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OCR for page 298
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
OCR for page 299
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.
OCR for page 300
Representative terms from entire chapter:
drug treatment
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