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OCR for page 33
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
OCR for page 34
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 little—of society's pooled resources (basically, public
programs and private insurance) in drug treatment as is now being invested?
And if this much expenditure—or 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
OCR for page 35
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 coverage—ensuring 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.
OCR for page 37
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.
OCR for page 38
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
OCR for page 39
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.
Representative terms from entire chapter:
criminal justice
