Community Clinics

Introduction

The first section of this chapter traces the history of community clinic treatment for substance use disorders. Next, the chapter reviews various venues for community treatment and the effectiveness of approaches used where this is known. The definition of substance use disorders has been taken from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). There, “substance-related and addictive disorders” is defined and diagnostic criteria provided with the following specifiers: in early or sustained remission; in a controlled environment; and/or with perceptual disturbances. The disorders discussed in this chapter refer to substance-related and addictive disorders as described in the DSM-5. Where reviewed publications do not use these definitions, other terms used by the primary source are reported.

Although alcohol and nicotine abuse and dependence are listed in the DSM-5, coverage of community treatment is limited to exclude community interventions for these disorders. Community clinic is defined as an intervention that occurs in nonhospital settings and is affiliated with individual health practitioners, or community organizations.

Literature Review Methods

Several forms of literature search software were used to conduct this review. The primary sources have been PubMed and PsycINFO also included Google Scholar as a backup supplement. Key words used were: community clinic treatment for drug dependence (abuse, addiction, substance use disorder); community treatment for drug dependence (abuse, addiction, and so on); history of community clinic treatment for drug dependence (abuse, addiction, and so on); history of community treatment for drug dependence (abuse, addiction, and so on); substance-related disorders, psychotherapy, group, community health services, and adult. In addition, where particular authors or groups of authors have published widely, sources were searched by author names. Thus by definition other forms of addictive phenomena such as alcohol dependence, gambling, compulsive eating, sexual behavior, and other behaviors sharing similarities with the DSM-5-defined substance use disorders were excluded.

History of Community Substance Abuse Treatment

There is no obvious historical marker for when group treatment or community clinic treatment for substance use disorders began. It is likely that the first community treatment for substance use disorders in America originated in pharmacies when opium and laudanum were sold over the counter in community pharmacies. These drugs were widely available in the 1800s and much earlier before that in China, Great Britain, and other countries involved in trade with Asian sources of opium. Historical sources document extensive morphine dependence as both a result of the US Civil War treatment of wounded soldiers and sales of over-the-counter potions and tonics laced with opium and cocaine. The residual addiction among Civil War veterans was called “army disease,” and was treated extensively by physicians and community pharmacists with morphine or laudanum maintenance (our term), before the scientific discovery of the cause of addiction. Likewise, dependence upon cocaine-laced tonics and potions was treated by community pharmacists in the same way by making maintenance or restorative doses of “Mrs. Winslow’s Soothing Syrup,” “Godfrey’s Cordial,” and other available over-the-counter tonics for those having the as-yet-to-be-identified withdrawal syndrome, and the modest fees to purchase them. Godfrey’s Cordial was a mixture of opium sweetened by molasses and flavored with sassafras. It appears that these early community treatments were individual ones rather than group interventions.

When the Harrison Act was passed in 1914, it required registration with the Internal Revenue Service by those involved in any phase of the opium or coca industry, and careful record keeping. The US government made an effort to establish some 40 community clinics to treat individuals who were addicted to morphine, and other opioids, and for whom the new law restricted and cut off their supply. However, these clinics became the source of much controversy and were soon abandoned when the Internal Revenue Service declared them illegal and forced their closing. Persons still addicted faced the challenge of obtaining illegal supplies and risked arrest and incarceration for their opioid addiction. Some physicians continued to treat opioid addiction with prescription opioids, including morphine, even after the Harrison Act. However, in 1919 the Supreme Court ruled physicians could no longer prescribe narcotics for the purpose of treating addiction. By making this community-based treatment illegal, the ruling curtailed this humane medical practice, driving addicted individuals to sources of illegal drugs, to immediate withdrawal, or attempts at detoxification.

The period between the Harrison Act in 1914 and 1935 marked a period where there were strong cultural beliefs and community emphasis on legal and moral sanctions against all narcotic addiction. This social context, including court rulings and Internal Revenue Service actions, proscribed a more humanitarian approach to addiction. Thus during this period there appears to be little, if any, available community clinic or group intervention for substance abuse disorders. However, 1935 marked a significant change in the US government’s approach to addictive disorders.

A New Era Begins

In 1935 the US Public Health Service opened large institutions to treat narcotic addiction, first in Lexington, Kentucky, and 3 years later in Fort Worth, Texas. These programs were large federal facilities drawing clients from across the United States, mostly incarcerated addicts convicted of crimes. Although not community clinics, these institutions marked a new and growing attitude toward addictive disorders. These facilities set a precedent for subsequent development of local community clinics, group treatment, and other resources to treat addicted persons. The opening of these two federal treatment facilities that used a civil commitment approach to treat addiction was the beginning of a new era. Addiction became increasingly accepted by society as a disorder in need of special intervention, including medical intervention by community physicians and nonmedical individual and group intervention in various community agencies and programs. These were added to, but did not replace, the predominant community model and legal-based sanctions. Thus more-humane intervention for addictive disorders slowly developed and was accepted, if not widely supported, in subsequent years. Noteworthy is that research conducted at Lexington and Fort Worth greatly established a scientific understanding of the pharmacology and psychopharmacology of addiction, and many scientific behavioral principles that support and maintain addictive behavior, such as the function of drugs as behavioral reinforcers. These facilities also provided a platform for psychosocial assessment, individual and group treatment intervention and follow-up, and epidemiological methods that gradually spread to American urban areas where addictive disorders were prevalent.

Impact of the Community Mental Health Movement

In response to federal court rulings, the community mental health movement spread across the country during the 1960s, providing outpatient treatment for mental disorders. Many clinics developed group interventions for substance abuse and dependence. Most of these embedded substance use disorder clinics focused on alcohol dependence, which was the most prevalent disorder. However, forms of drug dependence were treated in community clinics, most using the Alcoholics Anonymous model prevalent at the time. In addition, during this period, religiously affiliated clinics developed to provide spiritually guided individual and group intervention for substance use disorders. Several of these are described in Milby, but rarely, if ever, did reports of their work or evaluations of their effectiveness reach the professional health and addiction literature.

The Alcoholics Anonymous model can be conceptualized as a spiritually guided intervention that uses a manual. The manual, called the “Big Book,” describes 12 steps guiding recovery from alcoholism. The recovery process is guided for each individual by a recovering sober sponsor. A key component of this intervention was the use of ubiquitous Alcoholics Anonymous community groups. As the Alcoholics Anonymous movement grew, the model provided widespread community intervention for alcoholism and gradually came to accept persons with other substance use disorders into their network of community Alcoholics Anonymous groups. Increased acceptance of individuals with substance use disorders was aided by the fact that most substance abusers also abused or were dependent on alcohol. The expansion of Alcoholics Anonymous peer-led community group meetings to Narcotics Anonymous helped gather and focus those with substance use disorders to participate in aftercare and continued rehabilitation and recovery efforts. Many persons entered these community-based groups after formal medical or psychosocial-based community treatment. However, despite the fact that Alcoholics Anonymous was one of the most widely utilized community interventions to treat substance use disorders, it was rarely scientifically evaluated. Only over the last 20 years have the Alcoholics Anonymous interventions been scrutinized with rigorous scientific methodology to study its efficacy and effectiveness. A problem for individuals with co-occurring mental disorders and alcohol/drug dependence who utilized the Alcoholics Anonymous model treatment, especially peer-run aftercare groups, was the cultural bias against using a medication to treat a co-occurring disorder. Individuals with dual diagnoses sometimes found a lack of peer support for their medication treatment.

As community group interventions expanded, two predominant models emerged across American communities. One was the Alcoholics Anonymous movement, which focused initially on alcohol treatment and was especially influential as an aftercare intervention for the other, a medical model intervention. The medical model conceptualized addiction as a drug-induced disorder or disease maintained by an artificially induced biological drive from chronic addictive drug use. Intervention required inpatient hospitalization for detoxification and restoration of abstinence and normalizing of natural biological drives devoid of addiction side effects and biological disruptions. Various psychosocial models were usually added to this medical approach, especially group rehabilitation and recovery procedures to support a drug-free lifestyle. As medical detoxification was studied, outcomes defined as return to abstinence after medical detoxification were considered successful, especially for inpatient detoxification. But outcomes defined as sustained abstinence at follow-ups were recognized as a dismal failure. ^a

a References 13, 30, 32, 38, 43, 44, 52, 53, 75, 85.

Such accumulating evidence provided the impetus for greater emphasis on developing psychosocial intervention to support behavioral lifestyle change, both during medical treatment but especially following hospitalization and in outpatient clinic group intervention and aftercare.

Community mental health interventions for substance abuse disorders and co-occurring mental and substance use disorders predominantly used a rehabilitation model for intervention, as distinguished from pharmacological and other somatic interventions. Initial efforts to treat co-occurring disorders involved separate clinicians working for separate treatment agencies. These initial efforts met with failure, mainly due to problems in coordinating care and accessing needed services.

The development of second-generation neuroleptic medication for serious mental illness was concurrent with refinement of psychosocial treatments, including group interventions, which, within community mental health clinics, served as a floor intervention. These emphasized development of a trusting relationship to help clients cope with a chronic mental illness. Within this relationship, clinician and client establish goals to maximize self-control over symptoms and minimize interference from the illness. This intervention is collaborative, utilizing psychosocial education, especially about the illness, and cognitive behavioral therapy. The intervention often involves peer groups to supplement individual counseling, psychotherapy, and medication monitoring. The recent decade has seen increasing emphases on involving families and use of evidence-based family interventions, and psychoeducation. Drake and colleagues have contended that since the 1990s psychiatric rehabilitation became the dominant method employed in most community mental health clinics.

In the 1990s, specific approaches for treating co-occurring mental and substance use disorders began to be developed and tested. However, as Drake et al. noted, although controlled research has provided support for effectiveness of these integrated approaches, they are yet to be widely adopted in community clinics.

Effectiveness of Community Clinic Approaches 1935–1980

Community methadone maintenance treatment was initiated in New York City by Vincent Dole in 1965. Based on a disease model of addiction, methadone, as a long-acting synthetic opiate, is given orally to opioid-addicted individuals as a treatment medication. It both alleviates withdrawal symptoms and blocks the effects of illicit opioid use. Methadone is a federally regulated, commercially pure medication, devoid of often dangerous adulterants (drug cutting/mixing agents), and administered in once daily doses in a medically supervised clinic. After initial assessment, many clients are administered take-home doses, which require less than daily attendance. As originally developed, psychosocial counseling and access to other community rehabilitation services provided additional therapeutic leverage for a changed lifestyle and sustained abstinence. The outcome studies of Dole and colleagues showed excellent treatment success as measured by the ability of addicts to reduce criminal activity, obtain or return to jobs or training programs, and otherwise make lifestyle changes to support abstinence. The success of this early work soon led to a proliferation of methadone maintenance treatment across the nation and was supported by government grants to establish and maintain them with community matching funds. Although not as successful as original efforts by Dole and Nyswander, subsequent research from other communities generally found successful outcomes defined as treatment retention, reduced illicit drug use, criminal activity, and increased employment and other measured lifestyle changes. However, when outcomes were considered as successful detoxification from methadone and sustained abstinence at follow-up, results were much less impressive. Detoxification success was complicated by the discovery of a detoxification phobia, which hampered about 20%–30% of addicts in methadone maintenance from even attempting detoxification despite their goal to eventually do so. Although it seems likely that some group psychosocial intervention was utilized in community methadone maintenance during this era, its use was not described in the studies cited here.

Much of the treatments predominantly oriented toward opioid dependence and most other polydrug abuse and dependence disorders were not treated in methadone maintenance programs. Rather, they were treated by other interventions. Many of these are reviewed later. Hospital-based inpatient treatment usually utilized medical procedures for detoxification, but these were embedded within a floor psychosocial recovery and rehabilitation intervention. When they first evolved, hospital stays of 1–2 months were common. However, these long stays succumbed to economic pressures from health insurance companies and gradually evolved to 28-day interventions.

Therapeutic community intervention usually involved the longest stays in a controlled access institutional environment, of up to 6 months or more, and many utilized psychosocial intervention conceptualized as community as the treatment intervention. The community-as-intervention utilized peer group review and confrontation for antisocial and other nonadaptive behaviors that the community evaluated as nonadaptive for a drug-free lifestyle. These were usually staffed by few professional health personnel and relied heavily on recovering persons as peer mentors and group leaders. Finally, by far the widest used community intervention was drug-free clinics, where a variety of psychosocial and religious-spiritual intervention models were employed. Up until 1981 there was little scientifically sound clinical research on the effectiveness of any of these approaches (see Milby ; Chapter 10, Chapter 9 for a review of these). Where outcome data were published, because of flawed research methods, occasional reported successful outcomes were interpreted with much skepticism.

Community Responses to the 1980s Cocaine Epidemic

During the 1980s, cocaine abuse and dependence increased dramatically in the United States with the availability of less-expensive free base crack cocaine crystals, which could be smoked instead of snorted or injected. This caused a great influx of clients to existing substance abuse community treatment programs at a time where there was no scientifically based effective treatment (medication or psychosocial intervention) available. University and community clinics treated this influx of new clients with their usual care, namely through medical or Alcoholics Anonymous models. However, the few studies that assessed clinical outcomes showed very disappointing results of high treatment dropouts and high relapse rates after treatment established abstinence.

In response to this frustrating failure to provide a scientifically supported effective treatment for cocaine dependence, several empirically supported innovative interventions emerged in the 1990s. Two effective outpatient interventions emerged from university clinics and utilized either a group treatment model or a more individualized contingency management behavior therapy program. Soon after that, Milby and colleagues described a sufficiently effective community-based intervention for cocaine-dependent homeless persons that utilized contingency-managed access to abstinence-contingent housing and paid work/training along with a group-based behavioral day treatment. This effective community intervention has been improved and systemically replicated in three subsequent randomized trials and found to be cost-effective. However, to date there have been few efforts to transfer and systematically replicate this evidence-based intervention in other communities. In addition, during this period, other researchers developed community-based, empirically supported, effective group psychosocial interventions for cocaine dependence.

Since initial studies by Higgins et al. and Carroll et al., there has been steady development of effective psychotherapeutic interventions for cocaine dependence from randomized controlled trials employing both different study populations and interventions. ^b

b References 10, 16, 27, 48, 56, 63, 68.

All of these, except perhaps Higgins et al. (who utilized an individual-focused intervention), utilized group interventions, which included psychoeducational group psychotherapeutic approaches, sometimes including couple or family interventions. It is important to note that some of these recent studies have shown sustained abstinence at follow-up after initial treatment. This increased availability of research-based efficacious psychosocial interventions for cocaine dependence has led Carroll to argue persuasively that manual-guided psychosocial treatment should be used as a therapeutic platform to evaluate the efficacy of new pharmacotherapies.

Categories of Community Clinics

Rodgers and Barnett examined types of community treatment programs and defined two main types: public and privately funded programs. These were further divided into four main types: public nonfederal programs (i.e., state-run or local programs), public federal programs, private nonprofit programs, and private for-profit programs. Data were derived from the 1991 National Drug and Alcoholism Treatment Unit Survey, and included a final total of 8865 programs. Some of these programs were inpatient hospital facilities, which are outside the scope of this chapter, but this study provides an introduction to different categories of substance abuse programs, as well as information about the differences among them. Overall, the largest number of programs were private nonprofit, followed by private for-profit, public nonfederal, and public federal programs. Thus the majority of programs were private programs comprising approximately 82.7% of the sample.

A key issue examined in comparisons among categories was staffing. Rodgers and Barnett found that public nonfederal programs had the highest number of staff, followed by private nonprofit and private for-profit programs. Although public federal programs had the fewest number of staff, they were the most likely to employ doctoral level staff, followed closely by private for-profit programs. When examining the size of residential programs, federal programs were the largest, and private for-profit programs were the smallest. Public drug-free outpatient programs were also larger than the private drug-free outpatient programs. For-profit programs were the smallest. For methadone maintenance programs, private for-profit programs were the largest, with the rest of the categories lagging far behind.

The study of Rodgers and Barnett also provided information on specific services offered by the different categories of substance abuse programs. Both public federal programs and private for-profit programs were most likely to offer aftercare and follow-up. Public federal programs were the most likely to offer medical care. All programs were equally likely to offer individual therapy; private nonprofit programs were slightly more likely than for-profit programs to offer group therapy, and private programs were more likely to offer family therapy. Their survey of services for special populations (discussed in more detail later), showed that public nonfederal programs were more likely to offer special services for pregnant individuals and youth. Private for-profit programs were more likely to offer services specialized for cocaine users.

There were also differences in funding sources for the categories of substance abuse treatment. Both private nonprofit and public nonfederal programs were more likely to receive Medicaid funding, although private for-profit programs that did receive Medicaid funding received more money than did public nonfederal programs. In addition, private for-profit programs were more likely to receive funding from both private insurance and client fees, and they also received the most from these funding sources, followed by nonprofit programs. Public federal programs received the least funding from these sources.

Overall, Rodgers and Barnett found that private for-profit programs were smaller (with the exception of methadone maintenance programs), more specialized, and had less staff, but had staff with a higher level of training. These programs were also more likely to receive funding from private insurance and client fees, as opposed to Medicaid.

Types of Community Clinics