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National Drug Control Strategy
Update 2003
February 2003
- Healing America’s Drug Users:
Getting Treatment Resources Where
They Are Needed
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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.
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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.
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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.)
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Figure 9: Most of Those in Need of Drug Treatment Did Not Seek It
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Total in need of treatment = 6.1 million
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Source: National Household Survey on Drug Abuse (2001)
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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.
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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.
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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.
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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.
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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.
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Figure 10: Drugged Driving Is Highest Among Young Adults
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Percent Reporting Driving Under the Influence of an Illicit Drug
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Source: National Household Survey on Drug Abuse (2001)
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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.
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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
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