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Abuse Treatment Unit, New Haven, Connecticut; Dr. Stanley S. Wallack, Director, Bigel Institute for Health Policy, Brandeis University, Waltham, Massachusetts; Dr. Dooley Worth, Medical Anthropologist, New York City; Beverly Chisholm, Clinic Director, Eleonore Hutzel Recovery Center, Detroit, Michigan; Kattie Portis, Community Coordinator, National Women and AIDS Risk Network and Founder, Women's, Inc., Dorchester, Massachusetts; and, Audrey Martin, mother of five children and recovering crack addict.
3. The Impact of the National Drug Control Strategy on California, July 2, 1990.-Page 9 of the Prevention section.
4. The Impact of the National Drug Control Strategy on Illinois, July 28, 1990.-Page 10 of the Prevention section.
Treatment is only one stage of a continuous process to reduce the demand for illicit or other drugs. As the line between prevention and early intervention is not distinct, so too is the line between early intervention, treatment, and aftercare. Prevention policy should be in harmony with treatment options, and as Dr. Allan Cohen put it
In one sense, effective treatment and aftercare ultimately becomes prevention-the sober or recovering individual becomes an ever larger part of the American population, high-risk for substance abuse even after years of a drugfree lifestyle.83
We have learned that substance abuse is a disease of relapse, requiring continuous attention and state-of-the-art research which will assist policy makers and program implementers to provide access to appropriate treatment for all who want it. Evidence over the past two decades indicates that treatment clearly works.
Yet there are a number of weaknesses in existing substance abuse treatment programs. Primarily, there is a general lack of access to appropriate programs that work because of limited funding. Committee hearings and examination of treatment facilities indicate that programs that work are characteristically small, community-based efforts which are barely able to survive due to uneven and scarce funding. Poor addicts are unable to access innovative treatment programs for particular addictions such as the addiction to crack, because the programs that work best are in the private sector. 84 The U.S. Conference of Mayors, who individually preside over already financially strapped cities, recognize these problems first hand and have tried unsuccessfully to change the funding allocation so that it passes through directly to the larger cities where the needs of their constituencies can be better met.85 Recently the U.S. Conference of Mayors found that "only a small portion of the funds are reaching the nation's cities, and that these
83 Allan Y. Cohen, op. cit., July 17, 1990, p. 10.
84 Response to questions by Dr. Dooley Worth, medical anthropologist, for the Subcommittee on Legislation and National Security, May 10, 1990, pp. 2-6.
85 J. Thomas Cochran, Executive Director, U.S. Conference of Mayors memorandum on direct funding to its Task Force on Drug Control. January 24, 1990.
funds are not reaching the cities in either an efficient or an equitable manner.
Another glaring problem is the lack of treatment programs for women. Women have different and more complex needs, including the need for childcare. For pregnant women access to treatment is even more difficult, as most facilities will not admit them due to lack of insurance. In a recent survey conducted in New York City, 54 percent of treatment programs refused to treat pregnant women, 67 percent refused to treat pregnant women on Medicaid, and 87 percent had no services available to pregnant women on Medicaid who were addicted to crack.87
Inner city residents encounter the most serious problems obtaining drug treatment. Waiting lists for these communities are usually quite long, and often the facilities that become available are not appropriate for particular addictions. Many of these clients are polydrug addicts requiring more than what can be offered. The pervasive role of AIDS in the inner city has further complicated and overwhelmed an already complex treatment system that is unable to cope with the sweeping and changing nature of the drug subculture in the cities.
Drug and alcohol abuse are as common in rural areas in the nation as they are in larger urban cities. Yet funding formulas passed in the Anti-Drug Abuse Act of 1988 tend to give urban areas more federal funds for treatment (and interdiction) programs. 88
There is a lack of information on the cost of different treatment modalities and the number of people with substance abuse problems. As previously stated, the National Household Survey and the Annual High School Senior Survey only count people in houses and in school, a primarily educated and middle class population. Excluded from the data are those who are institutionalized, the homeless and dropouts. Absent such important assessments, providing appropriate treatment for all who need it is unrealistic.
The consideration of substance abuse treatment within the context of broader health, social and economic problems in our society will allow policy makers to address drug use as a symptom of an unraveling "social safety net" where fewer economic opportunities exist, and hopelessness and despair prevail. The commitment of resources to a more equitable, comprehensive approach that can respond to the needs of our communities should be the goal; achieving it will require long-term planning.
1. Drugs of choice
As discussed in the prevention section, the number one (legal) drug of choice in American society is alcohol. Eighteen million Americans were reported to experience problems as a result of
86 U. S. Conference of Mayors, "Controlling Drug Abuse in America's Cities: A 30-City Survey on the Implementation of Anti-Drug Abuse Act Block Grants Programs and in Local Drug Control Efforts," (Washington: September, 1990), p. 1.
87 Statement of Dr. Wendy Chavkin, Prenatal Addiction Research Institute on Chemical Dependency, Beth Israel Medical Center before the Energy and Commerce Subcommittee on Health and the Environment, October 30, 1989, p. 1.
88 U.S. General Accounting Office, "Rural Drug Abuse: Prevalence, Relation to Crime and Programs," GAO/PEMD-90-24, September 1990).
their alcohol use in 1987. Absent a role in the National Drug Control Strategy, states have taken the lead in merging alcohol with substance abuse in drug treatment strategies, since many program providers report that most patients experience both alcohol and illicit drug use upon entering treatment facilities. Of the 1.7 million people seeking treatment in 1989, two-thirds reported alcohol as their primary problem according to NASADAD, hence its label as a "gateway drug." Alcohol is by far the most widely abused drug in rural areas.89 In Iowa, for example, four out of five people seeking treatment were admitted for alcohol, while in Nebraska and Colorado, nine of ten treatment admissions were for alcohol.90 As a socially accepted, and widely available substance, the economic costs of alcohol-related problems to society are enormous, especially as they relate to lost employment, reduced productivity and health care costs for accidents and illnesses.
Measuring illicit substances
ONDCP relies upon the National Household Survey to measure the use of illicit drugs in the United States. As previously stated, the household assessments present an incomplete evaluation of total use due to the failure to include the homeless, dropouts, college/universities, and institutionalized populations such as those who are incarcerated. Health consequences of drug abuse are tracked by the Drug Abuse Warning Network (DAWN), an ongoing reporting system initiated in 1972 which gathers information on drug abuse-related emergency room visits from approximately 700 hospitals in 21 metropolitan areas, and a panel of hospitals outside of these areas. Information is also gathered on drug abuse-related medical examiner cases in 27 metropolitan areas.
According to the National Institute on Drug Abuse, marijuana is the most commonly used illicit drug in the United States. The 1988 National Household Survey on Drug Abuse estimated that over 66 million persons have tried marijuana/hashish at least once during their lifetime. Current use of marijuana has declined since 1979 among all age groups.
Emergency room survey data collected by the Drug Abuse Warning Network (DAWN), indicates that marijuana/hashish mentions in all metropolitan areas increased slightly from 1985 to 1988, and increased significantly in Washington, D.C. Significant increases were reported in 1988 when 84 percent of all marijuana emergency room mentions were in combination with another substance, such as PCP, alcohol or heroin. According to 1988 DAWN reports, 72 percent of emergency room mentions were male; 40 percent white, 44 percent African American and 8 percent Hispanic.
The 1988 National Household Survey on Drug Abuse indicates that the percentage of persons who have ever tried PCP is decreas
89 G.A.O., op. cit., p. 44.
90 Michael Isikoff, "Alcohol: The 'Worst' Drug Problem: Officials in Midwest Frustrated by Government Priorities," the Washington Post, p. 1.
ing, as is the number of related emergencies reported during the same period, except for two metropolitan areas-Baltimore and New York City, which reported a steady increase in use. One hundred and forty of PCP-related deaths were reported in all metropolitan areas between the period from July 1988 through June 1989; 68 deaths (49 percent) occurred in Washington, D.C. The DAWN survey shows that the majority of emergency room patients were African American (57 percent); 75 percent were male.
Household surveys do not adequately measure the prevalence of heroin use and it is thus believed to be seriously underestimated. Yet the 1988 Household Survey reported that 1.9 million people (one percent) in the United States had tried heroin, and DAWN reported that all metropolitan areas experienced increases in emergency room intakes; New York, Washington, D.C., Detroit and Seattle reported more than twice as many heroin-related emergencies over the 12-month period ending in June 1989. Heroin-related deaths increased 42 percent from the period of July 1985 through June 1988. Sixty-nine percent of all heroin emergencies were males; 48 percent African American, 31 percent white and 15 percent Hispanic. Emergency room visits related to heroin dropped from 3,554 in the last three months of 1989 to 3,070 the first quarter of 1990. During the same period, heroin-related deaths rose from 1,884 to 1,995 over the same period.
The combined use of cocaine and heroin known as "speedballing" has become increasingly more common, as DAWN emergency room data indicated a doubling between the period from July 1985 through June 1988 in all metropolitan areas. From July 1988 through June 1989, 627 deaths were attributed to speedballing, up from 220 deaths recorded from the period of July 1984 through June 1985.
In March 1990, the Department of Justice (DOJ) reported that the number of frequent cocaine users may be more than twice as high as official government surveys have estimated, due to the failure to record the unusually large number of criminal suspects who are using the drug.91 NIDA reports that more than 1.2 million people use cocaine weekly, and DOJ has indicated that as many as 1.3 million criminal suspects use cocaine regularly. The 1988 Household Survey demonstrated that while an estimated 21 million persons had tried cocaine, and of these approximately 8 million had used it at least once in the past year, only 11 percent had used the drug once a week or more, and 4 percent used cocaine daily. DAWN indicates that cocaine-related hospital emergencies declined four percent during the first three months of 1990. ONDCP has interpreted this trend as indicative of cocaine use having leveled off. Yet there was a 10.7 percent increase in the number of
91 "Drug Use Forecasting" (Washington, D.C.: Department of Justice, March 1990).
cocaine-related deaths from the period of July 1988 through June 1989. The metropolitan areas with the largest increases in the number of cocaine-related mentions over this period of time were Dallas, Baltimore, Atlanta and St. Louis.
Recent trends in cocaine use can be attributed to the method of intake, availability, cost, and purity of substance. In the past cocaine was sniffed or snorted. In recent years, smoking or "freebasing" cocaine has become more common. Freebasing is more serious since smoking cocaine increases the pharmacological effects of the drug resulting in an enormous craving for it. The increased smoking of cocaine appears to have accelerated in some parts of the country following the introduction of the base form of cocaine called "crack". The 1988 Household Survey indicated that 31 percent of past year cocaine users smoked cocaine in the year prior to being interviewed. Approximately 1.9 million lifetime users of cocaine have used it intravenously at some time in their lives.
DAWN information indicates that 67 percent of cocaine-related emergency room patients were males; 27 percent were white and 57 percent African American.
According to congressional testimony by Dr. Jerome Jaffe, Senior Science Advisor at the National Institute on Drug Abuse, methamphetamine is a drug in the amphetamine group which is synthesized in a laboratory and is a psychostimulant which affects the central nervous system.92 Also referred to as crystal, ice, crank, meth and speed, methamphetamine was available in epidemic proportions in Hawaii. However, drug abuse indicators suggest an increasing trend of abuse on the mainland, particularly in West Coast cities. DAWN indicators show significant increases in emergency room cases, deaths and treatment admissions of methamphetamine in Atlanta, Dallas, Los Angeles, Phoenix, San Diego and Seattle. During the last half of 1986, DAWN showed a 70 percent increase over the six month period from July to December 1988.
Contrary to the ONDCP White Paper which reported that "little evidence exists to suggest ice has penetrated the mainland drug market," 93 recent trends point to the increase in methamphetamine use in small towns and rural areas of the United States, including Iowa, where this potent stimulant is as "common as a row of corn, ,"94 according to Sandra Stoltenow, who heads the state drug laboratory where samples confiscated by law officers are tested. State narcotics agents seized twice as much methamphetamine in 1989 than the average for the previous three years. According to the State Narcotics Enforcement Division, Iowa can expect an increase of at least 20 percent this year, with most supplies provided by California motorcycle gangs. Availability of methamphetamine is expected to overwhelm Midwestern states by the end of 1990, due partly to the dwindling cocaine supplies, the lower
92 Statement by Jerome Jaffe, Senior Science Advisor, National Institute on Drug Abuse, before the Select Committee on Narcotics Abuse and Control, October 24, 1989, p. 1. 93 ONDCP. "Leading Drug Indicators," September 1990, p. 5.
94 Marilyn Hauk, "Methamphetamine: Potent Stimulant Growing Problem in Rural Iowa," Associated Press, August 1, 1990.