IV. A Comprehensive Approach
3. Treating the Addicted
Despite our best efforts, some people invariably will use drugs. A proportion will become addicted. Since they constitute a group that causes untold damage to themselves, their families, and their communities, the addicted population is a group that must be targeted as a vital part of the Strategy. In any 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 and addiction also have 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 -- and for the infliction of violence as well. Because addiction is such a complex and pervasive health issue, overall strategies must encompass a committed public health approach, including extensive education and prevention efforts, treatment, and research.
Research on Addiction18
Scientific research and clinical experience have yielded a greater understanding of the essence of addiction, manifested by compulsive drug seeking and use, even in the face of negative health and social consequences. Virtually all drugs of abuse have common effects, either directly or indirectly, on 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. All addictive substances affect this circuit. Not only does acute drug use modify brain function in critical ways, but prolonged drug use causes pervasive changes in brain function that persist long after the individual stops taking the 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 brainmetabolic activity, receptor availability, gene expression, and responsiveness to environmental cues. Some of these long-lasting brain changes are unique to specific drugs, whereas others are common to many different drugs. We can actually see these changes through use of recently developed technologies, such as 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 either to reverse or compensate for brain changes through medication or behavioral modification.
Addiction is not just a brain disease. The social context in which the disease develops and expresses itself is critically important. The case of thousands of returning Vietnam veterans who were addicted to heroin clearly illustrates this point. In contrast to addicts on the streets of America, the returning veterans were relatively easy to treat. The American soldier in Vietnam became addicted in a totally different setting from the one to which he returned. At home in the United States, he was exposed to very few of the conditioned environmental cues that had been associated with drug use in Vietnam. Conditioned cues can be a major factor in causing recurrent drug cravings relapses even after successful treatment.
Addiction is rarely an acute illness. For most people, it is a chronic, relapsing disorder with a significant volitional dimension. Total abstinence for the rest of one's life is a relatively rare outcome from a single experience in treatment. Relapses are not unusual. Thus, addiction must be approached like other chronic illnesses -- diabetes, chronic hypertension -- rather than like an acute illness, such as a bacterial infection or broken bone. This approach has tremendous implications for how we evaluate the effectiveness of treatment. Viewing addiction as a chronic, relapsing disorder means that a good treatment outcome may be a significant decrease in drug use and long periods of abstinence, with only occasional relapses. Abstinence, however, should always be the goal.
Closing the Public Treatment System Gap
In 1996, approximately 4.4 to 5.3 million people were estimated to need drug treatment.19 Slightly less than two million people currently receive drug treatment. Clearly, there is a substantial gap between the number of persons in need of treatment and the number receiving it. One aspect of the Administration's efforts to reduce this gap is the expansion of SAMHSA's Substance Abuse Prevention and Treatment Block Grant. This grant is awarded annually to states based on a formula that includes funding for prevention activities and treatment services for drug and alcohol abuse as well as a number of other purposes including tuberculosis services and early intervention services for HIV. The grants specifically target substance-using pregnant women, women with dependent children, and injection drug users. SAMHSA estimates that each federal dollar spent on treatment through this grant program generates 1.5 dollars in state and local spending on treatment.
The second component of the federal effort to reduce the public treatment system gap is expansion of the Targeted Capacity Expansion program that makes awards directly to states, counties, cities, and service providers. The goal of this program is to address gaps in treatment capacity by supporting rapid and strategic responses to demand for treatment. Grants will target communities with serious, emerging drug problems as well as communities with innovative solutions to unmet needs. In 1999, these programs will include an HIV/AIDS component targeting minority populations at risk of contracting HIV/AIDS or living with HIV/AIDS. The goal is to enhance and improve existing substance abuse treatment services for minority populations in states and cities significantly affected by the twin epidemics of substance abuse and HIV/AIDS. An associated challenge is providing comprehensive services that address the complex needs of substance abusers with co-occurring mental disorders. These people experience greater functional impairment and are more likely to have multiple health and social problems.
Expanding Treatment for Adolescents
The need for community-based treatment for troubled teens who are dependent on drugs is particularly great, and there is an even more dramatic shortage of treatment in the juvenile correctional system. Adolescents with alcohol and drug problems are not adequately served in most existing drug-treatment programs designed for adults. IOM's 1990 report, Treating Drug Problems estimated that about four hundred thousand people under eighteen years of age were annually in need of treatment. Adolescents rarely seek help for problems related to alcohol and other drug 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 like unprotected sex and driving while intoxicated. There is also a paucity of research-based information about the effectiveness of juvenile treatment. SAMHSA is addressing these problems by evaluating adolescent-focused interventions and providing communities grants for adolescent treatment through its Targeted Capacity Expansion program.
Services for Women
Although women use illegal drugs at lower rates than men, women experience the use and consequences of drugs and alcohol differently from men and require gender-appropriate prevention and treatment services. Women who use illegal drugs, alcohol, or tobacco during pregnancy create health risks to themselves and to the fetus in-utero. Exposure to these substances in-utero is associated with increased risk for Fetal Alcohol Syndrome, Fetal Alcohol Effects, infant mortality and morbidity, attention deficit disorder, and other health problems. Women face unique barriers to treatment like the stigma associated with being a substance abusing mother, fear of losing custody of children or housing, 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 increasing attention as our population ages.
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 delivery system, needed services may be less available to vulnerable populations, including racial and ethnic minorities such as African-Americans, Native Americans, Hispanics, and Asian American/Pacific Islanders; the children of substance-abusing parents; the disabled; youth living in poverty; and people with co-occurring mental disorders. Our overall challenge is to help chronic drug users overcome dependency so that they can lead healthy and productive lives and the social consequences of illegal drug abuse are lessened.
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. Survey data suggests that mental disorders precede substance abuse more than 80 percent of the time, generally by five to ten years.20 This strongly indicates the existence of a significant window of opportunity for substance abuse prevention and the clear need to target substance abuse prevention activities to children with serious emotional disturbance and other, less severe mental health problems. In addition, treatment providers must recognize and address co-occurring mental disorders in order to prevent relapse and improve the likelihood of recovery from addiction.
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 100,000 addicts off heroin, off welfare, and on the tax rolls as law-abiding, productive citizens. SAMHSA is conducting a comprehensive review of the current system for regulating opioid treatment programs (OTPs). The intent is to develop a regulatory proposal that will transfer regulatory oversight from the FDA to SAMHSA, and incorporate accreditation as a requirement for federal approval of OTPs.
NIDA will continue to fund a high-priority program for discovering new medications to treat drug abuse. These research projects may result in new pharmacotherapies. Specific projects include development of an anti-cocaine agent, a controlled-release dosage form of oral methadone, medications to treat withdrawal symptoms in babies born to opiate-dependent mothers, and medications to treat methamphetamine addiction. SAMHSA will develop treatment standards as required by the Narcotic Addict Treatment Act (NATA).
National Drug Abuse Treatment Clinical Trials Network
Over the past decade, NIDA-supported scientists have developed and improved pharmacological and behavioral treatment for drug addiction. However, most of these newer methods are not widely used in practice, because they have been studied only in relatively short-term, small-scale studies 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 treatment 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. Medications to be studied include naltrexone, LAAM, buprenorphine for heroin addiction, and a few currently being developed by NIDA for cocaine.
Treatment Research and Evaluation
NIDA supports over 85 percent of the world's research on drugs of abuse. Recent research in the area 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 the new therapies. NIDA will conduct clinical and epidemiological research to improve the understanding of drug abuse and addiction among children and adolescents. These findings will be widely disseminated to assist in the development of effective prevention programs. To ensure that the basic research supported by NIDA and others is applied in communities throughout the country, SAMHSA supports applied research including effectiveness studies of pharmacotherapies and behavioral therapies and establishes epidemiological measurement systems. For example, SAMHSA is funding evaluations of eight- and sixteen-week methamphetamine interventions in non-residential (outpatient) psychosocial treatment settings in California, Hawaii, and Montana. The objective is to determine whether promising results in methamphetamine treatment attained by the MATRIX Center in Los Angeles can be replicated.
Improving Federal Drug-Related Data Systems
This initiative will develop a comprehensive data system that adequately informs drug policy makers. It will specifically support the ninety-four targets that constitute the Strategy's PME system. The ONDCP-coordinated Advisory Committee on Drug Control Research, Data, and Evaluation is reviewing existing data systems to identify "data gaps" and determine what modifications can be made to enhance the system. SAMHSA, for example, is increasing the sample size and scope of NHSDA to provide state-by-state data and greater information about drug use by twelve to seventeen year olds. More frequent estimates of the social costs of drug abuse will be made. The U.S. interdiction coordinator will complete a "cocaine flows" estimate model.
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, to develop interventions to reduce AIDS risk behavior, and to disseminate new interventions to practitioners in the field. More specifically, this initiative will focus on adolescent drug use.
Reducing Infectious Disease Among Injection 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, mental health, and complex social issues that must be overcome in order to successfully address their addiction, criminal recidivism, and disease transmission problems.
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 on drug abuse and its relationship to other diseases through biomedical and behavioral research. This research incorporates a range of scientific investigation from basic molecular and behavioral research to epidemiology, prevention, and treatment. Knowledge from each of these areas is essential to understanding the links between drug abuse and AIDS, TB, and hepatitis and for developing effective strategies for stemming infectious diseases spread through injection drug users. NIDA is also 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, fund a National Minority AIDS Council that will examine HIV/AIDS and related substance-abuse issues among minorities, and work with the National Alliance of State and Territorial AIDSDirectors to improve program coordination.
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. Manycompetent 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, which was developed 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 in the Addictive Disorders, provides a developmental framework for the acquisition of the knowledge and skills required for professional counselor certification.21