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1 Introduction A provision in the Anti-Drug Abuse Act of 1986 instructed the sec- retary of health and human services to seek an independent study of substance abuse treatment coverage. The study was mandated to report on the extent and adequacy of financing public and private for treating and rehabilitating drug abusers and to make recommendations as needed.) It seemed likely that the study might identity unmet needs for new federal action. For example, the state-level components of the national drug treat- ment system had been cast adrift in the 1980s from earlier, more restrictive federal controls, and the system's ability to help communities respond to new challenges, such as the crack-cocaine epidemic, the acquired immune deficiency syndrome (AIDS) epidemic, and the growing violence of drug markets, appeared tenuous. What was not clear was what to do about the situation. This volume is the response to the congressional charge, fulfilling an agreement, finalized in December 1987, between the National Institute on Drug Abuse and the Institute of Medicine. It is the outcome of an Institute of Medic~ne/National Academy of Sciences committee process that included reviews of the scientific literature, specially commissioned ~ The operative language of the law (P.L~ 555, section 6005) reads: ". . .the Institute of Medi- cine of the National Academy of Sciences [is] to conduct a study of (1) the extent to which the cost of drug abuse treatment is covered by private insurance, public programs, and other sources of payment, and (2) the adequacy of such coverage for the rehabilitation of drug abusers.... The report shall include recommendations of means to meet the needs identified in such study." 33

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34 TREATING DRUG PROBLEMS papers (to be published in a separate volume), field visits to cities around the country, conferences and correspondence with experts in many relevant fields, and application of the expertise accumulated by committee members and staff in their own professional work. The operational questions the committee has tried to answer are tempered versions of the congressional mandate: Is it good policy to invest as much- or as littleof society's pooled resources (basically, public programs and private insurance) in drug treatment as is now being invested? And if this much expenditureor more- is truly necessary and worthwhile, how can these dollars be spent most prudently and equitably, with the highest likelihood of yielding good results? The committee's overall conclusion is that it is a "good bet" to put more resources into drug treatment. Public expenditures should be increased, especially at the federal level, to support the most carefully validated treat- ment modalities, as well as to improve clinical training and facilities, treat- ment research activities, and program evaluation and management systems. Public funding should focus on boosting the average quality of treatment as well as the number of program admissions, with special emphasis on increasing treatment opportunities for those under criminal justice super- vision and for pregnant women or women who care for young children. In the private sector, coverage policies should be revised. Insurers should institute better control over tendencies toward preferential reimbursement of an increasing number of high-cost treatment episodes. They should also encourage more widespread reimbursement and utilization of less expen- sive facilities and programs, under comprehensive systems of utilization review based on performance evaluation. These conclusions appear straightforward, but they did not in fact come quickly or easily. The controversies that have surrounded drug treatment stem as much from the sheer complexity of the drug problem and the resulting potential for misconception and confusion as from any other factor. The series of investigations and arguments that led to the committee's conclusions are logically retraced and presented in the chapters that follow. The report's organization is described briefly in the sections below. THE LOGIC OF THE REPORT Chapters 2, 3, and 4 set the stage for analyzing the clinical effectiveness and organizational features of drug treatment coverage. Because it is critical to understand how drug treatment fits into and is shaped by drug policy as a whole, the committee undertook a general review of the historical and contemporary dimensions of drug policy, commissioning original analyses by Karst Besteman and committee member David Courtwright. Based on

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INTRODUCTION 35 these and other sources, Chapter 2 assesses the role assigned to treatment in the ideas that govern drug policy, emphasizing the combination of medical and criminal conceptions of the problem that dominate current thinking. Chapter 3 focuses on epidemiological research knowledge and clinical experience regarding patterns of drug consumption behavior, the individual and social consequences of drug patterns, and the extent of the need for treatment. The special concerns of this chapter are drug abuse and dependence, recovery, and relapse the behavior patterns that have the greatest significance for treatment programs. A special analysis of data from the Research Triangle Institute/National Institute on Drug Abuse (RTI/NIDA) 1988 National Household Survey and analysis of U.S. Bureau of Justice Statistics reports provide important reference points for this chapter. Given the policy contexts and the extent and character of the problems that require attention, what can treatment for drug problems be expected to achieve? Chapter 4 takes up the issue of defining a realistic set of treatment goals, particularly in terms of reducing illicit drug consumption and other criminal behavior. It notes the reluctance many individuals express about entering and complying with treatment, as well as the close association between the objectives of criminal justice agencies and drug treatment programs. This chapter draws on commissioned papers by Mary Dana Phillips and Gregory Falkin and colleagues. With the parameters of policy, epidemiology, and treatment objectives in place, it is possible to review efficiently the literature on clinical modalities of treatment and characterize the state of knowledge about their results under controlled conditions and in the field. Chapter 5 thus surveys the available evidence on "what works" among the handful of conventional modalities of drug treatment. Discussing such aspects as how effective a treatment modality is, for whom, why or why not, at what cost, and with what level of benefits, the chapter draws heavily on analyses of the large-scale Treatment Outcome Prospective Study, a NIDA/RTI project. The chapter is equally concerned with what is not known about treatment modalities and results and leads finally to recommendations for improving the knowledge base about treatment. In analyzing the treatment literature, reviewing submitted evidence, and visiting treatment programs in the field, committee members were struck by differences between programs that principally served privately insured clients and programs that did not. These differences became dra- matically evident in detailed analyses of data collected in the 1987 National Drug and Alcoholism Treatment Utilization Survey. The differentiation of treatment providers into public and private tiers and the effects of this structure on treatment provision and accessibility in this country are discussed in Chapter 6.

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36 TREATING DRUG PROBLEMS Chapter 7 considers the public tier of treatment delivery, which is largely supported by federal, state, and local funds and in the main com- prises nonprofit treatment programs that hold contracts with government agencies. 1b achieve the general goal of public coverageensuring that ap- propriate treatment is available to those who cannot afford it themselves- the committee offers a plan, complete with breakdowns of estimated costs, for three alternatives: a $2.2 billion comprehensive program, a $1 billion core program, and a $1.6 billion intermediate program of expanded public support. The plan relies in the near term on direct program financing, with a longer term goal of incorporating drug treatment support more systematically into Medicaid and other mainstream health care payment mechanisms. Important components of the plan are more extensive out- reach to mothers and criminal justice populations in need of treatment, well-developed systems of performance assessment, and better utilization review and control, particularly of high-cost elements. Private coverage for drug treatment is a result of decisions and nego- tiations by individuals, employers, insurers, care managers, and providers. Chapter 8 considers private coverage in terms of eligibility, benefit design, costs, and provisions for the management of care. Drug treatment is a relatively small but fast-growing element among private health insurance claims, and it is difficult to titrate precisely the factors that have led to this growth. Mandates for specific coverage have played some role but do not appear to be the most important factors at this time. The com- mittee's major recommendation in this area is to broaden the scope of covered treatment while instituting better cost management and account- ability. Commissioned papers by Richard Steinberg and by Paul Roman and Terry Blum were particularly useful in shaping the committee's analysis of private coverage. In reaching conclusions and formulating recommendations, the com- mittee has relied wherever possible on rigorous evidence. On many issues, however, there is no such evidence by the usual standards of the scientific community. Consequently, the committee made judicious use of its best expert judgment in cases in which logic and experience pointed strongly but good evidence was scant. The grounds for this course lie in the com- plexity and severity of the nation's drug problem, the congressional charge to provide recommendations, and the public's underlying determination to respond. These conclusions are clearly signaled by explicit use of the formula, "in the committee's judgment." In virtually every such instance, the committee also specifies the new knowledge that needs to be generated to test and strengthen such judgments.

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INTRODUCTION 37 ADDITIONAL POLICY QUESTIONS There are several issues bearing on drug treatment to which the com- mittee members returned again and again during their deliberations but that they could not satisfactorily address because there was no clear basis from which to draw firm conclusions. In some cases, the issues involved large amounts of unanalyzed data and conceptual problems that extended beyond the sphere of treatment coverage. It was impossible to pursue in depth those matters that were centered far outside the study's mandate, however revealing the inquiries might eventually be. Nevertheless, the committee resolved to highlight here those issues it considered the most important: drug treatment specifically for adolescents and younger chil- dren, including drug-affected babies; the operations of the criminal justice system in relation to the drug consumer; and modification of the socio- economic environment that conditions drug use, especially in impoverished neighborhoods. Treating Adolescents and Women with Children Most of the findings and recommendations in this report are based on and pertain directly to the treatment of adults, especially those aged 18 to 4() years old. Juvenile drug problems rightfully capture a great deal of attention, but in terms of sheer demographic mass, the drug problems of major concern today occur principally in adult populations. The over- whelming majority of drug transactions are between adults, the social costs of their problems clearly predominate, and most identified drug treatment resources are directed toward them. Moreover, in comparison to juveniles, treatment research and evaluation data for adults are richer, the criteria for differential diagnoses are clearer, and typical adult treatment modalities are more sharply distinguished (for better or worse) from other mental and physical health care, education, criminal justice, and social/rehabilitative services. Unfortunately, much evidence suggests that juveniles who are directly or proximally involved in drug problems today are the source of tomorrow's pool of more severe adult drug problems. The committee consequently reviewed the scattered literature and discussed some of the problems en- countered in treating adolescents, women with children, and drug-exposed infants. However, no conclusions could be drawn from these investigations, although some substantive possibilities were derived and are discussed in the report. Of principal concern is the extent of the limitations of the knowledge base on whether treatment of the young has requirements dif- ferent from those for treatment of adults. Also at issue are the changes in outcome that might be produced by variations in services.

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38 TREATING DRUG PROBLEMS Considering the importance of treatment for juveniles and the paucity of necessary knowledge, the committee urges that drug treatment of the young adolescents, drug-exposed infants, and the ages in between be subjected to intensive study. Investigations must be designed to plumb the reservoir of practical clinical experience and research knowledge as deeply and systematically as possible to stimulate development of the kind of foundation and synthesis for policy purposes that is not yet at hand. The National Forum on the Future of Children and Families, a joint effort of the Institute of Medicine and the National Research Council, has recently conducted the first in a series of workshops and panel meetings to address some of these issues. The Criminal Justice System The criminal justice system at present is the first line of societal re- sponse to drugs, absorbing about 90 percent of the public expenditures allocated to this problem. In fact, much of the nation's current drug treat- ment strategy and system was designed to allay public concern about street crime engendered and aggravated by drugs. This report examines the ef- fectiveness of community-based treatment programs in terms of how well those concerns about drugs and crime are being satisfied. In addition, it presents conclusions about the legitimacy and effectiveness of correctional treatment and treatment of individuals on probation and parole and identi- fies ways in which treatment programs can and should relate to the criminal justice system. Beyond these issues, however, lie a range of critical questions about how the law enforcement and criminal justice systems are organized to deal with drug-related crime and how they distribute attention and resources to address its various manifestations- possession, trafficking, and other serious crimes. There is a crowded field of opinion and vested interest about these questions, as well as some relevant research. But there is no objective, comprehensive, up-to-date analysis of the criminal justice response to the drug problem, and the committee doubts whether any current efforts, including those of the Office of National Drug Control Policy, even aspire to develop one. This issue is a rapidly growing, multi-billion-dollar vacuum that demands to be filled. The Socioeconomic Environment It is difficult to overstate the critical importance of the socioeconomic environment. Individuals make choices, but they always do so in a social and economic environment, and there is ample evidence that such environments exercise great influence over drug consumption. They can promote the

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INTRODUCTION 39 initiation of drug use, aggravate and amplify drug effects, and counteract the process of recovery from drug dependence. The capabilities necessary to change socioeconomic factors must be developed so that these environments will help channel more individuals away from rather than toward drug problems. The report covers some aspects of drug etiology and relapse that are relevant to environmental dimensions. Nevertheless, a comprehensive assessment of the extent and adequacy of preventive interventions in this domain was beyond the purview of this study. The committee looks toward investigations, such as the study of drug abuse prevention research now being conducted by the National Research Council, to address these issues and work toward comprehensive recommendations regarding appropriate environmental interventions to prevent drug problems.