Progress in the Development of Cost- Effective Treatment for Drug Abusers U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES • Public Health Service • Alcohol, Drug Abuse, and Mental Health Administration Progress in the Development of Cost-Effective Treatment for Drug Abusers Editor: Rebecca S. Ashery, D.S.W. Division of Clinical Research National Institute on Drug Abuse NIDA Research Monograph 58 1985 DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration National Institute on Drug Abuse 5600 Fishers Lane Rockville, Maryland NIDA Research Monographs are prepared by the research divisions of the National Institute on Drug Abuse and published by its Office of Science. The primary objective of the series is to provide critical reviews of research problem areas and techniques, the content of state of-the-art conferences, and integra- tive research reviews. Its dual publication emphasis is rapid and targeted dissem- ination to the scientific and professional community. Editorial Advisors Martin W. Adler, Ph.D. Temple University School of Medicine Philadelphia, Pennsylvania Sydney Archer, Ph.D. Rensselaer Polytechnic Institute Troy, New York Richard E. Belleville, Ph.D. NB Associates. Health Sciences Rockville, Maryland Gilbert J. Botvin, Ph.D. Cornell University Medical College New York, New York Joseph V. Brady, Ph.D. The Johns Hopkins University School of Medicine Baltimore, Maryland Theodore J. Cicero, Ph.D. Washington University School of Medicine St Louis, Missouri Sidney Cohen, M.D Los Angeles, California Reese T. Jones, M.D. Langley Porter Neuropsychiatric Institute San Francisco, California Denise Kandel, Ph.D. College of Physicians and Surgeons of Columbia University New York, New York Herbert Kleber, M.D. Yale University School of Medicine New Haven, Connecticut NIDA Research Monograph Series William Pollin, M.D. DIRECTOR, NIDA Jack Durell, M.D. ASSOCIATE DIRECTOR FOR SCIENCE, NIDA EDITOR-IN-CHIEF Eleanor W. Waldrop MANAGING EDITOR Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857 Progress in the Development of Cost-Effective Treatment for Drug Abusers ACKNOWLEDGMENT This monograph is based upon papers presented at a technical review which was held in Rockville, Maryland on June 7 and 8, 1984. The meeting was sponsored by the Division of Clinical Research, National Institute on Drug Abuse. COPYRIGHT STATUS The National Institute on Drug Abuse has obtained permission from the copyright holders to reproduce certain previously published material as noted in the text. Further reproduction of this material is prohibited without specific permission of the copyright holders. All other material in this volume except quoted passages from copyrighted sources is in the public domain and may be used or reproduced without permission from the Institute or the authors. Citation of the source is appreciated. DHHS publication number (ADM)85-1401 Printed 1985 NIDA Research Monographs are indexed in the Index Medicus. They are selectively included in the coverage of American Statistics Index, BioSciences Information Service, Chemical Abstracts Current Contents Psychological Abstracts, and Psychopharmacology Abstracts. iv CONTENTS Executive Summary........................................... vii Jacqueline P. Ludford Issues in the Brief Treatment of Drug Abusers.............. 1 Rebecca Sager Ashery Psychotherapy for Opiate Dependence . 9 George E. Woody, Lester Luboreky, A. Thomas McLellan, and Charles P. O’Brien Behavior Therapy in Drug Abuse Treatment: Review and Evaluation . 31 Maxine L. Stitzer, George E. Bigelow, and Mary E. McCaul One-Person Family Therapy: A Modality of Brief Strategic Family Therapy . 51 Franklin H. Foote, Jose Szapocanik, William M. Kurtinee, Angel Perez-Vidal, and Olga K. Hervis Personalized Nursing: An Effective Intervention Model for Use with Drug-Dependent Women in an Emergency Room........... 67 Marcia D. Andersen Brief Effective Treatment Strategies: Pharmacological Therapy for Opiate Addicts . 83 Herbert D. Kleber Medical Maintenance Feasibility Study....................... 101 Don C. Des Jarlais, Herman Joseph, Vincent P. Dole, and Marie E. Nyswander The Role of Employment in the Rehabilitation of Heroin Addicts ........................................ 111 Jerome J. Platt and David Metager v Who Is Serving Drug Abuse Clients: Treatment Delivery by Professionals Versus Paraprofessionals, by Paid Staff Versus Volunteers . 123 Leona S. Aiken, Leonard Losciuto, and Mary Ausetts The Harvard Group Aftercare Program: Preliminary Evaluation Results and Implementation Issues................. 147 William E. McAuliffe, James M.N. Ch'ien, Elaine Launer, Rob Friedman, and Barry Feldman Project Skills: Preliminary Results from a Theoretically Based Aftercare Experiment . 157 Richard F. Catalano and J. David Hawkins List of NIDA Research Monographs . 182 vi EXECUTIVE SUMMARY Jacqueline P. Ludford A technical review meeting was convened by the National Institute on Drug Abuse on June 7-8, 1984, to: examine findings from studies of brief drug treat- ment interventions; and based on what has been learned, consider the future directions of such research. In recent years, considerable progress has been made in assessing the effectiveness of treatment modalities. Studies have shown that drug abusers have a wide range of problems and needs, and that a variety of treatment approaches are required. Numerous factors have been found to be associated with treatment outcomes, including psychopathology (especially depression and antisocial personality disorders), physical health status, cultural factors, family relationships, social networks and community supports, employment status, vocational preparedness, and past criminality. Existing treatment modalities (e.g., methadone maintenance, thera- peutic communities, and outpatient drug free) have proven to be effective in treating drug abusers, but they are limited in many respects. For example, therapeutic communities have been particu- larly successful with clients sufficiently motivated to commit themselves to stay in a residential environment for 6 months or more, but a high percentage drop out before completing 3 months in residence. Researchers have found that methadone programs are less successful in treating clients who have psychiatric disorders and clients who use alcohol excessively. Many women, particularly those with dependent children, are not able to make the commitment to a long-term rehabilitation process. Thus, it is not surprising that existing (long-term) programs are failing to engage large numbers of drug abusers. Studies of people treated in hospital emergency rooms for drug-related episodes show that fewer than 12 percent are enrolled in treatment. Of those persons enrolled in vii short-term detoxification, only about 12 percent are successfully recruited into longer term treatment from detoxification. Despite a growing recognition of the need for alternative treat- ment methods that are cost effective, the basic drug treatment system has not changed fundamentally over the past 10 years. Some therapeutic communities have been experimenting with short-term residential treatment followed by aftercare. Methadone programs have also been testing methods of tapering or detoxifying clients who are highly motivated to pursue a drug-free lifestyle. This technical review brought together researchers who have successfully conducted controlled studies of promising brief therapies for different types of drug abusers. It provided them an opportunity to present their findings and consider the impli- cations for future research in this area. In the first presentation, Ashery provided the rationale for the review of research on brief therapies, She pointed out that there is increasing pressure on agencies to use brief treatment methods as programs become more effective in diagnosing and individual- izing client needs and make efforts to become more cost efficient. She highlighted the importance of diagnostics, client matching, strategies, treatment specificity, and cost-effectiveness in enhancing the treatment repertoire in the drug field. Woody discussed findings from a study on the efficacy of short- term psychotherapy for opiate dependence. The brief treatments included drug counseling alone, drug counseling plus supportive expressive psychotherapy, and drug counseling plus cognitive behavioral psychotherapy. The results suggest that brief supple- mental psychotherapy can make a significant difference in outcomes for high severity (seriously depressed) methadone maintenance clients. Stitzer reviewed four operant-based behavior therapies for use in drug abuse treatment: extinction, satiation, punishment, and reinforcement. Among her findings, effectiveness of contingent reinforcement and punishment intervention has been impressive in the short-term studies conducted to date. Findings suggest that contingency management procedures involving methadone dose deliv- ery may be a clinically useful adjunct in methadone treatment. Outcomes from a study of short-term family therapy approaches were presented by Foote. Positive changes occurred in both One-Person Family Therapy (OPFT) and Conjoint Family Therapy (CFT) groups in reducing drug use and psychopathology, and in strengthening family structure. The successful use of CPFT is especially significant, since it is difficult to recruit whole families into treatment. Andersen described a study which evaluated the effectiveness of a nursing intervention model