To assess the effectiveness of treatment for individuals concurrently abusing heroin and cocaine, we should evaluate the methadone treatment programs that serve them.
These evaluation efforts should consider the needs of all patients but emphasize issues relevant to concurrent cocaine and heroin abuse.
Evaluation of MTPs is particularly important because they constitute the predominant modality for treating heroin addiction.
Evaluating the effectiveness of MTPs is essential in improving the services that they deliver.
MTP service improvement, in turn, critically impacts on the longer term goal of improving AOD treatment nationwide.
Further, evaluation studies allow treatment providers to incorporate results into individualized plans for quality improvement.
Not only are such plans part and parcel of many State regulations for MTPs, but they are also required of programs working toward accreditation through either the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) or the Commission on the Accreditation of Rehabilitation Facilities (CARF).
Additionally, issues of noncompliance with State and Federal treatment regulations can be realized and resolved.
Through treatment program evaluation, problem areas are identified and opportunities for treatment improvement become available.
Of particular interest here are problem areas related to concurrent heroin and cocaine abusers.
Recognition of a problem area should be followed by appropriate action, and the effectiveness of that action in improving overall treatment effectiveness should be continuously monitored (JCAHO 1987). If improvement does not result, the validity and reliability of the performance indicators used in the evaluation could be reassessed along with the adequacy of the remedial action.
In formulating an evaluation design, choosing the variables to be measured (dependent variables) is of utmost importance.
Two variables have typically held primary status in assessing MTP intreatment effectiveness: The extent to which drug abuse (e.g., heroin and cocaine abuse) is reduced or eliminated, and the extent to which criminal activity is reduced or eliminated (Ball and Ross 1991). Although these variables maintain considerable importance in investigating treatment effectiveness, they measure only treatment results.
The evaluator must also review many other factors to conduct an evaluation that reflects overall program effectiveness.
These factors would include the environment in which a program operates (e.g., funding opportunities), the types of clients served (e.g., the proportion with comorbid psychiatric conditions), and program policies and procedures, such as actions taken if a patient produces a urine that is positive for cocaine.
Typically, three major treatment phases can be identified: Admission, intreatment, and posttreatment.
Patient-level data collection and analysis should occur during and between each treatment phase.
The following sections discuss the variables that must be examined within each phase.
During this initial phase, pretreatment, or baseline, measures are developed regarding patient characteristics.
Thorough evaluation should also include domains that have been shown to relate to patient outcomes (Phillips et al. 1994). Baseline measures and factors related to outcomes include the following:
Patient demographics (age, race, gender, etc.)
Past and present use of heroin and cocaine (especially frequency, amount, duration, route of administration, and age of onset)
Legal issues or illegal activities (e.g., charges pending, such as possession of cocaine)
Employment and financial status
Education and training
Social support systems (e.g., Does the patient spend time with people who use cocaine or other illicit drugs? Does the patient have any friends who do not use cocaine or other illicit drugs?)
Living arrangements (e.g., Is the patient in a stable relationship? Does he or she live with drug-using individuals?)
Physical and mental health, including psychiatric comorbidity
Engagement in high-risk activities (e.g., needle sharing or sex with multiple partners)
What is the average methadone dosage and program dosage range? What are the program guidelines regarding raising or lowering the dosage?
What are the type and frequency of counseling activities? What is the educational level of the staff and what are the opportunities for in-service training?
Does the program have a thought-out plan for dealing with patients with cocaine or alcohol problems?
It is also important for later analysis to ask the following about program characteristics:
What criteria do the program use for admission?
What is the program's average monthly admission rate?
Does the admission rate correspond to the desired patient-counselor ratio and number of available treatment slots?
What are the opportunities and constraints with current funding arrangements? (e.g., What services will the primary funding sources cover?)
As commonly prescribed by psychosocial research protocols, reassessment of the problem severity described above should be conducted at 1 and 3 months after admission and then every 3 months for at least the first year of treatment.
During the intreatment phase, it is necessary to begin collecting data on reductions in problem severity because such reductions are indicative of effective treatment.
Comprehensive reviews of treatment plans (required by 21 CFR, § 291.505, some State regulations, and the JCAHO) and other patient records (e.g., counseling notes and arrest records) provide vital clues to understanding problem severity.
The information provided by these records factors into the analyses of treatment effectiveness and should be included in the discussion of results.
Day-to-day stresses and a crisis in the patient's life can have a profound effect on whether or not a patient succeeds in treatment.
A complete patient record should document urinalysis results (especially cocaine-positive urines), counseling and medication attendance rates, treatment goals and whether these were achieved, referrals (e.g., whether the patient has been referred to any cocaine-specific treatment or support groups, such as CA), and notes on other factors in the patient's life that may affect treatment effectiveness (e.g., personal crises such as a recent breakup with a partner or the death of a loved one).
During this phase, analysis of all data collected through the entire treatment process (from admission to posttreatment) begins.
Evaluation studies commonly identify the following two events as qualifying a patient for followup evaluation:
Successful completion of the treatment program-Successful completion is defined as one of the following:
For the duration of treatment, the patient adheres to the treatment protocols (including cocaine-specific treatment policies) and is discharged from treatment following successful detoxification and achievement of abstinence.
The patient remains in the program for the duration of the evaluation study; maintains abstinence from heroin, cocaine, and other illicit drug use; and adheres to program rules.
Administrative discharges-Three types of administrative discharge occur:
Program-initiated discharge occurs as a result of the patient's failure to adhere to treatment program protocols and guidelines; the patient's discharge is initiated by program staff.
Patient-initiated discharge occurs when the patient asks to be discharged from treatment or leaves treatment of his or her own accord prior to completion of the program as defined by treatment protocols.
Transfer includes both treatment-related and non-treatment-related transfers (e.g., due to job or family relocation or economic considerations) to another treatment program and may be suggested by the treatment staff or requested by the patient.
For example, a patient enrolled in an MTP for treatment of heroin abuse who consistently abuses cocaine while receiving methadone may be transferred because the patient needs a more highly specialized and intensive level of care, such as a methadone treatment facility offering a day treatment program or a contingency protocol for cocaine abusers.
At discharge, data should be collected on each patient participating in the evaluation study since the time of admission. It is important to review program criteria on discharge for cocaine abuse, as well as treatment approaches to cocaine abuse (e.g., referral to additional treatment programs, increased frequency of urinalysis, and contingency contracting).
The posttreatment phase is also the time to look at program retention rates: the average length of time patients remain in treatment.
Along with overall retention rates, comparing rates of those who abuse both heroin and cocaine with those who abuse only heroin provides information specific to cocaine use issues.
It is important to ask about which treatment protocols must be followed and what special protocols are necessary for those who also abuse cocaine.
Data should be gathered on whether patient needs are being met by the particular protocols being used.
If protocols are deficient in meeting patient needs (e.g., lack of specialized services for those who abuse cocaine), areas of deficiency should be examined to determine what changes are necessary.
In MTPs, additional questions warrant investigation.
For example, what is the average methadone dosage level and is it adequate? If the patient exhibits or reports symptoms of withdrawal or a strong and persistent craving to use heroin, dosage should be revisited and the patient's counselor and the program's medical director should determine whether or not the patient may benefit from a dosage increase. Further, the evaluator should ask whether patients participate in these decisions about dosage.
The evaluator should analyze data in relation to the predetermined operational definition of success in treatment (e.g., reduction in patient problem severity rating on a given patient characteristic, such as reduction in cocaine use or spending less time with drug-using friends).
Several possible methods can be used to develop these predetermined success rates.
One is for a group of informed individuals, such as key staff members, to agree upon a set of goals for patients as a whole.
Another is to compare the program's success rates longitudinally.
For example, compare the success rate for a particular period in the current year with that of the same period for the previous year. (Using data from the same time of year helps to control for any seasonal variations in patient behaviors.) A third option is to compare a program's success rates with those of other programs.
Obtaining success rates for other programs, however, may be difficult.
Results providing a point of comparison on narcotic addiction program outcomes are available from two large-scale national studies, the Drug Abuse Reporting Program (DARP) and the Treatment Outcome Prospective Study (TOPS).
A major limitation of these studies is that both were conducted before the widespread use of cocaine.
The successor study, the Drug Abuse Treatment Outcome Study (DATOS), is currently under way in 11 cities nationwide and includes a significant number of narcotic addiction treatment programs.
This study will include findings related to cocaine use among patients in narcotic addiction programs.
However, results from this study will not be available for several years.
In addition, NIDA is funding the Methadone Treatment Quality Assurance System (MTQAS) study, which includes 25 narcotic treatment programs across the Nation.
Findings from this study, which should be available by the end of 1994, may also yield a point of comparison.
Rates of successful and unsuccessful treatment are measured by comparing patient severity ratings between the various components of the evaluation (e.g., admission, intreatment, and discharge).
Changes (negative or positive) in severity ratings are then analyzed to determine whether or not any correlations exist between the increase or decrease in severity and other factors, mainly patient demographics (e.g., age, race, and gender) and patient characteristics (e.g., age of onset for heroin use and history of cocaine use).
In another NIDA-supported study, completed in 1993, McLellan and others found that patients maintained on methadone who received either a standard or enhanced package of counseling and professional services had dramatically better treatment outcomes than those patients who received only methadone.
Methadone alone was not sufficient to reduce opioid or cocaine use in most patients nor did it decrease associated psychiatric and medical problems.
Earlier, the opposing case was made by Yancovitz and coworkers (1991), who argued that methadone maintenance alone is better than no treatment at all.
Until DATOS results are available, TOPS provides the most up-to-date data on treatment effectiveness.
It should be noted in reading the TOPS results that programs participating in TOPS tended to focus on treating patients' abuse of their drug of choice rather than on their multiple drug use.
However, the TOPS endeavor did produce convincing evidence that long-term treatment is effective in reducing drug dependency (Hubbard 1992); other research supports this finding (D'Aunno and Vaughn 1992). TOPS data did not allow researchers to draw any conclusions regarding the match of particular types of patients (e.g., patients using heroin and cocaine concurrently) with particular types of treatment; this question may still be unanswered.
Analyses show, however, that the daily posttreatment rate of heroin and cocaine use was half the pretreatment rate for patients who stayed in treatment for at least 3 months.
It is hoped that the analysis of data from future studies, such as those mentioned above, will provide information on which factors are most often associated with patients who benefit from treatment and, if possible, which factors are associated with those who do not.
The following is a list of treatment factors that may be examined in evaluating the effectiveness of treatment of cocaine and other types of substance abuse among patients receiving methadone:
Treatment protocols (especially policies specific to cocaine use)
Average treatment duration
Types of therapy and counseling provided (especially whether cocaine-specific counseling is provided)
Access to community resources (e.g., AA or CA groups)
Type of staff available on site and level of staff training
Finally, program operations are examined to determine whether program variables influence the level of treatment effectiveness.
At this point in the analysis, the evaluator should consider information on program costs, including allocations to various components of the program, and available funding.
Examination of financial issues, such as cost per patient per day, and outcome measures over time, may yield information on the interplay between fiscal issues and program effectiveness.
Likewise, considering variations in costs associated with specific program activities (e.g., counseling over time) may yield information on the value gained from those activities by comparing costs with outcomes.
Treatment may be improved with increased financial resources or more efficient use of existing resources.
Factors to be included in program examination include the following:
Program location and proximity to outside resources
Because of the critical nature of the MTP evaluation process, measures should be taken to itemize and detail the findings with regard to Federal, State, and local MTP regulations; that is, are program protocols and facilities operating in compliance with these restrictions and guidelines? If not, what are the changes necessary to achieve compliance, and could merely instituting these changes result in treatment improvement? The future calls for more research in the area of MTP effectiveness, not just measuring treatment effectiveness of a particular program but also looking at how to structure national MTP service improvement.
5The Consensus Panel appreciates the review and comments of James Luckey, Ph.D., research psychologist, Substance Abuse Treatment Research Program, Research Triangle Institute, on this chapter.
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