The designations employed and the presentation of the material in this publication do not
imply the expression of any opinion whatsoever on the part of the Secretariat of the United
Nations concerning the legal status of any country, territory, city or area or of its authorities,
or concerning the delimitation of its frontiers or boundaries.
The Office for Drug Control and Crime Prevention became the Office on Drugs and Crime
on 1 October 2002.
The present discussion paper was commissioned by the United Nations International Drug
Control Programme (UNDCP). Gratitude is expressed to A. Thomas McLellan, Treatment
Research Institute, University of Pennsylvania/Veterans Administration Center for Studies of
Addiction, United States of America, who wrote the discussion paper (and whose work is
supported by the National Institute on Drug Abuse, the Center for Substance Abuse
Treatment, the Office of National Drug Control Policy, the Department of Veterans Affairs
and the Robert Wood Johnson Foundation); to Robert Ali, Drug and Alcohol Services
Council, Adelaide, South Australia, Australia, and Manit Srisurapanont, Department of
Psychiatry, Chiang Mai University, Thailand, who both provided valuable feedback; and to
the drug demand reduction experts and focal points at the UNDCP regional and country
offices, who kindly provided feedback and helped bring a multicultural perspective into the
discussion paper. iii
Summary
Drug addiction produces serious, pervasive and expensive social problems. Regardless of
whether substance abuse is a sin, a crime, a bad habit or an illness, society has a right to
expect that an effective public policy or approach to the drug abuse problem will
reduce drug-related crime, unemployment, family dysfunction and disproportionate
use of medical care.
Science has made great progress over the past several years, but it is still not possible to
account fully for the physiological and psychological processes that transform controlled,
voluntary use of alcohol and/or other drugs into uncontrolled, involuntary depend-
ence on those substances, and there is still no cure. What can be done is to treat use
effectively and to provide an attractive return on societal investment in treatment.
Controlled clinical trials and large-scale field studies have shown statistically and clini-
cally significant improvements in drug use and in the drug-related health and social
problems of treated individuals. Further, those improvements translate into substantial
reductions in social problems and costs to society. The present paper compares the
effectiveness of various forms of treatment with non-treatment alternativessuch as no
treatment at alland criminal justice interventions. In each case, the research evidence
suggests that treatment interventions are more effective than non-treatment.
The main phases of substance abuse treatment are detoxification/stabilization, rehabil-
itation and continuing care. The published scientific literature provides evidence of
effective treatment components with the length of stay being the clearest predictor of
beneficial effects from treatment. Treatment modalities with longer recommended dura-
tion typically have better outcomes, as do patients who remain engaged in treatment
longer, regardless of the modality.
The research evidence is clear that, for those with severe forms of drug dependence, the
best available treatments are:
Ongoing, like treatments for other chronic illnesses;
Able to address the multiple problems that are risks for relapsesuch as medical and
psychiatric symptoms and social instability;
Well integrated into society to permit ready access for monitoring purposes and to
forestall relapse.
Importantly, the research shows that while motivation for treatment plays an important
role in maintaining treatment participation, most substance-abusing patients enter
treatment with combinations of internal motivation and family, employment or legal
pressure. Those pressures can be combined with treatment interventions for the benefit
of the patient and society.
The evidence is compelling that, at the present state of knowledge, addiction is best
considered a chronic relapsing condition. It is true that not all cases of addiction are
chronic and some who meet diagnostic criteria for substance dependence recover
completely without treatment. However, many of those who develop addiction disor-
An effective public
policy or approach to
the drug abuse
problem will reduce
drug-related crime,
unemployment,
family dysfunction
and disproportionate
use of medical care. iv
ders suffer multiple relapses following treatments and are thought to retain a continu-
ing vulnerability to relapse for years or perhaps a lifetime. Like so many other illnesses,
it is impossible to predict whether or when an acute care strategy is likely to achieve
complete remission. For example, while change in diet, exercise and lifestyle can reduce
high blood pressure in some patients without medication or continuing treatment,
many others require sustained management with medications as well as regular moni-
toring of diet, stress and exercise. In considering addiction a chronic condition, it is no
longer surprising that incarcerations or brief stabilizations are not effective.
The available research is quite clear on these points:
Education does not correct drug dependence: it is not simply a problem of lack of
knowledge.
Consequences of drug use (e.g. hangovers, loss of job, arrest, etc.) appear to be
important stimuli leading to entry into drug abuse treatment.
Very few addicted individuals are able to profit from a corrections-oriented approach
by itself. Relapse rates are over 70 per cent from all forms of criminal justice inter-
ventions.
Addiction is not simply a matter of becoming stabilized and getting the drugs out
of ones system. Relapse rates following detoxifications are approximately the same
as those following incarceration.
Based on these findings, drug abuse is best treated by combinations of continuing outpa-
tient therapy, medications and monitoring, with the goal of retaining drug abusers in that
treatment/monitoring regimen to maximize and maintain the full benefits of treatment.
Recent pharmaceutical research has produced effective medications for the treatment of
alcohol, nicotine and opiate dependence and has identified promising candidate medica-
tions that will provide even more assistance to physicians in treating those illnesses. From
this, one must conclude that drug and alcohol dependence are treatable medical illnesses.
While this paper compares addiction to other chronic illnesses, there are many differ-
ences. One of the most prominent differences is the impact of the disease on the family
and society. The major focuses of most treatments for other chronic illnesses are symp-
tom remission and return of function for the benefit of the patient. This has also been
true for many addiction treatments, which has left much of society with the view that
the major goal of addiction treatment is simply to make the patient feel better-not
something those who have suffered from the crime, lost productivity and embarrass-
ment of addiction are eager to do.
The perspective taken here suggests that addiction treatment providers must
broaden their responsibilities and focus on such socially important goals as:
Working with employers and social welfare agencies towards the goals of returning
toor findingwork;
Working with criminal justice agencies and parole/probation officers towards the
goals of keeping the patient from returning to drug-related crime and incarceration;
Working with family agencies and families towards the goals of returning to, or
taking on, responsible family roles, especially parenting.
Drug abuse is best
treated by combina-
tions of continuing
outpatient therapy,
medications and
monitoring.
Investing in Drug Abuse Treatment:
A Discussion Paper for Policy Makers v
These are the addiction-related conditions that most affect society and reduction or
elimination of them are what society expects from any effective intervention.
This paper concludes that substance abuse treatments can and should be expected to
improve the public health and social problems of patients and that there are
methods of organizing the structure and delivery of care to achieve those outcomes.
Substance abuse
treatments can and
should be expected to
improve the public
health and social
problems of patients.
Executive summary
vii
CONTENTS
SUMMARY
iii
INTRODUCTION
1
1. WHAT WOULD MAKE AN INTERVENTION SOCIALLY WORTHWHILE?
SOCIETY'S EXPECTATIONS FOR "EFFECTIVE" INTERVENTIONS
5
What brings substance abusers to treatment?
5
What outcomes are expected from substance abuse treatment?
6
Outcome domains based on public expectations
9
2. NON-TREATMENT ALTERNATIVES TO ADDRESS SUBSTANCE ABUSE
13
Evidence for treatment effectiveness
13
What happens if substance abuse is not treated?
13
Non-treatment interventions for substance abuse
17
Combining treatment and non-treatment interventions for substance abuse
18
3. WHAT COMPRISES CONTEMPORARY ADDICTION TREATMENT?
23
What components contribute to treatment effectiveness?
23
Phases of treatment
23
Patient and treatment factors shown to be important in determining outcome
25
4. WHY ARE ADDICTION TREATMENTS NOT AS EFFECTIVE AS TREATMENTS
FOR OTHER ILLNESSES?
29
Implications for the delivery and evaluation of addiction treatment
29
Compliance, symptom remission and relapse in addiction treatment
29
Compliance, sympto