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Summary
QUESTIONS THE REPORT ANSWERS
AND THOSE IT LEAVES UNRESOLVED
(CHAPTER 1)
The Anti-Drug Abuse Act of 1986 called for the Institute of Medicine
(IOM) to conduct a study of the extent and adequacy of coverage by
public programs, private insurance, and other sources of payment for the
treatment and rehabilitation of drug abusers. The act also requested IOM
to recommend the means by which the needs identified in the study could
be addressed. In responding to this charge, the committee established to
conduct the study has covered the following major questions in its report:
· The role of treatment What is the role of treatment in the ideas
that govern and shape drug policy? (Chapter 2)
· The need for treatment- In light of the patterns of drug consump-
tion and consequent problems, what is the estimated extent of the need for
drug treatment? (Chapter 3)
· The goals of treatment What should drug treatment seek to ac-
complish in the context of treatment seekers' motives and medical-criminal
drug policies? (Chapter 4)
· The effects of treatment What are the available modalities of drug
treatment? What are their expected and actual clinical accomplishments?
Why do the results of treatment programs vary? What are their respective
benefits and costs? (Chapter 5)
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TREAT NG DRUG PROBLEMS
· The organization of treatment How, in general, is the supply of
treatment organized and financed? (Chapter 6)
Public coverage What is the rationale, the priorities, and the
optimal level of public coverage of drug treatment? How can public
coverage be best arranged and managed? (Chapter 7)
· Private coverage What are the responsibilities of private coverage
for drug treatment in terms of eligibility, benefit and service design, costs,
and care management? (Chapter 8)
In answering these questions, and more detailed ones within each
chapter, the committee relies on the preponderance of rigorous evidence
(where enough evidence is available to be weighed) and judiciously uses
expert judgment, including specification of the new knowledge needed to
strengthen this judgment, where logic and experience point strongly but
rigorous evidence is scant. In view of the severity and complexity of the
drug problem and the public's determination to respond, the committee
tries to recommend policy decisions regarding drug treatment that are most
consistent with the current state of knowledge.
There are three important questions relevant to the drug problem
that the committee returned to more than once but could not answer in
this study. In one case, neither evidence nor experience were sufficient
to counsel a specific judgment; in the other two cases, the questions—
and the expertise and evidence needed to answer them were outside the
committee's charge and resources. The most urgent unanswered questions
in this regard are the following:
· With sufficient resources and related services, would different drug
treatment modalities than the ones now available be more effective for
adolescents and mothers of younger children?
How efficient and effective Is the current distribution of criminal
justice responses to the drug problem?
How can society intervene more effectively in socioeconomic en-
vironments to prevent drug initiation and discourage rather than facilitate
relapse?
IDEAS GOVERNING DRUG TREATMENT POLICY
(CHAPTER 2)
The national response to drugs has always been governed by simple,
powerful ideas about the nature of the drug problem and how to control it
(see Figure 2-l).1
1 The tables and figures referred to in this summary appear in the chapters of the report.
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SUMMARY
3
· From Revolutionary times to the Reconstruction era, the drug
problem was a minor concern, left at first to the realm of private behav-
ior, and later managed in a loosely enforced regulatory framework; this
approach derived from libertarian ideas.
A medical conception of opiate and other addictions was for-
mulated in the late 1800s, explaining clinical observations among drug-
consuming older women and other groups. Various treatment approaches
were devised, including detoxification and, where total abstinence was
deemed unachievable, medically supervised maintenance.
· From 1910 to the 1920s, medical approaches were almost wholly
swept aside by the rise of a criminal conception of the problem focusing on
underworld characters who used heroin and other drugs. That conception
held sway, with little effective challenge, for 40 years.
In the 1960s and 1970s, medical ideas reappeared in more sophisti-
cated forms, taking much more explicit account of the various criminal
contexts of drug use. During 1965-1975, a national medical-criminal treat-
ment policy was made viable chiefly by the emergence of promising new
treatment modalities: methadone maintenance and therapeutic communi-
ties for heroin and outpatient nonmethadone programs oriented toward
nonopiate drugs. In the same period the federal government sponsored
the buildup of a substantial public tier of community-based drug treatment
programs. This system of programs was the leading edge of national drug
policy, complementing criminal justice efforts in responding to drug-related
crime.
Other factors that contributed to the reemergence of medical ideas
were a shift in attitudes during the "Great Society" period that brought
a greater assumption of collective responsibility for the casualties of so-
cioeconomic forces. This shift was followed by the Nixon administration's
energetic search for responses to large-scale unrest, particularly the social
problems of increasing crime and heroin use.
From 1975 to 1986, federal dollar support for drug treatment eroded,
although states moved to replace this support to some degree. The growth
of the community-based public tier of treatment stopped while the criminal
justice system as a whole entered a period of unprecedented sustained
increase. The momentum of medical ideas shifted to a rapidly expanding
private tier. In the 1980s, chemical dependency programs, largely com-
prising hospital-based alcohol treatment providers, began treating growing
numbers of heavy alcohol and drug consumers (mostly of cocaine and mar-
ijuana) who could afford to pay with private insurance coverage or personal
assets.
The public tier of drug treatment has been the neglected front in
the drug wars of the 1980s. In formulating the federal anti-drug abuse
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TREATING DRUG PROBLEMS
legislation of 1986 and 1988, the great bulk of the debate and the new sums
actually spent were directed toward enforcement against traffickers and
prevention among nonusers. Outside of concern with isolating the growing
acquired immune deficiency syndrome (AIDS) epidemic, public treatment
was all but ignored.
With the rise in alarm about crack-affected children and neighbor-
hoods, however, the pendulum of public policy is once again moving.
Modalities of treatment attuned to medical-criminal ideas again seem in-
creasingly attractive. It is becoming widely appreciated that the drug
problem does not lend itself to simple characterization or solution, that a
combination of ideas and policies is the most fruitful way to respond to
it, and that treatment programs can and should reflect this principle of
combination.
DRUG PROBLEMS AND THE NEED FOR DRUG TREATMENT
(CHAPTER 3)
Patterns of Drug Consumption
The nation's drug problem is a complicated evolving composite of mil-
lions of individual patterns of drug-consuming behavior and consequences
that may differ according to time and place and that change as the mar-
keting, technology, and reputations of drugs evolve. Crack-cocaine, heroin,
marijuana, amphetamines, and all other illicit drugs are consumed In pat-
terns that range from experimental use to dependence. 1b determine the
extent of need for treatment in the population, drug consumers must be
categorized based on the frequency and amount of their drug consumption
and the severity of associated problems and consequences.
A conceptual paradigm of individual drug consumption, consequences,
and societal responses is presented in Figure 3-1. Although individual
patterns are not always so orderly, patterns or types of drug taking in this
simplified scheme occur in progressive stages of use, abuse, and depen-
dence, each more hazardous and intrusive than the one before. Each stage
entails the risk of further progression, but progression is not inevitable. A
minority of experimental users reach the stage of abuse, fewer yet the stage
of dependence.
The bulb of initial, experimental drug use occurs during the teenage
years. Very few children aged 10 or younger have begun to use drugs.
Nearly as few people begin using drugs—or even any particular type of
drug, unless it was never previously available—after reaching 25 years of
age.
For many years, the introduction to drugs in the great majority of
cases that go on to further stages has proceeded in a general cumulative
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SUMMARY
s
sequence: alcohol and tobacco, to marijuana, to other inhalable or orally
ingestible substances, to hypodermic injection of opiates or powerful stim-
ulants (cocaine, amphetamines). This sequence is almost always initiated
between the ages of 12 and 15, and the injection phase, when reached, gen-
erally begins between the ages of 17 and 20. The sequencing phenomenon
is thought to reflect drug availability and the degree of opprobrium at-
tached to respective types of drugs. However, as the marketing of cocaine
continues to expand and that of marijuana diminishes, the sequence of
introduction to these drugs may become less uniform.
The mixture of drug effects that consumers seek or are satisfied with
tends to change subtly over time, moving typical from just "getting high"
or being sociable in the early stage of use to the achievement of temporary
relief from the persistent desire or learned need for a drug (which persists
even after short-term withdrawal is completed) in the stage of dependence.
Drug-seeking behavior is highly volitional during initiation and continuation
of use, although profoundly influenced by the environment. But the initial
voluntary component of drug-seeking behavior is Epically compromised
by the psychological, physiological, and social aspects of the dependence
process, which dramatically increases the probability that treatment will be
needed to extinguish drug-seeking behavior.
Dependence
Dependence (not only on illicit substances but also on such licit agents
as alcohol and tobacco) is the most extreme pattern of drug consumption.
It is the persistent seeking and consumption of one or more types of drugs
in excessive amounts, despite such high costs as the accumulation of harm
to health and functioning, viewed broadly by social standards and judged
specifically according to clinical diagnostic criteria. The most severely drug-
impaired individuals are dependent on one drug and make heavy use of
one or more others (including alcohol), perhaps to the point of multiple
dependencies. Many such individuals also have serious mental illnesses and
medical complications.
There is a range of individual vulnerability to drug dependence when
environmental conditions are held constant. But social environments are
not constant, and variation in environmental conditions correlates strongly
with ecological variation in drug dependence rates.
Recovely and Relapse
Drug dependence is characteristically a chronic, relapsing disorder.
Drug abuse often assumes this character as well, but not as often. De-
pendent drug-seeking behavior and the strong desire or craving for drugs
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TREATING DRUG PROBLEMS
that is its subjective aspect are difficult to lose completely, or extinguish,
once they have been established. It is easier to complete detoxification
(the short-term transition from being acutely dependent to being free of
dependence symptoms) than it is to sustain that asymptomatic state beyond
the short term that is, to avoid relapse. Nevertheless, individuals can suc-
cessfully put a complete stop to an established pattern of chronic dependent
behavior. Not only can they safely stop using drugs in the short term, with
or without formal assistance, but they can also avoid the recurrence of drug
seeking that ends in relapse. This extinguishing of individual drug-seeking
behavior is the most fundamental element in the recovery process.
Studies of the life history of dependent individuals indicate that there
is usually a complicated path to recovery. Individuals with severe problems
(including deficits in their social environment) that precede their drug
dependence or abuse—for example, family disintegration, lack of legitimate
job skills or opportunities, illiteracy, or psychiatric disorders will probably
continue to have these problems unless specific services are available to
deal with them. These individuals are also at intrinsically high risk of
relapse.
Many individuals are too damaged by the consequences of drug de-
pendence or other factors, too bereft of alternative behavioral skills and
supports, to complete (sometimes even to begin) the recovery process
without lengthy or continuing help in coping with psychological, social, eco-
nomic, or pharmacological problems. For these individuals, recovery is not
only a matter of extinguishing drug-seeking behavior but also of address-
ing directly a range of functional impairments that usually preceded drug
seeking and were worsened by it. Recovering functionality in society to
whatever degree is possible is a more comprehensive definition of recovery.
Treatment of drug problems, therefore, often addresses itself not only
to drug consumption as such but also to the chronic personal impairments
and social and economic deficits that often characterize those who enter
treatment. Individuals without accompanying problems, who have long-
term assets such as a stable job and supportive family, are not likely to
need specific adjunctive services and have been found to be intrinsically
less likely to relapse.
It is characteristic of recovery processes from any type of drug depen-
dence that, although many people do recover, recovery is seldom achieved,
or even begun, before the individual recognizes that he or she has suffered
and caused significant personal and social harm an understanding that
often requires overcoming a strong tendency to denial. The more severe
and prolonged the periods of dependence or severe abuse, the greater the
need for help in extinguishing drug-consuming behavior.
Autonomous cessation, or self-recovery, although not uncommon, is
not universal. Many, probably the majority, of those who are dependent or
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SUMAL4RY
7
severe abusers relapse after their first (and later) attempts at self-recovery.
Most people who enter drug treatment have tried self-recovery previously
but did not succeed. Most people who recover after treatment do so after
more than one treatment episode.
Determining the Need for '[reatment
Drug treatment is (or in most cases should be) an intensive, person-
alized intervention. Iteatment is not an appropriate or efficient response
to the most common patterns of drug consumption, namely, experimental
and occasional use, and may not be needed in cases of abuse in which
impairment is slight or the pattern of abuse is new. Other interventions,
such as brief preventive counseling, educational services, and disciplinary
sanctions, may be legitimate, useful, or effective in promoting cessation and
abstinence in these instances.
Formal diagnostic criteria for determining the appropriateness of treat-
ment have evolved over the years and now encompass a constellation of
drug-related problems rather than focusing exclusively on classical signs
such as tolerance and withdrawal symptoms. Practice in diagnosis is highly
variable; nevertheless, the majority of individuals entering drug treatment
programs are dependent or severe abusers by any reasonably discriminating
a-- r
criteria.
In the committee's judgment, drug treatment is justified and appropri-
ate for an individual if there are clinically significant signs of dependence or
chronic abuse. Assessment of individual problem severity and the degree
of help needed for recovery is thus exceedingly important. These factors
are usually but not always taken into account in matching individual treat-
ment seekers with appropriate modalities and in "fine-tuning" treatment by
choosing among specific therapeutic components.
Estimating the Aggregate Need for Treatment
An estimated 5.5 million Americans clearly or probably need treatment
at this time, which is somewhat more than 2 percent of the total population
over 12 years of age. About one-fifth of the estimated population needing
treatment—and two-fifths of those who clearly need it are under the
supervision of the criminal justice system as parolees, probationers, or
inmates (see Table 3-4~.
In the household population not under criminal justice supervision,
those clearly or probably needing drug treatment are two-thirds male and
heavily concentrated among adults aged 18 to 34. Youths under the age of
18 make up about 9 percent (about 400,000 persons) of the total household
group needing treatment, and adults over 34 account for about 16 percent
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8
TREATING DRUG PROBr EMS
(roughly, 725,000 persons). Most of the household adults 75 percent—
hold some type of job at least part of the time, 10 percent are unemployed
(twice the national average), and 15 percent are in school, retired, disabled,
or carrying household responsibilities.
Current survey and surveillance data indicate that, although lighter
drug consumption—experimental and occasional use is becoming less
prevalent, the problem of severe drug abuse and dependence is grow-
ing larger, more difficult, and more costly. The difficulties are due both
to the expanded menu of drugs that are now widely consumed most
prominently, marijuana and cocaine, barbiturates and other depressants,
amphetamines and PCP in some parts of the country, and heroin and to
the complications induced by AIDS, chronic unemployment, and extended
family disintegration in the inner cities. Because of the complex, protean,
time-extended character of the drug problem, aggregate treatment needs
are not necessarily closely linked to the current overall societal prevalence
of drug involvement. Total social costs are especially difficult to estimate,
being subject to many uncertainties of measurement. The costs of drug
problems in the form of treatment for AIDS, prevention programs, and
drug treatment programs are not insubstantial, but they are clearly much
smaller than the costs incurred as a result of drug-related crime.
THE GOALS OF DRUG TREATMENT
(CHAPTER 4)
~ know whether treatment is appropriate and whether the money
it costs is well spent, the goals of treatment need to be made explicit.
Lifetime abstinence from all illicit drug consumption is the central goal
of drug treatment. However, in light of the chronic, complex nature
of drug problems, the more pragmatic day-to-day objective is to reduce
illicit drug consumption by as large a fraction as possible relative to the
consumption one might expect in the absence of treatment. Reduction of
illicit drug consumption produces socially and personally valuable results
and may serve as a critical intermediate step to lifetime abstinence. A
useful shorthand for the pragmatic goal of drug treatment is that it tries to
initiate, accelerate, and help sustain the recovery process.
The goals of the treatment delivery system are not confined to reducing
the drug consumption of specific individuals. These goals, assigned overtly
or implicitly by public policy or private payers, are multiple and may include
the following:
· reduce the overall demand for illicit drugs;
.
reduce street crime;
· change users' personal values;
· develop educational or vocational capabilities;
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SUMMARY
9
· restore or increase employment or productivity;
· improve the user's overall health, psychological functioning, and
family life; and
reduce fetal exposure to drug dependence.
Success in achieving one set of these goals may be related to but is
not equal to success in achieving the others. Generally, the more severely
the user is impaired with respect to these various goals when he or she
enters treatment, the more services will be needed for drug treatment to
be effective.
Motivations for Treatment
The nature and success of drug treatment is complicated by the typical
reluctance of dependent or abusing individuals to seek treatment or stay in
it. The main reason for this reluctance is that drug consumers like drugs;
drugs "work" for them and provide the effects they seek, which vary from
pleasure to relief. Drug dependence or abuse, in and of itself, is often not
what sends people to treatment, at least, not initially. Individuals often
enter treatment as a strategy of partial rather than full recovery that is,
to help manage serious problems with the law, their family, their mental
or physical health, other drug consumers or dealers, a threat involving
criminal justice supervision, or an abrupt loss of customary income. In
other words, they may enter treatment to establish better control over
their drug behavior or its consequences but not necessarily to extinguish
the behavior entirely. Another factor that contributes to some individuals'
reluctance to enter or stay in treatment is that drug treatment is often
demanding, imposing schedules and controls and requiring extensive work
on the part of the client to overcome social deficits and heal psychological
impairments.
Overall, because of the inherent disinclination toward drug treatment,
some form of perceived threat or pressure is nearly always present as a
triggering element when treatment is sought. The pressure can derive from
an internal or an external problem, which is usually but not necessarily a
direct consequence of drugs. The most common internal pressure is the
cumulative and demoralizing realization that the increasing trouble that
comes with sustained drug abuse or dependence leads to a dead end.
Clients formulate exterior motives for entering treatment as "to get
[someone] off my case." External pushes are usually allied to some de-
gree of positive pull or motivation to change. The positive motives are
often not strong enough in themselves to initiate or sustain recovery, but
reinforcement though external pushes into treatment and therapeutic pres-
sure within treatment can be effective in doing so. The specific mixture
and source of motives vary with the circumstances. For someone with a
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TREATING DRUG PROBLEMS
high-paying, prestigious job, the direct threat of losing that livelihood and
position can carry a great deal of weight. For someone who is unemployed
and unskilled, no threat short of a long prison sentence may carry a com-
parable degree of weight or pressure. The civil liberties implications of this
inequity are troubling, but such is currently the state of affairs.
Treatment and Criminal Justice
The treatment system and crime control systems in this country share
important goals especially, the attainment of less criminal and drug-
involved lives by their clientele. On a given day, out of 1 million persons in
confinement, there are probably 40,000 individuals in jail or prison custody
who are also in drug treatment programs. More broadly, many courts and
correctional systems use commitment or referral to community-based treat-
ment programs, usually ones involving close supervision, as alternatives or
adjuncts to probation or parole status. Half or more of the admissions
to typical community-based residential and outpatient drug treatment pro-
grams (except perhaps for methadone) are on probation or parole when
they enter treatment. These statistics are a direct manifestation of the
criminal-medical policy idea regarding the drug problem.
The criminal justice system is already the largest single source of
external pressure on individuals leading them to enter drug treatment.
In most cases, the court (or another criminal justice agency) has simply
ordered the individual to stay free of drugs and crime or else be remanded
to custody. In this instance the individual chooses to seek treatment
under the assumption that avoiding drug use (or at least avoiding abuse or
dependence, which are far more troublesome and difficult to conceal) will
be facilitated by treatment. In more direct cases the court or other agency
offers the client a choice, generally between a term in prison and a period
of probation or parole with treatment.
Criminal justice referral to treatment occurs for several reasons, includ-
ing relief of court and prison overcrowding. Treatment takes responsibility
for a case somewhat out of the criminal justice system, reduces the high
cost of continuing incarceration, and assures a degree of supervision be-
yond what probation or parole offices may be able to afford. When referral
occurs to relieve overcrowding, however, the stipulation "go to treatment
and comply with the program or risk being resumed to custody" loses its
credibility. The more overcrowded and strained the criminal justice system,
the less pressure it can muster to help push any particular individual into
seeking and complying with treatment.
There is frequent favorable reference today to "mandatory," "compul-
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SUMMARY
11
very," or "required" treatment. Contrary to earlier fears among clinicians,
criminal justice pressure does not necessarily vitiate treatment effectiveness
and probably improves retention. Yet the most important reason to consider
these or related schemes to compel more of the criminal justice population
to seek treatment is not that coercion may improve the results of treatment
but that treatment may improve the rather dismal record of plain coercion
particularly imprisonment—in reducing the level of intensively criminal
behavior that ensues when the coercive grip is relaxed.
EFFECTIVENESS OF TREATMENT
(CHAPTER 5)
In the context of a medical-criminal policy, the practical objective
of treatment at present is primarily to reduce illicit drug consumption
and other criminal activity, secondarily to increase success in conventional
activities such as employment and child rearing, and to improve health
status, including, most recently, reducing AIDS risk behavior among clients.
The standard for success is whether behavior during and after treatment
is appreciably better than what would probably occur in the absence of
treatment.
Does drug treatment achieve these goals? It varies; for a more dis-
crim~nating answer, it is necessary to pose a more sophisticated set of
questions.
What are the basic concepts or modalities of treatment? That is,
what are the underlying designs or theories of treatment, what specific
types of drug problems or population groups are being addressed by each
design, and what are the best results that have been obtained under ideal
conditions?
· How well does each modality work in practice? If a modality works
less well than might be expected, what are the reasons for this variance? For
example, is the implementation or replication of the modality flawed or
incomplete? Are the wrong kinds of clients being treated? Are there
unexpected side effects? Does the environment neutralize the effectiveness
of the treatment?
Do the benefits of treatment justify the costs? In other words, is
treatment a good investment?
· In addition to the above questions about treatment as it exists:
How might Fisher research help to improve treatment?
All of these questions must be asked, but they cannot all be answered
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TREATING DRUG PROBLEMS
for less than 10 years and has grown very rapidly. Per diem charges in
private-tier outpatient programs (methadone and nonmethadone) appear
similar to those in the public tier, but residential and hospital per diem
charges are three to four times greater. The private tier reports abundant
reserve capacity.
In 1987, reports of reserve treatment capacity were highest (more than
50 percent above the current census) in private and public hospitals and
in private-tier residential facilities; reserve capacity was lowest in public-
tier methadone and outpatient facilities. There were substantial regional
differences in public-tier availability; when these are taken into account,
it appears that some areas of the country are sorely pressed for public
residential treatment as well.
There is a need to selectively expand the public tier but with a very
important reservation. The current resource intensity of the public-tier
programs is marginal at best. Expansion will almost certainly reduce and
dilute this intensity unless aggressive measures are instituted. The need
for more resource-intensive treatment appears equal in importance to the
need for increases in capacity. Research data on returns to more intensive
resources per patient are scarce, but the most sensible course is to increase
public resources to restore earlier levels of service intensity, facility quality,
and staff skills, as well as to increase the capacity for new admissions.
In selected regions, the public tier needs greater investments in both
intensity and capacity. The private tier appears at this time to be heavily
committed to acute care hospital treatment for cocaine and marijuana
problems and may benefit most from either a shift toward greater use of
nonhospital residential and outpatient modalities or, if such a shift cannot
be effected, a move toward cost or charge structures that will permit and
encourage the more extended periods of care typical of these modalities,
in contrast to the short stays and high per diem charges now characteristic
of hospital-based chemical dependency treatment.
PUBLIC FINANCING OF DRUG TREATMENT
(CHAPTER 7)
The Goals and Priorities of Public Coverage
Two basic principles justify public coverage of drug treatment, and
these principles in turn suggest specific priorities for the expansion of the
public tier that is now under way largely as a result of the recent federal
anti-drug legislation. The first principle is that public coverage should
seek to reduce external social costs in particular those relating to crime
and family role dysfunctions. The second principle is that public coverage
should remedy constraints arising from inadequate income. Based on these
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SUMMARY
23
principles, the general goal of public coverage should be to provide adequate
support for appropriate and timely admission, as well as completion or
maintenance, of good-quality treatment for individuals who cannot pay for
it (fully or partly) whenever such individuals reed treatment, according
to the best professional judgment, and seek treatment or can be induced
through acceptable means to pursue it, assuming there is some probability
of positive response.
The committee estimates that 35 million individuals qualify as indigent
with regard to private purchase of any form of drug treatment; that is, they
are neither adequately insured nor able to pay out of pocket for appropriate
forms of specialized treatment if needed and thus would have to rely on
public services. For residential drug treatment, the committee's estimate of
those who are unable to afford it if needed rises to 60 million.
The resources still needed to achieve the general goal of public cov-
erage represent a major increase in public support for treatment, and
even under the current conditions of extraordinary public concern about
the drug problem and the possibility of commensurate appropriations, ev-
erything cannot be done at once. Priorities for treatment thus need to be
defined The committee recommends the following priorities for public-tier
expansion:
· end delays in admission when treatment is appropriate, as evi-
denced by waiting lists;
improve treatment (by raising the levels of service intensity, per-
sonnel quality and experience, and retention rates of existing modalities;
by having programs assume more integrative roles with respect to re-
lated services; and by instituting systematic performance monitoring and
follow-up);
· expand treatment through more aggressive outreach to pregnant
women and young mothers; and
· further expand communi~-based and institutionally based treat-
ment of criminal justice clients.
The upgrading of performance and quality levels is intrinsic to the
other three priorities and would be needed even if expanded treatment
admissions were not an objective. The recent decade-long hollowing-out
of treatment programs through resource attrition, together with research
findings about substantial variations in program performance, and the
consistent importance of retention in predicting outcome all support the
need for restoration of funding and quality levels in treatment.
The upgrading of staff capabilities and morale and modest but criti-
cally needed renovation of decrepit facilities and furnishings have multiple
significance. Good staff morale and decent facilities increase the attractive-
ness of treatment programs and thus their ability to recruit and retain staff.
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TREATING DRUG PROBLEMS
These factors also affect client interest in program admission and reten-
tion. Most critically, the competence, quality, and continuity of care givers
may well be a critical element in explaining the differential effectiveness of
treatment programs.
It is possible to estimate the amount of new public financing needed
to meet these priority objectives, although to do so, key assumptions must
be made about such parameters as capital costs, training expenses, and the
number of individuals who could be induced to enter treatment at various
levels of effort. The committee judges that the amount needed to upgrade
and expand the drug treatment system, beyond current spending rates, is
$2.2 billion in annual operating costs (plus $1.1 billion in one-time costs)
for a comprehensive plan, $1 billion annualb (plus $0.5 billion up front)
for a core plan, or $1.6 billion annually (plus $0.8 billion in up-front costs)
for an intermediate plan. Details are provided in Table 7-1. Because data
supporting the costs of the recommended strategies are uncertain, it is
essential that relevant data collection be developed very quickly and its
products analyzed as soon as possible.
The committee's recommended strategies lead to a consideration of
needed changes in how to manage the public tier. These issues divide
into the following: the roles and interrelations of the states, the federal
government, and public-tier providers; the most appropriate shorter and
longer term financing mechanisms for providing public support (direct
service programs versus public insurance); and the controls needed to
make the most effective and efficient use of public funds.
Federal and State Roles
State governments have played the major role in financial administra-
tion and quality control of drug treatment programs in recent years, but
there has also been cyclical movement between state and federal leader-
ship. The federal government originally built most of the public tier of
providers and then transferred responsibility for regulating and supporting
this tier largely to the states; it is now moving back into the lead role.
This expansion of federal support should be accompanied by more active,
centralized direction and control of treatment resources.
States will continue to have the major operational responsibility for
implementing new drug treatment priorities and standards. The increasing
streams of federal monies must be allocated so as to help support the
critical data collection, training, and technical assistance functions to be
deployed through state offices. In the recommended expansion of sup-
port, it is appropriate for the federal government to take the lead in the
short term in upgrading program quality and extending outreach to critical
populations. In so doing, there are two important near-term management
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SUMMARY
25
objectives. One objective is to ensure the most efficient and effective ex-
penditure of existing and incremental funds, preserving as much discretion
as possible on the federal level so that federal agencies have the flexibility
to encourage states to reach the new goals. The second objective is to max-
imize coordination with other anti-drug abuse activities (including public
safety, justice, and correctional institutions) and other social welfare and
health services.
In lieu of fixed formulas for the allocation of funds received by the
states (which, as most recently revised, are based on population weighted
somewhat by degree of urbanization), the committee recommends that
state agencies be required to submit plans that analyze the conjunctions
and mismatches among the most current epidemiological information and
known treatment capabilities; it further recommends that the states be
required to propose annual spending patterns that reflect this information.
In addition, a portion of the federal dollars must go into technical assistance
and data system building to ensure at the state, local, and program levels
that this planning effort will have a factual basis.
One other notable element of the federal role is support for veterans.
The Veterans Administration has previously targeted drug programs for
drastic budget reductions in order to meet overall fiscal limitations. At
the very least, outpatient or residential drug treatment services furnished
directly or by contract should be made available to meet the needs of
former inpatients.
Mechanisms for Providing Public Support
At present, the public sector provides access to drug treatment through
two distinctly different financial mechanisms: direct program financing
through service contracts and grants to formally defined and certified ad-
diction treatment programs, versus individual insurance financing through
Medicaid and similar programs. The largest and most important guarantee
of access to drug treatment is the program of public grants or contracts
with public-tier treatment providers, who serve virtually all of the medically
indigent population (the poor, uninsured, or underinsured) needing drug
treatment. Continued expansion of the dollar level of this form of support
is the primary means recommended by the committee to address public
coverage goals and priorities over the next 5 years.
Emphasis on direct service is an appropriate model for directed system
building, but long-term system maintenance may be better sensed by a
proportionately greater use of public insurance financing, supplemented by
direct service grants to ensure critical program elements such as outreach
and other important services to the many individuals for whom low income
is not the only barrier to seeking and responding well to treatment. The
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TREATING DRUG PROBEFMS
ground should be prepared to "mainstream" drug treatment more fully in
the next 5 to 10 years, incorporating it as much as possible into public
health care insurance for the poor, that is, the set of state programs
presently gathered under the tent of federal Medicaid.
Currently, eligibility for Medicaid among poor people is sharply cir-
cumscribed for those between the ages of 18 and 65 who are not perma-
nently disabled. There are large gaps in eligibility in the health insurance
programs of the 50 states and the District of Columbia, all of which par-
ticipate in the federal Medicaid matching program. Medicaid does provide
significant health care coverage for low-income women (especially if they
are pregnant) and their children who are less than 18 years old (especially
if the children are less than 6 years old). All states, however, exclude
nondisabled single men from coverage, and there is great variation across
states in the family income ceilings for Medicaid eligibility, which can be
and often are well below the federal `'poverty line."
Fewer than a handful of states with the broadest eligibility and ben-
efits now account for a large majority of all Medicaid support for drug
treatment. Yet even in these states, the programs cover only some of the
services needed in—or adjoined with—drug abuse treatment (e.g., medical
examination at intake, visits for methadone dispensing, hospital-based ser-
vices), and payment levels are often much lower than the cost of covered
services.
There are five steps that would be particularly useful as incentives tot
ward a larger role for Medicaid in treating drug problems and that would
not compromise the efficiency of the direct service support mechanism.
The first step is to require all parties to cooperative agreements, grants,
or contracts involving federal funds to develop and display evidence of
progress toward the long-term goal of increasing the receipt of funds from
the Medicaid system. Examples of potential strategies include facilitating
the registration of clients eligible for Medicaid benefits and meeting rel-
evant accreditation standards familiar to Medicaid, such as those of the
Joint Commission on Accreditation of Healthcare Organizations or the
Commission on Accreditation of Rehabilitation Facilities.
The second useful step is to begin stipulating matching requirements
rather than maintenance-of-effort requirements for increases in grant sup-
port to the states. By determining the matching ratio with the same formula
used to determine Medicaid matching, the incentive to states to use Med-
icaid structures will be increased, and the disincentive states must match
every new Medicaid dollar but can get more block grant dollars without
increasing state appropriations will be removed.
The third step is for the federal government to require state Medicaid
programs to include drug treatment as part of the standard package of
benefits offered to all current (and any newly added) Medicaid-eligible per-
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SUMMARY
27
sons. The drug benefit package should cover methadone treatment, outpa-
tient nonmethadone treatment, and residential treatment in state-accredited
freestanding (nonhospital) as well as hospital-affiliated residential facilities
and outpatient programs. No special copayments or limitations that is, no
copayments or limits not generally applicable to medicaVsurgical benefits-
should be applied to drug treatment. For those states with private insurance
mandates for drug treatment insurance coverage, the Medicaid drug treat-
ment benefit should be at least as comprehensive as (which does not mean
identical with) the mandated private insurance benefit.
The fourth step is to reduce gross inconsistencies in the way drug
problems are handled in eligibility determinations for Medicaid, Aid to
Families with Dependent Children, Medicare, Supplemental Security In-
come, and other income maintenance, education, and housing assistance
entitlement programs. These inconsistencies create a bureaucratic night-
mare for the drug treatment programs and state agencies that draw on more
than one such source of funds which most of them try to do. The Office
of National Drug Control Policy should analyze definitional inconsistencies
among federal programs and lay out a plan to minimize resulting problems.
The fifth step is to develop a thoroughgoing system of public uti-
lization management (a term describing arrangements to define access to
effective treatment while keeping costs at efficient levels). Good utilization
management works to ensure that a fully appropriate and needed range
of services is used and that different service components are coordinated.
Many of the components of such a system were developed in the early
1970s but subsequently disestablished. These components are described in
the next section.
Utilization Management
The most fundamental principle of utilization management is that ac-
cess to and utilization of care should be controlled and managed on a case
basis by "neutral gatekeepers" or central intake personnel (although this
triage or central intake function may need to be dispersed geographically).
These personnel should be regulated by certification standards and un-
dergirded by time-limited, performance-accounted licenses and contracts.
Client assessment, referral, and monitoring of progress in treatment should
be reviewed (or performed) independently of the treatment provider. These
personnel should have appropriate clinical credentials that include the un-
derstanding that longer residential and outpatient durations are strongly
correlated with beneficial results among public clients. Effective utiliza-
tion management should recognize that drug abuse and dependence are
chronic, relapsing disorders and that for any one client, more than one
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TREATING DRUG PROBLEMS
treatment episode may be needed and different types of treatment may
need to be tried. "Gatekeepers" should have access to ongoing perfor-
mance evaluation results and responsibility for implementing cost-control
objectives.
There should be rigorous preadmission and concurrent review of all
residential drug treatment admissions, and especially of hospital admissions,
and concurrent review of outpatient treatment. Unlike the objective in
utilization management of acute hospital care for most medical conditions,
which is basically to hold inpatient lengths of stay to a minimum, the
objective for drug treatment services should be to increase client retention
in appropriate, cost-e~cient treatment settings.
The major cost-control concern in this area is the use of high-cost
treatment when lower cost alternatives could be as effective. This hazard
attaches principally to acute care hospital inpatient services for detoxifi-
cation or rehabilitation treatment. The public tier generally has not been
heavily invested in hospital-based drug treatment, and this should continue
to be the case—but not as a matter of rigid exclusion. The committee
recommends that hospital-based drug services be reimbursed at the same
level as nonhospital residential treatment rates, unless there is evidence
that a client specifically requires continuing acute care hospital services.
Hospital-based drug detoxification should only be covered in the event of
medical complications such as those noted below or the lack of appropriate
residential or outpatient facilities nearby. Indications for hospital-based
inpatient drug detoxification are the following:
serious concurrent medical illness such as tuberculosis, pneumo-
nia, or acute hepatitis;
· history of medical complications such as seizures in previous detox-
ification episodes;
· evidence of suicidal ideation;
dependence on sedative-hypnotic drugs as validated by tolerance
testing (therapeutic challenge) to determine the appropriate length of stay;
and
· history of failure to complete earlier ambulatory or residential
detoxification versus completion in inpatient settings.
As perhaps the most important and immediately needed utilization
management requirement, the committee recommends that all drug treat-
ment programs receiving public support be required to participate in a
client-oriented data system that reports client characteristics, retention,
and progress indicators at admission, during treatment, at discharge, and
(on a reasonable sampling basis) at one or more follow-up points. There
should be periodic, independent investigation on a sampling basis of the
quality and accuracy of the data system or systems, and the systems should
be designed to dovetail or link with ongoing services research and data
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SUMMARY
29
collection in other government agencies and units concerned with drug
problems (see the discussion of research needs in Chapter 5~. Certification
for public support should be time limited and based on performance-
especially client retention and improvement rather than on process stan-
dards. Performance is to be demonstrated by outcome evaluation, and
the standards of performance adequacy should be informed by past and
ongoing treatment effectiveness research on retention and outcomes.
PRIVATE COVERAGE OF DRUG TREATMENT
(CHAPTER 8)
Extent, Costs, and lYends of Coverage
The private tier of drug treatment providers is largely oriented toward
treating the employed population and their family members. The majority
of this population, about 140 million individuals, have specifically defined
coverage for drug treatment in their health insurance plans. About 48
million others who are privately insured do not have specifically defined
coverage for drug treatment, although coverage may occur de facto under
general medical or psychiatric provisions. As of 1988, the health plans of
about 67 percent of full-time employees of firms with 100 or more employ-
ees offered specifically defined coverage for some types of drug treatment,
although the actual extent of benefits under these defined coverage provi-
. . .
sloes IS uncertain.
Actuarial studies of claims experience yield rather modest estimates for
the overall cost of covering drug treatment. Drug treatment expenditures
tend to be buried under more inclusive headings and behind "horror stories"
involving troubled adolescents with multiple diagnoses spending months in
psychiatric facilities. Nevertheless, the committee estimates that a health
plan with typical coverage now spends 1 percent or less of its total outlays
for explicit drug treatment, most of it for hospital inpatient charges—with
a large fraction of that cost devoted to detoxification. There has been a
substantial apparent growth in the rate of drug treatment claims in recent
years, although it is unclear how much of this increase is due to more
revealing or accurate drug problem diagnoses versus increased demand for
drug treatment.
Although this growth is disturbing to the degree it increases the ag-
gregate cost of health insurance premiums, it is desirable if it means that
more of those who need treatment are seeking and receiving it, particularly
if the treatment delivered is appropriate, effective, and reasonable in cost.
Some payers, however, reacting in part to the high costs of a small number
of cases and the high incidence of recidivism, have strongly questioned the
value of drug treatment episodes, and they have moved to differentially
limit reimbursement of drug treatment to help trim increasing overall costs.
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TREATING DRUG PROBLEMS
Mandating Drug Treatment Coverage
There are legislative mandates in 18 states plus the District of Columbia
requiring that certain categories of employer-supplied group health plans
specifically cover—or offer optional coverage for drug and alcohol treat-
ment. (Another 19 states require some degree of coverage for alcohol
treatment only.) In the committee's judgment, private coverage of drug
treatment is beneficial to individuals and employers and should be included
in every health package; however, legislative mandates at the state level
have not necessarily proved to be an effective way, and are clearly not the
only way, to induce adequate coverage. Most insured individuals whose
plans include explicitly defined coverage for drug treatment reside in states
that do not have legislative mandates for such coverage. Moreover, the po-
litical process has often produced less-than-optimal mandatory provisions
that are difficult to adjust, overly rigid, and pay too much attention to
limits on the length of stay and the number of visits rather than to the
cost and effectiveness of treatment. Most mandatory provisions have the
constraining effect of funneling people toward one particular modality of
treatment by favoring inpatient stays of prespecified lengths.
The committee believes that the development of soundly derived stan-
dards for admission, care, and program performance will do more at this
time to generate appropriate coverage than a further set of mandates. If
mandates are to be used, efficiency and fairness dictate that they be applied
to all competing insurers. Yet if the private market leaves large numbers
of the insured population without coverage for drug treatment, it may be
necessary for government to intervene. Such action could involve subsidies
for drug treatment coverage, tax preferences for certain kinds of coverage,
or mandates, with the choice dependent on judgments about the incidence,
efficiency, and equity of alternative ways of financing coverage.
Optimal Coverage Provisions
Private insurance provisions (including most legislatively mandated
benefits) often include financial incentives for beneficiaries to seek more
expensive hospital or residential treatment. Although residential drug
treatment, including hospital treatment, often serves clinically important
functions such as permitting intensive therapy and isolating the patient
from an adverse environment or treating concurrent psychiatric or medical
complications, hospital-specific components (e.g., 24-hour onsite medical
coverage) do not seem to be the therapeutically important elements in
drug treatment programs that are sited there, even though the availability
of these components is used to justify charging acute care hospital rates for
all clients.
The committee recommends that curbs on unit-of-service costs for
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SUMMARY
31
inpatient care be strengthened and that payers insist on the generation
of reliable performance/outcome data. Drug treatment services at hospital
sites should be reimbursed separately from other diagnoses or hospital
services; there appears to be no compelling reason why these services for
most drug treatment patients should routinely command fees comparable to
acute care rates rather than to reasonably competitive residential treatment
rates.
Insurers and employers need to become better informed about drug
treatment and to structure their benefits to support controlled access to
a broad range of the most appropriate, effective, and efficiently priced
treatments rather than to a narrow (and expensive) band of options that
are similar in form to the treatment of acute medical conditions. Private
plans should cover appropriate, adequate, cost-effective drug treatment and
not reimburse the cost of excessive, inappropriate treatments or charges
(see liable 8-2 for placement guidelines).
The committee recommends that private risk bearers, in lieu of arbi-
trary payment caps or exclusions, institute rigorous, independent pread-
mission review (where possible) and concurrent review of all hospital and
residential admissions as a way to control access and utilization, ensure
appropriate placement, and manage costs. Preadmission review may not
be necessary for such admissions, but early concurrent utilization review is
important for such treatment to ensure that diagnostic criteria are observed
and charges are reasonable. Employee assistance programs can serve as
utilization managers in cases in which their personnel have appropriate
training for matching patients to treatment. Hospital utilization should be
managed under the same terms as those recommended for public coverage
(see the section on utilization management in Chapter 7~.
The committee further recommends that private payers insist that
providers participate in and agree to the publication of regular, indepen-
dent follow-up surveys to determine client outcomes, taking into account
data on admission characteristics such as problem severity. Providers and
payers should be able to compare treatment results with overall program
norms to ensure the maintenance of good performance and the identifica-
tion of poor performance when it occurs.
The committee recommends that the provisions of drug treatment ben-
efits, including deductibles, copayments, stop-loss measures, and scheduled
caps, be similar to provisions for treatment of other chronic, relapsing
health problems. Except in terms of limitations on the length of stay
and number of visits, such provisions are mostly the rule today. Sound
utilization management that includes reliable performance and outcome
measurements is likely to obviate the need for separate length-of-stay and
dollar caps on coverage. Nonhospital residential and outpatient treatment
delivered in state-certified treatment programs should be covered. Cov-
erage limitations, charge schedules, and cost-containment incentives (e.g.,
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TREATING DRUG PROBLEMS
copayment schedules) should be adjusted to reflect the findings of research
on appropriate models, lengths, and costs of drug treatment—especially
the recognition that longer residential and outpatient stays are strongly
correlated with more beneficial results.
CODA
The drug problem is not a fixed constellation but a restless, ever-
changing composite. Within this pharmacological and sociological diver-
sity, treatment addresses the chronic, relapsing disorders of drug depen-
dence and abuse. The best treatment interventions have been shown
to "work" reversing drug-seeking behavior, related criminal activity, and
other dysfunctions only partially; that is, the different treatment meth-
ods encourage recovery from these imperfectly understood disorders to a
greater or lesser degree. Moreover, each modality of treatment can attract
and affect only some of the people in need.
Success in treatment is not guaranteed and is often not complete, but
even if it managed to be both, there would still be a major problem: most
people who need treatment seek it only reluctantly, after failing at self-help,
after much harm has been done, and after much pressure interior and
exterior has been brought to bear. However, as with heart disease and
cancer in the health domain, theft and assaultive behavior in the realm of
violent crime, or homelessness and family dissolution in the area of social
welfare, the lack of a panacea does not excuse society from responding to
the best of its ability. The overall costs of drug problems are so high that
reducing them even modestly is worthwhile. The committee is persuaded
that the treatment methods available today can at least potentially realize
benefits that well exceed the costs of delivering these services. Treatment
makes sense on the grounds of utility as well as humanity.
The treatment system should do a better job of knowing itself and
acting on that knowledge. Much of the knowledge gained in the past
about the elements and optimal costs of effective treatment was brushed
aside in the 1980s in the zeal to cut public spending and increase private
revenues. In the 1990s, a different perspective seems to be gaining ground.
Solutions to the challenge of improving drug treatment can be achieved if
current financial trends continue and if leaders of the public and private
tiers of drug treatment bend their efforts to the modest but necessary task
of making the system learn its lessons.
Representative terms from entire chapter:
treatment programs
