Chapter 5–The Importance of Patient-Treatment Matching

The consequences of alcohol and other drug addictions include individual losses of income, jobs, educational opportunities, health, family relationships and self-esteem because of dysfunctional social behavior related to substance abuse. Societal costs include lost productivity because of work-related accidents and absenteeism, rising health care expenditures, the price of criminal victimization and responses by the criminal justice system, and the human suffering of drug-exposed infants, family violence, and other accidents.

There are no "quick fixes" or "magic bullets" to solve the problem of addictive disorders. Research indicates that treatment can be successful with drug- and alcohol-involved persons. However, different people respond to various approaches in diverse ways, making individualized treatment matching an essential component of intervention. In this chapter, considerations for matching patients with the most advantageous treatment regimen will be explored.

Alcohol and other drug addiction is a chronic, progressive, relapsing disorder. It is caused by interrelated biopsychosocial influences. Assessment is one of the five critical areas of treatment, and it is the first step in the treatment process. Comprehensive assessment is essential in determining an individual's particular constellation of strengths, problems, and needs. An effective treatment plan can be developed only after a thorough assessment has been completed.

When a patient has a physical illness, diagnostic assessments are performed to determine the specific cause of the malady. Then, the most appropriate treatment is provided. For example, if a patient goes to a physician with a cough, several types of assessments are performed until the physician thinks the cause of the complaint has been found. Among the possible causes for a cough could be a simple cold, irritation from smoking or other inhaled substances, whooping cough, tuberculosis, and lung cancer. The physician will select different courses of treatment for each of these ailments. The correct treatment for the diagnosed cause of the cough must be selected. Applying chemotherapy to a cold or prescribing cough syrup for lung cancer is clearly inappropriate. Similarly, selecting the most appropriate form of treatment for a substance abuse problem is crucial.

There are at least three important reasons why effective patient-treatment matching is essential.

• Improved success. When individuals receive the treatment that is most appropriate for their needs, they are more likely to respond positively, remain in treatment longer, and begin recovery.
• Programmatic efficiency. No program can meet the needs of every individual. Instead, patient-treatment matching helps channel persons with specific problems to the most appropriate program for them. This results in more effective use of scarce treatment resources. If patients are not matched with the appropriate treatment for their assessed needs, the treatment resource will be misused, and other persons who might benefit from that particular treatment approach may be excluded from entering the program because of limited program space.
• Financial savings. When individuals receive appropriate treatment and enter recovery, there are financial savings. Money is saved because of lower health care, crime-related, and other costs associated with substance abuse. The ultimate cost of treatment also may be lowered. If people are treated by methods that are effective for them, the funding for that treatment will be spent wisely; if appropriate patient-treatment matching does not occur, money will be spent imprudently.

Patient-treatment matching is not an exact science; it might be necessary to adjust the treatment plan following periodic reassessment of the individual's progress in treatment or when a relapse occurs. Much has been learned, but additional research is needed to maximize the benefits of selecting the most appropriate treatment approach for various individuals.

An Overview of Patient-Treatment Matching Considerations

Various studies about patient and program ingredients related to successful treatment of alcoholism have been conducted. These are summarized in Table 5-A. There are wide variations among the elements of various treatment programs. While the factors reported here can provide general guidance, much more information must be gained from the assessment of individuals and from evaluation of agency programs. This table also demonstrates that there are many areas about which sufficient research knowledge has not been gained. There are many other questions about patients and programs that need further evaluation (McLellan & Alterman, 1991).

The type and duration of drug use, treatment history, and other patient characteristics also can be matched with certain drug treatment methods. The Office of National Drug Control Policy has developed a model (Table 5-B) for matching drug use to treatment methods (Office of National Drug Control Policy [ONDCP], 1990).

Referral of individuals to various treatment programs must attempt to make the best possible fit between the patient's and the program's characteristics. Unfortunately, the state of the art is imperfect, and there is still much to learn about the precise combination of factors that ensure positive treatment outcomes. Nevertheless, existing information, and the experience of practitioners with patients and treatment modalities, can facilitate appropriate treatment matching. Such practices are ultimately most likely to keep patients engaged in the treatment process to achieve recovery, and to be cost-effective (Allo, Mintzes, Nischan & Brook, 1988).

Goals of Treatment

There are three levels at which goal setting for treatment is important: the individual level; the program level; and the community, State, or societal level. The focus of this chapter will be primarily on individual treatment goals. However, mention of the other two levels will be made, and further discussion will be provided in later chapters.

Individual Treatment Goals

Before attempting treatment with substance abusing patients, professionals must assess their needs and problems and establish goals for treatment. Without doing so, both the patient and professional run the risk of being side-tracked during the process and missing their objectives. Just as the assessed needs and problems of each person develop into a unique configuration for that individual, the treatment goals and plans also must be distinctive and realistic. The goals become the guide by which the rest of the treatment plan is directed, implemented, and evaluated.

Among the possible goals that may be appropriate for individuals entering treatment are the following (Institute of Medicine, 1990; Schuckit, 1989; Vuchinich, Tucker & Harllee, 1988):

• End substance abuse. Recovery is the process of initiating and maintaining abstinence from alcohol or other drug use. It also involves making personal and interpersonal changes (Daley & Marlatt, 1992). Whether an individual is addicted to or abusing alcohol, illegal drugs, prescription drugs, or a combination of these, the most important goal is to discontinue the use of alcohol and/or drugs. In some cases, it may be a feasible aim for a person to control his or her alcohol consumption or the use of prescribed medicines. However, most chemically dependent persons will have difficulty with this, and many will find they must adopt a goal of abstinence if they are to enter recovery.
• Improve health. Chemically addicted persons typically have concomitant health problems. These vary widely, and some illnesses are closely associated with the use of specific substances. (See Chapter 7 on substance abuse-related infectious diseases.) In some cases, health problems may have preceded the initiation of substance abuse.
  • Medical care. Appropriate medical attention should be a high priority for many patients. It is especially important that patients who are pregnant, at risk for HIV disease, or exhibiting symptoms of severe illnesses, such as pain and convulsions, receive immediate medical attention.
  • General health. Overall improvement of health includes helping the individual develop positive health practices. This may include a regular and enriched diet, vitamin supplements, sufficient sleep, and regular exercise. Routine and corrective dental care may be needed, as well.
  • Risk reduction. Patients need education and assistance in ending specific practices that place themselves at risk for diseases. Drug injection practices, as well as unsafe sexual behaviors, are associated with the transmission of HIV (the causative agent of AIDS) and other infectious diseases. The spread of tuberculosis also is increasing rapidly among drug-involved persons. Substance abuse-related infectious diseases will be discussed in more detail in Chapter 7.
• Treat psychiatric disorders and psychological problems. Long-term use of several substances of abuse, including alcohol, can result in neurological damage, as well as other psychiatric and emotional problems. Brain impairments can affect a person's mental and physical abilities and emotional control. Other psychiatric disorders, such as manic depression, antisocial personality, or schizophrenia, may be present before the development of chemical addiction. Emotional, psychological, and psychiatric disorders may interfere with treatment efforts. Treatment providers should recognize the indicators of these problems and provide or refer patients for evaluation and treatment.
• Meet employment and educational needs. School performance and attendance problems are highly correlated with substance abuse among young people. For adults, addiction often affects employment, sometimes resulting in under- or unemployment. Treatment not only needs to help individuals resume patterns of productive employment or educational involvement, it also may be necessary to address deficits that have accrued during the period of substance abuse and addiction. Youth may need remedial education services; both youth and adults may need vocational training and other skill development related to seeking and maintaining appropriate employment.
• Reduce criminal behavior and resolve legal problems. There is a strong possibility that many persons who are chemically dependent also may be involved in illegal activities. This may include income-generating crimes (e.g., shoplifting, burglaries, prostitution), expressive crimes (e.g., assault, homicide), and drug-related charges (e.g., drug possession, drug sales). Treatment for substance abuse has been linked with decreases in the amount of criminal activity in which an individual engages. Whether individuals are within the criminal justice system or not, many will be facing legal problems. In some cases these may be related to civil matters, such as divorce, child custody, and other suits. Those who are aliens to this country may need to resolve issues related to their immigration status. All of these persons may need help in understanding the complex legal system. They also may need the services of an attorney to represent their interests. However, they may be unable to locate or pay for such help. Therefore, an important goal is to help the person understand and resolve legal problems so his or her attention can be more firmly focused on the substance abuse treatment.
• Improve personal circumstances:
  • Personal values. Through treatment, the individual's beliefs and attitudes in various spheres should be examined. Exposure to other viewpoints and discussion of problems that may have resulted from previous perspectives can be helpful in bringing values about work, family, and the law more closely in concert with those of society.
  • Coping skills. Substance abuse is often a result of inadequate coping skills, or the inability to function satisfactorily in the environment. The coping skills needed often include stress management, decision making, assertiveness, parenting skills, financial management, personal care (e.g., nutrition and physical hygiene), and many others. The lack of these coping mechanisms may interfere with progress in treatment programs.
  • Basic needs. Many persons with serious alcohol or drug dependencies may not be able to meet even their basic subsistence needs for shelter, food, and clothing. Providing assistance in these areas will, again, help center attention more clearly on the individual's treatment goals. It is also important that individuals learn skills to help them achieve greater control, independence, and autonomy in these areas in the future.
  • Positive social support systems. Formal and informal support systems are vital to every person. These support systems are composed of family members, friends, co-workers, churches, and social organizations, among others. They help persons with basic needs and personal care, provide a sense of belonging, and afford opportunities for emotional expression. For many chemically dependent persons, previous social relationships have been lost, were never formed, or were part of the substance abuse problem or environment. Thus, it is important to help them develop positive, trusting relationships within and outside the treatment setting.

Program Goals

Treatment program goals often will be closely aligned with individual treatment goals. Agencies and organizations will have goals to provide specific services that are effective and cost-efficient. Retention of individuals in treatment, and preventing relapse, may be additional program goals. Recruitment and training of qualified staff may be other areas for goal setting. Program evaluation and improvement are additional considerations for goal development at the program level. Program goals will be discussed more thoroughly in Chapter 10, on program evaluation.

Social Goals

At the community, State, and national levels, there are several goals for effectively treating, and thereby reducing, substance abuse. These include, but are not limited to, the following:

• Reduction in the health consequences of substance abuse. Decreasing the incidence of substance abuse is directly related to slowing the spread of HIV/AIDS and other infectious diseases related to chemical dependency. Reductions in chemical dependency also may affect the numbers of accident, homicide, and suicide victims. Another important goal in treating substance abusing women is reducing the number of infants born with drug dependence or other impairments resulting from exposure to alcohol and other drugs.
• Reduction in crimes related to alcohol and other drugs. Treatment of chemical dependency is associated with diminished criminal activity, especially income-generating and violent crimes that may be directly related to the drugs taken. Decreasing demand for drugs also diminishes the substantial profits that can be gained from the manufacture and sale of illegal drugs. These, in turn, result in lower criminal justice system costs related to drug and alcohol crimes, including costs for arrests, processing, court services, and supervision or incarceration.
• Improved productivity. Persons who are not dependent on drugs are more likely to be able to maintain employment, take care of their own financial needs, and pay taxes.

These goals, among others, underscore the fact that substance abuse treatment is cost-effective. It can result in savings in health care costs related to infectious diseases, accidents, and deaths. The expense of providing criminal justice services or incarceration, and the losses suffered by victims of crimes, can be diminished. With more productive citizens who are recovering from chemical dependency, the need for welfare expenditures, health, and other maintenance costs can be reduced.

Patient-Treatment Matching

Each patient's personality, background, and mental condition and the duration, extent, and type of drug use must be considered when selecting a treatment program or approach (ONDCP, 1990). A comprehensive assessment and setting individualized, realistic goals for treatment are the essential first steps for effective patient-treatment matching. An analysis of program resources and characteristics is also important in the patient-treatment matching process. Both individual and program factors to be considered in treatment matching will be discussed.

Program Factors

Several program factors that must be considered for treatment matching are discussed in this section.

Availability and Accessibility of a Variety of Treatment Modalities

Within communities and regions a range of treatment options should be available. These should encompass the various types of substance abuse occurring in the area (e.g., alcoholism, heroin addiction, cocaine abuse), as well as differences in patient characteristics (e.g., age, gender, racial or ethnic group identification, socioeconomic level). Thus, a service network of different programs providing a multifaceted continuum of care to facilitate referrals and movement of patients to the most appropriate program is needed (Allo, Mintzes, Nischan & Brook, 1988; McLellan & Alterman, 1991).

In some cases, one agency may be able to provide several treatment services; however, typically, various treatment modalities are the province of separate agencies. Effective case management for patients, and linkages with various agencies, will ensure that individuals have access to the most appropriate type of program to meet their needs (Allo, Mintzes, Nischan & Brook, 1988).

Program Characteristics

The stated purpose of the program and the patients for which it was developed is important. Some programs are designed to treat only those addicted to a specific drug. Other programs are geared to meet the needs of a particular demographic group, such as adolescents, women, or Hispanics. Program characteristics, such as cost, location, and referral network, also largely determine the eligibility and type of patients for whom a particular program is appropriate (McLellan & Alterman, 1991).

Program Proficiency

It is not only important that programs exist; they also must be run properly and must accomplish what they say they will accomplish. Programs must be able to demonstrate that treatment is delivered in the intended manner, quantity, and intensity, and that the outcome with a majority of patients is positive (McLellan & Alterman, 1991).

Basic Elements of Treatment

There are some common ingredients that should be included in all treatment approaches. Basic human needs for food, rest, medical care, and other essentials should be met through the program or referral to other resources. Programs should hold patients accountable for their behavior, including attendance, punctuality, and abstinence from use of chemicals. Frequent drug tests, and consequences for use, are advisable. Accountability measures encourage chemically dependent persons to make responsible, age-appropriate decisions. Consequences and accountability measures do not mean harsh punishment for first-time or minor rules infractions. Rather, programs should incorporate an array of possible responses appropriate for various situations. These might range from verbal confrontation and counseling, loss of a privilege, or increased supervision to more restrictive or rigorous reactions to repeated or more serious program violations. Programs should attempt to instill in participants basic ideas of trust, respect, honesty, and responsibility (ONDCP, 1990). Treatment programs need to provide a consistent structure to help patients, whose lifestyles have been chaotic, adjust and conform to the rules and realities of life (Nurco, Hanlon & Kinlock, 1990).

Staff Competency and Attitudes

There should be enough staff members to meet the needs of the patients in the program. They also should be experienced and trained in providing the services for which they are responsible. Staff must be firm and provide strong leadership, while showing compassion and modeling positive personal characteristics (ONDCP, 1990). Staff attitudes also are an important program factor. Permissive attitudes among staff may result in viewing society or outside forces as responsible for one's addiction. Thus, neither the staff nor the person in treatment is confronted with taking responsibility for actions to change behaviors and attitudes during treatment (Nurco, Hanlon & Kinlock, 1990). Rather, attitudes that require responsibility and accountability may be more productive.

Patient Factors

Successful treatment outcomes largely depend on the accuracy of assessment, the development of realistic goals, and the appropriateness of the match between the individual and the treatment program. There are several individual patient factors that should be considered.

Readiness and Motivation for Treatment

Drug use is fraught with difficulties, including illnesses, withdrawal effects, financial burdens, threat of legal problems, and the potential of death. At the same time, use of drugs may produce pleasurable effects and relief from anxiety, depression, or boredom. Discontinuing the use of many substances can result in painful physical and psychological withdrawal symptoms. Many substance abusers have developed networks of friends among other chemically dependent persons. They may have replaced persons from their support system, who would encourage them to recover, with persons who motivate or support continued addiction. Thus, there is often ambivalence on the part of chemically dependent persons about discontinuing their substance abuse (Nurco, Hanlon, & Kinlock, 1990).

Individuals facing a crisis as a result of substance abuse must receive appropriate services regard-less of whether or not they intend to discontinue their use of alcohol or other drugs. This may include emergency medical care, detoxification, temporary shelter, and similar types of services. However, once they have been stabilized, they may or may not be ready to enter a treatment program. Such crises may enhance treatability; thus, it is important that service providers take advantage of these opportunities and actively prepare and recruit patients for treatment (Allo, Mintzes, Nischan & Brook, 1988). Although one never wants to "give up" on the possibility of helping someone, when treatment programs have limited space for participants, it may be most cost-effective to assess the individual's goals and determine whether or not s/he is ready to make a serious attempt at recovery.

Treatment programs that facilitate interpersonal, vocational, and economic gains and maintain pressures to remain engaged in treatment are likely to be more effective. Besides the efforts of staff to motivate patients to remain in treatment, programs can encourage family members to encourage patients and, when appropriate, keep legal authorities apprised of the person's participation in treatment (Nurco, Hanlon & Kinlock, 1990).

Drug Use Pattern

Some treatment programs are specifically aimed at treating addiction to one type of substance. For example, methadone maintenance is limited to treatment for heroin addiction. However, many chemically dependent individuals have a history of abusing more than one type of substance. When selecting the most appropriate treatment program, consideration must be given to the type(s) of substances abused and the effectiveness of the particular program in treating persons with such addiction(s). Persons with serious polydrug problems may benefit from residential or inpatient treatment initially (Hubbard, 1992; Nurco, Hanlon & Kinlock, 1990).

Pharmacologic Therapy

The physiological nature of addiction to some drugs makes pharmacological treatment a preferred option for some persons. Heroin addiction is particularly amenable to treatment with methadone, which is a synthetic form of opiate that provides a more manageable form of addiction. Medications that block the effects of abused chemicals or cause adverse reactions in patients may also be good adjuncts to treatment for some persons. These may be helpful in the treatment of heroin, alcohol or other central nervous system (CNS) depressants, and cocaine addiction. In Chapter 8 various pharmacotherapeutic treatments, and the recommendations for using them, will be discussed.

Some addicts also have psychiatric conditions. If possible, these should be treated with non-pharmacologic approaches. However, for some, medications (e.g., antidepressants, lithium) will be needed and may be more likely to help the individual remain in treatment for drug abuse (Nurco, Hanlon & Kinlock, 1990).

Presence and Severity of Psychological Problems

The way substance abusers respond to treatment approaches may be affected by the presence and severity of psychological problems. For example, one study found that persons with severe psychological problems did not respond well to confrontation and the prohibition of psychotropic drugs that are characteristics of therapeutic communities (Nurco, Hanlon & Kinlock, 1990). When assessment findings indicate that individuals have a concurrent psychiatric illness, they should be placed in a treatment program that will address both the addictive and the mental disorder. If such programs are not available within a single agency, services that can each treat a respective problem, but will work collaboratively to provide the patient with comprehensive, consistent care, must be found. More information on addicted persons with psychiatric disorders is provided in Chapter 6.

Ethnic and Gender Considerations

Drug abusers from different ethnic and gender groups have different problems, requiring diverse treatment approaches. Differences may include variations in current and past behavior and in the need for treatment. For example, one study found that Hispanic males were most frequently unemployed and undereducated compared with other groups in the study, including black and white males and females. This finding suggests they need a wide range of services, including vocational rehabilitation and interventions to control illicit drug use and crime. Residential drug treatment may be the most appropriate option. White males, on the other hand, had the highest occupational status and education. However, they tended to be polydrug abusers and were more likely to use illicit non-narcotic drugs and commit crime while in treatment. Thus, a highly structured program with careful monitoring of crime and drug use would be indicated (Nurco, Hanlon & Kinlock, 1990).

The ethnic composition of persons in a treatment agency has been found to influence treatment success. In one study, members of particular ethnic groups remained in outpatient treatment significantly longer if more than three-quarters of the treatment program patients were from the same ethnic group. Majority/minority status was less important to the success of patients in residential and methadone maintenance programs. It has also been suggested that the ethnic representation of staff should be similar to that of patients in a program (Nurco, Hanlon & Kinlock, 1990).

Rehabilitation vs. Habilitation

Persons with vocational and interpersonal skills may be helped by just stopping the use of illicit drugs and making concomitant lifestyle changes. However, for those who began using drugs at an early age and did not develop necessary skills, additional help is needed. Therapeutic communities often provide work and skill development for these individuals (Nurco, Hanlon & Kinlock, 1990).

Lifestyle Changes

Severing contact with drug-using peers contributes to the success of treatment. Programs need to help patients avoid contact with active drug users, learn to use leisure time in different ways, and cope with the anxiety associated with adjusting to living drug-free (Nurco, Hanlon & Kinlock, 1990). When contact with drug-using associates cannot be severed in community-based treatment, separation from the drug-using environment through residential change or treatment may be necessary.

Family Involvement

Family involvement in the treatment process is very important, especially for adolescents. An effective program needs to be able to develop working relationships with family members and gain their cooperation (Nurco, Hanlon & Kinlock, 1990). For those patients with available family members (i.e., parents, spouse, children, significant others), it is important to include them in the treatment program.

Comprehensive Services

The variety of patient factors just described indicate the need for a comprehensive array of treatment programs and auxiliary services to meet the range of needs presented. The type of substance being abused and individual patterns of substance abuse will require different models of treatment. Ethnic and gender differences, psychological problems, and motivation and readiness for treatment are among the individual characteristics that require different treatment programs.

Any effective substance abuse treatment system must provide a comprehensive continuum of programs and services. This will include a wide range of substance abuse treatment modalities and services. In addition, treatment programs will be linked with related services, such as health care, education, and housing programs, to ensure that patients can obtain help with associated physical, social, and psychological problems.

Effective treatment matching can occur only when needed services are provided. This requires systems coordination and communication at both the local and the State levels.

Conclusion

A comprehensive assessment of the addictive disorder is the first step in developing a treatment plan that matches optimal treatment programs and services with the identified patient characteristics and needs. Although more research is needed, the chapter reviewed significant findings about selecting appropriate programs for particular types of problems.

Patient-treatment matching considers individual characteristics and differences, as well as program features. Program proficiency and staff competency and attitudes are important areas to assess. A comprehensive array of services is needed to meet a variety of patient needs. Individual motivation, drug use patterns, psychological problems, and ethnic and gender variables are part of the equation for treatment matching.

Patient-treatment matching is an essential element of effective treatment for alcohol or other drug addiction. Collaboration among various parts of the treatment system at the local level is crucial to achieve effective treatment matching. In turn, effective matching of treatment resources to the addicted individual offers improved treatment success, programmatic efficiency, and financial savings. Similarly, coordination is needed among decision makers at the State level to ensure that needed programs are available and appropriately funded.

References

Allo, C.D., Mintzes, B., Nischan, J.A., & Brook, R. C. (1988, January 22). Purchasing substance abuse treatment: Toward a system for enhancing positive outcomes. Lansing, MI: Michigan Office of Substance Abuse Services.

Daley, D.C., & Marlatt, G.A. (1992). Relapse prevention: Cognitive and behavioral interventions. In J.H. Lowinson, P. Ruiz, R.B. Millman, & J.G. Langrod (Eds.), Substance abuse: A comprehensive textbook. Baltimore: Williams & Wilkins.

Hubbard, R.L. (1992). Evaluation and treatment outcome. In J.H. Lowinson, P. Ruiz, R.B. Millman, & J.G. Langrod (Eds.), Substance abuse: A comprehensive textbook. Baltimore: Williams & Wilkins.

Institute of Medicine. (1990). Treating drug problems. Washington, DC: National Academy Press.

McLellan, A.T., & Alterman, A.I. (1991). Patient treatment matching: A conceptual and methodological review with suggestions for future research. In R.W. Pickens, C.G. Leukefeld, & C.R. Schuster (Eds.), Improving drug abuse treatment (Research Monograph 106). Rockville, MD: National Institute on Drug Abuse.

Nurco, D.N., Hanlon, T.E., & Kinlock, T. W. (1990, March). Offenders, drugs, crime and treatment: Literature review. Washington, DC: U.S. Department of Justice, Bureau of Justice Assistance.

Office of National Drug Control Policy. (1990, June). Understanding drug treatment. Washington, DC: Author.

Schuckit, M.A. (1989). Drug and alcohol abuse: A clinical guide to diagnosis and treatment. New York: Plenum Medical Book Company.

Vuchinich, R.E., Tucker, J.A., & Harllee, L.M. (1988). Behavioral assessment. In D.M. Donovan & G.A. Marlatt (Eds.), Assessment of addictive behaviors. New York: The Guilford Press.

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