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The President's
National Drug Control Strategy
February 2005

Healing America’s Drug Users: Getting Treatment Resources Where They Are Needed

As risky behaviors go, drug use ranks among the worst. While it is difficult to draw precise inferences from the data available, the likelihood that an adult who uses drugs on at least a monthly basis (a so-called “current” user) will go on to need drug treatment is approximately one in four—high enough to constitute a substantial risk but low enough that many individuals are able to deny the obvious risks or convince themselves that they can “manage” their drug-using behavior. One drug treatment practitioner compares the problem to that of people who do not wear seatbelts. Although such people are risking self-destruction at every turn, every trip that ends safely actually reinforces the erroneous belief that seatbelts do not matter.

There is a word for this problem—“denial.” Addicts deny the nature and severity of their problem even in the face of mounting evidence to the contrary. Denial explains why such a small percentage of the more than four million Americans who meet the clinical definition of dependence and are therefore in need of drug treatment actually seek it in a given year.

Not only does denial keep people from seeking help, it also maintains the destructive behavior long enough to allow the disease of addiction to gain an even firmer hold and be transmitted to peer groups and friends. The power and tenacity of denial are thus real and must be met with a force of equal and opposite magnitude.

Fiscal Year 2006 Budget Highlights

  • Substance Abuse and Mental Health Services Administration (SAMHSA)—Access to Recovery: +$50.8 million. Through Access to Recovery (ATR), the President is committed to providing individuals seeking alcohol and drug treatment with vouchers to a range of appropriate community-based services. The fiscal year 2006 budget proposes $150 million for ATR, an increase of $50.8 million over the fiscal year 2005 enacted level. By providing vouchers, ATR promotes client choice, expands access to a broad range of clinical treatment and recovery support services, and increases substance abuse treatment capacity. Vouchers may be used to access various services, including those provided by faith- and community-based programs.

  • Substance Abuse and Mental Health Services Administration (SAMHSA)—Screening, Brief Intervention, Referral, and Treatment (SBIRT): +$5.8 million. This initiative supports one of the Strategy’s goals to intervene early with nondependent users and stop drug use before it leads to dependence. This initiative will improve treatment delivery to achieve a sustained recovery for those who are dependent on drugs. SBIRT is designed to expand the continuum of care available to include screening, brief interventions, brief treatments, and referrals to appropriate care. By placing the program in both community and medical settings such as emergency rooms, trauma centers, health clinics, and community health centers, the program can reach a broad segment of the community.


AN ANGEL ON MY SHOULDER: ATR OPENS DOORS TO TREATMENT

Note: Portions of the following were adapted from the case narrative of the recipient of the Nation’s first Access to Recovery voucher.

On December 13, 2004, the state of Wisconsin issued the Nation’s first Access to Recovery voucher to Kimberly Washington, a 41-year-old mother from Milwaukee.

Washington was admitted to treatment from her most recent stay in jail. Her incarcerations stemmed from drug-related offenses such as shoplifting and forgery. Because of a long history of cocaine abuse that started at age 22, Washington is unable to care for her children. Although she has three years of college and has managed a restaurant, prior felony convictions are now a barrier to employment, and she has no income.

Washington was screened by a Milwaukee County central intake unit, where it was determined she would benefit from residential treatment. Given a choice of providers, she selected an agency called Meta House, having heard positive things about it from other women in jail. She liked the fact that Meta House would allow her one-year-old baby to stay with her in treatment when she is ready for reunification and that the agency provides an array of recovery support services along with treatment. In addition to reunification with her children, Washington hopes to get help finding employment.

Like all Wisconsin ATR clients, Washington has been assigned a recovery support coordinator, who will support her throughout her enrollment in ATR, even after leaving Meta House. The coordinator will help her put together a recovery support team, including service providers, her probation officer, members of her family, and other supports in the community, that will help develop a plan to attain her goals and sustain her recovery post-treatment. Washington has a strong religious background and sees her faith as intimately linked to her recovery.

In response to Wisconsin’s invitation, Milwaukee’s faith community has developed an ATR Faith Community Advisory Council, which is developing and coordinating the resources of the faith community to support recovery. Even though her treatment provider, Meta House, is not a faith-based organization, the recovery coordinator is available to support Washington’s desire to reconnect with her church. The coordinator will also recruit faith community members for her recovery support team. The council will search among its congregations for a member who is willing to employ Washington despite her felony record.

This coordinated approach to care would not have been available to Washington without ATR. “Knowing there’s someone, or something, like an angel on my shoulder gives me hope, and motivation, that I will not fail this time,” says Washington. “Someone will be there.”

The Access to Recovery program is the result of the convergence of numerous forces demanding customer choice as well as increased cost-effectiveness, accountability, and results. ATR seeks to leverage the twin benefits of client choice with careful Federal oversight and performance measurement, rewarding high-performing providers. The fiscal year 2005 round of funding totaled $99.2 million and supports programs in 14 states and one tribal organization. The President’s fiscal year 2006 request contains $150 million for ATR.

“With the voucher, people sit down with the assistance of a case manager and choose a provider,” says John T. Easterday, project director for the ATR program in the state of Wisconsin. “Part of the process is deciding what it is that this individual really needs to succeed while in treatment.”

Faith-based providers of treatment and ancillary services are welcome to sit at the table with everybody else. “Getting the faith community involved was comparatively easy,” says Easterday. “In a lot of these areas, they were already leading the charge.” He adds, “Faith means the hope that I can improve, the knowledge that I can abstain, and the certainty that I am worth it.”

Chapter I of the Strategy describes this opposing force in terms of its public manifestations, including a media campaign to encourage parents to monitor their children’s behavior, community efforts to enforce standards of conduct by young people at risky periods like prom time, and school-based efforts to protect students through drug testing programs.

This section of the Strategy describes that opposing force in its more focused and institutional forms. These include drug courts, where the power of the criminal justice system is combined with the skillful healing of treatment providers in service of the drug dependent individual. They include hospital emergency rooms, where doctors are now screening individuals for evidence of drug dependence and referring them to treatment as needed. They also include nonprofit organizations that serve the needs of formerly addicted prisoners reentering society. These groups support their clients’ first tentative steps in freedom, steering them away from established patterns of crime and drug use and into recovery after what for too many has been a life of addiction.

Empowering individuals by allowing them to choose among various drug-treatment programs is a goal of President Bush’s Access to Recovery (ATR) initiative, which allows drug dependent individuals who are so inclined to turn to faith-based programs in time of need.

WOMEN AND CHILDREN FIRST: A TREATMENT CENTER THAT THINKS “FAMILY”

On Martin Luther King Jr. Avenue in Washington, D.C., a couple of blocks from the bustle of the Anacostia Freeway, sits the largest private provider of behavioral health services to children and families in the Nation’s capital. The Center for Mental Health is a treatment center founded on the belief that addicts, particularly women, are not atomized individuals but often mothers with responsibilities.

“Some 85 percent of the women we treat have minor children,” says Dr. Johanna Ferman, the center’s chief executive officer. “To get a parent into treatment on a consistent basis, you have to deal with the concerns of a parent with children, a central concern being making sure that that child will be cared for during treatment.”

Transportation to the treatment facility is another key concern.

“We have patients who have three or four kids,” says Ferman. “They’re not going to be able to negotiate getting those kids taken care of and getting over here. So we go to them. We have a fleet of twelve vans that go out into the community. You want to reduce every barrier to getting people into treatment and staying there. You want to take away people’s excuses. And transportation and childcare are classically the biggest barriers to a woman entering and staying in treatment.”

The center’s insistent attention to physically getting people to treatment seems to be paying off. A University of

Illinois study found that the center had a remarkable 72 percent success rate in meeting the treatment goals, significantly higher than that of comparable programs.

But Ferman does not stop with the moms. She wants to help their children too.

“Some of these children have been exposed to drugs during pregnancy,” says Ferman. “Some have been witnesses to violence, to sexual behavior—all of which are tremendously traumatizing. And these kids have parents who are only intermittently available or not available at all.

“By the time [these children] are five years old, they are not school-ready. When people pick up the newspapers and read headlines with teachers saying, ‘We can’t deal with these kids,’ these are the kids they are talking about. School is a social setting, and these kids lack the social and emotional skills to handle a social learning environment.”

The Center for Mental Health maintains cutting-edge treatment programs for these youngest victims of drug dependence, in some cases starting before birth. “If a woman is pregnant, we make sure that she’s got prenatal care,” Ferman says. “We work with her to provide in-home services, and make sure she’s getting clean. We have case managers who will go out and visit her to assist with life’s challenges—from housing to paying the utility bills to making sure there is enough food in the house. If a client is not staying clean, we will move her into residential care.”

Over more than a decade, the center has moved hundreds of previously dysfunctional families from welfare and other forms of institutional dependence, including chronic stays within the child welfare system, into stable families and gainful employment.

“The center is a place for hope,” says Ferman. “We believe in the capacity of very, very ill people to recover.”

The President has committed to expanding the drug treatment system through the ATR initiative. The fiscal year 2006 budget proposes $150 million for ATR, an increase of $50.8 million over the 2005 enacted level.

Their connection to the community is so strong that faith-based and other community organizations have been called on to help reintegrate returning prisoners. Indeed, the transforming power of faith is an integral part of many drug treatment programs. As one practitioner put, “Faith means the hope that I can improve, the knowledge that I can abstain, and the certainty that I am worth it.”

The Power of Pressure: Coercing Abstinence through Drug Courts

Programs like Exodus Transitional Community target a specific population: reentering prisoners, many of whom were drug dependent before being incarcerated. Drug courts represent another approach to handling drug dependent individuals who are arrested for non-violent offenses, such as theft, arising from their drug-using behavior.

Drug courts use the authority of a judge to coerce abstinence through a combination of clear expectations and careful supervision—a remarkable example of a public health approach linked to a public safety strategy.

The best drug courts are more demanding than prison, with intensive requirements including frequent treatment sessions, regular public hearings, and, of course, frequent mandatory drug tests.

As Judge Jeffrey Rosinek, who runs the Miami Drug Court (see box), puts it: “Why would you want to take a program that is going to make you go to treatment twice a week, undergo drug testing twice a week, and attend twice-a-week fellowship meetings like Narcotics Anonymous? It’s so much easier just to use your drugs.”

Figure 10: Number of Drug Courts Nationwide

    Source: National Drug Court Institute


Drug court programs have a real effect on criminal recidivism. A National Institute of Justice study compared rearrest rates for drug court graduates with those of individuals who were imprisoned for drug offenses and found significant differences. The likelihood that a drug court graduate would be rearrested and charged for a serious offense in the first year after graduation was 16.4 percent, compared to 43.5 percent for non-drug court graduates. By the two-year mark, the recidivism rate had grown to 27.5 percent, compared to 58.6 percent for non-graduates.

MIAMI’S DRUG COURT: “SAVING LIVES ONE ADDICT AT A TIME”

For Judge Jeffrey Rosinek, who runs the Miami Drug Court, drug court is so different from a traditional court that they might as well not be called by the same name.

“In a traditional court, there is a prosecutor on one side, a defense attorney on the other side, and a judge in the middle,” says Rosinek. “Here, the court is unified and non-adversarial. Everyone is here to get that person off drugs. These people have never seen a judge who does that. They have never had a team of people who are there to help them the way we are.”

Rosinek presides over the country’s oldest drug court, founded in 1989. The court has roughly 1,600 clients at any given time— whom it keeps for a minimum of 12 months. Many stay for 18 months, and some for more than two years.

The drug court’s mix of supportive cheerleading and persistent confrontation is what it takes to get many dependent individuals to start down the road to recovery, although the confrontation usually comes first.

“Our job is to use every way including coercion to get them off those drugs, because most people simply do not want help,” says Rosinek. “The judge and their attorney might tell them, ‘Try it and see how you feel when you have been clean for a few weeks,’ at which point they are starting to feel that maybe it’s working. And at the drug court, they have a whole team of people pulling for them.”

When clients come in for their monthly hearing, the judge receives a two-page report that spells out whether they are employed, what they are doing in treatment, and the results of the all-important drug tests. “If it’s not a good report, I’ll drug test them again right there,” says Rosinek. “We try graduated sanctions. The final sanction is jail—but we always take them back.” Clients can also earn special rewards, such as free bus passes, for good conduct.

The most recent drug court class graduated in February 2005, bringing the number of program graduates to well over 10,000. “We are saving lives one addict at a time,” says Rosinek, “by convincing people that they have to give up their past life to have a life.”

The drug court movement continues to grow rapidly (see Figure 10). There were just a handful of courts operating in 1991, when the President’s National Drug Control Strategy first called attention to the idea. Today there are 1,621 courts in operation in all 50 states—an increase of more than 400 courts in just the past year.

To support and broaden this promising trend, the Administration recommends a funding level of $70.1 million for the drug courts program in fiscal year 2006, representing an increase of $30.6 million over the 2005 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 is also included to generate data on drug court program outcomes.

FROM PRISON TO THE PROMISED LAND: HELPING ADDICTS MAKE THE TRANSITION

The first time many of Julio Medina’s clients have the urge to use drugs is about an hour after leaving prison.

“When you get out of prison in New York, you take a bus down through New Jersey and past the city skyline,” says Medina. “We have people literally say that when they see the skyline, they start to get the urge to go out and [buy drugs].”

Medina is executive director of Exodus Transitional Community, a faith-based nonprofit organization in Harlem that helps prisoners make the transition to stability and, ultimately, a job. Exodus is one of 16 pilot sites in a three-year reentry initiative called Ready4Work, a program of the Department of Labor.

“Our name comes from Exodus,” says Medina. “Remember, the Israelites were in bondage, then the wilderness, before they reached the promised land. Our clients come out of prison; that’s their bondage.

They think being ‘outside’ is the promised land, but all too many end up in a different kind of bondage—drug addiction.”

Medina, who has served time in prison himself, understands why returning inmates so often return to a life of crime, but he uses that understanding to good effect.

“I tell these guys, ‘Look, I was locked up. And I never heard anyone say they wanted to come back to prison,’” Medina says. “People [in prison] would talk about the job they were going to get. I remember people even saying that they couldn’t wait to start paying taxes. And then those same people would be coming back into prison six months later. And so often the reason they gave was, ‘I couldn’t cope with it, so I just went out and got high.’

“They have all these plans. They’re going to live with their mom, reunite with their wife, they’re going to see their kids. And the reality is that their wife is with someone. The kids don’t know them. And their mom doesn’t want them back because the last time they were home they stole their son’s Christmas present to get money to cop drugs. And they are in the wilderness. They start to use drugs again, and it’s the beginning of a downward spiral.”

“But some of them also realize how frail they are and how desperately they need to latch onto something,” says Medina. That’s where Exodus comes in.

Medina sees his first responsibility as giving people realistic expectations about life after prison, a sort of bookend to the orientation inmates receive on beginning incarceration. “We tell people, ‘It’s a tough job market, and you have to compete with people who don’t have a felony record.’”

It takes some prodding, but many of Medina’s clients blossom and show remarkable creativity and receptiveness to the job market. “It’s hard being a drug addict,” says Medina. “You have to get money every day to stay high. The challenge for us is to get that creativity channeled in a good direction. I just had a guy come back. He’s working three jobs; he’s silk-screening T-shirts and he wanted help with his resume because he wants to go after a job with better pay.”

The availability of drugs is a major problem. “We’re in Harlem,” says Medina. “Just to get here, people have to walk by drug spots. It makes my job so much harder. On the other hand, I can honestly tell people that they have won half the battle just by getting here in the morning.”

Exodus is nondenominational, and its services are open to all ex-offenders regardless of religion. Clients are invited to sit for silent prayer time in the morning, but participation is voluntary, and some prefer not to. Medina’s dedication is as real as it is irrepressible. “I get up every day and feel lucky to be serving these men and women,” he says.

Screening and Intervening: Short-Circuiting the Path to Addiction

The first priority of the Strategy is to stop drug use before it starts. It should be obvious that robust efforts involving community action and public education are central to an effective drug control program—one that seeks to denormalize drug use by creating a climate of public intolerance toward the drug-using behavior that all too often leads to addiction.

Considerably less obvious is how to target drug users still on the pathway to addiction—those individuals whose drug use is on the verge of causing noticeable levels of difficulty with work and relationships. It is never easy to identify individuals with such an incipient problem. A new approach holds much promise, however, using the reach of physicians to identify problems as early as possible.

This new approach, known as Screening, Brief Intervention, Referral and Treatment (SBIRT)— and more informally as screen and intervene—is being fielded in medical facilities from major city hospital emergency rooms to a system of rural health clinics.

SBIRT has a special utility for addressing the underreported problem of drugged driving on our Nation’s highways. Almost eleven million drivers per year get behind the wheel of a car while under the influence of an illegal drug. Drugged drivers have a much higher than average likelihood of having a serious accident and thus coming into contact with medical professionals. In fact, it is estimated that illegal drugs are used by approximately 10 to 22 percent of drivers involved in fatal motor vehicle crashes.

The SBIRT approach capitalizes on this alarming fact by placing the drug screening resources where the users are likely to be. In an SBIRT setting, for instance, a motorist involved in an accident may be asked about his drug use history before discharge; this screening, in turn, may unearth a developing drug use problem.

SCREENING AND INTERVENING

How does SBIRT work in practice? The answer to this question is coming from six state-level sites and one tribal council, that are implementing the approach under a five-year federal grant.

Michael S. Cunningham oversees 21 SBIRT sites for the state of California. “The intent of SBIRT is to identify the nondependent drug users,” says Cunningham. “These are people whose behavior is such that they are starting to show the strain of their drug use but who have yet to run afoul of those institutions that would result in a referral, such as the criminal justice system.”

“We want to get to people before they become too entrenched in their bad habits,” adds Theodora Binion Taylor, who oversees an SBIRT program for a large community hospital in Chicago. “We know from the research that the sooner we act, the greater the likelihood of sustained recovery.”

How does an individual end up on the receiving end of an SBIRT screening?

“Let’s say you have an automobile accident,” says Cunningham, “and you present yourself as a patient in one of those hospitals where we have SBIRT services. Once you are stabilized, you are going to be interviewed by a health advisor. These people are very good at building rapport and guiding you through a list of questions. This in turn results in an assessment, which is provided to your doctor.”

Doctors have always had the ability to refer patients to a treatment program, a traditional course but one that is appropriate only for individuals who are already dependent on illegal drugs or alcohol. Where SBIRT breaks new ground is by giving doctors a range of possible interventions, from a brief counseling session to a short treatment program of up to six sessions to a full-blown inpatient treatment admission complete with detoxification.

“Let’s take the example of James,” says Cunningham. “James just turned 21, and he and his buddies went through the ritual of ‘21 and 21’—having 21 drinks in a row. James ended up wrecking his car. This is the first time James drank that much, but we would still do an intervention with him. A doctor needs to sit down and say ‘Look where this behavior is leading you.’

“People are surprisingly receptive to being lectured when it’s delivered by a doctor. They came for help, and this is part of their prescription.”

“Tom, on the other hand, goes out with his buddies. They smoke some marijuana and use some cocaine,” says Cunningham. “Tom is still gainfully employed and has not yet had any major family problems. But his drug use has been slowly increasing over time, he’s starting to miss Mondays at work, and he’s had some arguments with his wife.” Problems are starting to show up, in other words. But Tom may not need detox or a full-blown course of treatment. “Tom might be a good candidate for brief treatments,” says Cunningham.

In total, the pilot SBIRT sites have now interviewed some 113,000 patients. In 15 percent of cases the patient’s drug use was deemed to warrant some form of brief intervention, while 2 percent of those interviewed were found to be in need of drug treatment.

A Continuing Focus on Prescription Drug Safety

Surveys show that the non-medical use of prescription drugs, particularly narcotic painkillers, continues to rise in several populations. The number of people who had used pain relievers non-medically at least once during their lifetime increased 5 percent, to 31.2 million Americans, from 2002 to 2003. Among young adults, the non-medical use of any psychotherapeutics in the past month (“current” use) increased from 5.4 to 6.0 percent. Also among young adults, current non-medical use of pain relievers increased by 15 percent, from 4.1 to 4.7 percent.

Although this is an emerging drug abuse problem, the challenge it presents is of a different order from the traditional drug threats. Existing as they do in every pharmacy in every city and town in America, prescription drugs are both more ubiquitous and more susceptible to regulatory control, with the mechanisms to reduce the threat of prescription drug misuse substantially within the scope of state and Federal regulatory authority. What is needed is continued improvement in the surveillance of practices like “doctor shopping” coupled with more careful and responsible medical oversight, preserving legitimate access to needed medicines while deterring unlawful conduct.

CURTAILING DOCTOR SHOPPING: THE IDAHO EXPERIENCE

Doctor shoppers in Idaho are finding life more difficult, thanks to a statewide computer network that monitors purchases of most controlled substances. The system receives electronic records from Idaho’s 240 pharmacies, including the practitioner who wrote the prescription, the pharmacy that filled it, the patient’s name and address, the drug and amount that was dispensed, and how it was paid for.

“If you have a controlled substance prescription filled in this state, it will be in our database,” says Richard Markuson, who runs the Idaho board of pharmacy. “Patients attempting to obtain controlled substances by doctor shopping and visiting a number of different pharmacies will show up as well.

“If our database indicates a patient has visited five or more practitioners and received controlled substance prescriptions we will notify those practitioners. This alerts them that a patient may be getting into trouble and gives them a chance to intervene and assist the patient.”

For instance, a practitioner may enter into a “contract” with a patient. “If the patient breaks that contract, the practitioner might refuse to see the patient any longer,” Markuson says.

Although the system was designed to identify doctor shoppers through analysis of purchase patterns after the fact, it has also become a useful tool for practitioners to review patterns of use on new or questionable patients before writing a prescription.

“If a physician has concerns about a patient, they simply fax us a request for the patient’s profile and that information is returned to them within two hours,” says Markuson. “We receive over 800 inquiries a month from practitioners.”

Idaho’s entire program, including staff costs, is budgeted at $170,000 per year.

In fact, there is already some indication that effective measures can make a difference. Rural America, which had been especially hard hit by the use of oxycodone-based drugs, including OxyContin, has experienced a 54 percent decline in current use of illicit drugs in just one year; driven in large measure by a 78 percent drop in the non-medical use of pain relievers.

State-level prescription drug monitoring programs (PDMPs) (see box for a description of Idaho’s program) have taken a leading role in detecting and deterring the diversion of popular prescription controlled substances, such as OxyContin and Vicodin. PDMPs, as they are known, are operational or plan to be operational in 24 states in 2005, with Ohio, Alabama, Wyoming, and New Mexico all establishing programs in the past year. Additionally, at least six states—New Jersey, Tennessee, South Carolina, Iowa, Missouri, and New Hampshire—are contemplating legislation to establish programs of their own. Some states, notably Mississippi and Oregon, expect to implement the program through administrative rule rather than legislation.

State PDMPs typically track prescription drug sales at the pharmacy level, helping pharmacists ensure the validity of prescriptions and helping physicians confirm that would-be abusers of prescriptions are not doctor shopping for prescription drugs. In the end, everybody benefits: doctors can better assist a patient when they know the patient is not receiving prescriptions from other doctors, the potentially abusing patient can only be the beneficiary of an intervention when his or her abuse comes to light, and law enforcement has better information on which to target the occasional unscrupulous practitioner or pharmacist.

Fiscal Year 2006 Budget Highlights

  • Office of Justice Programs—Drug Courts Program: +$30.6 million. The President’s budget includes funding of $70.1 million for the drug courts program in fiscal year 2006. 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 to generate data on drug court program outcomes is also included. 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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Last Updated: February 23, 2005



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