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Chapter II.
Demand Reduction Goals, Objectives and Target Measurement

D. Principles of U.S. Demand Reduction Effort

Once viewed as essentially a moral problem or character defect, drug use is now more accurately considered a complex behavioral problem with personal, social, and biological underpinnings. Some individuals are at greater risk of drug related problems than are others. Thus, implementing prevention strategies requires awareness of factors that place individuals at increased risk and, conversely, factors that protect individuals from such risk. Similarly, drug treatment and rehabilitation strategies must address factors that foster or hinder entry into, and successful completion of, drug treatment. America's drug demand reduction strategy takes into account:

  • Scientific advances in our understanding of education, prevention, and treatment, which must be reflected in practice;

  • Recent setbacks in youth attitudes toward and use of drugs, especially marijuana;

  • Pro-use messages sent to our young people by well-organized drug legalization efforts, the media, and other manifestations of popular culture;

  • The cost and service reduction pressures inherent in managed health care approaches being adopted by private employers and public programs, which threaten the effectiveness, stability, and continuity of prevention, early intervention, and treatment programs; and

  • The shifting of resource allocation decisions and program accountability from the federal to the state and local level.
1. Prevention

Progress in prevention will require significant, long-term change in youth attitudes toward drug use. Such a change in attitudes will depend in large part on a consistent "no use" message from American society, together with predictable negative consequences for use and affirmation of the benefits of abstinence.

Principles. Prevention programs must work at all levels, but especially where they can do the most immediate good -- at the local level. Local leaders must be given the tools to implement and manage effective programs.

  • Prevention must be incorporated into the institutions that are closest to our children and our families. It must start with the informed leadership of parents and remain constant and consistent.

  • Numerous scientific investigations have established the fact that families play the most important role in determining how young people handled the temptations to use alcohol, cigarettes, and illegal drugs. If families are to succeed in preventing substance abuse by children, many parents and children need to develop new behaviors and skills.

  • Interrelated, family-focused prevention programs should be conducted in schools, health clinics, faith communities, workplaces, and communities.

  • No one approach or program is the answer, but each is part of the answer. Individual programs should be structured to complement one another. They should be viewed and judged in terms of their contribution to the overall, cumulative results in the community.

  • Individual programs should be required to incorporate the established results of research and evaluation and held accountable for producing results.

  • targeting all forms of drug use, including underage alcohol and tobacco use.

  • matching activities to the nature of the problem in the community.

  • beginning early in young peoples' lives and continuing with developmentally appropriate interventions.

  • providing long-term, intensive efforts for children most at risk, with special attention to appropriate booster sessions during critical life transitions (e.g., middle school to high school).

  • reflecting a sensitivity to the specific needs of gender, and particular ages and ethnic and cultural groups.

  • assessing and strengthening social norms against drug use.

  • imparting drug resistance skills, critical thinking skills, social competency skills, and the needed communication skills to explain and reinforce personal anti-drug commitments.

  • maintaining a family focus, with significant parent involvement.

For example, school-based programs must: instill strong social norms against drugs, evoke a commitment to avoid drugs, provide solid drug resistance skills, provide self-management and social skills, recruit peer leaders to work with teachers, and involve parents in a strong leadership role with their children.

The federal government is uniquely equipped to help states, local governments, and communities gather and disseminate information on effective family, school, health provider, faith community, workplace, and community prevention approaches. Provision of information on proven effective approaches, and support for its application must be our highest, short-term, domestic priority. Federal government provision of information about state-of-the-art approaches to prevention is also critical, and must be continuous in response to new research findings.

Treatment Reduces Drug Use

Changes in Illicit Drug Use in 12 Months Before Versus 12 Months After Treatment Exitfigure 8
Figure 8

2. Treatment and Rehabilitation Services

Reducing the numbers of addicted persons is also essential to reducing drug demand. While intervention and treatment are important first steps in accomplishing this goal, many addicts also will require rehabilitation services if they are to achieve stable abstinence and recovery.

Drug addiction is a chronic relapsing condition involving a long-term change in brain chemistry. Drug seeking and using behavior also trains the brain. Addicts are not simply sick people. Rather they are sick people who engage in a web of behaviors that exacts a toll on the health and safety of all society's institutions, starting with the family. Many drug users cannot, and sometimes do not want to, control their behavior. They may resist efforts to bring their actions in line with the requirements of society.

Only the most structured interventions can get chronic users and addicts into treatment, keep them in treatment, provide the supervision and support required to start them on recovery, and enable them to maintain their recovery over the long term. It is progressively more apparent that long-term progress in reducing and managing this population requires a rehabilitation approach that: confronts and exposes thinking errors and the addictive lifestyle, provides for values and character development, matches specific services to specific needs, and continues needed services for a significant period of time.

Intensive (often residential) drug treatment or therapy is essential for many addicts but may be of reasonably short duration. The services that prepare the addict for recovery and support continuing recovery, while much less expensive, are of much longer duration.

  • Vocational skills, social survival skills, relapse prevention skills, social supervision and support, medication -- most of these will be necessary to some extent, and for a long period of time, to allow the continuation of the process that begins with intensive treatment.

  • During this transitional, or "aftercare," period self-help groups, social model programs, faith-based programs, and other nonprofessional groups can offer the structure, sanctions, and support that are so critically needed.

Principles. Given the chronic relapsing nature of addiction, the consequences of addictive behavior for the individual, the family and society, and given the condition of existing service systems, our efforts to rehabilitate and assist people with addictive disorders are governed by the following principles:

  • We must take full advantage of any opportunity to get addicts into a formal treatment and rehabilitation program.

  • The criminal justice system offers an immediate opportunity to engage significant numbers in treatment and long term rehabilitation;

  • The child welfare system offers a similar opportunity most drug dependent mothers can be motivated and helped to act in the interest of their children. Since the children who are involved in the child welfare system are also at high risk for substance abuse, such involvement also offers an opportunity to prevent future substance abuse by providing these children with needed therapeutic and supportive services.

  • Existing criminal justice and child welfare systems of treatment and rehabilitation should be expanded and systematic support and referral systems should be developed for workplaces and health care service settings.

  • All treatment programs should employ a comprehensive assessment instrument at the point of intake, and to update that assessment periodically during the course of treatment and recovery. Programs should assess progress and respond to lack of progress.

  • All treatment programs should develop a formal, long-term rehabilitation plan, in accordance with the results of the assessment; and review and revise it in accordance with periodic assessments. This should include the initial intensive therapy and pharmacology and the longer-term recovery plan.

  • All formal treatment interventions should include specific, realistic relapse prevention training and compliance motivation training, during the initial course of treatment and as a continuing part of recovery.

  • Consequences for non-compliance should be established clearly; they should be graduated and employed swiftly and fairly.

  • Treatment programs should be held accountable for results in light of the relative difficulty of the population they serve, as determined by the initial, comprehensive assessment.

  • A supervision and support person or organization should be designated for each person who completes the initial stage of treatment, to manage and supervise and ensure continuing compliance with the recovery plan.

The federal government plays a leadership role in assisting the states to establish systems of rehabilitation. Federal treatment programs, such as those in the Department of Veterans Affairs and the Federal Bureau of Prisons, can lead by example. Grant-in-aid programs, supported by the Departments of Health and Human Services and Justice, provide explicit guidance and assistance to states and localities.

3. Focus on the Criminal Justice System

The nexus between drug use and the criminal justice system is clear. As Arrestee Drug Abuse Monitoring (ADAM) statistics show, between one half and three quarters of all arrestees tested in the 35 ADAM cities have drugs in their systems at the time of their arrest. Not only are these arrestees deeply involved in drugs, many are severely addicted, and few have ever been in treatment. Furthermore, frequent drug users who are involved in the criminal justice system are responsible for consuming a significant portion of the illegal drugs consumed in this country.

Reducing drug use among the criminal justice population not only contributes significantly to the overall goal of reducing drug use by half by 2007, it also goes a long way to reducing crime in America. The treatment needs of the population under control of the criminal justice system should be based on four principles:

  • Treatment works. Not all treatment works equally well for all populations, and relapse is to be expected. However, we are striving to be more accurate in matching treatment to drug users, and hope to differentiate treatment settings that are appropriate for juveniles, for poly-drug users, for those with co-occurring substance abuse and mental disorders, and for different, and for different cultural and ethnic groups. Scarce treatment resources have to be allocated according to the best match between participant and provider, based on scientific evidence of effectiveness and solid diagnostic profiles of clients.

  • Coerced Treatment Works. Addiction is a brain disease, but one that often results in criminal behavior. Treatment of addiction requires management of behavior, and the criminal justice system can provide "incentives" for an addict to change behavior, such as rewards and sanctions. It should be noted that coercion also includes the threat of losing a job or a relationship.

  • Length of time in treatment is correlated with success. Drug use for individuals who participated in either long-term residential or outpatient treatment programs showed reductions in both criminal activity and drug use, especially those who had been in treatment for at least 90 days. Research also shows that the presence of criminal justice supervision increased the likelihood that the individual would stay beyond the 90-day mark.

  • Post-release supervision is an essential ingredient to successful prison-based treatment. Results of an evaluation of Delaware's Key-Crest Program, those prisoners who participated in a transitional work release program after in-prison drug treatment were more than twice as likely to remain drug free, and were one-third more likely to remain arrest free eighteen months after release.