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Old Habits

Medicalization is the hot new thing in drug treatment. Just like in 1970.

Ibhinc.Org
Dr. Robert Dupont
Joseph Kohl
Kurt Schmoke

By Edward Ericson Jr. | Posted 7/28/2010

Second of a four-part series.

Read part 1, part 3, and part 4.

Page 4 of 5.   1  2  3  4  5  

Like the 1970s treatment pioneers, Schmoke was unafraid of new ideas--some based on the harm reduction model. He instituted the nation's first government-run needle exchange program and, in 1994, a drug court to channel non-violent offenders into drug treatment programs instead of prison. The city also set up an acupuncture clinic inside the city jail--it served almost 40 percent of drug court convicts by the mid-1990s, despite being an uncertified (and untested) treatment approach.

The city was in such desperate straits that it was willing to try almost anything--whether or not anyone could show that it actually worked. (Schmoke was not available for an interview for this article.)

Needle exchange was successful in combating AIDS among intravenous drug users, according to former Health Commissioner Peter Beilenson. But the drug courts' outcomes were marginal. Fully "49.5 percent of drug court participants self-reported being arrested in the year prior to their follow-up interview," a three-year follow-up study found, "versus 57.8 percent of controls." The study's authors noted that the difference between 49.5 percent and 57.8 percent was "not statistically significant," yet concluded that the drug court was successful.

With almost every new approach deemed "successful," treatment advocates argued that the principal obstacle to widespread recovery was lack of funds for more treatment centers.

In 1995, Beilenson recast bSAS as a quasi-governmental non-profit corporation in order to access private grant funding more easily. But gaining access to the city's treatment centers was increasingly difficult, as Beilenson discovered in 1996 when, dressed in a mud-stained shirt and a ratty ball cap, he wandered into several treatment centers to see how an addict seeking help might be treated.

"He was turned down at a number of centers," Schmoke told The Sun at the time. "That points out the need for more drug treatment centers."

Beilenson says the effort to increase drug treatment in the city was ongoing from before he took over as Health Commissioner in 1992, "but we didn't get our money where our mouth was until 1999 or so--when [Gov. Parris] Glendenning came in. Mayor [Martin] O'Malley and I really pushed for that--we got about $20 million."

Drug treatment funding in Baltimore increased about three-fold thereafter, from about $17.7 million in 1996 to nearly $53 million in 2005--nearly double (in inflation-adjusted dollars) what DuPont was given in 1971 Washington, D.C. Yet, after decades of drug treatment, Baltimore had about 10 times the number of addicts than D.C. had in the early 1970s.

In 2000, Beilenson implemented DrugStat. "Every four weeks each of the different modalities had to come before this drug stat meeting--so adolescents, residential, methadone, adult out-patient--we held them accountable for outcomes," Beilenson says. One of the main measures was "how long the [patient] stays, because it's well proven that 90-day-plus [in drug treatment] is correlated with better outcomes."

DrugStat also took note of urine test results, employment, housing status, and other measures that were first used in the late 1960s. Beilenson says the stat meetings led to improvements in treatment methods, citing one center that had remarkably good job placement numbers. "They said that instead of job placement programs, we found some potential employers who could take people," Beilenson recalls. "So we changed the contract so that they [all] had to make that effort . . . we were able to identify best practices and spread that around."

Baltimore treatment programs' 90-day retention rates slowly improved, with nearly 90 percent methadone maintenance patients and nearly 50 percent of outpatients staying at least three months by 2005.

While bureaucratic systems were adapting modern management techniques, drug treatment researchers were slowly developing better methods with which to treat patients. One of them was Maxine Stitzer, a professor in the Department of Psychiatry and Behavioral Science at the Johns Hopkins University School of Medicine, who for the past 30 years has focused on incentives.

"People respond to the consequences of their own behavior," Stitzer says. "The problem is that the rewards of foregoing drug use are out there in the future. So today, it's hard. It's painful. It's difficult. So we're trying to bring those distant rewards and make them more immediate."

The prizes for presenting clean urine samples (or just showing up) can range from modest things such as toiletries to elaborate such as like electronic devices or even cash. Perhaps unsurprisingly, "the [remission-prevention] benefit of the prizes increases with the value of the prize."

During the 1980s and '90s, as researchers conducted these small-scale experiments, the drug treatment industry lumbered along with few practitioners learning about the new, scientifically tested techniques. In 1998, the Institute of Medicine published a study called "Bridging the Gap Between Practice and Research," calling for better coordination between clinical researchers and treatment providers.

"They said, this is nuts," Stitzer recalls. "We have all this research, then we have this entrenched network of people using [12-step recovery] techniques." (Not, she hastens to add, that there is anything wrong with 12-step techniques, but the field was not learning from the research done by people like her.)

In 1999, the National Institute on Drug Abuse established the Clinical Trials Network as a clearing house for new research on drug-treatment effectiveness. Now, part of Stitzer's job involves attending conferences where researchers and practitioners meet and evangelizing for the techniques that are proven to work. "There is way more interest in the use of incentives than I ever thought possible," she says.

While incentives to stay in treatment have borne good results, DuPont has advocated a punishment-based approach that may work even better.

DuPont designed a drug court program called Hawaii's Opportunity Probation with Enforcement (HOPE) that combines more intensive monitoring with swift--yet light--punishment for relapse. The idea is to make the sanction for drug use or missing a probation meeting immediate, and progressively harsher for more noncompliance. Jaffe endorses this as well. "You should have graduated sanctions," Jaffe says. "The first time for using [drugs] you maybe go to jail for four days. Next time, maybe it's eight days. And so-on."

In most probation and parole programs, offenders face the possibility of years in prison for a single relapse. But those consequences typically come months after the relapse. Drug courts--including Baltimore's--have for years experimented with graduated penalties, with mixed results.

Relying on an outside study, DuPont claims drug use reductions of more than 90 percent in his HOPE program, and crime reduction of 50 percent. Only five percent of the HOPE group saw their probation revoked, versus 37 percent for the non-HOPE probationers. In a longer article about a different study, this one involving drug-abusing doctors covered by the comprehensive Physicians Health Services (PHS) plan, DuPont and his co-authors show how the combination of extensive random drug testing; swift, progressive sanctions for drug use; and long-term monitoring and treatment combine to produce lasting abstinence in four out of five treated individuals.

PHS programs "are not involved in the financial aspects of addiction treatment," DuPont wrote. This eliminates potential conflicts of interest for the treatment providers.

"If the key ingredients of [such programs]--particularly ongoing monitoring for this chronic illness linked to meaningful consequences--were universally available," the study contends, "we might find that relapse was far from inevitable, and that active addiction careers could be significantly shortened and stable recovery careers extended."

So after 40 years, evidence-based practices are finally becoming something of a priority in drug treatment. But improvement of the drug treatment industry is fitful. "There is increasing pressure to adopt evidence-based practices," Stitzer says. "Well, the problem is, which evidence-based practices? The funders are just allowing anything from a big menu of possibilities."

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More from Edward Ericson Jr.

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Cleaning Up (6/23/2010)
Federal money is expanding drug treatment in Baltimore--and causing providers headaches.

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