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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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2 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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4 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 drugsor even any particular type of drug, unless it was never previously availableafter 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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6 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 abusefor 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 treatmentand 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 consumptionexperimental 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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10 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 imprisonmentin 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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22 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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24 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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26 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 inor adjoined withdrug 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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28 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 casebut 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 chargeswith 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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30 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 coveror 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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32 TREATING DRUG PROBLEMS copayment schedules) should be adjusted to reflect the findings of research on appropriate models, lengths, and costs of drug treatmentespecially 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.