Though the evidence cited in the literature has tended to support the effectiveness of IDDT, questions have been raised about the validity of the research studies. One important source that has questioned the validity of IDDT comes from the Cochrane Review. First becoming widespread in the 1990s, Cochrane reviews focus on specific medical specialties or subspecialties, systematically gathering all relevant data generated from controlled clinical trials. Named for one of the earliest proponents of this idea, Professor Archibald L. Cochrane, the reviews are commissioned by the Cochrane Collaboration (http://www. cochrane.org). Formed in 1993, the collaboration which is based in Oxford, England, currently has 10,000 collaborators from more than 80 countries around the world. A number of Cochrane reviews have focused on treatment and rehabilitation services for severe mental illness, including the issue of integrated treatment for persons with severe mental illness who are substance abusers.
A Cochrane review conducted by Jeffery, Ley, McLaren, and Siegfried (2000, 2003), reviewed six studies they deemed relevant to the issue. While they reported that the design quality of the studies was not high and several clinically important outcomes such as mental illness relapse, satisfaction, and social functioning were not assessed, they found no clear evidence supporting one strategy of providing care over another. In short, they concluded that the current trend toward integrated programming is not based on good evidence. This challenges the basis of an integrated treatment strategy for persons with dual disorders.
Why did the Implementing Evidence-Based Practices group described in Chapter 1 determine that integrated treatment strategies were superior while the Cochrane review team found no evidence for this advantage?
The most obvious answer to this question is that each group looked at somewhat different evidence. The Cochrane group accepted data for review from only six of the most rigorously designed studies (e.g., controlled trials with random assignment), whereas the EBP group looked at results from 26 studies with all types of study designs. In both cases reviewers commented on the quality of the studies under review. Clearly, the EBP reviewers applied more liberal criteria for inclusion. One might speculate whether a large amount of data from all different types of studies may or may not outweigh a much smaller amount of data generated by stricter criteria. Given the emphasis EBP places on outcome assessment, it is likely that this question and those like it will be answered shortly.
CONTROVERSIAL ISSUE Total Abstinence versus Harm Reduction
The notion that substance abuse is a disease and that state and federal governments should provide funding for its treatment and rehabilitation is a relatively new idea. Today it seems clear that different people have different levels of tolerance for substance use, some are more prone to addiction than others, and substance abuse has a number of related physiological manifestations. Recognition of the physiological, social, and spiritual damage caused by substance abuse is worldwide. Still, a good deal of controversy surrounds whether the goal of services for substance abusers should be total abstinence or harm reduction.
One of the most successful models for dealing with substance abuse, Alcoholics Anonymous was begun in 1935 in Akron, Ohio, by a New York City stockbroker, Bill W., and an Ohio surgeon, Dr. Bob (http://www.alcoholics-anonymous.org). Based on self-help in the form of mutual support and a 12-step process, the goal of AA is total abstinence from alcohol. In fact, the first step of the process is to admit that one is powerless over alcohol. The AA website reports having more than 2,000,000 members attending 100,000 AA groups worldwide. AA has helped virtually millions of people with alcohol addiction.
Today, many substances besides alcohol, both legal and illegal, are abused. In the 1950s a similar organization based on the principles of AA, Narcot ics Anonymous, emerged (http://www.na.org). NA simply substituted the word "addiction" for "alcohol" in the first step of the 12-step process: One is powerless over the addiction. The NA website reports that by 2002 there were some 20,000 groups worldwide conducting more than 31,000 meetings per week. Recognition that one is powerless over either alcohol or drugs implies that abstinence is the best solution for achieving and maintaining sobriety. Not everyone is in agreement with this position.
Reducing, the negative consequences, or harm reduction, is the idea that the goal of treatment or rehabilitation should be to reduce the harm caused by the substance abuse rather than require total abstinence (Marlatt, Blume, & Parks, 2001). The harm reduction strategy, which fits well with motivational interviewing and Prochaska and colleagues' (1994) stages of change, has the advantage of meeting people where they are with respect to their substance abuse problem. It is no secret that many substance abusers have no intention of quitting (Marlatt, 1998). In fact, the drug rehab adage that someone has to "hit bottom" before they can start to recover from their addiction is based on just this recognition. The idea seems to be that not until someone hits bottom will he or she decide that the costs of using substances outweigh the benefits.
Interestingly, harm reduction is not as uncommon as one might first suspect. Methadone maintenance, the provision of free methadone to heroin addicts, is a successful harm reduction program.
Needle exchange programs to reduce the spread of HIV are another harm reduction strategy. Even ensuring that an intoxicated person does not drive is a harm reduction strategy. In the area of alcohol addiction, one self-help group, Moderation Management, uses a nine-step program to help people modify and manage their drinking (http://www. moderation.org). Starting in the 1980s in Rotterdam, the Netherlands, harm reduction was a natural outgrowth of liberalized drug laws that allowed drug users to organize publicly. This organization, "Junkiebond," began advocating for harm reduction strategies for drug users and was able to establish the first needle exchange program in 1984 (Saladin & Santa Ana, 2004).
The research on harm reduction appears to show that while some people benefit (e.g., suffer fewer negative consequences), others do not and would be better served by adopting the goal of total abstinence. The question may be how to best engage individuals in rehabilitation and then help them to decide whether they should have a goal of harm reduction or total abstinence. As Rusty Foster (personal communication, October, 2005) an experienced professional in this area puts it:
The problem for the severely mentally ill population is their sensitivity to even small amounts of a substance. Though it is important to recognize that most consumers begin reducing substance use gradually rather than moving right to abstinence, and it is important to recognize and reward these changes, in the long range the treatment goal usually is abstinence. But here the movement to abstinence is seen as a process not an event.
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