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OCR for page R1
TREATING
DR dG
-
PROBLEMS
VOLUME ~
A Study of the Evolution, Effectiveness, and Financing
of Public and Private Drug Treatment Systems
Committee for the Substance Abuse Coverage Study
Division of Health Care Services
INSTITUTE OF MEDICINE
Dean R. Gerstein and Henrick J. Harwood, editors
NATIONAL ACADEMY PRESS
Washington, D.C. 1990
OCR for page R2
National Academy Press · 2101 Constitution Avenue, N.W. · Washington, D.C. 20418
NOTICE: The project that is the subject of this report was approved lay the Governing
Board of the National Research Council, whose members are drawn from the councils of
the National Academy of Sciences, the National Academy of Engineering, and the Institute
of Medicine. The members of the committee responsible for the report were chosen for
their competencies and with regard for the appropriate balance.
The report has been reviewed by a group other than the authors according to
procedures approved by a Report Review Committee consisting of members of the National
Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences
to enlist distinguished members of the appropriate professions in the examination of policy
matters pertaining to the health of the public. In this, the Institute acts under both
the Academy's 1863 congressional charter responsibility to be an adviser to the federal
government and its own initiative in identifying issues of medical care, research, and
education. Dr. Samuel O. Thier is president of the Institute of Medicine.
This study was supported by the National Institute on Drug Abuse, U.S. Department
of Health and Human Services, under Contract No. 283-88~009 (SA).
Library of Congress Cataloging-in-Publication Data
Treating drug problems / Committee for the Substance Abuse Coverage
Study, Division of Health Care Services, Institute of Medicine;
Dean R. Gerstein and Henrick J. Harwood, editors.
p. cm.
"This study was supported lay the National Institute on Drug Abuse,
U.S. Department of Health and Human Services, under Contract No.
283-88-0009 (SA)" T.p. verve.
Includes bibliographical references.
Includes index.
ISBN 0-309-04285-2 (v. 1)
1. Drug abuse Treatment United States. ~ Drug abuse-
licatment Government policy United States. 3. Drug abuse-
lLeatment Economic aspects United States. 4. Insurance, Health
United States. I. Gerstein, Dean R. II. Harwood, Henrick J.
III. Institute of Medicine (U.S.~. Committee for the Substance
Abuse Coverage Study. IV. National Institute on Drug Abuse.
[DNLM: 1. Financing, Government United States. 2. Substance
Abuse therapy. WM 2701784]
RC564.1734 1990
362.29'097~dc20
DNLM/DLC
for Library of Congress
90-6633
CIP
Copyright ~ 1990 by the National Academy of Sciences
No part of this book may be reproduced by any mechanical, photographic, or electronic
procedure, or in the form of a phonographic recording, nor may it be stored in a retrieval
system, transmitted, or otherwise copied for public or private use, without written permission
from the publisher, except for the purpose of official use by the United States government.
Printed in the United States of America
OCR for page R3
COMMITTEE FOR THE SUBSTANCE ABUSE COVERAGE STUDY
LAWRENCE S. LEWIN,* Chair, Lewin/ICF Health Group, Washington,
D.C.
RAUL CAETANO, Alcohol Research Group, Institute of Epidemiology
and Behavioral Medicine, Medical Research Institute of San
Francisco at Pacific Presbyterian Medical Center, Berkeley, California
DAVID T. COURTWRIGHT, Department of History, University of North
Florida, Jacksonville, Florida
DAVID ~ DEITCH, Daytop Village, Inc., New York, New York, and
Pacific Institute for Clinical Gaining, Education, and Consultation,
Berkeley, California
DOUGLAS ~ FRASER, Department of Labor Studies, Wayne State
University, Detroit, Michigan
JAMES G. HAUGHTON,* Martin Luther King, Jr./Charles R. Drew
Medical Center, Los Angeles, California
ROBERT L. HUBBARD, Center for Social Research and Policy Analysis,
Research Triangle Institute, Research Triangle Park, North Carolina
JAMES D. ISBISTER, Pharmavene, Inc., Gaithersburg, Maryland
HERBERT D. KLEBER,** Substance Abuse Treatment Unit and
Department of Psychiatry, Yale University School of Medicine, and
APT Foundation, Inc., New Haven, Connecticut
JUDITH R. LAVE,* Graduate School of Public Health, University of
Pittsburgh, Pittsburgh, Pennsylvania
DAVID J. MAMAS, Marathon, Inc., Providence, Rhode Island
DONALD J. McCONNELL, Connecticut Alcohol and Drug Abuse
Commission, Hartford, Connecticut
JOHN H. MOXLEY III,* Health Care Division, Korn/Ferry International,
Los Angeles, California
PETER S. O'DONNELL, The KEREN Group, Princeton, New Jersey
MARK V. PAULY,* Leonard Davis Institute of Health Economics,
University of Pennsylvania, Philadelphia, Pennsylvania
HAROLD ~ RICHMAN, Chapin Hall Center for Children and School of
Social Service Administration, University of Chicago, Chicago, Illinois
MAXINE L. STITZER, Department of Psychiatry and Behavioral
Sciences, Johns Hopkins University School of Medicine, and Francis
Scott Key Medical Center, Baltimore, Maryland
*Member, Institute of Medicine.
* *Herbert D. Kleber resigned August 17, 1989, and Henrick J. Harwood resigned December 4,
1989, to accept positions in the Office of National Drug Control Policy, Executive Office of the
President, Washington, D.C
. ..
1D
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Preface
The committee members and staff appointed In 1988 to conduct the
Institute of Medicine's Substance Abuse Coverage Study were given a
three-part task:
· investigate the extent of private and public funding of treatment
for the chronic, relapsing disorders of drug abuse and dependence;
· evaluate the adequacy of funding patterns to meet the national
need for rehabilitation of individuals with these disorders; and
· make recommendations to responsible parties, such as the U.S.
Congress, which originally requested the study, regarding what they should
do to meet the needs identified by the investigation.
Based on its legislative title, the Substance Abuse Coverage Study
seemed destined to focus on the design of health insurance benefits, which
had entered the picture of drug treatment financing in a major way in the
1980s. But after carefully reviewing the charge, the character and organi-
zation of the treatment system, and the concerns that third-party payers
on both the public and private sides persistently voiced about treatment
programs and clients, the committee adopted a more comprehensive def-
inition of its task. That definition is suggested by the title and descriptor
chosen for this report: Beating Drug Problems; A shady of the evolution,
effectiveness, and financing of public and private drug treatment systems. The
various chapters of the report discuss the history of ideas governing drug
policy, the nature and extent of the need for treatment, the goals and ef-
fectiveness of treatment, the need for research on treatment methods and
v
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V1
PREFACE
services, the costs and organization of the two-tiered national treatment
system, the scope and organizing principles of public and private coverage,
and recommendations tailored to each kind of coverage. Seven papers
commissioned to inform and accompany the report are in a companion
volume.
Notwithstanding this broad range of issues, there are still some very
important constraints and limits on what the committee has done and how
this report should be understood. First, the report is about drug treatment
and not about drug policy in general. Although the committee is care-
ful to note where treatment fits within the context of prevention and law
enforcement approaches to drug problems, it did not study these other ap-
proaches comprehensively. Consequently, its recommendations concerning
additional resources for treatment do not derive from a systematic compar-
ison of allocations for treatment versus allocations of comparable resources
to law enforcement or prevention, but rather from a consideration of treat-
ment needs alone. Comparison of the relative marginal benefits of these
different approaches ultimately must be made, based on appropriate studies
(which the report calls for), but it was not part of the committee's charge
to perform this more encompassing task.
A second limitation is that the committee's recommendations are
confined to and reflect drug treatment in the United States. There is
relevant scientific literature from other countries pertaining to treatment
modalities in the United States, and the committee has explored these
important sources. An adequate investigation of treatment systems in other
countries, however, would require the same level of historical analysis,
expert workshops, intensive site visiting in various localities, and other
procedures that the committee employed in the United States. This type of
careful international comparative study was beyond the committee's scope
and resources.
A third limitation is that the report does not delve into the treatment
of alcohol problems. The committee recognizes that alcohol and drug
problems overlap in a substantial proportion of the cases now being seen,
a fact manifested by the range of problems most programs are willing to
treat and the variety of services they provide. The limitation in scope
here is largely due to a parallel study of alcohol treatment in the Institute
of Medicine, chaired by Robert D. Sparks and directed by Frederick B.
Glaser and Herman I. Diesenhaus; their committee's report, Broadening
the Base of Treatment for Alcohol Problems (~1990), is readily available from
the National Academy Press.
The alcohol study derived from the same legislation that initiated this
study; however, the specific requests proceeded through separate federal
channels and followed different timetables. Readers of both reports will
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PREFACE
. .
V11
easily see that problems associated with the two kinds of substances (legal
alcohol and illegal drugs) and their partially divergent treatment systems
justify separate investigations, even though the two have much in common.
Both committees tried to maintain clear perspectives on each others' work
while the studies were in progress. Mark V. Pauly served as a member of
both committees, and there was other extensive liaison, including joint staff
work. Now that both studies are completed, we are hopeful that a way
will be found to draw the results even closer together, perhaps in a future
report that focuses on the overlap of alcohol and drug problems.
A fourth limitation is that the committee did not devote major energies
to examining the relationship between drug treatment and AIDS (the
acquired immune deficiency syndrome). Another committee of the National
Academy of Sciences has recently completed two comprehensive studies
of AIDS in its behavioral and social contexts, and their reports include
a consideration of drug problems from the perspective of AIDS research
and policy. We therefore refer the reader to AIDS: Sepal Behavior and
Intravenous Drug Use (1989) and AIDS: The Second Decade (1990), which
are both available from the National Academy Press. The latter report is
particularly notable for its thorough analysis of women, adolescents, and
AIDS.
A final limitation on the scope of the committee's work was imposed
by the scarcity of research data since the onset of the crack-cocaine era
concerning treatment for drug dependence in women who are pregnant or
mothers of young children. Of particular importance here is the question
of how such treatment affects not only these women but also the quality of
prenatal development, parental care, and environmental conditions in which
their children are raised; and how, in turn, the children's health, behavior,
and opportunities in life are affected when treatment intervenes. Another
disheartening problem is the fragmentary knowledge base underpinning the
treatment of drug abuse and dependence among adolescents. The absence
of systematic research is perpetuated by excessive barriers to conducting
treatment follow-up studies among individuals under 18 years of age. These
obstacles arise because of inappropriate and unrealistic requirements at
the federal level and in many states to obtain written parental consent
for minors to participate (generally, through confidential interviews) in
treatment services research.
Although the committee was limited in these respects, we believe the
report is fully responsive to its original charge, which expresses a legitimate
and urgent national need. Perhaps in part because of the urgency of this
need, the committee received willing assistance from many sources. Scores
of individuals provided valuable information and trenchant ideas in exten-
sive correspondence with the committee and in the formative workshops
OCR for page R8
· ~ ~
V111
PREFACE
it organized during 1988 in Washington, D.C., and Irvine, California. The
contributions of M. Douglas Anglin, who took part in both workshops and
assisted the committee in other respects, deserve special mention.
The committee is also indebted to programs and agencies that hosted
committee site visits in New York Miami/Dade County, Pittsburgh, St.
Louis, the San Francisco Bay area, Los Angeles and Orange Counties, and
Portland and Salem, Oregon. Closer to home, James M. Kaple and Albert
M. Woodward, the study's project officers at the National Institute on Drug
Abuse, were unfailingly helpful, constructive, and circumspect in facilitating
the progress of the study. Charles R. Schuster, Salvatore di Menza, Edgar
Adams, and other past and present staff of the National Institute on Drug
Abuse were also instrumental in the acquisition of important data.
The Research Triangle Institute, which performed the Treatment Out-
come Prospective Study and the 1988 National Household Survey on Drug
Abuse, among other signal contributions to the field, provided invaluable
assistance in developing this report, and its staff, particularly J. Valley
Rachal and Lynn E. Guess, have earned the committee's thanks. Two
former members of the Lewin/ICF staff, Nina E. Teicholz and Karen F.
Monborne, directly assisted the chair, as did Lewin/ICF colleagues Jack
Needleman and Robert J. Rubin.
The authors of commissioned papers made major contributions to the
committee's thinking and responded graciously to its many requests for
more, less, different, or clarifying information. The committee does not
necessarily concur with every conclusion drawn by these authors; neverthe-
less, we learned a great deal from them and are pleased to publish their
papers in a second volume of the report.
The committee also benefited from a perceptive and unusually exten-
sive set of review comments solicited by the Institute of Medicine. These
reviews stimulated many specific improvements in the draft report, and
their contributors represent an admirable tradition of unsung, voluntary
professional service to the public interest. We are grateful to be among its
beneficiaries.
Speaking for ourselves and for the members of the committee, we
cannot praise too highly the quality and dedication of the Institute of
Medicine staff. Linda B. Kearney, administrative secretary, and Elaine
McGarraugh, research associate, performed coolly and indefatigably in dis-
posing of an unending succession of logistical and technical requirements.
The ingenuity, eye for detail, and good judgment of these veterans kept
the study on track in the face of numerous complications. Technical editor
Leah Mazade carefully graced and polished every line of text in preparing
the report for publication. Henrick J. Hardwood, associate study director
and co-editor of the report, left late in the study to serve in the White
OCR for page R9
PREFACE
IX
House Office of National Drug Control Policy -- but not before organizing
and leading several intensely valuable site visits, completing state-of-the-art
literature reviews and data analyses, and generally earning the very highest
regard of the committee.
Finally, we are fortunate to have a committee whose members are
thoroughly distinguished in their professional achievements, demanding
in their intellectual standards, congenial and unassuming in person, and
thoughtful, persistent, and generous in their abiding commitment to the
public good. On behalf of this splendid group, we are pleased to submit
the report of the Substance Abuse Coverage Study.
Lawrence S. Lewin, Chair
Dean R. Gerstein, Study Director
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Contents
CONTENTS OF VOLUME 2
SUMMARY
Questions the Report Answers and Those It Leaves Unresolved, 1
Ideas Governing Drug Treatment Policy, 2
Drug Problems and the Need for Treatment, 4
Patterns of Drug Consumption, 4; Dependence, 5; Recovery and
Relapse, 5; Determining the Need for Treatment, 7; Estimating
the Aggregate Need for Treatment, 7
The Goals of Drug Treatment, 8
Motivations for Treatment, A, Treatment and Criminal Justice, 10
Effectiveness of Treatment, 11
Methadone Maintenance, 12; {herapeutic Communities, 14;
Outpatient Nonmethadone Programs, 15; Chemical Dependency
Programs, 16; Detoxification, 16; Variations in Effectiveness of
Programs Within Modalities, 17; Treatment in Prisons, 17; Costs
and Benefits of Treatment, 18; Comparison of Data on
Effectiveness and Expenditures for the Major Treatment
Modalities, 18; Needs and Priorities for Research on Treatment
Services and Methods, 19
The lo-Tiered Structure of the Treatment System, 21
Public Financing of Drug Treatment, 22
The Goals and Priorities of Public Coverage, 22; Federal and
State Roles, 24; Mechanisms for Providing Public Support, 25;
Utilization Management, 27
TO
. .
XV11
1
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xii
Private Coverage of Drug Treatment, 29
Extent, Costs, and Trends of Coverage, 29; Mandating Drug
Treatment Coverage, 30; Optimal Coverage Provisions, 30
Coda, 32
1 INTRODUCTION
The Logic of the Report, 34
Additional Policy Questions, 37
Treating Adolescents and Women with Children, 37; The Criminal
Justice System, 38; The Socioeconomic Environment, 38
IDEAS GOVERNING DRUG POLICY
The Character of Governing Ideas, 41
The Spectrum of Ideas About Drugs, 42
Libertarian Ideas, 44; Medical and Criminal Ideas, 46; The Classic
Era of Narcotics Control, 48
The Rise of Modern Treatment, 49
Methadone Maintenance, Therapeutic Communities, and
Outpatient Nonmethadone Programs, 50; Chemical Dependency
Treatment, 53; The Medical/Criminal Idea of Treatment and the
Evolution of Governmental Roles, 53
Conclusion, 56
THE NEED FOR TREATMENT
The Individual Drug History: A Model and Overview, 59
Abstinence, Drug Types, and Normative Attitudes, 62; Learning
and Drug Experience, 64; Environmental Variations, 66; Age of
Onset and Drug Sequencing, 68; Diagnosing Dependence and
Abuse, 6~, Recovery and Relapse, 72
Estimating the Extent of the Need for Treatment, 76
Household Survey Data, 77; Criminal Justice Populations, 81; The
Homeless Population, 84; Pregnant Women, 85; Summary, 86
Quantifying the Consequences, 88
Conclusion, 90
Appendix 3A Estimating the Need for Treatment in the Household
Population, 92
Appendix 3B Estimating the Need for Treatment Among
Arrestees, 97
Appendix 3C Estimating the Costs of Drug Problems, 102
Drug-related Crime—Victim Losses, 102; Crime Control
Resources, 102; Employee Productivity, Losses, 103; Health Costs,
104
4 DEFINING THE GOALS OF TREATMENT
Diverse Interests, 106
Reasons for Seeking Treatment, 109
CONTENTS
33
40
58
105
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CONTENTS
Criminal Justice Agencies and Treatment, 113
Court Referral to Treatment, 114; Prison and Parole Referral to
Treatment, 117; Preliminary Conclusions About "Mandatory
Treatment," 119
Employers and Treatment, 120
Employee Assistance Programs, 121; Drug Screening Programs,
123; How Employers View Drug Treatment, 124
Ambivalence and the Spectrum of Recovery, 125
Full, Partial, and Nonrecovery from Drug Problems, 126; Setting
Realistic Goals, 128
Conclusion, 130
5 THE EtLL;CTIVENESS OF TREATMENT
Methadone Maintenance, 136
What Is Methadone Maintenance?, 136; How Well Does
Methadone Work?, 142; Why Do the Results of Methadone
Treatment Vary?, 147; Costs and Benefits of Methadone
Treatment, 151; Conclusions, 152
Therapeutic Communities, 154
What Is a Therapeutic Community?, 154; How Well Do
Therapeutic Communities Work?, 156; Why Do the Results of
Therapeutic Communities Vary?, 163; Costs and Benefits of
Therapeutic Community Treatment, 165; Conclusions, 166
Outpatient Nonmethadone Treatment, 167
What Is Outpatient Nonmethadone Treatment?, 167; How Well
Does Outpatient Nonmethadone Treatment Work?, 168; Why Do
the Results of Outpatient Nonmethadone Treatment Vary?, 169;
Benefits and Costs of Outpatient Nonmethadone Treatment, 170
Chemical Dependency Treatment, 170
What Is Chemical Dependency Treatment?, 170; How Well Does
Chemical Dependency Treatment Work?, 172; Why Do the
Results of Chemical Dependency Treatment Vary?, 173; Benefits
and Costs of Chemical Dependency Treatment, 174
Detoxification, 174
Correctional Treatment Programs, 176
Stay'n Out and Cornerstone, 177; The California Civil Addict
Program, 180; Boot Camps, 183; Conclusions about Prison
Treatment, 184
Summary and Conclusions about Treatment Effectiveness, 185
Methadone Maintenance, 187; Therapeutic Communities, 188;
Outpatient Nonmethadone Programs, 189; Chemical Dependency
Programs, 190; Detoxification, 190; Correctional Treatment, 191
Recommendations for Research on Treatment Services and
Methods, 192
Rebuilding the Research Base, 192; Major Research Questions,
194
. . .
xu~
132
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XIV
6 TWO TIERS: PUBLIC AND PRIVATE SUPPLY
The To Tiers: An Overview, 201
Financing Differences, 202; Client Differences, 205; Capacity
Differences, 206
The Growth of the National Treatment System, 206
Trends in Client Numbers and Provider Characteristics, 206;
[tends in the Funding Base, 210; Sources of Treatment Dollars,
211; Attends in Federal Funding, 214
Conclusion, 216
7
8
CONTENTS
200
PUBLIC COVERAGE
The Principles of Public Intervention, 221
External Costs, 222; Income Constraints, 225; Positive Response to
Treatment, 227; Balancing Treatment Needs and Cost Concerns,
228
From Principles to Priorities, 230
Eliminate Waiting Lists, 232; Improve Treatment, 232; Reach
More Young Mothers, 233; Induce More Criminal Justice Clients
to Accept Treatment, 235
Three Strategy Options, 235
The Core Strategy Option, 237; Comprehensive and Intermediate
Strategy Options, 238
Public Intervention in the 1990s, 239
Federal and State Roles in the 1970s, 240; The 1980s: Block
Grants, 241; The 1990s: Appropriate Shifts in Federal and State
Roles, 245; Transitional Steps Toward the Year 2000, 249;
Utilization Management, 250
The Special Case of Veterans' Coverage, 252
Conclusions, 254
Appendix 7A Baseline and Strategy Option Calculations, 256
Baseline Comparison Values, 256; Core Strategy Option, 257;
Comprehensive Strategy Option, 260; Intermediate Strategy
Option, 263
Appendix 7B Modeling Future Treatment Needs and Effects, 265
Appendix 7C Medicaid, 266
Coverage Policy Determination Under Medicaid, 267; Eligibility,
268; Coverage Provisions, 270; Me Current and Future Status of
Medicaid Coverage, 271
PRIVATE COVERAGE
The Logic of Private Coverage, 276
The Extent of Private Insurance Coverage, 277
Employees of Private Companies, 278; State and Local
Government Employees, 279; Federal Employees, 281; Employers
and Coverage Decisions, 282
Trends Affecting Private Coverage: Cost Containment of
Health Benefits, 283
220
273
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CONTENTS
Private Insurance and State Mandates, 288
Access to Coverage, 289; Adequacy of Coverage, 290; Cost
Containment, 291; The Value of Additional Mandates, 292
Conclusions, 293
Extent, Costs, and Trends of Coverage, 293; Mandating Drug
Treatment Coverage, 294; Optimal Coverage Provisions, 294
CODA
REFERENCES
BIOGRAPHICAL SKETCHES OF COMMI 1 l L;E MEMBERS
AND STAFF
INDEX
xv
298
301
313
321
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Contents of Volume 2
COMMISSIONED PAPERS ON HISTORICAL, INSTITUTIONAL, AND
ECONOMIC CONTEXTS OF DRUG TREATMENT
A Century of American Narcotic Policy
David T. Courtwright
Federal Leadership in Building the National Drug Treatment System
Karst ~ Besteman
Drug Treatment in State Prisons
Gregory ]? Ralkin, Harry K Wexler, and Douglas S. Lipton
Employee Assistance and Drug Screening Programs
Paul M. Roman and Terry C. Blum
Markets for Drug Treatment
Richard Steinberg
Cycles of Cocaine
Ronald K Siegel
Acknowledgments
. .
XV11
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TREATING
DRUG
PROBLEMS
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