confessing, making amends, confirming a new, sober, self-image, and extending oneself to help other alcoholics (called "twelve stepping"). In addition to these 12 steps, AA has established "Twelve Traditions," which specify how AA should be organized and governed. Emphasis is on the unity of AA, and on the autonomy of groups. Using the "Twelve Steps" and the "Twelve Traditions" as its prevailing principles, AA functions as a self-help group, in which one's drinking problem can be overcome by the support of fellow sufferers.

The influence that AA has had in the field of alcoholism over six decades cannot be overstated. AA has acquired "a moral ascendancy which has enabled many of its members to be preeminently successful in asserting a claim to be the voice of the alcoholic, a claim which has never been effectively challenged" (Tournier, 1979, p. 230).

Challenges, however, to the traditional disease model of alcoholism, and its accompanying AA treatment philosophy, have arisen. These challenges resulted because of the emerging realization that the AA approach "precluded early intervention and tied us to a treatment strategy which, in addition to reaching only a small portion of problem drinkers, is limited in its applicability to the universe of alcoholics" (Tournier, 1979, p. 231). In other words, the disease model's assumption that the only cause of alcoholism lies within the drinker diverts attention from the circumstances surrounding one's drinking, and precludes comprehensive treatment during the rehabilitation process. The realization that there are special treatment populations, such as youth, women, the aged, mixed alcohol and drug populations, and minority and ethnic groups, has resulted in a need to develop more comprehensive treatment approaches that are responsive to people with varying backgrounds and different types of drinking-related problems.

Additionally, studies have raised questions concerning AA's effectiveness, and doubt has even arisen concerning its ability to help the more seriously impaired drinker. Boscarino (1980b), for example, reported that seriously impaired drinkers "tend to do worse in treatment…[and] AA appears to be no exception to this tendency" (p. 846). Also, AA affiliates who are younger, male, and from lower socioeconomic groups tend

Evolution of Substance Abuse Treatment 38 April 2003 Institute for Circumpolar Health Studies to have more "slips," are in AA for a shorter time, are less involved in AA activities, and tend to be unstable members (Boscarino, 1980b). The implications of Boscarino's findings are important because they suggest that AA affiliation may not be appropriate for all alcoholic-related problems, and especially that individuals with the characteristics that are associated with lack of success in AA may require another type of treatment intervention. These findings, however, confirm that AA may be most effective for the less seriously impaired, older drinkers who come from middle or higher socioeconomic levels.

In a review of the effectiveness of AA, Tournier (1979, pp. 233-234) indicated that its success rate may be seriously overstated because:

[Such claims are] flawed by sampling biases, for most [researchers] ignore persons who, having failed to find help through AA, drop out of its activities and out of the potential sample…Even if one accepts an estimate as high as 67% as valid, and it is rather difficult to do so, it is not a demonstration of AA's effectiveness, but may suggest that only recovered alcoholics gravitate toward AA as a means of sustaining a recovery already begun, and may thus use it as a form of aftercare. (P. 237)

Thus it is important to become aware that AA's philosophy of intervention may not be appropriate for different kinds of people who experience different types of drinking problems. As Tournier (1979) stated, it is necessary to begin "to evaluate on their own merits alternatives and innovative strategies for dealing with the extremely complex range of problems too often lumped under the rubric of 'alcoholism'" (p. 237).

The effectiveness of AA, as Tournier noted, has not been scientifically documented, and methodological problems make such an evaluation difficult (NIAAA, 1990). Emrick (1987), found that of among active long-term AA members, between 40-50 percent had several years of abstinence, and between 60-68 percent improved to some extent, drinking less or not at all during their participation. Those who combined AA with other forms of treatment appeared tended to do better than those who only participated in AA. It may be, as two researchers (Fry, 1985; Sheeren, 1987), suggested, that AA is more helpful in maintaining abstinence than clinical treatment.

Despite these issues, AA helps people, and it continues to be the most popular self- help organization for aiding alcoholics. Although questions have arisen concerning its efficacy, difficulties in evaluating its effectiveness should not preclude its utilization in treatment. What may be occurring is that there is a self-selection process at work with respect to who benefits most from participation in AA. That is, people who are able to identify with AA, practice its 12 steps and 12 traditions, and benefit from the fellowship it offers, remain affiliated, and perhaps sober, while others, who do not identify with AA, drop out. Research thus needs to concentrate on questions raised by Tonigan and Hiller-Sturmhofel (1994): “Who does well in AA, and why do these people succeed?” (p. 308).

Evolution of Substance Abuse Treatment 39 April 2003 Institute for Circumpolar Health Studies B. Other Self-Help Groups

1. Rationale Recovery

An alternative to AA, and based in the principles of Rational Emotive Therapy (RET), is the self-help approach called “Rational Recovery (RR)” advocated by Jack Trimpey (1989), a recovered alcoholic. His position is espoused in a book titled “Rational Recovery from Alcoholism: The Small Book.” He believes that not only is it unnecessary to perceive of alcoholism as a disease, but that many of the assumptions on which the disease model is based are “irrational.” He stated that “The idea that confession is intrinsically therapeutic and a vital part of recovery from alcohol dependence is one of those assumptions” (pp. 13, 14). He also believes that any debate over whether alcoholism is a disease is unnecessary. With respect to the question “Is alcoholism a disease?” Trimpey (1989) stated:

A much better question is, “Who Cares?” There is much bitter debate over this question, and one would think that the answer would have some great importance to those who habitually drink too much. Alas, it doesn’t really matter, because the solution is the same either way. If “alcoholism” is a disease and you have a drinking problem, then continuing to drink is folly. You will almost certainly have to stop it. But, if “alcoholism” isn’t a disease, and you are having persistent problems related to drinking, you had also better learn to abstain. Abstinence is simply the final stage in one’s effort to moderate, when it becomes easier to quit for good than to moderate. Abstinence is also a commonplace thing that human beings have been achieving for millennia without the assistance of Alcoholics Anonymous or any other recovery program. In RR, we know that either way, disease or not, we are not powerless. (p. 15)

The key to RR is that people with an alcohol problem are not powerless over their drinking and do not act accordingly, thereby becoming practicing “alcoholics.” Instead, people become ”alcohol dependent,” which means that they need to learn to become “independent” from alcohol. They have the responsibility to change their thinking about alcohol and develop a personal philosophy that conveys to them that they can think rationally about their drinking behavior and take responsibility for change. “When you change your thinking about drinking . . . then you are recovered” (Trimpey, 1989, p. 17).

C. Patient-Treatment Matching

As a result of the recent questioning concerning the traditional methods of treating alcoholism, and because no single therapy produces the best outcomes for all persons with alcohol problems, interest emanated in designing treatment programs tailored to client needs, that is, in matching clients with the treatment approach that would be most effective rather than adhering to a single format that primarily relies on AA. The practice of tailoring treatment to client needs, however, is in its formative stage, and its practical application still awaits verification by research evidence. Finney and Moos (1986), in

Evolution of Substance Abuse Treatment 40 April 2003 Institute for Circumpolar Health Studies beginning to investigate the problem of matching patients with treatments, outlined three conceptual and three methodological issues that underlie attempts to match patients with optimal forms of treatment and to conduct research on patient-treatment matching: (a) selecting effective matching variables, (b) specifying the end result that matching is to enhance, and (c) determining the stage(s) in the treatment process at which matching decisions are to be made. The three methodological issues are: (1) determining nonlinear-interaction effects, (2) determining higher-order interaction effects, and (3) determining multilevel interaction effects.

With these issues in mind, Finney and Moos'(1986) research on client-treatment matching led to the conclusion that:

Given the "strength" and "dosage" levels of current treatment modalities, the matching hypothesis seems the best hope for improving treatment services for alcohol-dependent patients, as well as for persons suffering from other types of psychological-behavioral disorders. As we have seen, however, patient-treatment matching may involve multiple patient (personal and environmental) and treatment (therapeutic and delivery) dimensions interacting in multiple forms or "powers" (linear and nonlinear), in multiple orders, at multiple levels and during multiple stages of the treatment process to influence multiple end results or outcomes. Thus developing effective differential treatment systems poses a substantial challenge. (p. 132)

As Finney and Moos pointed out, various client types differ in their reaction to various treatment techniques and to a wide variety of counseling orientations. Miller (1989) proposed a self-matching approach in which the client is presented with an array of options, given an accurate description of each, and encouraged to choose the approach that seem appropriate. It is assumed that the client is most likely to select those options to which they would be most responsive, thereby improving chances for a positive treatment outcome.

Providing treatment based on individual client needs (i.e., treatment matching), as opposed to providing the same intervention to all clients with a common diagnosis, calls for a precise plan that includes three components (Mattson, 1994):

(a) systematic assignment of patients to well-defined treatments; (b) comprehensive assessment of client characteristics and needs; and (c) explicit treatment-matching guidelines or rules.

Interest in patient matching prompted the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to fund a large scale controlled clinical trail study, named Project MATCH, to evaluate the effectiveness of client matching. The aim of the research was to study client outcomes with respect to participation in three treatment conditions: (a) 12-step facilitation (TSF), which involved clients participation in traditional AA activities, (b) cognitive-behavioral coping skills therapy (CB), which focused on interpersonal and self-management skills to control drinking, and (c) motivational enhancement therapy

Evolution of Substance Abuse Treatment 41 April 2003 Institute for Circumpolar Health Studies (MT), which focuses on helping clients to gain motivation to change and on strengthening the commitment to change.

Surprisingly, the results of the study found that patient-treatment matching made no significant difference in treatment outcomes (NIAA, 1997). This finding, however, does not reflect on treatment efficacy as a whole because its focus was patient-treatment matching, not on whether treatment works or not.

D. Counseling or Psychotherapeutic Approaches

Counseling or psychotherapy (used synonymously) involves the use of psychological techniques helps people to achieve an under-standing of their alcoholic behavior, thereby leading to change. Although largely provided on an individual basis, it is also used in conjunction with other program aspects such as family and group procedures. The particular philosophy or orientation practiced in counseling reflects the personal predilection of the counselor or that espoused by specific treatment programs. Among the more popular therapeutic orientations are the following:

1. Client-Centered (Rogerian) Therapy

This approach is based on the doctrine that treatment consists of helping persons to mobilize their own psychological resources to obtain solutions to their problems (Rogers, 1951).

2. Reality Therapy

This therapeutic modality focuses on reexamining a person's values in the context of how the person is currently functioning. Emphasis is on the "here and now" problems of the client, and on helping clients to accept responsibility for their drinking behavior and for changing their behavior with respect to alcohol (Glasser, 1965).

3. Transactional Analysis

Transactional Analysis (TA) is an approach derived from psychoanalysis in which people explore their roles (scripts) in life. TA views a person's life as a series of transactions involving one's scripts, and TAs aim is to help the person correct faulty transactions and establish appropriate interpersonal relationships by redefining one's scripts. The technique has been adopted by many counselors, who model their approach after the work of Steiner (1971, 1979), who wrote Games Alcoholics Play and Healing Alcoholism.

4. Gestalt Therapy

Derived from psychoanalysis, Gestalt therapy emphasizes the person as a whole and, beyond this, the person in the environment. In its approach to understanding behavior, Gestalt therapy interprets an individual's behavior in terms of being a total response to

Evolution of Substance Abuse Treatment 42 April 2003 Institute for Circumpolar Health Studies the whole situation in which one finds oneself, with specific components serving as important elements that contribute to one's difficulties. Gestalt therapy focuses on the immediate experiences of the client, and helps the client to restructure his or her perception of self and to change the ways in which he or she responds to events in the environment (Perls et al. 1951).

5. Rationale-Emotive Therapy

This therapeutic strategy seeks to minimize the client's self-defeating ideas and replace them with more realistic ways of viewing herself or himself and life (Ellis, 1973).

These therapeutic procedures, and other innovative treatment modes (cf. Harper, 1975; Suinn & Weigel, 1975), including eclectic approaches, are chiefly utilized in individual counseling or psychotherapy, where the practitioner is involved in a face-to-face relationship with the client. If individualized counseling is to have any chance of success, however, it is necessary for the counselor to "differentiate between the patient's presenting problems and the underlying biopsychological factors that precipitate, sustain, or reinforce dysfunctional behavior" (Brill, 1981, p. 86). Individualized treatment should be based on a careful differential diagnosis and on a clear understanding of the client's present and past behavior.

6. Cognitive Therapy

Cognitive theory is based on the idea that mistaken beliefs or perceptions (i.e., cognitive structures), people have about themselves are the source of their psychological problems. These misperceptions, which are learned, become the way an individual sees the physical and social worlds, including all one's facts, concepts, beliefs, and expectations, and the pattern of their interactions. “The way an individual labels or evaluates a situation determines his or her emotional and behavioral responses to it” (Gold, 1980, p. 8). Therapeutic intervention involves relearning, which can be achieved by restructuring one's way of perceiving.

An important assumption within the cognitive model is that drinking represents a form of coping. Coping represents an effort to maintain control when an individual’s resources, in response to stress, are taxed or are about to be exceeded. Coping behavior can take the form of acting to change a situation so that it is less of a threat, or can be expressed in the form of attempting to act on the stress-related emotion itself. Thus an important element in approaching an alcohol-related problem is an individual’s beliefs about the effect that drinking has on her/his own behavior, such as anxiety or stress reduction. Cognitive behavior strategies are used to help people deal effectively with the sources of stress (e.g., conflicts) and with the tendency to drinks as a means coping with stress. It is not used to treat one’s drinking problem directly, but to assist in reducing the event(s) (i.e., the source of the stress) that maintain drinking.

There are two types of cognitive therapies. The first, cognitive restructuring, is directed at trying to alter irrational beliefs and illogical thought processes by replacing them with

Evolution of Substance Abuse Treatment 43 April 2003 Institute for Circumpolar Health Studies more rational ones derived through discussion and rational self-examination. The second type is self-instructional training, which consists of attempting to replace maladaptive cognitive styles with more flexible and adaptive cognitions. Both approaches, when used in alcohol treatment, are directed toward helping the person develop an understanding of their alcohol-related problem, and form new and more sensible patterns of thinking.

7. Cognitive-Behavioral Therapy

Derived from traditional learning and cognitive theories, cognitive-behavioral therapy (CBT) represents an approach that has developed among practitioners to treat alcohol dependence. CBT differs from traditional behavioral approaches in that it deals with unobservable events, such as thoughts and feelings, which are inferred through self- reports provided by clients, and these phenomena are perceived as contributing to precipitate and maintain behavior. CBT thus views alcohol-related problems as learned behavior, which can be modified through learning-based clinical methods. These techniques include coping skills training, relapse prevention, marital or family interventions, and development of broad-based social supports for clients (Kadden, 1994).

CBT is based on the belief that alcohol-related problems represent maladaptive means of coping with difficulties or meeting one’s needs. Problem drinking thus represents a sequence of learned behaviors acquired in the same manner as any other learned behaviors, such as through imitating role models, the result of experiencing the positive (rewarding) effects of alcohol (i.e., anxiety reduction), pain relief, or enhancing sociability. After repeated positive experiences with alcohol, some individuals begin to rely on alcohol consumption as the preferred way of coping with problems or meeting needs, especially because the alcohol’s effects are felt fairly rapidly and require relatively little effort on the part of the drinker. According to cognitive-behavioral theory, these learned drinking patterns can be altered through the application of combined cognitive and behavior modification interventions, which can help people with alcohol dependence achieve and maintain sobriety (Miller & Hester, 1989).

8. Motivational Counseling

Motivational interviewing, a therapeutic technique developed by Miller and Rollnick (1991), is designed to prepare people to change addictive behavior by helping them to recognize their problems and assist them in either preventing or doing something about them. Motivational interviewing also involves helping people to take responsibility for their predicaments, and for moving to change their ways of dealing with them. The strategies of motivational interviewing involve supporting the person to change from within, rather than responding to pressures imposed from without.

Motivational interviewing stresses that resistance is unwilling-ness or difficulty on the part of the client to recognize problems, take responsibility for them, and seek solutions. Resistance occurs in large part as a defensives strategy on the client's part to protect

Evolution of Substance Abuse Treatment 44 April 2003 Institute for Circumpolar Health Studies him/herself from dealing with threatening things, and a reluctance to change by not taking responsibility for their behavior and for seeking solutions to problems. Resistance is also related to the counselor's therapeutic style, and is frequently connected to the counselor moving too fast for client. The counselor's response to resistance determines how counseling will progress.

Motivation interviewing is based on client-centered counseling, cognitive therapy, systems theory, behavioral theory, and the social psychology of persuasion. It is described by Miller and Rollnick (1991) as presenting a practical, research-tested, and potentially powerful approach to effecting change in persons with addictive behaviors.

9. Group Therapy

Group therapy represents a procedure in which persons with similar problems are able to relate to each other in a therapeutic setting. The aim of group therapy is to have each participant learn to relate to and understand others, and to gain a sense of self- understanding from the experience of others. There are many different types of group techniques or orientations, and they may range from traditional supportive groups to such techniques as psychodrama, marathon groups, transactional groups, and encounter groups, among others. The use of group therapy is fairly wide-spread in the treatment of alcoholics, and is a procedure that the clients themselves report as responding to best when in treatment (Hoffman et al. 1975).

Research evidence, however, has not generally been supportive of group therapy as an effective treatment method (Miller & Hester, 1980; Solomon, 1983). One of the difficulties in evaluating group therapy, as reported by Miller and Hester (1980), is that "the precise nature of group procedure is often unspecified, and different techniques often overlap" (p. 54). While this point may be important in attempting to evaluate the effectiveness of specific techniques, the more salient issue is being able to parcel out the effects of participating in group therapy, particularly when a client also may be engaged in several other different treatment modalities, such as AA, individual counseling, family therapy, and specific rehabilitation programs. This same problem applies when attempting to evaluate any single treatment modality.

10. Family Therapy

Family therapy or counseling provides an opportunity for the members of the family (spouse and children) to "heal their wounds," and to begin to make the necessary changes, as a family, to support the afflicted family member in maintaining sobriety. The basic assumption in undertaking family therapy is that alcoholism is a shared problem, and that the patient may not be able to "recover" completely unless the family also recovers. In contrast to other treatment efforts, research has shown support for the efficacy of family therapy, and indications are that it is a method that requires consideration in the treatment of alcoholism.

Evolution of Substance Abuse Treatment 45 April 2003 Institute for Circumpolar Health Studies E. Marital Counseling

This is a technique used to focus specifically on the inter-personal problems of the drinker and spouse, with the aim of clearing up any antagonisms and misconceptions, as well as assisting the spouse to adjust to the patient's recovery process. Such counseling may involve participation in a couples group or meeting as a couple with a counselor. Marital counseling, which is a form of family counseling, has also been reported to be helpful in treatment of the alcoholic.

F. Adjunctive Treatments

This section reviews some of the specific adjunctive methods used to treat alcoholism. Some of these methods are used to supplement counseling, while others may be used as specific treatment modalities in their own right. Many are oriented toward achievement of abstinence; others are directed at achieving moderate or controlled drinking.

1. Pharmacotherapy

There has always been interest, especially on the part of the medical community, to use pharmacological agents in the treatment of alcoholism. Medications assist in treating secondary conditions, help to lessen the severity of withdrawal, and can help to deter drinking. Disulfiram and psychotropic drugs are some of the pharmacotherapeutic agents used to treat alcoholism. A very recent advance is the use of naltrexone, a narcotic antagonist, to reduce relapses in recovering alcoholics. a. Disulfiram (Antabuse)

One of the most commonly used drugs in the treatment of alcoholism is Disulfiram, better known as Antabuse. Disulfiram, originally a chemical used in research with rubber, was accidentally discovered to produce a rather severe adverse reaction in alcohol-drinking workers who were exposed to it. This reaction became known as the Disulfiram-ethanol reaction (DER). Antabuse, since the 1950s, has thus been used to deter drinking. It is believed to achieve its effect by disrupting the normal process of alcohol of elimination by interfering with the metabolism of acetaldehyde, which is highly toxic when it accumulates in the body. If alcohol is consumed while Antabuse is present in the body, and when acetaldehyde levels are high, it evokes a strong physical reaction that produces flushing, nausea and vomiting, severe headache, violently accelerated heartbeat, a decrease in blood pressure, blurred vision, and vertigo. Antabuse is used to help the alcoholic resist impulsive drinking while in treatment, or to help maintain sobriety after completion of treatment. The noxious effect of mixing alcohol and Antabuse serves as the deterrent to drinking.

Side effects of using Antabuse have been noted, and must be taken into consideration if Antabuse is considered. These effects, which can vary from person to person, include skin eruptions, fatigue and drowsiness, headache, impotence, and peculiar aftertastes.

Evolution of Substance Abuse Treatment 46 April 2003 Institute for Circumpolar Health Studies

A major problem in prescribing Antabuse is that the user may decide to discontinue it at any time and resume drinking. To overcome this problem, interest developed in implanting long-lasting doses of Antabuse in the lower abdomen, but the difficulty with this approach is that the amount of Disulfiram that enters the bloodstream is unpredictable (Miller & Hester, 1980).

Despite the fact that many individuals discontinue their use of Antabuse, its use as a treatment aid has generally been helpful in assisting people to maintain sobriety, particularly those who are older, are socially stable, and are former compulsive drinkers who are motivated to refrain from drinking. Nevertheless, it is difficult to determine whether the positive effects are "due to specific action of Disulfiram, or to other nonspecific factors" (Miller & Hester, 1980, p. 21). b. Psychotropic Drugs

A variety of psychotropic drugs - mild tranquilizers, lithium, and antidepressants, among others - are used in the treatment of alcoholism, but no evidence is present that suggests that such treatment by itself is effective in attenuating drinking (Rada & Keller, 1979). Such drugs may help to alleviate emotional states that often accompany chronic drinking, and their use, in most instances, has been to achieve this aim. Few clinical practitioners expect psychotropic medications by themselves to provide a cure. Recent thinking about treating alcoholism, particularly when other drugs may also be abused, is that medication may be necessary to help treat any emotional distress while simultane- ously helping the patient achieve and maintain abstinence through self-support groups (Smith, 1985).

Recent research, however, has emphasized the importance of pharmalogical adjunctive treatment of a comorbid psychiatric disorder, such as depression, as essential in helping to prevent relapse of drinking. Mason et al. (1996), in a double-blind placebo- controlled trail of desipramine (Norpramin, Pertofrane), a trycyclic antidepressant with primary effects on the noradrenergic system, found that depressed alcoholics reduced relapse risk compared to untreated patients. An implication, of their findings is that it is important to integrate pharmacotherapy with behavioral and psychosocial treatments to facilitate recovery from both depression and alcoholism. c. Naltrexone

Advances in the pharmacological treatment of alcoholism have been made during the past 10-15 years, largely attributable to progress in: (a) an improved understanding of the process of neurotransmission and how this procedure is affected by alcohol and other drugs; (b) by achievements in learning about the neuropathways involved in drug effects, particularly about the structure and function of the brain’s reward circuitry; and (c) by advances in comprehending alcohol’s effects on opiate receptor activity, which has specifically lead to theory development about how alcohol dependence develops. It has been hypothesized, for example, that alcohol stimulates the release of endogenous

Evolution of Substance Abuse Treatment 47 April 2003 Institute for Circumpolar Health Studies opioids, such as beta-endorphin, which may produce the euphoric feelings associated with alcohol intoxication. The release of endorphins may thus serve to reinforce (reward) drinking, thereby establishing a linkage between drinking and its sought after affects. Thus the positive sensations that result from drinking serve to encourage drinking in persons who are vulnerable because of underlying genetic or psychosocial reasons (Wise & Rompre, 1989). The implication of the above findings and theory suggest that different chemical substances, including alcohol, produce a positive reinforcing effect through a common biological mechanism. Volpicelli et al. (1992) indicate that because there appears to be a specific interaction between alcohol and opioids, opiate antagonists may be useful in the treatment of alcoholism. It is thus logical to infer that if opiate antagonists block opiate drugs from occupying receptor sites, thereby inhibiting a neurochemical response to opiates, then alcohol, which may occupy many of these same sites, may be affected by a narcotic antagonist; this effect might be one of blocking activation of brain functions stimulated by alcohol (i.e., reward), thereby negatively reinforcing drinking behavior. One opiate antagonist, naltrexone, has been reported to be a safe and effective adjunct for the treatment of alcohol dependence due to its blocking alcohol’s rewarding effects (Bohn et al. 1994; E. Gordis (personal communication, Feb. 6, 1995 - letter from NIAAA); O'Malley et al. 1992; Volpicelli et al. 1992, 1993).

Clinical studies of naltrexone have demonstrated its efficacy as an adjunctive aid when used in connection with a comprehensive treatment effort. Volpicelli et al. (1992), and O’Malley et al. (1992), reported that Naltrexone was effective in helping to reduce drinking among alcohol-dependent clients when it was part of a total treatment approach. In the study by Volpicelli et al. (1992), naltrexone was tested in a double- blind randomized placebo controlled 12-week study. Fifty mg of naltrexone or placebo was administered daily on an outpatient basis to 70 male alcohol-dependent patients, chiefly African American, who had been drinking heavily for an average of 20 years. The medication was provided in conjunction with their participating in a comprehensive treatment program. It was found that the naltrexone treated cases showed a gradual decline in alcohol craving during the 12-week period, with placebo cases demonstrating higher overall levels of continuous alcohol craving. The experimental group also reported less drinking than the control group. The most important finding, however, pertained to relapse, where about one-half of the placebo group relapsed during the 12- week clinical trial period, and less than one-fourth of the naltrexone-treated group relapsed.

O’Malley et al. (1992), who involved 97 alcoholic clients (72 men, 25 women) in a similar design, also reported that naltrexone helped to reduce drinking and lower relapse rates. These studies were supported by the findings from Bohn et al. (1994) who, in a double blind study, also found that frequency and intensity of drinking declined in their subjects.

All these studies reported that naltrexone was safe and produced little in the way of side effects. One conclusion that can be derived from their results is that naltrexone helped to reduce alcohol craving and, in association with psychosocial treatment,

Evolution of Substance Abuse Treatment 48 April 2003 Institute for Circumpolar Health Studies contributed to help clients with drinking-related problems. It is believed that naltrexone works by interfering with the release of endogenous opioids by blocking opiate receptors, thereby reducing craving and limiting any euphoric feelings associated with drinking (Volpicelli et al. 1993).

The clinical implications of these findings are apparent: (a) there appears to be a biological basis for alcohol craving, (b) a reduction in the positive reinforcing effects of alcohol is related to a decrease in consumption, and (c) pharmacological treatment is insufficient by itself - its effectiveness is also related to the nature of the psychosocial context of treatment.

Interest in Naltrexone, which received approval from the Federal Drug Administration (FDA) for alcohol treatment subsequent to the reports published by Volpicelli et al. and O’Malley et al., has grown rather quickly, and numerous clinical trials continue to test its efficacy.

2. Biofeedback

Biofeedback training has recently appeared as a technique to assist in the treatment of alcoholism. This is a procedure in which one learns consciously to control one's physiological processes by observing the output of one's own brain waves and other autonomic functions (heart rate, pulse, etc.). The aim of using biofeedback is to help the drinker reduce the stress or anxiety that may contribute to or accompany drinking; without such stress the need to drink should lessen. The value of biofeedback training in treating alcoholism is still being investigated, but an early study reported that a reduction in drinking was achieved when muscle tension levels and anxiety were reduced through biofeedback training (Steffen, 1975).

G. Behavioral Approaches to Alcoholism

Behavioral approaches to alcoholism, in very broad terms, represent approaches or theories that lend themselves to scientific investigation; that is, they are ultimately open to assessment or empirical investigation. More specifically, behavioral approaches, as applied to alcoholism, represent the systematic application of behavioral methods, based on either classical or operant learning theory, to drinking-related behaviors (i.e., alcoholism). Behavioral techniques may be used to help a person achieve abstinence or to return to controlled or moderate drinking. This latter application of behavioral procedures remains extremely controversial, and will be discussed in detail later. Prior to this, other forms of behavioral techniques are presented.

H. Aversion Techniques

Aversive procedures involve the pairing of the undesirable (negative or conditioned stimulus) behavior (drinking) with a strong aversive stimulus (unconditioned stimulus), thereby conditioning the person to avoid the negative behavior - that is, creating a condition in which the sight, smell, and taste of alcohol are experienced as extremely

Evolution of Substance Abuse Treatment 49 April 2003 Institute for Circumpolar Health Studies unpleasant and so are avoided. The aversive stimulus can be either a chemical agent, electrical stimulation, or aversive imagery.

1. Chemical Unconditioned Stimuli - Nausea-Producing Drugs

By pairing alcohol with chemically induced nausea, obtained by means of an injection of a strong emetic such as emetine or apomorphine, a violent reaction is elicited that establishes a forceful aversive reaction to alcohol (Lemere & Voegtlin, 1950). The typical procedure involves intramuscular injection of emetine, which produces nausea and vomiting after ingestion of alcohol. Prior to the onset of nausea, the patient is given alcohol, and shortly after the alcohol is absorbed, vomiting occurs. Alcohol is readministered several times, thereby establishing a cycle of drinking and vomiting that lasts for about 30 minutes. A full treatment cycle may require up to five or six aversive sessions, usually on an inpatient basis, with subsequent "boosters" after the person is discharged. "The object of the treatment is to provide the alcoholic with a temporary, involuntary 'time-out' from alcohol abuse by creating an aversion to . . . alcohol. During this time-out, the alcoholic has the opportunity to rearrange his or her life and develop behavioral patterns which are incompatible with alcohol abuse" (Miller & Hester, 1980, p. 31). Chemical aversive conditioning originated at the Shadel Hospital in Seattle, Washington (Voegtlin, 1940), and has been in use in that institution since the late 1930s.

Chemical aversive conditioning has achieved mixed success for alcoholic patients. It seems to have its best results among people who maintain relatively intact lives despite their drinking, who are from middle or higher socioeconomic groups, and who are highly motivated to stop drinking. Nathan (1985) pointed out that success rates for aversion therapy are related to client motivation, chiefly because those who participate in aversive therapy enter treatment with a better outlook than those entering other types of treatment. They are mostly well-motivated, well-educated, relatively stable people with the financial resources to support their treatment.

2. Electrical Aversive Stimulation

The use of electricity as an unconditioned stimulus (UCS) dates back to reports from the USSR, where the technique is believed to have originated (Kantorovich, 1929, cited in Wilson, 1978). Because chemical aversion therapy had many unpleasant side effects, and because of medical complications in using emetine, electric shock emerged since the 1960s as the "most widely used and intensively researched form of aversion therapy" (Wilson, 1978, p. 91). Using shock as the UCS provides a more exact means of controlling the onset, intensity, and duration of reinforcement; it also allows a greater number of applications during a treatment session.

In contrast to chemical techniques, electrical aversion conditioning has not been found to be effective (Cannon et al. 1981; Miller & Hester, 1980), and Wilson (1981) has recommended that it be discontinued.

Evolution of Substance Abuse Treatment 50 April 2003 Institute for Circumpolar Health Studies I. Controlled Drinking (Moderation) Theory

The idea of controlled drinking represented the most radical departure, in both theory and practice, from the traditional unitary disease model of alcoholism, and its emphasis that abstinence is the only conceivable form of treatment. It is based on the belief that some individuals can recover from problem drinking without being totally abstinent. The pioneering work in controlled drinking was conducted by Mark and Linda Sobell (Sobell & Sobell, 1971, 1972, 1978), who called the procedure they developed "Individual Behavior Therapy" (IBT).

Based on the premise that drinking is a learned behavior in response to stressful, anxiety-laden situations, the Sobells proceeded on the assumption that if drinking reduces the discomfort that reinforces drinking, then such behavior can be modified when the drinker learns alternative, more appropriate responses to stimulus conditions that evoke heavy drinking. Relearning consists of training sessions in which emphasis is placed upon specifically defining prior settings for heavy drinking, and training the drinker in alternative, socially acceptable responses to these situations. The training program is specifically tailored to each participant's drinking history and specific needs. Punishment, in the form of mild electric shock delivered to the hand, videotape feedback of drinking behavior, problem solving, and practice in refusing drinks are all part of the training program.

The Sobells reported that persons participating in their IBT program functioned significantly better for at least six months following discharge than a control group of drinkers who did not take part in the program (Sobell & Sobell, 1972). Subsequent studies also reported positive outcomes (Sobell & Sobell, 1973, 1976). The work by the Sobells fostered an interest in the application of behavioral techniques in treating alcohol-related problems, and resulted in furthering research that explored controlled drinking as an appropriate treatment goal for problem drinkers (Heather & Robertson, 1981, 1989; Lloyd & Salzberg, 1975; Marlatt & Nathan, 1978). This new approach, which has come to be known as “moderation training,” was generally found to have promising results as an alternative to abstinence for some drinkers (Miller, 1978, 1983; Miller & Barlow, 1973; Peele, 1984).

Rather than being viewed as a potential additional treatment modality, which was chiefly an experimental procedure in need of further study, the idea of "controlled drinking" was met with strong antagonism by many practitioners and researchers in the field of alcoholism. In fact, the concept of controlled drinking was anathema to the more traditional disease-oriented thinkers who rejected it as a viable treatment approach, even when those who advocated behavioral treatment attempted to moderate their position to achieve a rapprochement with disease-theory believers (Peele, 1984). Additionally, the findings from a comprehensive alcohol treatment evaluation study, called the Rand Report (Polich et al. 1981), were rejected out-of-hand because they contradicted the standard beliefs of abstinence-oriented followers by suggesting the possibility that for some alcoholics moderate drinking is not necessarily a prelude to a full relapse, and that some alcoholics can return to moderate drinking with no greater

Evolution of Substance Abuse Treatment 51 April 2003 Institute for Circumpolar Health Studies chance of relapse than if they had abstained. This conclusion was based on the finding that close to 40% of a sample of former alcoholic clients who were followed up for four years after treatment were free of drinking problems, but still drank at controlled or moderate levels. Yet the Rand Report was dismissed as methodologically inadequate and its full implications were never addressed. As described by Heather and Robertson (1989):

The National Council on Alcoholism, which was centrally involved in the formation of the Alcoholism Movement in the 1940s…hastily assembled two press conferences. At these the report was condemned as “dangerous” and “unscientific,” even though no one at the NCA had an opportunity to see a copy! The conclusion in respect of normal drinking was described as unethical, unprincipled and as “playing Russian roulette with the lives of human beings.” There was even a suggestion that the entire report should have been suppressed. (p. 95).

Peele (1984) noted that an immediate result of this reaction was that "Today, no clinician in the United States publicly speaks about the option of controlled drinking for the alcoholic" (p. 1342). The reason for this rejection is that the disease concept is so embedded in our society that it has, according to Peel (1984): "modified our basic conceptions about the nature and prevalence of drinking problems and about the need for treatment, the proper type of treatment, and the efficacy of treatment for alcoholism. Nondisease conceptions have not fared well in this atmosphere" (p. 1339).

Indeed, Pendery, Maltzman, & West (1982), in an apparent attempt to refute any further consideration of the notion of controlled drinking, publicly questioned the legitimacy of the Sobells' findings and conclusions (cf. Sobell & Sobell, 1972, 1973, 1976, 1978). After a detailed retrospective analysis of the drinkers who participated in the Sobells' original training project, Pendery et al. (1982) reported that their results did not match those presented by the Sobells, and asserted that:

A review of the evidence, including official records and new interviews, reveals that most subjects trained to do controlled drinking failed from the outset to drink safely. The majority were rehospitalized for alcoholism treatment within a year after their discharge from the research project. A 10-year follow up (extended through 1981) of the original 20 experimental subjects shows that only one, who apparently had not experienced physical withdrawal symptoms, maintained a pattern of controlled drinking; eight continued to drink excessively - regularly or intermittently - despite repeated damaging consequences; six abandoned their efforts to engage in controlled drinking and became abstinent; four died from alcohol-related causes; and one, certified about a year after discharge from the research project as gravely disabled because of drinking, was missing. (p. 169)

Furthermore, and more important, Pendery et al. clearly alleged that the Sobells had falsified their results.

Evolution of Substance Abuse Treatment 52 April 2003 Institute for Circumpolar Health Studies The allegations made by Pendery and her colleagues were welcomed by the traditionalists in the alcohol field who viewed these criticisms not only as a revelation confirming that abstinence is the only possible treatment for alcoholics, but also as vindicating the disease concept of alcoholism as the only true approach to understanding and treating the alcoholic.

Pendery et al’s (1982) accusations embroiled the alcohol field in heated controversy. In response, the Addiction Research Foundation (ARF) of Toronto, Ontario, Canada, a well-respected alcohol and drug research center where the Sobells were working when the Pendery et al. report appeared, commissioned an inquiry into the allegations of fraud and other improprieties. The results of this investigation, abstracted in a special section of The Journal (December 1, 1982), a publication of the ARF, reported that “After a painstaking and lengthy review, an independent Committee of Inquiry has reached this ‘clear and unequivocal conclusion’ that there is ‘no reasonable cause to doubt the scientific or personal integrity’ of the psychologists employed at the Addiction Research Foundation (ARF) since 1980” (Dickens et al. 1982, p. 7).

The committee was critical of the Pendery group's approach for its failure to reexamine subjects treated with abstinence techniques, its reliance on testimony from individuals who were emotionally involved in the controversy, and its failure to review the larger body of evidence that had accumulated about controlled drinking. Interestingly, it was never pointed out by Pendery et al. that six of the 20 control subjects (who received standard abstinence treatment) also died from alcohol-related causes (Marlatt, 1983).

The ramifications that this encounter engendered went beyond the allegations made by the Pendery group and the rebuttals provided by ARF (c.f., Marlatt, 1983), and by the Sobells (Sobell & Sobell, 1984). What was crucial about this controversy was the issue of which ideology should prevail. Did the aspersions cast by the Pendery group mean that there can be no other viable alternative to the disease model and its accompanying philosophy of abstinence as the only treatment goal? Or can there be alternative models that, as part of their treatment philosophy, emphasize a return to moderate drinking as a legitimate treatment goal? What the Pendery-Sobell controversy risked is the possibility that any or all research that had the potential to restore social drinking would be reacted to with skepticism and criticism from the traditionalists in the field at a level far beyond what a reasonable review would entail. Research findings can thus be rejected out-of-hand and their replication discouraged. Such a phenomenon would constitute a significant disservice to those in need of treatment for alcohol-related problems. But, in any case, as Peele (1984) noted, and which has been cited earlier, there appears to be a consensus in America against the application of controlled drinking, or any method that does not accept alcoholism as a unitary disease for which abstinence is the only treatment.

It should be noted that the Sobells, when they conducted their research, represented what was then the "new breed" of psychologists - those who believed that the solutions to all human dilemmas could be achieved through the application of behavior theory and the techniques of behavior modification or learning theory - the new panacea

Evolution of Substance Abuse Treatment 53 April 2003 Institute for Circumpolar Health Studies espoused by behavioral psychologists. By defining alcoholism only in terms of learned behavior, and by proposing to treat it in the context of one's particular drinking environment, they may have disregarded the fact that people drink for many reasons, only one of which is to relieve tension, and that drinking also takes place in a multitude of contexts. Furthermore, the context of drinking may not be the primary reinforcer of problem drinking behavior. Rather, a need to maintain a dependent state may serve this function, and such reinforcement may be represented by a combination of environmental, biological, and psychological events.

There are undoubtedly many alcoholics whose drinking behavior is not going to be amenable to change through behavioral techniques because their behavior is not readily subject to environmental control. Problem drinkers who show a consistent inadequacy in behavior, or who are not responsive to reinforcing stimuli, are examples of two types of problem drinkers who may be severely limited in their ability to respond to behavioral control measures.

Furthermore, in behavioral terms, a person's drinking behavior may be maintained by behavioral reinforcers that are either stronger than or beyond the reach of those stimuli that can be utilized in therapy or training sessions. Mark Keller (1979a), a staunch supporter of the disease concept and a fierce opponent of the concept of controlled drinking, has expressed his criticism of controlled drinking as follows:

A big issue in treatment is whether an alcoholic can return to social drinking. [The suggestion has been made] that alcoholism is a learned condition…Assume that this is the right hypothesis. What happens if a person has learned to respond to a certain signal that comes to him, say from the environment? I made up a funny example once. A man's mother-in-law comes to live with him and she never liked him and when she gives him that "wall-eyed" look of hers, he exits and goes to the tavern and gets drunk. He does this so often that he becomes conditioned. Every time that he gets that "wall-eyed" look he has to go and get drunk. Then comes the rule, the law of generalization. Psychologists employ this. This means that next time any woman gives him the "wall-eyed" look he is going to go and get drunk. Now here we get into trouble. Then the rule of generalization works further. When any woman gives him any kind of look he goes and gets drunk. But there are other connections and other ramifications which occur. It comes about that it is not only a look, but now his drinking occurs even if he sees a red haired woman.

So there are now lots of cues and by the time the man has been an alcoholic for a few years there are 350 cues and signals which are likely to set him off, depending on circumstances. You see, a certain cue will set him off if it happens indoors, but not out doors. There is another one that has to happen outdoors.

This is the way it works. So, now you have got this alcoholic who has come to your clinic and you are treating him with behavioral therapy. You are really good and you have got him so that he has got substitute learning. He can take a drink and another drink and he does not have to go on drinking to get drunk. He is in control. This is great. Except that there were 350 cues and actually you deconditioned him from

Evolution of Substance Abuse Treatment 54 April 2003 Institute for Circumpolar Health Studies only 349. You did not know them all. There was one that you never thought of. So he goes ahead and drinks moderately and everything is fine for a couple of years and one fine day that 350th cue happens and he finds himself sitting in a bar drinking his 10th drink.

Keller's lighthearted, but nevertheless pointed criticism of controlled drinking, indicates the reaction of many who find controlled drinking an impractical solution for the plight of the alcoholic. The argument can be summed up succinctly: Is it worth the risk of having an alcoholic continue to drink, or to risk abusive drinking again, when drinking is the primary problem to begin with? Why not just remove the temptation and focus on living without alcohol?

The dispute in the field of alcoholism between traditionalists and behavioral theorists has resulted in a situation that has "thrown the baby out with the bath water." Whatever potential merit behavior theory may have to assist some problem drinkers to resume a "normal" life - even if it involves controlled drinking - has been disregarded by traditionalists because the idea of controlled drinking violates the basic tenets of the disease model, and because controlled drinking is subject to the type of criticism raised by Keller. However, rather than totally denying the prospect that some "alcoholics" can assume "controlled drinking" after undergoing a course of treatment - and even Mark Keller (1979b; 1986) recognized that this may be possible in a few cases - it may be more productive to determine more precisely what controlled drinking actually means, and to establish criteria for determining who may be the best candidates for achieving abstinence through traditional treatment and who may benefit from a moderation approach.

Sanchez-Craig and Wilkinson (1987) addressed some of these issues, and raised questions of their own about the efficacy of moderation in treating drinking-related problems. They concluded that it is important, in attempting to treat anybody with an alcohol-related problem, to first ascertain, by mean of a comprehensive assessment, the level of alcohol dependence. Although advocates of moderation, Sanchez-Craig and Wilkinson noted the importance of recommending abstinence for severely dependent drinkers, but they also stipulated that less severely dependent drinkers could be candidates for moderation. They stated:

When choice of goal is permitted to the client, he or she must choose between the alternatives of abstinence or moderation of drinking. It is the therapist’s responsibility to ensure that before making the choice the client is informed of the relevance of the data obtained during assessment. Specifically, the client should know of his or her status in regard to variables known to be associated with successful moderation or successful abstinence. (pp. 55, 56).

Interestingly, moderation has taken hold in Great Britain, where many treatment programs reported that nonabstinence was an acceptable outcome goal (Rosenberg et al. 1992). The treatment programs that endorsed controlled drinking (CD) reported that their choice was based on the severity of clients’ dependence, client attitudes and

Evolution of Substance Abuse Treatment 55 April 2003 Institute for Circumpolar Health Studies beliefs about controlled drinking and abstinence, drinking history, liver function tests and social stability/social relationships. Rosenberg et al. indicated that:

In contrast to what one might expect in an American sample, the “disease model” played only a small role in the acceptance or rejection of controlled drinking by these British treatment providers. One reasonable explanation for this result is that alcohol services in the United kingdom do not make extensive use of non-professionals and former drinkers as counselors and administrators are not dominated by Alcoholics Anonymous and the "Minnesota model." Instead, subjects [interviewees] relied overwhelmingly on their own professional experience and, to a lesser though still frequent extent, on research evidence and agency policy. Also, it is interesting to note that professional experience and research evidence were cited as a basis both to accept and reject CD. Presumably, some clinicians have had clients successfully engage in controlled drinking and some clinicians have not had such success. (p. 445)

It is apparent that questions relating to behavioral treatment of alcohol-related problems have far-reaching implications, and behaviorally oriented researchers themselves have raised questions about their methods and the utility of their approaches, in order to resolve controversies and to demonstrate the utility of behavioral treatment. Sobell and Sobell (1987) for example, stated, "The never ending debate over the relative merits of abstinence and moderation sometimes clouds the fact that parties on all sides are seeking the same objective - the elimination of alcohol problems for individuals and for society." Research by Foy (1987) has focused on achieving an understanding of the practical issues that distinguish between abstinence and moderation drinking goals in patients with severe drinking problems. His findings suggest that in both abstinence and moderation drinking stable outcomes are about equally rare (10% combined). Foy's findings are not surprising in light of Miller's (1987) belief that "it has become abundantly clear that there is no single robustly effective treatment for alcoholism . . . [but] the picture that emerges from outcome research is of a variety of promising methods, each of which may have a specific impact for a particular type or subset of alcoholics." Miller (1987) also stated that: "failure to provide appropriate alternative goals and approaches may have substantial negative effects on the prevention of alcohol-related problems, both at the individual and the societal level." Nathan and McCrady (1987), in support of Miller's conclusions, found that abstinence as a goal of behavior therapy for alcohol abusers and alcoholics is achievable. They believe that:

behavior therapists have limited their ability to influence or contribute to the treatment of alcoholism by being identified exclusively with a moderate drinking goal, and that this lack of influence has been as unfortunate for clients as it has been for behavior therapists…Behavior therapists and traditional alcoholism workers alike [should] attempt to identify ways in which the two approaches could be integrated.

Much has happened, nevertheless, with respect to the development of controlled drinking since its inception 25 years ago. After having been largely shunned in the

Evolution of Substance Abuse Treatment 56 April 2003 Institute for Circumpolar Health Studies United States, or put on the shelf elsewhere, moderation approaches have begun to make inroads in contemporary alcohol treatment. Sobell & Sobell (1995) believe that three factors contributed to an acceptance of moderation approaches in the treatment of alcohol abuse: (a) epidemiological studies that have identified a large population people with low severity alcohol problems, (b) introduction of the alcohol dependence syndrome concept, and (3) consideration of alcohol as a public health concern. In the Sobells’ view, moderation research can be summarized by the following three statements:

1. Recoveries of individuals who have been severely dependent on alcohol predominately involves abstinence. 2. Recoveries of individuals who have not been severely dependent on alcohol predominately involves reduced drinking. 3. The association of outcome type and dependency severity appears to be independent of advice provided in treatment. (Sobell & Sobell, 1995, p. 1149)

Although Sobell & Sobell present a positive picture regarding he efficacy of moderation approaches in the treatment of alcohol-related problems, caution, however, must be taken in its application in that any potential candidate for moderation treatment has to be free from any alcohol-related medical anomaly such as live damage, pancreatitis, cardiomyopathy, etc. Moderation treatment can only be applicable in the absence of organic problems among people who are problem drinkers, and not dependent on alcohol.

Despite the Sobell's optimism regarding moderation, it is important to note, as Vaillant (1995) states that: " . . nobody any longer contests that severely alcohol-dependent individuals can on occasion return to problem-free drinking; the caveat is that it is a relatively unusual occurrence" (p. 384). Heather (1987), in an earlier review of the moderation approach, noted that few providers expected that controlled drinking outcome is probable as severity of dependence increases.

J. Relapse Prevention

Relapse prevention, which emerged in the mid 1980’s (Marlatt & Gorden, 1985), is a behaviorally-based scheme that focuses on identifying high-risk drinking situations and structuring behavioral changes that prevent the drinker from responding as they did before, that is, drinking in reply to stimuli that elicited drinking before treatment. Fundamental to this approach is helping the alcoholic (or drug dependent individual) develop a strong sense of self-efficacy that provides confidence in being able to cope with drinking situations. Marlatt (1985) proposed five factors that account for drinking episodes: (1) exposure to situations that hold high risk for drinking; (2) use or nonuse of successful coping responses in these situations; (3) enhanced self-efficacy for noncoping; (4) expectancies about the effects of alcohol in the situation; and (5) the abstinence violation effect - the alcoholic’s cognitive and emotional reaction to the ingestion of alcohol. Annis and Davis (1991) described relapse prevention as being “based on self-efficacy theory, [and] proposes that when a client enters a high-risk

Evolution of Substance Abuse Treatment 57 April 2003 Institute for Circumpolar Health Studies situation for drinking, a process of cognitive appraisal of past experiences is set in motion which culminates in a judgment, or efficacy expectation, on the part of the client of his or her ability to cope with the situation. That judgment of personal efficacy determines whether or not drinking takes place (p. 204).”

Relapse prevention consists of effecting an increase, through behavioral training, in the client’s self-efficacy or confidence across all drinking situations to maintain control over one’s drinking behavior. Relapse prevention is represented by the client’s ability to cope with different drinking contexts, and by not drinking heavily in situations that previously evoked such drinking. There are three major approaches involved in current relapse prevention programs: (a) Social support, which focuses on the client's needs for emotional support from family members and friends, as well as seeking their assistance in reducing inter-personal conflict and stress; (b) Lifestyle change, which focuses on helping clients to develop, and sustain new social identities as sober (or drug free), including breaking ties with drinking associates, developing new interests and social relationships, and learning new methods of coping with stress; and (c) Cognitive/ Behavioral, which emphasizes identifying internal and external cues associated with craving and relapse and learning how to avoid them, as well as learning how to prevent a full-blown relapse if drinking (or drug-taking behavior) were to reoccur.

While these three approaches can be viewed as separate, they are often combined into a single process focusing on helping the individual to prevent relapse. Relapse prevention, as Annis and Davis (1991) noted, is most effective when clearly defined areas of drinking risk are identified, but it is nevertheless applicable to the treatment of all forms of alcohol problems.

Evolution of Substance Abuse Treatment 58 April 2003 Institute for Circumpolar Health Studies

V. Treatment of Drug-Related Problems

Drug-related disorders are as complicated and difficult to treat as alcohol-related problems. Not only are different professions involved in the treatment of such problems, but each (as with the treatment of alcoholism) has evolved its own notion of etiology and treatment philosophy or strategy. Initially, large numbers of treatment programs were primarily concerned with treating the physically dependent heroin user, but the widespread use of other psychoactive drugs prompted changes in their approach, and fostered the development of treatment programs specifically for nonopiate drug-related problems. The emergence of cocaine as a major drug problem, for example, specifically the use of highly addictive “crack” cocaine, resulted in the development of programs specifically for cocaine users. Thus, over the past 40 years, there has been a substantial increase in the number and type of treatment programs designed to provide assistance for substance abuse problems in both the public and private sectors. In 1979 it was estimated that nearly 3600 drug treatment units were in operation in the United States, about 60 percent of which were treating only drug-related problems, with the remainder treating both alcohol and drug cases; over 237,000 cases were seen by all the programs (NIDA, 1981).

As these programs emerged, it became evident that many of the problems that are inherent in the field of alcoholism are also prevalent in the treatment of drug-related disorders. Lack of an agreed-on definition and understanding of the nature of addiction and drug abuse, drug-free versus drug-maintenance treatment, absence of adequate evaluation criteria, and single versus multimodality treatment, are just a few of the many issues that mark the field of drug treatment. But progress in treating drug abusing clients has been made, and a rather remarkable transformation in American policies and practices has occurred.

Most of the counseling or psychotherapeutic techniques employed in alcohol rehabilitation are also applied in the treatment of drug-related problems; such procedures were reviewed in the previous section and need not be re described here. Treatment for substance-abuse problems is also provided in inpatient, intermediate care, and outpatient settings, and the effectiveness of each will be reviewed in the discussion that follows. In many respects the treatment of drug-related problems is comparable to that provided for alcohol-related problems, and many procedures have been adopted from those used in treating alcoholism -- but many important differences also exist. These differences, together with a brief history of the philosophy of substance abuse treatment, a review of current treatment trends, and a discussion of treatment effectiveness, are presented in this unit.

A. Historical/Philosophical Perspective on Drug Treatment

The history of treatment for drug-related problems, chiefly those of opiate addiction, is long and varied, and has been of concern since the discovery of opium as an addictive drug. In the United States the formal treatment of opium dependence is linked to the emergence of the morphine-dependency problem among many Civil War veterans. The

Evolution of Substance Abuse Treatment 59 April 2003 Institute for Circumpolar Health Studies widespread use of the newly discovered morphine for relief of pain during the Civil War resulted in morphine addiction among thousands of soldiers. Treatment was primarily provided by private physicians and involved either helping the addict through withdrawal (detoxification) or undertaking morphine maintenance. The addiction was seen by the medical profession as an "illness," and morphine maintenance was considered a legitimate means of providing treatment. When heroin was introduced, around 1898, it was first seen as a means of relieving morphine addiction and was quickly adopted as a method of treatment for "morphinism." But it was soon discovered that heroin created its own form of dependence that required treatment in its own right, and its use for treatment of morphinism was discontinued.

The widespread use and abuse of all forms of drugs in the early 19th century resulted in the Harrison Act of 1914, which restricted the distribution of opiates and subsequently led to a banning of their use by physicians to treat opiate dependency. One of the effects of the restrictions imposed by the Harrison Act was that the use of opiates was driven "underground," and the ability of physicians to treat this problem was effectively curtailed. Although opiate dependency continued, it was no longer viewed as a medical problem; it became a legal or law enforcement problem, and the federal government thus had to assume responsibility for it.

The government, in its early attempt to deal with this problem, and to undercut the illegal distribution of drugs, encouraged the establishment of morphine maintenance clinics in some of the nation's larger cities. The idea behind these clinics was to withdraw some people gradually from addiction to opiates, and to provide maintenance for others. While this effort was generally successful in providing short-term care, and in combating the underground distribution of opiates, the clinics were unsuccessful in obtaining long-term abstinence. This lack of success was related to the clinics' inability to deal with the lifestyle problems and character of the opiate user, and not to a failure to assist people to withdraw from opiates. Most addicts, after successful withdrawal, would resume drug use if drugs were available when they returned to the streets. As a result of what was deemed a failure in being able to stop opiate dependence, and in response to the urging of the medical community to discontinue outpatient treatment of drug addicts, the federal government began closing these clinics in 1917, and by 1925 they were all gone. From 1925 to 1935, treatment for the narcotic addict was virtually nonexistent.

Around 1925 the characteristics of the addicted population started to change. No longer was addiction chiefly prevalent among middle-aged persons; it had gradually shifted to a new group of mostly young male users who preferred heroin, taken intravenously, to morphine. Inciardi (1992) indicated that: "heroin use developed rapidly during the 1930s and became widespread after 1945.. . [and] that between 1950 and the early 1960s, most major cities experienced a low-level spread of heroin use, particularly among Black and other minority populations. Thereafter, use began to grow rapidly, rising to peaks in the late 1960s and then falling sharply. The pattern was so ubiquitous that it came to be regarded as epidemic heroin use" (p. 80).

Evolution of Substance Abuse Treatment 60 April 2003 Institute for Circumpolar Health Studies This widespread use resulted in crowded jails resulting from arrests for drug-law violations, and something had to be done to curb the growing number of convicted drug addicts. Congress, acting out of a need to separate the increasing number of heroin- addicted prisoners from other criminals, passed legislation (in 1929) authorizing the establishment of two narcotic treatment hospitals for addicted inmates. The first opened in Lexington, Kentucky, in 1935, and the second in Fort Worth, Texas, in 1938. In addition to treating prisoners, the hospitals also accepted voluntary admissions. Lewis and Sessler (1980) noted that the underlying philosophy of the Lexington and Fort Worth programs was based on the belief that: "The key to successful treatment was complete detoxification in prolonged isolation from the environment where addiction occurred. Thus, physical isolation from access to drugs and withdrawal under medical supervision formed the basis of their program. This approach to treatment in the Lexington and Fort Worth programs stood in marked contrast to the earlier community- based morphine maintenance clinics" (p. 98).

Although the two hospitals were built primarily to house convicted heroin addicts, voluntary admissions soon outnumbered incarcerated patients. Because of the singular orientation of these two programs, and due to their lack of focus on the psychological and social readjustment problems patients would experience after discharge, recidivism was high; the failure rate was estimated at more that 97 percent (Brecher, 1972). A follow-up study of 12,000 addicts discharged from the Lexington hospital found that within a year 90 percent of this group relapsed to regular narcotic use (Vaillant, 1966). In addition, the fact that voluntary residents were free to leave whenever they wished was an important factor that helped mitigate against successful treatment. Part of their failure was related to the fact that knowledge about addiction and narcotics was elementary at that time, and established treatment procedures for narcotic addicts were nonexistent. "Both hospitals are now considered abject failures" (Bellis, 1981, p. 135). Nevertheless, these two hospitals were the only major treatment facilities for narcotic addiction in the country for 20 years.

While these two hospitals were delivering services to adult narcotic users, heroin dependence among youth began to rise alarmingly, particularly in large urban cities. New York State, for example, responded to this problem by establishing the Riverside Hospital in 1952, the first program for juvenile addicts. Treatment consisted of hospitalization for 18 months or more followed by outpatient care. Because the treatment facility had custody of the juveniles for up to three years, most of the residents completed the entire program. It was closed in 1963, however, after a follow- up study found that 95 percent of the juveniles returned to using drugs after separation from the program.

In reviewing the treatment efforts undertaken from the early 1900s to the 1950s, it is clear that despite the best intentions the programs were unsuccessful. Three reasons may account for their lack of accomplishment. The first is that attempts to induce abstinence as the only treatment goal were insufficient. Basic behavioral and personality changes also needed to be addressed if drug-free behavior was to be maintained. Drug users needed to understand the dynamics and problems involved in

Evolution of Substance Abuse Treatment 61 April 2003 Institute for Circumpolar Health Studies their use of drugs, as well as the kind of problems that will be involved in their movement to drug-free behavior.

A second reason was that they did not address the patient's problems after discharge from treatment. Most of these people were returned to the same environment from which they came, and had to face many of the same problems that had contributed to and supported their drug use. If drug-free behavior is to be achieved, it requires helping people to reestablish themselves in a different environment, one that does not support drug-taking behavior.

The third reason that these treatment programs failed was related to attitudes concerning addicts. Many people believed that heroin addiction is incurable and that the addict does not want to be "cured." It is conceivable that such attitudes may have contributed to a "self-fulfilling prophecy" among addicts themselves, thereby adversely impacting their motivation to respond to treatment.

B. The Changing Role of the Federal Government

The federal government subsequently converted the narcotic treatment hospitals at Fort Worth and Lexington to research centers, operating with research patients only, and thus essentially discontinued providing direct treatment for narcotic addicts. The government, in a change in policy, preferred to delegate treatment responsibility to the states so that federal efforts could be directed at combating drug abuse through programs aimed at restricting the supply of drugs. Drug abuse was perceived by governmental authorities as a criminal justice problem, and consistent with this new policy treatment was secondary to apprehending criminal offenders. In support of this new federal policy, the Narcotic Addiction Rehabilitation Act (NARA; P.L. 89-793), passed by Congress in 1966, contained four key provisions that provided for treatment of apprehended narcotic addicts (federal prisoners). These were:

• Title I, which authorized diversion to treatment before conviction for a restricted class of federal offenders. • Title II, which provided for treatment as a sentencing alternative for a slightly higher class of federal offenses. • Title III, which provided for voluntary and involuntary civil commitments to federal treatment facilities in localities where no adequate state treatment facilities existed. • Title IV, which mandated that the federal government begin to provide assistance to the states and cities for the development of drug-abuse treatment programs.

Other important pieces of federal legislation affecting treatment for drug abuse that soon followed the rehabilitation act were: (a) the comprehensive Drug Abuse Prevention and Control Act of 1970 (P.L. 91- 513), which further expanded community assistance programs to include all types of drug-dependent persons and drug abusers in addition to narcotic addicts; (b) the Addict Rehabilitation Amendment of 1972, which amended the Narcotic Addict Rehabilitation Act of 1966 to increase treatment options

Evolution of Substance Abuse Treatment 62 April 2003 Institute for Circumpolar Health Studies available through judicial disposition of addicts; and (c) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255), which provided greatly increased federal resources to develop community-based, multimodality treatment centers throughout the United States.

Furthermore, in following through on the provisions of Title I under P.L. 89-793, which called for the initiation of diversion programs, the federal government, in 1973, instituted a national diversion program for identified heroin users in the federal criminal justice system. This program, called Treatment Alternatives to Street Crime (TASC), provided referrals to community-based treatment programs while monitoring the drug-free status and treatment progress of its clients. The TASC concept was considered a successful undertaking, but funding was subsequently discontinued and programs were either abandoned or "picked up" by states to handle all types of drug-related offenders.

Other legislation enacted between the 1980s and 1990s revised earlier acts or established new anti drug programs. The 1988 Anti-Drug Abuse Act (P.L. 100-690), for example, created a number of new anti drug programs, expanded others and, with respect to treatment, provided an increase in treatment funds as well as establishing programs to facilitate getting drug users into treatment by reducing waiting time for entry into treatment programs. In 1990 Congress established the Office of Treatment Improvement (OTI) to coordinate the various substance abuse treatment activities funded by the federal government.

The significance of all the legislation was that the government, while relinquishing control over treatment of drug users, provided funds that helped to establish treatment programs at state levels. By also mandating that treatment be provided for adjudicated drug offenders, a need was established for the initiation of programs that were responsive to the growing population of drug-related criminal cases requiring treatment.

The federal government's policy was a direct result of the explosion of drug abuse across the country during the 1960s, particularly when such use involved White, middle- class youth. The extensive drug use resulted in a national outcry for effective treatment programs to provide services to the expanding number of young people with drug- related problems. Although the federal government furnished a substantial amount of money for treatment, the result was not development of comprehensive programs that addressed the physical, psychological and sociological aspects involved in drug abuse. Rather, many of the newer treatment approaches that evolved tended to follow singular orientations that reflected each program’s own beliefs about the cause and treatment of addictive behavior. While some of these programs gave the appearance of being multidisciplinary, they treated drug abuse in their own distinctive fashion. One of the more important approaches to emerge was the Therapeutic Community, which is discussed later in the section.

Evolution of Substance Abuse Treatment 63 April 2003 Institute for Circumpolar Health Studies C. Approaches to Drug Treatment

1. Methadone Maintenance

Methadone is a synthetic opiate analgesic whose chemical structure is completely dissimilar to that of morphine, but which evokes similar actions. Its use in the treatment of heroin dependency has had a profound impact on the rehabilitation process for heroin addicts.

Although methadone was used in the early 1940s to treat withdrawal symptoms, its use as a maintenance drug was not fully realized until the 1960s. Methadone's utilization coincided with the belief of Drs. Vincint Dole and Marie Nyswander that the real basis of narcotic addiction is an unspecified metabolic deficiency (Dole & Nyswander, 1967); this neurological susceptibility mediates addiction in a manner analogous to that of the addictive personality construct. Dole and Nyswander were also singularly unimpressed with what they believed was the ineffectiveness of traditional psychotherapeutic procedures in treating the heroin addict. "A careful search of the literature has failed to disclose a single report in which withdrawal of drug and psychotherapy has enabled a significant fraction of the patients to return to the community and live as normal individuals" (Dole et al., 1966, p. 304).

Dole and Nyswander clearly defined heroin dependency as a medical problem whose treatment should involve medical methods. What was needed, they believed, was a substitute for heroin that provided a longer acting pharmacological effect, thereby allowing the addict to break the constant preoccupation with "needing a fix." Addicts should then be able to redirect some of their energy to restructuring their lives. The longer pharmacological action of methadone (up to 48 hours) made it an attractive alternative to heroin.

An experimental methadone maintenance program administered by Dole and Nyswander was initiated in 1964 in New York City. After having been hospitalized to achieve a gradual stabilization on fixed daily dose of methadone, the program's participants were transferred to outpatient status and maintained on a daily dose of methadone. They were provided with counseling, job training, and other forms of rehabilitative services.

The program was remarkably successful. Participants showed improvements in social functioning in terms of employment or enrollment in school. Methadone apparently did more than just afford a substitute for heroin; it seemingly helped participants to respond to rehabilitative efforts.

Based on the success of this initial experimental program, methadone maintenance proliferated across the country. By 1972 methadone had become the most widely used treatment for heroin dependence. The federal government established regulations and guidelines for methadone programs, and provided funding for their implementation.

Evolution of Substance Abuse Treatment 64 April 2003 Institute for Circumpolar Health Studies Soon after methadone had become established as an effective treatment for heroin addicts, an even longer acting form of methadone was introduced. Called LAAM (levo- alpha-acetylmethadol), this alternative to heroin could be administered three times a week, as opposed to a daily dose of methadone. LAAM does not yield as quick a high as methadone, and it has a level, sustained effect.

Since their inception in 1964, drug maintenance programs, using methadone and LAAM, have continued to be the predominant mode of treatment for heroin dependency, involving a large number of participants who have shown a moderately high level of success as compared with other treatment methods. Part of this success is attributable to support given to drug maintenance programs by the federal government, and to their acceptance by the public, which does not interpret the administration of methadone as a continuation of the provision of narcotic drugs to maintain the "habit" of the heroin user. The public has viewed methadone as an aid to rehabilitation, and so did not challenge it as a form of heroin maintenance. The adoption of drug maintenance clinics thus represented a significant shift in public policy, away from earlier attitudes that reflected a totally punitive attitude toward heroin addicts. Yet, on further examination, methadone treatment, in principle, resembles the morphine maintenance clinics established earlier this century to treat addicts.

Senay and Renault (1971), in reviewing the efficacy of some of the early methadone maintenance programs, believed that "the pharmacological advantages of methadone would not have been realized if there had not been a reassessment of what treatment goals are desirable and possible for chronic heroin abusers" (p. 328). The need for a reassessment of treatment goals arose from knowledge gained from the experience in federal hospitals, which documented that (Seney & Renault, 1971):

Immediate and sustained abstinence for the addict seeking treatment is simply not a realizable goal; while the addict may "clean up" for a period of weeks or months in the hospital, when he goes back to his community his return to drug abuse has a 95% probability attached to it. When the goals of treatment programs changed from excessive preoccupation with drugs to a concern for the person treatment results began to improve. Given a patient's psychological realities and pharmacologic state what are achievable next steps for him or for her was and is the "right" question, for most of the effective treatment methods for chronic addicts today is a function of the fact that treatment efforts are not drug oriented [sic.]. (p. 328)

Methadone made it possible, according to Senay and Renault (1971), to establish new tangible treatment goals: (1) a return to legitimate employment; (2) cessation of or substantial reduction in criminal behavior; (3) simple reduction of the amount of time an addict must think about drugs and a reduction in the amount of time spent in drug- seeking behavior; (4) involvement with a social system in which there is a positive reinforcement for relating to people - particularly family and other addicts in various stages of readjustment; and (5) furnishing of an impetus for living by reestablishing

Evolution of Substance Abuse Treatment 65 April 2003 Institute for Circumpolar Health Studies abandoned goals. While not all of these objectives may be realized by all persons receiving methadone, the realization of some of them was a major step in rehabilitation.

The apparent success of methadone maintenance programs, however, has not been without criticism. Two issues of concern are the failure of methadone maintenance to decrease drug-seeking behavior in many patients, and the problem of illegal methadone use (Milby, 1981). It has been observed that it has become a fairly common practice in many programs for clients to divert methadone to the streets for illegal use (Callahan, 1980). This was especially evident when methadone was administered orally in pill form. When liquid doses were initiated, the problem diminished greatly. An important factor in the use of methadone is the claim that it blocks the addict's craving for heroin, thereby helping to stop drug abuse. Milby (1981) noted that:

Experience has definitely shown this not to be true…[It has been shown] that continued drug abuse occurs with methadone maintenance treated patients…The problem of illicit drug use by patients on methadone maintenance is a substantive criticism, and represents a failure of the modality to some extent. However, what is often forgotten is that patients showing illicit use may be making progress in other areas (e.g., reduced criminality, increased productivity). Also, as methadone maintenance programs have evolved, they have become much less selective in admission policies. Consequently, when many patients use illicit drugs, this often represents treatment engagement of addicts who have been intractable to other forms of treatment and have been referred to methadone as a last resort. (pp. 183- 184)

Another significant concern that has been expressed regarding methadone maintenance is that drug maintenance programs have attracted governmental support because methadone showed far more promise for controlling drug-related crime and other problems, and not because of any prospect for individual rehabilitation (Newman, 1983). Methadone maintenance programs were thus seen as attempts at social control, and as not being really concerned with clinical management of the heroin addict. The essential question this criticism raises is: What constitutes treatment and what essentially constitutes social control? While there is no easy answer to this question, Newman (1983) indicated that the clinical benefits derived from methadone were the primary goals for the establishment of such programs, and that any social gains that may have been achieved were accepted - but these were always secondary to clinical goals.

Another important criticism of methadone maintenance is that while it has been successful in removing heroin addicts from the streets and distracting them from their preoccupation with securing a continuous heroin supply, nothing has really changed (Platt, 1995). Not only are the addicts continuing to rely on a drug, but the conditions that give rise to drug use have not been altered; nor have any personal or inter- personal problems been confronted. The same cycle of failure persists and addicts still find themselves with unmarketable skills. If total rehabilitation of the heroin addict is to be attained, then treatment should include plans for the termination of methadone at

Evolution of Substance Abuse Treatment 66 April 2003 Institute for Circumpolar Health Studies some point in the treatment process. Once off methadone the person can become involved in a program that relies on starting to utilize one's own resources to confront one's problems. The support provided while on methadone should be keyed to moving the person in a drug-free direction.

In all, there is little doubt that methadone maintenance has had a significant impact on the treatment of narcotic dependency. The major question is: What does the future hold for it? Part of the answer involves a search to develop drugs that will be more effective than methadone or LAAM, drugs that will demonstrate an improved therapeutic potential through a longer acting effect.

There has also been increased recognition that any form of drug maintenance therapy must be accompanied by treatment of the accompanying problems, such as psychiatric disorders, and that vocational rehabilitation and educational services must be an essential part of treatment for methadone clients. Comprehensive services have to be developed that address all the problems involved in substance-abuse behaviors. Not all heroin users will be responsive to this treatment approach, but the opportunity to participate in a comprehensive program should be made available. In this context methadone maintenance therapy can be more than what some people allege it to be - a better drug to be addicted to than heroin or morphine - and the person may have a greater chance to move to a drug free life-style.

2. Narcotic Antagonist Therapy

Another approach in the pharmacological treatment of opiate dependence has been the use of narcotic antagonists. An antagonist is a drug that neutralizes the effects of another drug. Narcotic antagonists are drugs that, if administered prior to opiate injection, prevent the opiates from producing their characteristic effects. Among narcotic antagonists currently in use are cyclazocine, naloxone, nalorphine, and naltrexone. At sufficient doses such drugs can block the psychological and physiological effects of opiate narcotics, including the development of tolerance and physical dependence. They also can prevent or reverse the toxic effects of opiate drugs.

The use of narcotic antagonists in the treatment of opiate dependence is based on the principle that the experience of the "high," "rush" or "euphoria" associated with a drug reinforces its continued use. It is assumed that when heroin or other opiates are injected immediately following administration of an antagonist, the failure to experience the anticipated euphoria will lead to the extinction of the response causally related to the drug.

Naltrexone was specifically approved by the Food and Drug Administration in 1984 as an adjunct to the treatment of opiate-dependent individuals. The development of this pharmacological entity was a result of a joint effort of the National Institute on Drug Abuse (NIDA) and private industry. "Unlike methadone treatment regimens which require program-based therapeutic interventions, naltrexone will permit treatment

Evolution of Substance Abuse Treatment 67 April 2003 Institute for Circumpolar Health Studies regimens to be focused around the particular needs of the client" (Ginzburg, 1984, p. 5).

Overall, naltrexone has shown that it appears to be clinically safe and efficacious when used in the treatment of heroin addicts with higher social competence, and within the context of a comprehensive treatment program (Platt. 1995). Highly motivated patients demonstrated a willingness to maintain a therapeutic regimen that included taking a long-acting oral dose of naltrexone. "Careful screening of patients treated by knowledgeable professional staff appears to be the cornerstone of a successful treatment program that incorporates naltrexone with other supportive therapies" (Ginzburg, 1984, p. 18). The patients who responded best to naltrexone therapy were employed, married, stabilized on low-dose methadone prior to detoxification or detoxified from their narcotic dependency seven or more days previously, and were highly motivated to be maintained on a nonnarcotic chemotherapeutic agent.

Naltrexone, however, is not a cure for narcotic dependency; it only blocks the effects of opiates. It does not block the effects of any other class of psychoactive drugs, and it is effective only when taken regularly. Nevertheless naltrexone shows promise of being a clinical adjunct that can help the user remain drug-free while participating in a larger, comprehensive rehabilitation program that will help to establish a drug free lifestyle. Research is still being conducted concerning the utility and effectiveness of naltrexone in the treatment of narcotic dependency.

Recently, buprenorphine, in combination with naloxone, has been found to be a safe and effective remedy to treat opiate dependence (NIDA, 1999a). Pharmacologically, buprenorphine is related to morphine but is a partial agonist (possesses both agonist and antagonist properties), which infers that the drug does not tend to induce respiratory depression. Buprenorphine, though not yet available, in the United States, in combination with naxolone, may be more effective than a low dose of methadone in reducing opiate use (NIDA, 1999a).

3. Clonidine

Clonidine, an antihypertensive agent, continues to be explored in the treatment of heroin addiction. It has been found to be effective in suppressing certain withdrawal symptoms such as restlessness, rhinorrhea and sweating (Platt, 1995). It is less effective, however, in reducing subjective symptoms and discomfort levels. It has been combined with naltrexone to provide outpatient detoxification because the combination of drugs reduces overall distress. Further research is necessary, however, to determine the efficacy of clonidine regarding opiate treatment.

4. Acupuncture

Interest has developed in applying the ancient Chinese technique of acupuncture in the treatment of drug dependency (Wen & Cheung, 1973). As conceived by Dr. Wen, the idea is to relieve the withdrawal symptoms of heroin and opium users through controlled

Evolution of Substance Abuse Treatment 68 April 2003 Institute for Circumpolar Health Studies electrical stimulation applied via acupuncture needles inserted at specific points in the "concha" region of the person's ears. It is speculated that acupuncture stimulates the release of endorphins - naturally occurring pain killers in the body that are believed to mimic the painkilling effects of opiates, specifically heroin - and that their release reduces craving by blocking the brain mechanisms involved in addiction (Swan, 1992).

Research has shown that acupuncture may be helpful in alleviating the symptoms of acute withdrawal and in reducing drug craving, including cocaine, but much more research needs to be conducted to determine its effectiveness and implications in treating addictive behavior.

5. Therapeutic Communities

The drug-free therapeutic community (TC) was one of the many different treatment programs that developed in response to the need for treatment that emerged in the 1950s. TCs represented an organized effort by former addicts to help other addicts solve their problems through self-help techniques. The first such program was Synanon, founded in Los Angeles in 1959 by Charles Dederich, a former alcoholic. Synanon was characterized by Lewis & Sessler (1980) as:

. . . founded on the belief that only a former addict could break through the shell of denial and pathological lying of the addict. The Synanon leaders prided them-selves on their rejection of the traditional medical approaches to addiction. Instead they concentrated on the psychological factors contributing to readdiction, and tried to restructure the addict's character so that a return to drugs would be unimaginable. The Synanon program espoused the view that those who entered the program must from that time forward be drug-free and rely only on the discipline and support of their peers. In some respect, Synanon resembled Alcoholics Anonymous, but was strikingly different in its demand for total immersion into a thoroughly disciplined lifestyle involving indefinite residence in the Synanon facility. (p. 99)

The novelty and success of the Synanon program quickly attracted the public's attention, and by the late 1960s TCs were in operation in many of the nation's larger cities. Phoenix House and the Odyssey program in New York City, for example, are two of the better known TCs that were directly derived from the Synanon experience. These TCs developed primarily in the private sector with funding from both state and federal agencies.

As TCs continued to proliferate, each pursued its own style of therapeutic practices, but the emphasis continued to remain on the achievement of a drug-free life-style by continuously confronting addicts with aspects of their own personality that had to change in order to become drug-free. Gerstein and Harwood (1990) described TCs as follows:

To a significant extent the TC stimulates and enforces a model family environment that the client, so to speak, should have had during critically formative preadolescent

Evolution of Substance Abuse Treatment 69 April 2003 Institute for Circumpolar Health Studies years. The TC tries to make up for lost years of formation in an intensive, relatively short period of time - approximately 6 to 12 months of residential envelopment and an additional 6 to 12 months of gradual re-entry to the outside community prior to "graduation." There is encouragement as well as continued alumni involvement for the benefit of role modeling for news residents, recognition and reinforcement for the graduate, and psychological and financial support for the program. (p. 156)

Many of these programs have recently expanded to include persons with nonopiate drug problems. People experiencing difficulty with alcohol, cocaine, stimulants, hallucinogens, depressants, and other drugs now participate in TCs.

The underlying philosophy of the TCs, according to Peele (1989), is “that addicts are doing something wrong, that they should change, and that their problems are due to a combination of their social milieu and their personalities, which they must do something about themselves - very different assumptions from the disease approach and medical treatment” (p. 264).

In evaluating the effectiveness of TCs, many critics believe that the treatment of residents is harsh, demeaning, and punitive, and violates the principles of supportive psychotherapy. Further-more, TCs are not for everybody: many who enter drop out within the first month - but TCs appear to be effective for those who stick with them. De Leon (1984), after conducting an extensive study of the effectiveness of the Phoenix House Therapeutic Community, concluded that there was "convincing evidence for the effectiveness of the therapeutic-community approach for drug abuse" (p. vi). Follow-up studies found that 75 percent of the graduates were drug-free and had not committed a crime, and that 93 percent of the graduates were improved when compared with their pretreatment status. Even among the dropouts, 31 percent remained drug-free and crime-free, and 56 percent of the dropouts were also improved when compared with their pretreatment status. Graduates of TCs are usually considered to be “ex-addicts,” in contrast to the term “recovering” used in alcohol treatment.

Winick (1980), in evaluating the effectiveness of therapeutic communities in New York City, found that they were successful helping TC members to acquire fundamental living skills, to complete a high school education and to learn to take personal care of themselves. Subsequent research (c.f., Gerstein & Harwood, 1990) also found that TCs are effective, but that success was tied to program retention - those who complete the program are most likely to achieve its goals than those who drop out. A positive outcome is also related to an emphasis on helping residents take responsibility for themselves, and with occupational training, educational enhancement and job placement.

6. Behavioral Techniques

Behavioral intervention techniques are based on the premise that behavior is controlled by its positive and negative consequences, and can be modified by making changes in selected aspects of the environment so as to reinforce desired behaviors or extinguish

Evolution of Substance Abuse Treatment 70 April 2003 Institute for Circumpolar Health Studies undesirable ones. It should be noted that "behavioral intervention techniques" represent a number of specifically related procedures that are guided by the rules of behavior modification - behavior therapy, contingency contracting, token economy, etc. Such procedures are being used with increasing frequency and are being integrated with other, more traditional forms of therapy in the treatment of drug dependency.

The behavioral treatment of narcotic addiction has evolved parallel with the evolution of behavioral approaches to treating human disorders. As with the application of behavioral modification procedures to the treatment of alcoholism (see Chapter 13), these techniques focus on eliminating the excessive behavior. Therefore, the same procedures that are utilized in treating the alcoholic are applied to the drug abuser. Aversive conditioning, covert sensitization, electrical aversion therapy, and systematic desensitization, among other methods, are used as behavioral interventions. (These procedures were reviewed in the previous chapter.) Behavioral intervention techniques have been helpful in improving the efficacy of some medical techniques, and appear to be successful in working on a single-case basis with addicts who manifest few other behavioral deficits (Callahan, 1980). Research is needed that will investigate how these techniques can be used to complement advances in the psycho-pharmacological and behavioral pharmacological treatment of drug dependency.

7. Psychotherapeutic Approaches

Traditional psychotherapeutic or psychoanalytically oriented approaches are based on the assumption that addictive behavior represents a manifestation of a fundamental underlying or repressed emotional conflict. Involvement in traditionally oriented psychotherapy requires a long-term commitment and entails a reexamination of one's personality structure. With few exceptions traditional long-term psychotherapy has not been generally successful with drug addicts, mainly because introspection is not meaningful to such people (Platt, 1995). Some derivatives of traditional approaches, however, have been moderately successful when used in treatment settings. Reality therapy (see Chapter 13) has been helpful, particularly with adolescents, because of its emphasis on "the here and now." Short-term psychotherapy, in which the emphasis is on solutions to immediate problems, has also been helpful in providing support to clients while they work to improve their self-concept and to adapt to a drug-free lifestyle.

In addition to individual psychotherapeutic treatment, family counseling or therapy and group therapy are also utilized. Methods of treatment may differ among individual practitioners who specialize in various "schools of thought:" Gestalt, psychodrama, transactional analysis, and client-centered therapy (reviewed in Chapter 13), are some of the approaches pursued.

8. Drug-free Outpatient Treatment

In the 1960s treatment methods evolved that offered drug-free services entirely on an outpatient basis. Mostly found in larger urban cities, the type of treatment provided by

Evolution of Substance Abuse Treatment 71 April 2003 Institute for Circumpolar Health Studies such clinics has been referred to as either drug-free outpatient, ambulatory drug-free, or outpatient abstinence. Many of the programs charge minimal or no fees and provide emergency intervention and medical and social services. The best known of these clinics is the Haight-Ashbury Free Clinic, opened in 1967 in San Francisco. Although it is still in operation, many other programs have since closed. These programs, in contrast to therapeutic communities and methadone maintenance, offered drug-free treatment on an outpatient basis. They varied greatly in their scope or level of treatment, but usually included some or all of the following services: group or individual counseling, vocational and social counseling, family counseling, and educational opportunities. Those still in operation have expanded to treat all forms of drug-related problems.

9. Multimodality Treatment

Subsequent to the Vietnam war, the American public's concern over the number of veterans returning with drug-related problems prompted Congress to appropriate funds to assure treatment for all veterans who wanted help; Congress also mandated that treatment programs offer a multimodality approach - defined as providing a variety of program components including methadone maintenance, detoxification, inpatient and outpatient drug-free programs, and a therapeutic community. The philosophy behind this comprehensive type of program was that by providing a multitude of services, clients would be able to select the one most appropriate for them, thereby facilitating a successful outcome. Transfer between programs was made relatively easy to help people take advantage of different modalities. Community-based multimodality treatment continues to be supported by federal funding.

10. Treatment for Non-opiate Drug Problems

As the problem of drug abuse, which involved many drugs other than heroin, became more widespread, there was a corresponding need for treatment programs to address nonopiate drug-related problems. Many of the programs or intervention strategies for nonopiate drug abuse, however, are patterned largely after the procedures to treat narcotic dependency. At the present time, there are no pharmacological agents, such as methadone, to aid in the treatment of problems related to cocaine, barbiturates, amphetamines, and hallucinogens. The response has been in two general directions: extension of some heroin treatment programs to include persons with other types of drug-related problems, and the development of a broad variety of services designed to be responsive to the needs of nonopiate drug abusers. Many of these services, which have evolved over the past three decades, are reviewed below.

11. Self-Help Groups

The development and apparent success of AA in helping alcoholics spawned an interest in self-help groups for abusers of narcotics and other types of drugs. In 1953 Narcotics Anonymous was formed, a self-help, peer support group, patterned after AA, that provides aftercare for "recovering" addicts. The group helps its participants deal

Evolution of Substance Abuse Treatment 72 April 2003 Institute for Circumpolar Health Studies with such matters as basic principles of recovery, interpersonal relationships, job- related stress, family issues, and other problems that may interfere with recovery. The emergence of peer support groups has added a very specific component to the treatment and recovery of addicts, and the notion of the self-help process has generalized so that groups such as Cocaine Anonymous, among other drug-related groups, have been formed.

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VI. Measuring Treatment Success

Treatment outcomes for addiction depend on the extent and nature of the person's presenting problems, the appropriateness of the treatment components and related services used to address those problems and the degree of active engagement of the patient in the treatment process. Yet many people who enter treatment drop out before receiving all the benefits that treatment can provide. Successful outcomes may require more than one treatment experience; many addicted individuals have multiple episodes of treatment, often with a cumulative impact.

Much of the uncertainty and conflict involved in attempting to assess treatment effectiveness is related to the fact that there many varied, and even competing, approaches to treatment of alcoholism and drug dependence, each espousing a particular philosophy and rationale. Many alcohol counselors, as Hester and Miller (1995) noted, are trained to treat clients from “one true light” perspective, in which the counselor would be “thoroughly indoctrinated into that perspective,” expounding the rationale for its superiority over all others. “Students learned by heart the faults and failures of all other approaches to treatment, and were taught that their approach was the one true avenue toward the lasting alleviation of human problems” (p. 1).

Thus, how one thinks about the nature of alcohol problems guides how one goes about treating alcoholics. Yet, as Miller et al. (1995) indicated, “There does not seem to be any one treatment approach adequate to the task of treating all individuals with alcohol problems” (p. 33). It may be that flexibility in one’s approach is required, rather than a dogmatic perspective that does not utilize techniques responsive to clients’ needs.

Regardless of the approach taken, serious questions have arisen concerning the efficacy of current methods of treating alcoholism, and a specific challenge has been raised concerning the efficiency of treatment in general.

Addressing the issue of treatment effectiveness has to begin with an understanding of the of the theoretical considerations that underlie treatment of alcoholism and other forms of drug addiction. What follows is a review of some of the dimensions underlying treatment, together with a discussion of treatment-related issues. The discussion begin with a focus on alcohol, then transfers to a review of treatment for addictive disorders.

A. Effectiveness of Treatment Settings

Comparisons of the effectiveness of inpatient versus outpatient treatment programs revealed that "no strong evidence exists to support the view that either inpatient or outpatient treatment per se is preferable" (Solomon, 1983, p. 17). Additionally, research has found no significant differences in outcome among inpatient, outpatient, partial hospitalization, and day clinic settings (NIAAA, 1990). While there may be qualitative differences between patients admitted to outpatient and inpatient programs, it has been extremely difficult, from a methodological point of view, to account for such differences in research designs that compare the efficacy of the two. Inpatients, it should be noted,

Evolution of Substance Abuse Treatment 74 April 2003 Institute for Circumpolar Health Studies tend to present more severe initial problems and to have less stable lifestyles, while those in outpatient treatment tend to be less severely dependent and are able to maintain an ongoing lifestyle. If an effective evaluation is to be achieved that distinguishes among different types of treatment modalities, then research needs to be designed that will account for the characteristics of patients who enter the different programs.

One of the concerns of practitioners, laypeople, administrators, legislative and governmental authorities, and problem drinkers themselves, is the question of whether treatment (in any form) for alcoholism is effective. The issue of treatment effectiveness was examined by Vaillant (1983), who concluded that "treatment effectiveness may have been exaggerated . . . in an effort to justify to Congress and to health insurance companies their enormous expenditure in the treatment of alcoholism" (pp. 9-10). He went on to quote an editorial in the Annals of Internal Medicine, that indicated that "the treatment of alcoholism has not improved in any important way in 25 years . . . [and] only a minority of patients who enter treatment are helped to long-term recovery” (pp. 9-10).

Two factors contribute substantially to this state of affairs. One is the difficulty involved in developing uniform criteria or measures to assess outcome objectives. The second factor, which has been alluded to in numerous instances in preceding discussions, is the absence of uniform criteria for a generally acceptable definition of alcoholism that can be related to standardized outcome criteria. It is not unusual, in reviewing the research literature on outcome evaluations of alcohol treatment, to find that rates of treatment success or failure vary according to the outcome criteria selected. One method of attempting to overcome this difficulty has been to develop multiple outcome indices, which allow conclusions to be made that stress that a positive outcome may not necessarily be related solely to achieving abstinence. Solomon (1983) called this a "shotgun" approach to treatment evaluation, and indicated that the long-term goal needs to establish specific outcome measures that fit specific clients in specific treatment programs, as generally called for in a multidimensional approach (discussed earlier).

Outcome research, however, has not been as generally lacking as Vaillant implied. Emrick (1974), for example, after an exhausting review of psychologically oriented treatment programs, concluded that "the vast majority (about two-thirds [of all clients]) are improved or abstinent, indicating that once an alcoholic decides to do something about his drinking and accepts help, he stands a good chance of improving" (p. 523). The key phrase in Emerick's statement is the indication that "once the alcoholic decides to act" the chance of remission improves. The implications of this statement will be discussed shortly. Moos and colleagues (1981) also reported that some successfully treated alcoholics can reestablish normal life patterns for themselves subsequent to cessation of drinking. Overall, however, systematic and well-designed studies of treatment effectiveness have been lacking, and efforts continue to be made to develop methodologies that will be scientifically rigorous.

Evolution of Substance Abuse Treatment 75 April 2003 Institute for Circumpolar Health Studies More recently, Miller et al. (1995), concluded that treatment provides positive benefits, but that the treatments that are effective do not represent “those components commonly employed in U.S. alcoholism treatment programs" (p. 32). The phrase “those components,” as used by Miller et al., represent traditionally oriented disease model approaches that emphasize a twelve-step program. High on Miller et al.’s list of effective treatments were brief interventions, social skills training, and motivational enhancement. Lowest was psychotherapy, general alcoholism counseling and educational lectures/films.

Questions about whether formal treatment of any kind is better than no treatment at all for alcoholics has also arisen. This becomes a critical issue in light of some studies that indicate that some alcoholics experience a spontaneous remission or recovery without treatment; that is, there is a natural healing process that seems to occur whether or not treatment is provided (Armor et al. 1976; Cahalan, 1970; Emrick, 1975; Tuchfeld et al. 1976; Vaillant, 1983). Oxford and Edwards (1977) went so far as to suggest that common-sense advice plus the natural history of the disorder may be just as effective as any other form of treatment, including hospitalization, family therapy, Antabuse, and even participation in AA. Such findings raise further questions as to whether alcoholism progresses inexorably, or spontaneously abates with some individuals, or remains essentially stable. The answer is clear: Consistent research leads to no other conclusion than that some people, with or without treatment, move in and out of problem drinking, while others spontaneously move on to controlled drinking or to abstinence.

This phenomenon means that some people with drinking problems will continue to drink, even predictably so, regardless of what form of treatment they may receive, while others will improve, whether they receive treatment or not. Because this happens, however, does not justify abandonment of treatment altogether. There is a clear need to continue to maintain treatment services. Most evidence, despite some research limitations, indicates that persons undergoing any form of intervention are better for short periods of time subsequent to their treatment (Keller, 1979b). What may be needed to enhance treatment is to develop a better understanding of the natural healing process and to apply these findings to formal treatment programs. One of the reasons AA is helpful is that it provides a set of conditions that may conform to the natural healing process and to the needs of the individual at a particularly relevant time in the person's healing process.

Clinical interventions also help to prevent death and to deal with crisis situations. Treatment programs provide support and assistance to the families of the problem drinker and initiate education and prevention programs in communities. But if treatment programs are to demonstrate greater effectiveness, it is imperative that they begin to move with the times. No longer, in light of recent developments, can a single approach be justified. As Vaillant (1983) put it: "There is no single best, or only treatment for alcoholism, and it is easier to walk with two crutches than one. Therefore, combinations of treatment, such as group therapy and renewed church attendance and disulfiram and vocational rehabilitation may be employed to provide therapeutic components" (p. 302).

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Emrick's (1974) very important observation, that the drinker's own characteristics and motivations to stop drinking may be the most essential factor in the treatment process, indicates that people can and do overcome problem drinking. "Subjective beliefs about the disease of alcoholism and about the nature of the person's drinking problem can be more important than objective levels of dependence for selecting treatment goals" (Peele, 1984. p. 1344). Thus, to maximize treatment outcome, it may be more advantageous to have clients develop their own treatment plans, and to utilize the resources of the treatment program to work toward achieving them.

Perhaps the issue of treatment effectiveness, as expressed recently by Vaillant (1995) and earlier by McCance and McCance (1969), is moot. They believe that prolonged hospital treatment does little to alter the natural history of alcoholism. McCance and McCance summed up this argument as follows:

The outcome in alcoholism depends very little on the treatment given, but largely upon individual factors relating to each patient and upon the natural history of the condition. The cost of establishing and running the type of special unit which caters mainly to the treatment of alcoholics with social and behavioral characteristics with good prognosis may not be justified. More attention should be given to the provision of a range of facilities to suit the management of alcoholics with less favorable attributes who are more likely to continue drinking in spite of psychiatric treatment. (p. 198)

What then is effective treatment? According to Vaillant (1995);

Effective treatment lies not so much in professional intervention for acute relapses as in training the individual in the prevention of relapse. . . . empirical evidence overwhelmingly supports three conclusions: First, inpatient treatments of a few weeks to a few months produce no better outcomes than a brief inpatient stay. Second, day treatment or partial hospitalization is as effective as inpatient treatment. Third, in general, outpatient treatment produces long-term results comparable to those of inpatient treatment. (p. 385)

B. Measuring Drug Treatment Effectiveness

The issue of treatment outcome or effectiveness for drug-related problems, chiefly heroin or narcotic addiction, is one that has consistently been raised, without any accurate answer. Both success and failure have been reported, and questions still abound as to whether treatment really makes a difference.

An important issue in attempting to evaluate the effectiveness of any form of drug treatment is that of achieving a better understanding of the factors involved in the treatment process. Einstein (1980) indicated that a significant problem in evaluating drug treatment is not related to an examination of "what we are doing (or not doing) or who is doing it . . . [but rather] why we are treating, the goal system used, who the

Evolution of Substance Abuse Treatment 77 April 2003 Institute for Circumpolar Health Studies treatment agents are and who they should and can be, and factors related to the treatment process for the patient" (p. 774). Einstein (1981) discussed a scheme that delineates specific criteria that are critical to the evaluation of any treatment process. The basic treatment factors Einstein proposes are treatment goals, treatment focus, treatment techniques, and suitability for treatment; and he formulated specific criteria within each category.

C. General Findings of Treatment Effectiveness

There is a growing body of evidence that indicates that treatment does work, and that some treatment is better than no treatment (Gersteon & Harwood, 1990; Platte, 1995). Simpson and Sells (1982), for example, in a lengthy, well-designed follow-up study of clients five to seven years after admission to either methadone maintenance, TCs, or outpatient drug-free programs, concluded that treatment was effective in diminishing recurrent drug use and antisocial behavior. Outpatient detoxification, however, was found to be less effective (Lipton & Maranda, 1982).

Although many of the drug treatment evaluation or outcome studies in the literature are methodologically flawed, mainly because it is not possible to control for all the variables that affect the treatment process, the findings do suggest that treatment makes a difference. Recent treatment outcome research sponsored by NIDA (Hubbard et al. 1989) indicated that drug treatment does work, but that it typically involves a lengthy recovery period. This conclusion was derived from a 12-year follow-up study of drug users (N=490) enrolled in treatment programs from 1969 to 1973. The following are the study’s major findings: (Swan, 1991).

• After multiple intervals of addiction and treatment, 76 percent of those interviewed had not used opioids daily in the previous year, 63 percent had not used opioids daily in the last 3 years, 48 percent had not used opioids daily in the last 6 years, and 29 percent had abstained from daily opioid use over the last 10 years. • One-quarter of those interviewed reported no relapse to daily heroin use following treatment. • Few study participants used opioids continuously throughout the 12 years. Only 27 percent reported daily opioid use for more than 3 years at a time, and only w1 percent for 2 years. • More than half of all recovering opioid users interviewed 12 years after starting treatment said that they had quit daily opioid use while they were enrolled in a treatment program. • One quarter of those interviewed reported using alcohol as a substitute for opioids. • Quitting daily opioid use is not simply a matter of growing older, but involves emphasis on assessing clients’ goals and motivations, and improved counseling.

Although the treatment evaluation research described above is optimistic concerning heroin users, the question of treatment effectiveness for cocaine users remains

Evolution of Substance Abuse Treatment 78 April 2003 Institute for Circumpolar Health Studies unanswered. More research is needed that will provides a better understanding of the natural history of recovery from substance abuse, and on the development of techniques that optimize this recovery process. Such research is particularly imperative for cocaine users.

Additionally, Segal (1986b) noted that emphasis should be given to perceiving drug- taking behavior as a multidimensional phenomenon (as is emerging in the field of alcoholism), in which the choice of drug, reason for its use, and personality and social factors, among other variables, need to be interrelated. Better knowledge of the interrelationships among these factors will help in the development of differential intervention strategies for different drug-related problem behaviors, and help to establish criteria to evaluate the effectiveness of these strategies.

As with treatment for alcoholism, the question of whether treatment for drug abuse works has also arisen. Findings from a recent study released by the National Institute on Drug Abuse (NIDA) (Mueller & Wyman, 1997) provided answers to this important question.

The Drug Abuse Treatment Outcome Study (DATOS) specifically compared treatment outcome among four types of programs, out-patient methadone (29), long-term residential care (21), outpatient drug-free (32), and short-term inpatient (14), in nearly 100 programs in 11 cities. It was found that “For the four treatment types, DATOS investigators found reductions almost without exception in the use of all drugs - including cocaine, heroin, and marijuana - after treatment” (Mueller & Wyman, 1997, p. 4). This finding was viewed as verifying the effectiveness of drug abuse treatment, no matter what its form, and as an opportunity to continue to improve treatment effective- ness based on an understanding of how core treatment services, such as drug abuse counseling and mutual self-help groups, contribute to treatment outcome.

Although these effectiveness rates hold in general, individual treatment outcomes depend on the extent and nature of the patient's presenting problems, the appropriateness of the treatment components and related services used to address those problems, and the degree of active engagement of the patient in the treatment process.

Other studies of drug treatment found that treatment reduces drug use by 40 to 60 percent and significantly decreases criminal activity during and after treatment. For example, a study of therapeutic community treatment for drug offenders demonstrated that arrests for violent and nonviolent criminal acts were reduced by 40 percent or more. Methadone treatment has been shown to decrease criminal behavior by as much as 50 percent. Research shows that drug addiction treatment reduces the risk of HIV infection and that interventions to prevent HIV are much less costly than treating HIV- related illnesses. Treatment can improve the prospects for employment, with gains of up to 40 percent after treatment. The following describe the advantages and benefits of effective treatment.

Evolution of Substance Abuse Treatment 79 April 2003 Institute for Circumpolar Health Studies D. Research Findings on the Value of Treatment

1. Effective Treatment Saves Money

From a fiscal perspective, every man, woman and child in America pays nearly $1050 each year to cover the $276 billion total national costs of untreated substance abuse. Costs are from lost productivity, law enforcement, health care, justice, welfare, and other social costs. Corporate America spends $100 billion annually on costs related to substance abuse. In 1995, substance abuse cost Federal welfare programs, including Medicare, Medicaid, Food Stamps and Unemployment Compensation, an estimated $77.6 billion. Approximately 33% of all justice system costs derive from untreated substance abuse, but the $250 billion in losses borne by the victims of drug- related crime are not included. Medical costs associated with injuries to women by their partners total over $44 million annually, and 50% of domestic batters are believed to have addiction problems, while 80% of all child abuse cases are believed to involve parental substance abuse. All these costs, and more, derive from the affects of large numbers of persons who need treatment, but who are unable to receive it.

The 1997 National Household Survey on Drug Abuse (NHSDA) estimates 27.8 million Americans need substance abuse treatment. Despite the enormity of the need for effective treatment, only 3 million persons are admitted for services in any year. The national treatment system, at current capacity, can serve only one-third of the most needy, usually adults who are severely and chronically addicted. The data strongly suggest untreated substance abuse is the nation's number one health problem and a major economic problem as well. Costs to the Medicaid program alone are expected to top $1 trillion over the next 20 years if current trends in substance abuse continue unabated.

2. Treatment is a Good Investment

In contrast to the exorbitant costs of untreated substance abuse, it would cost about $45 per year for each American to provide the full continuum of services needed to effectively treat addictive disorders. Treatment for substance abuse and addictive disorders, when appropriately administered, is highly effective and yields impressive savings in avoided social costs. For example, a California study found that $1 invested in substance abuse treatment saves taxpayers $7 in future costs. Other examples: In the first year after treatment, Minnesota saved $28.7 million in reduced medical, hospitalization, psychiatric, DUI, and justice costs, and recovered 67% of its investment in treatment. Oregon spent $14.9 million on treatment in 1991-92, and produced savings of more than $83.1 million in avoided costs over the next 3 years, a return of $5.60 for each $1.00 invested in treatment.

3. Treatment Reduces Health Care Costs

Over 72 medical conditions have risk factors attributable to substance abuse. Blue Cross/Blue Shield found that families' health care costs dropped by 87% after

Evolution of Substance Abuse Treatment 80 April 2003 Institute for Circumpolar Health Studies treatment, a reduction from $100 a month in the 2 years prior to treatment to $13.34 per month in the fifth year after treatment. Aetna Federal Employee Health Benefit Plan showed overall health care costs for alcoholics rose from $130 to $1,370 per month prior to treatment; three years after treatment costs had dropped to $190 per month. Substance abuse frequently mimics or exacerbates mental health disorders; after receiving substance abuse treatment, clients in a California program showed a 44% de- crease in mental health hospitalizations. During the first year of Massachusetts' managed health care program, which provided substance abuse treatment to Medicaid recipients, the use of the services rose 10% while the costs of treatment declined by 45%, giving the State an approximate savings of $12.2 million in decreased use of hospitals and detoxification centers.

4. Treatment Cuts Costs of Crime, Violence and Law Enforcement

More than 1.2 million correctional inmates are substance abusers and addicts: in 1996, 840,188 State and Federal inmates needed treatment, but only 18% received it. Without treatment, these offenders are likely to repeat drug-seeking or drug-supporting crimes. With the average annual cost to incarcerate one inmate over $18,400, states are yielding impressive returns on their investment in correctional treatment. In just six months after treatment, Iowa saved $87 million from reductions in crime. In Oregon, a 1-year investment in treatment resulted in 58,000 fewer crimes in the following 3-years. Illinois reports less than 5% of the participants in one treatment program are reincarcerated, and treatment, at $39 per day per participant, is more effective and more economical than incarceration which costs $89 per day, thereby yielding a savings of $50 per day per participant.

Criminal justice costs are avoided via reduced arrest rates resulting from effective treatment. Arrests decreased among participants one year after treatment in the following States (compare with the national average rate of rearrest without treatment at 47%):

Ohio arrests down 90% Minnesota arrests down 90% Hawaii arrests down 87% Florida arrests down 82% Colorado arrests down 80% Texas arrests down 80% Maine arrests down 79% California arrests down 60%

5. Treatment Reduces Welfare Costs

$4,474 per year is saved for each woman who leaves welfare and becomes employed. CSAT reported that one year after treatment, 40% of the women eliminated or reduced their dependence on welfare. Colorado reports an average increase in employment status of 60% from the time of treatment admission to post-treatment follow-up. Arkansas showed an increase of 127% among clients who became employed full-time

Evolution of Substance Abuse Treatment 81 April 2003 Institute for Circumpolar Health Studies after entering treatment. Missouri's treatment system doubled clients' employment rate. Wisconsin reported that after treatment, 64% of women were employed and 39% returned to school. Florida increased the employment or school enrollment rate by 76% from before treatment to about one year after beginning treatment.

6. Treatment Restores Families

The national basic payment for foster care in 1995 was approximately $4,230, and the total estimated costs of care for abandoned infants ranges between $22.3 to $125 million per year. Approximately 78% of children entering foster care are from families in which substance abuse is a major factor in foster home placement, and drug exposure is a factor in 87% of abandoned infants. A study by CSAT showed that 87% of children and mothers were reunited one year after their mothers had completed treatment. Wisconsin reported 56% children returned from foster care within one year after their mothers completed treatment, and Massachusetts reported 85% of mothers were living with their infants and 69% with all their children. Florida returned 580 children to treatment group of 180 women.

7. Treatment Yields Returns to Business

United Airlines estimates it receives a $16.95 return for each dollar invested in a drug- free workplace program. The U.S. Small Business Administration reports drug-free workplace programs cost $22 to $50 per employee, and favorably compares them with the estimated annual costs of $640 incurred by each untreated substance abusing employees. The former McDonnell-Douglas Corporation received a return of $3 for each $1 invested in treatment in its Employees Assistance Program.

E. Concluding Remarks

After a review of the nature of treatment for drug-related problems, and an examination of some of the issues involved in treatment of the substance abuser, it is apparent that the major investment of funds and resources in this country has been concentrated on addressing the problem of narcotic (heroin) addiction, and that progress in dealing with nonopiate drug-related problems is mostly a spin-off from this larger effort. Moreover, many of the treatment methods, except for the newer pharmacological approaches, have been modeled after those used in the treatment of alcoholism. What is needed is a shift away from the traditional, and often parochial, views of the alcohol field to a more flexible approach, one that does not advocate a specific form of treatment, but instead seeks alternative forms of interventions better matched to client needs. This new approach, as Milby (1981) noted, avoids the assumption that:

All drug abusers are alike because they have an undifferentiated disorder. Having a large federal agency, the National Institute of Alcoholism and Drug Abuse, fosters this assumption in the public's mind. This monolithic notion obscures the diversity of people who abuse drugs and the diversity of their problems. It has dulled awareness of how changeable people are and how they have different problems at different

Evolution of Substance Abuse Treatment 82 April 2003 Institute for Circumpolar Health Studies times as they progress in treatment. To be maximally effective, treatment plans should be individualized both in type and timing of intervention; unfortunately, this approach is the exception, not the rule. (p. 215).

Another important issue that affects treatment for drug-related problems is the erroneous notion that assumes the validity of common addiction stereotypes, for example, that most addicts are criminals who maintain their addiction by criminal acts (Milby, 1981). Not only is this assumption invalid, but many addicts maintain their addiction through legitimate employment, and a large number of substance abusers are from middle- and upper-class backgrounds and are not part of a drug subculture. If further headway is to be achieved in the treatment of drug abuse, there needs to be the realization that there are a variety of different types of users, and that specific services have to be developed around such needs. Research is necessary to help provide a knowledge base upon which innovative approaches may develop, and to formulate procedures to evaluate their effectiveness.

Another issue in need of consideration, now that a discussion of treatment of alcoholism and drug abuse has been accomplished, is whether alcoholism and drug- related problems should be treated in separate or unified treatment programs. Traditionally alcohol and drug treatment programs have differed not only with respect to the methods used, but also with respect to the clientele treated. Alcoholics, as a rule, were older, with histories of relatively stable lives in spite of their drinking problems. Drug-related clients were younger, often with a history of unstable behavior or criminal offenses. These differences not only dictated a need for separate treatment strategies, but made it highly unlikely that the two populations could share a common treatment program. Thus alcohol and drug treatment programs tended to remain separate, each following their own philosophy and treatment methods.

But today alcoholics are younger, and drug-related clients tend to be more stable and, more significantly, many drug users abuse alcohol and many "alcoholics" use other drugs. The use of opiates combined with excessive drinking has long been noted among opiate addicts (Joseph & Appel, 1985), and an increasing number of people are seeking treatment for dual addiction. Pragmatically, it would seem productive to combine treatment in terms of economics and resources, and some alcohol programs are admitting clients with cocaine or other nonopiate drug-related problems. But there is often a failure to distinguish between the special needs of drug-related clients and alcoholics; both are exposed to the same course of treatment. The question that faces the alcohol treatment field is: How should the clinical staff deal with substance abuse other than alcohol by their clients? The question for drug treatment programs is: How is dual addiction (alcohol and other drugs) to be treated? It is important that clinicians begin to develop models of therapy that are effective for such clients. The emergence of a best practice or science-based treatment approach provides an answer to this question.

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VII. Science-Based or Best Practice Treatment

"Science has revolutionized our fundamental understanding of the nature of drug abuse and addiction and what to do about it," wrote NIDA Director Dr. Alan I. Leshner in an article on drug addiction and its treatment that appeared in the October 14, 1999 issue of the Journal of the American Medical Association. By articulating the essential characteristics of addiction and effective treatment methods, Dr. Leshner established science-based (or research-based or best-practice) treatment as the new foundation for addiction treatment.

Science-based treatment is thus defined as " treatment that provides a wide range of components, based on research, that supports their utilization in order to address the unique combination of biological, social, and behavioral aspects of addiction presented by each person." The concept of a Science-Based approach has been adopted by CSAT, the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as a method of identifying what succeeds in the treatment of substance abuse. The underling philosophy of a science-based treatment program is that a treatment program based on research insures that the program is based on a proven model that has resulted in measurable outcomes. Recently, NIAAA published its “Principles of Drug Addiction Treatment” in which it details 13 scientifically based approaches to treatment (NIAAA, 2000). What follows is review of these Thirteen Principles of Effective Drug Addiction Treatment that form the basis for a best practice or science-based treatment.

1. No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each individual's particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.

2. Treatment needs to be readily available. Because individuals who are addicted to drugs may be uncertain about entering treatment, taking advantage of opportunities when they are ready for treatment is crucial. Potential treatment applicants can be lost if treatment is not immediately available or is not readily accessible. (Research has shown that providing services, such as a weekly group session, to wait-listed clients has a positive impact compared to potential clients who receive no services while waiting to enter a program.)

3. Effective treatment attends to multiple needs of the individual, not just his or her drug use. To be effective, treatment must address the individual's drug use and any associated medical, psychological, social, vocational and legal problems.

4. An individual's treatment and services plan must be assessed continually and modified as necessary to insure that the plan meets the person's changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy a patient, at times, may require medication, other medical services, family therapy, parenting instruction, vocational rehabilitation, and social and legal services. It is critical

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5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The appropriate duration for an individual depends on his or her problems and needs. Research indicates that for most patients, the threshold of significant improvement is reached at about 3 months in treatment. After this threshold is reached, additional treatment can produce further progress toward recovery. Because people often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.

6. Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address issues of motivation, build skills to resist drug use, replace drug-using activities with constructive and rewarding non drug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships and the individual's ability to function in the family and community.

7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and levo- alpha-acetylmethadol (LAAM) are very effective in helping individuals addicted to heroin or other opiates stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opiate addicts and some patients with co-occurring alcohol dependence. For persons addicted to nicotine, a nicotine replacement product (such as patches or gum) or an oral medication (such as bupropion) can be an effective component of treatment. For patients with mental disorders, both behavioral treatments and medications can be critically important. Researchers are also currently evaluating the efficacy of naltrexone (i.e., ReViaä ), a medication recently approved for alcoholism treatment.

8. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. Because addictive disorders and mental disorders often occur in the same individual, patients presenting for either condition should be assessed and treated for the co-occurrence of the other type of disorder.

9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use. While detoxification alone is rarely sufficient to help addicts achieve long-term abstinence, for some individuals it is a strongly indicated precursor to effective drug addiction treatment.

10. Treatment does not need to be voluntary to be effective. Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or criminal justice system can increase significantly both treatment entry and retention rates and the success of drug treatment interventions.

11. Possible drug use during treatment must be monitored continuously. Lapses to drug use can occur during treatment. The objective monitoring of a patient's drug and alcohol

Evolution of Substance Abuse Treatment 85 April 2003 Institute for Circumpolar Health Studies use during treatment, such as through urinalysis or other tests, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that the individual's treatment plan can be adjusted. Feedback to patients who test positive for illicit drug use is an important element of monitoring.

12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection. Counseling can help patients avoid high-risk behavior. Counseling also can help people who are already infected manage their illness.

13. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term abstinence and fully-restored functioning. Participation in self-help support programs during and following treatment often is helpful in maintaining abstinence.

The principles of science-based or best practice treatment for persons addicted to alcohol and other drugs has been adopted by the Center for Substance Treatment (CSAT), and conveyed to the treatment community in the form of "wrap-around" or "system of care" services. System of care can be defined as a comprehensive spectrum of substance abuse and other necessary services that are organized into a coordinated network to meet the multiple and changing needs of addicted clients with emotional disturbances and medical disorders. A comprehensive system of care also provides for community development and linkages between systems such as educational facilities, welfare agencies, mental health organizations, the justice system and other formal systems as well as informal stakeholders such as service clubs, the faith community, volunteer networks, parent networks and other organizations. The wraparound process includes a set of framing elements, which serve as the philosophical base for the process.

1. Wraparound efforts must be based in the community. 2. Services and supports must be individualized to meet the needs of the clients and their families. 3. The process must be culturally competent and build on the unique values, preferences, strengths of clients and families. 4. The process must be implemented on an interagency basis. 5. Wraparound plans must include a balance of formal services and informal community and family resource. 6. Services must be unconditional. 7. Outcomes must be measured. If they are not, the wraparound process is merely an interesting fad. Fortunately, the wraparound process is increasingly the object of scientific investigation.

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VIII. Substance Abuse Prevention

As substance use and abuse increased, there was a corresponding effort to combat such behavior through prevention programs, many of which continue to be directed at youth. Although such efforts achieved some success, most prevention programs have been hampered because there is a lack of a clear understanding of what is meant by "prevention." Beyond the implication that the term conveys that there is an intent to do something about substance use, what actually needs to be accomplished has not been generally clear.

This dilemma exists, in large part, because prevention has so many facets that it is extremely difficult to formulate successful strategies that include all the factors that are related, directly or indirectly, to drug-taking behavior. Additionally, many of the prevention programs that have been undertaken (e.g., media campaigns, community awareness programs, alcohol and drug education curricula, etc.) were conducted independently of one another. Few attempts have been made to develop systematic prevention strategies that represent a unified approach that simultaneously involves diverse community elements such as schools, families, media, and community organizations. Additionally, there has been little attention given, until very recently, to cultural and ethnic factors that are involved in drug-taking behavior.

Another confounding factor is the failure to distinguish between substance-abuse prevention and substance-abuse education. The two are often used interchangeably, a practice that hinders an understanding of what is implied by the term "prevention." This lack of clarity, along with the other problems indicated above, contribute to difficulty in designing effective prevention strategies and methods to evaluate their effectiveness. Drug education, as it will be defined here, is a component of drug prevention or a particular prevention strategy. Drug education programs are programs that are specifically designed to present information about drugs and their effects with the intent of changing peoples' attitudes toward drugs and thereby preventing their use.

Another problem in defining drug prevention is that of differentiating between programs or activities designed to deter drug use by influencing a person's behavior and those directed at reducing the supply of available drugs or the demand for drugs. The first type of activity generally involves educators, treatment programs, medical authorities, and researchers. The latter activity generally refers to the actions of law enforcement authorities. This is an important distinction because it has serious implications that impact funding, program emphasis, and outcome. The criminal justice aspects of prevention focus on aspects of drug use that are generally divorced from those addressed by practitioners and researchers, and will not be reviewed here. Rather, our discussion will be limited to those activities concerned with attitude changes and attempts to deter or reduce drug-taking behavior.

The recognition of the difficulties involved in the development, implementation, and evaluation of substance-abuse prevention programs has led to a rethinking about what constitutes prevention. In a shift in policy, beginning in 1975, the federal government

Evolution of Substance Abuse Treatment 87 April 2003 Institute for Circumpolar Health Studies recognized that there was a need for prevention programs that would promote the growth of individuals and discourage the use of drugs as a way to solve (or avoid) problems. In other words, there was a realization that if progress were to be achieved in combating drug abuse, the problem had to be dealt with before it emerged. Furthermore, it was recognized that if prevention programs were to succeed, they needed to be redefined and redirected to have communities themselves work to promote healthier, substance-free life-styles. As a result of this decision, a great quantity of resources in terms of time, activity and money, was invested in prevention efforts, many of which have been highly visible at various levels of community awareness, especially within school systems. Such programs have recently undergone a critical evaluation, mainly because weaknesses were becoming apparent that led to questions about their effectiveness.

This section reviews some of the issues involved in prevention, and briefly reviews the history and philosophies of alcohol and drug prevention programs and offers recommendations for prevention policy making and program planning. Following an initial discussion of issues common to both alcohol and drug prevention, the unit will be divided into two sections covering alcohol and other drugs.

A. Issues and Concerns Common to Both Alcohol and Drug Prevention

Two primary questions arise in formulating prevention programs: "Who should have responsibility?" and "To whom should the program be directed?" With respect to the first question, should responsibility for prevention programs be vested in federal, state, or local governments, in schools, community groups, the medical establishment or in alcohol and drug programs? Concerning the focus of prevention programs, should they be directed primarily at youth, at the community as a whole, or at high-risk groups? Another important question is: "What is to be prevented?" Unless specific objectives are made explicit, there is no basis for developing programs and no criteria for evaluating their effectiveness. Further complicating the situation is the fact that such objectives can be very diverse. They may range from attempts to eliminate all drug use to only providing information to influence choices about taking drugs. Each specific prevention objective necessitates a specific target group, strategy, and method of evaluation.

Even if a well-defined prevention program is conceived, two factors need to be taken into consideration. The first is that costs are involved. Prevention is an expensive undertaking, requiring a mobilization of resources to plan, implement, and evaluate the program. The second factor is that prevention programs need to address the nature and extent of the problem within the context in which the problem is occurring. For example, if a community perceives that an immediate problem with cocaine is more severe than alcohol-related problems, then a campaign directed at alcohol may not have any impact on cocaine use. Prevention efforts must be timely and relevant to the problem at hand and avoid losing the message meant to be conveyed. This problem is particularly pertinent with regard to smoking and moderately heavy social drinking, two behaviors that many people find pleasurable and wish to continue for personal and

Evolution of Substance Abuse Treatment 88 April 2003 Institute for Circumpolar Health Studies social reasons, despite the fact that educational programs have repeatedly publicized their potential harm.

A further important concern in devising prevention programs is the level at which they are to be presented. Historically, three traditional types of prevention strategies have evolved based on a public health model:

• Primary prevention, represents actions that anticipate problems and pursues action to prevent their occurrence. As applied to substance abuse, primary prevention can involve the identification of high-risk groups, such as offspring of alcoholic parents, and informing them about their vulnerability in order to decrease their potential for abusing drugs. Primary prevention programs have mostly been directed at elementary-grade schoolchildren in an effort to immunize them from becoming involved in using drugs.

• Secondary prevention, involves efforts to have people who have tried or experimented with drugs, or have used them with some degree of frequency, to discontinue such use before it evolves into problem use.

• Tertiary prevention, is the process of preventing the retaking of chemical substances after users have achieved abstinence, usually as a result of some form of therapeutic intervention.

As used in the context of the public health model, prevention in the drug-abuse field has usually meant primary prevention and, to a lesser extent, secondary prevention. The special aim of prevention has been to keep nonusers from becoming users, and to help experimental users return to nonuse, or from progressing to abuse. Those who have reached the point of abuse are not candidates for prevention, but for intervention. Rehabilitation programs constitute tertiary prevention.

In 1994 The Institute of Medicine (IOM, 1994) introduced a new framework for classifying prevention. This scheme has subsequently been adopted by the Center for Substance Abuse Prevention (CSAP) as a way of organizing intervention programs and matching them to the needs of targeted populations. This new framework establishes three categories: prevention, treatment and maintenance. The prevention category is further divided into three classifications, universal, selective and indicated prevention. Definitions of these terms follow:

Universal program prevention strategies address the entire population (for example: school, neighborhood, community, region, state, all adolescent girls), with messages or programs aimed at preventing or delaying the abuse of alcohol, tobacco, or other drugs. The purpose of universal prevention is to deter the onset of use by providing all individuals the information and skills necessary to prevent the problem. All individuals share the same general risk for substance abuse, although the risk may vary greatly among them.

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Selective prevention strategies target subsets of the total population that are deemed to be at risk for substance abuse by virtue of their membership in a particular segment of the population, for example, children of alcoholics. Risk groups may be identified based on biological, psychological, social, or environmental risk factors known to be associated with substance abuse (IOM 1994). Age, gender, family history, place of residence such as high drug-use or low-income neighborhoods, and victimization may define targeted subgroups by physical and/or sexual abuse. Selective prevention targets the entire subgroup regardless of the degree of risk or any individual. The selective prevention program is presented to the entire subgroup because the subgroup as a whole is at higher risk for substance abuse than the general population. An individual's personal risk is not specifically assessed or identified and is based solely on a presumption given his/her membership in the at-risk subgroup.

Indicated prevention strategies are designed to prevent the onset of substance abuse in individuals who do not meet DSM-IV criteria for addiction, but who are showing early danger signs, such as falling grades and consumption of alcohol and other gateway drugs. Indicated prevention programs address risk factors associated with the individual, such as conduct disorders, and alienation from parents, school, and positive peer groups. Less emphasis is placed on assessing or addressing environmental influences, such as community values. Individuals can be referred to indicated prevention programs by parents, teachers, school counselors, school nurses, youth workers, friends, or the courts. Young people may also volunteer to participate in an indicated prevention program.

Another recent advance in behavioral research has shifted prevention efforts away from the more traditional concepts of prevention to identification of factors related to drug abuse (risk factors). (Drug use, for purposes of discussion herein, represents initiation to and experimentation with or limited recreational use of illicit drugs; drug abuse is referred to as regular or sustained drug use.)

The contributing factors that may predispose an individual to or protect s/he from initiation, escalation, and maintenance of drug abuse may be a combination of biomedical (including genetic), psychological, psychiatric, social, familial and environmental factors. The etiology of drug use [however] does not appear to be identical with the etiology of drug abuse. That is, factors that constitute risk for use do not in themselves necessarily predict the transition from use to abuse; vulnerability to use seems to be largely distinct from vulnerability to abuse. (Glantz & Pickens, 1992, pp. 5, 7).

A risk factor has been defined as "an individual attribute, individual characteristic, situational condition, or environmental context that increases the probability of drug use or abuse or a transition in level of involvement with drugs" (Clayton, 1992, p. 15). Examples of risk factors are: economically disadvantaged; children of alcoholics or of other substance-abusing parents; victims of physical, sexual, or psychological abuse; runaways or homeless youth; school dropouts; pregnant youth; youth involved in violent or delinquent acts; youth with mental health problems; and youth who have attempted suicide. Other risk factors are poor academic achievement, lack of religiosity, early

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drinking, poor self-esteem, and poor relationship with parents. Many of these factors can be either causes or consequences of drug use. The determination of the role of each is related to the temporal ordering of events.

In addition to risk factors, the concept of protective factors, which act in opposition to risk factors, or which may nullify risk factors, has also been advanced. Protective factors represent an "individual attribute, individual characteristic, situational condition, or environmental context that inhibits, reduces, or buffers the probability of drug use or abuse or a transition in level of involvement with drugs" (Clayton, 1992, p. 16). Examples of protective factors are: quality schools, cohesive family, high intelligence, church involvement, involvement in clubs and organizations, positive self-esteem, available role models and high controls against deviant behavior.

What has been described thus far represents some of the more prominent issues concerns and advancements involved in the formation of prevention policies and programs. However, the most important question is: "How effective are prevention programs?" Answers to this question are uncertain, largely because many prevention programs are so diverse that they have not been fully evaluated. The need for well- designed evaluation criteria and procedures persists.

In all, the field of prevention is relatively new, subject to all the problems inherent in any evolving discipline. Although there are many identifiable limitations to be dealt with, none are insurmountable, and efforts to address them are in progress. The following sections will review some of these efforts. The first discussion focuses on alcohol, with its own inherent history of prevention efforts that are intricately tied to the history of alcohol control policies in this country. The second part describes prevention efforts directed at the use of other drugs. This relatively new area also has its own brief history and specific strategies.

B. Prevention of Alcoholism

1. Control Strategies as Prevention

The major strategy evoked in the United States earlier in this century to curtail and prevent alcoholism was the enactment of prohibition. But even after the repeal of prohibition, prevention policies and procedures continued to be concerned with the diminution of drinking as the main strategy for preventing alcohol problems. This goal was woven into the very fabric of society by means of two fundamental social and political control policies: situational and individualistic.

Situational policies are those directed at the circumstances and conditions in which drinking takes place, and at the actions that may result as a consequence of drinking. These policies are implemented through the enactment of laws that regulate the sale and consumption of alcoholic beverages; for example, control of opening and closing hours for liquor stores and drinking establishments. Such laws make no effort to alter drinking behavior directly, but are enacted chiefly to regulate the availability of alcohol

Evolution of Substance Abuse Treatment 91 April 2003 Institute for Circumpolar Health Studies and the conditions for its consumption. Zoning regulations, fixed hours of sale, excise taxes on alcohol, state-owned monopolies of alcohol retail outlets, price controls, and direct prohibition on the sale or possession of alcohol in many states are all measures representative of situational control or prevention measures.

Individualistic policies attempt to control or influence the actions of the person toward drinking. Two very different types of individualistic prevention efforts or social policies have evolved -- legal and educational. Legal policies represent laws enacted against the effects of drinking, such as statutes dealing with drinking and driving, public intoxication, drinking in public, and other alcohol-related behaviors. These policies use the threat of punishment to persuade people either to conform or to suffer serious penalties for breaking laws.

Educational policies are directed at presenting information to educate the public about alcohol and alcoholism. Such information usually conveys the message that drinking must be curtailed. The public service slots seen on television that call attention to drinking problems are examples of such educational campaigns.

Many of the prevention policies that have originated as situational or individualistic policies are necessary to help society deal with the adverse effects of drinking. Drinking and driving, for example, must be minimized, and regulation of the distribution and consumption of alcohol does help in reducing alcohol abuse. But it is important to realize that many of today's control policies originated in the attitudes of the prohibition movement earlier in this century, and that many of these attitudes have also been adopted by advocates of the disease concept of alcoholism as necessary to help combat alcoholism. Prevention programs have thus been significantly influenced by the theory or philosophy of the etiology of alcoholism, and this influence has not always been beneficial.

One adverse result of this phenomenon is that public attitudes have been shaped in a very negative way with regard to drinking behavior in our society; the education that took place tended to indoctrinate people only with information about the painful consequences of drinking. Aside from the advertising by the beverage alcohol industry to promote social and recreational benefits of drinking, little effort has been made to inform the public that alcohol can have social benefits, that it plays a significant role in many cultural rituals or practices such as religious celebrations, and that it is part of many festive occasions. Nor has the public had an opportunity to observe and identify with role models who provide standards for appropriate drinking behavior. While it is necessary to make people aware of the adverse consequences of drinking excessively or abusively, a constant portrayal of the adverse effects of drinking can loses its message. For one thing, the traditional model of knowledge-attitude-behavior change is breaking down, especially when only negative information is imparted. Thus, while some aspects of prevention/control policies are necessary, there is a need to develop new, innovative approaches that are more effective in evoking appropriate responses from the public.

Evolution of Substance Abuse Treatment 92 April 2003 Institute for Circumpolar Health Studies 2. Prevention Models

The concepts of situational and individualistic control or prevention strategies have been incorporated, directly or inadvertently, into models of alcohol prevention. Three major prevention models underlie the development of alcohol prevention programs: the distribution-of-consumption model, the sociocultural model, and the social-psychological model. a. The Distribution-of-Consumption Model

The distribution-of-consumption model, or single distribution theory, is concerned with differences in prevalence of drinking, and the resulting damage, across national and social groups; it is particularly concerned with per capita consumption and the overall level of consumption in a society. The model assumes a direct relationship between per capita consumption and alcohol abuse (Ledermann, 1964). Prevention programs based on this model follow the basic premise that a reduction in per capita consumption can be attained by reducing the availability of alcoholic beverages, thus resulting in a decrease in the number and severity of alcohol-related problems.

The implications of this model for prevention is that manipulation of the availability, price, and age limitations will restrict consumption, and so lessen the adverse impacts of drinking. The increase of the legal drinking age to 21 years in the U.S. is an illustration of how a prevention model is transformed into direct action. b. Social-Psychological Model

A social-psychological model considers drinking behavior and drinking-related problems to be the result of an interaction between personality and social factors; among these are peer pressure, the family, and sociocultural and environmental factors. Personality factors are those characteristics or traits that are inherent, including one's attitudes toward alcohol. Prevention programs that follow this model emphasize that social- psychological factors need to be modified in order to affect drinking behavior. Parenting groups, values clarification, assertiveness training, and encouragement of attitude changes would be some of the methods utilized in prevention programming. Attitude changes would be brought about through media campaigns. c. Sociocultural Model

A sociocultural model focuses on the relationship between the social context of drinking and the consequences of such drinking, particularly alcohol-related problems. The basic premise of this model is that alcohol problems result from improper social norms regarding the inappropriate consumption of alcohol. The implications for prevention thus involves the development of new or appropriate drinking norms that stress healthier drinking patterns. The establishment of social norms regarding drinking that are clear and consistent is seen as contributing to lowering the incidence of alcohol- related problems. The emphasis on "responsible drinking" advocated by Dr. Morris

Evolution of Substance Abuse Treatment 93 April 2003 Institute for Circumpolar Health Studies Chafetz, the first director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), was an example of an attempt to establish social norms that promoted more healthful attitudes and practices regarding drinking behavior (Chafetz, 1974).

Although these three prevention models are based on different theoretical assumptions or premises about drinking, many of the programs that evolved contained elements of all three models. That is, when these notions are transformed into practical applications, it is difficult to develop a program that is uniquely representative of just one model. Although one particular model may be featured, elements of the others may be involved.

C. National Prevention Policies

Under the direction of the NIAAA, national prevention policies have been developed and funding was allocated for the implementation of programs that promoted these guidelines. The first of NIAAA's policies that was promulgated was that of "responsible drinking," which sought to induce moderate drinking among Americans. In its "First Special Report to Congress on Alcohol and Health" (NIAAA, 1971), Dr. Chafetz, as NIAAA's director, stated that: "Ours is a nation that is ambivalent about its alcohol use. This confusion has deterred us from creating a National climate that encourages responsible attitudes [emphasis added] toward drinking for those who choose to drink; that is, using alcohol in a way which does not harm oneself or society" (pp. 3-4). In reviewing the policy of controlled drinking, Parker (1984) has stated:

The responsible drinking prevention policy was intended to gain acceptance for moderate drinking and thereby make it unnecessary for drinkers to engage in compulsive behavior such as episodic heavy drinking. This required that alcohol not be viewed as a "forbidden fruit" to be used excessively, but as a substance that could be consumed responsibly during most leisure activities. Proposals were advanced to lift restrictions on the availability of alcohol in restaurants, grocery stores, theaters, and other settings and to introduce lighter proof liquors in these settings…The goal was to substitute responsible drinking practices for less responsible ones. (p. 239)

The idea of responsible drinking, however, was not widely accepted, and was even rejected outright by many of the traditionalists in the field of alcoholism. That problems could be avoided by moderate drinking or by establishing acceptable norms for drinking behavior was unacceptable, and NIAAA's prevention policy was openly opposed. There was also little research evidence to demonstrate that liberalizing drinking regulations would reduce alcohol consumption. NIAAA's promotion of responsible drinking was discontinued in favor of a policy of attempting to reduce the level of alcohol consumption, as advocated by NIAAA's second director, Dr. Ernest Noble.

Interestingly, some of the notions held by Dr. Chafetz are now being initiated, in the form of the introduction and popularization of beer with less alcohol content (Light Beers), and the introduction of "coolers," wine combined with fruit juice and carbonated

Evolution of Substance Abuse Treatment 94 April 2003 Institute for Circumpolar Health Studies water. Both products were placed in the market to promote the consumption of lighter alcoholic beverages, while still maintaining, and encouraging, the social and recreational aspects of drinking. These new products were in large part a reaction to the public's growing awareness, as a result of prevention programs, that perhaps it is time to examine our drinking practices, and from an emerging awareness that an excessive intake of alcohol can have adverse effects. These new beverages also represented a way for the alcohol beverage industry to capitalize on the new concept of "responsible drinking," and the industry profited significantly from its promotional campaign. (These new beverages were also not so subtly promoted as drinks that would go well with marijuana and other "recreational drugs."

NIAAA's emphasis on prevention, beginning in 1977, was to stabilize and reduce the per capita consumption of alcohol. At the same time, NIAAA embarked on a policy of targeting groups at high risk for alcohol-related problems - youth, women, the aged, and minorities - and sought to increase treatment and prevention efforts directed at these groups. This policy has generally remained in effect, and funding has been provided for developing and implementing programs that meet these objectives.

D. Alcohol Prevention Programs

Proceeding along the direction established by NIAAA, the general trend in alcohol prevention up to the early 1990s was toward developing an effective means of preventing problem drinking among youth, reducing drunk driving, and preventing alcoholism in the workplace.

1. Drinking and Driving

The extensive social, health, and economic costs resulting from drinking and driving inspired increased efforts to prevent alcohol-related automobile accidents that result in an increasing number of fatalities (particularly among young people); someone is killed in a drunk driving accident in the United States every 23 minutes. Attempts to reduce drinking and driving have followed the traditional public health approaches of primary and secondary prevention. Primary prevention efforts are directed at deterring drinking and driving from occurring; secondary efforts are mostly directed at preventing the recurrence of any incident of drinking and driving after an individual has been adjudicated for driving while intoxicated (DWI).

Youth is the main target for primary prevention, which has involved establishing minimum legal-drinking ages. (Currently, all 50 states raised the minimum drinking age to 21 years.) Alcohol education has also been included as part of drivers' education programs in high schools and privately owned driving instruction schools. Other primary prevention efforts, directed at the population at large, involve severe penalties for conviction of DWI, increased police visibility and surprise field-sobriety testing, and direct media campaigns.

Evolution of Substance Abuse Treatment 95 April 2003 Institute for Circumpolar Health Studies Secondary prevention programs have followed two directions. One was to strengthen penalties for DWI, making them increasingly stricter for multiple DWI offenders. Along with fines and jail sentences, offenders are also mandated to alcohol treatment programs for evaluation and treatment.

The second approach, chiefly directed at first-time DWI offenders, consisted of court- mandated referrals to short-term alcohol safety education programs to attempt to alter the behavior of these offenders through educational programs or by participation, when necessary, in specific intervention programs aimed at treating problem drinking or alcoholism. These programs came into effect in 1968, when the Secretary of Transportation, through the National Highway Traffic Safety Administration (NHTSA), enacted a plan for an extended effort to combat drinking and driving. Part of the plan called for the initiation of federally funded Alcohol Safety Action Projects (ASAPs), which required a coordination of activities among law enforcement agencies, the courts, and alcohol rehabilitation/educational programs. ASAP programs made it possible for courts to refer DWI offenders for a comprehensive evaluation and, based on the report's recommendations, judges could exercise discretion in referring offenders to education, rehabilitation, or treatment programs.

As a result of ASAPs, new services, funded by client fees, began to develop to respond to court referrals. Alcohol and traffic education programs were specifically designed to be responsive to first-time offenders and long-term educational and rehabilitation programs for those with more serious drinking problems. Although federal funding of ASAP programs was discontinued, the Alcohol Traffic Safety and National Registration Act of 1982 (PL 97-364) authorized incentive grants to the states to encourage the establishment of effective alcohol safety programs. Many states have maintained ASAP programs under grants administered by NHTSA.

The effectiveness of DWI countermeasures, particularly secondary prevention efforts, are very much in question. "Simply put, the problem of drunk driving continues to plague society without any obvious remedies" (Klajner et al. 1984, p. 459). Legal sanctions alone have not resolved the problem. According to Klajner and colleagues:

When legal sanctions for drunk driving are examined, the evidence suggests that, with the exception of license suspension, they are inconsistently enforced, reluctantly applied, and far from optimally effective. However, despite such shortcomings, one undeniable fact persistently emerges: the recidivism rate for first DWI offenders is low (20% to 25%). One plausible reason may be that a simple encounter with the criminal justice system is, for many people, a sufficient deterrent from future violations. An alternative explanation also exists. The enforcement- apprehension system for drunk driving is inefficient and ineffective; the chance that any driver will be caught for DWI more than once is very low, especially in contrast with other crimes (e.g., bank robbery) where the odds of apprehension and punishment are reportedly higher. Unfortunately, this may falsely impact the impression that legal countermeasures are effective, as well as obscure the fact that recidivism rates (in terms of further incidents of drunk driving) among DWI offenders

Evolution of Substance Abuse Treatment 96 April 2003 Institute for Circumpolar Health Studies are high. In essence, an illusion of effectiveness may be fostered by inadequate law enforcement. (p. 450)

Although ASAP programs have been beneficial, Klajner et al. (1984) note, "Evaluations of the ASAP approach have been negative . . . [but] despite the lack of evidence showing marked effects, DWI schools undoubtedly will continue to be a popular counter-measure for two reasons: First, they are often entrepreneurial enterprises that depend on court referrals for their existence. Second, they constitute an expeditious alternative to certain legal sanctions (e.g., jail terms) and to treatment" (pp. 458, 459).

Given that the reports by Klajner et al. indicate that DWI countermeasures do not appear to be advantageous, the question arises as to why we continue to maintain such programs. The answer is that by themselves such programs may not be as effective as possible, but when they are part of a comprehensive, integrated national prevention program that is aimed at limiting alcohol- related traffic accidents, such as in Sweden, DWI can be curtailed. Borkenstein (1981) has suggested that the role of alcohol in traffic accidents can be mitigated by (1) reducing per capita alcohol consumption (by increasing price or raising drinking age); (2) constructing streets and highways that place fewer demands on drivers so the effects of alcohol are not as severe; and (3) increasing enforcement to bring about general deterrence of drinking and driving. When the probability of being apprehended for DWI increases, that is, when law enforcement efforts are considerably increased and such action is linked with immediate and stringent mandatory legal sanctions, including immediate suspension or revocation of one's driving license, then a reduction in the amount of drinking and driving may be attained. ASAP programs, operating within this overall scheme, may then yield more effective results.

And more effective results have been achieved since the emphasis on reducing DWI started. The raising of the drinking age to 21 years, a greater stress on apprehension along with stricter penalties, and a national effort to reduce the blood alcohol level to 0.08 (initiated in some states) for DWI, along with a major public service campaign, has succeeded in lowering DWI-related deaths.

2. Employees Assistance Programs

Alcohol treatment personnel have long recognized that a major factor in treating alcoholism is that many people who experience alcohol-related problems do not readily seek help, and typically resist the efforts of others to help them. A means of overcoming this limitation has been the development of job-based alcohol programs, called Employees Assistance Programs (EAPs). Such programs have been effective in helping people rehabilitate themselves because intervention occurs at a fairly early stage in one's drinking career, when the individual is still relatively productive and psychologically and physically intact, and has family support. Furthermore, the commitment by management, including the funding of costs, to the rehabilitation of the worker furnishes an added incentive for obtaining help. Conversely, the potential threat of job dismissal if the worker is unwilling to seek intervention is an additional motivation

Evolution of Substance Abuse Treatment 97 April 2003 Institute for Circumpolar Health Studies to seek treatment. Among the organizations that provide programs for staff members with alcohol-related problems are voluntary associations, labor unions, federal, state, and local governments, and both large and small corporations.

EAPs activities initially consisted of helping in the identification of and intervention with the (drug- or) alcohol-troubled employee. Some EAPs undertook direct counseling or provided referrals to alcohol treatment programs. As the success of EAPs became evident, broad-spectrum programs were instituted that were much more comprehensive and extended beyond addressing alcohol and drug problems. Family discord, financial problems, job satisfaction, the psychological and behavioral effects of medical conditions, consequences of organizational change, and the usual range of functional psychological, psychiatric, and behavioral problems became areas of concern for EAPs. More recently EAPs have been expanded further to promote more healthful life-styles among employees, focusing on establishing fitness and exercise programs, smoking and weight-control clinics, and stress management training, and providing organized family recreational and social activities.

Although many of the newer EAPs cannot be considered primary alcohol (and drug) prevention programs in the traditional sense, and they were not designed to be such, they have been successful, as have the more traditional alcohol-related EAPs. The benefits, however, are largely or exclusively derived from prevention-oriented programs, rather than from those that are largely treatment-oriented because of the optimism and enthusiasm the former generate and the relative ease with which interest among employees can be elicited.

NIAAA administered prevention programs until 1992, following a transfer of such authority to the newly formed Center for Substance Abuse Prevention (CSAP) under the enactment of P.L. 102-32, which established the Substance Abuse and Mental Health Services Administration (SAMHSA) to assume responsibility for reducing and controlling substance abuse and mental health problems, which encompassed prevention activities. CSAP's prevention efforts emphasized: (a) a High-Risk Youth Demonstration Grant Program, directed at identifying and eliminating or reducing factors that placed school-aged youth at-risk for using alcohol, tobacco, or other illicit drugs; (b) Pregnant and Postpartum Women and Their Infants Demonstration Grant, which supported comprehensive, community-based programs to help women of child- bearing age (especially low income women) to avoid the use of alcohol and other drugs during pregnancy; and (c) Community Partnership Demonstration Grant Program, which encouraged the formation of community-based, public and private sector partnerships involving schools, business, industry, professional organizations, and others who will jointly sponsor long-term, comprehensive substance abuse prevention programs, especially ones that incorporate drug and alcohol services into a community's general system of delivering primary health care.

CSAP, also supported (a) curriculum development and training to develop and test materials to combat substance abuse, (b) medical education, which insured that students in medical schools, nursing, and social work receive appropriate drug-related

Evolution of Substance Abuse Treatment 98 April 2003 Institute for Circumpolar Health Studies training to help them become more effective in preventing alcohol and other drug abuse problems (c) Community prevention training, which provided specialized training for people and groups involved in community partnerships and coalitions countering local problems of alcohol and other drug abuse; and (d) National volunteer training for substance abuse prevention, which involved training volunteers to do a better job and remain involved in prevention activities.

As can be observed, the transfer of responsibility for prevention to CSAP, within the newly formed SAMHSA, led to a new approaches, and shifted emphasis to community- based programs addressing alcohol, tobacco, and other drugs. The effectiveness of these programs remains to be determined.

In summary of alcohol prevention activities, although many advances have been made, it has become evident that there is no single prevention strategy that is going to be effective or is likely to have widespread generalizabilty. Rather, a combination of diverse strategies, addressing different target groups, may achieve greater success than the singular efforts that have been initiated thus far.

E. Prevention of Drug Abuse

1. Prevention Strategies

For a variety of reasons, the development of effective drug abuse prevention programs has remained an elusive goal. Some efforts directed solely at prevention of drug use are relatively new, having come into their own in the late 1980s, but most efforts have paralleled or been combined with procedures followed in alcohol-abuse prevention programs. These program also enjoyed the same levels of success and failure. Attempts at drug prevention, which began in the late 1930s, when marijuana was the principal target, consisted largely of scare tactics, involving efforts to frighten people away from taking drugs. Some of the techniques used were to expose people to unpleasant movies about drugs; to convey horror stories about drugs; to dispense information about the physical, psychological, and social dangers of drugs (which was often untrue and misleading); and to stress punishment for the sale, possession, or use of drugs. These tactics were epitomized in a film called "Reefer Madness," distributed in the late 1930s. This film portrayed marijuana as an "evil drug," one that would make the user "mad" and cause the carrying out of "despicable" acts, such as murder. Although this film ultimately came to be rejected, it reflected an attitude that authorities wanted to impart about drugs.

Scare tactics continued to be used as the main prevention strategy well into the early 1970s. Many prevention programs, sponsored by the federal government, consisted of having "ex-addicts" or "ex-drug abusers" address juvenile, college, and adult groups about how harmful drugs could be, how drugs contributed to their personal difficulties and problems, and how drugs would do the same thing to others who used them.

Evolution of Substance Abuse Treatment 99 April 2003 Institute for Circumpolar Health Studies Other tactics involved distributing inaccurate information about drugs to young people in the hope of discouraging them from using drugs. Such attempts, however, caused the young people, who mistakenly were thought to be naive about drugs, to discredit both the information and the presenter. The bestowing of information about drugs was also not particularly helpful in prevention. It is believed that the manner in which it was done may have contributed to an increase in drug experimentation because people were using the information to obtain even better highs.

Overall the particular prevention strategy of scare tactics was much less effective than anticipated. Contributing to this failure was the fact that many young people, although recognizing the potential dangers involved in drug use, believed that they were personally immune to such reactions. Additionally, the desire to be part of the drug scene, and to satisfy curiosity about the experiences drugs were alleged to induce, apparently served as strong motivating forces that overrode any considerations to refrain from trying drugs. If the scare tactics had any success, it was with the parents of adolescents and of young adults, who, reacting out of fright and concern, demanded that something be done to protect their children.

The policy of scare tactics, initiated by the then President's Special Action Office for Drug Abuse Prevention (SAODAP), in conjunction with the National Institute on Drug Abuse (NIDA), proved to be a major disappointment, and a moratorium on all prevention materials and activities was declared in 1973 until a reevaluation of prevention philosophies and procedures could take place.

This reexamination resulted in a dramatic change of direction in prevention policy instituted by NIDA, the organization that had responsibility for prevention within the National Institutes on Health (NIH). Emphasis was to be shifted away from a preoccupation with drugs and drug information to a concern with people, focusing on their environment and their total life situation.

A majority of drug prevention programs currently in operation are based on NIDA's prevention model or policies, and have been implemented in school settings as part of the health curriculum. Efforts at community prevention programs have been more difficult to initiate because such programs lack the kinds of organizational and systematic planning that are available in school organizations. Many of the attempts to launch community-based prevention programs have tended to be fragmented and uncoordinated. A major problem hampering such efforts was, and continues to be, how to develop messages that communicate effectively to the diverse elements that comprise a community. One general theme that was tried was "responsible use of drugs," a strategy adopted from NIAAA's "responsible drinking" campaign. Some community members responded favorably to this approach, while others totally rejected it and interpreted the message of responsible drug use as evidence of further "permissiveness" in our society, the "evil" that contributed to drug use in the first place. The strategy of "responsible drug use" was quickly abandoned.

Evolution of Substance Abuse Treatment 100 April 2003 Institute for Circumpolar Health Studies In an attempt to shift prevention programming from national to local levels, NIDA changed its role from that of initiating prevention policy and programs to providing technical assistance and support -- the scope and content of prevention programs were now to be determined at the local level. NIDAs role was to assist in the development of systematic prevention strategies that represented a unified approach that simultaneously involved such diverse community elements as school, families, media, and community organizations, and to formulate methods to evaluate the effectiveness of such programs.

A significant attempt at preventing drug use was also initiated through enactment of strongly punitive state laws designed to "keep drugs off the streets and out of the hands of users." The 1973 revision of the New York State drugs laws represented the most radical of these criminal laws relating to drug use. It had two main objectives: to frighten drug users out of their habit and drug dealers out of their trade, and to reduce drug- related crimes. A subsequent evaluation of the New York State laws reported that "the availability of the data indicate that despite the expenditure of substantial resources neither of the objectives of the 1973 drug law was achieved. Neither heroin use nor drug-related crime declined in New York State" (National Institute of Law Enforcement and Criminal Justice, 1977, p. 7).

The prevention activities sponsored by NIDA were also transferred to CSAP in 1992. CSAPs approach, noted above, constituted a major effort against "drug abuse," using strategies to reduce drinking, tobacco use and other forms of drug-taking behavior.

2. Concluding Remarks

Alcohol and drug prevention programs have undergone major changes since their initiation. Although the theoretical underpinnings of prevention remain unclear, and deficiencies exist with respect to evaluation procedures, some successes and some failures have been experienced. It seems, however, that the general consensus of prevention research literature is that there have been more failures than successes in the actual prevention of substance use or abuse. Nevertheless, prevention efforts persist, and the field of prevention is becoming more sophisticated and flexible in its approach, involving schools, parents, and communities in alcohol and drug education programs. These newer approaches will achieve more success if they are based on an understanding that the attitudes, beliefs, personality, and social and cultural experiences of the people taking drugs are all implicated in the drug-taking behavior. Prevention efforts need to focus on the individual, and on the individual's motives for trying drugs, and less on the drugs themselves. Prevention planning also has to be designed to correspond to current trends or fads of drug use, that is, be "time bound." A long-term prevention strategy may no longer remain relevant because the pattern of drug use it is addressing may have changed. In order to be effective, new prevention strategies will need to be developed to correspond to changing patterns of drug use.

In the absence of effective prevention programs, and in a period of increasing drug- taking behavior among youth, efforts turn away from developing meaningful prevention

Evolution of Substance Abuse Treatment 101 April 2003 Institute for Circumpolar Health Studies programs and energy is directed toward reducing drug use through legislative measures. Legislative attempts to control or prevent drug use, however, have not proved generally successful in reducing or preventing drug. Rather, this approach has led to a preoccupation with elaboration of penalties associated with drug use. It has also placed an overwhelming burden on the justice system, with the unfair expectation that this system will eliminate the problem. Under current law drugs and drug use are partially justice problems, but drug-taking behavior is primarily a "people problem," and the justice system, in many drug-related cases, is dealing with manifestations of personal problems. If successful prevention is to be achieved, it is also necessary to focus on the many circumstances that contribute to drug- taking behavior, such as poverty, racism, unemployment, the stress of social and cultural changes, job-related stress, family conflict, and the unique characteristics of people's personal and social environments that mediate the use or nonuse of drugs. For example, developing a comprehensive job training program in a high unemployment area, and insuring job placement after training, may be more effective in preventing drug use than television campaigns conveying messages about drugs or alcohol. Our society is in need of reexamining its priorities with respect to combating drug abuse, and invest its resources, including financial support, in programs that have a chance of succeeding.

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IX. Conclusions

As has been noted throughout the preceding review, the field of alcoholism is beset with controversy and contentions concerning an understanding and definition of the nature of alcoholism and methods of alleviating this disorder. So rife is this discord that it detracts from allowing the field to progress. Indeed. Peele (1984), in commenting on the situation, pointed out that "alcoholism is a primary example of how political and social forces blunt and even reverse the thrust of social-scientific research and psychological conceptions" (p. 1348).

An important issue is the consideration being given to the idea that recovery from alcoholism may be largely a natural process, one that may be enhanced by formal treatment. It thus behooves practitioners and researchers not to reject this notion in the interest of self-preservation, but to search for an understanding of the factors involved in the process and to transfer this knowledge to practical application.

The benefits of research, however, can only be realized if those in the field are willing to accept new ideas, particularly when such information may be counter to one's own views about alcoholism. Unless there is a willingness to incorporate new knowledge and methods, the alcoholism field will continue to be involved in strife, much to the detriment of people with alcohol-related problems. If progress is not made because practitioners are unwilling to be flexible, then major responsibility for treating alcoholics will shift away from publicly funded programs to the private sector, where competition and a need for cost-effective treatment require an openness to new ideas. Such a trend has already started.

Additionally, the recent events in the field of alcoholism clearly demonstrate a need for a multidimensional approach for both understanding and treating problem drinking. Such an approach does not preclude the disease concept, nor does it omit a need for AA. A multidimensional approach seeks to establish an effective treatment plan, one designed to respond to the client's specific alcoholism syndrome at a given time together with meeting the client's overall needs at this point in life. In view of the current attention being directed at the natural healing process, it is necessary to be aware that if treatment is to be effective, it has to address other life problems and health needs to ensure a productive outcome. The multidimensional approach seems best suited to achieve these goals.

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