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1. Federal Government
Two drug wars According to committee research, witness testimony and interviews, a two-tiered drug war is being waged. Educated middle and upper class users are targeted by prevention programs and obtain treatment that is partially or wholly subsidized by third-party medical insurance plans. Less educated poor people, many of whom are minority, have little access to appropriate prevention planning, little access to treatment programs, and are more likely to be targeted by law enforcement efforts and spend time in prison or jail.
Decades of research tell us that treatment works, but primarily for individuals who have more to lose—those with jobs, families, and friends, the majority of whom come from the middle and educated upper classes. Yet to help the addicts in the inner city and residents of other communities that have been left out we lack sufficient knowledge about what works to stop drug abuse, particularly to help crack users. Hearings across the country revealed skepticism of the Federal Government's commitment to the war on drugs, primarily due to funding that prioritizes law enforcement over treatment and prevention, the lack of a goal to provide treatment on demand, and the inability of current treatment systems to address the multiple problems that affect drug use.
Insurance The reasons for the inequities of the treatment system are many. Few treatment facilities are available for people without insurance or who are on public assistance. Waiting lists for this type of care are enormous, and individuals who become discouraged or continue to use drugs become lost in the system and most likely do not receive assistance. The treatment system is essentially segregated from the general health care system. Because financing mechanisms are disconnected from the decision to seek care, the supply side is not keeping up with demand. Drug abuse is viewed by Medicaid and private insurance as a chronic condition which sanctions delay in treatment. Yet Medicaid costs in large residential centers are limited by the current exclusion from coverage of most individuals in Institutions for Mental Disease (IMD's). According to Claude Rhodes:
The greatest barrier [to people seeking treatment) is their lack of money and insurance. People with insurance, medical assistance, or SSI are put at the front of the waiting list, while an individual with no support can't even get
into a treatment program. The philosophy behind the treatment system leads to ineffective and uneven care.
Privately funded programs are flourishing, and accessible, because they are fueled by the availability of insurance dollars. Pub
229 Response to questions by Claude Rhodes for the Subcommittee on Legislation and National Security, September 1990, p. 1.
licly funded clinics, such as Methadone Maintenance, are chronically oversubscribed since clients generally have no payment sources, budgets are tight and the controversy over methadone modality places restrictions on availability.
The concern of some community based providers regarding Medicaid restrictions was expressed by Michael Darcy:
It's time to seriously consider modifying the federal Medicaid rules so that community based programs can tap this source of funding nationally. Presently, many addicts qualify for Medicaid treatment under Medicaid. Once the immediate medical problem is alleviated, the addict is discharged to become re-addicted because community based treatment programs put the individual at the end of the waiting list. In Illinois, community based providers who pass a rigorous certification process can access Medicaid
Rhodes, a former addict and currently an outreach worker, cautioned that:
treatment slots of a variety of concepts are opening almost
at treatment but were not successful.231 Chairman Conyers questioned Rhodes who was treated and rehabilitated a generation earlier, whether he thought he would be able to overcome his heroin addiction under the current treatment system. Rhodes replied that he would not be able to rid himself of his addiction now, due to the impersonal nature of the system and the lack of available, appropriate, affordable, treatment services.
Women Very little research has been conducted on, and few programs are available for, women-especially poor women and those who are pregnant. As the fastest growing population seeking treatment for drug dependency, the lack of knowledge about women's pathways into addiction, the influences on their drug careers, and treatment options and outcomes is abysmal, and has accounted for a poor basis on which policy decisions have been made. Current coed treatment programs are mostly inaccessible to women, and inadequately address the needs of drug dependent women including child care and transportation. These facilities do not have appropriate personnel sensitive to womens' needs and concerns, such as sexual abuse, prostitution, divorce, and single parenthood.
230 Statement of Michael Darcy before the Subcommittee on Legislation and National Security, July 28, 1990, p. 13.
231 Člaude Rhodes, op. cit., p. 6.
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.
Congressional set-asides for women have not succeeded in creating more treatment programs for women, since most states have merely recommended that existing facilities enroll more women. Pregnant women have even fewer options in the treatment system as it currently is structured.
Block grants The current block grant process does not meet the needs of larger cities which receive disproportionately less funds from the states to address their particular drug-related problems. The committee found that addiction is not an individual problem which can be solved individually. It is something that must be handled by the community, neighborhood by neighborhood, as they see fit and in a culturally appropriate manner. By making a stable funding base available at the local level, programs that address all aspects of the problem: medical, social, economic, political, legal and spiritual can be developed. The U.S. Conference of Mayors has pushed unsuccessfully for several years to change the current funding mechanism. The mayors remain leery of federal attempts to impose requirements for comprehensive state plans because local needs would not necessarily be appropriately addressed. They want the Federal Government to take the lead financially in the drug war, since currently the states must shoulder nearly 60 percent of the law enforcement, treatment and prevention burden.
The U.S. Conference of Mayors report that 20 cities did not receive any funds from the formula grant program during the first three quarters of Fiscal Year 1990.232 The G.A.O. has found that rural areas experience similar substance abuse problems to those of urban areas, but receive less than their fair share of funds through the block grant process.233
Funding Despite dramatic increases over the past two years, available treatment funds remain inadequate to meet the need. While the exact number of people seeking treatment but unable to receive it is not known, current waiting lists and epidemiological studies reveal the severity of the problem. Mayors are convinced that they appreciate the intricacies of local concerns and are better able to address them with the available resources than might otherwise be handled by the states. Issues concerning communities of color, the homeless, and poor addicts are not being adequately addressed in the national strategy or by state governments. Roller coaster funding cycles and the inability of cities to support local efforts once federal monies have been depleted have damaged the treatment system, and left local program managers and providers scrambling for available funds.
232 U.S. Conference of Mayors, op. cit., September 1990, p. 1. 233 G.A.O., op. cit., September 1990.
This situation exists even though we know that for every one dollar spent on treatment, $11.54 is saved in social service costs. Yet only three percent of the cost of alcohol and drug problems is now spent on treatment.
Waiting lists Even though Congress has appropriated $140 million since 1988 for the Waiting List Program to enable existing drug abuse treatment programs to expand their capacity to serve drug abusers, cities continue to report that they are unable to handle the demand. The wait for treatment openings in many cities exceeds four months causing many individuals to become discouraged and disappear. Additionally, the administrative nature of the Waiting List Program, which makes it difficult to manage and provides for an unstable funding base, may cause inadvertent damage to state treatment efforts by providing the artificial capacity for lessening waiting lists with money that would have to be sustained by state drug budgets. Local providers and mayors agree that the ideal objective of policy makers should be to eliminate waiting lists by providing sufficient funding to accommodate treatment on request.
Treatment on demand The Administration's opposition to establishing treatment on demand (or request) as a key goal for the National Drug Control Strategy has enormous implications. The effectiveness of the Federal Government's commitment and leadership to fight a war on drugs is diminished without short- and long-term planning and prioritizing necessary to achieve a system that can provide treatment to all who need it.
Research The current emphasis on medications development is a noble one, but one which receives a disproportionate amount of the treatment research funds. Keeping in mind that there are no "magic bullet” cures and that the creation of methadone has spawned a new generation of addicts, treatment research must address comprehensively the drug problems which are deeply rooted in behavioral and social causes.
The nation's ability to assess information on, and respond to, treatment needs is hampered by the lack of a mandatory data collection system. Eliminated in 1981 with the onset of the block grant process, states are not required to provide information on the number of people in need of treatment, and on the severity of abuse for particular drugs, as was required under the Client Oriented Data Acquisition Program. The lack of adequate information hampers the ability of program administrators to provide access to state-of-the-art treatment for those in need, let alone access to basic treatment programs.
G.A.O.'s recent evaluation of research on treatment concluded that NIDA has not had a strategic planning process, but has instead planned its research within the context of the annual budget process, which does not address the long-term future direction of NIDA's research program. Unfortunately, NIDA has had to operate
under these circumstances due to the lack of a stable funding base determined by changing administrations. G.A.O. concludes that,
while much of NIDA's research aims to improve drug
Alcohol The absence of alcohol in the National Drug Control Strategy has created an uneven response to substance abuse care, requiring many states to merge, without the benefit of federal funding, drug and alcohol programs to address a situation where over two-thirds of people seeking treatment report alcohol as their primary problem. Program officials and administrators have called for the inclusion of a focus on alcohol and alcoholism-related problems within the national policy to provide a more comprehensive strategy on substance abuse. Program providers also stressed the need for a federal focus on tobacco use, especially as it relates to youth.
Federal role/leadership Substance abuse treatment must be viewed within the context of the broader health care system. William Atkins articulated the concerns of many program administrators, when he said that more leadership is needed from the Federal Government to help state and local providers coordinate services and provide the infrastructure necessary for a more comprehensive and higher quality treatment system:
In Chicago, for example, out-patient health services are de-
234 U.S. General Accounting Office. "Drug Abuse Research on Treatment May Not Address Current Needs.” GAO/HRD-90-114, September 1990, p. 15.
236 Atkins, op. cit., p. 10.