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Background briefing | Professor David Clark
What the science shows, and what we should do about it (Part 5)
Professor David Clark completes the main recommendations from a major new book based on the
views of America’s leading clinicians and researchers of how treatment would look like if it were
based on the best science possible. Professor David Clark completes the main recommendations
from a major new book based on the views of America’s leading clinicians and researchers of how
treatment would look like if it were based on the best science possible.

On the basis of discussions at a ‘think-tank’
address the client’s own goals, needs, priorities, and conference, leading US addiction experts proposed a
values. Offer a menu of alternative services and goals set of ten recommendations for ‘designing programs,
from which people can choose what best meets their systems, and social policy to reduce drug and
needs and preferences. Express clearly that there is no associated suffering, societal harms and costs’. We
one effective approach for all affected individuals and look at the last four of these recommendations.
make a commitment to keep working with the personuntil you find what works and his or her goals are Recommendation 7: Enhance positive reinforcement
met. An unsuccessful outcome is a failure of for non-use and enrich alternative sources of positive treatment, not the person, and warrants trying a Stopping the use of substances removes one source of reinforcement. If the person giving up Recommendation 10: Use evidence-based
substances does not have alternative sources of positive reinforcement, they are likely to start using or There are large differences in outcomes depending ‘An unsuccessful outcome
drinking again. It is important to organise treatment on the services provided. Some forms of treatment efforts around helping people to develop meaningful is a failure of treatment,
are ineffective or harmful. Treatment services should concentrate on those approaches with the best not the person, and
People with substance use problems are often cut evidence of efficacy. ‘It is long overdue for science, off from alternative sources of reinforcement. A warrants trying a
rather than opinion and ideology, to shape significant task for them is to establish or re-establish interventions for drug [substance use] problems.’ different approach.’
contact with social networks that favour abstinence, Learning a new treatment approach involves more and to sample and gain access to sources of non-drug than reading a book or attending a workshop. It requires training involving supervision and coaching, substance use, and most of the time can engage an as well as support from administrative officials and responsibilities can be important sources of initially unmotivated loved one in treatment.
funding sources. Learning a new complex skill rarely reinforcement that are incompatible with substance Conditions that protect people from the natural occurs without feedback on actual practice, but this negative consequences of their own substance use can rarely happens in the treatment system.
spiritual/religious organisations, or involvement in 12- Attention should be given in hiring to the qualities of the practitioner (eg accurate empathy) that are ‘In essence, the goal is to develop a rewarding Recommendation 9: Make services easily accessible,
associated with better outcomes. ‘One of the largest drug-free life that competes successfully with the affordable, welcoming, helpful, potent, rapid, and determinants of how clients will fare in treatment is allure of positive and negative reinforcement that the clinician to whom they are entrusted.’ ‘Common obstacles include waiting lists, stigma, It is important to have ‘a system that monitors the geographic inaccessibility, cost, restricted hours, and ongoing outcome of treatment services, providing Recommendation 8: Diminish the rewarding aspects
limited program goals that do not match the timely, accurate, and reliable feedback to treatment individual’s priorities. All of these obstacles can be providers, managers, and funding sources as well as Pharmacotherapies represent one effective means addressed in redesigning service systems.’ to affected individuals and their families’. of doing this. Various medications (eg methadone, Intake systems should be welcoming and attractive.
The experts do not recommend reducing practice A professional should be seen from the outset, and into a list of ‘approved’ evidence-based treatments, pharmacological incentives for taking drugs by questions in the initial consultation should be kept to a since this would stifle creativity and limit services to blocking, replacing, or offsetting drug effects. A minimum. ‘Half an hour of listening, letting people tell the practices of the past. ‘While interventions with a principal problem in their therapeutic use has been their story and express their concerns and goals, is a good evidence base are a good starting point, a medication compliance. Drug use is also responsive to good start before asking questions and completing the creative system will also encourage innovation to forms needed for administrative purposes.’ accomplish specified goals and to monitor outcomes In treating an individual, it is important to Programs and practitioners are there to meet the to know which practices do, in fact, promote the consider what reinforcement the person is receiving needs of the client, not vice versa. Drop-out in early for drug use, beyond the pharmacological incentives stages of treatment often occurs because the person sees a mismatch between what is on offer and their Rethinking Substance Abuse: What the science shows, With proper support and coaching, families can and what we should do about it, edited by William R. learn to reinforce behaviour incompatible with ‘Services should take into account, respect, and Miller and Kathleen M. Carroll, Guilford Press, 2006
18 June 2007 | drinkanddrugsnews | 15


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Notes from the gastro tube video

A. CLEANING THE SITE: It might be red and tender and may have dry, yellow crust. IMPORTANT—Keep tension off the site and tape the catheter to the abdomen. THREE STEPS TO CLEAN—1. Wash hands. 2. Prepare mixture of half water and half hydrogen peroxide. 3. Use solution to clean around the site With a Q-tip (gently loosen crust or drainage) and then dry gently. Will see normal

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