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Prevention and Treatment: A Continuum of Care

Experts in the AOD field recognize the need for a coordinated, comprehensive continuum of care to effectively address AOD problems. San Mateo County provides the basic elements of a continuum of care for AOD, from prevention programming through outreach, crisis intervention, screening and assessment, referral, detox, recovery services, and aftercare. In response to interest in this issue expressed by the ADP, this report includes a discussion of the roles of prevention and treatment in the continuum of care based on current research findings.

In recent years, the AOD field has witnessed an increased emphasis on prevention. This is in part the result of changes at the national level. Prevention messages such as the "this is your brain on drugs" commercial are routinely delivered through the media. The U.S. Department of Health and Human Services Center for Substance Abuse Prevention was established during the Bush administration, and makes grants to local agencies for demonstration projects. This and other federal initiatives have resulted in the prevention message being increasingly reflected in state and local activities. Most public schools have added information about AOD prevention to their curricula.

The familiar adage states that an ounce of prevention is worth a pound of cure, but it does not necessarily follow that AOD systems should emphasize prevention at the expense of recovery services. The AOD field recognizes the necessity for a complete continuum of care. Prevention and recovery programs are both emphasized, because prevention efforts do not address people who already have AOD problems. To use a common-sense analogy, brushing your teeth does not make existing cavities go away. People who currently have AOD problems, and do not receive recovery services, contribute to a number of social problems and create costs for other service systems (criminal justice, social services, mental health, child abuse, etc.). While we can seek to prevent today's children from becoming AOD abusers, we must also recognize that there are many adolescents and adults who are now AOD users.

Prevention evaluation. While there is optimism about the effect prevention may have, studies indicate that we have a great deal left to learn. Botvin, Schinke, and Orlandi (1989) reviewed the literature and concluded that most single-component prevention programs-such as those that give information on the effects of AOD, and may also attempt to raise the self-esteem of youth-are not effective. This conclusion was also reached by Tobler (I 987) and Dryfoos (I 99 1). Each of the reviewers concluded that though anti-drug information programs do not work, comprehensive multi-component approaches may be effective as prevention. Tobler concluded that social influence and life skills programs worked to some extent, and Botvin's review, although using somewhat different terminology, supported this general idea. Dryfoos proposed that community-wide multi-agency collaborations would be the best approach. In general, prevention evaluation studies support the continuation of multi-component programs that provide substantially more than more than anti-drug information.

Work is ongoing to better understand AOD prevention. One major project is a structured evaluation of prevention programs nationwide, which has been funded by the federal Center for Substance Abuse Prevention. The first phase, the design of the evaluation, was completed in 1991 by the University of California, San Francisco in collaboration with Allen/Loeb Associates (Brindis, Allen, & Loeb, 1991). The second phase, the design implementation, is being conducted by Conwal, Inc.; a final report should be available in the fall of 1994. Results may indicate which prevention approaches may be effective. The hope is that more effective prevention programs can be established so that, in the future, there will be less need for treatment. However, there is no indication in the literature that prevention can or should now replace treatment.

Treatment evaluation. Substance abuse treatment has been extensively evaluated, and there is general consensus that it is effective despite certain limitations (McLellan, Luborsky, O'Brien, Woody, & Druly. 1982; Simpson, 1984: Hubbard, Collins, Rachal, & Cavanaugh, 1988; Tims, Fletcher, Bennet, & Hubbard, 1991). Success rates depend on treatment modality and the characteristics of clients. As one might expect, briefer treatments are usually less effective than longer treatments. Residential treatment is generally considered the most effective modality, and the longer the length of stay, the better the treatment outcomes. Residential programs are more costly, on a per participant basis, than outpatient programs. However, some specific residential programs can be more cost-effective on a cost per successful outcome basis than some non-residential programs.

Some people are not helped by treatment, and others go through treatment a number of times before they recover. Work is ongoing to improve the effectiveness of treatment. But overall, AOD treatment has been shown to make a substantial, long-term difference. Besides helping people achieve and maintain abstinence from alcohol and other drugs, outcome studies (reviewed by Hubbard, Collins, Rachal, & Cavanaugh, 1988) have shown that treatment reduces crime and violence.

The evidence refutes the notion that addicts are incurable. Instead, people can recover from addiction. In the process, society benefits from people recovering.

Need for both treatment and prevention. Treatment and prevention both have a place in the continuum of services. Efforts to prevent people who are not now abusing AOD from becoming abusers are important. To the extent these efforts are successful, they will eventually reduce the need for treatment. But there are many people who already are AOD abusers. To address our current AOD-related problems, such as crime, family violence, and people out of the workforce on welfare, making treatment widely available is justified by both practical concerns and research findings. For the foreseeable future, both prevention and treatment will be important elements of a comprehensive continuum of services to address AOD problems (graphically represented on Table 7, next page).

Table 7. The Continuum of Care for AOD Services








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