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National Drug Control Strategy
Update 2003

February 2003
  1. Healing America’s Drug Users: Getting Treatment Resources Where They Are Needed

Budget Highlights

  • Substance Abuse and Mental Health Services Administration (SAMHSA)— President’s Treatment Initiative: +$600 million over three years. The President has committed to add $1.6 billion to the drug treatment system over five years. As part of this effort, the fiscal year 2004 Budget includes new funding of $200 million in indirect aid for substance abuse treatment and other supportive services. People in need of treatment, no matter where they are—emergency rooms, health clinics, the criminal justice system, schools, or the faith community— will receive an evidence-based assessment of their treatment need and will be issued vouchers for the cost of providing that treatment.

  • Office of Justice Programs—Drug Courts Program: $68 million. The Administration proposes an increase in the Drug Courts program of $16 million above the fiscal year 2003 requested level. This enhancement will expand the number of drug courts; increase retention in, and successful completion of, drug court programs by expanding the scope and improving the quality of drug court services; and generate drug court program outcome data. Successful drug courts provide alternatives to incarceration by using the coercive power of the court to force abstinence and alter behavior with a combination of escalating sanctions, mandatory drug testing, treatment, and strong aftercare programs.

  • National Institute on Drug Abuse (NIDA): +$35.6 million. This proposed increase would enable NIDA to fund ongoing commitments, undertake research collaborations with other National Institutes of Health organizations, and embark on new initiatives to advance treatment and prevention. NIDA projects that are instrumental in helping to meet the drug use reduction goals outlined by the President include the National Prevention Research Initiative, National Drug Abuse Treatment Clinical Trials Network, and Research-Based Treatment Approaches for Drug Abusing Criminal Offenders.

In 1854, Dr. John Snow revolutionized the field of public health when he discovered how a plague of cholera was spreading through London. In one neighborhood, the number of deaths reached more than 500 in ten days. Snow mapped the cases and found they radiated out from the Broad Street pump, where infected people had drawn their water. Snow had the pump handle removed. The epidemic ceased.

Medicine was transformed by Dr. Snow’s strategy, which was to block the vectors that spread contagion. The same logic can help us fight a modern epidemic—the spread of drug use and addiction.

Medical research has established a clear fact about drug use: once started, it can develop into a devastating disease of the brain, with consequences that are anything but enticing. No young person watching an addict stumbling on the street looks at the loss of human potential and decides to seek the same end.

And yet the disease spreads. It spreads because the vectors of contagion are not addicts in the streets but users who do not yet show the consequences of their drug habit. Last year, some 16 million Americans used an illegal drug on at least a monthly basis, while 6.1 million Americans were in need of treatment. The rest, still in the “honeymoon” phase of their drug-using careers, are “carriers” who transmit the disease to others who see only the surface of the fraud. Treatment practitioners report that new users in particular are prone to encouraging their peers to join them in their new behavior.

Applying Principles of Public Health

The public health model offers three key lessons for drug policy.

First, as discussed in the previous chapter, young people must be educated about the lie that drug use represents. Drug use promises one thing but delivers something else—something sad and debilitating for users, their families, and their communities. The deception can be masked for some time, and it is during this time that the habit is “carried” by users to other vulnerable young people.

A second, key lesson of the public health model applies to those still in the honeymoon phase. It is a lesson with important implications for the field of drug treatment, where a large and growing collection of providers have been hampered by an imperfect intake mechanism for directing individuals in need of help to the most appropriate form, or modality, of drug treatment. Simply put, for many users—including the large majority in the 18–25 age group—the optimal response to their drug use is not an extended stay at a treatment center but screening to determine if help is needed. This screening can be followed, if necessary, by a brief period of drug treatment.

The third lesson involves those whose use has progressed to the point where they need drug treatment but who are not actively seeking help, because even the best treatment program cannot help a drug user who does not seek its assistance. According to a survey by the Department of Health and Human Services, the overwhelming majority of drug users who need treatment fail to recognize it (see Figure 9), a fact that would not come as a surprise to those with a loved one who has battled drug dependency. Of the estimated five million individuals who needed but did not receive treatment in 2001, fewer than 8 percent felt they actually needed help.

The conventional wisdom about drug treatment— that the hardest to help are the down-and-out cases—turns out to be less than accurate, because the hardest cases are actually those who are never seen. The third lesson of the public health model thus involves the crucial need to get people into treatment—no small matter when dealing with an illness whose core characteristic is denial.

Closing this “denial gap” requires us as a Nation to create a climate in which Americans confront drug use honestly and directly, encouraging those in need to enter and remain in drug treatment. Compassionate coercion of this type begins with family, friends, and the community, including colleagues in the workplace. It also requires the support of institutions and the people who run them—law enforcement, faith communities, and health care providers, among others—to identify and direct individuals in need into drug treatment. And it requires the use of innovative techniques for fighting addiction, such as specialized pharmaceuticals. (The approval in October 2002 of buprenorphine, a drug used for fighting opiate dependence, marks the first narcotic drug available for the treatment of opiate dependence that can be prescribed in a doctor’s office.)

Figure 9: Most of Those in Need of Drug Treatment Did Not Seek It

Total in need of treatment = 6.1 million

Figure 9: Most of Those in Need of Drug Treatment Did Not Seek It. Total in need of treatment = 6.1 million  
Pie chart with 4 items. 
Item 1, Did not feel need for treatment 76%
Item 2, Received treatment 17%.
Item 3, Sought but did not get treatment 2%.
Item 4, Felt need but did not seek treatment 5%.

Source: National Household Survey on Drug Abuse (2001)

While most of those who are dependent on illegal drugs are in denial, the good news is that more than one million Americans receive treatment each year and have started down the road to recovery. They deserve our respect for having the courage to come forward and seek help. Unfortunately, it is estimated that as many as 101,000 of those who seek treatment each year are not able to receive it. They have an immediate need, and when that need goes unfilled, many revert to their old ways and may not seek help.

To address this critical need, this year we will launch a new program, funded with $600 million over three years, that will expand access to substance abuse treatment while encouraging accountability in the treatment system. For those without private treatment coverage, we will make sure that medical professionals in emergency rooms, health clinics, the criminal justice system, schools, and private practice will be able to evaluate their treatment need and at the same time issue a voucher good for the cost of providing that treatment. Treatment vouchers will be redeemable on a sliding scale that rewards the provider for treatment effectiveness. Services can range from interventions designed for young substance abusers before they progress deeper into dependency, to outpatient services, to intensive residential treatment. For the first time, we will provide a consumer-driven path to treatment.

Lifechange: Harnessing the Power of Faith

At the Union Gospel Mission in Portland, Oregon, homeless men and women can get food, clothing, and blankets. The people who walk through the doors of this faithbased center may also find an opportunity to change their lives for better through LifeChange—a drug treatment program with a difference.

LifeChange was founded in 1995 by Bill Russell, a former prosecutor, and has since graduated 62 people. Although drug treatment programs typically last 90 days, LifeChange’s much longer duration limits it to 32 people at any given time, although expansion to a total of 80 recovery beds is in the works. Close to one-third of those in the program were ordered to LifeChange by judges and parole officers.

Although members of LifeChange do not have direct access to money while in the program, they do earn a living of sorts, working full-time at the Union Gospel Mission thrift store, where two-thirds of the program’s budget is raised. Residents also help area homeless. A staff member puts it this way: “When you’re in the program, you’re supposed to give something back. You have to make up for all the bad things you did to your family and community when you were an addict.” In addition to the work they do, residents attend academic classes, go to Bible study, and tackle the issues that led to their life of addiction.

Residents gradually attain increasing levels of responsibility, in preparation for the world after LifeChange. Coupled with education, the program arms graduates with job skills, a GED, and, frequently, vocational training. Assistance and mentoring are provided as residents make the transition to full employment and independent living. LifeChange is a faithbased program that works.

The path to help will be direct, appropriate, and open on a non-discriminatory basis to all treatment programs that save lives, including programs run by faith-based organizations. For many Americans, the transforming powers of faith are resources in overcoming dependency. Through this new program, we will ensure that treatment vouchers are available to those individuals who choose to turn to faith-based treatment organizations for help. Our goal is to make recovery the future for all those struggling with substance abuse.

Ending the Honeymoon: A New Focus on Brief Treatments

The nearly 12 million current drug users whose use has not progressed to dependence face an uncertain future. Their likelihood of eventually crossing over into addiction ranges from one in three to roughly one in ten, depending on the drug—high enough to be unacceptable but low enough to encourage many to persist in their drug use. More urgent, from the public health perspective, is the need to head off the destructive message non-dependent users send to others. A developing trend toward “brief treatments” offers promise in this area.

A drug addicted individual typically comes into contact with the health care and criminal justice systems repeatedly and in a variety of ways. Not so for the relatively asymptomatic casual drug user, whose use is not obvious and may go for months or years before a triggering event such as an automobile accident, an overdose, or an arrest.

One promising way to reach out to people in this latter category is to use the existing medical infrastructure, which already has extensive experience in identifying problem drinkers, to screen for drug use during some of the millions of emergency room and primary care visits that occur each year.

The majority of those identified as drug users will have an incipient problem (see box), one that has not progressed to the point of requiring admission to a treatment facility. These individuals are likely to respond to a brief intervention, ranging from a highly structured, five-minute talk to half a dozen counseling sessions. The degree of professional training needed to conduct these interventions increases with their length and intensity, but most can be accomplished in a doctor’s office or within a hospital’s social services department.

While a referral for thorough assessment and treatment is in order for some, even brief interventions can be quite effective when delivered to a nonaddicted drug user by an authority figure. Recent research supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) through the Cannabis Youth Treatment Study found that brief treatments are very successful, especially with low-severity clients. As can be imagined, cost savings are substantial when compared with the alternative of detoxification followed by an extended treatment stay.

Of course, many drug users have more serious problems, which not uncommonly include mental and other medical disorders. Such disorders interact in unfortunate ways: drug users are more likely to develop mental problems, while individuals with mental disorders are more likely to use illegal drugs than the population at large. These “co-occurring disorders” take a terrible toll on individuals and complicate the task of helping them through drug treatment. As a result, some state treatment systems are moving toward routinely screening individuals for both types of disorders.

Programs That Work: Screening, Brief Intervention, and Referral

John Doe, age 45, is admitted to the emergency room after a car accident. What the doctors do not know at the time of his arrival is that he uses cocaine and marijuana. At many hospitals, the doctors would not pursue John’s health care needs beyond his injuries, thereby missing an opportunity to intervene early and derail behavior that could lead to greater harm.

Not so at Scripps Mercy Hospital in San Diego, where a Screening and Brief Intervention and Referral (SBIR) program has been implemented in various settings, including the emergency room, primary care unit, and trauma service. At Scripps Mercy, John Doe is interviewed by a specially trained peer health educator while still in the emergency room. This interview, which principally seeks to determine John’s drug and alcohol use, does not interfere with traditional medical care. It does, however, determine whether Mr. Doe has a problem with drinking or drug use.

On determining that Mr. Doe has a problem, a five-minute “brief intervention” will be delivered by a physician attached to the emergency room. If Mr. Doe is found to need a more extensive intervention, he will be referred to appropriate treatment services.

John Doe, like most drug users in America, was determined in this instance not to be dependent or an abuser. (As defined by the American Psychiatric Association, drug dependence—characterized by significant health problems, emotional problems, difficulty in cutting down on use, drug tolerance, withdrawal, and other symptoms—is more severe than drug abuse.) The brief intervention Mr. Doe received was reinforced by the doctors who treated his injuries and may be enough to get him to stop using drugs.

Unfortunately, despite growing evidence of the effectiveness of this modest form of intervention, most primary care settings, emergency rooms, and trauma centers around the country do not integrate the SBIR program with medical care. In other words, John Doe would have been treated for his injuries and sent home, with his developing substance abuse problem overlooked.

Targeting Drugged Driving

Over time, brief treatments should allow treatment professionals to reach non-dependent drug users through other institutions with which they have regular contact, notably workplace and school settings, and provide appropriate assistance. Drug users who trigger such interventions are among the most fortunate; many injure themselves or others on our Nation’s roads before coming to the attention of the drug treatment system.

Drug legalization advocates who suggest that drug use is “victimless” are brought up short when confronted with the grief of a family that has lost a parent or child to a driver who was high on marijuana. The problem is real: research indicates that in 2001, some eight million drivers got behind the wheel of a car after using drugs, and the problem is particularly acute among younger drivers (see Figure 10).

More than two decades ago, a group of brokenhearted mothers formed what came to be known as Mothers Against Drunk Driving (MADD), whose tireless efforts—along with those of the National Highway Traffic Safety Administration—have contributed to a 43 percent decline in alcohol-related highway fatalities. Groups like MADD have expanded to focus on drug-impaired driving, but there exists at present no reliable system that identifies drugged drivers and directs them into drug treatment before innocent lives are lost. Because slightly more than half of all contacts between law enforcement and the public occur during traffic stops, giving police officers tools to better recognize drug use is a tremendous opportunity to make our roadways safer and get users into treatment.

Figure 10: Drugged Driving Is Highest Among Young Adults

Percent Reporting Driving Under the Influence of an Illicit Drug

Figure 10: Drugged Driving Is Highest Among Young Adults. Percent Reporting Driving Under the Influence of an Illicit Drug. 
Vertical bar chart with 3 items. 
Item 1, 12-17 years old 3.2%
Item 2, 18-25 years old 12.4%.
Item 3, 26 or older 2.1%.

Source: National Household Survey on Drug Abuse (2001)

One means of accomplishing these two goals is support of the Drug Recognition Expert (DRE) program, which trains police officers to recognize and readily identify the signs of drug use. Such training is crucial in avoiding the common scenario where a driver who has used drugs is stopped for suspicion of driving under the influence but released after failing to register evidence of drinking. DRE training, in contrast, relies on behavioral cues to better recognize the signs of drug use and gets dangerous drivers off the road and into treatment or an appropriate correctional setting.

The chief limitation with current DRE-trained officers is simple: there are too few of them, and a drugged driver’s chances of encountering a DRE-trained officer at a traffic stop are slim. (If there is an encounter, however, the odds shift; DRE training is rigorous, and toxicology tests confirm the assessments of DRE-trained officers more than 90 percent of the time.)

Research into new detection technologies promises to lead to a version of the familiar alcohol breath-testing devices to supplement officers’ expertise in confirming drug use and presence. ONDCP’s Counterdrug Technology Assessment Center (CTAC) is sponsoring research into saliva tests that can quickly, cleanly, and accurately help an officer tell if a driver has used illegal drugs. CTAC will fund this research at a level of $1.5 million over the next three years.

Reducing Recidivism through Drug Courts

In addition, the Administration proposes a $16 million increase in federal support for the Drug Courts program in fiscal year 2004. Drug courts use the coercive authority of a judge to require abstinence and alter behavior through a combination of graduated sanctions, mandatory drug testing, case management, supervised treatment, and aftercare programs. Intrusive and carefully modulated programs like drug courts are often the only way to free a drug user from the grip of addiction. Such programs represent one of the most promising innovations in recent memory.

New research findings suggest that drug courts are effective in reducing criminal recidivism. A preliminary report from the National Institute of Justice, “Estimate of Drug Court Recidivism Rates,” followed more than 2,000 graduates from 100 drug courts and determined that the recidivism rate (defined as being arrested and charged for an offense that, on conviction, would result in a sentence of at least one year) was just 16.4 percent one year after graduation and 27.5 percent at the two-year mark. Figures for individuals who were imprisoned for drug offenses, instead of entering drug court, are 43.5 and 58.6 percent, respectively. (Because violent drug offenders are typically ineligible to be admitted to drug court, the drug court and prison populations are not strictly comparable.)

Results like these explain why the drug court movement has progressed from the novel status it enjoyed when the concept was first highlighted in the President’s National Drug Control Strategy in 1991, when there were fewer than half a dozen drug courts. Now, more than 940 drug courts operate in 49 states, with an additional 441 courts in the planning stages. Key goals for the program in coming years include expanding the number of drug courts, improving retention rates, and generating credible post-program outcome data.

Getting People Back on Track at Cincinnati’s Drug Court

Dan Smith, a 32-year-old drifter, is arrested on charges of possession of cocaine and methamphetamine. Numerous prior arrests of a similar nature have been documented throughout his life, but this is the first time Dan has been detained in Cincinnati. In the Hamilton County Drug Court, he will be given the tools he needs to get on track to a law-abiding, drug-free life.

After his arrest, a public defender identifies Dan as a potential candidate for the drug court. For two weeks he undergoes an inpatient assessment period conducted by substance abuse professionals at Talbert House Treatment Center. Four probation officers are assigned to the site to foster coordination between the criminal justice system and the treatment providers.

After the center’s clinical experts determine that Dan is dependent on illicit drugs, he goes before the Honorable Kim W. Burke. Dan is placed on probation and ordered to complete a treatment regimen that typically includes 90 days of residential treatment, followed by six weeks of intensive outpatient care, and a minimum of 12 months of continuing care.

Judge Burke keeps a close eye on the drug court’s clients, meeting with all 400 of them at least once a month and some as often as weekly. Key to the drug court’s success is creating an environment that is supportive but firm. Says Judge Burke, “At our evening status reports, I have the probation officer there, I have the treatment counselor there, and I have the attorney there. That avoids a lot of people saying ‘My probation officer told me I could do this,’ or ‘My counselor told me I could do that’.”

As long as Dan remains drug- and alcohol-free for the duration of this sentence, he will serve no jail time for the original charge. The program relies on Dan’s knowledge that he will receive weekly drug tests; if he is found to have used illegal drugs, he can expect immediate consequences.

Judge Burke puts it this way: “If a person tests positive, I find out about it pretty quickly—usually the next day. Relapse is part of what we deal with, but when they come in with a dirty drug screen, they know that they’re going to spend a couple of days in jail. The point of it is for them to have immediate consequences for their actions.”

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Last Updated: May 7, 2003