Chapter 7. Evolution in Addiction Treatment Concepts and Methods

A. Thomas McLellan, Ph.D.
DOI: 10.1176/appi.books.9781585623440.345610



There has always been broad recognition that alcohol and drug abuse are partly or fully responsible for such serious public health and public safety problems as traffic accidents, street crime, transmission of infectious diseases, child abuse and neglect, and excessive use of medical services. During the 1970s, addiction treatments gained prominence as a social response to these addiction-related problems. This was because addiction treatments were less expensive than the available alternatives (e.g., jail or hospitalization) and because there was social compassion for the many addicted veterans of the Vietnam War whose substance use problems were seen as a result of that war.

Your session has timed out. Please sign back in to continue.
Sign In Your Session has timed out. Please sign back in to continue.
Sign In to Access Full Content
Sign in via Athens (What is this?)
Athens is a service for single sign-on which enables access to all of an institution's subscriptions on- or off-site.
Not a subscriber?

Subscribe Now/Learn More

PsychiatryOnline subscription options offer access to the DSM-5 library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing PsychiatryOnline@psych.org or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Table Reference Number

Addiction treatment is best considered as at least three separate stages—each with distinct goals and methods: 1) detoxification or stabilization is designed to eliminate the acute effects of substance use and prepare the patient for life change; 2) rehabilitation is designed to continue the initial abstinence and to help the patient develop a life that will be enjoyable without substances; and 3) continuing care follows formal treatment and consists of mutual help groups (usually Alcoholic Anonymous [AA]), professional therapy as needed, and often telephone monitoring calls designed to prevent relapse.

Within the rehabilitation and continuing care stages of treatment there is now an impressive array of treatment components that have shown U.S. Food and Drug Administration–level evidence of effectiveness.

Medications include naltrexone, buprenorphine, and methadone for opiate dependence; naltrexone, acamprosate, and disulfiram for alcohol dependence; and disulfiram for cocaine dependence.

Therapies include cognitive-behavioral therapy; motivational enhancement therapy, behavioral couples therapy, 12-step facilitation, community reinforcement and family training, and individual drug counseling.

Adjunctive interventions and services include voucher-based reinforcement for abstinence, clinical case management and wraparound social services, linking of patients to AA, and posttreatment monitoring (telephone, Internet, and home visit).

Despite these very promising new developments, most addiction treatment is delivered within a specialty care treatment system that does not have the personnel, information management, or administrative support to implement most of these practices. Although there will be a continuing need for new and more sophisticated treatment interventions and components, there is a pressing need for financial and organizational development to permit the treatment system to provide the kind of quality care that is now possible.


Anglin MD, Hser Y, Grella CE: Drug addiction and treatment careers among clients in the Drug Abuse Treatment Outcomes Study (DATOS). Psychol Addict Behav 11:308–323, 1997
Anton RF, O'Malley SS, Ciraulo DA, et al: Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA 295:2003–2017, 2006
Balldin J, Berglund M, Borg S, et al: A 6-month controlled naltrexone study: combined effect with cognitive behavioral therapy in outpatient treatment of alcohol dependence. Alcohol Clin Exp Res 27:1142–1149, 2003
Bien T, Miller WR, Tonigan JS: Brief interventions for alcohol problems: a review. Addiction 88:315–336, 1993
Bodenheimer T, Wagner E, Grumbach K: Improving primary care for patients with chronic illness. JAMA 288:1775–1779, 2002
Brewer C: Controlled trials of Antabuse in alcoholism: the importance of supervision and adequate dosage. Acta Psychiatr Scand Suppl 369:51–58, 1992
Carise D, Gurel O, McLellan AT, et al: Getting patients the services they need using a computer-assisted system for patient assessment and referral—CASPAR. Drug Alcohol Depend 80:177–179, 2005
Carroll KM, Onken L: Behavioral therapies for drug abuse. Am J Psychiatry 162:1452–1460, 2005
Carroll KM, Rounsaville BJ, Nich C, et al: One year follow-up of psychotherapy and pharmacotherapy for cocaine dependence: delayed emergence of psychotherapy effects. Arch Gen Psychiatry 51:989–997, 1994
Carroll KM, Nich C, Fenton LR, et al: Treatment of cocaine and alcohol dependence with psychotherapy and disulfiram. Addiction 93:713–727, 1998
Carroll KM, Fenton LR, Ball SA, et al: Efficacy of disulfiram and cognitive behavioral psychotherapy in cocaine dependent outpatients. Arch Gen Psychiatry 61:264–272, 2004
Cornish J, Metzger D, Woody G, et al: Naltrexone pharmacotherapy for opioid dependent federal probationers. J Subst Abuse Treat 15:134–141, 1998
Crits-Christoph P, Siqueland L, Blaine J, et al: Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Arch Gen Psychiatry 56:493–502, 1999
De Leon G: The Therapeutic Community: Theory, Model, and Method. New York, Springer, 2000
Dennis ML, Scott CK, Funk R: An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use disorders. Eval Program Plann 26:339–352, 2003
DuPont RL, McLellan AT, Carr G, et al: The Structure and function of physician health programs in the United States. J Subst Abuse Treat (in press)
Editorial Commentary. Treatment?—For Drug Abuse? Wall Street Journal, July 18, 1997, p A12
Fals-Stewart W, O'Farrell T, Birchler B: Behavioral couples therapy for male methadone maintenance patients: effects on drug using behavior and relationship adjustment. Behav Ther 32:391–411, 2001
Fals-Stewart W, Kashdan TB, O'Farrell TJ, et al: Behavioral couples therapy for drug-abusing patients: effects on partner violence. J Subst Abuse Treat 22:87–96, 2002
Finkelstein R, Ramos SL (eds): Manual for Primary Care Providers: Effectively Caring for Active Substance Users. New York, New York Academy of Sciences Press, 2002
Fiorentine R, Anglin MD: Does increasing the opportunity for counseling increase the effectiveness of outpatient drug treatment? Am J Drug Alcohol Abuse 23:369–382, 1997
Garbutt JC, Kranzler HR, O'Malley SS, et al: Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA 293:1617–1625, 2005
Gutman M, McKay JR, Ketterlinus R, et al: Potential barriers to work for substance-abusing women on welfare. Findings from the CASAWORKS for Families pilot demonstration. Eval Rev 27:681–706, 2003
Higgins ST, Budney AJ, Bickel WK, et al: Achieving cocaine abstinence with a behavioral approach. Am J Psychiatry 150:763–769, 1993
Higgins ST, Budney AJ, Bickel WK, et al: Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Arch Gen Psychiatry 51:568–576, 1994a
Higgins ST, Budney AJ, Bickel WK, et al: Participation of significant others in outpatient behavioral treatment predicts greater cocaine abstinence. Am J Drug Alcohol Abuse 20:38–45, 1994b
Hser Y, Anglin MD, Grella C, et al: Drug treatment careers: a conceptual framework and existing research findings. J Subst Abuse Treat 14:543–558, 1997
Hser YI, Huang Y, Chou CP, et al: Longitudinal patterns of treatment utilization and outcomes among methamphetamine abusers: a growth curve modeling approach. J Drug Issues 33:921–938, 2003
Humphreys K: Circles of Recovery: Self-Help Organizations for Addictions. Cambridge, England, Cambridge University Press, 2003
Humphreys K, Wing S, McCarty B, et al: Self-help organizations for alcohol and drug problems: toward evidence-based practice and policy. J Subst Abuse Treat 26:151–158, 2004
Inciardi JA, Martin SS, Butzin C, et al: An effective model of prison-based treatment for drug-involved offenders. J Drug Issues 27:261–278, 1997
Institute of Medicine: Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC, National Academy Press, 1997
Institute of Medicine: Bridging the Gap Between Practice and Research: Forging Partnerships With Community-Based Drug and Alcohol Treatment. Washington, DC, National Academy Press, 1998
Institute of Medicine: Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington, DC, National Academies Press, 2006
Kadden R, Carroll, KM, Donovan D, et al (eds): Cognitive-behavioral coping skills therapy manual: a clinical research guide for therapists. Project MATCH Series, Vol 3 (DHHS NIH Publ No 98–2620). Washington, DC, U.S. Government Printing Office, 1997
Kirby K, Marlowe D, Festinger D, et al: Community reinforcement training for family and significant others of drug abusers: a unilateral intervention to increase treatment entry of drug users. Drug Alcohol Depend 56:85–96, 1999
Leichsenring F, Leibing E: The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. Am J Psychiatry 60:1223–1232, 2003
Marlatt GA, Gordon JR (eds): Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York, Guilford, 1985
Maude-Griffin P, Hohenstein J, Humfleet G, et al: Superior efficacy of cognitive-behavioral therapy for urban crack cocaine abusers: main and matching effects. J Consult Clin Psychol 66:832–837, 1998
McCrady B, Epstein E, Hirsch B: Maintaining change after conjoint behavioral alcohol treatment for men: outcomes at 6 months. Addiction 94:1381–1396, 1999
McKay JR: The role of continuing care in outpatient alcohol treatment programs, in Recent Developments in Alcoholism, Vol XV: Services Research in the Era of Managed Care. Edited by Galanter M. New York, Kluwer, 2001, pp 357–372
McKay JR: Is there a case for extended interventions for alcohol and drug use disorders? Addiction 100:1594–1610, 2005
McKay JR, Alterman AI, Cacciola JS, et al: Group counseling vs. individualized relapse prevention aftercare following intensive outpatient treatment for cocaine dependence: initial results. J Consult Clin Psychol 65:778–788, 1997
McKay JR, Alterman AI, Cacciola JS, et al: Continuing care for cocaine dependence: comprehensive 2-year outcomes. J Consult Clin Psychol 67:420–427, 1999
McKusick D, Mark T, Edward D, et al: Spending for mental health and substance abuse treatment. Health Affairs 17:147–157, 1998
McLatchie BH, Lomp KG: Alcoholics Anonymous affiliation and treatment outcome among a clinical sample of problem drinkers. Am J Drug Alcohol Abuse 14:309–324, 1988
McLellan AT: The outcomes movement in substance abuse treatment: comments, concerns and criticisms, in Drug Abuse Treatment Through Collaboration: Practice and Research Partnerships That Work. Edited by Sorenson J, Rawson R. Washington, DC, American Psychological Association, 2002, pp 58–63
McLellan AT, Meyers K: Contemporary addiction treatment: a review of systems problems in the treatment of adults and adolescents with substance use disorders. Biol Psychiatry 28:345–361, 2004
McLellan AT, Weisner C: Achieving the public health potential of substance abuse treatment: implications for patient referral, treatment "matching" and outcome evaluation, in Drug Policy and Human Nature. Edited by Bickel W, DeGrandpre R. New York, Plenum, 1996, pp 247–261
McLellan AT, Woody GE, Luborsky L, et al: Is the counselor an "active ingredient" in substance abuse rehabilitation? J Nerv Ment Dis 176:423–430, 1988
McLellan AT, Arndt IO, Woody GE, et al: The effects of psychosocial services in substance abuse treatment. JAMA 269:1953–1959, 1993
McLellan AT, Grissom GR, Zanis D, et al: Problem-service "matching" in addiction treatment: a prospective study in 4 programs. Arch Gen Psychiatry 54:730–735, 1997
McLellan AT, Hagan TA, Meyers K, et al: Supplemental social services improve outcomes in public addiction treatment. Addiction 93:1489–1499, 1998
McLellan AT, O'Brien CP, Lewis DL, et al: Drug addiction as a chronic medical illness: implications for treatment, insurance and evaluation. JAMA 284:1689–1695, 2000
McLellan AT, Carise D, Kleber HD: The national addiction treatment infrastructure: can it support the public's demand for quality care? J Subst Abuse Treat 25:117–121, 2003
McLellan AT, McKay JR, Forman R, et al: Reconsidering the evaluation of addiction treatment: from retrospective follow-up to concurrent recovery monitoring. Addiction 100:447–458, 2005
Meyers R, Apodaca TR, Flicker S, et al: Evidence-based approaches for the treatment of substance abusers by involving family members. The Family Journal 10:281–288, 2002
Milby JB, Schumacher JE, Raczynski JM, et al: Sufficient conditions for effective treatment of substance abusing homeless persons. Drug Alcohol Depend 43:39–47, 1996
Moos RH: Addictive disorders in context: principles and puzzles of effective treatment and recovery. Psychol Addict Behav 17:3–12, 2003
Morgenstern J, Longabaugh R: Cognitive-behavioral treatment for alcohol dependence: a review of evidence for its hypothesized mechanisms of action. Addiction 95:1475–1490, 2000
Morgenstern J, Blanchard, KA, Morgan TJ, et al: Testing the effectiveness of cognitive-behavioral treatment for substance abuse in a community setting: within treatment and post-treatment findings. J Consult Clin Psychol 69:1007–1017, 2001a
Morgenstern J, Labouvie E, McCrady B, et al: Affiliation with Alcoholics Anonymous following treatment: a study of its therapeutic effects and mechanisms of action. J Consult Clin Psychol 167:85–92, 2001b
Moyer A, Finney JW, Swearingen CE, et al: Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 97:279–292, 2002
Musto DF: The American Disease: The Origins of Narcotic Control. New Haven, CT, Yale University Press, 1973
National Institute on Drug Abuse: A cognitive-behavioral approach: treating cocaine addiction, in Therapy Manual for Drug Addiction: Manual 1 (NIH Publ No 98–4308). Washington, DC, U.S. Government Printing Office, 1998
Nowinski J, Baker S, Carroll K: The twelve-step facilitation manual: a clinical research guide for therapists treating individuals with alcohol abuse and dependence (DHHS Publ No 94-3722). Rockville, MD, National Institute on Alcohol Abuse and Alcoholism, 1994
O'Brien CP: Anti-craving medications for relapse prevention: a possible new class of psychoactive medications. Am J Psychiatry 162:1423–1431, 2005
O'Brien CP, McKay JR: Psychopharmacological treatments of substance use disorders, in Effective Treatments for DSM-IV Disorders, 2nd Edition. Edited by Nathan PE, Gorman JM. New York, Oxford University Press, 2002, pp 125–156
O'Brien CP, McLellan AT: Myths about the treatment of addiction. Lancet 347:237–240, 1996
O'Farrell T, Fals-Stewart W: Behavioral couples and family therapy for substance abusers. Curr Psychiatry Rep 4:371–376, 2002
O'Farrell T, Fals-Stewart W: Alcohol abuse. J Marital Fam Ther 29:121–146, 2003
O'Malley SS, Jaffe AJ, Change G, et al: Six-month follow-up of naltrexone and psychotherapy for alcohol dependence. Arch Gen Psychiatry 53:217–224, 1996
Ouimette PC, Finney JW, Moos R: Twelve step and cognitive behavioral treatment for substance abuse: a comparison of treatment effectiveness. J Consult Clin Psychol 65:230–240, 1997
Petry NM: A comprehensive guide to the application of contingency management procedures in clinical settings. Drug Alcohol Depend 58:9–26, 2000
Prendergast M, Podus P, McCormack K: Bibliography of literature reviews on drug treatment effectiveness. J Subst Abuse Treat 15:267–270, 1998
Project MATCH Research Group: Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH posttreatment drinking outcomes. J Stud Alcohol 58:7–29, 1997
Rounsaville BJ, Carroll KM, Onken L: A stage model of behavioral therapies research: getting started and moving on from stage I. Clin Psychol Sci Pract 8:133–142, 2001
Saitz R, Horton N, Larson MJ, et al: Primary medical care and reductions in addiction severity: a prospective cohort study. Addiction 100:70–78, 2005
Silverman K, Higgins ST, Brooner RK, et al: Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Arch Gen Psychiatry 53:409–415, 1996
Silverman K, Wong CJ, Umbricht-Schneiter A, et al: Broad beneficial effects of reinforcement of cocaine abstinence in methadone patients. J Consult Clin Psychol 66:811–824, 1998
Simpson DD: A conceptual framework for drug treatment process and outcomes. J Subst Abuse Treat 27:99–121, 2004
Simpson DD, Joe GW, Fletcher BW, et al: A national evaluation of treatment outcomes for cocaine dependence. Arch Gen Psychiatry 56:507–514, 1999
Smith J, Meyers R, Miller W: The community reinforcement approach to the treatment of substance use disorders. Am J Addict 10(suppl):51–59, 2001
Stout RL, Rubin A, Zwick W, et al: Optimizing the cost effectiveness of alcohol treatment: a rationale for extended case monitoring. Addict Behav 24:17–35, 1999
Substance Abuse and Mental Health Services Administration (SAMHSA): Uniform Facility Data Set (UFDS): data for 1996 and 1980–1996 (DHHS Publ No SMA-98-3176). Washington, DC, U.S. Government Printing Office, 1997
Substance Abuse and Mental Health Services Administration (SAMHSA): National Survey of Substance Abuse Treatment (NSSAT): data for 2000 and 2001 (DHHS Publ No SMA-98-3176). Washington, DC, U.S. Government Printing Office, 2002
Thevos A, Thomas S, Randall C: Social support in alcohol dependence and social phobia: treatment comparison. Res Soc Work Pract 11:458–472, 2001
Tonigan JS, Connors GJ, Miller WR: Participation and involvement in Alcoholics Anonymous, in Treatment Matching in Alcoholism. Edited by Babor T, DelBoca F. New York, Hollis Press, 2000, pp 14–31
Vocci FJ, Elkashef A: Pharmacotherapy and other treatments for cocaine abuse and dependence. Curr Opin Psychiatry 18:265–270, 2005
Volkow ND, Hitzemann R, Wang GJ, et al: Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184–190, 1992
Wagner E, Austin BT, Von Korff M: Organizing care for patients with chronic illness. Milbank Q 74:511–544, 1996
Weisner CM, Mertens J, Parthasarathy S, et al: Integrating primary medical care with addiction treatment: a randomized controlled trial. JAMA 286:1715–1723, 2001
Wesson DR: Pharmacotherapy of addictive disorders, in SAMHSA Treatment Improvement Protocol 24 (DHHS Publ No SMA 06–1221). Rockville, MD, Substance Abuse and Mental Health Services Administration, 2006, pp 162–179
White W: Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, IL, Chestnut Health Systems, 1998
White W: Transformational change: a historical review. J Clin Psychol 60:461–470, 2004
Winters J, Fals-Stewart W, O'Farrell TJ, et al: Behavioral couples therapy for female substance-abusing patients: effects on substance use and relationship adjustment. J Consult Clin Psychol 70:344–355, 2002
Woody GE: Research findings on psychotherapy of addictive disorders. Am J Addict 12 (suppl 2):S19–S26, 2003
Woody GE, McLellan AT, Luborsky L, et al: Psychotherapy and counseling for methadone-maintained opiate addicts: results of research studies. NIDA Res Monogr 104:9–23, 1990
Zarkin GA, Dunlap LJ, Hicks KA, et al: Benefits and costs of methadone treatment: results from a lifetime simulation model. Health Econ 14:1133–1150, 2005
Zweben A, Zuckoff A: Motivational interviewing and treatment adherence, in Motivational Interviewing: Preparing People for Change, 2nd Edition. Edited by Miller RW, Rollnick S. New York, Guilford, 2002, pp 12–26

CME Activity

Add a subscription to complete this activity and earn CME credit.
Sample questions:
An initial stage in the clinical treatment of substance dependence is often the medical management of withdrawal states, which may be associated with a period of autonomic instability. For which of the following substances is the dependence illness not associated with a "true" physiological withdrawal state?
Following the initial detoxification and stabilization of substance-dependent patients, the clinician proceeds to a rehabilitation treatment model. Rehabilitation models may have different lengths of treatment. Among the following rehabilitation models, which one may be associated with an indefinite time period?
Adjunctive use of medications may be a critical part of the comprehensive care of the opioid-dependent patient. Which of the following statements about these medications is false?
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Related Content
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 22.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 13.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 14.  >
The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th Edition > Chapter 9.  >
The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th Edition > Chapter 19.  >
Topic Collections
Psychiatric News
PubMed Articles
  • Print
  • PDF
  • E-mail
  • Chapter Alerts
  • Get Citation