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Fueled by an outraged American public concerned with the impact of drugs in their communities, the enactment of the AntiDrug Abuse Acts of 1986 and 1988 and related amendments authorizing the creation of the ONDCP and significant infusion of funding signaled yet another turnaround in the cycle of attention to the growing drug crisis.
Today, program managers in Detroit, Los Angeles and Chicago are struggling to maintain quality and effectiveness in their treatment programs, primarily as a result of roller coaster funding cycles which have debilitated the system over the past twenty years. 73 Patients who are currently able to access treatment programs place more severe and complex demands on treatment programs than patients presented a decade ago. Today, program design must provide more varied treatment strategies. Greater resources are needed to address multiple addictions, HIV positive patients, pregnant women, and primary health care complications of substance abusers.
Program managers also voiced concern regarding the loss of essential personnel during periods of fiscal constraints. Today, clinical staff must be well trained and prepared to recognize and address the complications of multiple drug abuse and AIDS prevention and treatment, as well as gender specific problems, e.g. addicted pregnant women and the addicted babies born to them.74 Program managers are struggling to keep qualified personnel despite numerous difficulties, including low compensation and lack of adequate training, increased hostility to new program sites by communities, the endless waiting lists in public facilities, a climate of greater stigmatization for the addict and the call for increased sanctions against addicted persons.
State tax revenues became the single largest source of funding for drug abuse treatment in the public sector programs during the period between 1981 and 1988. The 1990 National Drug Control Strategy summary indicates that State and local governments have a crucial role to play in carrying out a national drug control strategy.75 According to Mayor Richard M. Daley of Chicago, this is an underestimate:
More than 80 percent of the anti-drug effort-including law enforcement, treatment and education-takes place on the local level . . . Yet, local and state governments receive just 38 percent of all federal antidrug abuse funds.76 Increased emphasis on local and state government responsibility for the drug crisis has required program directors and their Boards of Directors to become skilled at fundraising to cover the diminished federal contribution. According to Karst Besteman, Executive Director of the Alcohol and Drug Problems Association of North America:
73 Statement of Michael Darcy before the Subcommittee on Legislation and National Security, July 28, 1990, pp. 10-13.
74 Besteman, op. cit.
75 Office of the National Drug Control Policy. "National Drug Control Strategy," January 1990, p. 6.
76 Statement of the Honorable Richard Daley, Mayor of Chicago, before the Subcommittee on Legislation and National Security, July 28, 1990, pp. 2-3.
Several publicly funded programs were able to market their services to persons with health insurance benefits. While this sustained the local treatment program it further limited the access to care for the poor and unemployed addicted patient."
As discussed in the prevention section of this report, hearings, interviews and research point to the importance of community involvement in responding to the drug crisis in America. The treatment aspect of the strategy is no exception, particularly as it relates to community acceptance of new and improved treatment facilities and the need to establish comprehensive services for its members.
3. Principal findings
The past several decades of research lend strength to the certainty that treatment works. But this must be read with caution. Treatment works for some people, some of the time—primarily for the more educated middle and upper classes.
1. Despite the fact that treatment programs do work, treatment is available for only 12.83 percent of the estimated 6.5 million serious drug abusers in the United States.78 According to NASADAD, that means that only one in eleven people who need substance abuse treatment are receiving it; only one in seven adults and only one in thirteen adolescents nationwide needing treatment receives assistance.
2. We know that for every one dollar spent on treatment, $11.54 is saved in social service costs. Yet, the total investment in treatment (and prevention) services was roughly one percent of the cost of alcohol and drug problems to American society.79 Stanley Wallack, Director, Bigel Institute for Health Policy, Brandeis University, updated the analysis of the total investment in treatment services: three percent of the cost of alcohol and drug problems is now spent on treatment.80
3. The opposition to providing treatment on demand (or request) by the Administration has enormous implications. This perspective diminishes the effectiveness of the Federal Government's commitment and leadership to fight a war on drugs that requires a greater investment of resources to solve.
4. The committee learned that surprisingly little is actually known about the costs of providing treatment. According to Wallack, "due to a lack of data and analytical research, the present state of our knowledge is less than adequate to meet the information needs of policy makers." 81
5. Hearings before the committee revealed long waiting lists of individuals wanting to access treatment programs. In many cases this has resulted in individuals becoming discouraged and dropping off those waiting lists. NASADAD's survey displayed similar find
77 Besteman, op. cit., pp. 6-7.
78 NASADAD, op. cit., p. 24
79 NASADAD, op. cit., p. 4.
80 Statement of Stanley S. Wallack before the Subcommittee on Legislation and National Security, April 17, 1990, p. 1.
ings, reporting that the average number of days between request and admission to residential treatment programs is 45. In many cities around the country waiting lists run as long as three to five months. While measuring the need for treatment through waiting lists is an imprecise science, it is the current method utilized by states to evaluate the need for treatment.
6. The omission of alcohol and tobacco use from the NDCS ignores some of the most effective drug treatment programs which handle the complete spectrum of drug problems. Treatment programs examined by the committee included both alcohol and tobacco. This is because many state strategies link substance abuse with alcohol and tobacco since most clients' drug problems are interrelated. The discussion about prevention programming and policy is parallel.
7. While evidence points to the successes of methadone maintenance, witnesses and research conducted by the committee indicate that this form of treatment modality is still controversial.
8. Research and information regarding promising treatment modalities for cocaine, particularly crack, is inadequate.
9. The committee is very concerned about the abysmal state of treatment for pregnant women who have different and more complex problems than do addicted men. Treatment facilities are designed primarily for male addicts and are not necessarily appropriate for women. In addition to the lack of facilities for women, there are enormous barriers to the participation of women that have not been addressed in the national strategy. For example, the emphasis on a criminal approach to drug control has an adverse impact on women and children in the inner city.
10. Treatment facilities are not readily available to inner city addicts, primarily as a result of the lack of insurance coverage and long waiting lists at public facilities. The emphasis and resources on methadone maintenance in the inner city does not leave enough resources to address the polydrug abuse problems prevalent today.
11. Under the current block grant system, the inner cities with the population in greatest need of prevention and treatment resources have been shortchanged. The mayors of Chicago, Los Angeles and Philadelphia all stressed the need to have direct access to federal funds for demand reduction strategies, so that city priorities could be addressed in a timely and effective manner. The U.S. Conference of Mayors has made proposals over the last three years for such a change, citing inadequate funding and delays in funding, as well as the need to play a major role in planning state programs which affect major cities.
12. While it is true that a majority of addicts are not prepared to enter treatment at any given time, and are left to their own devices and therefore excluded from consideration in the national drug strategy, evidence from hearings across the country indicates that new options must be developed for addicts which can be used as stepping stones out of the life of addiction and the drug subculture. 82
82 Eric E. Sterling, "Harm Management, Not Drug-free Nation, Should Become USA's Antidrug Objective." Law Enforcement News, September 30, 1989, vol. XV, No. 299.
The committee is convinced that Congress and the Administration should revise the National Drug Control Strategy's treatment design and programming efforts to reflect the unique problems and needs facing our communities throughout the United States. The recognition that treatment must be considered within the context of broader health, social and economic issues facing this nation will allow policy makers to provide sufficient resources to address the complex nature of treating substance abusers, enable the Federal Government to work toward providing treatment to all who need it in a cost effective manner, and contribute to the general success of drug treatment efforts.
To better enable the Congress and the Administration to formulate substance abuse treatment policy and program design, the Committee on Government Operations recommends, among other things, that the National Drug Control Strategy:
1. Increase the drug abuse treatment budget to reflect a 5050 split of the National Drug Control Strategy budget allocation of law enforcement/interdiction and treatment and prevention, which would help eliminate the waiting lists and would assist individuals who otherwise might be discouraged by an overloaded system.
2. Provide federal funds directly to larger cities, which are better able to gauge the drug problem in their individual communities and are more aware of specific needs and local options of which state officials may not be apprised, including the special needs of the homeless, pregnant women with children, and IV drug users with AIDS.
3. Provide more comprehensive treatment programs at the community level and include culturally sensitive assessments of patient needs and aftercare; vocational, medical, educational, and psychiatric assessments; and, alternative activities for youth and adults to replace "street life" and assist individuals to escape the drug subculture.
4. Expansion of treatment capacity should include federal assistance to improve the quality and effectiveness of treatment programs, including staff training and capital projects improvements and expansion.
5. The goals of the NDCS should include the provision of treatment on demand. This would necessitate the re-ordering of priorities to develop a time frame to achieve this goal. Priority should be given to key population groups, e.g. pregnant women, within certain time periods. In this way, waiting lists will be eliminated, and all individuals seeking drug treatment will be helped.
6. All medicaid eligible individuals seeking drug treatment should be admitted to treatment facilities. Currently, most individuals seeking treatment in residential facilities are excluded from coverage. Legislation has been introduced to expand coverage for all individuals and for pregnant women and their children.
7. Increase investment in treatment design research, particularly on crack addiction and, increase research on costs of
treatment which are currently inadequate, incorrect and outdated, which would allow policy makers and program managers to appropriately designate resources to attain "treatment on demand."
8. The Congress should reconsider the inclusion of alcohol in the national drug strategy so as to reflect the concurrent abuse and dependence on alcohol within the drug abusing patient population.
9. Institute a uniform data collection system which would be more reflective of addicted and dysfunctional drug abusing populations and thus would better characterize the status of the nation's substance abuse problems.
10. Increase funding for research on women and addiction, on specific treatment models for working with drug dependent women, or of gender-specific drug treatment outcomes.
11. Increase funding for women-only treatment facilities, of which there are only 22 in the country, to meet the different needs of women, especially those who are pregnant and/or have other children, and eliminate various barriers to their access to, and participation in, effective drug treatment.
12. Create "harm reduction" demonstration projects which would address the needs of current addicts who are committed to continued drug use. More detailed recommendations are listed at the conclusion of this report.
The committee has held four hearings which examined treatment efforts, including national oversight and three field hearings in large urban cities-Detroit, Los Angeles and Chicago. Common issues emerged from these field hearings, including: (1) treatment works, but primarily for the more educated middle and upper classes; (2) state administrators are unable to use funds effectively since surprisingly little is actually known about the costs of providing treatment; (3) long waiting lists of people wanting treatment but unable to access care are due to the shortage of treatment slots at public facilities; (4) a lack of services for inner city residents; (5) treatment providers believe alcohol services should be merged within a substance abuse strategy; and, (5) women, especially pregnant women, are unable to access appropriate care due to the lack of facilities and understanding of their unique needs.
The following hearings pertaining to substance abuse treatment efforts were held by the Subcommittee on Legislation and National Security.
1. The Impact of the President's National Drug Strategy on Michigan, December 14, 1989.-Page 8 of the Prevention section.
2. Oversight hearing on drug treatment of the National Drug Control Strategy, April 17, 1990.-Chairman John Conyers, Jr. presided at this Washington, D.C. hearing, and the witnesses were: the Honorable W. Wilson Goode, Mayor of Philadelphia; Karst J. Besteman, Executive Director, Alcohol and Drug Problems Association of North America, Washington, D.C.; Dr. Robert G. Newman, President and Chief Executive Officer, Beth Israel Medical Center, New York City; Dr. Thomas R. Kosten, Acting Director, Yale Substance