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eral entities charged with carrying out prevention-related efforts, and inspiring, characterizing and mobilizing nationwide understanding of the importance of, and nature of the war against substance abuse.
8. Local prevention providers are concerned about the efficacy of prevention efforts disseminated by the Federal Government. Prevention has been defined too broadly which leads to inefficient use of scarce resources. To improve the efficiency of programming, the Federal Government should implement in a consistent fashion a reasonable definition of the term prevention to be utilized by federal entities and state representatives charged with distribution of funds to better ensure against the funding of non-prevention activities.
9. The committee has found that most states have merged alcohol and drug prevention and treatment services to reflect the widespread use of alcohol, and problems related to alcoholism, with that of illicit drugs. Congress should reconsider merging alcohol and tobacco into the national strategy to reflect a comprehensive understanding, and provide a coordinated response to, substances which are widely available and linked to more deaths and diseases than are illicit drugs.
10. The committee finds that community-based prevention efforts which are developed by, and for the target community, work best. Local prevention providers look to the Federal Government for guidelines and resources with which they can develop community-specific strategies. School-based efforts are primarily targeted to meeting the needs of certain students. Curricula that do not reflect diverse ethnic backgrounds are inappropriate mechanisms to disseminate prevention programming. The committee recommends that ONDCP should convene a panel of prevention experts to assess the efficacy of the Department of Education's (DOE) prevention efforts and the appropriateness of allocating the majority of scarce prevention funds to DOE.
11. The committee has found that the most successful prevention programs are community-based as opposed to schoolbased, and notes in particular, that viable prevention programming that targets poor, urban and minority communities is community-based. Such community-based efforts are primarily funded through ADAMHA. Therefore, the committee recommends that ONDCP prioritize community-based prevention programming and increase significantly ADAMHA's budget to enable them to expand their prevention programming.
12. The committee finds that community-based prevention efforts work best. The Federal Government should support community empowerment efforts by strengthening fragile infrastructures through which successful prevention programming could be designed and disseminated.
13. Prevention research is spotty and does not sufficiently examine the needs of communities of color. The lack of evaluations of current prevention programming does not allow local prevention providers to determine what works best for their communities. Prevention research must be supported to provide long-term information on both risk factors and protective factors, and on strategies that are proving successful. Research on communities of color must be increased to assist practitioners in identifying populations at risk and their needs, and minority prevention researchers must be identified and supported to provide culturally sensitive analyses and realistic information on hard-to-reach groups.
14. The Department of Education has many prevention-related programs. Yet many of these efforts are operating in isolation from the community at-large and not meeting their specific needs or addressing their unique problems. Information on the multiple components of school-based curriculums must be disseminated by the Department of Education, including the need for: community awareness and ownership of a strategy; involvement in school policies by teachers, students, parents and others; school districts to invest in teacher training; curriculum guides that provide lessons and strategies; strategies, to meet the needs of the students, that are age-related and responsive to the significant concerns of the population in a culturally sensitive manner; Student Assistance Programs; and Employee Assistance Programs designed to help administrators, teachers and staff who are experiencing similar problems.
15. Representatives of the poor and communities of color believe school-based prevention curricula are not meeting the needs of their children. The Congress and the Administration should work with state education agencies and school districts to examine appropriateness of basic curricula within a system that has failed to keep youth in school, and to reassess cultural sensitivity and awareness in those districts which service communities of color. At the same time, school-based prevention efforts should be reviewed under similar criteria.
16. Representatives of communities of color are concerned about the lack of minority representation within the decisionmaking process regarding prevention efforts. Every effort should be made to include significant representation by individuals from communities of color in all areas of the Federal Government structure related to substance abuse prevention including in: the Office of Substance Abuse Prevention, Department of Education, Drug Enforcement Administration, National Institute on Drug Abuse, and the Alcohol, Drug Abuse, and Mental Health Administration to assure equal access to, and cultural sensitivity in prevention programming services. Greater minority representation among long-term prevention officials in grant awarding positions should be initiated.
17. Many communities do not possess the means to develop prevention programming. The Federal Government should create technical and training regional centers targeting communities of color to better disseminate material designs, testing, production information; and to provide training, organizational development, and community Outreach techniques. Better communication between federal, state and local entities would be forged, thereby fostering the equitable distribution of resources and control over how that distribution is being implemented.
18. Billboard companies are saturating low-income, minority neighborhoods with alcohol and tobacco ads. Alcohol and tobacco advertisement guidelines should be established to prevent the barrage of advertisements by the alcohol and tobacco industries in communities of color that influence attitudes of acceptance and approval, and contradict public health messages and prevention efforts.
19. The committee believes the private sector has a vital role to play in discouraging substance abuse. Private sector efforts such as those by the Media-Advertising Partnership for a Drug-Free America should work directly with communitybased organizations to create appropriate, meaningful, antisubstance abuse messages that respond directly to local concerns.
II. SUBSTANCE ABUSE TREATMENT
Helping people to rid themselves of drug dependency through treatment requires understanding the process of addiction, the influences that drive and sustain addiction, and the efficacy of attempts to address addiction. As discussed above in the section on prevention programming and policy, the drug crisis must be considered within the context of broader health, social and economic issues facing our nation; it should not be viewed primarily as a moral and criminal problem, but rather as a public health concern which demands immediate attention and swift action.
The lack of drug treatment programs for all who request it is one of the most pressing issues in the war on drugs today. The target populations include groups of people that cut across racial, ethnic and class lines, with dissimilar patterns of addictive behavior.
Treatment strategies have improved since the early 1930s, and after several decades of research and implementation, we know that treatment works. According to the National Association of State Alcohol and Drug Abuse Directors (NASADAD), "the evidence decisively demonstrates that alcohol and other drug abuse treatment is effective in reducing abuse, increasing employment, improving psychological adjustment, and decreasing crime as well as other negative behaviors.” 64 Yet federal leadership and financial support of substance abuse treatment has been uneven, and has resulted in an inadequate and underfunded response.
This report examines the salient issues regarding the National Drug Control Strategy's treatment efforts and recommends appropriate action to strengthen this nation's response to an epidemic that has tragically affected communities across the country. 2. History
The Federal Government's involvement in drug abuse treatment dates back to 1935 when many inner cities were experiencing sudden increases in heroin use primarily in poor city neighbor
64 NASADAD, op. cit., p. v.
hoods and communities of color. The U.S. Public Health Service hospital in Lexington, Kentucky opened to serve prisoners and voluntary patients dependent on drugs controlled by federal statutes-opiates, cocaine and marijuana. Another hospital opened in 1938 in Fort Worth, Texas. Both operated as federal drug treatment centers until the early 1970s when they were closed and transferred to the Bureau of Prisons for use as federal prisons.
The effectiveness of these facilities was negligible according to Claude Rhodes, a former patient at the Lexington facility in the 1940s who testified before the committee at a hearing on the impact of the drug strategy on the State of Illinois:
Those of us who were able to access the Lexington treatment facility soon found that it wasn't much different than jail, except that detox occurred in a more humane manner. The rest of the "cure” amounted to little more than eating well and working hard. Most counseling was of the unofficial variety. Older inmates and patients tutored the rest of us on street hustling skills and alternative criminal careers. Almost to the man, everyone re turned to their respective cities and started to use drugs and engage in criminal acts again. Lex just didn't work as a treatment center, but that was all there was for most of my twenty-five years as an addict. It was jail, Lex, jail, Lex
for me and the majority of my friends. 6 5 Follow-up studies of addicts treated at these facilities revealed that almost all heroin addicts relapsed within the first year after leaving treatment in Lexington. 66
The Narcotic Addict Rehabilitation Act, enacted in 1966, reformed the sentencing of federal prisoners who were addicted, and authorized drug addicts not under federal indictment to be civilly committed to the care of the Surgeon General for treatment and rehabilitation. All costs incurred by services under this Act were the responsibility of the Federal Government.67 The growth in numbers of treatment programs funded by private donors also expanded.
Though not explicitly stated, the thrust of this legislation was directed at the adolescent use of illicit drugs that might be related to street crime, not at the specific problems of tranquilizer abuse or alcoholism.
The first Public Health Service grants to communities for the sole purpose of treating persons addicted to drugs was authorized under the Narcotic Addict Rehabilitation Act of 1966. With the enactment of this legislation the Federal Government became the established authority on drug treatment, until 1981, when the creation of block grants to the states for alcohol, drug abuse, and mental health services allowed the Federal Government to withdraw from its commitment as a primary support for substance abuse treatment services. 68
65 Statement of Claude Rhodes before the Subcommittee on Legislation and National Security, July 28, 1990, pp. 2-3.
68 Jaffe, op. cit., p. 5.
67 Statement of Karst J. Besteman, Executive Director, Alcohol and Drug Problems Association, before the Subcommittee on Legislation and National Security, April 17, 1990, p. 1.
68 Besteman, op. cit., p. 2.
The federal leadership role in supporting community-based drug treatment programs expanded rapidly during the period between 1966 and 1975, as evidenced by the phenomenal growth of local clinics from less than 200 to over 3000. Federal Government emphasis was placed on meeting all requests for treatment. During this time the Client Oriented Data Acquisition Program established a national data system to monitor federally funded treatment programs by number, age, gender, race, drug of choice and legal status for all patients; quarterly reports were issued to all policy makers and program managers. All federally funded programs were guided by consistent policies and directives. 69
Under President Richard Nixon support for treatment reached its peak with the creation, by Executive Order, of the Special Action Office for Drug Abuse Prevention within the Executive Office of the President in 1971. This period was marked by the commitment to make treatment readily available to all who need it. The Drug Abuse Office and Treatment Act of 1972 was created on the basis that treatment would reduce the number of crimes committed by addicts, and that the capacity of the law enforcement system could no longer contain the growth of the drug problem. 70 According to Jaffe, the intent of the Federal Government to expand treatment at this time was to reduce the
social costs of illicit drug use by making treatment more
youth.71 While the federal commitment to combat drug abuse intensified during the early 1970s, the arsenal to combat poverty—the Office of Economic Opportunity-was being dismantled. The appearance that treatment programs were growing at the expense of poverty programs was not coincidence, but reflected the reordering of priorities during that time.
By 1976 federally supported community-based treatment programs began to dwindle, due to double digit inflation and reduced federal funding. The creation of block grants in 1981 set forth formally the premise that treatment programs were no longer a federal responsibility and that states were to assume the primary role in the war on drugs. Additionally, the Client Oriented Data Acquisition Program, the only national data collection system, ceased when states were given sole discretion over compilation and distribution. Most states opted to discontinue reporting requirements. Research in the treatment area was curbed primarily due to the lack of funding. As a result, the availability and quality of treatment programs significantly deteriorated. 72
69 Ibid., pp. 2-3.
70 G.A. Austin and D.J. Lettieri, eds. "Drugs and Crimes: The Relationship of Drug Use and Concomitant Criminal Behavior." (Rockville, Md.: National Institute on Drug Abuse, 1976.)
71 Jaffe, op. cit., p. 7.