The President's
National Drug Control Strategy
March 2004
- Healing America�s Drug Users:
Getting Treatment Resources Where
They Are Needed
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Budget Highlights
Substance Abuse and Mental Health Services Administration (SAMHSA)—Access
to Recovery: up $100.6 million. The President has committed to expand the drug treatment
system over five years, including through the Access to Recovery initiative (ATR). The fiscal
year 2005 budget proposes $200 million for ATR, an increase of $100.6 million over the 2004
enacted level.
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This initiative will provide people seeking clinical treatment or recovery services with
vouchers to pay for the care they need. Vouchers may be redeemed for services at eligible
organizations, including those that are faith based, and will allow more flexible delivery
of services to individuals based on their treatment need.
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Office of Justice Programs—Drug Courts Program: up $32 million. The Administration
recommends a funding level of $70.1 million for the drug courts program in fiscal year 2005.
This represents an increase of $32 million over the 2004 enacted level. This enhancement will
increase the scope and quality of drug court services with the goal of improving retention in,
and successful completion of, drug court programs. Funding also is included to generate drug
court program outcome data.
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The drug courts program provides alternatives to incarceration, using the coercive power
of the court to force abstinence and alter behavior by drug-dependent defendants with a
combination of clear expectations, escalating sanctions, mandatory drug testing, treatment,
and strong aftercare programs.
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National Institute on Drug Abuse (NIDA): up $28.3 million. This increase will ensure
NIDA�s continuing commitment to key research efforts, including basic research on the nature
of addiction, development of science-based behavioral interventions, medications development,
and the rapid translation of research findings into practice.
- NIDA�s efforts include: the National Prevention Research Initiative, Interventions and
Treatment for Current Drug Users Who Are Not Yet Addicted, the National Drug Abuse
Treatment Clinical Trials Network, and Research Based Treatment Approaches for
Drug Abusing Criminal Offenders.
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The Strategy uses the public health model as a
way to understand the epidemiology of drug use
and control its spread. The public health model is
the only understanding of addiction that can
explain why people continue to use drugs when
the consequences are a devastating disease of the
brain and a terrible loss of human potential.
Conventional wisdom on the topic suggests that
young adults use drugs because they think they are
invincible. Adults, presumably wiser but also selfdestructive
or simply optimistic, are thought to
recognize the dangers but use drugs anyway. They
watch an addict and tell themselves that things
will be different for them.
But the conventional wisdom only explains so
much. Why, for instance, do people initiate the
use of methamphetamine—a drug that can cause
a complete unraveling of home life, work, and
social connections in a matter of months?
The public health model suggests a deeper
explanation, one touched upon in the previous
chapter�s discussion of prevention and the role of
newly drug-using teens in proselytizing their peers
to join in the fun, and seeking to normalize their
own drug using behavior. Simply put, many
people use drugs because they know someone who
is using and not suffering any apparent consequences.
The disease of drug dependence spreads because
the vectors of contagion are �asymptomatic� users
who do not yet show the consequences of their
drug habit, and who do not have the slightest
awareness of their need to seek help.
It is especially important to intervene with users
during this �honeymoon� phase. A new approach
suggests a way ahead, using the existing medical
infrastructure—which already has extensive
experience in identifying problem drinkers—to
screen for drug use and offer appropriate and
often brief interventions. The Department of
Health and Human Services has awarded
seven grants in the past year to advance our
understanding of screening and brief intervention
in treatment. In Chicago, for example, Cook
County Hospital emergency room staff as well as
doctors and nurses in other areas of the hospital
will be trained to detect the signs of developing
drug use and direct users into treatment.
Expanding Access to
Recovery
Screening and brief interventions hold promise for
cutting short the drug problems of millions of
Americans. Yet 20 million Americans are past month,
or current, users of at least one illegal
drug, and seven million Americans need drug
treatment, according to diagnostic criteria
developed by the American Psychiatric Association.
More than one million Americans receive
treatment each year and start on the road to
recovery. In recent years, however, an average of
100,000 of those who seek treatment each year
have not been able to receive it. They have an
immediate need, and we have launched a new
program to address it—Access to Recovery. Begun
in fiscal year 2004, with an additional $100
million requested in fiscal year 2005, the program
will expand access to clinical substance abuse
treatment, including recovery support services,
while encouraging accountability in the treatment
delivery system.
The program will work as follows: Those without
the means to pay for treatment will be assessed
and issued a voucher for the cost of treatment or
recovery services as appropriate.
Recognizing that there are many routes to
recovery, this initiative envisions a pathway to help
that is direct and open on a nondiscriminatory
basis to all, including services provided by faithbased
organizations. For many Americans, the
transforming powers of faith are crucial resources
in overcoming dependency, and this new program
will work to ensure that treatment vouchers are
available to the programs that work the best,
including those that are faith-based (see box below).
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KEY ELEMENTS OF ACCESS TO
RECOVERY:
Flexibility. With a voucher, people in need of treatment
or recovery support services will have the freedom to
select the programs and providers that will help them
most�including programs run by faith-based
organizations.
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Results Oriented. Grantee institutions will be asked to
develop systems to provide an incentive for positive
outcomes.
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Increased Capacity. Access to Recovery is projected to
support treatment or recovery support services for
approximately 100,000 people per year.
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From Waiting to Denial
Most policy analyses of drug treatment begin and
end with a discussion of waiting lists. Although such
lists are a staple of journalistic accounts of the
drug treatment system, even the roughly 100,000
individuals seeking but unable to obtain treatment
represent a tiny fraction—perhaps one in 70—of
the number in need of help. The real problem is
that a much larger number of Americans�some
six million—are dependent on an illicit drug and
are not seeking treatment (see Figure 7). Thus the
central problem is not waiting lists, but waiting
for individuals who are in denial about their need
for drug treatment to recognize that need.
A voucher system, for the first time, offers those
seeking drug treatment a consumer-driven path to
the services they need; yet, the larger challenge for
our society is to direct drug-dependent
individuals—one in five of whom also suffers from
a serious �co-occurring� mental illness—to the
help they so desperately need but fail to consider.
Closing this �denial gap� is a vast undertaking.
Helping our brothers and sisters in need and staring
down the social discomfort and risk of alienation
to offer the hope of recovery requires the energy
and commitment of all Americans.We must create
a climate in which Americans confront drug use
honestly and directly, offering the compassionate
coercion of family, friends, and the community,
including colleagues in the workplace, to motivate
the change that brings recovery.
When such efforts fail, and when individuals run
afoul of the criminal justice system, we must make
all reasonable efforts to identify and direct individuals
in need into court-supervised drug treatment. In
this connection, the Administration has requested
a $32 million increase in Federal support for the
drug courts program in fiscal year 2005.
Drug courts use the authority of a judge to require
abstinence and altered behavior through a
combination of clear expectations, graduated
sanctions, mandatory drug testing, case management,
supervised treatment, and aftercare programs—a
remarkable example of a public health approach
linked to a public safety strategy. Carefully
modulated programs like drug courts are often the
only way to free a drug user from the grip of
addiction. More than 1,183 drug courts operate in
all 50 states, with an additional 414 courts in the
planning stages (see Figure 8).
Figure 7: Most of Those in Need of Drug Treatment Do Not Seek It
Source: National Survey of Drug Use and Health, 2002
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OPERATION PAR�S THERAPEUTIC
COMMUNITY WITH A DIFFERENCE Operation PAR (Parental Awareness and
Responsibility) got its start the way many
effective programs do: a parent concerned
about her child�s drug use took action.
That parent was Shirley Coletti. The west
central Florida-based nonprofit she
founded in 1970 has grown to more than
625 employees in four counties serving
9,800 individuals a year, from juvenile
felons to outpatient heroin addicts on
methadone maintenance.
One of the group�s many remarkable
programs is PAR Village, a residential,
therapeutic community-type drug
treatment campus spread over three acres.
At PAR Village, 25 to 30 mothers and
expectant mothers spend up to 18 months
living with their young children. Another
20 mothers with older children live alone
but can have their children stay overnight.
The program grew out of in-house
research. As Nancy Hamilton, Operation
PAR�s CEO, explains, �We studied the
question of whether mothers did better
if they were able to keep their children
[while] in treatment,� says Hamilton. �We
found that they did.�
Some of the women at PAR Village are at
risk of losing their children and come as a
condition of maintaining parental rights.
Some have been sentenced by a drug court
but are given a chance to have their
children join them.
Drug use by parents and its effects on children
are treated simultaneously. �You have two
clients�the mom and the child,� says
Hamilton. �While you are doing treatment
with the mom, you are doing prevention
with the child.�
Many of the women who enter PAR Village
are hard cases, but Hamilton is impatient with
treatment providers who take only the most
promising clients. �A lot of programs explain
their failures by saying that they just need a
better class of clients.We think there�s no such
thing as client failure—only program failure.�
�These moms come in and they are pretty
much unsuccessful in every area of their
lives,� says Hamilton. �And they come in
here and we create an environment where
they can be successful. But it�s not easy.
Our counselors and staff have to teach
them how to bathe their kids, how to feed
their kids dinner, how to put the kids to
bed.We tell the nurses who want to work
here that they have to be prepared for the
unexpected.�
The unexpected sometimes has to do with
clarifying the line between discipline and
abuse. �Often, we have to teach parents
how to discipline their children without
being abusive,� says Hamilton. �But it is a
joy to watch children flourish as their
recovering mothers learn better parenting
skills and as their recovering mothers learn
to give them the greatest gift of all�the
time that drugs used to occupy.�
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ONE-STOP SHOPPING AT NASHVILLE�S
DRUG COURT Judge Seth Norman spent five years as a
criminal court judge in Nashville before
tiring of the parade of familiar faces and
deciding to try something different. �I saw
the same person coming through the door
time and time again,� says Judge Norman.
He and colleagues investigated the
possibility of securing funding for a drug
court, and even after being awarded a
Federal grant, found that he still had to
scrounge for furniture.
�I took five guys out of jail,� says Judge
Norman. �I took them to an abandoned
state mental hospital�it was in terrible
shape�and I told them that if they�d clean
it up, I�d find them some counseling.�
Eight years later, the Davidson County Drug
Court is nationally known as much for its
impressive results as for its unusual approach.
In the reverse of the usual pattern, the drug
court refers the majority of its clients not
to outpatient treatment but to an intensive,
year long residential treatment regimen
known as a therapeutic community.
�Most of the people we deal with have
serious enough problems that they are
going into inpatient treatment,� says Judge
Norman. �Drugs like crack cocaine are just
so potent that [users] are going to have to
spend some time in treatment before they
are going to be better.� The remainder, less
than 20 percent of referrals, is assigned to
outpatient treatment with weekly hearings
and regular drug testing.
The drug court is unusual for another
reason: the inpatient therapeutic
community to which it refers clients, which
houses up to 100 long-term residents, is
co-located with the drug court. Supervision
is intense. �The Judge and the treatment
counselors know all of the residents by
name,� says Jeri H. Bills, the court�s
program coordinator. �People here learn to
be responsible�and these people have
never had any responsibility. They�ve never
had a job, paid taxes, gotten up early to
walk their kids to the school bus. Here,
they get up every day before six, they run
the place, they keep the grounds.�
The program comprises three phases, an
acclimation phase for roughly the first six
to eight weeks is followed by six to eight
months during which residents have
minimal freedom of movement. They can
earn passes to leave for four hours at a
time, with the understanding that they will
be drug tested on their return.
To enter the third and final phase, residents
must find work. �We provide all residents
with a bus pass,� says Judge Norman, �and we
coach those with literacy issues, but they have
to go out and find their own job.� One-third
of residents� pay goes back into the program
to cover costs, one-third goes to a savings
account to provide some stability when
residents return to the outside world, and
one-third goes to court-related costs such
as child support and restitution to victims.
Keeping a job for 90 days is one
requirement for �coining out� (graduates
get a commemorative coin on graduation
from the residential portion of the
program). Coining out is followed by
another six months of supervision while
clients reintegrate into society.
Recidivism—here defined as being
convicted of any crime after graduation—is
about 18 percent. �We take each of our 260
graduates and we run them through an
NCIC [National Crime Information
Center] check and a local police arrest
query,� says Judge Norman. Not that the
program�s graduates are all that hard to
track down. An alumni association meets in
the courtroom every other Tuesday night.
The program�s graduation rate is about
65 percent. �Some people come in and
just say �to heck with this—I�ll just do my
10 years,�� says Judge Norman. �Many of
them have done time so many times that
for them, it�s just another trip to prison.
Here, you�re not going to find a boom box
or a TV. You have to do exactly what you
are told to do, when you are told to do it.
And you know what? These folks find
that they love having some structure in
their lives.�
Judge Norman and the drug court staff
feel strongly about the supportive role
family members can play in a resident�s
recovery. �We don�t push it until midway
through phase two,� says Jeri Bills.
�The family wants to help the person,
but often they haven�t known what to
do. Having them there says that the
person in treatment is not doing it on
their own�they have the support of a
family that has probably been alienated
for so long.�
Judge Norman still has his day job in the
criminal court, but he looks forward to
the time he spends in drug court. �It�s just
about one of the most satisfying things
a person can do is see a person become
a successful citizen after they have been
addicted to drugs for many years.�
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Figure 8: Number of Drug Courts Nationwide
Source: National Drug Court Institute
Focus on Prescription
Drug Safety
Traditional drug threats involve illicit substances
grown or produced abroad and smuggled across America�s borders by traffickers. By contrast, with
few exceptions, prescription drugs are legal
medicines, legitimately manufactured, distributed
by licensed pharmacists, and prescribed in good
faith by physicians. And while most Americans
understand the risks of addiction or even death
from drugs like heroin or cocaine, they are less
likely to appreciate the risks associated with
prescription drugs, which are approved and
certified by the government. Yet, through
negligence, theft, fraud, or forgery, these addictive
substances are being diverted and abused with
alarming frequency.
Surveys confirm that the nonmedical use of
prescription drugs has emerged in the last decade
as a major problem. The illegal diversion, theft, and
medical mismanagement of prescription drugs
(particularly opioid pain medications) have increased
and, in some areas, present a larger public health and
law enforcement challenge than cocaine or heroin.
According to the most recent National Survey
of Drug Use and Health, the misuse of
psychotherapeutic drugs—pain relievers,
tranquilizers, stimulants, and sedatives—was
the second leading category of illicit drug use
in 2002, following marijuana. An estimated
6.2 million Americans (approximately 2.6 percent
of the population age 12 and older) had used a
psychotherapeutic drug for nonmedical reasons
in the month prior to the survey.
The bulk of this abuse involves narcotic
analgesics—an estimated 4.4 million Americans
are past-month (so-called current) nonmedical
users of pain relievers. OxyContin, a powerful
time-release painkiller with an addiction potential
similar to morphine, was used nonmedically at
least once by 1.9 million Americans in 2002. The
rate of OxyContin abuse in 2002 was ten times
higher than in 1999.
The University of Michigan�s Monitoring the
Future survey for 2003 finds a similar pattern
among young people, with the nonmedical
use of prescription drugs second only to
marijuana. The abuse by high-school seniors of
the brand-name narcotic Vicodin is more than double their use of cocaine, Ecstasy, or
methamphetamine. This drug has become a
deadly youth fad, with one out of every ten high-school seniors reporting nonmedical use.
Some 5 percent of seniors report nonmedical use
of OxyContin.
Additionally, according to the Drug Abuse
Warning Network (DAWN), a nationwide
sentinel system that monitors drug-related
emergency room episodes, nonmedical use of
narcotic analgesics as a reason for an emergency
room visit rose 163 percent between 1995 and
2002. More alarming, trend data from DAWN for
the years 1995�2002 shows a dramatic rise in
emergency room mentions of single-entity
oxycodone (formulations of the narcotic without
other drug combinations), from 100 mentions in
1996 to nearly 15,000 mentions in 2002.
Curtailing Doctor
Shopping
Pharmaceuticals can be diverted in multiple ways.
The most popular form of diversion is known as
doctor shopping—visiting many doctors to
acquire large amounts of controlled substances.
Other diversion methods focus on the pharmacies
themselves, which may experience theft or
inappropriate distribution of controlled drugs by
pharmacists or employees or may receive forged
prescriptions. Physicians may inappropriately
prescribe controlled substances through either
insufficient risk-management of patients with a
potential for abuse or outright fraudulent medical
practice. Those who acquire diverted substances
may themselves abuse them or sell them to others
at enormous profit.
The most alarming form of prescription drug
abuse involves substances classified under the
Controlled Substances Act as Schedule II or III
drugs. By definition, these drugs have a high
potential for abuse, but also an accepted medical
use. Simply to ban such substances would
undermine the legitimate medical purposes that
they serve and would increase the suffering of
many. The challenge for policymakers is to
suppress the abuse of prescription drugs
without infringing unnecessarily on legitimate
medical practice.
The Federal Government has sophisticated
systems in place for tracking and controlling drugs
with high potential for abuse, from the
manufacturer down to the wholesale level. The
Drug Enforcement Administration (DEA) has
regulatory and investigative jurisdiction over the
diversion of controlled pharmaceuticals, and
accomplishes its control and monitoring functions
through a nationwide database. As a result,
relatively little of the diversion problem originates
in the manufacturing-to-wholesaling system.
It is at the retail level, the most frequent site
of diversion, where the need for increased
monitoring is greatest.We are now closing
this gap in part through the development of
something most Americans assume already
exists�state-level prescription monitoring
programs. PMPs, as they are known, are designed
to facilitate the collection, analysis, and reporting
of information on the prescribing, dispensing,
and use of pharmaceuticals.
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FIGHTING PRESCRIPTION DRUG ABUSE
AT THE STATE LEVEL In Nevada, pharmacies are required to
download prescription information to
the state�s Prescription Controlled
Substance Abuse Prevention Task Force,
which sifts through the data to identify
doctor shoppers. The Task Force then
sends informational letters to each of
the patient�s practitioners and pharmacies
asking them to intervene, referring
the patient to appropriate treatment
or counseling.
The program has had the added benefit
of encouraging both practitioners and
pharmacies to recognize the potential
doctor-shopping problem and encourages
them to review their patients� drug history,
soliciting reports instead of waiting to be
contacted.When the program began in
1997, the task force received 480 such
requests for reports; by 2003 this number
had risen to 13,925.
The benefits of the program have far
outweighed its annual $131,000 budget.
Nevada instituted the system in 1997, and
in just the first year alone, the number of
narcotic drug doses dispensed to suspected
abusers was cut by 46 percent—a result
typical of other states� experiences.
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The data generated by PMPs is analyzed by
licensing, regulatory, or law enforcement agencies
to track a patient�s use of prescription medicines.
When cases of inappropriate prescribing or
dispensing of controlled substances appear,
regulatory and law enforcement officials are
alerted. PMPs also offer physicians a way to
obtain information on whether their patients or
prospective patients have obtained the same or
similar prescription drugs from other doctors.
State programs like these do not interfere
with legitimate prescribing and dispensing of
pharmaceuticals. Nor do they violate patient
confidentiality requirements. Currently, 21 states
have some form of reporting mechanism, with
additional states in the development stage.
The effectiveness of PMPs can be seen in a simple
statistic: in 2000, the five states with the lowest
number of OxyContin prescriptions per capita all
had PMPs. According to DEA, the five states
with the highest number of prescriptions per
capita all lacked them.
An important feature of successful PMPs is
developing the authority to share data across state
lines to combat border-crossing abusers trying to
avoid detection. The startup cost of a PMP is
surprisingly modest�approximately $300,000
per state, with most states able to operate them
continually for between $150,000 and $1 million
per year. Internet monitoring tools are essential
for establishing an effective system. DEA is also
currently developing a method to track and
monitor illegitimate Internet prescription offers.
Prescription monitoring programs offer real
hope for effective diversion control and restoring
prescription safety, but they cannot succeed in
isolation. The pharmaceutical industry itself must
become a part of this partnership in a constructive
way. Manufacturers must commit to responsible
advertising and risk announcements involving
their products.
The Food and Drug Administration (FDA) will
continue to monitor promotional materials for
controlled substances, particularly for sustainedrelease
products, to ensure that false and
potentially misleading claims are not made.
The FDA Office of Criminal Investigations is
working with DEA on investigations involving
the illegal sale, use, and diversion of controlled
substances, including illegal sales over the
Internet. DEA will improve its training on the
recognition and pursuit of diversion cases so that
they can pursue cases aggressively without
limiting proper pain management by physicians.
Finally, physicians must perform risk assessments
on patients at risk for potential abuse. This is
particularly true for patients entering opiate
therapy for chronic pain. Physician licensing
boards must insist on more effective education for
future doctors, and on remedial courses in risk
management and awareness of dangerous new
drugs for existing practitioners. State licensing
boards must exercise appropriate oversight and
take action against physicians who undermine the
integrity of medical practice.
Last Updated: March 29, 2004
