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Harm reduction model 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 indicate 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. 2. State and local treatment
Funding States are having to support the majority of treatment services, and thus have shouldered the increasing burden of providing treatment funds since supplemental federal funds are inadequate to meet the needs of communities. In California, the chief of Contract Management/Program Budget of the Los Angeles County Department of Health Services, Drug Abuse Program Office, Richard Browne stated:
At the State level, the revenues to support the Governor's
Contracts Local providers voiced concern over the inordinate amount of time it takes for programs to receive operating funds. Funds for services are generally allocated to an agency but not awarded until months into the contract term. Agencies are unable to expend funds until the contract is signed. By then the program intent can be compromised, recruited personnel have gone elsewhere, facilities rented by others, and inevitably, programs are unable to meet the goals and expend the funds as originally intended. Program providers have called for a more streamlined funding system so that services can be provided on an effective basis.237 Mayor Goode reported that Philadelphia had to wait 18 months to receive the initial distribution of treatment funds, and 9 months for the most recent distribution. 238
Program providers have reported that the required annual single agency audits place a tremendous financial burden on treatment programs which are already audited by funding sources. Since funds for this annual audit are paid with grant monies, it has been recommended by local providers that the state incur the costs. 239
236 Richard E. Browne, op. cit., pp. 3-4. 237 Duran, op. cit., p. 6. 238 Goode, op. cit., p. 3.
Program managers are having difficulty retaining experienced counselors, many of whom are former addicts, since funding sources limit the type of counseling that peer counselors can do, and the amount of money a program can bill for services provided by someone without formal credentials. Thus, without funds to pay the higher salaries demanded by credentialed staff program managers are forced to hire counselors who may not have
counseling experience. Program managers have recommended that the state or other funding source take the leadership in developing the training to remedy this problem. 240
Many local program managers spend valuable time and much money to meet the codes imposed on treatment facilities by government agencies, e.g. fire, zoning, license. Government agencies at all levels have conflicting regulations which create problems for providers, including the expenditure of treatment funds to settle these disputes. Most notable is the problem of finding suitable locations for new treatment facilities. Most communities counter such efforts with a "Not in My Backyard” syndrome and treatment facilities, more often than not, are left to grapple with the problem alone, without assistance from state or local government.
Root causes Many states and cities are on shoe-string budgets and must provide services and alternatives to substance abuse in local communities. The failure to address the fundamental causes of substance abuse and to provide immediate intervention strategies will impact inner city residents most.
Although there has been a slight increase in available treatment slots, still, the basic problems remain the same. What happens after the client leaves treatment? What environment does he or she return to? What are the options? Upon completion of these programs, provisions should be made for follow through; such as providing jobs, training and education. By providing a different way of life, we provide new hope and opportunities, to replace the drugs. One can say no to drugs, but we must provide something to which one can “say yes.” 241
Cultural sensitivity In the prevention section the committee stressed the importance of cultural sensitivity in providing programming services. Diverse populations require different strategies with which to meet the spe cial needs of their communities. Frequently this requires the ability to communicate in different languages. In Los Angeles, for example, despite the large number of Spanish-speaking people, there are very few drug treatment programs that are staffed to treat Spanish-speaking clientele, since providing services for this population has not been a priority with the funding agencies.242 Similarly, the Asian/Pacific community report that language problems prevent the delivery of services to their growing and culturally diverse community.
239 Duran, op. cit., p. 7. 240 Duran, op. cit., p. 9. 241 Thelma Brown, op. cit., p. 4.
E. RECOMMENDATIONS There are a number of measures that can be undertaken to improve treatment policy and programming. Some require the infusion of significant funding, others require changing the philosophy of the payment system in order to deliver immediate care. While some recommendations are easily attainable, some require presidential and congressional action. To better enable the delivery of substance abuse treatment services, the committee recommends the following:
1. Research, interviews and hearings revealed the need for greater funding for treatment services. The budget for demand reduction efforts which includes treatment programming and research must be increased to reflect a 50-50 split of the National Drug Control Strategy budget allocation of law enforcement/interdiction and, treatment and prevention; to serve individuals on waiting lists, and reach those presently underserved. Currently, treatment programming and research account for 15.7 percent of the total drug strategy budget, which places the burden on already financially strapped states to budget increasing resources for treatment.
2. Mayors of larger cities report that only a small portion of block grant funds are reaching the nation's cities, and that these funds are not reaching the cities in either an efficient or an equitable manner. The committee calls for the provision of a mechanism for larger cities to allow direct access to federal funds to better enable them to serve their communities more expediently and effectively with the appropriate resources.
3. Far too many people are unable to access treatment services. A number of barriers to participation prevent Medicaid eligible individuals from receiving help for drug problems. The committee recommends that all Medicaid eligible individuals should be provided access to comprehensive treatment programs. By viewing treatment services within the context of the broader health care system, the act of seeking help would be considered an acute episode requiring immediate action. The health care system should be revamped to connect financing mechanisms with the decision to seek care. Treatment would be better able to meet the demand for individuals seeking help. Communities in the inner city and rural areas would then have similar access to treatment services as those able to pay expensive inpatient services.
4. The committee recommends that the National Drug Control Strategy be framed by broader social and economic problems which require dramatic reforms in order to attack the root causes of substance abuse. We need to begin to build the infrastructure necessary to improve the quality of treatment
242 Duran, op. cit., p. 13.
services by requiring medical schools to provide comprehensive training to identify and treat substance abusers; provide adequate treatment services at the community level, including after care, vocational, educational, and psychiatric assessments; and develop alternative leisure activities for youth and adults to replace "street life" and assist individuals to escape the drug subculture.
5. Cities around the country are in need of expanded treatment services to meet the needs of communities. The committee recommends that more flexible funding be made available for capital project improvements and expansion to meet the demand for treatment services. The Federal Government must work with communities to educate neighborhoods about the value of locating treatment programs in their communities.
6. Little is known about the costs of treatment services. As a result, the ability of policy makers, state administrators and local providers to allocate resources efficiently is hampered. The committee recommends an increase in the investment in treatment design research and research on the costs of treatment, which are currently inadequate, incorrect and outdated, to allow policy makers and program managers to better allo cate available resources effectively and work toward the goal of treatment on demand."
7. The committee recommends that the goals of the national drug strategy should include the provision of treatment on demand. Currently, treatment needs of pregnant women, adolescents and IV drug users go unmet. 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. National leadership in the drug war will continue to be questioned unless treatment on demand becomes a national goal.
8. The committee has found that most states have merged alcohol and drug prevention and treatment services to reflect the widespread use of alcohol and alcoholism problems with that of illicit drug drugs. The Congress should reconsider the inclusion of alcohol in the national drug strategy to reflect the concurrent abuse and dependence on alcohol within the drug abusing patient population. Congress should also reconsider the inclusion of the "gateway drug” tobacco in the national strategy so as to reflect a comprehensive understanding and coordinated response to substances which are widely available and are linked to more deaths and diseases than are illicit drugs.
9. States are not required to report substance abuse-related information to the Federal Government on a systematic basis. The committee calls for the institution of a mandatory, uniform data collection system such as the Client Oriented Data Acquisition Program, which would be reflective of addicted and dysfunctional drug abusing populations and thus better characterize the status of the nation's substance abuse problems.
10. Little research is conducted on women addicts. As a result, most women receiving drug treatment have not been
successful in ridding themselves of addiction. The committee calls for an increase in funding for research on women and addiction, on specific treatment models for working with drug de pendent women, or of gender-specific drug treatment outcomes.
11. There are less than two dozen women-only treatment facilities in the country. The committee calls for an increase in funding for women-only treatment facilities which would be comprehensive in nature. Requiring states to account for expenditures on women-only treatment services would enable more women, especially pregnant women, to receive treatment and eliminate barriers to access to, and participation in, effective drug treatment.
12. Increasingly, addicted pregnant women around the country are being incarcerated and separated from their children. This trend deters addicted pregnant women from seeking prenatal care. The committee encourages states to offer alternatives to punitive actions, and suggests that ONDCP develop guidelines for such alternatives, against drug dependent pregnant women which would assist inner city poor and minority women who are currently adversely impacted by the growing emphasis on a criminal approach to drug control, and are often separated from their children.
13. The committee recognizes that many drug dependent individuals do not voluntarily seek help for their addiction. Therefore "harm reduction" demonstration projects must be created to address the needs of current addicts currently committed to continued drug use. Such a model would engage intravenous drug addicts in safer drug use to reduce the harm from use to themselves, families and the community. Once engaged, addicts are encouraged but not coerced to make incremental behavior changes which are meant to assist them in moving toward reducing or stopping drug use. The committee recommends that ONDCP issue guidelines and fund harm reduction demonstration projects
14. While the development of new pharmacotherapeutic approaches to treatment of drug abuse is vital, the current emphasis (money and research) placed on medication development implies that a "magic bullet" cure is realistic. Such an approach must take into consideration that the nation's drug problems, particularly that of cocaine, are as deeply rooted in behavioral and social causes, especially in the inner city, as they are in brain chemistry. Keeping in mind the class of methadone addicts that has been generated by the use of methadone, policy makers must be mindful of the limitations of developing medications to cure drug abuse. The committee recommends that NIDA be required to submit long-term research plans that are comprehensive in nature, and reflect the complex characteristics of drug dependency.