TREATMENT OUTCOME PROSPECTIVE STUDY (TOPS)

This is a prospective clinical, epidemiological study of clients who entered drug-abuse treatment programs from 1979 to 1981. During the course of TOPS, 11,182 clients were interviewed at admission to drug-abuse treatment by program researchers hired to work in assigned clinics and professionally trained and supervised by Research Triangle Institute (RTI) field staff. The interviews at admission covered demographics, history of drug use, treatment, arrest and employment behavior in the year prior to treatment, and status upon admission to treatment. The study was sponsored by the National Institute on Drug Abuse (NIDA) and by the RTI. The study population included 4,184 clients from 12 outpatient methadone programs, 2,891 clients from 14 residential programs, and 2,914 clients from 11 outpatient drug-free programs in 10 cities. Interviews with questions on behavior, services received, and satisfaction were collected by the program researchers every three months while clients remained in treatment. The self-report data were supplemented with data abstracted from the clinical and medical records of all clients selected for the follow-up, and questionnaires describing the treatment philosophy, structure, practice, and process were completed by counselors and program directors.

The follow-up data included interviews 1 and 2 years after treatment with 1,130 clients who were admitted in 1979; follow-ups 90 days and 1 year after treatment of 2,300 clients who entered treatment in 1980; and follow-ups 3 to 5 years after treatment of 1,000 clients who entered programs in 1981. Professional field interviewers hired, trained, and supervised by RTI field staff were able to locate and interview between 70 and 80 percent of the clients selected for these interviews.

TOPS has resulted in a substantial body of important knowledge about drug-abuse treatment and treatment effectiveness. The client populations of outpatient Methadone Programs, long-term residential programs, and outpatient drug-free programs who participated in TOPS differed on many sociodemographic and background characteristics. The residential clients were significantly more likely to report multiple use of drugs, more drug-related problems, suicidal thoughts and attempts, heavy drinking, predatory crimes, and less full-time employment compared to the methadone clients. Outpatient drug-free clients were more likely than methadone clients to report drug-related problems, suicidal thoughts or attempts, predatory crimes, and heavy drinking, but they were less likely than residential clients to use multiple drugs. These results demonstrated that each type of program served very different, important segments of the drug-abusing population. The high rates of self-referrals to methadone (48%) and criminal-justice referrals to residential and outpatient drug-free treatment (31%) suggest differences in clients' motivations for seeking treatment and, consequently, differences in retention, services received, and outcomes.

The drug-abuse patterns reveal the differential concentration of types of drug abusers across the major categories. Clients on methadone were primarily (52%) traditional heroin users who used only cocaine, marijuana, and alcohol, in addition to heroin. One in five of these clients, however, used heroin and other narcotics, as well as a variety of non-narcotic drugs. The remaining quarter of clients on methadone were classified as former daily users who had histories of regular use but did not use heroin on a weekly or daily basis in the year before treatment. Residential clients had diverse patterns of use, and the majority of outpatient drug-free clients were users of alcohol and marijuana (36%) or single non-narcotics users (22%).

Symptoms of depression are very commonly reported by clients entering drug-abuse treatment programs. Overall, about 60 percent of TOPS clients reported at least one of three symptoms of depression at intake: nearly 75 percent of the women under 21 years of age reported one or more symptoms of depression. Other results suggest that the duration of regular drug use and the number of prior treatment episodes are important indicators of the effectiveness of any single treatment episode; clients with lengthy drug-abuse or drug-treatment histories have poorer prognoses.

Clients who have come into treatment by way of the criminal justice system do as well or better than other clients in drug-abuse treatment. Formal or informal mechanisms of the criminal justice system appear to refer individuals who had not previously been treated and many who were not yet heavily involved in drug use. Involvement with the criminal justice system also helps retain clients in treatment up to an estimated six to seven additional weeks. Drug abuse treatment programs vary in the nature and intensity of the treatment services provided, the types of therapists and therapies provided, the average length of stay, and the inclusion or exclusion of aftercare.

The study of the treatment process in TOPS programs focused on many important aspects of the structure, nature, duration, and intensity of drug-abuse treatment. Descriptions of aspects of the treatment process were developed from clients' self-reports of needs for treatment services, services received, and satisfaction, combined with abstractions of clinical and medical records and descriptions of programs by counselors and directors. The outpatient methadone and outpatient drug-free treatment programs had budgets per slot of approximately 2,000 dollars per year. Therapeutic communities had an average expenditure of 6,135 dollars per bed.

The number of available services (medical, psychological, family, legal, educational, vocational, and financial services) varied during the years 1979 to 1981. Fewer services appeared to be available in the later years of the study. The proportion of clients in residential treatment programs who received family, educational, and vocational services decreased noticeably during the three-year period. During this same period, the clients' demands for services increased. Programs in TOPS appeared to focus on the client's primary drug of abuse rather than addressing the client's multiple drug use, drug-related problems, and social and economic functioning. Low-dose methadone (69% of the clients admitted were initially treated with less than 30 mg of oral methadone daily) was the most common pattern of methadone treatment in the programs participating in TOPS.

In TOPS, multiple measures of treatment outcome were necessary to describe changes in the client's ability to function in society after treatment. In general, clients who remained in treatment at least three months had more positive post-treatment outcomes, but the major changes in behavior were seen only in those who remained in treatment for more than twelve months. Analyses of the TOPS data show that the post-treatment rate of daily heroin, cocaine, and psychotherapeutic-agent use among clients who spent at least three months in treatment was half that of the pretreatment rate. The post-treatment rates of weekly or more frequent use for clients who stayed in treatment at least three months were 10 to 15 percent lower than the rates for shorter-term clients. The results showed that time spent in treatment was among the most important predictors of most treatment outcomes. Stays of one year or more in residential or methadone treatment, or continuing maintenance with methadone, produced significant decreases in the odds of a client using heroin in the follow-up period. Clients in TOPS also reported a substantial decrease in depression symptoms during the years after treatment.

Analyses of the effects of treatment on behavior have focused on reductions in predatory crime and the costs associated with crime. The assessment of the benefit/cost ratio indicates that substantial benefits are obtained in reductions of crime-related costs regardless of the measures used within the year after treatment. Reducing transmission of the Aids virus would increase the benefit portion of benefit/cost ratio even more.

(See also: Drug Abuse Treatment Outcome Study ; Treatment Alternatives to Street Crime ; Treatment Types )

Robert Hubbard