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Coda The best way to envision the drug problem is not as a fixed constellation but rather as a composite moving through time. As they age, each of the cohorts that constitute the U.S. population spreads across a broad continuum. At one end are lifelong abstainers, keeping a puzzled or horrified distance from illicit drugs. Partway across the continuum are light users, dabbling with newfound or occasional pleasures and, for the time being, feeling little pain. At the other extreme are devotees whose lives orbit around drug intoxication like moths worrying a flame, leaving in their wake not motes of dust but a trail of misery. Exactly who stands where on the continuum and in what numbers varies as behavior changes across time. As a further complication, each new generation of Americans enters a transformed world. New drug technologies batten on older methods; shifting coalitions of producers and sellers maneuver for markets and profits; and social responses range from benign neglect to bruising, large- scale mobilization of force. Each new generation inserts into the picture its own quotient of social hope, morality, anger, and fear. In this seemingly endless pharmacological and sociological diversity, treatment is both a rock of redemption and a hard place on which to secure a foothold. Treatment is designed to address the chronic, relapsing disorders of drug dependence and abuse, which characterize a minority of all illicit drug consumers but which yield probably the lion's share of the damaging consequences of drug consumption. The best treatment interventions "work"—reversing drug-seeking behavior, related criminal 298
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CODA 299 activity, and other dysfunctions—only partially; that is, different types of treatment for these aggravated and imperfectly understood disorders work to a greater or lesser degree, and each works for only some of the people in need. In short, success in treatment varies. It is not guaranteed and often not complete, and even if it were both, a major problem would still remain: 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 absence of a panacea does not excuse society from responding with the tools at hand and to the best of its ability. The overall costs of drug problems are so high that reducing them even modestly is worthwhile. There is enough evidence to persuade this committee that a substantial proportion of the treatment available today is at least potentially capable of realizing benefits that exceed the costs of delivering it. Treatment seems to make sense on utilitarian as well as humanitarian grounds. There are numerous managerial complications in trying to raise the level of performance of the two tiers of treatment providers public and private and improve the different mechanisms of funding and control that lie behind them. If there is a brief way to summarize or at least place a simple label on the recommended approaches to these complications, it is this: the drug treatment system should do a better job of knowing itself and acting on that knowledge. Much that was learned in the past about the elements and optimal costs of effective treatment was forgotten or brushed aside in the early and mid-1980s in the zeal to cut public spending and increase private revenues. The mechanisms that generated useful knowledge were largely disassembled or never installed in parts of the treatment system that took shape during that era. As the l990s begin, a different perspective is apparent with regard to issues of economy and accountability in the treatment system. There are still many obstacles to improving existing drug treatment, including iner- tia, vested interests, and the difficulties of finding, training, or reclaiming skilled and dedicated care givers. The weight of these obstacles should not be underestimated but there are powerful levers to move them. Improve- ments are bound to fall into place, assuming that current financial trends continue, but only if the leaders of the public and private tiers bend their efforts to the modest but necessary task of making the system learn its lessons.
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