When can we say that treatment of drug addiction has been successful? The problem of deciding what constitutes success, or even improvement has generated heated debate between therapists, most notably in the past between 12-steps, psychoanalytic and behavioural enthusiasts. It has also divided policy makers. Those who favour prevention and environmental control are sceptical of the proposal that more elaborate treatment strategies will contribute to eliminating the problems caused by drug addiction.
Those who provide treatment interventions need to justify confidence in their value. When can we say that treatment has delivered a satisfactory outcome? Without an answer to this question, there will never be a satisfactory answer to the underlying debates, nor to questions of the relative effectiveness of different interventions.
There has been a recent exchange of views between U.S. and European experts which explores the question of how treatment success should be assessed. The National Institute on Drug Abuse in the USA sponsored two recently published reports (1,2). The first argues that the primary outcome measure should be drug use, measured by both self-report and by toxicology testing. The authors argue that problems of the reliability of both self-report and toxicology testing can be overcome by tailoring the method used to the drug in question. The authors provide a useful guide to this process, and they also sensibly recognise the likelihood of one drug being substituted by another, and hence the need to test for a range of substances (and behaviours?), and not only for the one that has initially proved problematic. By following the guidance in this report there is no doubt that the validity of self-report, and the efficiency of toxicology tests, can be maximised.
However, even given the will to deal with the complexities of improving validity and efficiency of these measures of drug use, is information about drug usage all that we need to consider, or even the most important information we might obtain?
Questions about quality of life and well-being are also acknowledged in the report as a legitimate focus in the evaluation of treatment interventions, but they are relegated to the status of “secondary outcomes”. The argument for this downgrading is based on the assumption that reducing or eliminating drug use will in itself transform the lives of those users whose lives are in disarray. However, the converse argument that poor quality of life sustains drug abuse, and should therefore be the “primary” target of interventions can also be convincingly argued. This reflects the view developed in the second report, and the authors there contend that assessment of well-being or quality of life, should be given equal status to that of drug use in the evaluation of treatment success. Reduction of craving is also said to be an important contributor to quality of life: craving “is ubiquitous across all abused substances”, and is related to an “attenuated quality of life [that] has been associated with a range of substance-use disorders” (2). The authors describe in detail the ways in which assessment of quality of life (and of craving) have been reliably assessed, and can hence be justifiably used in research.
There is a need for a coordinated strategy that incorporates both drug use and quality of life in the assessment of treatment outcomes, a view variously expressed by commentators on the two reports. And reliable techniques exist to assess this broader range of outcomes, not least from the contributions of positive psychology. More importantly, a similar broadening of approach is required in relation to treatment strategies. The “primary” focus on reducing or eliminating use of the drug in question, evident in most conventionally available treatment programmes, should be enhanced by components that focus on teaching clients how to “flourish”. Such techniques have been developed (3), but their use in drug rehabilitation programmes awaits systematic evaluation.