The demand on substance abuse treatment programs to respond to the multiple presenting problems of incoming clients is neither new or likely to diminish over time. Nor is that demand likely to vary greatly in association with the availability of resources. Indeed, there is every indication that treatment providers themselves feel it their responsibility to attend, to the extent it is feasible, to the range of client problems they confront. In that context it is important to take note of findings from several studies that individuals manifesting low to moderate levels of mental disorder in association with substance abuse appear to respond positively in terms of both drug use and psychiatric symptoms to the non-specialized treatment provided in drug abuse programs. However, those same studies also point to the importance of specialized treatment specifically responsive to the needs and functioning of those showing moderate to severe levels of mental disorder. That is, in the interest of expending limited resources wisely, it is important for substance abuse treatment programs to have the capacity to identify for specialized treatment those COD clients whose disorder is of a severity and type that justifies the use of those resources. The dearth of human resources appropriate to specialized care within substance abuse treatment is evident from several studies and is a cause for concern. In that context it is noteworthy that the mental health and substance abuse treatment systems have been found to serve clients manifesting different levels of mental disorder severity, and with differing profiles of co-occurring disorder. It seems unlikely to be happenstance. Rather, one can posit that the individual and/or the system effects a partial solution to demands that would otherwise overtax the capability of each system. Nonetheless, it remains our responsibility to develop and test treatment strategies appropriate to the needs of clients – and to the real capabilities of the treatment systems serving those clients. As the papers in this special issue demonstrate, that challenge has been embraced by many of our colleagues.
An additional treatment concern is associated with the changing conceptualization of drug abuse and its particular significance for the client showing evidence of co-occurring disorder. The drug abuser is widely characterized as continuously at risk for relapse. Several studies suggest that where drug abuse is complicated by mental disorder, the long-term prognosis is even more bleak. Nonetheless, treatment programming continues to be episodic at best rather than recovery-based as the changed conceptualization of the drug user would suggest. In short, a next challenge would appear to be the development and testing of strategies of long-term monitoring and support consistent with a view of the exited client as being at continuing risk for relapse to substance use and/or psychiatric disorder. While recognizing the obvious complexity of moving from a treatment objective of cure through an emphasis on acute care to a treatment objective of recovery through an emphasis on long-term monitoring and support, that transition is both consistent with the changed conception of the drug abuse client and would seem critical to the increased effectiveness of treatment efforts with clients evidencing co-occurring disorder.