INVESTING IN DRUG & ALCOHOL TREATMENT Heather Proudfoot & Maree Teesson National Drug and Alcohol Research Centre Sydney, AUSTRALIA NDARC TECHNICAL REPORT NUMBER 91 ISBN: 0 7334 0705 6 2000 TABLE OF CONTENTS ACKNOWLEDGEMENTS…………………………………………………………iv EXECUTIVE SUMMARY......................................................................................ii 1.0 INTRODUCTION.............................................................................................2 1.1 BACKGROUND AND CONTEXT .....................................................................2 1.2 AIMS OF THE PROJECT....................................................................................2 1.3 REVIEW METHOD .............................................................................................2 1.4 DEFINITION OF DRUG AND ALCOHOL PROBLEMS...................................2 1.5 THE MAGNITUDE OF DRUG PROBLEMS.......................................................2 1.6 THE EPIDEMIOLOGY OF DRUG PROBLEMS.................................................2 1.7 AIMS OF TREATMENT...................................................................................... 2 2.0 ALCOHOL..........................................................................................................2 2.1 GENERAL INTRODUCTION.............................................................................2 2.2 TREATMENT SETTING...................................................................................... 2 2.3 ASSESSMENT.....................................................................................................2 2.3.1 Screening........................................................................................................2 2.3.2 Assessment and Treatment Planning.................................................................2 2.4. DETOXIFICATION ............................................................................................2 2.5. SPECIFIC INTERVENTIONS............................................................................2 2.5.1. Pharmacotherapies.........................................................................................2 Disulfiram.............................................................................................................2 New pharmacotherapies.......................................................................................2 (a) Naltrexone..................................................................................................2 (b) Acamprosate.............................................................................................. 2 (c) Other pharmacotherapies and comorbid groups...........................................2 2.5.2. Brief Interventions..........................................................................................2 2.5.3. Social Skills Training ...................................................................................... 2 2.5.4. Behaviourally-Oriented Marital/Family/Community Interventions .....................2 2.5.5. Cue Exposure................................................................................................2 2.5.6. Cognitive-Behavioural Interventions ................................................................2 2.5.7. Other Interventions.........................................................................................2 2.5.8. General Commentary.....................................................................................2 3.0 OPIATES .............................................................................................................2 ii 3.1 GENERAL INTRODUCTION.............................................................................2 3.2 ASSESSMENT.....................................................................................................2 3.3 DETOXIFICATION.............................................................................................2 3.4 SPECIFIC INTERVENTIONS.............................................................................2 3.4.1 Methadone replacement therapy...................................................................... 2 3.4.2. LAAM (levo-alpha-acetylmethadol) ...............................................................2 3.4.3. Buprenorphine ...............................................................................................2 3.4.4. Naltrexone.....................................................................................................2 3.4.4. Prescribed Heroin..........................................................................................2 3.4.5. Drug-Free Treatment .....................................................................................2 4.0 CANNABIS.........................................................................................................2 4.1 GENERAL INTRODUCTION.............................................................................2 4.2. SPECIFIC INTERVENTIONS............................................................................2 4.2.1 Evidence from large-scale studies ....................................................................2 4.2.2 Evidence from controlled trials.........................................................................2 5.0 COCAINE............................................................................................................2 5.1 GENERAL INTRODUCTION.............................................................................2 5.2 TREATMENT SETTING...................................................................................... 2 5.3 ASSESSMENT.....................................................................................................2 5.4. DETOXIFICATION & WITHDRAWAL ............................................................2 5.5. SPECIFIC INTERVENTIONS............................................................................2 5.5.1. Pharmacotherapies.........................................................................................2 1. Drugs treating comorbid psychiatric disorders...................................................2 2. Drugs treating withdrawal and craving...............................................................2 3. Cocaine antagonists..........................................................................................2 4. Aversive agents................................................................................................2 5. Stimulant replacement therapy..........................................................................2 5.5.2. Nonpharmacological Interventions..................................................................2 1. Behavioural Reinforcement Approach...............................................................2 2. Cognitive-Behavioural Interventions ..................................................................2 6.0 AMPHETAMINES ............................................................................................2 6.1 INTRODUCTION................................................................................................2 6.2 SPECIFIC INTERVENTIONS.............................................................................2 6.2.1 Pharmacotherapies..........................................................................................2 6.2.2 Non-pharmacological interventions..................................................................2 iii 7.0 APPENDICES: LARGE-SCALE REVIEWS AND STUDIES .............2 A1: LARGE-SCALE REVIEWS.................................................................................2 A1.1 An Outline for the Management of Alcohol Problems: Quality Assurance Project. ............................................................................................................................2 A1.2 A Treatment Outline for Approaches to Opioid Dependence: Quality Assurance Project. (Mattick & Hall, 1993)...........................................................................2 A1.3 What Works? A Methodological Analysis of the Alcohol Treatment Outcome Literature. (Miller et al., 1995).............................................................................. 2 A1.4 Methadone Maintenance Treatment and Other Opioid Replacement Therapies (Ward et al., 1998e)............................................................................................2 A2: LARGE-SCALE STUDIES..................................................................................2 A2.1 The California Drug and Alcohol Treatment Assessment (CALDATA) (Gerstein et al., 1994).........................................................................................................2 A2.2 Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes (Project MATCH Research Group, 1997).........2 A2.3 The National Treatment Outcome Research Study in the United Kingdom (NTORS): Six-month follow-up outcomes (Gossop et al., 1997) .........................2 A2.4 The Drug Abuse Treatment Outcome Study (DATOS) in the U.S.: 1-Year Follow-up. (Hubbard et al., 1997)........................................................................2 8.0 REFERENCES...................................................................................................2 Author Index…………………………………………………………………………158 ACKNOWLEDGEMENTS This research was funded by the Drug Strategy & Population Health, Social Marketing Branch, Commonwealth Department of Health and Aged Care iv EXECUTIVE SUMMARY There are two obvious trends in the drug abuse