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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

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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

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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

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~ ~ 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

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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 CrimeVictim 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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