The State of the Art in Drug Addiction Treatment

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NIDA Director, Alan I. Leshner

NIDA's recent publication, Principles of Drug Addiction Treatment: A Research-based Guide, distills the lessons of 25 years of scientific investigation. Principles is written for health care providers, to stimulate their awareness of the variety of effective approaches to drug treatment. It is also for patients and potential patients and their families, to help them understand the nature of addiction and to tell them about scientifically based treatments and what to expect if they enter treatment. And it serves planners and policymakers as well, enabling them to make informed decisions concerning treatment programs.

Based on a year-long review of treatment research, Principles describes where we stand today in our quest for the most effective, replicable treatments for drug abuse.

In short, this book is for you. That is why NIDA mailed a copy in October to every NIDA NOTES reader in the United States. If you have not yet read yours, I urge you to do so. If you did not receive a copy or want additional copies to pass on to friends or colleagues, the Tearoff on page 15 of this issue of NIDA NOTES gives ordering information.

Based on a yearlong review of treatment research, Principles describes where we stand today in our quest for the most effective, replicable treatments for drug abuse. The book contains many important messages, but one is central.

Treatment is effective. Scientifically based drug addiction treatments typically reduce drug abuse by 40 percent to 60 percent. These rates are not ideal, of course, but they are comparable to compliance rates seen with treatments for other chronic diseases such as asthma, hypertension, and diabetes. Moreover, treatment markedly reduces undesirable consequences of drug abuse and addiction-such as unemployment, criminal activity, and HIV/AIDS and other infectious diseases-whether or not patients achieve complete abstinence. Research has shown that every $1 invested in treatment saves $4 to $7 in costs related to drug abuse.

That treatment is effective will not be news to treatment providers or to the tens of thousands of individuals and families who have benefited from treatment. Unfortunately, many members of the public still mistakenly doubt that treatment can help someone overcome addiction, perhaps because-as Principles explains-recovery from addiction can be a long-term process and frequently requires multiple episodes of treatment. To these people, the message of Principles is: We have the tools, let's do the job.

By describing the current state of the art, Principles also clarifies the many challenging research pathways that remain to be traversed on the way to our goal of fully effective treatment for every patient. To cite just a few of the more pressing objectives, we need to:

  • Understand the complete behavioral and biological mechanisms of addiction
  • Obtain a full picture of the transition from drug use to drug addiction and the stages of recovery in order to fashion optimal treatments for patients at every point along that trajectory;
  • Understand better how gender affects vulnerability to drug addiction and the response to treatment in order to more appropriately tailor treatments for men and women;
  • Develop additional medications for treating opiate addiction and effective medications for addiction to stimulants such as cocaine and methamphetamine;
  • Continue to test the effectiveness of treatments in real-life community-based settings.

NIDA is adjusting its organizational structure and has instituted key procedures to expedite the next stage of our treatment research journey. As I write, the Institute is completing the creation of a new Division of Treatment Research and Development (DTRD). The new Division will facilitate research on combined medication and behavioral treatments, which appears to be an essential strategy for improving many patients' chances of successful treatment outcomes.

With the support of its Medications Development Division, one of DTRD's predecessors, NIDA has developed cooperative links with the pharmaceutical industry that enable NIDA-supported researchers to obtain proprietary chemical compounds for testing as possible medications for drug abuse. As a first fruit of these partnerships, a new cocaine "vaccine" is currently being tested in a large-scale clinical trial. Based on NIDA-supported basic studies, this new medication appears to reduce the desire to use cocaine by blocking the drug's euphoric effects. NIDA also is exploring ways for new medications to reach more of those in need. The demonstrated effectiveness of buprenorphine and naloxone in treating opiate addiction, for example, suggests that these drugs may be safely dispensed by physicians in controlled settings.

With respect to behavioral therapies, NIDA has established a three-stage process for developing, evaluating, and introducing new approaches into mainstream clinical use. The potential of each proposed new behavioral treatment is first explored in a small pilot study. If the preliminary data are promising, the treatment is tested in a full-scale clinical trial. If the trial demonstrates efficacy, clinicians take the treatment out of the research setting and adapt it as necessary for mainstream use. This new model establishes the first clear benchmarks for testing, comparing, and implementing behavioral treatments. To date, two new treatments have passed the preliminary stage of testing and moved on to the clinical trials stage.

As regular readers of NIDA NOTES are aware, the largest initiative in NIDA's history is focused on treatment. This is the National Drug Abuse Treatment Clinical Trials Network (CTN), in which research centers ally with nearby community treatment programs to set research goals and participate in large-scale multisite clinical trials. NIDA recently announced the establishment of the first five CTN locations. Ultimately, the CTN will provide a nationwide coordinating infrastructure with sufficient patient numbers and diversity to enable scientists to optimize treatment effectiveness by matching treatments with appropriate patient groups.

There is a pattern in scientific research in which knowledge and techniques are slowly, painstakingly developed until they reach a critical mass that makes possible a more rapid and direct approach to problem solving. This first edition of Principles reflects the power of this pattern of progress to produce epochal advances in public health and welfare. With well-defined questions and powerful new technologies and research techniques coming on line every year, we do not expect to wait very long before publishing the second edition of Principles.