Chapter III.
United States Efforts to Reduce Demand for Drugs
B. Treatment
1. Close the Public System Treatment Gap
Although treatment services are available to more people today than ever before, ONDCP and SAMHSA recognize that treatment need has expanded more rapidly than the service system designed to meet that need. Nationwide, there continues to be a great need for additional capacity for effective drug treatment. The largest problem in treatment (the "gap") revolves around three issues: accessibility, affordability, and availability. These three issues effect both private and public funding. The efforts of this initiative focus on the federal responsibilities in relation to closing the public system treatment gap. Drug treatment overall is funded in FY 1999 at over $3 billion. The National Drug Control Strategy also addresses private sector treatment issues through its efforts to ensure parity for substance abuse treatment.
Block Grants to States: For FY 1999, the Substance Abuse Prevention and Treatment (SAPT) Block Grant is funded at over $1.6 billion, an increase of $275 million over FY 1998. Of this increase, $185 million will be used for the provision of substance abuse treatment services that will reduce the public system treatment gap. Additional requests include funding for the SAPT Block Grant and the Targeted Capacity Expansion Program. The Substance Abuse Block Grant provides funding to states and has been a cornerstone of federal efforts to close the public system treatment gap.
Targeted Capacity Expansion Program: This program differs from the block grant in that all of its funds are directed toward providing treatment services. In addition, the Targeted Capacity Expansion program makes awards directly to states, localities, and service providers based on their ability to demonstrate an emerging or existing need for expanded treatment services.
Parity for Substance Abuse: The Office of National Drug Control Policy (ONDCP) supports the concept of parity --health insurance coverage for the treatment of drug dependence that is essentially similar to the coverage for treatment of other medical and health problems. The National Drug Control Strategy’s goal of reducing drug use by 50 percent in the next ten years can only be accomplished with a significant expansion of capacity to treat chronic drug users. Parity offers an immediate opportunity to expand capacity. ONDCP has developed a position paper and is working with the Federal drug control agencies to establish parity as Federal policy.
2. Expansion of Treatment in the Criminal Justice System
At midyear 1997, more than 1.7 million U.S. residents were incarcerated. Of this amount, 99,175 inmates were in federal prisons and the remainder in state and local prisons. Since FY 1990, prisoners sentenced for drug offenses constituted the single largest group of federal inmates--approximately 60 percent. (Note: Similar statistics do not presently exist for state facilities. However, the Bureau of Justice Statistics' census of state and federal correction facilities showed that an estimated 23 percent of state prisoners were serving time for a drug-related offense.) From 1990 to 1996 the increase of nearly 24,000 drug offenders accounted for 72 percent of the total growth in federal inmate population. This population is expected to exceed 168,400 by 2004. By 2004, if current trends continue, over 104,400 inmates will be serving time for drug offenses. As the National Drug Control Strategy states "our nation has an obligation to assist all who are in the criminal justice system to become and remain drug-free." In order to break the cycle of drug abuse and its consequences, all drug-abusing inmates must have access to effective drug treatment programs. This initiative seeks to build upon established drug treatment programs targeted toward the criminal justice system. The Federal Bureau of Prisons (BOP) provides drug treatment to all eligible inmates, prior to their release from Bureau custody. The number of institutions offering residential treatment has grown from 32 to 42 since FY 1994. In FY 1997, nearly 31,000 inmates participated in Bureau treatment programs (education, 12,960; non-residential, 4,733; residential, 7,895; community transition, 5,315). This program is funded at over $26 million.
Provide Drug Testing and Intervention Programs: Research has shown that when drug testing is combined with effective interventions, such as meaningful, graduated sanctions, drug use can be curtailed within the criminal justice population. Further, recent studies demonstrate that drug-dependent individuals who receive comprehensive treatment decrease their drug use, decrease their criminal behavior, increase their employment, improve their social and interpersonal functioning, and improve their physical health. Moreover, when compared to substance abusers who voluntarily enter treatment, those coerced into treatment through the criminal justice system are just as likely to succeed. Since the majority of drug users are processed through some part of the criminal justice system during their drug-use careers, it makes sense to consider that system for intervention. The Administration’s proposal for this program would provide drug testing and intervention programs to non-incarcerated populations. (Note: Incarcerated populations would receive drug treatment services under the Criminal Justice Treatment Priority through Office of Justice Program's (OJP) Residential Substance Abuse Treatment Program and the Federal Bureau of Prisons' Residential Treatment Program.) The President's Drug Testing Program for Federal Probationers is funded at $4.7 million in the federal courts.
Treatment Reduces CrimeChanges in Criminal Activity in 12 Months Before Versus 12 Months After Treatment Exit
Figure 10
Drug Courts: The criminal justice system often fails to subject nonviolent, substance-abusing adult and juvenile offenders to intervention measures that provide the sanctions and services necessary to change their deviant behaviors. Many of these individuals repeatedly cycle through our courts, corrections, and probation systems. Title V of the Violent Crime Control and Law Enforcement Act of 1994 authorizes the Attorney General to make grants to states and local units of government to establish drug courts. Statistics collected by recently established drug courts show a significant reduction in recidivism among drug court program graduates. This program seeks to provide alternatives to incarceration through using the coercive power of the court to force abstinence and alter behavior. A combination of escalating sanctions, mandatory drug testing, treatment, and strong aftercare programs are used to teach responsibility and to transition offenders back into the community.
The Department of Justice provides $40 million in grants to localities for Drug Courts. This initiative expands the Drug Court program to more sites, expands both national and local evaluations of drug courts, as well as builds the state and local capacity to incorporate drug courts into established court management systems. It includes the following components: 1) development of state level technical assistance and training capacity; 2) provision of drug court management information system development assistance; 3) national-scope evaluations, with 1-2 year follow-up periods, of 20 to 30 sites to examine which aspects of drug courts produce the best outcomes; 4) provision of assistance to local drug courts so that local evaluations are of high quality; 5) double the current number of drug courts; and 6) target as wide a range of defendants who are eligible for release as possible. The results of this demonstration will assist in the modification or development of future criminal justice drug control programs.
Breaking-The-Cycle (BTC): BTC combines the coercive power of the criminal justice system with research-based treatment for populations under supervision of the criminal justice system. BTC activities include a range of drug testing options, as appropriate, and the use of relapse prevention and control measures such as graduated sanctions to bring about behavioral change.
On November 10, 1998, ONDCP and NIJ announced the three jurisdictions selected to participate with Birmingham, Alabama in the BTC initiative. Jacksonville, Florida and Tacoma, Washington, will introduce BTC into their adult criminal justice systems. Eugene, Oregon will implement the initiative in its juvenile justice system. Each jurisdiction received a multi-year, multi-million dollar grant, as well as extensive technical assistance and other support coordinated by the National Institute of Justice.
BTC programs include: drug testing; individual and group counseling; academic and vocational instruction; and training. This initiative will increase the capacity of the criminal justice system to refer addicts and heavy drug users to treatment and rehabilitation and monitor their progress.
Although Congress provided no funding in the FY 1999 budget to expand BTC further, they included a provision that would allow up to ten percent of funds going to states for prison construction (up to $50 million) to be used for drug testing and treatment during and after incarceration. Related initiatives expand the Bureau of Prisons residential drug treatment program, continue support for prison Residential Substance Abuse Treatment at the level of $63 million for Department of Justice grants to states, and expand the Arrestee Drug Abuse Monitoring System (ADAM).
3. Treatment Research Development and Evaluation
National Institute on Drug Abuse (NIDA): Recent intramural and extramural research in the area of pharmacotherapies and behavioral therapies for the treatment of the dependence on and abuse of cocaine/crack, marijuana, opiates, and stimulants, including methamphetamine, has shown great promise. In the past several years, significant strides have been made in drug abuse research: we have learned not only how drugs affect the brain in ways that affect behavior, but also that behavioral and environmental factors may influence brain function. One of the most significant breakthroughs has been the identification of areas of the brain that are specifically involved in craving, probably the most important factor that can lead to relapse. Working with modern, high resolution, neuro-imaging equipment, scientists discovered many underlying causes of addiction. Research using positron emission tomography scans shows that when addicts experience cravings for a drug, specific areas of the brain show high levels of activation. Armed with this knowledge, scientists are now determining pre-addiction physiological and psychological characteristics so that "at risk" subjects can be identified before addiction or drug abuse takes place. A major focus of NIDA's research has been on developing new medications. During the past year, several compounds have been identified that show promise as long-acting cocaine treatment medications.
Medications for Cocaine Dependence: Researchers at NIDA have discovered compounds that can block the effects of cocaine without interfering with the normal mood-modulating effects of dopamine. NIDA studies have led to the discovery of receptors in the brain which act as re-uptake transporters for dopamine, a chemical that causes pleasure responses in the brain, much like cocaine. Also, research has found that there are multiple dopamine receptors that respond differently to various compounds. For example, one type of dopamine receptor, D1, suppresses drug seeking behavior and relapse, where as activation of the D2, triggers drug-seeking behavior. These findings have been used for clinical studies.
Using equipment such as the positron emission tomography (PET), to identify brain regions that are particularly responsive to cocaine associated-stimuli, researchers have been able to identify brain activity associated with drug craving. This could help lead to the development of treatments that might prevent or reduce craving.
The conclusion of animal studies published in August 1998 in the journal Synapse showed that the epilepsy drug gamma vinyl-GABA, or GVG, blocked cocaine's effect in the brains of primates, including the process that causes "high" feelings in humans. The GVG research was sponsored by the Department of Energy's Office of Energy Research and the National Institute of Mental Health with the involvement of NIDA.
Methadone and Other Opioid Agonists: The use of methadone and, more recently, other opioid agonists such as bupernorphine is widely accepted in drug treatment. Methadone treatment, along with counseling and other interventions, has been used successfully to treat heroin addictions. Approximately 115,000 Americans are able to lead stable lives as a result of methadone treatment received at the more than 900 methadone treatment programs. The Drug Abuse Treatment Outcome Study (DATOS), conducted by NIDA, found that among participants in outpatient methadone treatment, weekly heroin use decreased 69 percent, illegal activity decreased 52 percent, and full time work increased by 24 percent.
Unfortunately, regulatory barriers limit methadone availability and therefore methadone treatment capacity. To correct this problem, regulatory oversight is undergoing extensive reform. A pilot test of accreditation for methadone treatment programs is underway. If this test proves successful the current regulatory approach will be replaced by an accreditation system. In this system, programs will be subjected to clinically based performance standards that emphasize comprehensive treatment. The accreditation system being developed is consistent with recommendations from recent reviews conducted by the National Academy of Sciences, NIDA, and the General Accounting Office (GAO).
Behavioral Treatment Initiative: Behavioral therapies remain the only available effective treatment approaches to many drug problems, including cocaine addiction, where viable medications do not yet exist. Behavioral interventions are needed, even when pharmacological treatments are being used. An explosion of knowledge in the basic behavioral science field is ready to be translated into new behavioral therapies. NIDA is encouraging research to develop and establish the efficacy of promising behavioral therapies, to determine how and why a particular behavioral intervention is effective; to develop and test behavioral interventions to reduce AIDS risk behaviors, and to disseminate efficacious behavioral interventions to practitioners in the field. More specifically, NIDA's behavioral research initiative will focus on therapies for adolescent drug use, addressing drug addiction treatment as HIV risk reduction, and determining the transportability of behavioral therapies to the community.
National Drug Treatment Clinical Trials Network: Over the past decade, NIDA-supported scientists have made tremendous progress in developing new and improved pharmacological and behavioral treatments for drug addiction. However, most of these newer treatments are not widely used in practice, in large part because they have been studied only in relatively short-term and small-scale studies conducted in academic settings on stringently selected patient populations. To reverse this trend and to dramatically improve treatment throughout this country, NIDA is establishing a National Drug Treatment Clinical Trials Network (CTN) to conduct large, rigorous, statistically powerful, controlled multi-site Stage III and Stage IV treatment studies in community settings using broadly diverse patient populations. The National Drug Treatment Clinical Trials Network will enable rapid, concurrent testing of a wide range of promising science-based behavioral therapies, medications, and their combined use, across a range of patient populations, treatment settings, and community environments nationwide. Science-based behavioral therapies that are in queue for testing in the CTN include new cognitive behavioral therapies, operant therapies, family therapies, brief motivational enhancement therapy, and new, manualized approaches to individual and group drug counseling. Medications to be studied include naltrexone, LAAM, buprenorphine for heroin addiction, and those currently being developed by NIDA for cocaine.
Center for Substance Abuse Treatment (SAMHSA/CSAT) : Effective rehabilitation programs characteristically differentiate by substances, cause addicts to change lifestyles, and provide follow-up services. However, all treatment programs are not equally effective. That is why efforts are underway to raise the standards of practice in treatment to ensure consistency with research findings. ONDCP, NIDA and SAMHSA/CSAT have focused on treatment in national conferences on marijuana, methamphetamine, heroin, cocaine and crack. Additional conferences on treatment modalities and treatment in the criminal-justice system were held during the spring of 1998. SAMHSA/CSAT continues to develop Treatment Improvement Protocols (TIPS), which provide research-based guidance for a wide range of programs. SAMHSA/CSAT also supports thirteen university-based Addiction Technology Transfer Centers, which cover forty states and Puerto Rico. These centers train substance-abuse counselors and other health, social service, and criminal-justice professionals. In addition, SAMHSA/CSAT have several programs in their portfolios that are intended to move research into the field and establish an epidemiological measurement system.
4. Reduce Infectious Disease Among Injecting Drug Users
Illegal drug users and people with whom they have sexual contact run higher risks of contracting gonorrhea, syphilis, hepatitis, and tuberculosis. Chronic users are particularly susceptible to infectious diseases and are considered "core transmitters." The prevalence of HIV infection in Injecting Drug Users (IDUs) and their sexual partners and children is high in the United States, and is on the rise in many other parts of the world as well. Not only is the AIDS/HIV epidemic a problem in this country, the reemergence of tuberculosis (TB) is also something which should be taken notice of when working on programs for injecting drug users. These populations, especially drug users who are dually infected with HIV and TB and who congregate in poorly ventilated areas, are suspected to be the source of TB infection for non-HIV infected crack smokers. This epidemic has continued to grow, especially among women on welfare. Many times, these women have infected their children, further adding to the medical costs borne out by society. Both hepatitis B and hepatitis-C continue to be an infectious disease problem associated with drug abuse.
Interventions for HIV/AIDS: The National Institute on Drug Abuse (NIDA) is continuing research programs on the enhancement and further development of behavioral therapies focusing on AIDS risk reduction. NIDA research has determined specific factors that should be present in intervention programs aimed at reducing the spread of HIV, especially among youth. It will identify the most effective types of interventions appropriate for different groups and communities, as well as the effect of abused drugs on the progression of AIDS. Drug abuse prevention and treatment significantly reduce drug use, improve social and psychological functioning, decease related criminality and violence, and reduce the spread of AIDS, TB and other diseases.
SAMHSA continues to support early intervention services for HIV through the Substance Abuse Prevention and Treatment (SAPT ) Block Grant in 38 States. In addition SAMHSA is developing a strategic plan to address HIV/AIDS with an emphasis on minority communities. Planned activities include funding the National Minority AIDS Council (NMAC) for $100,000 to define the gaps in HIV/AIDS activities and substance abuse treatment and prevention and mental health services for women in minority communities. A cooperative project, among the CDC; the National Association of State and Territorial AIDS Directors (NASTAD); and the National Association of State Alcohol and Drug Abuse Directors (NASADAD), has been started to define the barriers to collaboration of state and local HIV and substance abuse and mental health programs in minority communities. In addition, SAMHSA/CSAT targets funds to support comprehensive treatment for women and their children, substance abuse treatment programs that include an HIV component for men and youth, and prevention and substance abuse prevention services for African American and Hispanic youths.
The Centers for Disease Control (CDC) provides funding for AIDS drug counseling and drug-related HIV prevention activities. The Substance Abuse and Mental Health Services Administration (SAMHSA) also provides HIV/AIDS activities in support of this initiative. The program studies the efficacy, outcomes, recidivism, and HIV risk behaviors (needle use and sex) among injecting drug users.
5. Training for Substance Abuse Professionals
The recognition of substance abuse is the first step in treatment. Unfortunately, although most medical students are required to have some background in mental health training, they receive little education regarding substance abuse. If physicians and other primary-care managers were more attuned to drug related problems, abuse could be identified and treated earlier. In 1997, ONDCP and SAMHSA/CSAP co-hosted a conference for leaders of health-care organizations to address this issue. In addition, SAMHSA/CSAT published a Treatment Improvement Protocol: A Guide to Substance Abuse Services for Primary Care Clinicians.
A related problem is that many competent community-based treatment personnel lack professional certification. The administration supports a flexible system that would respect the experience of treatment providers while they earn professional credentials. Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice, a SAMHSA/CSAT publication, will help provide criteria with which to certify practitioners.
Educational Materials for Substance Abuse Professionals: This initiative is intended to develop educational materials for substance abuse professionals using information such as SAMHSA's Laboratory Certification Program Standards and other national professional, accreditation, and certification organizations materials. It also provides the resources necessary to develop performance and educational materials for substance abuse professionals. Funding will also be used to conduct training for substance abuse prevention and treatment professionals, and for employee assistance professionals employed by programs receiving federal funds.
