National Conference on Drug Addiction Treatment: From Research to Practice

Details

Wednesday, April 8, 1998

Betheda, Maryland

Contact

United States

Meeting Summary

Introduction

On behalf of the National Institute on Drug Abuse (NIDA), I am pleased to welcome you to the National Conference on Drug Addiction Treatment: From Research to Practice.

Scientific advances over the past 25 years have shown that drug addiction is a chronic, relapsing disease that results from the prolonged effects of drugs on the brain and behavior. Research has shown that the most effective treatment approaches include biological, behavioral, and social components. As part of NIDA's Treatment Initiative, this conference will highlight over two decades of drug addiction treatment research including:

the health, social, and economic benefits of drug addiction treatment;
the role of behavioral treatment;
the role of medication treatment;
the barriers impeding the delivery of and access to drug addiction treatment; and
additional scientific research needed to improve treatment.

This conference is designed to inform leaders of national drug abuse and other professional organizations, treatment practitioners, the media, criminal justice and law enforcement personnel, and policy makers about effective drug addiction treatment strategies that can be implemented on a local level. In addition to plenary presentations, the conference will offer the opportunity for an active interchange among participants through question-and-answer sessions, workshops, and luncheon topic tables.

Drug addiction research should not only be useful, it should be used. I hope this conference provides information and strategies that can be applied to your work in the treatment of those affected by drug addiction.

Sincerely, Alan I. Leshner, Ph.D., Director

Conference Highlights

Goals and Objectives

The conference will inform leaders of national drug abuse and other professional organizations, treatment practitioners, the media, criminal justice and law enforcement personnel, and policymakers on findings from drug addiction treatment research. The conference will focus on effective drug addiction treatment strategies that can be implemented in the local community. In addition to plenary presentations, the conference will offer the opportunity for an active interchange among participants at a luncheon, a reception, question-and-answer sessions, workshops, and lunchtime Topic Tables.

Keynote Addresses

The Director of the Office of National Drug Control Policy (ONDCP), General Barry R. McCaffrey, USA (Ret.), will discuss the Administration's efforts to develop and implement effective drug abuse treatment programs.

Plenary Sessions

The plenary sessions will open with an overview of addiction treatment research, and a series of panels will address: health, social, and economic benefits of drug addiction treatment; the role of behavioral treatment; the role of medication; current issues in the delivery of and access to drug addiction treatment; and how emerging knowledge will shape the research agenda of the future.

Question-and-Answer Sessions

Each series of panels will be followed by a 30-minute Question-and-Answer (Q&A) session to allow participants to engage the speakers and clarify presentations.

Mini-Workshops

These concurrent sessions will allow conference attendees to interact informally with scientists and practitioners on issues addressed in plenary sessions and on new and emerging problem areas where research outcomes are still in the preliminary stages. Each speaker will present for about 10 minutes, and discussions will follow for the remainder of the session.

Lunchtime Topic Tables

On the first day of the conference, lunchtime will include a buffet lunch and a series of Topic Tables hosted by representatives, national drug abuse constituent organizations, and National Institute on Drug Abuse (NIDA) staff. The purpose of these sessions is to give conference participants the opportunity to hear about and discuss issues and services in their areas of interest. Topic Tables will be identified by a sign posted in the center of each table. A list of Topic Tables is included in your registration packet.

Exhibits

Exhibits sponsored by NIDA and other Federal agencies that address drug abuse and addiction issues will be on display in the conference area lobby.

Continuing Education

The National Institutes of Health/Foundation for Advanced Education in the Sciences is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians and must be included in all written and advertising materials. The National Institutes of Health/Foundation for Advanced Education in the Sciences designates this educational activity for a maximum of 11.25 hours in Category l credit toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity.

NIDA is authorized by regulations under Title 10, Subtitle 36, Chapter .05B of the Maryland Board of Examiners of Psychologists to award 11.25 hours of Category A credit to psychologists for this activity.

As an approved provider under the National Association of Alcoholism and Drug Abuse Counselors Educational Provider Program, NIDA's Continuing Education Program has approved this educational activity for 11.25 hours of credit for counselors (Provider #000226).

This conference may meet the criteria for 11.25 hours of Category II continuing education units as defined by a State Board of Social Work Examiners. Each State has its own laws and regulations, and you should check with your State Board about reciprocity.

Certificates of attendance will be provided for other professions.

Abstracts

Forum I: The Benefits of Treatment

Effectiveness and Cost-Effectiveness of Treatment

A. Thomas McLellan, Ph.D.

There are many issues to be considered in evaluating whether and to what extent problems of addiction are effectively addressed through treatment. First, what results can be expected from an "effective" intervention, and are conventional treatments for substance use disorders effective in terms of these explanations? Second, is treatment better and more cost-effective than alternatives such as no treatment at all, self-help groups, community service, jail, or other options?

Thus, the seemingly simple question of whether treatment for substance use disorders is "effective" is actually one of the more complex health, social, and financial issues. In this presentation, rationales are offered for what are considered reasonable expectations for addiction treatments and, based on these, outcome criteria are proposed against which to judge the effectiveness and worth of those treatments. In the second part of the presentation, these outcome criteria are used to compare the effectiveness of addiction treatments to several alternatives, including no treatment or incarceration.

Presentation Conclusions

Is it possible to evaluate the effectiveness of addiction treatments? The same scientific methods and criteria that have been used to evaluate medications and medical devices have been applied with equal credibility.
Outcome is more than abstinence. While abstinence remains a goal of drug abuse treatment, it is not adequate for a comprehensive and meaningful evaluation of treatment. At a minimum, it is necessary to measure patients' personal health and social function for a meaningful evaluation.
Addiction treatment can be effective. Standard treatments have been shown to produce significant reductions in drug use and in drug-related problems of crime, family violence, unemployment, and welfare dependence. At the same time, not all treatments are effective and some are even harmful.
Some of the "active ingredients" of treatments that have been proven effective through controlled research include: individual sessions of drug counseling; professional sessions of employment, family, and psychiatric services; voucher-based community reinforcement; and medications such as antidepressants to reduce psychiatric symptoms, in addition to methadone and naltrexone to reduce illicit opiate use.

The Effects of Treatment on Crime

James A. Inciardi, Ph.D.

The effectiveness of a multistage therapeutic treatment system that was instituted in the Delaware correctional system has captured the attention of the National Institutes of Health, the U.S. Department of Justice, members of Congress, and the White House. Initially supported by the National Institute on Drug Abuse (NIDA), the Center for Substance Abuse Treatment (CSAT), and the Bureau of Justice Assistance (BJA), treatment occurs in a three-stage system, with each phase corresponding to the client's changing correctional status: incarceration, work release, and parole. An analysis of 18-month followup data will be presented for clients who received treatment in: (1) a prison-based therapeutic community (TC) only, (2) a work-release TC followed by aftercare, and (3) the prison-based TC followed by the work-release TC and aftercare.

Presentation Conclusions

Based on a wide body of literature in the fields of treatment and corrections, and combined with clinical and research experiences with correctional systems and populations, it would appear that the most effective treatment strategy for incarcerated, drug-involved offenders requires three stages of intervention.
Each stage in this continuum should be adapted to each client's changing correctional status: incarceration, work release, and parole (or other form of community supervision).
Treatment should be of a residential nature, that is, isolated from the drugs, violence, and prison subcultures that tend to work against positive behavioral change.
Although corrections-based treatment initiatives must be sensitive to the custodial demands of the prison administration, programs must have autonomy in terms of admission and release criteria and the day-to-day operations of the program.

Health Benefits of Treatment

Mary Jeanne Kreek, M.D., Ph.D.

Methadone is a mu opioid receptor-directed specific agonist that has a very long-acting pharmacokinetic and pharmacodynamic profile in humans. In the racemic form (as used in oral treatment), methadone has a half-life of over 24 hours, as sharply contrasted with heroin, which has a half-life of 3 minutes, and morphine, the major metabolite of heroin, which has a half-life of 4 hours. Thus, methadone provides steady-state profusion of the specific mu opioid receptor, whereas heroin and morphine have rapid onset and rapid offset of action. Laboratory and clinical studies have shown that rapid onset and rapid offset of drugs of abuse such as heroin disrupt many aspects of physiology, as well as specific molecular and neurochemical events. In contrast, the long-acting opioid methadone does not cause any disruption of these functions and, in fact, allows normalization of disruption caused by heroin use. L-alpha-acetylmethadol (LAAM) acts similarly to methadone and has an even longer acting pharmacokinetic and dynamic profile due to the biological activity of its two major metabolites; overall, LAAM has the duration of action of 48 to 72 hours. Thus, both methadone and LAAM allow normalization of physiology and also significantly lessen drug hunger and drug craving, thus reducing significantly or eliminating any illicit short-acting opiate use. Methadone maintenance has been used for 34 years and has been shown in numerous studies to be both medically safe and effective. LAAM, although less widely used, and, to date, for a shorter duration of time, has again been shown to be both safe and effective in maintenance treatment of heroin addiction.

Presentation Conclusions

Methadone is a mu opioid receptor-directed, long-acting specific agonist in humans.
Heroin is a short-acting opiate (half-life of 3 minutes); the major metabolite of heroin, morphine, also is a short-acting opiate (half-life of 4 hours). Both of these have a rapid onset and rapid offset of action. In contrast, methadone has a long half-life of 24 hours with slow onset and offset of action.
Heroin and other short-acting opiates disrupt many physiological functions, as well as related molecular and neurochemical events. In contrast, methadone allows normalization of those functions which were disrupted function cycles of heroin addiction.
LAAM, a second long-acting specific opioid agonist which, like methadone, acts primarily at the mu opioid receptor, is longer acting than methadone.
Methadone, as well as LAAM, reduces hunger and craving and eliminates any illicit short-acting opiate use.

Treatment as HIV Prevention

David S. Metzger, Ph.D.

As the AIDS epidemic among injecting drug users (IDUs) enters its third decade, it is important to review the role drug treatment has played in reducing the spread of HIV infection. This presentation will review the research literature examining findings from studies with behavioral and serologic measures of the association between treatment participation, HIV risk reduction, and HIV infection. Numerous studies have documented that significantly lower rates of drug use and related risk behaviors are practiced by IDUs who are in treatment. These behavioral differences, based primarily on self-report, are consistent with studies that have examined HIV seroprevalence and seroincidence among drug users.

Presentation Conclusions

The underlying mechanism of action suggested by the collective findings of the available literature is rather simpleÑindividuals who enter and remain in treatment reduce their drug use, which leads to fewer instances of drug-related risk behavior. This lower rate of exposure results in fewer infections with HIV.
The protective effects of treatment can be realized only when programs are accessible and responsive to the changing needs of drug users.
Future research needs to be directed at developing a better understanding of the factors that enhance treatment entry and retention.

Forum II: The Role of Behavioral Treatment

Cognitive-Behavioral Therapies and Counseling

Kathleen M. Carroll, Ph.D.

Cognitive-behavioral therapies (CBTs), among the most frequently evaluated approaches used to treat substance use disorders, have been shown to be effective in several clinical trials of cocaine-dependent individuals and other types of substance users. The theoretical background and goals of this approach, the fundamentals of implementing CBT with substance users, and a brief review of the evidence supporting its effectiveness with drug abusers will be presented.

Presentation Conclusions

CBTs are based on social learning and behavioral theories of drug abuse.
The basic approach of CBT can be summarized as "recognize, avoid, and cope."
Treatment is organized around a functional analysis of substance use; i.e., understanding substance use with respect to its antecedents and consequences.
Skill training is focused on strategies for coping with craving, fostering motivation to change, managing thoughts about drugs, developing problem solving skills, planning for and managing high-risk situations, identifying apparently irrelevant decisions, and cultivating drug refusal skills.
Basic principles of CBT are that: (a) basic skills should be mastered before more complex ones are given, (b) material presented by the therapist should be matched to patient needs, (c) repetition fosters the development of skills, (d) practice is needed for mastery of skills, (e) the patient is an active participant in treatment, and (f) skills taught are generalizable to a variety of problem areas.

Behavior Therapy

Maxine L. Stitzer, Ph.D.

Structured behavior therapy techniques can be effective components of drug abuse treatment. Contingent incentive procedures are designed to enhance a patient's motivation to meet treatment goals by offering concrete rewards for specific performance outcomes. Two types of incentive rewards have been shown to be effective: methadone take-home doses and money-based vouchers. These incentives, when offered contingent on drug-free urines, can be used to reduce a patient's drug use during methadone treatment and to promote both retention and abstinence in outpatient drug-free programs. Strategies for practical application of research findings to real-life clinical situations will be discussed.

Presentation Conclusions

Drug abuse patients need motivation and skills to succeed in stopping drug use.
Research has shown that drug abuse behavior can be reduced by offering contingent incentives for abstinence (verified by drug-free urines).
Methadone take-home doses can be used effectively as a contingent incentive to increase counseling attendance and to promote abstinence.
The most striking successes have come from positive reinforcement programs that provide contingent incentives for abstinence using money-based vouchers as rewards.
Research provides examples, but treatment providers may need to be creative in discovering reinforcers that they can use for contingency management in their own clinical settings.

Family Therapy

José Szapocznik, Ph.D.

Findings from four major family therapy research programs have shown that, by using somewhat different approaches to family therapy when working with different ethnic groups, family therapy is a highly effective treatment for drug-abusing adolescents. Data will be presented from each of these four programs that demonstrate the efficacy of family therapy and the apparent generalizability across populations, as well as intervention sites.

While most drug treatments emphasize the individual as the target of intervention, the defining characteristic of family therapy is the transformation of family interactions. Repetitive patterns of family interactions are the focus of treatment. Changing these patterns results in diminished antisocial behavior, including adolescents' drug abuse.

Presentation Conclusions

Family therapy is an effective treatment for adolescent drug abuse.
While different family therapy approaches have somewhat different emphases, the defining characteristic of all family approaches is the transformation of repetitive patterns of family interactions.
Because family therapy is drastically different from individual approaches, specialized training is required. It is as complex to learn family therapy as it is to learn supportive-expressive psychotherapies.
Family therapy can work with a broad range of family and social network configurations.
Family therapy approaches have developed specific interventions for engaging and keeping reluctant, unmotivated adolescents and family members in treatment.

Therapeutic Communities: Overview of Approach, Applications, and Effectiveness

George De Leon, Ph.D.

A brief overview of the effectiveness of the therapeutic community (TC) approach to the treatment of substance abuse and related problems will be presented, and clinical criteria for referral to residential TCs will be reviewed. The essential elements of the treatment perspective, program model, and method will be outlined, and highlights of client profiles, retention in treatment, and post-treatment followup outcomes from 30 years of evaluation research will be presented. The current diversity, effectiveness, and cost-benefit of modified TC programs will be reported for special populations (such as women with children, the homeless, mentally ill chemical abusers, and adolescent/juvenile offenders), and for special settings (such as homeless shelters, prisons, schools, mental hospitals, and day-treatment clinics).

Presentation Conclusions

The TC is a unique social and psychological approach to the treatment of substance abuse and related disorders.
The TC serves a diversity of clients, but particularly those with serious substance abuse, social, and psychological problems. Thus the TC's treatment goals extend beyond recovery to changing lifestyles through habilitation and rehabilitation. 3. The TC model and method have been successfully modified for special populations and special settings (institutional, residential, outpatient, and day-treatment clinics).
The effectiveness of the TC is firmly documented by 30 years of evaluation research that demonstrates a lawful relationship between length of stay in treatment and reductions in drug use and criminality, increases in employment, and improvement in psychological status.
Current studies document favorable cost-effectiveness and cost-benefits for standard and modified TCs.

Forum III: The Role of Medication Treatment

Detoxification: Necessary Antecedent to Treatment

Herbert D. Kleber, M.D.

Successful opioid detoxification is a function of safety and minimal discomfort as well as retention and progress to longer term treatment. Methadone withdrawal is most common, but rebound mild withdrawal symptoms lasting over 1 month are frequently associated with relapse. The -2 agonist clonidine is associated with less "rebound," but also less symptom suppression and more side effects. Combined clonidine and naltrexone produce a marked shortening of time (to 48 to 72 hours) and higher completion rate, but there is more discomfort and more intensive monitoring. Withdrawal can be reduced to 5 to 6 hours under intravenous midazolam sedation or general anesthesia (e.g., propofol) with clonidine premedication and increasing doses of naltrexone. Advantages include very high completion rates and ability to reach addicts who fear any withdrawal discomfort. Disadvantages include anesthesia risks, less elimination of postwithdrawal discomfort than claimed, and high cost. Rapid detoxification using buprenorphine, naltrexone, and clonidine may be almost as effective as the anesthesia method, but with fewer risks.

Presentation Conclusions

Detoxification from opiates is usually only the first step into treatment, rather than the treatment itself.
A variety of methods exists, each with advantages and disadvantages. Successful detoxification is a function of safety, minimal discomfort and retention, and progress to longer term treatment.
Newer, rapid methods using clonidine and naltrexone, preceded by buprenorphine, may ultimately prove to be easiest and most successful.
The psychosocial approaches with these various medications need to be improved to increase the percentage of those who continue in treatment.

Pharmacotherapy of Addictive Disorders

Charles P. O'Brien, M.D., Ph.D.

Over the past 25 years, scientists have made important discoveries about the mechanisms of action of drugs of abuse and the brain changes that constitute what is known as addiction. Using animal models and careful clinical studies, medications have been developed that have significantly improved the outcome of treatment for opiate addiction, alcoholism, and nicotine dependence. Several promising medication candidates are currently under study for the treatment of cocaine addiction. The focus of pharmacotherapy is on the prevention of relapse and the reduction of coexisting medical, social, and psychiatric problems. This approach is based on the medical treatment of other chronic disorders such as hypertension, diabetes, and asthma.

Presentation Conclusions

Drug addiction is a chronic relapsing disorder.
Repeated use of addicting drugs produces conditioned responses that are involuntary and persist for months and years after the last use of a drug.
A memory trace produced by addiction cannot be "erased" by medication or psychotherapy, but the patient can learn coping mechanisms that permit, often with the help of medication, a drug-free lifestyle.
Maintenance medications for opiate addiction and nicotine addiction have resulted in significant improvements in success rates.
Naltrexone and bupropion are two new medications that have been shown to reduce involuntary compulsive drug craving and can now be prescribed by physicians. More such medications are under study.

Combined Behavioral and Pharmacological Treatment for Drug Addiction

Bruce J. Rounsaville, M.D.

Both behavioral treatments and pharmacological treatments have demonstrated efficacy, but even the most powerful methods have limited success. Combining medications and behavioral treatments makes sense because each approach works on different complementary aspects of addiction. Medications treat target symptoms such as craving, drug withdrawal, and intoxication effects. Behavioral treatments attempt to change desires, goals, cognitions, habits, and interpersonal relationships. Combined treatments should have an additive effect. The empirical literature on combined treatments for substance use disorders has consistently shown that combined treatments are either superior or equivalent to behavioral or medication treatments alone. No study has shown combined treatment to be worse than either treatment alone. Despite this, combined treatments tend to be underutilized because of differences in ideology and training of substance abuse clinicians who have medical and nonmedical backgrounds.

Presentation Conclusions

Effective behavioral and medication treatments are available for dependence on all classes of abused substances, but even the most powerful approaches have limited success.
Combining medications and behavioral treatments is an optimal strategy because the two approaches work on different aspects of addiction.
Combined treatments tend to be underutilized because medically trained clinicians tend toward pharmacotherapies for addictions treatment, and many behaviorally trained clinicians remain ideologically opposed to them.
A small but growing body of empirical literature has consistently shown that combined treatments are either superior or equivalent to behavioral or medication treatments alone. No study has shown that combined treatments reduce the effectiveness of either component treatment.
The time has come to more aggressively incorporate medication treatments into behaviorally oriented programs and incorporate behavioral treatments into pharmacologically oriented programs.

Forum IV: Current Treatment Issues

Treatment of Individuals With Comorbid Severe Mental Illness

Robert E. Drake, M.D., Ph.D.

Recent research on co-occurring substance use disorder and severe mental illness will be reviewed, and epidemiology, correlates, the evolution of integrated treatments, and research on integrated treatment will be covered. Emphasis will be on the content of evolving integrated treatment programs and the evidence that these interventions are effective. Ten recent studies indicate that integrated treatments produce stable remissions of substance use disorder and that stable remission is associated with improvements in several other domains of adjustment.

Presentation Conclusions

Substance use disorder is extremely common (approximately 50 percent prevalence) in persons with severe mental illnesses such as schizophrenia and bipolar disorder.
Substance use disorder in persons with severe mental illness is associated with several adverse outcomes, including exacerbations of mental illness, rehospitalization, unstable housing, homelessness, disruptive behavior, legal system involvement, poor family relations, and HIV infection.
Patients with co-occurring severe mental illness and substance use disorder do not fit easily into traditional mental health programs or substance abuse treatment systems.
Integrated treatments, which combine mental health and substance abuse treatments for individuals with co-occurring disorders, have been developed over the past 15 years.
Several recent studies indicate that these integrated treatment programs are effective in helping dually diagnosed individuals attain stable remissions of substance use disorder.

Treatment of Women

Andrea G. Barthwell, M.D.

Prior to the 1970s, psychoactive substance use and abuse research in epidemiological, clinical, and experimental forms did not focus on issues specific to women. Since that time, a number of initiatives have been developed that define gender differences: rates of initiation; distinct patterns of maintenance use common in women; rate of development and nature of consequences of chronic use; and effectiveness of outreach, intervention, and treatment using previously described models of care. Many of the initiatives critical to shaping the delivery of services to women and our understanding of women's treatment issues have been carried out through research sponsored through grants from the National Institute on Drug Abuse (NIDA) program announcements.

The antecedents shown to be associated with women's initiation of use of psychoactive substancesÑcritical life-defining events and the elements associated with critical life periods across the lifecycleÑwill be delineated. A brief overview of the epidemiology of substance use disorders among women will be presented, including a review of the utility of such data to program planning and resource allocation at the treatment delivery level. The consequences of substance use on general health, reproductive health, and mental health will be outlined. The implications of research and how research findings can improve treatment delivery will be explored.

Presentation Conclusions

Men and women differ in rates of initiation; maintenance; identification of abuse, dependence, and consequences of use; and cessation of chemical use.
Women experience a far greater ratio of health consequences to amounts of alcohol and other drugs consumed than do men.
Women present in a variety of settings, providing opportunities for intervention.
Research to define gender differences is developed sufficiently to inform clinical practice in the areas of sensitivities and services.

The Treatment of Adolescent Substance Use Disorders

Paula DeGraffenreid Riggs, M.D.

The developmental etiologic factors that put children at risk for adolescent substance use disorders will be briefly reviewed, to provide the basis for understanding the need for a comprehensive assessment and a multimodal treatment approach to such adolescents. Specific empirically supported treatments that are generally effectively employed as part of a multimodal and multisystem treatment approach will then be discussed. These treatment approaches include: motivational interviewing, social skills training, evaluation and treatment of comorbidity, behavioral and cognitive-behavioral interventions, urine toxicology monitoring, community reinforcement techniques, family-based interventions, and multisystemic treatment.

Presentation Conclusions

Many young people have serious substance involvement with nicotine, alcohol, marijuana, and other illicit drugs. Such adolescents have high rates of conduct disorder, attention deficit hyperactivity disorder (ADHD), learning disorders, and affective and anxiety disorders. Moreover, etiologic factors are multidimensional and must be assessed and treated multimodally in the context of many interrelated systems.
There is growing empirical support for specific modalities that are effective in the treatment of adolescent substance use disorders. These modalities include: operant behavioral techniques, urine toxicology screening, cognitive-behavioral therapy, motivational interviewing, social skills training, structural and functional family therapy, treatment of comorbidity, and multisystemic therapy. They should be used as primary treatment modalities over other methodologies without such empirical support.
Common comorbid disorders, such as conduct disorder, ADHD, affective disorders, and anxiety disorders, should be addressed and treated in an integrated manner with substance treatment.
Urine toxicology screening is a necessary component of all effective treatment modalities for adolescent substance use disorders and must be employed in outpatient and inpatient treatment settings.
Although there are several promising treatments for adolescent substance use disorders, a robust research agenda is needed to replicate these treatments and develop effective new treatments. The long-term outcome of such interventions must also be investigated.

Mini-Workshop Abstracts

Cognitive-Behavioral Therapy

Kathleen M. Carroll, Ph.D.

Presentation Conclusions

CBTs are based on social learning and behavioral theories of drug abuse.
The basic approach of CBT can be summarized as "recognize, avoid, and cope."
Treatment is organized around a functional analysis of substance use; i.e., understanding substance use with respect to its antecedents and consequences.
Skill training is focused on strategies for coping with craving, fostering motivation to change, managing thoughts about drugs, developing problem solving skills, planning for and managing high-risk situations, identifying apparently irrelevant decisions, and cultivating drug refusal skills.
Basic principles of CBT are that: (a) basic skills should be mastered before more complex ones are given, (b) material presented by the therapist should be matched to patient needs, (c) repetition fosters the development of skills, (d) practice is needed for mastery of skills, (e) the patient is an active participant in treatment, and (f) skills taught are generalizable to a variety of problem areas.

Community Reinforcement Approach to Treatment

Stephen T. Higgins, Ph.D.

The community reinforcement approach (CRA) is an intensive behavioral treatment for drug abuse. Initially demonstrated to be an efficacious intervention for severe alcoholism, CRA was later adapted for and shown to be efficacious in the treatment of cocaine dependence. The basic features of CRA will be outlined, with special attention to its use in outpatient treatment of cocaine dependence.

Presentation Conclusions

CRA is an effective treatment.
CRA can be adopted in part or as a whole.
CRA can be used with a wide range of substance abusers.
CRA is based on extensive scientific evidence regarding determinants of drug abuse and effective treatment.

How to Treat If You Only Have Three or Four Sessions

William R. Miller, Ph.D.

Regardless of the ongoing debate about the optimal intensity of treatment, many practical factors necessitate addressing substance abuse within a relatively short period of time. The average length of stay in outpatient drug abuse treatment is quite brief. Managed care continues to limit the duration of care. Substance abuse is most likely to be seen not in specialty clinics but in general healthcare settings where time is short. The good news is that, even if only a few sessions are conducted, it is possible to make a clinically significant difference. This presentation will discuss the essential characteristics of effective brief treatment for alcohol and other drug problems.

Presentation Conclusions

A supportive, empathic counseling style is one of the most important predictors of successful treatment outcomes.
Though tempting to use when time is short, confrontational approaches are associated with poor outcomes.
There are at least six common elements of effective brief treatment, summarized by the acronym FRAMES (feedback, responsibility, advise, menu, empathy, self-efficacy).
Motivational interviewing is a client-centered yet directive approach for resolving ambivalence and enhancing commitment to change.
Clinical trials consistently support the efficacy of brief treatment.

Family Therapy

José Szapocznik, Ph.D.

Presentation Conclusions

Family therapy is an effective treatment for adolescent drug abuse.
While different family therapy approaches have somewhat different emphases, the defining characteristic of all family approaches is the transformation of repetitive patterns of family interactions.
Because family therapy is drastically different from individual approaches, specialized training is required. It is as complex to learn family therapy as it is to learn supportive-expressive psychotherapies.
Family therapy can work with a broad range of family and social network configurations.
Family therapy approaches have developed specific interventions for engaging and keeping reluctant, unmotivated adolescents and family members in treatment.

HIV Risk Reduction: Sex, Drugs, and the Importance of Context

Martin Y. Iguchi, Ph.D.

Human immunodeficiency virus (HIV) risk behaviors as observed in both the field and in treatment settings will be discussed, with special emphasis on the importance of considering context in the development of effective harm reduction programs for drug abusers and their sexual partners. Bleach and condom use, the female condom, needle exchanges, single-use syringes, peer interventions, motivating behavior change, reducing barriers to treatment, and treatment as prevention will also be discussed.

Presentation Conclusions

Communicating appropriate harm reduction messages to drug abusers is complicated by: the hidden and stigmatized nature of the problem, the chaos that accompanies drug abuse, the struggle to survive in impoverished environments, and the cultural and situational diversity of the target population.
Researchers need to carefully consider context in developing harm reduction messages. For example, in a study of female sexual partners of injecting drug users, individuals reporting monogamous relationships were much more likely to be infected by HIV than were those reporting the exchange of sex with multiple partners for money or drugs. In this specific instance, monogamy increases the probability of exposure to HIV, thus highlighting the need to specifically develop and tailor the risk reduction message to the situation.
It is important to view HIV transmission from a social network rather than an individual perspective.
Effective treatments for substance abuse will prevent HIV infection by decreasing the frequency of higher risk behaviors, and perhaps by altering the social drug-using environment.
It is wrong to assume that drug abusers do not care and will not change. Small changes can yield bigger results if they are supported, but this process takes a great deal of time, effort, patience, and money.

Individual Addiction Counseling

Delinda Mercer, Ph.D.

The discussion will begin by describing a model of individual drug counseling that was used in the recently completed Multisite Cocaine Collaborative Study sponsored by the National Institute on Drug Abuse (NIDA). The training and supervision practices employed and the means by which counselors' adherence and competence were evaluated will be described. The philosophy and methods of this model will be compared and contrasted with other models of addiction counseling and psychotherapy. Modifications that could be made to adapt this treatment for use with alcohol and opiate dependence will be reviewed, with relevant research findings integrated into the discussion.

Presentation Conclusions

This approach addresses the symptoms of drug dependence and related areas of impaired functioning and the content and structure of the client's ongoing recovery program. It is a time-limited approach that focuses on behavioral change, educates about 12-step ideology and tools for recovery, and encourages self-help participation.
Adequate training and ongoing supervision are as important as the counseling approach itself in providing effective drug treatment. In this approach, counselors' adherence and competence were evaluated from audiotapes of sessions, based on a rating scale developed for this purpose, and their ratings were used as a supervision tool.
Treatment should be tailored to directly address specific drug dependencies. While the content of the counseling will be similar regardless of the particular drug, the intensity, frequency, and length of treatment will often need to vary to effectively provide for different drug dependencies.
Current research supports the use of addiction counseling for treatment of drug dependence, in some cases with adjunctive pharmacotherapy, depending on the particular drug addiction.

Group Drug Counseling

Dennis C. Daley, M.S.W.

The development and use of a group drug counseling (GDC) model of treatment in a multisite clinical trial for treatment of cocaine dependency will be reviewed. Training and selection of group counselors, goals of the group, structure and content of the group sessions, and the use of supporting interactive recovery materials for patients will be discussed. Applying this GDC model to community drug and alcohol programs will be examined.

Presentation Conclusions

Manual-driven group drug counseling is a cost-effective way of providing treatment services to clients with drug use disorders.
Time-limited, structured psychoeducational groups work best in the early months of treatment; semistructured, problem solving groups work best in the later months of treatment.
When group drug counseling is provided in addition to individual drug counseling, client outcomes are better compared to providing only a single treatment.
Clients generally prefer individual sessions in addition to group sessions, particularly those with high levels of social anxiety.
Group drug counseling strategies can be easily adapted to a variety of drug and alcohol treatment contexts and address the full range of different types of drug use disorders.

Treatment of Medically Ill Individuals

Lawrence S. Brown, Jr., M.D., M.P.H.

The prevalence of concurrent medical disorders among substance-dependent persons and the extent to which illicit or psychoactive substance use is related to the development of these medical disorders will be examined. Clinical and public health significance of the medical consequences of substance abuse will be emphasized. The challenge of providing medical care to substance-dependent persons and the difficulty of furnishing substance abuse treatment to medically ill substance abusers will also be explored.

Presentation Conclusions

There is a wide spectrum of concurrent medical disorders among substance-dependent persons.
Many of the concurrent medical disorders are related to the lifestyles of substance-dependent persons, but not necessarily to the physiologic or pharmacologic effects of the psychoactive substance.
Prevention, early identification, and treatment of concurrent medical disorders have significant benefit.
Collaboration between substance abuse treatment providers and medical and psychiatric care providers has the best potential of achieving successful clinical outcomes.

Ethnic/Cultural Issues in Drug Addiction Treatment

Kathy Sanders-Phillips, Ph.D.

This presentation will focus on ethnic and cultural issues impacting drug addiction treatment in minority populations. Issues to be discussed are cultural and ethnic attitudes regarding drug use; the impact of ethnic identity development on drug use; cultural and ethnic attitudes toward drug abuse treatment; gender differences in drug use and in response to drug treatment in minority populations; ethnic differences in response to drug treatment; ecological variables impacting drug treatment; and effective strategies of drug treatment for minority populations.

Presentation Conclusions

Understand the importance of culture and ethnicity to patterns of drug use and drug treatment.
Understand the potential impact of gender differences and differences between ethnic groups on drug use and treatment.
Identify effective strategies of drug treatment for ethnic minority groups.

Alternative/Complementary Therapies

Milton L. Bullock, M.D.

Using complementary/alternative medicine (CAM) therapies for treating drug addiction is the focus of this presentation. Therapies for which some controlled research has been performed will be discussed with regard to opiate, alcohol, cocaine, and nicotine addictions. Special emphasis will be on acupuncture research relating to the areas of alcohol and cocaine abuse. Methodologic problems confronting researchers who are attempting to more precisely define the role of CAM therapies in the treatment of drug addiction will be identified, and future directions will be explored.

Presentation Conclusions

Some preliminary reports and early research efforts show promise for treating substance abuse with CAM therapies.
Incorporating CAM into mainstream substance abuse treatment programming is outstripping the research required to justify it.
Many therapies require more rigorous investigation, but current research paradigms are inadequate.
To date, there is no definitive evidence that CAM therapies are or are not effective in treating drug addiction.

Detoxification

Herbert D. Kleber, M.D.

Presentation Conclusions

Detoxification from opiates is usually only the first step into treatment, rather than the treatment itself.
A variety of methods exists, each with advantages and disadvantages. Successful detoxification is a function of safety, minimal discomfort and retention, and progress to longer term treatment.
Newer, rapid methods using clonidine and naltrexone, preceded by buprenorphine, may ultimately prove to be easiest and most successful.
The psychosocial approaches with these various medications need to be improved to increase the percentage of those who continue in treatment.

New Medications

Thomas R. Kosten, M.D.

New medications are available for opioid and stimulant dependence, including nicotine, and for comorbid psychiatric and substance abuse disorders, most notably alcoholism. For opioids, substitution pharmaco-therapies such as buprenorphine address both cost-effective detoxification and relapse prevention. Stimulant dependence continues to benefit from specific pharmacotherapies for comorbid disorders such as schizophrenia with atypical antipsychotics, depression with tricyclics, and possibly attention deficit disorder with bupropion. Nicotine dependence has benefited from nicotine patches in combination with bupropion and naltrexone. Comorbid alcoholism, which occurs in 70 percent of cocaine users, improves with naltrexone treatment, and disulfiram (Antabuse) has reduced cocaine abuse.

Presentation Conclusions

With less severe withdrawal facilitating detoxification, Schedule 4 (not Schedule 2) Food and Drug Administration control, and longer action facilitating less than daily dosing, buprenorphine is an alternative to methadone for opioid dependence.
Opioid detoxification using buprenorphine with naltrexone and clonidine or lofexidine is more cost-effective than other outpatient approaches.
Stimulant dependence benefits from pharmacotherapy of comorbid psychopathology.
Nicotine abstinence is facilitated by combining nicotine patches with bupropion and naltrexone.
Comorbid alcoholism in stimulant abusers is well treated with naltrexone or disulfiram.

Methadone and LAAM Treatment

Mary Jeanne Kreek, M.D., Ph.D.

A brief definition of the medical problems that are common in untreated heroin addicts and, to a lesser extent, in patients with other addictive diseases will be presented, along with those aspects of physiology that become disordered in cycles of addiction. The negative impact of short-acting opiates (such as heroin) on physiology, including modulation of the hypothalamic-pituitary-gonadal function, hypothalamic-pituitary-adrenal function, gastrointestinal function, and immune function will be briefly summarized. The central focus will present those areas where treatment has been shown to be extremely effective in decreasing exposure to diseases, facilitating appropriate prevention and treatment of diseases, and allowing normalization of aspects of physiology that have been disrupted during cycles of addiction. Emphasis will be on the three most common diseases in heroin addicts: (1) HIV-1 infection progressing to AIDS, (2) hepatitis B infection with or without complications with hepatitis delta and hepatitis C infection, and (3) mental health disorders, especially comorbidity with anxiety and depression.

Presentation Conclusions

Effective treatments for each of the addictive diseases allow improvement in general health status.
The most extensive studies have been conducted in active heroin addicts before and during short- and long-term methadone maintenance treatment. It has been shown that such treatment allows significant improvement in overall health status.
It has been shown that during effective methadone maintenance treatment, and during other treatments for this and other addictions, the use of unsterile needles and injection equipment is significantly reduced, which in turn leads to decreased exposure to infectious diseases including HIV-1, hepatitis B, hepatitis delta, and hepatitis C.
Normalization of immune function, which has been disrupted during cycles of heroin addiction, due to different direct as well as indirect factors, becomes normalized during chronic long-term methadone maintenance treatment, which in turn may contribute to clearing of viruses such as hepatitis B antigenemia and to improvement in overall immune function.
Disrupting the stress responsive and reproductive biological axis, which is common during cycles of heroin addiction, cocaine addiction, and alcoholism, becomes normalized during methadone maintenance treatment. It partially (or fully) improves during abstinence-based treatment for cocaine dependency and alcoholism.

Improving Access to Drug Abuse Treatment Services

Thomas A. D'Aunno, Ph.D.

A summary of what is known about access to drug abuse treatment services and clients' use of medical and social services will be presented. Changes in treatment intensity and duration over the past several years and changes in clients' use of key medical and social services will be reviewed. Ways to improve access to services will be discussed, with special focus on the organizational factors (including managed care, treatment unit ownership, staffing patterns, and regulation) that affect access to and use of various treatment services.

Presentation Conclusions

Successful drug abuse treatment depends not only on treatment intensity and duration but also on clients' use of medical and social services.
Treatment intensity, duration, and medical and social services have decreased in the past several years.
Many factors affect this decrease, including some types of managed care.
Several organizational factorsÑclient-staff ratios, public ownership of treatment units, professional staffing, and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) accreditationÑcan promote access to and use of services.

Impact of Managed Care on Drug Abuse Treatment

Dennis McCarty, Ph.D.

Debate on the potential for positive and negative effects from the expansion of managed care intensifies as States follow commercial purchasers and use managed care techniques for publicly funded substance abuse treatment. If public funds are poorly managed, or if the system is designed poorly, vital and necessary services could be jeopardized in the name of cost control. Services research can help policymakers, providers, and consumers assess the effects of managed care strategies and improve program design. This presentation will offer an overview of managed care, identify opportunities and challenges associated with public sector managed care, examine three strategies used for managed behavioral healthcare initiatives, and conclude with an assessment of policy lessons and services research needs.

Presentation Conclusions

There are many opportunities to improve the quality of substance abuse treatment services.
Successful managed care programs appear to have the benefit of leadership that has clear vision, skillful implementation, and sufficient flexibility to make alterations. Most importantly, policymakers demonstrate a capacity to be assertive purchasers of serviceÑthey manage managed care.
There are multiple models of managed care, and each dimension can be modified and crafted to fit the unique implementation. It is critical to monitor the effects of managed care on the organization, financing, and delivery of services for the treatment of alcohol and drug abuse and dependence.
The relationships between Medicaid and non-Medicaid systems of care should be examined. The potential for undesired cross-subsidization should be assessed and monitored. Cost-shifting opportunities should be identified and reported.
Careful services research can contribute to better managed care design, implementation, and evaluation.

Speaker Biographies

Keynote Speakers

Alan I. Leshner, Ph.D.
Director, National Institute on Drug Abuse
National Institutes of Health
6001 Executive Blvd
Bethesda, Maryland 20892 (301) 443-6480

Dr. Alan Leshner was appointed Director of the National Institute on Drug Abuse (NIDA) in February 1994. As one of the institutes within the National Institutes of Health (NIH), NIDA supports over 85 percent of the world's research on the health aspects of drug abuse and addiction. Prior to joining NIDA, Dr. Leshner had been with the National Institute of Mental Health (NIMH) since 1988, holding the positions of Deputy Director, then Acting Director. He came to NIMH from the National Science Foundation (NSF), where he held a variety of senior positions, focusing on basic research in the biological, behavioral, and social sciences and on science education. As a professor of psychology at Bucknell University, Dr. Leshner's research concentrated on the biological bases of behavior. Dr. Leshner received his undergraduate degree in psychology from Franklin and Marshall College and his master's and doctoral degrees in physiological psychology from Rutgers University.

General Barry R. McCaffrey, USA (Ret.)
Director of the Office of the President
Office of National Drug Control Policy
Washington, DC 20503
(202) 395-6700

General Barry McCaffrey, USA (Ret.) was confirmed by unanimous vote of the U.S. Senate as Director of the White House Office of National Drug Control Policy (ONDCP) on February 29, 1996. He serves as the senior drug policy official in the Executive Branch as the President's chief drug policy spokesman. He is also a member of the National Security Council and the Cabinet Council on Counternarcotics. Prior to his current position, General McCaffrey was the Commander-in-Chief of the U.S. Southern Command based in Panama. General McCaffrey began his distinguished military career at the U.S. Military Academy at West Point, New York. He served four combat tours: one in the Dominican Republic, two in Vietnam, and one in Iraq. When he retired from active duty, he was the most highly decorated officer and the youngest four-star general in the U.S. Army. He received two awards of the Silver Star for heroism, four awards of the Bronze Star, and three Purple Heart medals for wounds sustained in combat. General McCaffrey has a master's degree in Civil Government from American University and has taught American Government, National Security Studies, and Comparative Politics at West Point.

Conference Speakers, Moderators, and Discussants

Andrea G. Barthwell, M.D.
Encounter Medical Group
1010 Lake Street, Suite 210
Oak Park, IL 60301
(708) 383-2700; Fax: (708) 383-2959
E-mail: agbmd@aol.com

Dr. Barthwell is President of Encounter Medical Group, Oak Park, Illinois, and Medical Director of BRASS Foundation and T.A.S.C. in Chicago, Illinois. She was certified by the American Society of Addiction Medicine (ASAM) in 1986. Dr. Barthwell cochaired ASAM's Review Courses in Substance Use Disorders and ASAM's State of the Art in Addiction Medicine Courses from 1989 to 1994, is presently a member of ASAM's Board of Directors, and is Immediate Past President of the Illinois Society of Addiction Medicine.

Dr. Barthwell is Senior Health Adviser, National Women's Resource Center for the Prevention and Treatment of Alcohol, Tobacco, and Other Drug Abuse and Mental Illness, and serves as a special consultant in the areas of training in chemical dependency, violence, cultural issues, and HIV spectrum disease to the Center for Substance Abuse Treatment (CSAT), U.S. Department of Health and Human Services (DHHS) in Washington, DC. Dr. Barthwell recently chaired one of CSAT's protocol statements on infectious disease screening in drug abuse treatment programs. As a nationally recognized lecturer, Dr. Barthwell has delivered thousands of hours of training to a variety of audiences. She hosted a weekly cable television show on AIDS and has provided expert testimony on cases that related to domestic violence and drug and alcohol use or abuse. Dr. Barthwell also authored a chapter in the State Methadone Maintenance Treatment Guidelines. She is a former member of the Drug Abuse Advisory Committee of the U.S. Food and Drug Administration.

Jack D. Blaine, M.D.
Treatment Research Branch, Division of Clinical and Services Research
National Institute on Drug Abuse
National Institutes of Health
6001 Executive Blvd
Bethesda, Maryland 20892 (301) 443-0107; Fax: (301) 443-8674
E-mail: jack_blaine@nih.gov

Lawrence S. Brown, Jr., M.D., M.P.H.
Division of Medical Services, Evaluation and Research
Addiction Research and Treatment Corporation
22 Chapel Street
Brooklyn, NY 11201
(718) 260-2917; Fax: (718) 522-3186
E-mail: artcbrown@aol.com

Dr. Brown is a physician-researcher trained in internal medicine, neuroendocrinology, and addiction medicine. He has appointments as Attending Physician at Harlem Hospital, Assistant Clinical Professor of Medicine at Columbia University College of Physicians & Surgeons, and Clinical Associate Professor of Public Health at Cornell University Medical College. Dr. Brown provides consultation to a host of government and private agencies, and he serves as Medical Adviser to the National Football League. Dr. Brown's scientific contributions have focused on sequelae of and improving treatments for drug addiction and drug abuse-related transmission of the human immunodeficiency virus (HIV). He has made presentations at national scientific public health and medical meetings and has authored over 40 peer-reviewed articles and more than 100 published abstracts.

Milton L. Bullock, M.D.
Hennepin County Medical Center
701 Park Avenue South
Minneapolis, MN 55415
(612) 347-2972; Fax: (612) 904-4299

Following his graduation from Yale University School of Medicine, Dr. Bullock interned at Minneapolis General Hospital. After serving for 2 years as General Medical Officer in the U.S. Air Force, Dr. Bullock returned to Minneapolis General (now Hennepin County Medical Center [HCMC]) for residency and a fellowship in nephrology. Dr. Bullock has served in a number of roles at HCMC and is presently Director of the Addiction and Alternative Medicine Division in the Department of Medicine. An Assistant Professor of Medicine at the University of Minnesota, Dr. Bullock has research interests in the use of acupuncture for substance abuse and outcome measurement for complementary/alternative medicine.

Kathleen M. Carroll, Ph.D.
Yale University School of Medicine
34 Park Street, Room S-208
New Haven, CT 06519
(203) 789-7080, ext. 336; Fax: (203) 789-7088
E-mail: carrollkm@masp03.mas.yale.edu

Dr. Carroll is an Associate Professor of Psychiatry at Yale University School of Medicine, Director of Psychotherapy Research at the Substance Abuse Treatment Unit, and Scientific Director of the Center for Psychotherapy Development for Opioids and Cocaine at Yale. The author of over 90 peer-reviewed journal articles, book chapters, and manuals, Dr. Carroll's research and treatment interests include studies specifying and evaluating psychosocial treatments for substance users, linking treatment interventions to outcomes, and evaluating combinations of psychotherapy and medications to enhance treatment outcome.

Dr. Carroll is currently a consulting editor for several addiction and psychology journals. She serves on the scientific advisory panel of a number of research institutions and consults frequently with treatment researchers and clinical programs across the country.

Shirley D. Coletti, D.H.L.
Operation PAR, Inc.
10901-C Roosevelt Boulevard, Suite 1000
St. Petersburg, FL 33716
(813) 570-5080; Fax: (813) 570-5083
E-mail: pdonalds@nurse.hsc.usf.edu

For more than 28 years, Dr. Coletti, Operation PAR's President, has been a leading advocate for women substance abusers, their children and families, and high-risk youth. She is also a leader in the field of substance abuse prevention and treatment. Dr. Coletti has served on the Senate Caucus on International Narcotics Control, the National Institute on Drug Abuse Advisory Council, as a U.S. delegate to international drug abuse conferences, and as an adviser to State and national leaders. She served on the National Commission on Model State Drug Laws and presently serves on the advisory council for the Center for Substance Abuse Treatment (CSAT). Dr. Coletti and Operation PAR have been recognized by the George Washington University Center for Health Policy Research in Washington, DC, as leaders in the substance abuse treatment provider field. Dr. Coletti holds an honorary doctorate in Humane Letters from the University of South Florida.

Dennis C. Daley, M.S.W.
Center for Psychiatric and Chemical Dependency Services
Western Psychiatric Institute and Clinic
University of Pittsburgh Medical Center
3811 O'Hara Street
Pittsburgh, PA 15213
(412) 383-2710; Fax: (412) 383-1268
E-mail: daleydc@msx.upmc.edu

Mr. Daley is involved in developing and managing treatment and research programs on addiction and dual disorders at the University of Pittsburgh Medical Center. Mr. Daley has contributed to more than 120 books, workbooks, and videotapes that deal with recovery from alcohol and drug problems, psychiatric disorders, dual disorders, and relapse prevention. Mr. Daley teaches classes on these subjects throughout the United States and other countries. He is involved in several federally funded research projects on treatment of cocaine addiction and treatment of dual disorders. He codeveloped the group drug counseling (GDC) treatment model used in a multisite clinical trial and served as coauthor of the GDC Clinician Manual.

Thomas A. D'Aunno, Ph.D.
School of Social Service Administration
University of Chicago
969 East 60th Street
Chicago, IL 60637
(773) 702-1121; Fax: (773) 702-0874
E-mail: tdaunno@midway.uchicago.edu

Dr. D'Aunno, Associate Professor in the University of Chicago's School of Social Service Administration, joined the University of Chicago in 1994 after 10 years as a faculty member at the University of Michigan and the Institute for Social Research. Dr. D'Aunno's research focuses on the structure and performance of human service organizations. He is currently the Principal Investigator of a national study of outpatient drug abuse treatment services funded by the National Institute on Drug Abuse (NIDA). This study, which involves several hundred treatment units over a decade, examines how well treatment units are meeting key standards of care, including access to care. Dr. D'Aunno received his doctoral degree in Organizational Psychology from the University of Michigan.

George De Leon, Ph.D.
Center for Therapeutic Community Research
National Development and Research Institutes, Inc.
Two World Trade Center, 16th Floor
New York, NY 10048
(212) 845-4421; Fax: (212) 845-4698
E-mail: george.deleon@ndri.org

Dr. De Leon is Director of the Center for Therapeutic Community Research in New York City, which is funded by the National Institute on Drug Abuse (NIDA), and Research Professor of Psychiatry at New York University. Author of numerous scientific publications, Dr. De Leon has edited three books and three NIDA Research Monographs, which address issues of theory, research, and practice in therapeutic communities. Dr. De Leon is associated with Therapeutic Communities of America (TCA) and the World Federation of Therapeutic Communities (WFTC). He regularly consults with drug treatment programs, community action groups, and schools. He is a founding member and fourth President of the American Psychological Association Division (50) on the Addictions. Dr. De Leon received the 1993 NIDA Pacesetter Award for Outstanding Leadership in Pioneering Research on the Therapeutic Community Approach to Drug Abuse Treatment. He has also maintained a private clinical practice for over 30 years. Dr. De Leon received his doctoral degree in Psychology from Columbia University.

Robert E. Drake, M.D., Ph.D.
Psychiatric Research Center
2 Whipple Place, Suite 202
Lebanon, NH 03766
(603) 448-0126; Fax: (603) 448-0129
E-mail: robert.e.drake@dartmouth.edu

Dr. Drake is the Andrew Thomson Professor of Psychiatry and Community and Family Medicine at Dartmouth Medical School and Director of the New Hampshire-Dartmouth Psychiatric Research Center. In addition to working actively as a clinician in community mental health centers for the past 18 years, Dr. Drake is well known for his research on co-occurring substance use disorder and severe mental illness. He has been Principal Investigator or co-Principal Investigator on 18 research grants and has written 200 books and articles that cover diverse aspects of adjustment and quality of life among persons with severe mental disorders.

Bennett W. Fletcher, Ph.D.
Services Research Branch, Division of Clinical and Services Research
National Institute on Drug Abuse
National Institutes of Health
6001 Executive Blvd
Bethesda, Maryland 20892 (301) 443-4060; Fax: (301) 443-6815
E-mail: bf31v@nih.gov

Allan W. Graham, M.D.
Chemical Dependency Treatment Services
Kaiser Permanente
10350 East Dakota Avenue, Suite C
Denver, CO 80231
(303) 367-2812; Fax: (303) 367-2828
E-mail: Allan.W.Graham@kp.org

Dr. Graham, a specialist in internal medicine, has worked in the field of addiction medicine since 1982, when he and two other internists opened a treatment facility for alcoholics in their rural Vermont community hospital. Over the past decade, Dr. Graham developed a specific interest in brief intervention strategies for alcohol use problems presenting in primary care medical settings. He is a strong proponent of research investigations concerning clinical efficacy of alcoholism treatment, and has been active in physician education through numerous programs of the American Society of Addiction Medicine (ASAM). Dr. Graham received his undergraduate education and medical education at Yale University and his postgraduate training at Stanford University and the University of Vermont. He is Board certified in Internal Medicine, certified in addiction medicine, a Fellow of the American College of Physicians, and a Fellow of ASAM.

John S. Gustafson
National Association of State Alcohol and Drug Abuse Directors, Inc.
808 17th Street, NW, Suite 410
Washington, DC 20006
(202) 293-0090; Fax: (202) 293-1250
E-mail: dcoffice@nasadad.org

As Chief Executive Officer of the National Association of State Alcohol and Drug Abuse Directors, Inc. (NASADAD), Mr. Gustafson represents State agencies that administer over $3.7 billion in Federal, State, and local dollars. NASADAD services include collection and analysis of data and research, training and technical assistance, and the transfer of technology and information to States. Mr. Gustafson is a proactive advocate for State alcohol and other disorders (AOD) programs. He has more than 28 years' experience in the prevention and treatment fields and has extensive knowledge of substance abuse-related issues such as HIV/AIDS, tuberculosis, crime, and services to youth and special populations. He assisted communities in developing strategies to reduce the incidence of drug abuse, and he designed and directed a statewide network of intake units for diagnostic screening, evaluation, referral, and followup services. Mr. Gustafson was a liaison to the President's Special Office on Drug Abuse Prevention and the National Institute on Alcohol Abuse and Alcoholism. He holds M.A. and B.A. degrees from the State University of New York at Albany.

Stephen T. Higgins, Ph.D.
Human Behavioral Pharmacology Lab, Department of Psychiatry
Ira Allen School
University of Vermont
38 Fletcher Place
Burlington, VT 05401-1419
(802) 660-3060; Fax: (802) 660-3064
E-mail: shiggins@pop.uvm.edu

Dr. Higgins earned his doctoral degree from the University of Kansas. He was a postdoctoral Fellow at Johns Hopkins and a staff Fellow at the National Institute on Drug Abuse (NIDA) Addiction Research Center from 1985 to 1986. In 1986, Dr. Higgins joined the faculty of the University of Vermont, where he is now a Professor of Psychiatry and Psychology. Dr. Higgins is currently Principal and co-Investigator on five NIDA grants. Dr. Higgins has received several scientific awards and has been published in more than 150 publications. Dr. Higgins' research is a blend of laboratory and treatment outcome research, with the goal of furthering basic scientific understanding of the behavioral and pharmacological processes involved in cocaine abuse. Dr. Higgins is President-elect of Division 28 of the American Psychological Association.

Martin Y. Iguchi, Ph.D.
RAND Drug Policy Research Center
PO Box 2138
1700 Main Street
Santa Monica, CA 90407-2138
(310) 393-0411, ext. 7816; Fax: (310) 451-7004
E-mail: martin_Iguchi@rand.org

Dr. Iguchi is a Senior Behavioral Scientist and co-Director of the Drug Policy Research Center at RAND and Principal Investigator of two National Institute on Drug Abuse (NIDA) treatment grants, one of which is entering its eighth year of funding. Dr. Iguchi is a member of the National Advisory Council for the Center for Substance Abuse Treatment, serves on the National Institutes of Health AIDS and Related Research Review Committee, served on NIDA's Clinical and Behavioral Research Review Committee, and is a former member of Philadelphia's HIV/AIDS Community Planning Group. Dr. Iguchi received his undergraduate degree in Liberal Arts from Vassar College and his master's and doctoral degrees in Experimental Psychology from Boston University. Dr. Iguchi also received 2 years of postdoctoral training in drug abuse and behavioral pharmacology at The Johns Hopkins University School of Medicine. In 1997, Dr. Iguchi published 10 peer-reviewed journal articles and book chapters: crack cocaine use in the American Journal of Public Health, natural classes of treatment response and on reinforcing appropriate nondrug-using behaviors in the Journal of Consulting and Clinical Psychology, and stages and processes of change as predictors of drug use in Experimental and Clinical Psychopharmacology.

James A. Inciardi, Ph.D.
Center for Drug and Alcohol Studies
College of Arts and Sciences
University of Delaware
77 East Main Street
Newark, DE 19716
(302) 831-6286; Fax: (302) 831-1275
E-mail: james.inciardi@mvs.udel.edu

Dr. Inciardi is Director of the Center for Drug and Alcohol Studies and Professor in the Department of Sociology and Criminal Justice at the University of Delaware; Adjunct Professor in the Department of Epidemiology and Public Health at the University of Miami School of Medicine; a Distinguished Professor in the Nœcleo de Estudos e Pesquisas em Aten‹o ao Uso do Drogas at the State University of Rio de Janeiro; and a Guest Professor in the Department of Psychiatry at the Federal University of Rio Grande do Sul in Porto Alegre, Brazil. Dr. Inciardi has published 45 books and over 225 articles and chapters in the areas of substance abuse, criminology, criminal justice, history, folklore, public policy, AIDS, medicine, and law, and has extensive research, clinical, field, and teaching experience in both substance abuse and criminal justice. Dr. Inciardi received his doctoral degree in Sociology from New York University.

Linda P. Kaplan, CAE
National Association of Alcoholism and Drug Abuse Counselors
1911 North Fort Myer Drive, Suite 900
Arlington, VA 22209
(703) 741-7686; Fax: (703) 741-7698
E-mail: naadac@internetmci.com

Ms. Kaplan has been Executive Director of the National Association of Alcoholism and Drug Abuse Counselors (NAADAC) since 1990. She is a strong proponent of a model system for continuing the development of professional standards and a national certification program for treatment professionals. She has led the drive to enact State licensure laws for alcohol and drug counselors. Ms. Kaplan helped to develop and promote the national public education campaign, Treatment Works!, on the disease of addiction, the need for trained alcohol and drug counselors, and the many health and socioeconomic benefits of treatment. In 1992, Ms. Kaplan became a Certified Association Executive. She recently Chaired the Greater Washington Society of Association Executives Community Service Committee and has presented at many conferences on association management. Ms. Kaplan has served as Executive Director of the National Women's Political Caucus and as Associate Director of B'nai B'rith Women.

Herbert D. Kleber, M.D. Division on Substance Abuse
Columbia University
722 West 168th Street, Unit 66
New York, NY 10032
(212) 543-5570; Fax: (212) 543-6018
E-mail: hdk3@columbia.edu

Dr. Kleber is Professor of Psychiatry and Director of the Division on Substance Abuse at Columbia University College of Physicians & Surgeons and the New York State Psychiatric Institute and is Executive Vice President of The National Center on Addiction and Substance Abuse (CASA). Between 1989 and 1991, Dr. Kleber was Deputy Director for Demand Reduction at the Office of National Drug Control Policy. During his tenure as Professor of Psychiatry at Yale, he was a pioneer in the research and treatment of narcotic and cocaine abuse for more than 30 years. Dr. Kleber has authored and coauthored more than 200 papers and books and was coeditor of the American Psychiatric Association Textbook of Substance Abuse Treatment. He has received numerous awards, holds two honorary degrees, is on the editorial board of seven scientific journals, and is a member of the Institute of Medicine.

Thomas R. Kosten, M.D.
Veterans Administration Connecticut Healthcare System
Department of Psychiatry 116A
950 Campbell Avenue
West Haven, CT 06516
(203) 937-4914; Fax: (203) 937-4915
E-mail: kosten.thomas@west-haven.va.gov

Dr. Kosten is a Professor of Psychiatry at Yale University School of Medicine and Chief of Psychiatry at the Veterans Administration Connecticut Healthcare System. Dr. Kosten is a Diplomate of the American Board of Psychiatry and Neurology, where he is also on the Board for Added Qualifications in Addiction Psychiatry. He is a Fellow and past Director of the College on Problems of Drug Dependence (CPDD), a Fellow in the American Psychiatric Association and American College of Neuropsychopharmacology (ACNP), and President of the American Academy of Addiction Psychiatry (AAAP). Dr. Kosten's contributions to medications development for substance abuse led to the Cochin Award from CPDD and the Elkes International Award from ACNP. Dr. Kosten is an editor for the American Journal of Drug and Alcohol Abuse, the American Journal on Addictions, and the American Journal of Psychiatry, and has contributed to more than 250 publications. Dr. Kosten trained at Cornell and Yale and has been supported by a Research Scientist Award from the National Institute on Drug Abuse (NIDA).

Mary Jeanne Kreek, M.D., Ph.D.
The Rockefeller University
1230 York Avenue
New York, NY 10021
(212) 327-8248; Fax: (212) 327-8547
E-mail: sudulj@rockvax.rockefeller.edu

Dr. Kreek is Professor and Head of The Laboratory on the Biology of Addictive Diseases at The Rockefeller University and Senior Physician at Rockefeller University Hospital. She is a Principal Investigator and Scientific Director of an NIH-NIDA Research CenterÑTreatment of Addictions: Biological Correlates. Dr. Kreek is presently working on research related to the molecular and clinical neurobiology as well as the biological correlates of the addictive diseases. Dr. Kreek was part of the original Rockefeller University Hospital team (with Professor Emeritus Vincent P. Dole and the late Dr. Marie Nyswander) that conducted the initial studies that led to the development of methadone maintenance treatment for heroin addiction. In collaboration with Dr. Don Des Jarlais, Dr. Kreek identified the problem of HIV infection and AIDS and the protective value of effective methadone maintenance treatment in parenteral drug abusers in New York, findings that were reported to the Centers for Disease Control in 1984. Dr. Kreek has also conducted and published numerous studies on the medical status of addicts in treatment and the changes in the status during short- and long-term treatment for addictions, as well as basic research studies of the molecular biological and neurochemical basis of addiction.

Dennis McCarty, Ph.D.
Substance Abuse Group, Institute for Health Policy
Heller Graduate School
Brandeis University
MS 035, Box 9110
415 South Street
Waltham, MA 02254-9110
(781) 736-3924; Fax: (781) 736-3928
E-mail: mccarty@binah.cc.brandeis.edu

Dr. McCarty is a Human Services Research Professor at the Institute for Health Policy located within Brandeis University's Heller Graduate School for Advanced Studies in Social Welfare. He directs the Brandeis/Harvard Research Center on Managed Care and Drug Abuse Treatment. Dr. McCarty collaborates with policymakers in State and Federal Governments and with community-based programs to conduct studies that examine the effects of managed care on the organization, financing, and delivery of substance abuse treatment services. Previously, Dr. McCarty served as Director of the Massachusetts Bureau of Substance Abuse Services for the Massachusetts Department of Public Health. He was a coeditor of an Institute of Medicine report titled Managing Managed Care: Quality Improvement in Behavioral Health Care.

A. Thomas McLellan, Ph.D.
Center for Study of Addiction
University of Pennsylvania School of Medicine
1 Commerce Square, Suite 1120
2005 Market Street
Philadelphia, PA 19103
(215) 665-2880; Fax: (215) 665-2892
E-mail: mclellan@research.trc.upenn.edu

Dr. McLellan is a Professor of Psychiatry at the University of Pennsylvania and Senior Scientist at the Pennsylvania Veterans Administration (PENN/VA) Center for Studies of Addiction. He was educated at Colgate and Bryn Mawr Colleges in the United States and at Oxford University in Great Britain. He has worked at the University of Pennsylvania and the Philadelphia VA Medical Center for over 20 years. Dr. McLellan and his colleagues developed the Addiction Severity Index (ASI) and the Treatment Services Review (TSR) and have used these instruments in over 150 experimental and field studies of various types of psychosocial, pharmacotherapy, and combined interventions in the treatment of substance abuse disorders. Dr. McLellan has been particularly interested in the measurement of treatment outcome and effectiveness and in the "matching" of particular types of treatments to specific types of patients.

Delinda Mercer, Ph.D. Department of Psychiatry
University of Pennsylvania
3600 Market Street, Room 783
Philadelphia, PA 19104
(215) 662-2848; Fax: (215) 349-5171
E-mail: mercerd@landru.cpr.upenn.edu

Dr. Mercer has considerable experience in the fields of addiction research and treatment. She was instrumental in the development of the models of individual drug counseling and group drug counseling used in the Cocaine Collaborative Study, and she was primary author of manuals for each. In addition, she was the Project Director for the Cocaine Collaborative Study at the University of Pennsylvania site. Her research interests include human immunodeficiency virus (HIV) prevention in substance abusers, borderline personality disorder and substance abuse, and gender issues in substance abuse treatment. She has written a number of articles and book chapters on substance abuse treatment.

David S. Metzger, Ph.D.
Center for Studies of Addiction
University of Pennsylvania/Veterans Administration Medical Center
3900 Chestnut Street
Philadelphia, PA 19104
(215) 823-6098; Fax: (215) 823-6080
E-mail: metzger@research.trc.upenn.edu

Dr. Metzger is Research Associate Professor and Director of the Opiate/AIDS Research Division at the University of Pennsylvania/Veterans Administration (VA) Medical Center, Center for Studies of Addiction. Since 1989, he and colleagues from the Center have been conducting longitudinal studies of injecting drug users (IDUs) from Philadelphia. Their work has been examining the factors associated with changes in human immunodeficiency virus (HIV) risk behaviors and incidence of HIV infection. Thus far, over 1,100 subjects have been enrolled in these studies, known collectively as the Risk Assessment Project (RAP). A primary objective of this work has been to provide valid and reliable data that can increase the understanding of the relationship between HIV risk behaviors and participation in substance abuse treatment.

William R. Miller, Ph.D.
Kaiser Permanente
Center for Health Research
3800 North Kaiser Center Drive
Portland, OR 97227-1098
(503) 335-6665; Fax: (503) 335-2424
E-mail: wrmiller@unm.edu

As a clinical psychologist, Dr. Miller's research career has focused on the development and evaluation of innovative treatment approaches for substance use disorders. He has been Director of Clinical Training at the University of New Mexico (UNM), founded a private practice, and directed New Mexico's largest public substance abuse treatment program in the era of managed care. Dr. Miller has received numerous awards for teaching and research, including the international Jellinek Memorial Award. With support by an NIH Senior Career Research Scientist Award, Dr. Miller is focusing fulltime on clinical research in substance abuse.

Dr. Miller is Regents Professor of Psychology and Psychiatry at the University of New Mexico (UNM) and has directed both the treatment and research branches at the Center on Alcoholism, Substance Abuse, and Addictions, UNM.

Charles P. O'Brien, M.D., Ph.D.
Department of Psychiatry
University of Pennsylvania
3900 Chestnut Street
Philadelphia, PA 19104-6178
(215) 222-3200, ext. 132; Fax: (215) 386-6770
E-mail: obrien@research.trc.upenn.edu

Dr. O'Brien is a physician trained in neurology, neurophysiology, and psychiatry. In 1971, he founded a large treatment program for addicts in Philadelphia, and since 1980 he has directed the Psychiatry Department for the Philadelphia Veterans Affairs (VA) Medical Center. His research focus over the past 25 years has been on the basic mechanisms of addiction and the development of new treatments. Dr. O'Brien's team has discovered numerous new behavioral and pharmacological treatments that have resulted in significant improvements in the success rate for the treatment of addictive disorders.

Lisa S. Onken, Ph.D.
Treatment Research Branch, Division of Clinical and Services Research
National Institute on Drug Abuse
National Institutes of Health
6001 Executive Blvd
Bethesda, Maryland 20892 (301) 443-0107; Fax: (301) 443-8674
E-mail: lo10n@nih.gov

Dr. Onken is Associate Chief of the Treatment Research Branch at the National Institute on Drug Abuse (NIDA). She directs NIDA's Behavioral Therapies Development Program and is co-Chair of the NIDA Treatment Initiative. Prior to joining NIDA, she conducted research on benzodiazepines, cognitive performance, and sleep at the Department of Behavioral Biology at the Walter Reed Army Institute of Research. Dr. Onken received her doctoral degree from Northwestern University and is a licensed clinical psychologist.

Paula DeGraffenreid Riggs, M.D.
Department of Psychiatry
University of Colorado Health Sciences Center
4200 East Ninth Avenue
Denver, CO 80262
(303) 315-7652; Fax: (303) 315-5641
E-mail: paula.riggs@uchsc.edu

Dr. Riggs is an Assistant Professor of Psychiatry at the University of Colorado Health Sciences Center (UCHSC) and Director of Psychiatric Services for Adolescents, Addiction Research, and Treatment Services at the University of Colorado School of Medicine. She is Board certified in Child, Adolescent, and Adult Psychiatry with added qualifications in addiction psychiatry. Dr. Riggs received a Scientist Development Award for Clinicians from the National Institute on Drug Abuse (NIDA) to develop new treatment for comorbid disorders in adolescents with substance dependence and conduct disorders.

Bruce J. Rounsaville, M.D.
Yale University
Connecticut Mental Health Center
34 Park Street
New Haven, CT 06519
(203) 789-7080, ext. 2; Fax: (203) 789-7088
E-mail: rounsavibj@maspo1.mas.yale.edu

Since he joined the Yale faculty in 1977, Dr. Rounsaville has focused his clinical research career on the diagnosis and treatment of patients with alcohol and drug dependence. Using modern methods for psychiatric diagnosis, Dr. Rounsaville was among the first to call attention to the high rates of dual diagnosis in drug abusers. As a member of the Work Group to Revise DSM-III, Dr. Rounsaville was a leader in the adoption of the drug dependence syndrome concept into the DSM-III-R Substance Use Disorders Section. Dr. Rounsaville has played a key role in clinical trials on the efficacy of a number of important treatments, including outpatient clonidine/naltrexone for opioid detoxification, naltrexone treatment for alcohol dependence, cognitive-behavioral treatment for cocaine dependence, and disulfiram treatment for alcoholic cocaine abusers.

Kathy Sanders-Phillips, Ph.D.
Department of Pediatrics
University of California, Los Angeles
Medical Center, Suite 403
111 North LaBrea
Inglewood, CA 90301
(310) 673-4130; Fax: (310) 673-5345

Dr. Sanders-Phillips, a developmental psychologist, is an Associate Professor in the Department of Pediatrics at the University of California, Los Angeles (UCLA) School of Medicine. She has also served as a Senior Program Director with the UCLA School of Public Health, Division of Community Health Sciences, and is currently an Associate Member of the Jonsson Comprehensive Cancer Center. She has conducted numerous studies in the area of drug abuse with particular emphasis on identifying social factors influencing drug use in minority populations. Much of her research has focused on health behaviors and health outcomes in low-income minority groups and the impact of violence on health behaviors such as drug use. She has published several papers on the psychosocial determinants of health behaviors and on community-based health interventions. In 1991, Dr. Sanders-Phillips was a University of California Wellness Lecture awardee for her work on exposure to violence and health behaviors in African American and Latino populations.

Dr. Sanders-Phillips serves as a member of the National Advisory Council for the National Institute on Drug Abuse (NIDA) and was the former Chair of the University of California AIDS Taskforce. She was also a member of the NIDA Extramural Science Advisory Board.

Maxine L. Stitzer, Ph.D.
Behavioral Pharmacology Research Unit
Bayview Medical Center
The Johns Hopkins University
5510 Nathan Shock Drive
Baltimore, MD 21224-6823
(410) 550-0042; Fax: (410) 550-0030
E-mail: mstitzer@welchlink.welch.jhu.edu

Dr. Stitzer received her doctoral degree in psychology and her training in psychopharmacology from the University of Michigan. Her extensive grant-supported research program focuses on both pharmacological and behavioral approaches to the treatment of substance abuse. Dr. Stitzer pioneered early research on use of contingency management techniques in treatment of drug abuse, and she continues to research this approach with both pharmacologically supported (methadone) and drug-free heroin abusers. Dr. Stitzer has served on National Institute on Drug Abuse (NIDA) Grant Review and Research Advisory Committees; she participated in development of an Institute of Medicine report on the availability and funding of drug abuse treatment in the United States; she helped in developing an American Psychological Association proficiency certification for psychologists in substance abuse treatment; and she served on the College on Problems of Drug Dependence (CPDD) Board of Directors.

José Szapocznik, Ph.D.
Spanish Family Guidance Center
Department of Psychiatry
University of Miami School of Medicine
1425 Northwest 10th Avenue, Suite 309
Miami, FL 33136
(305) 243-4592; Fax: (305) 243-5577
E-mail: jszapocz@mednet.med.miami.edu

Dr. Szapocznik is Professor of Psychiatry and Psychology and Director of the Center for Family Studies, Department of Psychiatry and Behavioral Sciences, at the University of Miami School of Medicine. He received his doctoral degree in Clinical Psychology from the University of Miami. As Director of the Center for Family Studies, which has been successfully funded through competitive national grants since 1972, Dr. Szapocznik has been a pioneer in the national effort to prevent and treat adolescent drug abuse and other behavior problems, such as delinquency and violence, using a family-oriented approach. Dr. Szapocznik serves on the editorial boards of Psychotherapy Research, the Journal of Consulting and Clinical Psychology, the Journal of Family Psychology, and the Hispanic Journal of Behavioral Sciences. He has over 125 professional publications in his area of expertise. Dr. Szapocznik's work has received considerable national and international recognition. He is a frequent lecturer and consultant nationally and internationally.

Stephen R. Zukin, M.D.
Division of Clinical and Services Research
National Institute on Drug Abuse
National Institutes of Health
6001 Executive Blvd
Bethesda, Maryland 20892 (301) 443-6697; Fax: (301) 443-2317
E-mail: szukin@helix.nih.gov

Dr. Zukin is Director of the Division of Clinical and Services Research at the National Institute on Drug Abuse (NIDA) and Chair of the NIDA Treatment Initiative. Previously, as Professor of Psychiatry and Neuroscience at the Albert Einstein College of Medicine, he conducted NIDA-funded research elucidating the actions of phencyclidine and related drugs in the nervous system, as well as clinical research on pharmacotherapies targeting excitatory amino acid receptors in the brain. He is a graduate of the Johns Hopkins University School of Medicine and is Board certified in psychiatry. Dr. Zukin received the Kempf Fund Award for Research Development in Psychobiological Psychiatry from the American Psychiatric Association in 1992.