Billions of Federal Dollars Support Drug Abuse Treatment

As part of its overall drug control effort, the federal government provides significant support for activities related to drug abuse treatment, including grants to states, direct services, and research. 1.) 2.) It requires agencies to set goals, measure performance, and report on their accomplishments and thus should provide a useful framework for assessing the effectiveness of federally funded drug treatment efforts. For those who do require treatment, services may be provided in either outpatient or inpatient settings, and via two major approaches: pharmacotherapy and behavioral therapy, with many programs combining elements of both. Other treatment approaches, such as faith-based strategies, have yet to be rigorously examined by the research community. Experts recognize that not all drug users require treatment to forgo drug use because some drug users do not progress to abuse or dependence. Drug Abuse Treatment Approaches and Settings

Data from 1992-93 on use of drug treatment in the United States (the most current available) show that about 1.4 million people received drug treatment during the previous year. Regardless of how faith-based treatment is defined, there has not been sufficient research to determine the results of this type of treatment. Research Issues Make Assessment of Treatment Effectiveness Difficult

The study of drug treatment programs is complicated by a number of challenging methodological and implementation issues. The ability to compare the results of effectiveness studies is also influenced, and often limited, by differences in how outcomes are measured, how programs are operated, and client variables. According to an analysis by the Lewin Group, among the reasons cited for the limited use of randomized trials are the difficulties in obtaining informed consent from drug abusers and the perceived ethical issue of randomly assigning people who are seeking drug treatment to a control group in which no treatment or a treatment regimen not of the client’s choice is provided. Recent major studies of drug treatment effectiveness have used urinalysis to validate self-reported data. At the same time, researchers emphasize that client reporting on use of illicit drugs during the previous year (the outcome measure used in most effectiveness evaluations) has been shown to be more accurate than reporting on current drug use. Assessing treatment effectiveness is also complicated by differences in client factors. In large-scale evaluations conducted over the past 20 years, researchers have concluded that treatment reduces the number of regular drug users as well as criminal activity. Major Studies Report Reductions in Drug Use and Crime Following Treatment

Comprehensive analyses of the effectiveness of drug treatment have been conducted by several major studies over a period of nearly 30 years: DATOS, NTIES, TOPS, and the Drug Abuse Reporting Program (DARP) (see table 4). These large, multisite studies were designed to assess drug abusers on several measures before, during, and after treatment. These studies are generally considered by the Institute of Medicine and the drug treatment research community to be the major evaluations of drug treatment effectiveness, and much of what is known about typical drug abuse treatment outcomes comes from these studies. Evidence Varies on the Best Treatment Approaches for Specific Groups of Drug Abusers

Research provides strong evidence to support methadone maintenance as the most effective treatment for heroin addiction. However, research on the most effective treatment interventions for other groups of drug abusers is less definitive. Despite a number of studies on the topic, little is known about the best way to treat adolescent drug abusers. The relative effectiveness of alternative approaches for treating adolescents remains uncertain. Drug and Alcohol Abuse: Billions Spent Annually for Treatment and Prevention Activities (GAO/HEHS-97-12, Oct. 8, 1996).
Why GAO Did This Study

Pursuant to a congressional request, GAO reported on: (1) the level of federal support for drug abuse treatment activities; (2) the treatment approaches and settings most commonly used and what is known about an alternative approach--faith-based treatment; (3) research issues affecting drug abuse treatment evaluations; and (4) research findings on the effectiveness of drug treatment overall as well as what is known about the effectiveness of treatment for heroin, cocaine, and adolescent drug addiction. GAO did not comprehensively analyze the extensive literature on drug treatment research methodologies and study results, independently evaluate the effectiveness of drug treatment programs, or verify the results reported in the studies it reviewed.

What GAO Found

GAO noted that: (1) billions of dollars are spent annually to support treatment for drug abuse and related research; (2) in 1998, 20 percent of the federal drug control budget, $3.2 billion, supported drug abuse treatment; (3) to meet the requirements of the Government Performance and Results Act, agencies are beginning to set goals and performance measures to monitor and assess the effectiveness of federally funded drug treatment efforts; (4) treatment services and research aim to reduce the number of current drug abusers; (5) experts recognize that not all drug users require treatment because some do not progress to the stage of abuse or dependence; (6) those who do need treatment can receive services in a variety of settings and via two major approaches: pharmacology and behavioral therapy, with many programs combining elements of both; (7) other treatment approaches, such as faith-based strategies, are sometimes used but have not been sufficiently evaluated to determine their effectiveness; (8) measuring the effectiveness of drug abuse treatment is a complex undertaking; (9) the most comprehensive studies have used an observational or quasiexperimental design, assessing effectiveness by measuring drug use before and after treatment; (10) few studies have used the most rigorous approach--random assignment to treatment and control groups--to isolate the particular effects of treatment on drug abuse; (11) in most studies, the conclusions researchers can draw are limited by factors such as reliance on self-reported data and the time frame planned for client followup; (12) furthermore, comparisons of study results are complicated by differences in how outcomes are defined and measured and differences in program operations and client factors; (13) a number of large, multisite, longitudinal studies provide evidence that drug abuse treatment is beneficial, but reliance on self-reported data may overstate effectiveness; (14) substantial numbers of clients report reductions on drug use and criminal activity following treatment; (15) research on treatment effectiveness relies heavily on client records of drug use; (16) when examining recent drug use, objective tests, such as urinalysis, consistently identify more drug users than self-reports do; (17) the research evidence to support the relative effectiveness of specific treatment approaches or settings for particular groups of drug abusers is more varied; (18) methadone maintenance has been shown to be the most effective approach to treating heroin abusers; and (19) research on the best treatment approach or setting for other groups of drug abusers is less definitive.