Best Practices : Substance Abuse Treatment and Rehabilitation

Introduction and Methodology

Substance abuse in Canada was estimated by the Canadian Centre on Substance Abuse to have cost Canadians $18.45 billion in 1992 in terms of health care, social welfare, criminal justice and lost productivity. More than $290 million was spent on attempts to reduce the social and economic costs of substance abuse through the provision of treatment and rehabilitation (Single et al., 1996). In the current economic climate, the substance abuse field is being challenged, along with all parts of the health sector, to give full account of its activities, expenditures and impacts. This call for effectiveness is occurring in the context of a radical reshaping of the delivery systems in much of the country. Health Canada has initiated this project, in collaboration with provinces and territories, to review substance abuse treatment and rehabilitation in Canada, and to offer evidence-based advice on program and system development.

This report is one of two initiated by Health Canada in collaboration with the provinces and territories to provide current baseline information concerning substance abuse treatment and rehabilitation. The purpose of this report is to provide advice on "where we need to go" in substance abuse treatment and rehabilitation in Canada. To complement this report, the other report, Profile - Substance Abuse - Treatment and Rehabilitation in Canada, provides current information on the scope and nature of substance abuse services at the federal, provincial, territorial and local levels.

The majority of Canadians support increased treatment efforts specifically for people who have problems with alcohol or other drugs (Single, 1997). Though many people who have problems with alcohol or other drugs overcome these problems without formal treatment, there is reasonably good evidence that those exposed to some types of treatment for substance abuse subsequently reduce their use of psychoactive substances and show improvements in other life areas. Section 1 of this report summarizes the evidence for the effectiveness of a variety of commonly used treatment approaches and, as will be seen, some approaches seem to be particularly promising with respect to their influence on substance use and related problems. Where there is reasonable consensus on the effectiveness of an approach among the reviewers referred to, we offer "best practice" guidelines to reflect that consensus.

Because a number of comprehensive reviews of the treatment literature have been undertaken in the past 10 years, we have taken a "review-of-reviews" approach to this work. The major reviews concerning the treatment of alcohol problems (Holder et al., 1991; Finney and Monahan, 1996; and Miller et al., 1995) included only studies with control or comparison groups and a proper procedure to equate the treatment and control groups. Although the literature on the treatment of drugs other than alcohol is more limited, strong reviews by Eliany and Rush (1992), Landry (1995) and Correctional Service of Canada (1996) provide the basis of the information provided on other drug treatment in this report. We confined our investigation to treatment approaches addressed by these reviews. In areas where more recent literature was available, we took this research into account.

Section 2 examines what is known about the matching of clients to treatment and therapists, including the results of the recent Project MATCH study.

Beyond actual treatment modalities, there are a number of factors that bear on treatment effectiveness and these are discussed in the third section of this report. Reflecting the breadth and complexity of the study of treatment effectiveness, these factors range from characteristics of the client and therapist to duration and setting of treatment. The issue of mandatory treatment is not new in Canada; however, it has re-emerged in the wake of Bill C-41, passed in 1996, and a Supreme Court case in Manitoba concerning the ability of a government agency to require the treatment of a pregnant woman. The literature on mandated treatment and its implications for treatment effectiveness is reviewed in this section.

It is generally accepted that certain populations or subgroups deserve special attention because of their unique characteristics, or because general programming does not adequately meet their needs. For a number of years, treatment programming has been designed for various "special populations," based on an understanding of shared characteristics that are thought to have relevance in attracting, motivating and retaining clients in treatment. Section 4 includes a review of what is known about providing effective treatment to women, adolescents, seniors, those with concurrent mental health problems and clients who are living with HIV/AIDS. At the time of writing, Health Canada was conducting a separate review of the literature on Aboriginal treatment issues; therefore, this population is not included in the discussion on special populations in this review.

It is difficult to draw a distinct line between program and systems issues, and the literature on substance abuse treatment systems is, in fact, diffuse. Nevertheless, we felt it was extremely important, in the context of current health system reform, to highlight the best thinking on the configuration of substance abuse treatment systems. Included in this review in Section 5 are discussions on who seeks help for treatment, coordination, case management and self-help/mutual aid groups.

In the current economic climate, there is a need to justify treatment activities from a financial perspective. In Section 6, we briefly review several studies from the United States that investigate the economic benefits accruing from treatment.

The challenges involved in conducting outcome research in community settings raise several issues and limitations concerning research to date, that call for caution in offering advice.

At the end of the report we list all of the "best practice" statements in the section titled, General conclusion and summary of best practices.

We conducted a search of French- and English-language sources using variations of the keywords "substance abuse treatment effectiveness" with the following databases:

• CCSADOCS (Database of the National Clearinghouse on Substance Abuse).
  
• CANBASE (Database of the Canadian Substance Abuse Information Network).
  
• DrugInfo (Drug information database produced by the University of Minnesota).
  
• IDA (Information about Drugs and Alcohol produced by the US National Clearinghouse on Alcohol and Drug Information-NCADI).
  
• ETOH (Alcohol database produced by NIAAA).
  
• Project Cork Database (Alcohol and substance abuse information database for clinicians and educators, Dartmouth Medical School, NH).
  
• Toxibase (Réseau national de documentation sur les pharmacodépendences, Lyon, France).
  

This was supplemented by an Internet search (which located the Correctional Service of Canada review of treatment approaches at: http://www.198.103.138/crd/litrev.htm), and suggestions from committee members, from which the sources used for this project were drawn. These are listed in the References section.

A Glossary of many of the technical terms used in this review has been compiled and is found at the end of this report.