INTRODUCTION

When I was invited to serve as the discussant for this technical review, I was asked to attune my ear, which is accustomed to alcoholism treatment research, and comment on what I heard from an outsider’s perspective. After listening to these 2 days of papers, I feel not at all like an outsider, for there are many familiar issues and problems for me here.

COMMONALITIES IN ADDICTIVE BEHAVIORS

Obviously, there are many overlaps between alcohol and other drug abuse. Our clients, in fact, do not seem to realize that there are two separate Institutes. We treat and study substantially overlapping populations. It is rare these days to find a client who has problems only with alcohol, and we have heard here that perhaps half of methadone-maintained people have active drinking problems.

Relapse is a familiar phenomenon to us all (as Dr. Marlatt’s writings have emphasized), as is the issue of impaired control of behavior.

The etiology of alcohol and other drug problems is clearly complex, involving biological, psychological, and social factors and (some of us would add) spiritual dimensions. The papers presented here suggest, not surprisingly, that the general treatment strategies that work well with drug problems resemble those with demonstrated efficacy for alcohol problems.

We even seem to make the same mistakes in treatment and research. I had rather hoped to find that the treatment of drug abuse is less mired in a dispositional disease model, but I see the same wide gap between science and practice that has plagued the alcohol field. The popular disease model posits that addicts (or alcoholics) are qualitatively different from normal human beings, not only in their behavior but in genetics, physiology, and character, and that this is why they have the problems they do.

In this way, the dispositional disease model is oddly like the moral model that creates “them” and “us.” In a recent dissertation in our lab, Moyers (1991) studied the factor structure of treatment providers’ beliefs about alcoholism; she found a robust first factor reflecting all of the traditional beliefs of the disease model.

The moralistic items included on the questionnaire (e.g., “Alcoholics are liars and cannot be trusted’) also loaded on this primary factor, as did characterologic attributions. The essence of the factor seemed to be that alcoholics are all like each other but different–biologically, genetically, morally, and characterologically– from normal human beings.

The papers presented here, in contrast, suggest that drug abusers are fundamentally like other people except that they use drugs and suffer the consequences. This is the same picture that emerges with alcohol. “Alcoholics” are as unique and different from one another as snowflakes.

No replicable prealcoholic personality has been found after half a century of searching for it (e.g., Vaillant 1983), and behavioral precursors are limited to the same childhood conduct and school problems that are related to drug abuse more generally (Miller and Brown 1991). People with alcohol and other drug problems do not respond any more favorably to being confronted than do the rest of us (Miller et al., in press).

DRUG USE AS BEHAVIOR

Another familiar picture from this conference is that drug use-even with supposedly “out of control” drugs and people–responds to operant contingencies. This was demonstrated in the early 1970s with alcoholics (for a review, see Heather and Robertson 1981). Drug use is, first and foremost, behavior, shaped by and responsive to principles of learning such as reinforcement, punishment, classical conditioning, and modeling.

This is one of the messages that I seek to convey to psychologists and other mental health professionals: “Alcohol and drug abusers are not Martians, governed by different laws of behavior and requiring referral only to an initiated inner circle of experts with unique knowledge and techniques. Everything that you have learned in your training is directly applicable because use is behavior, and users are people like everyone else.”

In 10 years, I hope, this statement will be seen as an uninformative and obvious observation. Today, in the United States, it remains embarrassingly controversial.

A common behavioral strategy for which I have heard many applications here is successive approximation.

Dr. Grabowski advocated reinforcing successive reductions in drug use, and Dr. Marlatt pointed out, in arguing for a harm reduction perspective, that steps in the right direction are just that. Dr. Schuster also reinforced this point: if an addict gives up shooting heroin, prostitution, crime, and smoking crack cocaine but continues to use marijuana, both the individual and society benefit nonetheless.

Again, one hopes that readers in 10 years will ask how anyone could not see this. In a recent article (Miller and Page 1991), we described a variety of “warmturkey” alternatives for clients unwilling to accept immediate, permanent, cold-turkey abstention.

These include a trial period of abstinence (sobriety sampling), gradual fading of dosage toward abstinence, or a trial span of moderation to reduce or eliminate problems and dependence.

In a long-term followup study (Miller et al. 1992), we found that drinkers treated with a goal of moderation more often opted, in the long run, for abstinence-about twice as often, in fact, as those maintaining problem-free drinking.

Even though the practitioner’s ultimate goal for the client may be abstinence, insisting on immediate, total, and permanent abstention from all psychoactive drugs is not necessarily the most effective way to achieve that goal.

In a way, this has been acknowledged more readily in drug abuse treatment (e.g., methadone and nicotine substitution) than in alcoholism treatment. One speaker here did advocate excluding from treatment those clients who say they want only a drug holiday–a view at odds with a harm reduction approach that provides people with whatever treatment and degree of improvement they are ready to accept.

Such flexibility in treatment goals may lead to better retention and improved outcomes (Sanchez-Craig and Lei 1986). Several examples were provided here that behaviors commonly believed to be nearly intractable or to lie beyond the person’s conscious control behave as operants and respond to reinforcement contingencies: cocaine use, illicit drug use to supplement methadone, and the parasuicidal and therapy-disrupting behavior of borderline patients.

In Dr. Higgins’ data, I saw a suggestion that the community reinforcement approach was less successful with those who might be judged to have the most impaired control: daily, heavy cocaine users.

Perhaps we will find parameters of drug use that predict differential modifiability by operant and volitional efforts (cf., Miller and Brown 1991). It is likewise clear that the social environment more generally exerts strong influence on drug use. Dr. Higgins reported that employment and spouse involvement–two longstanding predictors of alcohol outcomes–were prognostic of cocaine outcomes as well.

Dr. Henggeler provided a causal model in which neighborhood and peers exert separate and direct effects on the likelihood of adolescent drug use. Clearly, we should not underestimate the “social” in “psychosocial.”

Skill training strategies, as I indicated in my review, have accounted for at least half of the treatment methods with demonstrated efficacy for alcohol problems.

Here I note the findings of Dr. Childress that active, not passive, coping strategies reduced craving. Dr. Higgins’ encouraging success with the community reinforcement approach, which relies heavily on skill training, mirrors its reported strong effects with alcohol abuse and dependence.

BEHAVIORAL INTERVENTION RESEARCH

Although the National Institute on Drug Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA) have sponsored both biomedical and psychosocial intervention research, I am struck by the seemingly different patterns that have arisen–surely from historical and political factors rather than from inherent differences in our populations.

In prevention research, the alcohol field has emphasized “the quest for the test”–the search for pathognomonic biological factors that differentiate alcoholics from normal people. The preventive implications of this approach are limited at best, implying a program of identification and exhortation of alcoholics possessing the tainted gene or physiology. NIDA, in contrast, seems to have emphasized, to the dismay of some researchers, a supply-and-demand reduction approach that relies on interdiction and psychosocial strategies.

The idea of limiting the supply of (or access to) alcohol in our society, however, is difficult to sell to legislators, and the Norwegian Government’s official slogan, “Drink less alcohol,” seems as alien here as goat cheese. When it comes to treatment, oddly enough, the roles have been reversed.

NIDA has invested heavily in biomedical interventions for addicts, as shown by the proposed inauguration of a new $65 million initiative for medication development. The occasion of this conference witnesses a new interest at NIDA in strengthening behavioral treatment research.

At NIAAA, behavioral treatment research has a long and strong history, and psychosocial and biomedical studies share roughly equal proportions of the research budget. It was in a 1990 program announcement that NIAAA solicited new pharmacologic trials for alcoholism treatment. Again, we are dealing with heavily overlapping populations.

In treatment studies in our center, we now routinely include other drug use in our outcome measures. Alcohol use is obviously a significant factor in drug abuse treatment and trials. It is time, I believe, to explore how NIDA and NIAAA can cooperate in facilitating, coordinating, and funding treatment trials that increasingly bridge the missions of these Institutes.

It is time to develop consensus state-ofthe- art followup measures for alcohol and other drug use, the central dependent variables of our research. There are also many common issues in assessment methodology. Urine testing represents a gold standard in drug use assessment, a technology for which there is as yet no good parallel to verify recent drinking.

Consequently, alcohol treatment researchers have refined other methods for corroborating client self-reports–particularly collateral interviews, which have received curiously little attention in drug abuse treatment studies.

It remains to be seen how well the reports of significant others might serve to verify use or nonuse of cocaine, heroin, or marijuana, for example. The validity of collateral reports may vary from drug to drug. Heroin use, for example, is not as likely to be observed by nonusing spouses, and its effects may be harder to detect.

Cocaine runs, as Dr. Higgins commented, have more obvious effects observable by significant others. Marijuana use may be more readily observed directly by others. Collateral reports could serve as a further check on self-report, particularly in light of the known false positive rate (for recent drug use) inherent in urine testing due to residual traces of prior use.

NIDA and NIAAA researchers face similar assessment problems and could work profitably together to forge common treatment outcome measurement strategies. The growing awareness of multidiagnosis cases suggests that similar interface with the National Institute of Mental Health (NIMH) is overdue, and it is likely that quality alcohol and drug assessment will be of equal importance to research in other parts of the National Institutes of Health (NIH).

The reasons for joint measurement of alcohol and other drug dimensions are not limited to assessment concerns. Dr. Higgins reported that disulfiram, in essence, constitutes an effective treatment for cocaine use, specifically among those who also drink heavily.

A cocaine relapse may begin with drinking alcohol, suggesting a new meaning for the concept of “gateway” drugs. Similar attention should be paid to tobacco use, which is being explored in current NIAAA research as a correlate of alcohol use and relapse.

Suppression of only one drug, without paying attention to the impact on and effects of other drug use, makes little sense in a population in which polydrug abuse is normative.

Further, research should seek to disaggregate the effects of treatment modalities from settings. Residential and inpatient treatment have consumed the lion’s share of treatment dollars, despite the fact that nearly every literature review of the past two decades has concluded that such settings offer no overall benefit above that afforded by outpatient treatment (Annis 1985; Kiesler 1982; Miller and Hester 1986; U.S. Congress 1983).

If a specifiable subgroup does benefit differentially from more intensive and expensive care (a sensible possibility), this remains to be demonstrated, and the characteristics of this group should be documented and replicated.

Treatment process also deserves much greater attention. Dr. Borkovec’s call for research to delve deeply into treatment processes is well taken. Careful process research can help us understand how and why change occurs and elucidate the nature of the very problems we are treating.

Yet, such depth is not logically precluded in comparative clinical trials. It is possible to study two or more treatments deeply and simultaneously, gaining both process and relative outcome knowledge.

The comparison of different strategies is, I believe, entirely appropriate at this stage of knowledge development. The “horse race” pejorative unfairly oversimplifies the modem welldesigned clinical trial.

New insights into the nature of a disorder can arise from main effects and interaction (matching) effects as well as from the same within-treatment analyses that are possible in a singletreatment study.

The randomized trial also provides a level of causal inference not achieved readily through other designs. “Comparative” and “depth” are not alternative designs but different possible aspects within designs. Like process and outcome, both types of knowledge can be obtained from a well-designed trial.

Dr. Howard also was eager to hobble and humble randomized trials, or at least, by polemic attack, to inspire a defensive improvement in them. I surely favor the latter goal, and the methodologic criticisms he raised are worthy considerations, but they are worries for which remedies already exist.

His concern that randomization can result in nonequivalent groups on critical pretreatment variables is mitigated in larger samples, and it can be addressed by a variety of methods for ensuring balance while retaining essential randomization such as L.J. Wei’s (1978) urn randomization procedure.

The problem of data attrition is not unique to randomized trials, but, as several presenters here have shown, there are various effective ways to improve the retention of subjects in treatment and research. Dr. Howard’s worry that the distributions of experimental and control groups may overlap is real enough, but it is not properly solved by eliminating the control group from one’s design!

Noncomparative designs simply ignore the problem of relative outcomes. Having reviewed the alcoholism outcome literature over the past two decades, it is my experience that the relative contrasts of comparative trials yield a much more consistent picture across replications than do uncontrolled trials (cf., Holder et al. 1991; Miller and Hester 1980).

At the same time, I hasten to agree that randomized trials are not always the most appropriate method for generating new knowledge about treatment. Consider, for example, the need for new research with Alcoholics Anonymous (AA) and other 12-step groups, a priority highlighted by the National Academy of Sciences (1989).

Twelve-step group participation is too often regarded by researchers as a nuisance variable to be minimized.

Yet, the vast majority of alcohol and drug treatment programs in the United States espouse a 12-step philosophy and commend or require group attendance, and the 12-step fellowships serve far more individuals every year than do all treatment efforts combined. What happens to people over a course of involvement in such groups?

Why do some stay and others fail to return? What attracts people to 12-step fellowships? How, when, and for whom does change occur? These and many other questions can be answered by research (McCrady and Miller, in press), but the 12-step groups do not readily lend themselves to randomized trials because of their ubiquity.

Incidentally, contrary to statements made here, there is no official institutionalized resistance to research in AA. To the contrary, Bill Wilson wrote a memorandum encouraging AA members to participate in scientific research that continues to be circulated by the AA central offices.

My point though, for which this is but an illustration, is that there are behavioral outcome questions for which designs other than randomized trials are optimal. Both types of research are needed. On the issue of studying heterogeneous versus homogeneous samples, again it depends upon one’s purpose.

In seeking to discover client-bytreatment matching interactions, it is essential to start with a sample that is heterogeneous with regard to the predictor variables.

Recent Federal requirements to represent females and minority groups in study samples whenever feasible also favor heterogeneity. The limiting of a treatment study to a homogeneous sample may be warranted once there is already persuasive evidence that the intervention(s) under study will be differentially appropriate for that subsample.

We have little such knowledge regarding drug abusers. Had the NIMH collaborative trial been limited to “exogenous” depression, for example, the field would have been deprived of the important information that “endogenous” depression responds comparably to pharmacotherapy and cognitive therapy–a finding that in itself raises questions about the exogenous/ endogenous distinction and related etiologic assumptions.
  

IMPROVING TREATMENT

With regard to improving treatment, it is clear from the presentations made here that retention and compliance are crucial issues in treating drug problems in general as they are with alcohol problems in particular.

People who stay in treatment longer, follow advice, do homework assignments, and practice active coping strategies are generally found to fare better at followups. The tendency in this field is to regard these as the “good” patients and to blame attrition and noncompliance on poor client motivation or character.

There are persuasive reasons, however, to reevaluate this view. We have argued elsewhere that motivation, denial, and compliance are not client problems but therapist and program problems (Miller and Rollnrick 1991).

Dr. Higgins showed us data in which treatment retention varied from 11 percent to 93 percent across groups in randomized trials. Therapist behaviors have been shown to be strong predictors of client dropout, resistance, progress, and outcome (McLellan et al. 1988; Miller and Rollnick 1991).

Dr. Linehan described for us a treatment program that has retained 80 percent of its borderline patients for one year, an impressive achievement with a population usually assumed to be characterologically incapable of sustaining treatment.

If the characteristics of therapists and programs determine the rates of client retention and compliance, which in turn drive treatment outcomes, high priority ought to be given to identifying those characteristics and to learning how to train and influence them. As Dr. Grabowski observed, all treatment programs stand somewhere on these characteristics (contingencies) and, thus, are already influencing client behavior in crucial ways, for better or worse.

This, in turn, raises for me some reservations about selecting research subjects on the basis of their “wanting” or “willingness” for particular treatment(s). The willingness to accept disulfiram, for example, has been used as an inclusion criterion for clinical trials (e.g., Azrin et al. 1982; Fuller et al. 1986).

Yet, if client willingness (motivation) is so susceptible to influence, we need, at the very least, to specify the procedures used to “sell” interventions to potential subjects–an aspect of research procedure often unmentioned in proposals and reports.

These procedures will, in turn, impact recruitment rates, sample characteristics, external validity and replicability, and human research review considerations.

Here is another area for study! I believe that there is a real opportunity now to improve treatment by inculcating evaluation values in local programs. One way to do this is by tightening up accountability for program (or therapist) outcomes, and the Joint Commission on Accreditation of Healthcare Organizations is already taking steps in this direction.

The astounding lack of accountability in this field for using research-supported treatments needs to be remedied. At least as important, however, is encouraging and empowering treatment programs and professionals to evaluate their own work as a method for obtaining feedback and improving practice.

Learning does not occur without feedback; yet, most practitioners work in a nearly total feedback vacuum, receiving little or no useful information to help them become more effective.

Apparently, this problem is recognized by clinicians. Dr. Schuster reported here that, in a survey of drug abuse practitioners, the need for help in program evaluation was placed at the top of a wish list. It is possible to promote excitement and expertise for program staff by having them engage in evaluation studies, which need not be large-scale time-intensive trials.

Relatively simple studies of immediate practical importance can be conducted in ongoing care delivery settings (e.g., Chafetz 1968). How might this be accomplished? Develop intriguing do-it-yourself research workshops for program staff, and market and deliver them on a national scale. Find ways to reward staff and programs for evaluation that go beyond the documentation of effort and demographics. Encourage replications of promising treatment methods at the local level.

Dr. Higgins pointed out the importance of evaluating new methods in one’s own clinic to fine tune them and determine how and for whom they work. Contracts for such onsite replications in clinical settings could be offered through special programs in NIDA or the Center for Substance Abuse Treatment (CSAT).

Regional continuing education events could provide training on how to conduct program evaluation at the local level with ample opportunities for input and ideas from participants. Significant progress also might be accomplished through training and research centers. A predoctoral National Research Service Award at our center has had this effect as an originally unforeseen side effect of training.

Six trainees per year have been placed in community treatment and prevention programs with the sole focus of helping staff conduct program evaluation research. Rather than bringing preconceived projects with them, these trainees typically have interviewed program staff to ask what questions would be of particular importance and interest to them. Studies then are designed to meet these needs, with the trainee serving as a free consultant.

Over the first 5 years of this training program, we have developed not only trainees but also a number of community program research sites that now compete with each other for trainees. Publishable research has emerged from several sites, which also has had immediate practical importance for the sites.

Treatment training and research centers could be asked to propose plans for community training and dissemination efforts in new and renewal proposals. At the same time, as Dr. Moras discussed, we need to strengthen treatment research methodology.

There is a wealth of know-how scattered among investigators with regard to the usually undiscussed but critical aspects of how to conduct research: selecting and training personnel; recruiting and retaining samples; collecting, entering, and cleaning data; conducting interviews; instrumentation; and other aspects. Examples of this know-how have been shared at this meeting.

It is time to gather some of this accumulated wisdom together and make it accessible to new and current researchers before those who possess it are lost to retirement, burnout, or other fields. Special attention and development should be devoted to evaluation procedures that can be implemented in local program settings.

KNOWLEDGE DISSEMINATION

I have elsewhere bemoaned the immense gap that exists between practice and research in the alcohol field and suggested some possible causes and remedies (Miller 1987). This gap is, I believe, one of the most significant problems in the field of alcohol and drug abuse.

The move of our Institutes to NIH could worsen this gap, separating the research institutes further from the primary Federal program mechanisms of CSAT, the Center for Substance Abuse Prevention (CSAP), and the block grants. The fault does not lie clearly on either side, and there is much we can do as researchers to help bridge the gap. In order for research findings to be implemented in practice, for example, it is essential to do far more than publish them in scientific journals.

A broad range of practitioners must be informed, motivated, trained, and empowered to implement the new technology. There are models already available (e.g., drug companies), and we could draw upon the expertise of those who specialize in knowledge dissemination and technology transfer.

Let me suggest just a few ideas.

1. Make knowledge and technology accessible to practitioners. Few clinicians (and, for that matter, few researchers) are likely even to read a particular article in a scientific journal. Research needs to be made available, interesting, and comprehensible to service providers. This means publishing in the periodicals that practitioners read, attending and presenting at popular clinical conferences, and working with professional organizations.

The more practical the material, the better. Therapist manuals, as they are developed in research, can be reviewed and published for general use, and they are likely to be consumed eagerly. Self-help materials might be generated from some technologies and tested in separate studies. National and regional training (preferably free) could be offered in the newest clinical methods to emerge from research as an alternative to the tired recapitulations of unproven lore that currently characterize most substance abuse professional meetings.

2. Market new knowledge and technologies in ways that speak to the perceived needs and problems of clinicians. People are motivated to change when they: (a) perceive a significant problem or opportunity and (b) perceive an effective solution that is possible for them to implement (Rogers and Mewborn 1976). The striking popularity of “relapse prevention” training is a case in point: substance abuse clinicians recognize the problem of relapse and are searching for effective ways to address it.

3. Provide a carefully edited information resource for practitioners. The Prevention Pipeline and Brown University’s Digest of Addiction Theory and Application are examples of such efforts, though both are broader and contain little practical knowledge. The Journal of Substance Abuse Treatment has this potential, but most of the material it presents is lacking in a research base.

4. Require potential grantees to include, as part of an application for research or training funds, a plan for dissemination of research findings to be reviewed with the proposal. This would heighten attention to this issue and draw on the creativity of researchers to address it.

Alternatively, researchers with meritorious and applicable findings could be encouraged to apply for separate Phase II dissemination funding by proposing such a plan. Dissemination phase funding of this kind is already represented in the prevention programs of the U.S. Department of Education’s Fund for the Improvement of Post-Secondary Education and in Phase II review for Small Business Innovation Research grants.

Still another possibility is for independent contractors to propose plans for disseminating an Institute’s significant clinical findings to the practice field.

5. Create two-way research and practice partnerships. To the extent that service delivery programs can be recruited as partners with researchers through the training efforts described earlier, channels are created through which knowledge dissemination in both directions is possible.

Mechanisms for the formation of such partnerships could be developed. Again, investigators and centers applying for funding, particularly programmatic funding, could be asked to propose ways in which they will interact with their communities to establish such relationships with service providers.

It is our experience that these are long-range efforts in which significant fruit is borne over the span of a decade or more.

A CONTINUUM OF INTERVENTIONS

Finally, I would offer the challenge of fully recognizing and implementing in the drug abuse field the National Academy of Sciences’ (1990) perspective that the problems we address lie along a continuum. In fact, it appears that there are a number of loosely interrelated continua of severity, including: (1) use, (2) life problems, (3) dependence, (4) biomedical sequelae, (5) neuropsychological impairment, and (6) other quality-of-life factors.

In the drug abuse treatment field, as in the treatment of alcohol problems, the bulk of intervention efforts and funding have been concentrated on the tip of the triangle. As one proceeds away from this tip, the base broadens, and one encounters ever larger numbers of people with less severe but nevertheless significant problems.

The use of binary diagnosis has supported the notion that those above a certain severity cutoff point require intervention and those below it do not. A continuum of interventions can be conceived, ranging from primary prevention to intensive treatment (National Academy of Sciences 1990).

It has been the “middle classes” of the severity triangle who have received the least attention.

Primary prevention and intensive treatment both are offered widely. The former is insufficient and the latter too heroic for those with midrange severity. In the alcohol field these are the problem drinkers and risky drinkers, whose behavior is already worrisome and who account for the majority of alcohol problems in society (Moore and Gerstein 1981), but who do not evidence the deterioration and dependence that treatment programs usually are designed to address.

Many such individuals are currently identified through employee assistance programs (EAPs) and arrests for impaired driving. They are left, typically, to choose between diseasemodel treatment or no treatment at all. It is here that brief interventions and behavioral self-control training have shown the greatest promise, producing consistent improvement with individuals in the mild-to-moderate severity range.

NIDA faces a similar challenge. Drs. Higgins and Grabowski both presented data indicating that those who are less impaired at intake fare better in treatment-an argument for still earlier outreach. Dr. Marlatt appealed for brief services on a harm reduction model through which contact can be established with a broader range of drug abusers.

The rapid growth of drug testing is already turning up a substantial number of drug users with low severity of use, problems, and dependence, many of whom are employed and functioning well. As drug-testing practices spread, this number will continue to grow.

What is to be done with and for these less severe users? They are unlikely to respond well to being told that they have the primary disease of chemical dependency, confronted in group psychotherapy, sent to hospitals or 12-step groups, and instructed to abstain from all licit and illicit psychoactive drugs for life. 

A harm-reduction perspective holds that less use is better than more use and that fewer problems and risks represent an improvement.

Politics run high here, particularly in a zero-tolerance atmosphere, because illegal substances are part of the picture. Behavioral interventions with demonstrated efficacy for problem drinkers that are logically generalizable to other drug problems do exist. Behavioral self-control training, for example, has a strong track record in reducing alcohol use (Holder et al. 1991) and already has been applied with polydrug users (Wilkinson and LeBreton 1986).

Initial trials indicate that motivational interviewing and a “drinker’s check-up” suppress alcohol use in midseverity drinkers (Miller et al. 1988, in press) and increase responsiveness to treatment (Bien 1991; Brown and Miller, in press). Other researchers have applied this approach in addressing heroin use (Saunders et al. 1991; Van Bilsen 1991).

The alcohol field has long struggled with how to serve the midrange severity population who seem to require less intensive treatment and greater goal flexibility.

How will the drug abuse field respond? Perhaps it will be economics that, in the long run, forces a response. While EAPs, courts, and drug testing provide an ever-growing base of clients for treatment, public funding for services continues to wane. The result, like it or not, will be briefer, less-intensive interventions for many.

This is not necessarily a negative outcome. Dr. Grabowski reported here that less frequent visits increased patient retention in treatment, while the requirement of more visits after positive drug tests tended to elevate the relapse rate.

Dr. Stitzer listed less frequent counseling as a reinforcer for clients! In the alcohol field, few differences have been found in the efficacy of inpatient versus outpatient or brief versus extended treatment (Bien et al., in press).

Deaton and Olbrisch (1987) have proposed, tongue-in-cheek, that brevity of contact with therapists is the active ingredient in treatment effectiveness. For certain therapists, at least, it appears that less contact is indeed better (McLellan et al. 1988; Miller et al. 1980).

The brighter side of this picture is that brief, well-conceived treatment appears to be at least as effective as traditional intervention for many people, particularly those with less severe problems.

This makes it possible to provide services to a broader range of clients. It is an unanswered question whether and which people, failing to remit with brief intervention, will benefit differentially from additional treatment. In any event, the development of midrange interventions for less severe drug abusers remains important uncharted territory.

The realities of increasing demand and decreasing funding for treatment leave us with two options: continue trying to provide ever-diluted treatment in the traditional model or develop a well-planned system in which different levels and types of intervention are provided to people based on their needs and characteristics.

I am grateful for the privilege of reflecting on the proceedings of this interesting conference, and I look forward to the fruit this meeting may bear in the years ahead.

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ACKNOWLEDGMENT

Preparation of this chapter was supported in part by grant number K05-AA09051 from the National Institute on Alcohol Abuse and Alcoholism.

AUTHOR

William R. Miller, Ph.D. Professor of Psychology and Psychiatry Department of Psychology and Director Research Division Center on Alcoholism, Substance Abuse, and Addictions (CASAA) The University of New Mexico Albuquerque, NM 87131-1161

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From NIDA Research Monograph 137 Behavioral Treatments for Drug Abuse and Dependence [pdf with multiple chapters, diagrams]