Challenges and Opportunities in Drug Demand Reduction (Continued)
H. Westley Clark, M.D., J.D.,
M.P.H., CAS, FASAM, Director
Center for Substance Abuse Treatment
Department of Health and Human Services
Unites States
Estoy muy contento de estar aqui nuevamente
con ustedes. I am very pleased to join you
again to continue the dialogue between the U.S.
and Mexico on Drug Demand Reduction. I have
been asked to focus my comments on providing
effective treatment.
For the Center for Substance Abuse Treatment
known as CSAT, effective treatment means
scientifically based, culturally relevant treatment
that can be replicated in different settings and
adjusted for use among various ethnic groups. I
would also like to note that effective treatment
improves the lives of individuals and families
affected by alcohol and drug abuse and reduces
the health and social costs to our communities
and the nation.
To collect scientific base data, CSAT conducted
the National Treatment Improvement Evaluation
Study, known as NTIES from 1992-1997. This
was the largest sample ever studied, with one of
the longest client follow-up periods in the
substance abuse treatment field.
This study found that the average economic
benefit to society was over three times the
average cost of a client treatment episode. The
average cost of a treatment episode was
$2,941, while the average per client benefit to
society in the year after treatment was $9,177.
SAMHSA
National Treatment Improvement
Evaluation Study (NTIES) 1992 - 1997
Largest sample ever studied - 4,000
55% African/American, non-Hispanic
26% white, non-Hispanic
15% Hispanic
4% other ethnic and racial backgrounds
Longest client follow-up period - 5 years
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Comparing the year before treatment with the
year after treatment, crime-related costs
decreased by 75 percent, average health costs
decreased by 11 percent, and client earnings
increased by 9 percent.
In our continuing data analysis we looked at
four large scale studies of community-based
treatment programs – NTIES, the CALDATA
study from California, the CSAT-sponsored
Services Research Outcomes Study and the
Drug Abuse Treatment Outcomes Study. All
four of these studies showed that marijuana
use, powdered cocaine use, and heroin use
declined significantly after treatment. Based on
these outcomes, we know that treatment is
effective and that effective treatment is not
buying blindly into unproven theories, but
utilizing proven methods.
SAMHSA
NTIES Findings NTIES Findings
Average economic benefit to society was
over three times the cost of client treatment
episode
$2,941 - average cost of episode
$9,177 - average per client benefit to society
Crime-related costs decreased by 75%
Average health costs decreased by 11%
Client earnings increased by 9%
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Effective treatment also means looking for new
ways to distribute available medications. CSAT’s
Office of Pharmacologic and Alternative
Therapies has a priority to develop new
guidelines that can be used to take patients that
have been stabilized on methadone
maintenance from a clinic setting to a private
physician’s offices for their continued treatment.
CSAT is also addressing the use of partial
agonists in office-based treatment. There are
two new narcotic treatment medications,
buprenorphine and buprenorphine/naloxone,
that are being reviewed by our Food and Drug
Administration (FDA).
We are also developing proposals for standards,
procedures and training of physicians who would
prescribe these new medications to patients in
treatment for illicit opioid use.
On May 4, CSAT published a notice of intent in
the Federal Register to develop regulations that
would allow physicians to provide partial agonist
treatment medications, upon approval by the
FDA, in office-based settings to patients
addicted to heroin.
Since partial or mixed agonist medications are
different than full agonist medications, such as
methadone, and have different risks associated
with their use, the Department of Health and
Human Services has designated CSAT as the
appropriate agency to tailor federal opioid
treatment standards to the specific
characteristics of these future medications.
These standards could include limits on the
number of patients that any one physician may
treat. The standards may also determine the
requirements for medical and psychosocial
services follow-up, such as substance abuse
counseling, that must be identified by the
attending physician. The proposed rule could
include standards affecting the quantities of
medications that could be prescribed, dispensed
or administered to patients for unsupervised
use.
CSAT envisions that the new rule, when
proposed, will allow office-based physicians to
prescribe partial agonist treatment medications
for opiate addiction when these new
pharmaceuticals become available. This is
prohibited under current law in the United
States.
SAMHSA
Improving Current Delivery Systems
Physician office-based treatment for
methadone, buprenorphine and naloxone
Pharmacy distribution of methadone
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To deal with the problem of methamphetamine,
the fastest growing drug problem here in
Arizona, and a major problem in many other
states in the southwest, northwest and midwest,
CSAT is sponsoring a study to determine the
most effective and cost-effective methods of
treating methamphetamine addiction.
The CSAT program is designed to test a 16
week psychosocial intervention approach
developed by the MATRIX Center in Los Angeles
and existing treatment models at seven
treatment sites in California, Hawaii and
Montana. An eighth site, the UCLA Drug Abuse
Research Center in Los Angeles, will coordinate
the research and analyze the cross-site data.
This is a three year program to determine what
methods can be successfully used to treat those
addicted to this very dangerous substance that
is particularly appealing to women, since it does
affect weight loss.
The study has been designed to see if results
can be replicated in different user populations
such as Latino women, pregnant women and
women with children, and Asian Pacific Islanders
or Native Americans, or in the gay community in
Los Angeles.
The study is looking at adolescent and adult
white males, Hispanic males, and white women.
The site in Hawaii is looking at effective
treatment of younger, less-educated users
whose parents are using marijuana or cocaine.
Specifically, the principles of drug addiction
treatment include common-sense approaches
towards service delivery. Effective substance
abuse treatment programs have:
- tailored treatment approaches, treatment
settings and services to each individual’s
particular problems and needs
- availability to treatment services at the time
that the individual needs help (which means
clients will not have to be placed on a
waiting list to receive services)
- the program options address the full
spectrum of the individual’s needs including:
medical, psychological, social, vocational
and legal problems
- the individual’s treatment plans allows for
flexibility in the course of treatment and
recovery and addresses appropriate
treatment approaches based on age,
gender, ethnic and cultural needs
- degree to which individuals in the program
are allowed to remain in treatment for an
acceptable length of time based on the
client’s needs
- degree to which individuals in treatment are
offered individual or group counseling and
other behavioral therapies as part of their
treatment protocol
- degree to which programs offer or have
access to pharmacologic alternative options
as part of the treatment services
- degree to which programs offer or have
access to psychological, psychiatric or
mental health services for individuals
demonstrating a coexisting mental disorders
- degree to which individuals in recovery are
monitored once the leave formal treatment
and degree to which individuals have the
option to participate in long term treatment
and to join self-help groups once they leave
treatment
- degree to which individuals are provided
with counseling to help them avoid high-risk
behavior and degree to which treatment
program provides assessments for
HIV/AIDS, Hepatitis B and C, tuberculosis,
and other infectious diseases.
Beyond these factors, what is important to
underscore is the undeniable fact that
detoxification should not be confused with
treatment. Medical detoxification is meant to
overcome acute symptoms of withdrawal. It is
not designed to deal with the underlying
problems that lead to drug use or to motivate
the patient to work toward long-term
abstinence.
SAMHSA
Critical Factors
Detoxification alone IS NOT treatment
Injection drug use is highly associated with
HIV/AIDS, hepatitis, sexually transmitted
disease and other medical consequences of
drug use and unprotected sex
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Another critical factor is that injection drug use
is highly associated with medical problems that
include HIV/AIDS, hepatitis, sexually transmitted
diseases, and other medical consequences of
drug use and unprotected sex.
Just last month, CSAT released a new Treatment
Improvement Protocol, “Substance Abuse
Treatment for Persons With HIV/AIDS” - or TIP
#37. This new TIP volume provides the latest
information on what is known about the
intersection or interrelatedness of HIV/AIDS and
substance abuse.
The TIP includes chapters on demographic
trends, identifies the information that is
important for conducting medical assessments,
identifies ways to determine mental health
needs, and discusses issues that might come up
for substance abuse counselors, including
dealing with their own prejudices when treating
HIV/AIDS-positive clients.
The TIP also offers information on how to
integrate other necessary services for these
patients including the use of case management
techniques, ways of managing pain, ethical and
privacy issues and funding and policy
considerations in the delivery of services.
CSAT is working to develop comprehensive
treatment models that programs can replicate to
provide the highest quality of substance abuse
treatment available anywhere. This should be
the strongest component of every demand
reduction effort. Given the complexities and
different variables that influence society as a
result of substance abuse among its population,
we need to continue our call for increased levels
of funding for substance abuse treatment
programs.
My last point is perhaps the most telling point.
In the U.S. we are spending an inordinate
amount of the Federal tax resources to cover
the costs associated with drug related crimes.
These crimes include the use or trafficking of
illegal substances, domestic violence incidents
related to substance use, and a cyclical pattern
to recidivism related to substance use.
CSAT is working diligently with other sectors of
the Federal government ? the Department of
Justice, Department of Labor, Department of
Education, Department of Housing and Urban
Development, Department of Transportation –
and with states and local governments to try to
better coordinate substance abuse treatment
programs at all levels.
Increasingly, these systems realize that we must
work together to create continuum of care for
individuals that have a substance abuse
problem. The continuum of care means that
once we have an individual that wants help, he
or she will not be turned away from learning a
new skill to sustain their recovery and to offer
them an opportunity to earn a decent living.
He or she will not be turned away from finding a
decent place to live. He or she will be provided
with the necessary information and parental
skills development so they can attempt to keep
their families intact and prevent them from
losing custody of their children.
SAMHSA
Collaborative Support Systems
Provide Continuum of Care
- Helping those who want help to learn new
skills and opportunity to earn a decent living
- Availability of decent housing
- Parental skill development, keep families
together
- Necessary medical attention
- Access to on-going counseling to prevent
relapse
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He or she will be given the necessary medical
attention to deal with their diabetes, their
HIV/AIDS and any other medical condition that
can adversely impact the road to recovery.
And, most importantly, he or she will have
access to on-going counseling to prevent an
irreversible relapse episode from clouding the
road to recovery.
At CSAT, our mission is to determine how we
can best support the coordination of substance
abuse treatment services and to help facilitate
the development and implementation of a
integrated service delivery systems.
Both of our countries need the commitment of
our governments, the health insurance sector,
the private sector, the foundations and the
dedicated throngs of substance abuse service
providers and practitioners to work together to
continue to minimize the adverse effects of
substance abuse within our borders.
Together, we will all make a difference as we
strive for productive societies unburdened by
the current weight of addictive behavior.
