2002 National Drug Control Strategy
National Priorities II: Healing America's Drug Users
BUDGET HIGHLIGHTS
- Drug Abuse Treatment Programs—SAMHSA. The President has committed to adding $1.6 billion to the drug treatment system over 5 years. The following enhancements for the Substance Abuse and Mental Health Services Administration (SAMHSA) will provide additional funding to increase the capacity of the treatment system:
- Targeted Capacity Expansion (TCE) Program: +$109 million.
This additional funding will help SAMHSA expand the Treatment TCE program, which is designed to support a rapid, strategic response to emerging trends in substance abuse. Included in this proposal is $50 million to be used for a new component of the TCE program. This new component would be structured to reserve funding for state-level competitions, weighted according to each state's need for treatment services.
- Substance Abuse Prevention and Treatment (SAPT) Block Grant: +$60 million ($43 million of which will be drug related). This increase for SAMHSA's SAPT Block Grant will provide additional funding to states for treatment and prevention services. States use these funds to extend treatment services to pregnant women, women with dependent children, and racial and ethnic minorities.
- Promoting Drug Treatment in the Criminal Justice System—Department of Justice: Critical to breaking the cycle of drugs and crime is providing resources that promote drug treatment and early intervention to individuals who come into contact with the criminal justice system. This initiative expands two criminal justice treatment programs that seek to reduce recidivism among these populations.
- Residential Substance Abuse Treatment (RSAT) Program: +$7 million. This enhancement will expand the RSAT program to $77 million in fiscal year 2003. The RSAT program is a formula grant that distributes funds to states to support drug and alcohol treatment in state corrections facilities.
- Drug Courts Program: +$2 million. These additional resources will expand the Drug Courts program to $52 million in fiscal year 2003. The Drug Courts program provides alternatives to incarceration by using the coercive power of the court to force abstinence and alter behavior through a combination of escalating sanctions, mandatory drug testing, treatment, and strong aftercare programs.
Healing America's Drug Users: Getting Treatment
Resources Where They Are Needed
Many people stop using drugs on their own. Some stop only when faced with consequences, such as the loss of a professional license, a job, or personal liberty. Some do not or cannot stop. Their drug use has progressed to addiction, and they need our help.
To get them that help, the Federal Government needs more reliable needs assessments at the state and local levels to guide the expansion of particular types, or modalities, of drug treatment. We need better information about what works in drug treatment and where there are shortages of capacity. We also need to work toward administration of standardized assessments and to ensure appropriate placement for those in need of treatment.
Yet for more than a decade, the public agenda in this area has been preoccupied by an exclusive focus on the question of treatment capacity—whether the Federal Government is spending enough to make treatment services available to those in need.
But what is the total need? What is the capacity of our Nation's drug treatment system? And what, by extension, is the "right" level for federal treatment funding? Remarkably, until relatively recently, policymakers were saddled with a number of crude and deficient tools for estimating treatment capacity and the number of individuals in need of treatment.
Our understanding of treatment need advanced significantly with the release, in September 2001, of new data from the National Household Survey on Drug Abuse. By incorporating into the survey questions distilled from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), we are now for the first time able to estimate that there are roughly 2.8 million "dependent" users, along with an additional 1.5 million users deemed to fall in the less severe "abuser" category.
As defined in DSM-IV, 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. Abuse is characterized by problems at work, home, and school; problems with family or friends; voluntary exposure to physical danger; and trouble with law enforcement. Individuals in both categories will have difficulty ending their drug use without treatment.
As currently constituted, the treatment system is not able to help all those deemed to be in need of drug treatment; according to conservative estimates, only an estimated 800,000 individuals had received drug treatment in the year prior to the survey. The President has committed to supporting a $1.6 billion expansion in federal treatment aid over 5 years. Consistent with this pledge, the President's 2003 budget requests an increase of approximately $100 million in federal treatment spending for the Substance Abuse and Mental Health Services Administration. (This enhancement is part of an overall treatment increase of $224 million for fiscal year 2003.)
But the Household Survey contains another remarkable finding, one that argues that expanding the treatment system is not by itself sufficient. Frustrating the work of treatment providers, the overwhelming majority of users characterized with dependence or abuse do not see themselves as actually needing drug treatment. This tendency is particularly pronounced among adolescents and young adults. Of
the estimated 3.9 million individuals who needed but did not receive treatment in 2000, fewer than 10 percent—just 381,000—reported actually thinking that they needed help.
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There are good reasons for believing that the latter estimate is too low. The survey from which it is derived omits individuals currently in residential treatment and does not cover groups such as homeless people not living in shelters. ONDCP will convene experts to build on the significant work that has already been done by the Department of Health and Human Services and others to attempt to determine more precisely the number of individuals currently receiving drug treatment services as well as the number of those seeking access to drug treatment. New data collection systems will aid in this process, including the National Treatment Outcome Monitoring System—currently being developed by ONDCP and the Center for Substance Abuse Treatment—which will provide vitally needed information on treatment admissions,
waiting times, and treatment outcomes.
But the obvious conclusion one would draw from the data is in fact the correct one: most people who need drug treatment do not think they have a problem. To borrow a popular phrase, they are in denial. If there were ever any question about the role of coercion in getting people into treatment, these findings should answer it.
Most drug users—the lucky ones, at least—are no strangers to coercion. People in need of drug treatment are fortunate if they run up against the compassionate coercion of family, friends, employers, the criminal justice system, and others. Such pressure needs no excuse; the health and safety of the addicted individual, as well as that of the community, require it.
Compassionate coercion begins with family, friends, and the community.
Americans must begin to confront drug use—and therefore drug users—honestly and directly. We must encourage those in need to enter and remain in drug treatment.
Of course, drug users often conceal their involvement with illegal drugs. Yet looking back to the most recent Household Survey data, we know that there are more than 4 million Americans who, according to the DSM-IV definitions, suffer from a mix of difficulties that range from emotional problems to trouble with law enforcement. Drug users may be secretive, but their problems are often visible to us if we are willing to look for them.
Researchers estimate that well over half of all cocaine and heroin is purchased by individuals formally under the control of the criminal justice system—either on pretrial release, probation, or parole. Some 50-80 percent of arrestees in major cities tested positive for drugs at the time of arrest. The Bureau of Justice Statistics estimates that 150,000 state inmates are released each year without receiving needed
drug treatment, thus making the criminal justice system perhaps the most important natural ally of the drug treatment system. This Administration seeks to capitalize on the link between prison and drug treatment by expanding the Residential Substance Abuse Treatment program, a federal grant program that distributes funds to states to support drug and alcohol treatment in state corrections facilities.
At the federal level, with the goal of achieving a drug-free prison system, the Bureau of Prisons will be pushing for 100 percent inmate participation in prison treatment programs while improving treatment continuity for persons being released from confinement to community supervision. The Bureau will also seek to administer a drug urinalysis to every federal inmate within 60 days of release and will provide
appropriate sanctions for a failed test.
WHAT WORKS IN DRUG TREATMENT:
OPERATION PAR
Operation PAR (Parental Awareness and
Responsibility), serving five Florida
counties, got its start in 1970 in the way
many effective programs do—a parent
concerned about her daughter's drug use
took action. The organization's Family
Support Network, an initiative designed to
reduce marijuana use among youth, boasts a
superior retention rate, keeping 88 percent
of its clients in treatment after 10 months.
Operation PAR also provides drug
treatment programs for Florida felons and
boasts a 17 percent recommitment rate
after 2 years for individuals completing the
Long-Term Secure Drug Treatment
Program. A program for juvenile offenders
produces similar results.
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In addition, the Administration proposes to increase federal support for the Drug Courts program in fiscal year 2003. Drug courts use the coercive power of the judicial branch to force abstinence and alter behavior through a combination of escalating sanctions, mandatory drug testing, treatment, and effective aftercare programs. Some 782 drug courts now operate in 49 states and represent one of the most promising innovations in recent memory. Intrusive and carefully modulated
programs like drug courts are often the only way to free a drug user from the grip of addiction. The Federal Government will be undertaking a longitudinal review of selected drug court programs to determine the long-term effects of drug court participation.
The criminal justice system is far from the only lever treatment providers have over drug users, a majority of whom work for a living. Companies know that drug use among their employees detracts from the bottom line, translating directly into increased absenteeism and tardiness, higher employee turnover, more damaged and stolen property, and more workers' compensation claims.
KEY FINDINGS ABOUT DRUG TREATMENT
- Nearly 10,000 clients in community-based
programs in 11 cities were compared
before and after treatment on a number of
key outcomes. Depending upon treatment
modality, the data showed reductions in
weekly use of heroin (between 44 and 69
percent), cocaine (between 56 and 69
percent), and marijuana (between 55 and
67 percent); reductions in illegal behavior
(between 36 and 61 percent); and
improvements in employment status
(between 4 and 12 percent).
- One year following discharge from drug
treatment, use of the primary drug of
choice dropped 48 percent; arrests dropped
64 percent; self-reported illegal activity
dropped 48 percent; and the number of
health visits related to substance use
declined by more than 50 percent.
- Five years after discharge, there was a 21
percent reduction in the use of any illegal
drug—a 45 percent reduction in powder
cocaine use, a 17 percent drop in crack
cocaine use, a 14 percent decline in
heroin use, and a 28 percent drop in
marijuana use. Similar reductions were
reported for criminal activity: a 30
percent reduction in selling drugs, a 23
percent decrease in victimizing others,
and a 38 percent drop in breaking and
entering, as well as a 56 percent drop in
motor vehicle theft.
Sources: Drug Abuse Treatment Outcome Study,
National Treatment Improvement Evaluation Study,
and Services Research Outcomes Study.
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Private industry, including the vast majority of Fortune 500 companies, has been quick to adopt drug-free workplace policies, including employee assistance programs (EAPs), which can require employees to participate in drug treatment programs. The success of major companies may even have had the unintended consequence of making small businesses more attractive to drug using employees, since small companies are less likely to screen employees for drug use either before or during employment. Employees of smaller firms are also less likely to have access to EAPs.
Targeting Treatment Resources
By now, most Americans are acquainted with the idea that recovery from addiction is a lifelong challenge, yet few understand what that signifies for drug treatment programs. Simply put, for many people, ceasing a life of drug use involves more than one attempt at treatment and more than a single mode of drug treatment.
HELPING FAMILIES HELP THEMSELVES
In 1995, a tiny grocery store in
Manhattan�s Lower East Side was the
scene of a police shootout with local drug
dealers that left one person dead and a
police officer paralyzed. The following year,
in that same corner store, La Bodega de La
Familia opened its doors with an inventive
plan to make drug treatment work better
by helping the people around drug using
criminal defendants— including family and
friends. The strategy—helping families
help their loved ones—has been a big
success. Preliminary results of a study by
the Vera Institute of Justice indicate that
participants in La Bodega�s program
significantly reduced their use of illegal
drugs. Over a six-month period, pastmonth
use of cocaine among La Bodega
participants fell from 42 percent to just
10 percent (compared to a drop of 27
percent to 21 percent for a control group).
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Effective treatment programs face a daunting challenge. Research has demonstrated that drug use can change the very structure and function of the brain, diminishing the capacity to make judgments, control impulses, and meet responsibilities. Advances in brain imaging techniques are enabling scientists to observe real-time neurochemical changes occurring in the brain as it processes information or responds to stimuli—including illegal drugs or drug treatment medications.
Brain imaging techniques reveal that illegal drugs like MDMA, better known as Ecstasy, modify brain chemistry by damaging neurons and altering the functions responsible for the release of serotonin, a brain chemical responsible for regulating memory and other cognitive functions, such as verbal reasoning and the ability to sustain attention. Additional studies suggest that the toxic effects of drug use persist long after an individual discontinues use.
While roughly half of all treatment is funded through private or other non-federal means, policymakers pondering questions about treatment spending have found their work simplified by a calculus of self-interest. Briefly, the costs incurred in providing drug treatment are dwarfed by the costs of not providing treatment. Supporting drug treatment—helping drug users break the cycle of addiction—therefore makes sense on fiscal grounds as well as being the right thing to do.
Treatment capacity is an important question, and the President's $1.6 billion initiative to increase the system's capacity was previously discussed. Yet the exclusive focus on treatment capacity has diverted attention from other important questions, such as how to direct current treatment resources more effectively, as well as how to improve the quality and availability of aftercare services.
RALLYING FAITH-BASED ORGANIZATIONS
When attempting to bring about a
personal transformation of a drug user
whose life has spun out of control, it only
makes sense to call upon the lifetransforming
power of faith. The role of religion and spirituality in both preventing
and treating substance abuse is
documented in the results of a two-year
study titled So Help Me God: Substance
Abuse, Religion and Spirituality, by the
National Center on Addiction and
Substance Abuse at Columbia University.
The report found that participation in
spiritually-based treatment programs
increases the odds of maintaining
abstinence and concluded that "religion
and spirituality can play a powerful role in
the prevention and treatment of substance
abuse, and in the maintenance of sobriety."
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In considering the federal role in expanding the treatment system, the sheer diversity of approaches aimed at freeing individuals from addiction argues for a greater focus on our ability to direct those in need to the most appropriate type, or modality, of drug treatment. This Administration takes a major step in that direction with a request for an increase of 109 million for the Treatment Targeted Capacity Expansion (TCE) program—grants that are awarded to the cities, towns, counties, and states most in need. The program also targets high priority groups for treatment, such as adolescents, pregnant women, and racial and ethnic minorities.
Treatment programs take many forms. They vary from an 18-month, inpatient therapeutic community in the rural Catskills, where clients learn discipline and basic life skills, to an outpatient clinic in Los Angeles, where heroin addicts line up for a daily dose of methadone and periodic counseling, to a longterm, faith-based program in Portland, Oregon, that uses the power of faith as an essential part of the treatment process.
The most intensive aspects of treatment typically are relatively short lived, and treatment must be followed by an aftercare component if long-term abstinence is to be a realistic expectation. For an increasing number of people, that abstinence is coerced—by family, friends, an employer, or the criminal justice system. For tens of thousands, the key to staying away from drugs is a Twelve Step program, such as Narcotics Anonymous, an American success story that is modeled after the Alcoholics Anonymous movement, and which began developing in the 1940s. The success of NA and programs like it stems in large part form a single-minded emphasis on abstinence and the support of other individuals who also face the challenge of sustaining recovery for the rest of their lives.
