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day of school. It was estimated that 5 percent of the 60,000 kindergarten children were expected to be offspring of crack-addicted mothers. 188 Special testing will be conducted to judge the extent of their problems. Health professionals in New York have warned that perhaps an entire generation in sections of central Harlem has been affected by brain damage and other problems resulting from the upsurge in drug problems. 188 It is likely that cities such as New York will have to expand special education programs and screening since no provisions have been made thus far to help the children who will have developmental difficulties. This will place additional burdens on already strained city budgets. 5. Waiting lists
It has been conservatively reported from a survey of 41 states and the District of Columbia that only one in eight persons who needs treatment is receiving it (approximately one in seven adults and one in 13 adolescents); over 66,700 people are on waiting lists across the country.190 In response to this great need, treatment funds have been increased modestly, and by October 1, 1990, Congress will have appropriated $140 million since 1988 for the Waiting List Program. Yet community drug treatment program directors and state drug authorities continue to report that they are turning away many who seek treatment because there is no room. The problem is particularly severe in metropolitan areas, lowincome communities and neighborhoods, and areas with a high incidence of heroin or cocaine/crack use.
Philadelphia, like many cities, measures the need for additional treatment by the size of the waiting lists.
One of the primary indicators of the magnitude of the problem, and one which should serve as a barometer for the degree of additional federal assistance needed, is the length of the waiting lists of those wishing to enter treatment programs. In Philadelphia, the total residential waiting list is currently 500, a figure which does not include those who have decided it is not even worth trying to get
into a program. However, waiting lists do not reveal the full extent of the problem. According to Stanley Wallack:
Waiting lists are difficult to use. We have some indications from our own research that programs often have no way to contact people on waiting lists—there is no way to tell if they are still seeking treatment. Also, the same
person can be on the waiting list of many programs. 193 The Drug Abuse Treatment Waiting Period Reduction Amendments of 1990 Grant Program helped existing drug abuse treat
188 Associated Press, "Crack Babies Make First Day of School,” September 10, 1990.
191 Office for Treatment Improvement, “Drug Abuse Treatment Waiting Period Reduction Amendment of 1990 Grant Program," Request for Applications, August, 1990.
192 Statement of Mayor W. Wilson Goode, before the Subcommittee on Legislation and National Security, April 17, 1990, p. 2.
193 Stanley Wallack, op. cit., May 14, 1990, p. 6.
ment programs rapidly expand their capacity to serve drug abusers who want treatment but are not receiving it. The 1990 Amendments increased the authorization ceiling, extended the availability of funds, and resulted in three key changes to pre-existing authority for the Waiting List Reduction Grant Program. Under the 1990 Amendments, priority is given to applicants that will provide drug abuse treatment services for pregnant or postpartum women, not more than 50 percent can be expended for follow-up or aftercare services that will help to prevent the relapse of patients who have successfully completed the primary phase of treatment, and grantees that received awards previously under the Waiting List Reduction Grant Program are eligible for additional funding. 194
Due to the administrative nature of the Waiting List Program, committee research questions the efficacy of states relying on an unstable funding source. Difficult to administer, waiting list grants could inadvertently damage state treatment efforts by providing an artificial capacity to program providers to shorten waiting lists with money that would have to be sustained by state drug budgets. Eligibility for such a grant requires an applicant to provide assurances that financial resources are available to continue the expanded treatment capacity once the grant period ends. More often than not, providers are unable to continue operating at such an increased capacity. According to the Office of Treatment Improvement, the State of Missouri has chosen not to apply for waiting list funds due to the difficulties in meeting treatment obligations created by the Waiting List Program.
States that rely heavily on waiting list funds still have difficulty meeting the needs of those who remain on lists, and those who become discouraged and disappear. In Illinois, persons seeking treatment usually wait up to three months to be accepted in a treatment program. At least 4,796 people are on current lists throughout the state and another 15,000 in the state's correction system are potential candidates for substance abuse treatment. 195 While inner city residents usually have to wait longer for public facilities that are filled to capacity, state funds and ADAMHA grant monies have recently provided for a new comprehensive health and social service center in a defaulted westside Chicago hospital for pregnant addicts and their children which will serve 900 women annually. 196
According to Richard Browne, Chief Contract Management/Program Budget in Los Angeles County, Department of Health Services, while waiting list grants have helped ease the burden of treatment facilities temporarily, the average wait for admission to residential treatment is about three months, 197 and 2000 individuals are on current waiting lists in the county. 198
It is estimated that the State of Michigan has over 7500 currently on waiting lists. 199 Three hundred and twenty-five are in Wayne County alone, 200 a disproportionately high number in an area that encompasses inner city Detroit. Executive Chief Judge Dalton Ro berson stated before the committee that
194 Office of Treatment Improvement RFA, op. cit.
195 Statement of William T. Atkins, before the Subcommittee on Legislation and National Se curity, July 28, 1990, p. 75. 196 Ibid., p. 76.
197 Statement of Richard E. Browne, before the Subcommittee on Legislation and National Security, July, 2, 1990, p. 64.
198 Ibid., p. 71.
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We convict and send hundreds of thousands of drug offenders to prison. That is why all our jails and prisons are overcrowded. But that is not enough. We need inpatient drug treatment facilities. We need treatment on demand,
not waiting lists. 201 Many states are looking at expanding facilities as an alternative to long waiting lists. Mayor Goode testified to the need for a greater share of federal resources for capital projects. Currently there is little leeway for creating new facilities, let alone rehabilitating old ones. When funds do become available, the problem then becomes one of finding appropriate treatment sites. The problem has become pervasive enough to warrant the acronym NIMBY—"Not In My Backyard."
Even though research conducted by NIDA suggests that the establishment of a treatment facility creates neither a discernable rise in crime nor a drop in property values in the surrounding area,
,202 the creation of new program sites continues to be thwarted. In Detroit no new treatment centers are allowed within the city, due primarily to zoning ordinances.203 In California program officials spend inordinate amounts of time and money on finding facilities which are adequate, can meet all the code requirements and will be accepted by the neighborhoods. Finding suitable locations and defending those decisions often take months of time and thousands of dollars away from services.204 The State of Missouri was unable to spend nearly $4 million it had budgeted for the St. Louis area because communities denied zoning for treatment centers. While similar difficulties have been encountered by other states, including New York, California, and Illinois, legislation has been proposed to permit the state government to override local zoning legislation prohibiting treatment facilities. 205 6. Treatment on demand
As discussed above, greater resources to reduce waiting lists help, but will not solve the problem. The real need is for the states to be able to provide treatment on demand. While the concepts of treatment on demand and the elimination of waiting lists are laudable goals, the key question for financially strapped states and local governments is how to make a treatment system that pro vides open treatment slots all the time affordable. According to Dr. Thomas Kosten:
Availability of treatment twenty-four hours a day, seven days a week including our most effective treatment for
200 Statement of Joan Walker before the Subcommittee on Legislation and National Security and the Subcommittee on Government Information, Justice, and Agriculture, December 14, 1990, p. 9.
202 ONDCP, op. cit., June 1990, p. 28.
heroin addicts, methadone maintenance, is not an easy
maintenance treatments. 206 Dr. Bowser indicated that it is vital that individuals have access to recovery programs on demand
We need a national system of drug recovery programs that works. Recovery from chemical dependency is a life long process, occurs in stages, and must be supported. The first stage is to seek help. When a number of addicted persons finally come forward to seek help, they are put on waiting lists because there are no openings in existing recovery programs. This is a national scandal. It is very difficult for an addict to maintain their resolve to recover,
while waiting for several months.207 Currently, estimating the cost of treatment on demand is an elusive goal. Wallack indicates there are no precise or valid measures of demand for treatment. Though waiting lists and epidemiological studies provide some estimates of the numbers of people with severe drug problems, these estimates of need do not translate easily into estimates of demand for treatment.208
If substance abuse treatment were considered part of the total health care system, and the infrastructure of care facilities and methods of payment were on a par with the general health care system, then the capacity to provide treatment on demand would be more tenable and within reach. But the current philosophy of treating drug abuse as a chronic condition condones delay in treatment, and the rigidity of current financing approaches leads to shortages in treatment slots. Policy makers shy away from revamping the health care system due to the necessity of investing enormous amounts of resources and funds. There are broad infrastructure needs since the quality of treatment depends on the quality of services. Physicians, social workers, and nurses would need to be trained to deal with substance abuse. Currently only eight or nine medical schools in the country provide this type of training in the medical profession. Facilities would have to be expanded and improved and broad medical coverage that included substance abuse treatment required. Karst Besteman placed treatment on demand in perspective.
It is as realistic a goal as it is to have treatment on demand when you fall off a curb and break your arm. We don't have a bit of a problem if somebody breaks an arm and they go to an emergency room and even if they wait a few hours, they get their arm set. But can you imagine the
206 Statement of Thomas R. Kosten, before the Subcommittee on Legislation and National Se curity, April 17, 1990, p. 1.
207 Bowser, op. cit., p. 9.
outrage in this country if we sent people with fractures
serve it. 209
ONDCP dismisses the concept of treatment on demand primarily due to the costs involved, but also on the thinking that most addicts (90 percent according to research conducted by Douglas Angin and Yih-Ing Hser in 1988), 210 would not undergo treatment voluntarily, let alone "demand" it. Instead, the thinking goes, most addicts are compelled to get treatment by family, legal, or employment pressure, or some combination of the three.211 ONDCP further contends that the goals of treatment providers and the addicts who do seek treatment are at odds and therefore providing additional treatment slots
does nothing by itself to ensure that treatment generally is made more effective and provided in a more rational way... A policy designed primarily to provide treatment "on demand” would create a costly, unbalanced system that brings no guarantee of higher treatment success rates. Moreover, the call for such a system obscures the far more pressing and practical needs of drug treatment. Addressing those needs requires us to come to grips with the fact that while the need for treatment is high, the actual
demand for it is relatively low.212 Committee research, hearings and interviews indicate that demand is in fact not low at all but rather quite high. This reflects the findings of the U.S. Conference of Mayors which also take issue with the statement that “the actual demand for it (treatment) is relatively low.” They point to: endless waiting lists in their cities which NASADAD conservatively estimates at 66,766 persons currently; 213 the treatment needs of pregnant women which go unmet; of the 1.6 million adolescents in need of substance abuse treatment only 123,500 receive it; and almost 90 percent of the nation's IV drug users are without treatment at any given time.214
As a result of the shortage of treatment slots across the country, cities have had to prioritize available treatment facilities. Mayor Goode has had to grapple with this:
Because of the length of the waiting list and the overall inadequacy of resources, sometimes difficult decisions must be made in terms of deciding who should be a priority for treatment. While every case is an individual one, and must be treated as such, I have directed that the most vulnera
209 Besteman, op. cit., p. 87.
210 M. Douglas Anglin and Yih-Ing Hser, “The Efficacy of Drug Abuse Treatment,” (Drug Abuse Research Group, Neuropsychiatric Institute, UCLĂ: University of California), October 1989.
211 ONDCP, op. cit., June 1990, p. 9.