Most people who enter drug abuse treatment leave shortly after they enter, far too early to have achieved the maximum benefit from their programs. Treatment evaluations show that the longer a drug abuser stays in treatment the better the long-term outcome. However even short stays in drug abuse treatment are of some benefit for the period immediately after treatment.

One place to start is by looking at the treatment approach that produces the best results: the nation's state Physicians' Health Programs (PHPs) that produce 5 year outcomes with 75% or more of the participants staying drug and alcohol free. How is that outcome possible given that addiction is a biological disease? If physicians had significantly better outcomes than any other class of patients for the treatment of any disease, that would be of great public health importance.

To improve treatment outcomes, IBH is teaming with the Treatment Research Institute (TRI) at the University of Pennsylvania and funded by the Robert Wood Johnson Foundation (RWJF) IBH is conducting the first-ever study of the nation's Physicians' Health Programs (PHPs) in collaboration with the Federation of State Physicians' Health Programs. IBH is working to identify the key elements of this treatment management system and to independently validate the outcomes claimed by these remarkable programs.

The PHPs include several features that make them unique in the world of addiction treatment. They are run by physicians, many of whom are themselves in recovery from addiction. They are long-term often lasting as long as 5 years. They involve active drug testing to identify relapses to drug and alcohol use so that early and effective interventions can be made promptly to stop the return to addictive drug use. These programs are generally linked to daily or near-daily attendance at 12-step meetings of Alcoholics Anonymous and Narcotics Anonymous throughout the entire PHP treatment experience. The PHPs also involve intensive formal addiction treatment -- often residential treatment as well as outpatient -- especially early in the course of care.

The IBH/TRI study not only validates the outcomes over the course of 5 years of these programs, but it also identifies the key elements of the PHPs that appear to be responsible for their stunningly favorable outcomes. This study will seek to identify future research opportunities including identifying ways to incorporate various aspects of the PHP approach to treatment management more widely into addiction treatment.

Make the Criminal Justice System More Drug Free

Drug abuse is endemic in the criminal justice system, making the drug-free state an important but elusive goal. Systematic application of the drug-free standard to all those released to the community under the supervision of the criminal justice system continues to be a daunting challenge.

The criminal justice system must increase drug testing using urine, hair, sweat and saliva. Sanctions should be invoked quickly and uniformly for all positive drug test results. For offenders on parole or probation, the first positive drug test might result in:

• closer supervision and more frequent drug testing;
• more counseling;
• a week or month back in prison.

All parolees released to community supervision, not just a small subset of released offenders, should participate in routine drug testing that is linked to progressive sanctions. "Non-users" must also be subject to drug testing and sanctions, since routine supervision has proven unreliable at identifying drug abusers within the total offender population. HOPE Probation provides an excellent model for offenders on probation with drug use problems. Funded by the National Institute of Justice, a research evaluation by Angela Hawken, Ph.D. and Mark Kleiman, Ph.D. clearly shows the efficacy of the program. The 24/7 Sobriety Project of South Dakota is another successful program which focuses specifically on DWI offenders.

Promote Greater Recognition of the Vital Role of 12-Step Programs in Long-Term Recovery

One of America's proudest contributions to world culture is the creation of the 12-step programs that overcome various forms of addiction. Each day, in every community of this nation, truly inspiring miracles are taking place.

Private sector drug abuse treatment programs have been revolutionized in the past two decades by:

• the near-universal adoption of the abstinence goal and
• application of the "disease concept" of addiction.

The disease concept approach is based on the belief that once a person is addicted to any brain-rewarding drug, there is little chance that person can ever use any brain-rewarding drug without negative consequences and the loss of control. These are central concepts that still are not sufficiently understood in the addiction treatment community, or in the general public.

For many years, some drug abuse treatment has been focused primarily on decreasing the use of the particular problem drug for each individual. This approach does not define addiction as a single unitary phenomenon that involves all non-medical drug use.

The depth to which the single-drug focus is imbedded in the current treatment system is well illustrated in the long-standing approach to methadone treatment. For many methadone programs, the treatment goal is to reduce only heroin use by addicts. There is too little attention paid to the addict's consumption of alcohol, marijuana, or cocaine in these programs.

Defining the problem in terms of only one drug is a losing strategy because addicts suffer from a self-induced, life-long disease of disordered brain reward. There are many chemicals that hold the passkey to that brain reward system. Thus, attempting to reduce, rather than end, non-medical drug use simply does not work.

The Alcoholics Anonymous program got it right from the start. The AA premise is that to stop using alcohol, the alcoholic must also stop using other drugs non-medically. This includes illegal drugs such as marijuana and cocaine.