Best Practices : Substance Abuse Treatment and Rehabilitation

8. General Conclusions and Summary of Best Practices

Despite the limitations of research to date, there are a number of conclusions that appear to be warranted that have been referred to in this report as best practices.

There is fairly good evidence that people exposed to some types of treatment subsequently reduce their use of psychoactive substances and show improvement in other life areas. While improvements in substance use behaviours are generally associated with improvements in other life areas, this is not always the case; nor are improvements in other areas (e.g. health, social functioning, criminality) necessarily contingent on abstinence. Different stakeholders may value some outcomes more than others and judgments of the success of treatment need to be made against multiple criteria assessed along a continuum. Dichotomous outcome measures (e.g. abstinent vs. relapsed) mask incremental benefits of treatment and disregard functioning in other life areas.

Some types of treatment seem particularly promising with respect to their influence on substance use and related problems (see below) and, in general, treatment outcomes are improved when appropriate treatments are provided for significant life problems (communication problems, lack of assertiveness, unemployment). However, treatment outcomes are influenced by pre- and post-treatment characteristics of clients and their social environments. Clients with severe psychiatric disorders and also those lacking social supports for abstinence or reduced substance use generally do less well than others.

Following is a listing of best practice guidelines arising from this review:

Best Practice Guideline (No. 1, p. 13)

There is a definite role for pharmacotherapies, if used in a controlled setting, as an adjunct to other forms of treatment. Those drugs which have addictive potential must be used with caution and monitored on a regular basis.

Selective use of disulfiram by socially stable, motivated clients, as an adjunct to comprehensive therapy, is supported by the literature.

Naltrexone can be an effective adjunct to other forms of treatment by reducing craving for alcohol.

Methadone, in adequate doses and with supportive therapy, is effective in reducing illicit opiate use, criminal activity and HIV transmission. Therapy involving methadone can improve social functioning, physical health and productivity and, in certain instances, can lead to cessation of heroin use. Better outcomes are achieved with longer retention in treatment.

Best Practice Guideline (No. 2, p. 16)

There is some support in the literature for behavioural relapse prevention programs for smokers and people with alcohol problems. The literature also provides support for the effectiveness of behavioural self-control therapy for those with less severe drinking problems, as a cost-effective alternative to extensive therapist-led approaches, and for behavioural contracting in the context of a comprehensive treatment program.

Best Practice Guideline (No. 3, p. 17)

The community reinforcement approach has consistently been shown to be effective, particularly with clients having fewer social supports and more severe drinking problems.

Best Practice Guideline (No. 4, p. 18)

Marital therapy, particularly marital behavioural therapy, in both brief and extended formats, is well supported by research.

Best Practice Guideline (No. 5, p. 18)

Social skills training is strongly supported by research, particularly with problem drinkers.

Best Practice Guideline (No. 6, p. 19)

There is good support for stress management interventions as a component of treatment for alcohol problems.

Best Practice Guideline (No. 7, p. 25)

Although the literature does not yet provide strong evidence by which to match clients to specific treatment interventions, it does not mean that all clients require the same types of services. A variety of flexible and individualized services is required and guidelines for the selection of appropriate services are needed.

Best Practice Guideline (No. 8, p. 26)

Considerations should be given to providing treatment in a group format unless otherwise contraindicated.

Best Practice Guideline (No. 9, p. 28)

Research continues to support the relative cost-effectiveness of treatment provided on an outpatient basis to that provided on a residential basis, but this does not deny that some people with substance use problems need short- or longer-term supportive accommodation. However, those who are provided this type of accommodation could still benefit from participating in outpatient or day programs for help with substance abuse and other problems.

Best Practice Guideline (No. 10, p. 30)

Intentionally brief interventions (up to eight sessions) appear to benefit socially stable, low to moderately dependent people with alcohol problems. Other people with alcohol problems may need longer-term treatment but the lower and upper limits for cost-effective treatment have not been established. Several studies have shown that treatment of shorter duration is as effective as that of longer duration.

Best Practice Guideline (No. 11, p. 31)

Better treatment outcomes have been achieved for clients with fewer problems and more resources. This indicates the need to research and develop effective interventions for those who currently have a poorer prognosis.

Best Practice Guideline (No. 12, p. 32)

Appropriate therapy by competent counsellors with strong interpersonal skills, such as empathy and the ability to forge a therapeutic alliance with the client, is associated with an increase in positive treatment outcomes.

Best Practice Guideline (No. 13, p. 34)

There is some evidence of the efficacy of mandated treatment in the context of civil commitment for heroin abuse and also for drinking-driving remedial programs. However, the broader literature on efficacy of mandated treatment is equivocal. Thus, it would be improper to conclude that legally mandated clients are necessarily less suitable candidates for treatment than others.

Best Practice Guideline (No. 14, p. 38)

There is insufficient research evidence to support the provision of specific types of interventions for women. However, it is clearly important to consider barriers to treatment and provide a range of modifications and support services (e.g. scheduling sessions while children are in school, the use of self-help materials, provision of child care services, transportation), and to provide specific ancillary services (e.g. services related to pregnancy, sexual abuse counselling, parenting skills training and vocational assistance).

Best Practice Guideline (No. 15, p. 41)

Adolescents may respond best to flexible approaches which adjust to individual needs. Important program elements include family therapy, behavioural skills counselling, family and peer support and continuing care. Ancillary services, such as the availability of school for dropouts, vocational counselling, recreation services, psycho-social development, crises counselling and sexuality counselling, are also important.

Best Practice Guideline (No. 16, p. 43)

Seniors are often reluctant to acknowledge a substance use problem or to seek help from specialized services. Community-based treatment provided in the broader context of support for health and activities of daily living, using a client-centred, flexible and holistic approach, is more effective.

Best Practice Guideline (No. 17, p. 46)

While evidence is limited, it appears that providing integrated services for people with co-occurring substance use and mental health problems holds more promise than offering services in sequence or parallel. Close liaison and coordination to enhance referral and case management need to occur among the respective specialized services in a community. Training appears crucial, not only for staff of respective specialized services, but also for social services and correctional staff where these clients often present themselves. Excluding people with mental health problems from addictions treatment and excluding those with alcohol or drug problems from mental health treatment should, in general, be discouraged.

Best Practice Guideline (No. 18, p. 49)

Injection drug users with HIV/AIDS tend to be very marginalized in their communities, and it is difficult for them to access appropriate care and treatment. The very considerable health risks facing this population call for better coordination of services and more innovative treatment measures to reduce this harm, particularly among Aboriginal people, women and those in prison settings.

Best Practice Guideline (No. 19, p. 49)

Special populations need improved access to treatment through some combination of: greater awareness of and access to informal help such as self-help/mutual aid groups and self-instructional material; greater involvement of general community services in identifying and supporting clients with substance abuse problems; and provision of specialized services through outreach efforts. Effective case management is particularly important to meet the unique and often multiple needs of these clients.

Best Practice Guideline (No. 20, p. 58 )

The majority of those who have problems with alcohol or other drugs do not seek help, and especially not from specialized addiction services. More efforts may therefore be required to increase awareness of specialized services among the general population and among social and health service providers.

Best Practice Guideline (No. 21, p. 60)

Research on effective configurations for service systems is quite limited. However, there is consensus in the literature that clients are better served when they can access a range of flexible and individualized services spanning the specialized and non-specialized sectors, linked through some form of coordination and case management, and accounting for the needs of special populations.

Best Practice Guideline (No. 22, p. 61)

Though by its nature it is difficult to evaluate the efficacy of attendance at AA or other mutual aid groups, many people find such groups of benefit, and clinicians should make themselves familiar with AA and other mutual aid groups and provide information and support to their clients in the use of these resources.

Best Practice Guideline (No. 23, p. 63)

There is good evidence that substance abuse treatment results in economic benefits for society as a whole, or at least for some sectors. Several studies indicate that the economic benefits resulting from some types of treatment exceed treatment costs.