Chapter III (continued)

2. Treating Addicted Individuals

Despite our best efforts, some people invariably will use drugs. A proportion will become addicted. Since this group causes untold damage to themselves, their families, and their communities, the addicted population must be targeted as a vital part of the Strategy. In a given year, addicts consume most of the heroin and cocaine in America. By reducing the number of addicts, we can greatly decrease the negative social and human consequences of drug abuse. Drugs have severe negative consequences for abusers' mental and physical health. Drug abuse also has tremendous implications for the health of the public since drug use is now a major vector for the transmission of infectious diseases, particularly HIV/AIDS, hepatitis, and tuberculosis. Because addiction is a complex and pervasive health issue, overall strategies must encompass a public-health approach, including extensive education and prevention, treatment, and research.

Research on Addiction³²

Scientific research and clinical experience have increased our understanding of addiction, which is characterized by compulsive drug-seeking and use — even in the face of negative consequences. Virtually all drugs of abuse affect a single pathway deep within the brain: the mesolimbic reward system. Activation of this system appears to be what motivates substance abusers to keep taking drugs. Not only does acute drug use modify brain function in important ways, but prolonged drug use causes pervasive changes in the brain that persist long after the individual stops taking a drug. Significant effects of chronic use have been identified for many drugs at all levels: molecular, cellular, structural, and functional.

The addicted brain is distinctly different from the non-addicted brain, as manifested by changes in metabolic activity, receptor availability, gene expression, and responsiveness to environmental cues. Some of these long-lasting changes are unique to specific drugs whereas others are common to many substances. We can actually see these changes through use of imaging technologies, like positron emission tomography. Understanding that addiction is, at its core, a consequence of fundamental changes in brain function means that a major goal of treatment must be to compensate for brain changes through medication or behavior modification.

Addiction is not just a brain disease. The social context in which drug dependence expresses itself is critically important. The case of thousands of returning Vietnam veterans who were addicted to heroin illustrates this point. In contrast to addicts on the streets of America, many of the veterans were relatively easy to treat. American soldiers in Vietnam who became addicted did so in a totally different setting from the one to which they returned. At home in the United States, veterans were exposed to very few of the conditioned environmental cues that had been associated with drug use in Southeast Asia. Conditioned cues can be a major factor in causing recurrent drug cravings and relapse even after successful treatment.

Addiction is rarely an acute illness. For most people, it is a chronic illness with a significant volitional dimension. Total abstinence for the rest of one's life is relatively rare following a single experience in treatment. Relapses are not unusual. Thus, addiction must be approached like other chronic illnesses — such as diabetes and hypertension — rather than acute conditions, like a bacterial infection or broken bone. This approach has serious implications for how we evaluate treatment. Viewing addiction as a chronic illness means that a good treatment outcome may be a sizeable decrease in drug use and long periods of abstinence.

Status of Drug Treatment

A significant treatment gap — defined as the difference between individuals who would benefit from treatment and those receiving it — exists. According to recent estimates drawn from the National Household Survey on Drug Abuse (NHSDA), the Uniform Facility Data Set (UFDS), and other sources, approximately five million drug users needed immediate treatment in 1998 while 2.1 million received it. The NIAAA report, Improving the Delivery of Alcohol Treatment and Prevention Services, estimates that there are fourteen million alcohol abusers whereas the 1998 NHSDA found approximately ten million dependent on alcohol. Certain parts of the country have little treatment capacity of any sort. Likewise, some populations — adolescents, women with small children, and racial as well as ethnic minorities — are woefully under-served. According to the Child Welfare League of America, in 1997 only 10 percent of child welfare agencies were able to locate treatment within a month for clients who needed it.³³ According to SAMHSA, 37 percent of substance-abusing mothers of minors received treatment in 1997.³⁴ Some modalities — namely methadone — fall short of needed capacity; 179,000 patients were in methadone treatment at the close of 1998. Furthermore, while treatment should be available to those who request it, society also has a strong interest in helping populations that need treatment but will not seek it. Drug-dependent criminal offenders and addicts engaging in high-risk behavior are important candidates for treatment, whether they want it or not.

Ultimately, calculations of the treatment gap should include both actual demand and populations that society has a special interest in treating due to the high social cost associated with their drug abuse. Starting in 2000, a new methodology — based on clinical criteria — will be employed in the NHSDA. This approach will provide improved national estimates by August 2001. More precise numbers will be helpful in determining the magnitude of the treatment gap and targeting resources to the areas where the gap is greatest.

Limited funding for substance-abuse treatment is a major factor that restricts the availability of treatment. Over the last decade, spending on substance-abuse prevention and treatment rose to an estimated annual level of $12.6 billion. Of this amount, public spending is estimated at $7.6 billion. The public sector includes Medicaid, Medicare, federal agencies like the Veterans Administration, the Substance Abuse Prevention and Treatment (SAPT) Block Grant, and other state and local government expenditures. Private spending is estimated at $4.7 billion and includes individual out-of-pocket payment, insurance, and other non-public sources. One of the main reasons for the higher outlay in public spending is the frequently limited coverage by private insurers. The lack of coverage and recent changes in payment structures affect attitudes, resources, treatment plans, and the quality of treatment. Private and public insurers are not working collaboratively; thus, more public resources are utilized, and government funds — which were intended to be a safety net — have become a primary option for many individuals.

In addition to resource limitations, other factors limit treatment, including restrictive policies and regulations, incomplete knowledge of best practices, resistance to treatment on the part of certain populations in need, and limited information on treatment at the state and local level. Action in the following areas can make treatment more available:

1. Increase SAPT Block Grant funding to close the treatment gap.
   
   
2. Use funding under SAMHSA's Targeted Capacity Expansion program; expansion of services to vulnerable and underserved populations; more outreach programs for those at risk of HIV/AIDS; and increased community options for sanctions among criminal and juvenile justice clients.
   
   
3. Use regulatory change to make proven modalities more accessible: reform regulation of methadone/LAAM treatment, maintain and improve program quality; train treatment professionals and physicians to employ the proper administration of opiate agonists and emerging pharmacotherapies; conduct demonstrations of administration by doctors of opiate agonists; and provide comprehensive evaluation of the impact of regulatory reform on treatment access, quality, and cost.
   
   
4. Continue examining possible changes in policy to remove barriers, such as lack of parity in insurance coverage. For example, the President recently announced that the Federal Employees Health Benefits Plan (FEHB) would provide parity for both substance abuse and mental health services.
   
   
5. Review policies, practices, and federal statutory requirements, such as the statutory exclusion of Medicaid funding for Institutes for Mental Disease (IMD), which may affect access to residential treatment services for substance abuse.
   
   
6. Prioritize research, evaluation, and dissemination — including state-by-state estimates of drug-treatment need, demand, and treatment resources; dissemination of best treatment practices; guidance on ways to increase retention and reduce relapse; and foster progress from external coercion to internal motivation.
   
   
7. Reduce stigma associated with drug treatment.

To improve treatment accountability, ONDCP is piloting an information system with treatment programs around the country that will be expanded by DHHS into the National Treatment Outcome Monitoring System (NTOMS). Under NTOMS, treatment performance will be measured and compared. In addition, an agreement has been negotiated with the states to establish a common set of outcome measures to be applied to programs receiving federal funding.

Treatment services are being fostered through manuals created by NIDA, Treatment Improvement Protocols and addiction curricula by CSAT, clinical guidelines by the Department of Veterans Affairs (VA), and a comprehensive curriculum for treatment by the Federal Bureau of Prisons (BOP). State and local treatment programs with promising results are applying these resources. CSAT has joined with the Certification Board for Addiction Professionals of Florida and a number of national stakeholder organizations to develop core competencies for substance-abuse counselors. Ultimately, these efforts will lead to a body of certified professionals equipped with manuals reflecting the most advanced approaches to treatment.

Adolescents with alcohol and drug problems are not adequately served in most existing drug-treatment programs designed for adults. Adolescents rarely seek help for problems related to drug and alcohol use. Referrals by juvenile courts are too often the first intervention. By this time, substance abuse has contributed to delinquent behavior, violence, and high-risk activities. There is also a paucity of research-based information about juvenile treatment. SAMHSA/CSAT, in collaboration with NIAAA, is supporting a five-year research grant, titled Treatment for Adolescent Alcohol Abuse and Alcoholism, which will contribute to the development of good programs for adolescents.

Services for Women

Although women use illegal drugs at lower rates than men, they experience the abuse and consequences of drugs and alcohol differently and require gender-appropriate prevention and treatment. Women who use illegal drugs, alcohol, or tobacco during pregnancy create health risks for themselves and their unborn children. Exposure to alcohol in-utero is associated with Fetal Alcohol Syndrome, Fetal Alcohol Effects, infant mortality and morbidity, attention deficit disorder, and other health problems. Women face unique barriers to treatment, such as the stigma associated with being a substance-abusing mother, fear of losing housing or custody of children, and lack of child-care. Substance abuse by older women, including alcohol and misuse of prescription and over-the-counter drugs, is a problem that merits more attention as our population ages.

Women in recovery from drug abuse are likely to have a history of violence and trauma. Consequently, they may be suffering from post-traumatic stress disorder. SAMHSA is addressing this issue in a two-phased study on Women, Co-Occurring Disorders, and Violence. This study seeks to discover ways to improve outcomes following substance abuse. In addition, the study promotes improved coordination of services through an integrated delivery system.

Substance Abuse and Co-occurring Mental Disorders

According to the National Comorbidity Survey, more than 40 percent of persons with addictive disorders also have co-occurring mental disorders. Data suggests that mental disorders precede substance abuse more than 80 percent of the time, generally by five to ten years.³⁵ We must take advantage of this window of opportunity to predict drug-abuse and prevent it. In addition, treatment providers must recognize co-occurring mental disorders and addiction in order to prevent relapse and improve the likelihood of recovery.

Roughly ten million people in the United States have co-occurring substance abuse and mental disorders. These individuals experience more severe symptoms and greater functional impairment than persons with a single disorder, have multiple health and social problems, and require more care. In addition, dual disorders are often associated with unemployment, homelessness, contact with law enforcement, and other medical problems like HIV/AIDS.

According to the Department of Veterans Affairs, about a third of adult homeless people once served their country in the armed services. On any given day, as many as 250,000 veterans (male and female) are living on the streets or in shelters, and perhaps twice as many experience homelessness at some point during the course of a year. About 45 percent of homeless veterans suffer from mental illness, and 70 percent have alcohol or other drug abuse problems. Considerable overlap exists between these two categories.

Treatment of co-occurring substance-abuse and mental-health disorders have historically been provided by multiple service delivery systems, which at times have been at odds with one another organizationally, philosophically, and financially — often to the detriment of the people in need. A new paradigm is necessary to provide services for a spectrum of co-occurring disorders. Early intervention, integrated treatment, cross-training of staff, licensing of medical personnel (psychiatrists, psychologists, etc.), consistent qualifications for other mental-health and addiction personnel, and sufficient funding are among the areas where innovative solutions are badly needed. Long-term studies of co-occurring disorders can help identify the best courses of treatment.

Parity for Substance-Abuse Treatment

From a scientific standpoint, management of addiction is similar to treating other chronic illnesses. Were insurance parity in place, substance-abuse treatment would be subject to the same benefits and limitations as other comparable disorders. Unfortunately, most employer-provided insurance policies currently place greater burdens on patients in terms of cost-sharing, co-payment, and deductibles while offering less coverage for the number of visits or days of coverage and annual dollar expenditures for treatment. Many health insurance companies impose lower lifetime limits on amounts that can be expended for drug and alcohol treatment than for other illnesses. Parity for substance-abuse treatment would correct these unfair practices and expand the amount of available treatment.

Parity is affordable. According to the SAMHSA report The Costs and Effects of Parity for Mental Health and Substance Abuse Insurance Benefits, the average premium increase due to full parity would be 0.2 percent — just a dollar per month for most families. Furthermore, other medical expenses incurred by treated patients are less than for untreated clients. Therefore, substance-abuse prevention and intervention saves employers money in both the short and long term. Documentation and validation of best practices for health-service providers are currently being prepared. These figures will include added cost offset, cost benefit, and cost utility incentives for both private- and public-sector employers.

Ending the disparity between drug abuse and other diseases through legislation would reduce the treatment gap. Such action could be particularly useful for adolescents who are covered by parents' insurance plans. Parity legislation will help lessen demands by people with private insurance on publicly funded treatment. Parity and the ensuing privatization of treatment would encourage more effective interventions. Indeed, the lack of private insurance for drug-abuse treatment discourages the development of new therapies.³⁶ Legislation supporting parity will move drug treatment further into the mainstream of health care and reduce the stigma associated with addiction.

The federal government has taken an historic step with regard to drug abuse and is serving as a model for other employers. In June 1999, the President announced that the Federal Employee Health Benefit Program (FEHB) would offer parity for mental-health and substance-abuse coverage by 2001. This unprecedented initiative will provide access to treatment for nine million people including federal employees, retirees, and their families. This move underscores the federal government's commitment to quality coverage for mental illness, substance abuse, and physical illness. In December, the FEHB began working with small businesses to provide these benefits.

Medications for Drug Addiction

Pharmacotherapies are essential for reducing the number of addicted Americans. Methadone therapy, for example, is one of the longest-established, most thoroughly evaluated forms of drug treatment. NIDA's Drug Abuse Treatment Outcome study found that methadone treatment reduced participants' heroin use by 70 percent and criminal activity by 57 percent while increasing full-time employment by 24 percent. A 1998 review by the General Accounting Office put the situation this way: "Research provides strong evidence to support methadone maintenance as the most effective treatment for heroin addiction." Methadone therapy helps keep more than 179,000 addicts off heroin, off welfare, and on the tax rolls as law-abiding, productive citizens. "A Notice of Proposed Rule Making" - published in the Federal Register on July 22, 1999 — proposed a new system of federal oversight for opioid treatment programs. This approach would transfer regulatory oversight from FDA to SAMHSA, provide greater flexibility to practitioners, and require program accreditation as a means of implementing best practice guidelines.

Buprenorphine is another medication under consideration for the treatment of opiate addiction. Buprenorphine and the combination drug Buprenorphine/Naloxone were developed under a cooperative research and development agreement between NIDA and a private corporation. Buprenorphine shares some, but not all, of the properties of an opiate. Unlike methadone, which is a full agonist, Buprenorphine is a "partial" agonist. In other words, it possesses both agonist and antagonist properties and therefore may pose less potential for abuse or overdose.^* Another benefit of Buprenorphine is that the withdrawal syndrome that occurs upon discontinuation is mild to moderate and often can be managed without the administration of other medications.

NIDA will continue funding a high-priority program to discover new medications for treating drug abuse. These research projects could result in new pharmacotherapies. Specific projects include development of an anti-cocaine agent, a controlled-release dosage of oral methadone, medications to treat withdrawal symptoms in babies born to opiate-dependent mothers, and medicines for methamphetamine addiction. Under ONDCP/CTAC sponsorship, Columbia University College of Physicians and Surgeons has been synthesizing highly active protein compounds of catalytic antibodies, which will act as a peripheral blocker and reduce serum cocaine concentrations in the blood. SAMHSA will develop treatment standards for new medications, as required by the Narcotic Addict Treatment Act (NATA).

Behavioral Treatment Initiative

Behavioral therapies remain the only effective treatment for many drug problems, including cocaine addiction, where viable medications do not yet exist. Furthermore, behavioral intervention is needed even when pharmacological treatment is being used. An explosion of knowledge in the behavioral sciences is ready to be translated into new therapies. NIDA is encouraging research in this area to determine why particular interventions are effective, develop interventions that could reduce AIDS-risk behavior, and disseminate new interventions to practitioners in the field. More specifically, this initiative will focus on adolescent drug use.

National Drug Abuse Treatment Clinical Trials Network

Over the past decade, NIDA-supported scientists have improved pharmacological and behavioral treatment for drug addiction. However, most of the newer methods are not widely used in practice because they have been studied in relatively short-term, small-scale contexts conducted in academic settings on stringently selected populations. To reverse this trend and improve treatment nationally, NIDA is establishing a National Drug Abuse Treatment Clinical Trials Network (CTN) to conduct large, rigorous, statistically powerful, multi-site studies in community settings using diverse patients. Science-based therapies that are ready for testing in the CTN include new cognitive behavioral therapies, operant therapies, family therapies, brief motivational enhancement therapy, and manualized approaches to individual and group drug counseling. Among the medications to be studied are: naltrexone, LAAM, buprenorphine for heroin addiction, and a few other substances currently being developed by NIDA for use against cocaine addiction.

Practice Research Collaboratives Program (PRC)

This SAMHSA/CSAT-supported initiative will improve the quality of substance-abuse services by increasing interaction and knowledge exchange among community-based stakeholders, including drug-abuse treatment providers, researchers, and policy makers. Nine grantees have been funded to create the necessary infrastructure for bridging the gap between research and practice in various parts of the country. During an implementation phase, PRCs will develop a provider-based knowledge agenda, create a provider-based research infrastructure, and implement studies on the application of evidenced-based practices in community settings.

Treatment Research and Evaluation

NIDA supports over 85 percent of the world's research on drugs of abuse. Recent studies of pharmacotherapies and behavioral therapies for abuse of cocaine/crack, marijuana, opiates, and stimulants (including methamphetamine) will improve the likelihood of successfully treating substance abuse. In addition, a comprehensive epidemiological system needs to be developed to measure the success of new therapies. NIDA will conduct clinical and epidemiological research to improve the understanding of drug abuse among children and adolescents. These findings will be widely disseminated to assist in finding more effective approaches to prevention. ONDCP/CTAC is sponsoring the development of the Drug Evaluation Network System (DENS), which will monitor and evaluate substance-abuse programs by tracking patients entering treatment, their characteristics, and discharge status. This information will be online and made available to treatment providers, researchers, and managers. To ensure that basic research is put to good use, SAMHSA supports applied research. For example, SAMHSA/CSAT's Methamphetamine Treatment Project (http://www.methamphetamine.org) is funding evaluations of sixteen-week methamphetamine interventions in non-residential (outpatient) psychosocial settings in California, Hawaii, and Montana. The objective is to determine whether promising results from stimulant treatment attained by the MATRIX Center in Los Angeles can be replicated.

Research into the Mechanisms of Addiction

Advanced brain imaging technology is being made available — under ONDCP/CTAC funding to research scientists working on grants from NIDA — to identify the underlying causes of substance abuse. Over the last two years, CTAC has sponsored the development of advanced brain imaging at several leading research facilities throughout the country:

• Functional Magnetic Resonance Imaging to map brain reward circuitry, blood volume and flow associated with drug metabolism, and interactions with potential therapeutic medicines (Massachusetts General Hospital and Emory University)
  
  
• Positron Emission Tomography (PET) for ultra high resolution of neurobiological substrates of addiction via use of radioisotope tracers (University of Pennsylvania)
  
  
• Magnetic Resonance Spectroscopy to image the drug's metabolic and chemical processes (Harvard University/ McLean Hospital)

Reducing Infectious Disease among Injecting Drug Users

Although the number of new AIDS cases has declined dramatically during the past two years because of the introduction of combination therapies, HIV infection rates have remained relatively constant. CDC estimates that 650,000 to 900,000 Americans are now living with HIV, and at least forty-thousand new infections occur each year. HIV rates among African Americans and Hispanics are much higher than among whites. Studies of HIV prevalence among patients in drug-treatment centers and women of child-bearing age demonstrate that the heterosexual spread of HIV in women closely parallels HIV among injection drug users (IDUs). The highest prevalence rate in both groups has been observed along the East Coast and in the South. Hepatitis B and C are also spreading among IDUs. IDUs represent a major public-health challenge. Addicted IDUs frequently have multiple health, psychological, and social problems that must be overcome in order to address their addiction, criminal recidivism, and disease transmission.

NIDA has created a center on AIDS and Other Medical Consequences of Drug Abuse to coordinate a comprehensive, multi-disciplinary research program that will improve the knowledge base about drug abuse and its relationship to other illnesses through biomedical and behavioral research. This work will incorporate a range of scientific investigation from basic molecular and behavioral research to epidemiology, prevention, and treatment. Information from each of these areas is essential for understanding the links between drug abuse and AIDS, TB, and hepatitis and for developing strategies for stemming infectious diseases spread through injection drug users. NIDA is conducting public-health campaigns to increase awareness of infectious diseases.

SAMHSA will continue its support of early intervention services for HIV through the SAPT block grants. Under the Congressional Black Caucus Initiative aimed at reducing the disproportionate impact of HIV/AIDS on racial and ethnic minorities, SAMHSA awarded 108 new grant totaling over $39 million. In FY 2000, SAMHSA expects to award in excess of $60 million to fund outreach, substance abuse prevention and treatment, and prevention services for women and youth in communities of color. The grants from SAMHSA's Targeted Capacity Expansion and Outreach Programs will improve substance-abuse treatment and prevention services in minority communities highly affected by the twin epidemics of substance abuse and HIV/AIDS.

Training for Substance-Abuse Professionals

Many health-care professionals lack the training to identify the symptoms of substance abuse. Most medical students, for example, receive little education in this area. If physicians and other primary-care managers were more attuned to drug-related problems, abuse could be identified and treated earlier. Many competent community-based treatment personnel lack professional certification. Consequently, SAMHSA/CSAT has worked collaboratively with the National Association of Alcoholism and Drug Abuse Counselors (NAADAC) and the International Certification Reciprocity Consortium/Alcohol and Other Drugs (ICRC) to improve the states' credentialing systems that respect the experiences of individual treatment providers while they earn professional credentials. CSAT's publication Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice — compiled in consultation with CSAT's National Curriculum Committee of the Addiction Technology Transfer Centers, NAADAC, ICRC, International Coalition of Addiction Studies Educators (INCASE), and the American Academy of Health Care Providers for the Addictive Disorders — offers a framework for the acquisition of knowledge and skills required for counselor certification.³⁷

Providing Services for Vulnerable Populations

For prevention and treatment to be effective, we must address the unique needs of different populations. As a result of managed care and changes in the welfare and health-care system, much-needed services may be less available to vulnerable populations, including racial and ethnic minorities like African-Americans, Native Americans, Alaskans, Hispanics, Asian American/Pacific Islanders; children of substance-abusing parents; the disabled; the poor; the homeless; and people with co-occurring substance abuse and mental disorders. SAMHSA/CSAT is addressing this problem in the Targeted Capacity Expansion Program, which responds to the treatment needs of serves these vulnerable populations. Our overall challenge is to help chronic drug abusers overcome dependency and lead healthy, productive lives. In addition, SAMHSA/Center for Mental Health Service's PATH program supports services to individuals who are homeless or at risk of homelessness, including homeless families. Three out of every five clients served through this program also have a co-occurring substance abuse disorder.

---

^* An agonist is a drug that activates a receptor in a manner that mim-ics the action of the natural neurotransmitter; an antagonist is a drug that occupies the receptor of a natural neurotransmitter but does not activate it, thus producing a functional blockade of the postsynaptic neuron