Spending on addiction treatment now tops $20 billion annually and could grow with the passage of the federal parity law, but more funders are pressing treatment programs to move beyond shaky claims of success and prove that they work.

The New York Times reported Dec. 23 that few treatment programs have evidence to prove their effectiveness: private programs generally don't allow outside evaluation, while publicly funded programs spend their money on providing services, not conducting studies.

Moreover, the addiction treatment field lacks standard measures of success.

"What we have in this country is a washing-machine model of addiction treatment," said A. Thomas McClellan, CEO of the Treatment Research Institute. "You go to Shady Acres for 30 days, or to some clinic for 60 visits or 60 doses, whatever it is. And then you're discharged and everyone's crying and hugging and feeling proud --  and you're supposed to be cured ... It doesn't really matter if you're a movie star going to some resort by the sea or a homeless person. The system doesn't work well for what for many people is a chronic, recurring problem."

However, states like Oregon, Delaware, and North Carolina are beginning to demand that grantees use evidence-based practices and increase accountability. A 2003 Oregon law, for example, sought to increase use of interventions like naltrexone for alcohol dependence, buprenorphine for opiate addiction, motivational interviewing for incoming treatment patients, and cognitive behavior therapy.

More than half of Oregon's treatment budget now goes to programs that use evidence-based practices. "Before the mandate, most programs had some evidence-based practices, and since then there has been a lot more interest and awareness of them," said researcher Traci Rieckmann of Oregon Health and Science University.

However, Rieckmann said that some programs that claim to use evidence-based treatment may not be doing so, or implementing programs correctly. Many smaller programs, for example, don't have an M.D. on staff, so they can't prescribe medications like naltrexone. True reform will only come when patients are tracked throughout the treatment process to ensure that goals -- clearly defined beforehand -- are met, experts said.

The Oregon experience also has resulted in a culture clash between researchers and other backers of standardized interventions and counselors used to doing things their own way. Some experts say that there needs to be a place for "practice-based evidence" as the treatment system is reformed.

"I'm a counselor, and I'd be defensive, too: 'What do you mean, all this stuff I've been doing my entire life is wrong?' " said Brian Serna, director of outpatient services at the Adapt treatment program. "So the challenge is to build a bridge between what the science says is effective and what people are already doing."