Published as "Recent developments: progress in scientific and clinical research", pp. 21-25 in:
Lane Porter, Mario Argandoña and William J. Curran, Drug and Alcohol Dependence
Policies, Legislation and Programmes for Treatment and Rehabilitation. Geneva:
World Health Organization, Substance Abuse Department, 1999.
WHO/HSC/SAB/99.10
RESEARCH DEVELOPMENTS AFFECTING THE ALCOHOL AND DRUG
TREATMENT SYSTEM(1)
The topic for this contribution is very broad, and I must necessarily be selective in
what is covered. First I will briefly discuss new drugs of abuse and of therapy; second, I will
discuss new approaches in epidemiological studies; third, I will talk a little about new
developments in treatment outcome research; and fourth, I will discuss the emergence of
treatment system research, and particularly the beginning which has been made on comparative
studies.
New drugs of abuse
On the matter of new drugs of abuse, the most discussed development of the last 10
years has been the proliferation of chemical analogue drugs -- the so-called designer drugs.
There has been much international and national legislative activity in this area, attempting to
control what has not even been thought of yet. But designer drugs have not become an
important presence on the mass illicit market anywhere. On the one hand, this may be viewed
as a success for the control regime. But on the other hand, the experience of recent years has
been that it is materials much more readily at hand, in most cases lying outside the existing
international control structure, which have been most successful on the illicit market.
Perhaps the three most significant trends, in an international perspective, have been the
emergence of steroids and other performance enhancing drugs as drugs of abuse, the rise in
use of volatile solvents, particularly in marginalized populations, and the diffusion of crack
cocaine. The idea of drugs as performance enhancers is by no means new, of course. Armies
have long issued stimulants and analgesics in wartime, long-distance truckers with schedules to
keep have long used amphetamines, and writers have long imagined that alcohol or opium or
some other drug enhances their creativity. What is largely new is that this use of drugs not for
recreation or excitement or solace but rather in instrumental ways has "come out of the
closet", become a topic of open discussion and thus both a source of emulation and a
politicized problem. The main crucible of this has been competitive sports. But the discussion
of drug abuse in this context carries with it some special characteristics. We are concerned
about steroid use in sports not only because of the potential harm to the steroid user and those
around him or her, but also because it is seen as giving an unfair advantage in competition.
The elaborate international regimes which have grown up around drug testing in sports are
primarily motivated by this concern for fairness in competition, a concern that differs from our
usual concerns about the individual and social harms from drug use.
The diffusion of crack cocaine is an example of a phenomenon well-known to those
who market legal commodities: the repackaging and repositioning of an existing product. The
chemistry required to transform cocaine to crack is available in any kitchen. There may be an
object lesson here in how the main attention in the control system was focused on science
fiction scenarios of high technology designer drugs, while the most successful drugs on the
illicit market tend to be either a direct agricultural product or a simple chemical transformation
of one.
Concerning the rise of glue, gasoline and other solvent sniffing, it is not always clear
how much there is a real increase in the problem and how much there is simply increased
attention to the problem. In some specific circumstances, solvents are the most significant or
the second most significant drug of abuse. This is true, for instance, among Australian
aboriginals and among aboriginal Canadians, particularly in rural populations, and it is often
said to be true also among Mexicans, particularly poor Mexicans. A common pattern, shared
by these three areas, is for alcohol to be the main adult drug of abuse and solvents to be the
main problem among teenagers. It is perhaps a mark of our civilization's dependence on
gasoline that there have been no very effective efforts to control its supply -- the closest we
have come is the armor plating of gasoline pumps and fuel tanks that one finds these days in
parts of the Australian outback. There has, however, been an effective if unintentional harm
reduction measure: getting lead compounds out of gasoline.
Despite an enormous investment, there has been little change in the last 10 years in our
practical inventory of pharmacological aids in drug treatment. Perhaps 10 years from now the
receptor research and the genetic identification studies will begin to point to practical
therapies, though I believe such therapies will pose strong ethical questions and dilemmas. In
the meantime, the main innovations have been in drug delivery systems -- rather simple
mechanical and technological innovations. Long acting methadone will put to us in acute form
whether the therapy involved in methadone maintenance is mostly the drug itself or whether it
is also the showing up each morning and the opportunities for other services which this opens
up. Perhaps the most important pharmacological innovation has been pharmacological means
for quitting cigarette smoking -- Nicorette and other nicotine chewing-gum, and now the
patch. These treatments have an importance extending beyond their direct effects in saving the
smoker's lungs; they have brought treatment of tobacco dependence into everyday clinical
practice, giving the doctor something he or she feels comfortable doing. As such, they are
part of the long march of tobacco smoking in its cultural position from being a matter of
personal habit to being a drug of dependence and abuse.
Epidemiological studies
Let me turn now to new approaches in epidemiological studies. One could say that
there used to be two worlds of alcohol and drug epidemiology: clinical epidemiology, which
described the demography and other characteristics of populations in treatment, and population
epidemiology, which described patterns of alcohol and drug use and problems in the
population at large. What has happened in recent years is that we have begun to bridge the
gap between these worlds -- to establish, if you like, the social ecology of treatment: how and
under what circumstances alcohol and drug users come into particular doors, and how a
particular treatment episode fits into the drug use career and the life-cycle.
One thing we have learned from this was mentioned by Harold Demone yesterday: that
very little treatment is absolutely voluntary, in the sense that the user just decides all by him or
herself to come in. But on the other hand, most of the social control of alcohol and drug use
does not happen either in the criminal justice system or in the treatment system. Far more
widespread, and far more common, are the comments and suggestions and control efforts
which come from family members and from friends and workmates. Entry to treatment
which is not legally coerced is usually the culmination of a long process of unsuccessful or
partly successful efforts at social control by family and friends. On the other hand, no
government has the resources to provide a treatment system which reaches as widely as the
network of family and friendship relationships, and those who end up in formal treatment are
usually only a small fraction of those who have been subject to these informal social controls.
For a number of reasons, cost being only one of them, we are well advised to frame our
treatment and criminal justice legislation so that these systems strengthen rather than undercut
the network of family and personal relationships which is the most important social control on
harmful drug use.
This research also suggests that there are negative aspects of tying the alcohol and drug
treatment system too closely to the criminal justice system. In the U.S. these days, this tie is
very strong. Nearly everyone in the public drug treatment system in the U.S. is there under
court pressure, and this is coming to be true too of the public alcohol treatment system. The
criminal justice system is a potentially endless source of alcohol- and drug-related cases; it
processes far more cases than the alcohol and drug treatment system. But it is far from clear
that the cases which it provides are amenable to treatment. And too close a connection to the
criminal justice system places substantial constraints on alcohol and drug treatment. One
example of this is given by Jerome Jaffe from his long experience in the U.S. system. At a
recent conference, Jaffe noted that a problem with diversion to treatment from the courts is
that the courts want the treatment to last longer that the jail sentence would have lasted: if
treatment is seen as a softer option than jail, it should at least last as long as jail. This impulse
potentially turns the treatment cost per case into a very expensive proposition. It also runs up
against a main finding in the next area of new research I want to mention, treatment outcome
studies.
Treatment outcome studies
In the last 10 years, the alcohol treatment outcome literature in North America and
English-speaking countries, at least, has gelled into a fairly consistent picture. All treatment
does a little good, the literature would say. The chances are only modest that a particular case
will benefit from a particular treatment episode. This finding poses an urgent task on us of
education of the criminal justice system and of policy-makers: we should not pretend that
treatment potentially offers a permanent "cure", and we must seek acceptance of the idea that
relapses are to be expected and indeed planned for. While this is more contentious, I would
say there is only limited evidence that one treatment modality is better than another. This
unpalatable finding has set off a search for a paradigm of "treatment matching", where clients
are sorted by what treatment is most appropriate and helpful for them, but I would say there is
little evidence yet that we can do better with any research-derived algorithm than we can by
offering the client his or her choice from a menu of treatments.
One main implication of the general finding that all treatments work a little and all
work to much the same degree is that treatment resources are better spent on less intensive
treatments of more cases than on more intensive treatments of fewer cases. This research
finding has fuelled a shift towards briefer alcohol treatments and towards outpatient treatment
in such countries as Canada, Britain, Australia and the U.S. (in the U.S. fiscal issues of cost
containment have also played a role). As I mentioned above, this shift tends to run against the
preferences of those staffing the criminal justice system, whose sense of natural justice wants
to see even the diverted criminal inconvenienced for a considerable period of time. How this
will play out in the U.S. situation of increased court coercion in the public alcohol treatment
system remains to be seen.
I have so far been talking about the alcohol treatment outcome research literature. The
literature on treatment outcomes for illicit drugs has been quite separate, indeed, and it is past
time for these two literatures to be brought together. One remarkable difference can be seen in
the two recent reports by the U.S. Institute of Medicine: the drug treatment literature takes as
a given that frankly coerced treatment works, while the alcohol treatment literature is very
sceptical about this. Given that most illicit drug treatment in the U.S. is under court diversion
or court pressure, the trend towards briefer treatments and more outpatient-based treatment
seen for alcohol has not been so prominent. I believe an advantage of the combined approach
is that it forces us to ask the question why a finding in one literature should not apply in the
other.
Increase in treatment system research
The last research development for me to touch on is the rise of treatment system
research. This trend is fuelled in the first instance by developments in scientific thinking, but
in the second by the fiscal crisis of health and welfare costs in even the wealthiest countries
which has brought a halt to the dynamic multiplication of treatment agencies. One hindrance
in the US scene to the development of treatment system research is that scientific
policy-makers in the biomedicalized U.S. research context tend not to regard it as "real
science", though this attitude is being neutralized by Congressional directives and funding.
The new epidemiology I have already mentioned is one of the contributors to the
emerging tradition of treatment system research, with its findings on the conditions of
treatment entry and more broadly on the social ecology of treatment. Another strand is
provided by studies of what really happens in referral and other relations between agencies --
often, indeed, these turn out to be studies of why referral does not happen very much -- and of
the careers of clients in the treatment system. A third strand is the study of the conditions and
patterns of growth and decline in treatment provision in particular jurisdictions or societies.
An emergent theme in this third strand, highly relevant to the present project, is the
growth of comparative studies of alcohol and drug treatment systems. Until recently, it has
been very difficult to get descriptions of national treatment systems in English; such
descriptions as there have been have been in the local language and not regarded as having a
broader audience. But we have begun to see that much might be learned from cross-cultural
comparisons of treatment provision and systems, and from looking at the history of such
systems as well as their current patterns. In a recent conference on treatment systems
research, for instance, a rough calculation by a Swedish colleague showed that Sweden was
spending about 6 times as much on alcohol and drug treatment as the Canadian province of
Ontario, though they have about the same population size and similar profiles of alcohol and
drug problems -- and though the Ontario system is generally seen as well-developed by North
American standards. One big difference, it emerged, was that in Sweden, as in Germany, the
normative model of treatment has been an inpatient stay of 3-6 months -- a model almost
unknown for professional treatment milieux in North America.
1. Presented at a WHO Advisory Group Meeting on Policies, Legislation and Programmes on Dependence and Harmful Use of Drugs and Alcohol, Cambridge, Massachusetts, 31 January-2 February 1994.