Planning drug abuse treatment: critical decisions
Introduction: the pitfalls in seeking and giving advice
Choosing the treatment modality
The role of government
Author: Robert G. NEWMAN
Pages: 41 to 48
Creation Date: 1978/01/01
Associate General Director, Beth Israel Medical Center, and Assistant Professor, Department of Community Medicine, Mount Sinai School of Medicine, New York, NY, USA.
This paper identifies and discusses certain key issues which must be recognized and resolved as part of the process of planning drug abuse treatment efforts. It is emphasized that the approach which is ultimately adopted must be tailored to the specific needs which prevail in a particular locale, at a particular time. It is urged that the addict population be viewed as the most significant of all critics in assessing the appropriateness of the therapeutic services which are provided.
The field of drug abuse is pervaded by controversy, much of it due to semantic confusion rather than substantive disagreement. Indeed, even the definition of "drug abuse" is ambiguous: it is couched in physiological terms, psychological terms, social terms, moral terms, legal terms, and combinations of two or more of these. The diversity of meanings which are intended by those who speak of drug abuse is matched by the diversity of meanings perceived by those to whom the comments are addressed. And what is true of the condition itself (if, indeed, there is "a" condition), applies equally to its management. The philosophical and procedural characteristics of different "therapeutic communities" may be more at odds than those which distinguish a therapeutic community from a chemotherapeutic programme. Similarly, a seven-day, hospital-based detoxification regimen has no commonality with a programme providing methadone maintenance treatment for indeterminate periods of time, although both happen to use the same medication.
Definitional problems are not the only barrier to meaningful, productive dialogue concerning the problem of drug abuse and its management. Temporal and geographical factors are also of paramount importance. What may have been true of the patterns of abuse in the mid-1960s (let alone those of the midnineteenth century) may be completely inapplicable to the current scene. The experiences of treatment programmes today, even if carefully documented and unambiguously presented (which is, unfortunately, not always the case), may have absolutely no predictive value tomorrow. Attempts to duplicate in one part of the world therapeutic modalities successfully employed elsewhere are often precluded by the vast social and cultural differences among countries, to say nothing of the divergent patterns of drug abuse per se. Confrontational therapy is no less foreign to the Meo hill tribesman in the Golden Triangle than acupuncture is to the Mexican-American heroin addict in Laredo, Texas. And even when implementation is feasible, there is certainly no reason to anticipate that treatment outcome will be identical.
*Prepared on behalf of the National Institute on Drug Abuse for presentation at the 7th International Institute on the Prevention and Treatment of Drug Dependence, October, 1977, in Lisbon, Portugal
For all of these reasons, the sagest advice to those who are planning to establish drug abuse treatment programmes may be to accept no advice. While it is stimulating to reflect on the viewpoints of others in the same field, the relevance of their opinions and experiences must be scrutinized carefully. Ultimately, we must all be guided by the responses of our own clients, in our own communities, in our own time. Accordingly, it is the aim of this paper to identify and discuss a few of the critical policy issues, rather than to present a clearly-defined blueprint for action. The response to these issues must be determined individually in the context of each reader's own philosophy, experience and frame of reference.
In establishing a treatment programme for addicts, it is imperative to define the primary and secondary objectives which one hopes to achieve. A major distinction which must be made at the outset is between clinical and public health goals  . The former relate to the provision of effective treatment services to individual clients, while the latter address the broader concerns of the general community. The distinction is by no means clear-cut, and there is inevitably much overlap - especially when clinically-oriented programmes serve very large numbers of patients. On the other hand, the goals are different, and occasionally conflict.
Programmes which seek to serve, primarily, the patient population will generally reject involuntary clients, maintain strict confidentiality of patient records, and conform in most respects to the professional and ethical canons which govern all other fields of medical practice. Where the intent is to focus first and foremost on the needs of the general community, involuntary commitment of addicts, close co-operation with law enforcement agencies, and punitive as well as therapeutic measures are all reasonable and consistent. Again, it must be emphasized that no clear demarcation exists between these two approaches. Clinically oriented programmes are politically acceptable precisely because they do serve the general population in addition to the enrolled clientele; programmes which accept a primary responsability to the non-addict community will certainly also strive to benefit their addict-clients in the process. Nevertheless, the distinction is not academic.
To the extent that programmes define their primary mission in clinical terms, success and failure will be measured according to retention in treatment, cessation of illicit drug use, employment, etc. It must be recognized, however, that a programme may be extraordinarily effective according to these parameters, while at the same time failing to halt a growing problem of drug abuse in the community. One of the reasons why drug addiction treatment (regardless of modality) is viewed with increasing cynicism in the United States is that there was an implication, if not overt promise, that treatment would eradicate the scourge of drug abuse. In no other field of medicine is treatment expected to be preventative as well as curative, to correct socio-economic problems as well as physiological and psychological ills. By failing to define clearly the objectives and limitations of addiction treatment from the outset, programme advocates set the stage for the widespread disillusionment with the "medical approach" which prevails in America today. It must be acknowledged, and repeatedly emphasized, that the factors associated with drug abuse are complex and varied, and that nothing we do to or for the individual addict will, on its own, eliminate the problem.
Another key distinction which must be made is between short-term and long-term goals. Regrettably, the outcome of addiction treatment programmes have, all too frequently, been viewed as an all-or-none proposition: either the treatment is "successful" and clients remain permanently abstinent, or clients return to drug abuse, and therapy is deemed a failure. This simplistic dichotomy ignores the reality that addiction represents a chronic, notoriously relapsing condition. Here, too, one can obtain insight by drawing analogies with other medical problems. We measure success in the treatment of cancer by noting how many patients survive for a specified time period (for example, we speak of "five-year survival" rates).
In the treatment of epilepsy, the reasonable and attainable objective is generally to reduce the frequency of seizures, rather than to eliminate them forever. And frequently, the clinician must settle for no more than the alleviation of pain in a terminally ill patient, and even this goal, when achieved, is highly gratifying to the doctor, the patient, and the patient's family. Paradoxically, however, in assessing the outcome of treatment for addiction, there is all too often an insistence for complete cure, and anything less is dismissed as irrelevant. To the extent that this perspective is shared by those who fund and who operate treatment programmes, frustration and disappointment are inevitable.
Whether the primary treatment philosophy adresses clinical or public health needs, success must be measured on a day-to-day as well as year-to-year basis. If one can assist an addict to interrupt the routine of illicit drug ingestion for a month, or a week, or even for one 24-hour period, this too has a definite value. Clearly, one should not become complacent with these temporary achievements, but neither must they be dismissed as inconsequential. Even from the broad, community-wide perspective of demand reduction, it is possible to have a major impact if short-term abstinence can be attained in large numbers of patients. It is for this reason that detoxification programmes, for instance, can and must play a role in the approach to addiction treatment, even though they may well represent, as critics are quick to emphasize, a "revolving door".
The almost religious fervour with which advocates of particular treatment approaches previously sought the support of the community, the funding agencies, and (last but not least) the potential client, was generally matched by the intemperance of their denunciation and vilification of other therapies. This counterproductive polarization and hostility has lately given way to the trend towards the "multi-modality" approach. As appealing as this rubric may be, however, one must not lose sight of the fact that there are different modalities which do differ quite markedly in their perspectives of the problem of substance abuse and whose treatment orientations and practices often do involve contradictions and conflicts. Integrating the distinctive characteristics of various treatment modalities into one unified approach inevitably yields a product which bears only superficial resemblance to any of the component therapies. A good example is the so-called "methadone-to-abstinence" approach which currently enjoys considerable popularity in the United States, and which is neither methadone maintenance nor abstinence treatment. On the other hand, attempts to preserve within one programme the distinctive features of two or more modalities and to do justice to the conceptual premises upon which they are based are also fraught with difficulty. All too often one orientation holds sway, and the others are compromised. At the same time, opposing philosophies within one programme frequently generate confusion and conflict among both staff and patients, with potentially disastrous consequences.
Because of the above pitfalls, alternatives to multi-modality programming should be considered carefully. Governmental agencies, funding sources and the general community can and should support a wide diversity of separate treatment approaches. The individual programmes, each committed to a specific conceptual model and providing treatment accordingly, can and should respect and co-operate with other types of programmes. And new approaches, including those of a hybrid nature such as methadone-to-abstinence, can and should be encouraged by all concerned, in order to complement existing therapeutic efforts. But a certain degree of separatism of the treatment services is imperative if one is to preserve a truly multi-modality approach. "Multi-modality", in short, does not mean, and should not become, "uni-modality".
A related issue concerns the desirability of establishing a "central intake unit" to serve as a single entry point to a network of treatment facilities offering a variety of therapeutic modalities. This, too, is an increasingly popular approach in the United States. In large part, it reflects the unassailable premise that different addicts require different forms of treatment. At the same time, however, it also implies that one can determine, through various objective measures, precisely which type of treatment is best suited to individual applicants. The validity of this latter premise is by no means clear.
There have been many reported studies which have sought to distinguish between clients who do and who do not respond favourably to specific treatment approaches. The results are rarely conclusive. Even when marked differences are noted, however, and a particular definable subgroup of the patient population is found to respond better than another, there is no guarantee that the results will be duplicated in another setting. For this reason, it is of dubious value to apply previous experiential data to an intake screening process designed to match applicants to programmes, despite the intellectual appeal of this approach.
Far more serious than the methodological flaws which are referred to above, however, is the general unwillingness of the addict-applicant to comply with this screening-referral mechanism. The experience of the programmes in New York City has been that addicts know precisely what type of treatment they are willing to accept; even within treatment modalities, the applicants frequently insist upon a specific programme and if that programme does not accept them, they will forgo treatment altogether rather than apply elsewhere. It does little good to predict that a particular applicant for a residential, drug-free programme conforms to a "type" which does better with methadone maintenance treatment, if the latter therapy is unacceptable to him. Indeed, many applicants strongly resent being "processed" by an intake unit which does not itself provide treatment services. They often see this as a bureaucratic hurdle to obtaining help, and ask, with considerable cogency, why they can't apply for admission directly to that programme which they seek to enter.
Agencies concerned with helping drug abusers must facilitate entry into treatment. All too often, the commitment of addicts to seek treatment is tenuous and fleeting, and unnecessary obstacles will be decidedly counter-productive. Although inherently patronizing, there may be some merit to the claim of addiction treatment experts that they know best what the addict needs. Nevertheless, merit is of little relevance if this premise is not shared by the addict. For this reason alone, the concepts which underly central intake units must be viewed with considerable skepticism.
Although adequate funding for large-scale addiction treatment almost certainly requires governmental financial support, there is difference of opinion regarding whether the treatment services should be provided primarily by government directly, or by voluntary and private organizations. Cogent arguments can be made for either option.
Frequently, government is able to launch a major effort considerably faster than can be achieved through the funding of non-governmental agencies. This was the experience in New York City in the early 1970s, when the Department of Health established a network of 40 methadone clinics; within two years, 12,000 patients had been admitted figure 1). Simultaneously, the Department initiated an Ambulatory Detoxification Programme, which within a year was admitting almost 20,000 clients annually (figure 2)  ,  . On the other side of the world, the Government of Hong Kong in 1974 was faced with a potential panic as a result of a highly successful police operation which abruptly curtailed the availability of narcotics, and led to a sharp increase in the price of heroin. In response, the Department of Medical and Health Services initiated, almost overnight, a series of out-patient methadone maintenance and detoxification centres which could accommodate many thousands of patients. It is very unlikely that in either instance such a massive effort could have been implemented as rapidly through a contractual mechanism involving a variety of local organizations.
The other side of the coin, however, must not be overlooked. Concern has been voiced  that government-controlled addiction treatment programmes lend themselves readily to abuse by those in authority, who may make medical treatment contingent upon social, and perhaps even political, conformity. In addition, there is a danger that such programmes will be unwilling or unable to maintain confidentiality, or in other ways give priority to the needs of patients over those of the community at large.
Although these dangers may be more potential than real, one must weigh carefully the perception of those whom the programmes are intended to serve: the addicts. If the target population views government-operated facilities with suspicion and trepidation, it is obvious that their usefulness will be severely limited.
An additional consideration is the candour with which government will evaluate its own treatment efforts. It is far easier, and politically more acceptable, to discontinue funding of a community-based programme which is not meeting expectations than to acknowledge that a programme operated by government itself is unsuccessful. And finally, provision of treatment through a variety of local agencies generally results in a greater diversity of approaches than is possible when service delivery is the responsibility of a single agency in the governmental bureaucracy.
FIGURE 1 - Admissions to the New York City, Methadone Maintenance Treatment Program, 1971-1974
Whatever the decision regarding the auspices under which addiction treatment programmes are to be operated, government should ensure the maintenance of certain standards, and provide for the on-going assessment of the treatment services which it is helping to finance. To ignore these obligations would be irresponsible. In the United States, high priority has been given to evaluation efforts in recent years by the National Institute on Drug Abuse. To be meaningful, of course, such studies must take into account the different treatment objectives of the various programmes, the characteristics of the patients being served, different environmental factors which may influence drug abuse and its treatment in various parts of the country, etc. There is no easy guide to effective evaluation, just as there is no easy guide to the delivery of treatment services-but the effort must be made.
FIGURE 2 - Admissions to the New York City Ambulatory Detoxification Program, 1971-1974
In the last analysis, those whom we wish to serve will judge the effectiveness of our efforts. It is imperative that we listen to these, our most important (and harshest) critics. Addicts "vote with their feet". If they perceive the treatment services as inappropriate, they will refuse to enroll, or will drop out soon after entry. The unattractiveness of our programmes represents our short-comings. When we fail to ameliorate the primary problem for which our patients seek help, we must recognize that it reflects our failure, and should lead us to reassess candidly what we may be doing wrong. But when success is achieved, it is their success, the success of our patients, and we must content ourselves with the knowledge that we, the providers of treatment services, played a role in helping them to achieve it.
R.G. Newman. The Epidemiological Approach to Drug Abuse: Its Relevance to the Teaching of Future Professionals. American Journal of Drug and Alcohol Abuse 3 : 3, 439-446, 1976.002
R.G. Newman and J. Kagen. The New York City Methadone Maintenance Treatment Program After Two Years - An Overview. Proceedings of the Fifth National Conference on Methadone Treatment , National Association for the Prevention of Addiction to Narcotics; New York, 1973, pp. 794-801.003
R.G. Newman. Methadone Treatment in Narcotic Addiction , Academic Press; New York, 1977.004
R.G. Newman. Special Problems of Government Controlled Methadone Maintenance Programs. Contemporary Drug Problems, 1 : 183-190, 1972.