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ble among those seeking help, namely pregnant women
treatment as expeditiously as possible. 215 7. Addiction treatment medications
The 1988 Anti-Drug Abuse Act funded one of NIDA's top research priorities: the development of new pharmacotherapeutic approaches to the treatment of drug abuse. The newly created Medications Development Division of NIDA focuses on discovering new pharmacological therapies for treating drug addiction and bringing those therapies to the market place. Though supervised by NIDA, the work itself will be contracted out to both the pharmaceutical industry and the academic research community. Research risks and expenses will be shared by government and private industry and promising compounds will be produced and marketed by individual companies.
Since there is no effective medication therapy currently available for cocaine, the Medications Development Division would most likely benefit regular users and addicts dependent upon cocaine.
While there is a great commitment to this new program by NIDA and ADAMHA, it will be a long and expensive process which will require decades of research and experimentation. Some scientists are skeptical of the emphasis placed on medications development as the evidence for using drugs to cure drug abuse remains unconfirmed. 216 Scientists warn that it is unrealistic to expect a "magic bullet” cure. The nation's cocaine problems are as deeply rooted in behavioral and social causes, especially in the inner city where the crack trade has flourished, as they are in brain chemistry. Dr. Charles O'Brien, director of the University of Pennsylvania's Center for Addiction Studies stated, “There's no way a drug is going to cure addiction. . . . You're dealing with a behavioral problem that has multiple causes.” 217 ONDCP deputy for demand reduction, Dr. Herbert Kleber, is a strong advocate of pursuing medications as a cure. He has stated that while increasing education and treatment can "pick away" at the number of cocaine and crack users, "the long-term answer is developing a medication.” 218
Critics point to the use of methadone, which is widely used and assists addicts to function within daily living, yet remains controversial because it is habit forming and has spawned a class of methadone addicts.
NIDA Director Schuster, a strong supporter of the new division, is well aware of the limitations of developing medications to cure drug abuse,
When new medications are developed and approved, we cannot fool ourselves into thinking that these will be "magic bullets." Drug abuse is a chronic, recurring disease more akin to arthritis and diabetes than to a broken arm
218 Goode, op. cit., p. 2.
216 Michael Isikoff, "Fighting Drugs With Drugs: Remedies Sought for Addiction,” the Washington Post, August 20, 1990, p. 1. 217 Ibid. 218 Ibid.
or a simple infection. . . . The medication may help the
other effective treatments. 219 8. Treatment programming
For the purposes of this report, the focus is on the treatment efforts of the three federal entities with the largest budgets to carry out the majority of treatment-related work: the Alcohol, Drug Abuse and Mental Health Administration, (ADAMHA) the Department of Veterans Affairs, and the Health Care Financing Administration (HCFA). According to the ONDCP January 1990 budget summary, 14 federal entities have budgets for substance abuse treatment efforts, including: the Office of the National Drug Control Strategy; Special Forfeiture Fund; the Alcohol, Drug Abuse and Mental Health Administration; the Health Care Financing Administration; Indian Health Service; Human Development Services; Department of Education; Department of Defense; Bureau of Prison; Office of Justice Programs; Bureau of Indian Affairs; Department of Labor; Department of Veterans Affairs; and the U.S. Courts.
Alcohol, Drug Abuse and Mental Health Administration The Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) of the U.S. Department of Health and Human Services (DHHS) conducts treatment-related services and research out of its three institutes, the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the National Institute of Mental Health (NIMH); and from the Office of Treatment Improvement (OTI).
ADAMHA administers the ADAMHA block grant program which provides the states with funding for planning, establishing, maintaining, coordinating and evaluating programs for the development of more effective treatment and rehabilitative programs and activities to deal with alcohol and drug abuse.
The three institutes are described in the prevention section of this report. In addition to NIDA's work in research on preventionrelated strategies, NIDA is also charged with sponsoring research to understand the causes of drug abuse and to develop and evaluate new drug abuse treatment approaches, and AIDS-related research and strategies to prevent HIV infection. Also within NIDA is the Medications Development Division, described above.
Office of Treatment Improvement The Office of Treatment Improvement was created in 1990 to improve treatment services for individuals who suffer from drug abuse and other problems associated with drug abuse, including alcoholism, and physical and mental illnesses, and to administer the ADAMHA and homeless block grants, and crisis and waiting list grants to the states, territories and Indian tribes.
219 Schuster, op. cit., pp. 22-23.
OTI collaborates with states, communities and treatment providers to upgrade the quality and effectiveness of treatment through improved coordination among drug treatment providers, primary health care entities, mental health care providers, human services agencies, educational and vocational services, the criminal justice system, and a variety of related services. OTI also works with ADAMHA's three institutes and OSAP to promote utilization of effective means of treatment and to develop treatment standards, as well as to collaborate on treatment data collection and training of health care providers.
Financial and technical assistance is targeted towards patient populations especially at-risk because of addictive disorders, and to groups that are presently underserved, including those within the criminal justice system.
Department of Veterans Affairs The Department of Veterans Affairs, Veterans Health Services and Research Administration, operates 123 specialized Alcohol Dependence Treatment Programs (ADTPs) and 53 Drug Dependence Treatment Programs (DDTPs) for the care and treatment of eligible alcohol and/or drug dependent veterans.
During Fiscal Year 1989, over 58,900 veterans were treated in specialized alcoholism treatment units. The bed occupancy rate was 78.3 percent with a turnover rate of 116 percent. Nearly 1,033,000 patient days of care were provided and another 41,500 veterans with alcohol problems were treated on other VA units, e.g. general psychiatry. Within the outpatient treatment components, there were over 448,000 patient visits. 220
The total number of veterans treated for drug dependence in Fiscal Year 1989 was 29,500, with half of these veterans receiving inpatient care. The average monthly turnover rate in the DDTP was 149 percent, and bed occupancy rate was 94.9 percent for 920 available beds. There were over 878,000 outpatient visits for drug dependence. 221
The VA conducts alcoholism and drug abuse research through individual and cooperative multi-hospital studies, and trains physicians in substance abuse through an initiative involving a two-year university affiliated fellowship program offered at six VA medical centers. Substance abuse research conducted by the VA is not funded by the ONDCP budget. In Fiscal Year 1980, the VA was given the authority to contract with non-VA community halfway houses for rehabilitation services and Public Law 100-689 extended this authority through Fiscal Year 1992.
Health Care Financing Administration The Health Care Financing Administration (HCFA) is responsible for the oversight of the Medicare and Medicaid Programs and related federal medical care quality control staff. Medicare and Medicaid eligible individuals requiring drug abuse treatment receive covered hospital and nonhospital services required to treat their condition. It is estimated that over 130,000 Medicaid eligible drug abusers sought treatment in 1989 on an outpatient basis, while 9,000 Medicare patients and 20,000 Medicaid patients were treated in hospitals and clinics.222
220 Department of Veterans Affairs, Veterans Health Services and Research Administration White Paper, "Alcohol and Drug Dependence Treatment Programs," p. 1.
According to HCFA,223 there is inadequate information available on which to base estimates of Medicaid and Medicare expenditures related to drug abuse. However, HCFA grossly estimates that Medicaid is currently expending about $150-200 million (federal and state funds) for treatment, with over half of the money spent in hospital settings and the rest in specialized drug treatment facilities. The larger residential care facilities used by people unable to pay exorbitant costs of private facilities are not covered by Medicaid. Many Medicaid eligible people are limited by the Institutions for Mental Disease (IMD's) exclusion which prevents them from receiving coverage for drug treatment. This exclusion has prevented thousands of individuals from receiving treatment. Due to ambiguities in Medicaid laws, states have indiscriminately implemented the IMD exclusion unaware of the services that would be covered by the Federal Government.
Senator Patrick Moynihan has sought to correct this ambiguity by introducing legislation to codify existing law, which will allow Medicaid eligible individuals to receive coverage for their drug problems. In addition, Senator Moynihan has introduced legislation to expand coverage under Medicaid for drug dependent pregnant women, their children and certain family relatives. 9. Funding
The Alcohol, Drug Abuse and Mental Health Administration receives the largest portion of the National Drug Control Strategy budget for treatment-related activities. According to ADAMHA's budget office, the allocation for Fiscal Year 1989 was $391.7 million (44.1 percent of the total treatment services funds), $619.1 million (46.3 percent of the total treatment service funds) in Fiscal Year 1990, and $688.4 million (46.1 percent of the total treatment service funds) is requested for Fiscal Year 1991. ADAMHA's research funds for both prevention and treatment is $255.5 million for Fiscal Year 1990; $301.4 million is requested for Fiscal Year 1991. (Chart follows.)
According to the Department of Veterans Affairs, Veterans Health Services Office, the allocation for treatment services for Fiscal Year 1989 was $283 million (31.9 percent of the total treatment service funds), $361 million (27 percent of the total treatment services funds) for Fiscal Year 1990, and $396 million (26.5 percent of the total treatment services funds) is requested for Fiscal Year 1991.
The Health Care Financing Administration roughly estimates that $140 million (15.8 percent of total treatment services) was expended in Fiscal Year 1989, $170 million (12.7 percent of the total
222 ONDCP, “National Drug Control Strategy Budget Summary, January 1990,” pp. 128-9.
223 Health Care Financing Administration, Cost of Drug Abuse to the Medicaid and Medicare Programs," December 21, 1989.
treatment funds) in Fiscal Year 1990, and $190 million (12.7 percent) is requested for Fiscal Year 1991.224 According to the ONDCP budget office, since HCFA does not deliver services directly, nor is it operationally disease specific, it does not receive specific funding from the National Drug Control Strategy budget. Inclusion of HCFA within the strategy merely reflects the expenditures (however incomplete) by eligible Medicaid and Medicare recipients who receive drug treatment service coverage.
According to the National Drug Control Budget Summary, (January 1990) the treatment budget for all 14 federal entities was $887.8 million (14 percent of the total Drug Control Strategy budget) for Fiscal Year 1989, $1.337 billion (14.1 percent of the total Drug Control Strategy budget) for Fiscal Year 1990, and $1.491 billion (14 percent of the total Drug Control Strategy budget) was requested for Fiscal Year 1991.
As stated in the prevention section, the Office of National Drug Control Policy has revised the budget figures within each federal entity providing demand reduction services to reflect actual monies spent; research funds were included within the treatment and prevention disciplines. While the revised budget figures are not available at this time, the new calculations regarding treatment research funding are as follows: total treatment research for Fiscal Year 1990 was $152.7 million, making total treatment dollars across all 14 federal entities $1.490 billion, (15.7 percent of the total National Drug Control Strategy budget); and treatment research funding for Fiscal Year 1991 is $183 million, making the total treatment dollars total $1.675 billion (15.8 percent of the total drug strategy budget).
The Administration's National Drug Control Strategy continues to emphasize supply reduction programs, and directs less than 30 percent for demand reduction efforts. Treatment programming represents 14 percent of the total drug control strategy budget.
225 Budget Office, ADAMHA