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Treating Drug Problems: Volume 1 (1990)

Chapter: 3 The Need for Treatment

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Suggested Citation:"3 The Need for Treatment." Institute of Medicine. 1990. Treating Drug Problems: Volume 1. Washington, DC: The National Academies Press. doi: 10.17226/1551.
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Suggested Citation:"3 The Need for Treatment." Institute of Medicine. 1990. Treating Drug Problems: Volume 1. Washington, DC: The National Academies Press. doi: 10.17226/1551.
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3 The Need for Treatment The history of drug policy provides evidence on the role of treatment programs in the array of policy responses to the drug problem. But what exactly needs to be treated? And how widespread is it? These questions are addressed in this chapter, which specifies the current need for treatment in terms of objective criteria based on scientific research and clinical experience. This is not the same as determining who wants treatment. Subjective motives or desires to seek help are not necessarily consistent with objective evaluation or practicality. Assessing need is also different from measuring the actual demand for treatment, which is critically bound up with treatment cost and the ability and willingness of someone- the individual, a charitable provider, a third party, or some combination of these—to cover that cost. The issues of wants/motives and demand/cost are covered in subsequent chapters; the focus here is on scientific and clinical understanding of the drug problem, which enables a definition and measurement of treatment needs. In clinical applications, diagnostic criteria can be used to determine, within an accepted range of precision and replicability, whether treatment is needed in an individual case. By appropriate methodological extension, these criteria can provide a probabilistic estimate of the aggregate need for treatment in the population as a whole. Refined diagnostic tools, in combination with treatment effectiveness studies, might further indicate not only whether treatment is needed but also what type is most likely to be beneficial. Diagnostic criteria, which are discussed in detail below, distinguish 58

THE NEED FOR TREATMENT 59 drug use- for which no treatment is called for, although other responses may be from drug abuse and dependence. The criteria are based on the level and patient of drug consumption and the seventy and persistence of functional problems resulting from these consumption patterns. Their development has been an evolutionary process, and consensus is not yet total. Reasons for this gradual rate of progress are not hard to locate. Drug consumption patterns and their consequences are extremely complicated and continually changing. The modalities and philosophies of treatment are diverse. And as new drugs and ways of administering them appear, the applicability of even well-tested diagnostic criteria must be reestablished. As a basis for understanding the need for treatment, the committee first outlines a conceptual model of the different types and stages of individual drug consumption and its consequences: use, abuse, dependence, recovery, and relapse. The major factors that are thought to propel this model are then summarized, namely, individual learning processes that lead to the modification, persistence, or extinction of drug consumption. Learning is contingent on drug effects, socially conditioned reinforcers, and, to some degree, personal characteristics. In turn, the availability of drugs and other reinforcers and of good opportunities for character development are strongly shaped by economic, political, and cultural factors that vary through time and across different geographic locations. Treatment focuses largely on ending or at least reducing the severity of an individual's dependence or abuse and associated problems that is, on initiating and maintaining recovery and averting relapse. In the sections that follow, the committee analyzes a number of general and special- population surveys that include items approximating the diagnostic criteria , ~ . ,, _ _ ~ . ~ . . ~ tor dependence and abuse. these analyses yield new estimates ot the need for treatment in the population at a fixed point in time. Yet these estimates are simple approximations only. Individuals continually move into and out of dependence and abuse. Although these movements can be understood qualitatively, quantitative data at the national level lack the necessary density and precision for a full-scale dynamic analysis. Nevertheless, when joined with calculations of the social costs associated with drug problems, these population estimates provide a basis for further analysis of the drug treatment system and its adequacy. THE INDIVIDUAL DRUG HISTORY: A MODEL AND OVERVIEW During any given month in the past 20 years, at least 14 million (in the peak months, more than 25 million) individuals in the United States consumed some kind of illicit drug. Each of these individuals had a specific

60 TREATING DRUG PROBLEMS history of drug experience, in the context of unique biographical circum- stances, yielding millions of different patterns of risks and consequences. To some degree, these patterns of drug behavior, context, and risk can be grouped according to familiar stereotypes. But even the stereotypes are highly diversified. For example, consider the differences among the following: . a young teenager who lives in a welfare-supported, innercity house- hold with no adult male relatives present, sporadically attends junior high school but appears daily at a street venue to deliver crack-cocaine to cus- tomers (mostly adults) of an older gang member, and feels superior to these customers but has recently smoked some crack and marijuana laced with phencyclidine (PCP) several times with another young "dealer"; · an adolescent college student from an affluent two-parent family, whose illicit drug experience is taking amphetamine pills to stay awake and cram for final exams and smoking marijuana with friends at house parties a few times during a semester; · a single person in the mid-20s, steadily employed as an office manager, who takes amphetamines for weeks at a time as an appetite suppressant and uses marijuana or cocaine several weekend nights a month on dates or at parties; · a divorced woman in her early 20s with two pre-school-age children, who supports herself mostly through welfare, intermittent prostitution, and larceny, which has led to several misdemeanor convictions and investigations by the family protective services office; she is currently pregnant and using crack-cocaine, marijuana, alcohol, and/or mood-lifting pills nearly every day by herself and with customers or boyfriends; · a white-collar professional about 30 years old with a working spouse and no children, who has been snorting progressively larger quantities of powdered cocaine night after night (and increasingly, during the day) for several months—abstaining and crashing for a few days occasionally with larger than usual doses of alcohol; and · a man in his mid-30s who was a childhood immigrant to the United States and has no fixed address or occupation, irregular contact with a common-law wife and children, and a 20-year criminal record that includes burglary, armed robbery, assault, and drug sales convictions leading to extensive prison time; he is currently injecting heroin several times a day and supplementing that with cocaine, PCP, amphetamines, alcohol, and whatever else comes to hand; he is also seropositive for the AIDS virus. The treatment implications of these drug consumption patterns are quite different, and many individual variations cut across these stereotypes. clarify clinical decisions and permit intelligible estimation of the overall need for treatment in the population, it is necessary to categorize drug

THE NEED FOR TREATMENT Abstinence 1 ~ ~ 1* Cessation * * "Self-help" remission 1 r * L _ RELAPSE FIGURE 3-1 A model of individual drug history. 61 | Onset . Use Low or infrequent doses: experimental, occasional, "social." Damaging consequences are rare or minor. I|, Intensification Abuse Higher doses and/or frequencies: sporadically heavy, intensive. Effects are unpredictable, sometimes severe. 1 Addiction Dependence High,frequent doses: compulsion, craving,withdrawal. Severe consequences are very likely. * * * * Indicates the influence of biological, physiological, and social factors that condition changes in behavior. Mild sanctions Prevention programs (Early/light stage responses) (Late/heavy stage responses) Severe sanctions TREATMENT PROGRAMS consumers based on their current dose, frequency, and method of drug consumption, taking into account their past consumption patterns and weighing the severity of associated problems and consequences including physical, emotional, and social problems. A conceptual paradigm of illicit drug consumption and responses is presented in Figure 3-1. This scheme depicts the principal patterns or types of drug-taking behavior and orders them into common stages that, taken together, con- stitute a developmental pathway for individuals. Across large numbers of people, transitions from one stage to another can be summarized as risks or probabilities. These transition probabilities are heavily influenced by the interaction of two elements: the specific pattern of drug consumption and the presence of other biological, psychological, and social factors. Drug consumption is divided into three levels or stages commonly distinguished by clinicians and researchers: use, abuse, and dependence. (Other terms—for example, those used by the National Commission on Marijuana and Drug Abuse [1973] and Siegel [1990]—are related to this

62 TREATING DRUG PROBLEMS triad: experimental, occasional, or sociaVrecreational use; intensified, reg- ular, sporadically heavy or "binge" abuse; and compulsive or addictive behavior, which is dependence.) Each of these stages is, on average, more hazardous, more obtrusive, and more likely to provoke or induce social interventions (e.g., punitive sanctions, attention by prevention programs, admission to treatment) than the one before. Abstinence, Drug Types, and Normative Attitudes Prior to drug consumption, there is abstinence. Abstinence here is de- fined behaviorally and means not seeking out, not consuming, and not being impaired as a result of having consumed psychoactive drugs. Abstinence so defined is usually but not necessarily the same as being physiologically `'drug-free," which refers strictly to the absence of pharmacological effects or traces of drugs or their metabolites. Taking psychoactive drugs under legitimate medical supervision at prescribed doses for generally recognized therapeutic purposes does not in itself violate abstinence. Federal and state codes define specific psychoactive drugs by their chemical names, dividing them into several classes of controlled and pro- scribed substances (Table 3-1~. Some drugs, such as the volatile solvents in model airplane glue, are virtually uncontrolled. Others, such as nicotine (in tobacco) and alcohol, are legally available to those above certain ages but only under circumscribed terms and conditions, including various sit- uational prohibitions (e.g., tobacco smoking is prohibited in many public and commercial locations, drinking of alcohol is prohibited while driving). Because of the partial legality of alcohol and tobacco, little attention is paid in this report to their use, abuse, or dependence except in conjunction with illicit drug consumption. Abstinence from illicit psychoactive drugs is normative that is, legally and morally unquestioned by most people most of the time. But social norms are much less homogeneous across social groups or situations than are legal definitions, and they are subject to change across time. The shifting normative status of marijuana among young middle-class Americans over the past 25 years is a good illustration. The overall degree of normative chill attached to illicit drug consumption varies from slight to grave depending on the details, gradations similar to the moral index applied to other classes of illegal acts ranging from traffic infractions through mass murder. For example, when a public sample was asked about the severity of crimes, only homicide/manslaughter and forcible rape were rated as worse offenses than selling cocaine (Jacoby and Dunn, 1987, cited in Flanagan and Jamieson, 1988~. Using cocaine, however, was seen as comparable in severity to drunk driving without an accident or thefts or burglaries of moderate amounts of goods—serious crimes but much lower on the scale. In a 1986 opinion

63 g . - c~ o I_ o o - ct cot ._ - c~ - m CD C) to =; D ._ =0 O C) ca .C-) 3 cat c' c~ x ca u, - ~ 2 0 ~ ~ I ' ~ ~ I ~ a ~ ~ ~ ~ ~ y 3 ;~ 0 ^ c ~ E ~ e Y e = c ~ c y e u c ~ ~ ~ ~s ,C, ~ ~ ~ ~OC ~ ~ 'CO ~ i B ~ ~ ~ ;> ~ ~ LD ,, ~ x ~ ~ 0 0 ~ 3 j ~ w j e u, c~ ~ c., . . O ~ o~ c ~ = s = c O ~ CQ ~ ~ V ~ ~ ~o oi (O ;> ~ o~ ~ ~ 0 . c: ce 0 ·~ ~n C) c, 0 c=e ~ c' 1 ~ o 0 0 ~ · C) I I C) Ct C c: 0 ~ 3 O ._ D ~ 3 0 -, c~ ~ O I;: ~ ~ .o Ct4 - c ~ c c-) ~c ~ ce u, ce c,) c) . ° _ 0 ce c c ~ c, ~.c x c, u~ c~ ~ ~ .5 °" 04 z .c ro ~ C) c c c) c -3 _ c c' 3 c _ =m ~ ° ~ x So.°.o c., ~ c, ~: ,$.ce ~o ~o c., 0 ~ c, ~ ' t4 .. ~ ~ 0 ~ z 0 ce

64 TREATING DRUG PROBLEMS survey in which 96 percent of respondents disagreed with the statement that all illicit drugs should be made legal, 85 percent agreed that "the best place for most drug abusers is a drug treatment program and not jail" (Flanagan and Jamieson, 1988:194~. LeaIning and Drug Experience An individual drug history is most readily understood as a sequential learning experience. An individual cannot know beforehand exactly how a drug will affect him or her because there is great variability in this response, depending on the drug and the specific dose exposure, the individual's biological and psychological state, and the social circumstances (Levison et al., 1983~. Every naturally occurring or synthetic psychoactive drug affects the brain and other nervous tissue by mimicking, displacing, blocking, or depleting specific chemical messengers between nerve cells, called endogenous neurotransmitters. Most drugs directly affect one or several of the numerous neurotransmitter systems, but the brain is so complex and interlinked that many functions may be significantly affected by action on a single type of messenger/receptor system. These dose- dependent metabolic effects are responsible for a number of phenomena: immediate changes in mood, thinking, and physiological states; medium and longer term neuroadaptation such as increased tolerance to some (but not all) drug effects; and, in some cases, persistent or irreversible changes in brain functioning or memory. (Such changes are not necessarily strange or ominous; strong memories of any kind produce persistent changes in the brain.) Some drug effects are hard to duplicate without the drug's presence; other effects differ, if at all, only quantitatively (that is, in how rapid, long- lasting, or uniform the effects are across individuals) from the way other kinds of stimuli can affect the brain (e.g., motion, touch, sights and sounds, including human communication). Drug effects depend heavily on the dose, the route of administration (smoking and intravenous [IV] injection are very fast; snorting, chewing, drinking, or eating, rather slow), previous exposure, and other characteristics of the individual consumer, including what he or she expects the drug to do. The metabolic mechanisms of drug action in humans are shared with some other mammalian species, which has been a basis for developing animal models that have been important sources of scientific insight and testing. Some individuals respond quite positively to their initial drug experi- ence;1 others react quite negatively (experiencing nausea, paranoia, or a 1In dramatic terms: "It's so good, don't even try it once." Although this exhortation mimics current beliefs about crack cocaine, it is actually a quotation about heroin (Smith and Gay, 1972~.

THE NEED FOR TREATMENT 65 painful drug hangover). Still others react with puzzlement: "Well, that's different but what's all the fuss about?" There are various reasons for these different responses, but their relative importance is uncertain. Not only the drug's metabolic effects, modulated by the individual's chemistry, but also the associated circumstances and activities, filtered through the individual's personality, shape the initial response to drugs, creating differ- ent degrees of satisfaction or discomfort. If the individual continues to use drugs which may occur even if the initial trial is not rewarding, as a conse- quence of continued curiosity, local custom, or peer pressure a history of experience is built up, a learning curve, in effect, that can lead in different directions depending on the specifics of the individual's experience. The balancing of pleasurable or rewarding experiences and punishing or unpleasant experiences that occurs during the early weeks or months of drug involvement may be of critical importance. If the net impact of those experiences is highly positive, the effect or memory of that "honey- moon" can remain remarkably strong over time, even as continuing reward diminishes and punishment increases, especially if alternative competitive behaviors are not exercised or reinforced as strongly. Social interventions directed toward the individual—criminal penalties, job-related or family sanctions, prevention programs, and treatment programs—contribute to the learning history, but precisely how depends on the details of that individual's experience (Ray, 1988~. Added to the specific hazards associated with each stage of drug use are the risks of transition to further stages. Each stage entails some chance of progression to the next, although progression is not inevitable. A minority of experimental users intensify their consumption to the level of abuse; fewer yet advance into dependence. Nevertheless, the entire U.S. population, even abstainers, can be viewed as incurring some risk from drug consumption: even those who have never used drugs are slightly at risk by virtue of drugs being available to them (in an ever-active market) and by virtue of the behavior of drug users in their environment. What the drug consumer learns through drug experience takes the specific form of tendencies to seek drugs. That pattern, at least, is what the observer sees; the consumer often defines this "tendency" as something else a habit, interest, hunger, or craving. These drug-seeking tendencies vary in when they are expressed as well as how forcefully that is, how effectively the tendency to seek drugs competes with other behaviors. The tendency may be entirely dormant unless some condition or cue evokes it. Cues may be purely internal or set off by external contingencies. Purely internal cues could be physiological sensations owing to earlier drug exposure-- for example, immediate or delayed withdrawal syndromes—or they may be moods, thoughts, or sensations that were associated in time or meaning with taking drugs. These phenomena are as varied as individual

66 TREATING DRUG PROBLEMS biography: for one person, pain, distress, or sadness may lead to drug craving; for another, feelings of pleasure, including the pleasure of certain company, may evoke the response; for yet another, waking up in the morning and going to bed at night may produce this effect. Times, places, people, objects- any association with earlier drug taking may evoke drug craving, and the closer the link, the stronger the cue. 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 (a desire that persists even after short-term withdrawal is completed) in the stage of dependence. From a subjective point of view, drug-seeking behavior seems highly volitional during initiation and early use; this voluntary period, however, is profoundly influenced by the conditions and responses of other people in the immediate vicinity and by individual variation in how drugs affect the brain and personality. Environmental Variations There is a range of individual susceptibility to the learning of drug- seeking behavior that would be seen clearly if environmental conditions were held constant. But social environments are not constant; indeed, variation in social environmental conditions correlates strongly with de- mographic and geographic variations in drug use, abuse, and dependence rates. Other factors that affect drug-seeking behavior are the contexts and conditions of availability of different drugs (e.g., cocaine, heroin, mari- juana, and amphetamines) as well as the new technologies and marketing organizations that are periodically introduced. Cocaine is a good example. Cocaine is a chemical in the leaf of the coca plant that functions for the plant as a pest repellent. Human societies in the Andean region have used the coca leaf as a stimulant in low but effective oral doses (often by chewing the leaf, although there are a variety of preparations) for about 5,000 years, both as an ordinary tonic and in various medicinal and ceremonial applications. By 1860 the cocaine alkaloid (base, or free-base) had been isolated and extracted; a few decades later, its water-soluble salt, cocaine hydrochloride, became widely popular in Europe and the United States. Cocaine hydrochloride was offered in a variety of commercial preparations, including cocaine snuffing powder, coca cigars, coca wines, Coca-Cola, and injectable solutions. This epidemic of popular use ended with the onset of better medical knowledge regarding the substance, pharmaceutical regulation, and criminal sumptuary laws motivated by strong racial fears. Cocaine was confined to the underworld, where it was used mostly by injection along with heroin.

THE NEED FOR TREATMENT ~ 5 o 4 I ~ 3 UJ 2 ~ 1 CO ~ O =) A: 7 ~ Cocaine 6 I I Heroin i, ~h~ ~ ~.j>~,~§ ~~°~ ~/////0 Hallucinogens Amphetamines ., ~ . . . ~ ~ .. . 67 ~~ OK ~~ ~! of, BEG' ,' LO .~ FIGURE 3-2 Drug visits to emergency rooms lay selected cities and drugs, 1987. DAWN = all cities reporting to the Drug Abuse Warning Network. Source: National Institute on Drug Abuse (1988a). Cocaine reemerged in the 1970s, mainly as an expensive snuffing powder. There was also a brief vogue of desalting the powder to return it to the free-base, heating it to vaporization, and inhaling the vapor (smoking it). More recently, cocaine base has been brought directly to market as "rock" or "crack." As a result of large-scale investments in cultivation, manufacture, and smuggling protection in the early 1980s, the product became widely available, packaged for street sale in a number of large urban areas in as small as single-dose amounts. The drifting of cocaine consumption between popularity and insu- larity, and through different technologies and recipes, is not atypical of ethnopharmaceuticals, although every drug has its own particular industrial and epidemiological history. As well as differences across time, there are differences from place to place at the same time. The Drug Abuse Warning Network (DAWN), which has tracked the ebb and flow of different drugs in the United States for approximately the past 15 years, reveals very dif- ferent comparative levels of severe drug reactions, and, by implication, of abuse and dependence patterns, in large U.S. cities (Figure 3-2~. Although there are relatively small differences among Hispanic, white, and black U.S. population groups in the overall use of illicit drugs, these differences are much larger for the consumption of specific drugs.

68 TREATING DRUG PROBLEMS Age of Onset and Drug Sequencing The onset of drug use has been studied fairly extensively. Leo salient findings common to surveys of youth, the general population, treatment enrollees, and prison populations involve the age of onset of use and the sequence of drug involvement. The bulb of initial, experimental drug usage occurs during the teenage years. Very few children aged 10 or younger have begun to use drugs. Nearly as few people begin using drugs- or even any particular type of drug, unless it was never previously available after reaching 25 years of age. (There is increasing concern about abuse and dependence syndromes among elderly individuals, but those conditions are largely the result of the escalated use of alcohol and prescription drugs.) Most new users of any drug do not progress very far, and there are often shifts from intermittent use back to abstinence. The use stage may continue for a long period, or it may be transitory; the individual may return to long-term abstinence either in response to some form of intervention or direct persuasion or on his or her own initiative. The earlier drug use begins, however, the more likely it is to progress to abuse or dependence; the later it begins, the more likely it is to "tail off" into renewed abstinence without further progression or, if progression occurs, to yield to earlier, more sustained recovery. Cessation without intervention does not necessarily imply a self- contained decision that "drugs are bad." A convenient source of a favored drug may disappear, and new sources may prove undesirable or too costly. Alternatively, an individual may cease drug use as a result of social cir- cumstances (changing friends, falling in love with someone who does not use or approve of drugs, marriage, child-rais~ng, and job responsibilities; Schasre, 1966; Waldorf, 1973; Eldred and Washington, 1976; Robins, 1980; Kandel and Maloff, 1983) that leave little time for evening bar-hopp~ng and party-going. Another incentive for cessation may be learning about previously unsuspected hazards through news stories or by personal ob- servation (Johnston, 1985~. For many years, introduction to drugs in the majority of cases has proceeded In a general, cumulative sequence: tobacco and alcohol, to marijuana, to other ~nhalable or orally ingested substances, to hypodermic injection of opiates or powerful stimulants (cocaine, am- phetamines).2 This sequence is almost always initiated between the ages of 12 and 15; the injection phase, when reached, generally begins between the ages of 17 and 20. The sequencing phenomenon is thought to reflect two factors: drug availability and the degree of opprobrium attached to 2 Drug preparations are often contaminated with biologics or adulterants. When the needle route is used and injection equipment is reused without thorough cleaning, transmission of infectious diseases is common. AIDS is the best known and most feared of such diseases, although hepatitis and heart infections are very commonly transmitted.

THE NEED FOR TREATMENT 69 the respective drug types. As cocaine's marketing expands and marijuana's diminishes, the sequence of introduction to these drugs may become less uniform. There are multiple theoretical reasons for these age and sequential uniformities, but the data are insufficient to scale these reasons precisely according to strength, distribution, or importance. The most frequently ad- vanced explanations for the uniformity of adolescent onset are sociological and biological: adolescence is a period of transition between childhood de- pendency and adult self-responsibility; in many cases, the continuous adult supervision characteristic of childhood diminishes substantially; errors in newly enfranchised judgment—exercised as "trying out identities," "testing limits," and "rebelling"—are more widely tolerated or permitted among adolescents than among children or adults; adolescents grow quickly to nearly adult size and mobility, experiencing strong passions and desires ("raging hormones") that they are slow to learn how to channel and con- trol. Whatever the reasons, a variety of mildly to seriously deviant behaviors (e.g., sexual profligacy, suicide attempts, assaultive behavior with weapons, thievery for profit) begin to occur at these ages. If progression occurs (from use to abuse to dependence), it generally takes from 5 to 10 years following the first experimental use of any drug in the late teens or early 20s and from 1 to 4 years following the experimental use of the particular drug that is being consumed in a dependent manner (Brown et al., 1971; Robins, 1980; Kandel and Maloff, 1983; White, 1988; Kozel and Adams, 1985~. Progression seems to be more rapid with stimulants such as cocaine and amphetamines than with other types of drugs. 'typically, the initial voluntary component of drug-seeking behavior is compromised by the cumulative physiological, psychological, and social effects of the dependence process. The conditioning of behavior by physio- logical and psychological drug effects and by the distribution of rewards and punishments in the proximate social environment can conspire to steadily undermine the individual's ability to control the level and timing of drug consumption. Eventually, continued high-frequency drug consumption be- havior becomes so ingrained that the individual must explicitly unleam it. Some individuals achieve such unlearning by trial and error; most drug- dependent individuals are unable to do so and thus discover they need help to unlearn their drug-seeking habits (i.e., to successfully extinguish drug-seeking behavior). Diagnosing Dependence and Abuse Drug treatment is not designed for the low-intensity drug user who is readily able to control his or her level of consumption and for whom

70 TREATING DRUG PROBLEMS functional consequences have not yet accumulated. When progression to abuse occurs, the less intrusive ambulatory drug treatments are generally brought to bear. The most resource-intensive modalities, which involve extended pharmacological interventions or residential stays, are designed principally to treat drug dependence. The importance of these distinctions has led clinicians and researchers to try to develop clear, standardized criteria for abuse and dependence. These criteria are most fully described in two authoritative, multiyear, multidisciplinary collaborative efforts built on extensive literature reviews and trials in research and clinical practice: the forthcoming 10th edition of the International Statisi'cal Classification of Diseases, Injuries, and Causes of Death (ICD-10), a product of the World Health Organization, and the 3rd revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), published in 1987 by the American Psychiatric Association. In codifying diagnostic criteria for abuse and dependence, both classification systems have converged on formulations that emphasize two fundamental observations. First, the criteria for dependence and abuse (the latter is called "harm- ful use" in ICD-10) apply uniformly to all psychoactive substances, which emphasizes the commonalities in drug-related behavior, physiology, and cognition or subjective awareness. The more specific pharmacological ef- fects and sociolegal status of each substance are recognized but do not directly affect the diagnosis. Second, both schemes concede the irreducible complexity of drug phenomena. Rather than offering a single file of de- scriptors that every positive diagnosis must match (e.g., the classical signs of tolerance and withdrawal), the two systems lay out an array of func- tionally significant problems, diverse formations or combinations of which are accepted as equally significant for diagnostic purposes. Perhaps a small monument to this complexity is the fact that, despite cross-consultation between the two projects, and although each retains the same number of defining criteria (nine), there are various differences between them in shades of meaning (Table 3-2~. The convergence is most complete in defining the dependence syn- drome: in the ICD-10, it is a cluster of physiological, behavioral, and cognitive symptoms or phenomena such that "the use of a drug or class of drugs takes on a much higher priority for a given individual than other behaviors that once had a higher value"; the DSM-III-R defines it as when "the person has impaired control of psychoactive substance use and contin- ues use of the substance despite adverse consequences." A positive ICD-10 diagnosis is triggered when three or more criteria are present at some time in the previous year or continuously during the previous month. Similarly, any three DSM criteria precipitate the diagnosis of dependence. There are also degrees of dependence mild, moderate, and severe- based on

THE NEED FOR TREATMENT TABLE 3-2 Correspondence Between the Cnter~a for Dependencea of the International Statistical Classification of Diseases, Injuries, and Causes of Death (lOth rev. ea.; ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders (3rd ea., rev.; DSM-III-R) ICD- 10 Progressive neglect of alternative pleasures or interests in favor of substance use. 71 DSM-III-R Important social, occupational, or recreational activities given up because of substance use. Continued substance use despite knowledge of having a persistent or recurrent social, psychological, or physical problem that is caused or exacerbated by the use of the substance. Persisting with drug use despite clear evidence of overtly harmful consequences. Evidence of tolerance such that increased doses of the substance are required in order to achieve effects originally produced by lower doses. Substance use with the intention of relieving withdrawal symptoms and subjective awareness that this strategy is effective. A physiological withdrawal state. Strong desire or sense of compulsion to take drugs. Evidence of an impaired capacity to control drug taking behavior in terms of its onset, termination, or level of use. A narrowing of the personal repertoire of patterns of drug use, e.g., a tendency to drink alcoholic beverages in the same way on weekdays and weekends and whatever the social constraints regarding appropriate drinking behavior. Evidence that a return to substance use after a period of abstinence leads to a rapid reinstatement of other features of the syndrome than occurs with nondependent individuals. Marked tolerance: need for markedly increased amounts of the substance in order to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount. Substance often taken to relieve or avoid withdrawal symptoms. Characteristic withdrawal symptoms. Persistent desire or one or more unsuccessful efforts to cut down or control substance use. Substance often taken in larger amounts or over a longer period than the person intended. Frequent intoxication or withdrawal symptoms when expected to fulfill major role obligations at work, school, or at home or when substance use is physically hazardous. A great deal of time spent in activities necessary to get the substance, taking the substance, or recovering from its effects. aA dependence syndrome is present if three or more criteria are met persistently (DSM: continuously) in the previous month or some time (DSM: repeatedly) in the previous year.

72 TREATING DRUG PROBLEMS the number of symptoms observed above the minimum criterion level and in particular the extent of social and occupational impairment. Diagnostic specifications for partial and full remission are also part of the classification schemes. Abuse is a lesser category in both schemes. In DSM-III-R, psychoac- tive substance abuse is defined as follows: the persistence of psychoactive substance use for at least one month or repeatedly over a longer period of continuing use despite the recurrence or persistence of one or more known adverse consequences (social, occupational, psychological, or physical) or the taking of recurrent physical risks such as driving while intoxicated. The substance abuse diagnosis is triggered only if the person has never met the criteria for dependence for this substance. ICD-10 diagnoses "harmful use" when there is clear evidence that the consumption of a substance or sub- stances is responsible for causing the user actual psychological or physical harm negative social consequences (e.g., arrest, job loss, marital break- down) are not considered psychological harm. (If, however, these negative consequences in turn cause psychological harm, it is unclear whether the pattern of use would then be deemed harmful.) The ICD-10 scheme puts less emphasis than DSM-III-R on the importance of earlier drug history; previous dependence does not preempt a current finding of the lesser diagnosis, as it does in the DSM system. The critical commonality in these definitions and measures is that these criteria focus on impairment of control and undesirable functional consequences of excessive drug consumption. These consequences may range from health problems to lost social opportunities, but they are alike in that they are unwanted. Indeed, individuals who become dependent are dismayed by the negative effects of their drug consumption. When the doses and schedules of use become dense enough, they take on a life of their own, which can impair an individual's capacity to reduce or cease drug use in spite of accumulating harm. Helping to strengthen this capacity for choice or self-control over drug seeking- particularly when the individual lacks the protection of confinement (e.g., closed hospital wards or prisons) where there is limited opportunity to exercise choice is the object of virtually all interventions (including mutual self-help groups) to rehabilitate drug-abusing and drug-dependent individuals. To achieve this goal, it is often necessary to help develop other capabilities (or to heal other disorders or damages) so that alternative ways of behaving become more accessible and their rewards easier to reap. Recovery and Relapse Dependence sometimes lasts indefinitely but slowly increases in sever- ity. More typically, however, dependence is interrupted, followed (after

THE NEED FOR TREATMENT 73 several months to several years of drug use) by some period of recovery.3 Although recovery is similar to abstinence in that drugs are not sought or used, the previous experience of dependence or extensive abuse leaves a variety of powerful residues. There may be craving and other strong drug-related emotions and sensations, which may take months to recede. There may also be permanently disabling physical illnesses and wounds. There will certainly be conditioned behavioral tendencies and responses closely associated with drug taking that are slow to extinguish fully and must be specifically countered if recovery is to last. A recovering individual may have to scrupulously avoid certain locations, situations, or people who were strongly associated with drug acquisition. The individual may carry indelible social stigmata, such as a record of criminal convictions. And there may be other losses created or aggravated by drug involvement: years without conventional employment, lack of formal education, irremediable family divisions, and deep emotional wounds. Recovery is not an easy process, and first, second, or later episodes may be followed by relapse. Cycling one or more times from recovery back through relapse to dependence or abuse (more rarely, to low-level use) is so common that it must be seen as an intrinsic feature of the natural history of individual drug behavior. Individuals may follow any one of a range of courses after an initial period of abuse or dependence. There is a cumulative literature on one such course that Winick (1%2) called "maturing out" of drug dependence. Although that description of recovery is now viewed as too restrictive and therefore misleading, it does suggest the decades-long span across which the cycle of drug dependence/recoveIy/relapse can continue. The bulb of the literature on cycles of dependence and recovery concerns heroin, the major drug of dependence of the 1950s and 1960s; it is not yet known whether long-term patterns of dependence on the major drugs of the 1970s and 1980s, marijuana and cocaine, will be similar. There are strong reasons to think that the heroin literature is a good guide, including the fact that findings regarding recovery and relapse from alcoholism resemble findings in the heroin literature. The classical study of recovery and relapse from heroin addiction prior to the availability of modern treatment modalities was carried out by Vaillant (1973), who followed 100 heroin addicts from New York City who were admitted to Lexington in the early 1950s. For most of the study period, the only form of drug treatment available was detoxification. Yet 3The term recovery is equivalent to the term remission generally used in clinical descriptions of other chronic relapsing disorders. Recovery is used more commonly in the alcohol and drug field and suggests the more active character of the recovery process, in contrast to the passivity implied by remission; that is, a disorder remits, but an individual recovem.

74 TREATING DRUG PROBLEMS 100 80 60 40 20 ~ {~ ~ YEARS is. 18 FIGURE 3-3 Status of 100 heroin addicts at three points in time after index hospital discharge. Source: Vaillant (1973~. the prevailing criminal approach to drugs, symbolized in New York by the Rockefeller "get tough" drug laws, guaranteed that there were powerful environmental incentives toward recovery. The results for this cohort are displayed in Figure 3-3. The number of actively heroin-dependent members declined as the cohort aged, but many remained until they died in a cycle of dependence, brief recovery (often while in prison only), and relapse. Deaths occurred at a sustained rate of approximately one per year—roughly the same as if this cohort of 100 men had been about 50 years old on average instead of less than 25 years old at the beginning of the period. Many became virtually permanent prison inmates as a result of unabated heroin use and other criminal behavior. As these data and much subsequent research (e.g., McGlothlin et al., 1977; Nurco et al., 1981a,b,c) powerfully argue, dependent drug-seeking behavior and its subjective aspect, the strong desire or craving for drugs, are difficult to extinguish once they have been established in a familiar drug-supplying environment. Nevertheless, some proportion of individuals succeed in eliminating an established, chronic pattern of dependent behav- ior. Studies indicate that there is usually a complicated path to sustained recovery, more often than not involving one or more relapses. Individuals with severe problems (e.g., family disintegration, illiteracy and other edu- cational failings, lack of legitimate job skills, psychiatric disorder) continue to have these difficulties (especially if they precede drug involvement) un- less specific help is received to deal with them. Such problems disrupt

THE NEED FOR TREATMENT 75 the process of unlearning (that is, learning self-control over) drug-seeking habits and responses; consequently, these disadvantaged individuals are at intrinsically higher risk of relapse than persons with fewer or less severe problems. The number of high-quality, long-term studies of recovery from de- pendence is relatively small, but the results have been consistent. Although many people do recover from dependence, recovery is seldom achieved, or even begun, before the individual recognizes that he or she has suffered and caused significant personal and social harm. Some proportion of individuals who are (or would be) diagnosed as drug abusing or dependent a propor- tion that may vary somewhat with the specific drug and especially with the level of problem severity- recover without treatment. The evidence sug- gests that successful, nontreated recoveries are most likely to occur when the level of consumption and problem severity is low and the individual has (or gains) close friends and relatives—perhaps including coworkers, em- ployers, or fellow members of mutual self-help groups—who provide daily support, encouragement, and disciplined help in avoiding relapse and en- gaging in non-drug-related activities. This kind of social support increases the chance of recovery whether or not formal treatment is received. There is as yet, however, no way of discerning who will or will not recover without treatment or over what time frame recovery will proceed, and this discrimination deficit has two important implications. First, it is reasonable and ethically incumbent to presume that treatment is needed whenever abuse or dependence is present, even though this presumption means some individuals may undergo treatment who would otherwise re- cover even without it but perhaps at a slower rate. It is clinically sensible to titrate the intensity of the prescribed treatment to some degree according to the severity of the condition, the degree of preexisting social and personal support available to the individual, and the number of earlier attempts at untreated recovery. The need for treatment is clearest, and the indication for intensive treatment measures strongest, in cases of severe dependence and prior relapses. The second implication of the inability to clearly discriminate those who may not need treatment in order to recover involves treatment evaluation. If a form of drug treatment contributes effectively to the recovery of various individuals who are so treated, it basically increases the overall group rate of recover over what would have occurred in the absence of treatment. Evaluation of treatment effectiveness therefore depends not only on adequately describing the form of treatment and measuring the outcomes among those treated but also on being able to estimate the untreated recovery rate for that group. In practical terms, this means identifying the outcomes in an appropriate untreated comparison group. I'here are other ways to test treatment effectiveness- for instance, investigating whether

76 TREATING DRUG PROBLEMS larger doses of treatment have more effect than smaller doses, up to the prescribed limit or an optimum. Nevertheless, an untreated comparison group offers the ultimate test. This important methodological issue is discussed in Chapter 5. ESTIMATING THE EXIENT OF THE NEED FOR TREATMENT Diagnosing drug abuse or dependence in an individual based on history-taking, physical examination, and the information in previous rec- ords is a different matter from estimating how many individuals in the general population meet such diagnostic criteria. Individual histories have never been taken and physical test batteries for drug problems have never been performed on a fully representative sample of the whole U.S. pop- ulation. A number of partial population studies have been conducted in the 1980s, however, and, taken together, these surveys provide a basis for estimating the extent of the need for treatment. The most clinically sensitive population study was conducted using the DSM-III Clinical Research Diagnostic Criteria. Nationally adjusted prevalence estimates from household interviews in five metropolitan areas for 1981-1983 (Regier et al., 1988) indicated that, in a given month, 2.3 million adults about 1 percent of the adult population would have met the clinical criteria for a diagnosis of drug dependence or abuse. These authors further concluded that, over a 6-month period, a total of 3.4 million adults would have met these criteria because individual drug problems (and particularly patterns of abuse) undergo change across even this short a time span. For the Presidential Commission on the Human Immunodeficiency Virus Epidemic (1988), the National Institute on Drug Abuse (NIDA) used 1985 household survey data (which were cruder than the Regier team's five-city instrument) to estimate that 6.5 million persons "used drugs in a manner which significantly impairted] their health and ability to function." More recently, for the September 1989 National Drug Control Strategy document (Office of National Drug Control Policy, 1989), NIDA used the 1988 household survey conducted by the Research Triangle Institute (NIDA, 1989) to estimate that 4 million persons (about 2 percent of the population aged 12 or older) had taken drugs 200 times in the past 12 months, thus defining the population most clearly in need of treatment. These variations not only reflect divergent methods of estimating the need for treatment but also show that the extent of need is not static. One good indicator of this changing picture is provided by a data series collected since 1976 from local emergency rooms and medical examiners in cities around the country. The series consists of incidents in which specific drug involvement was noted in medical reports that specifically

THE NEED FOR TREATMENT 320 280 240 200 160 120 80 40 77 ,, - / / l Marijuana ,~ Heroin ~_. ~ ~ . 1, 76 78 80 82 YEAR Cocaine 84 86 88 FIGURE 34 fiends in comine, heroin, and marijuana involvement in deaths and medical emergencies, 197~1988. Index Year 1985 = 100. Sources: National Institute on Drug Abuse (1987~; National Narcotics Intelligence Consumer Committee (1989~. called for this information. Figure 3-4 reports indices for cocaine, heroin, and marijuana from 1976 to 1988 in consistently reporting medical units, standardized to the 1985 value. The cocaine and heroin indices are an average of emergency room and medical examiner cases; marijuana is based on emergency room reports only. The paths of the three drugs have varied during the 12-year period, but all are clearly at higher levels in 1988 than in 197~for cocaine, dramatically higher. These indices of severe drug problems project a very different picture from that seen in data tracking all current use (once or more in the past month). This type of threshold prevalence data, displayed in Figures 3-5a, 3-Sb, and 3-Sc for three age strata, shows quite a different set of trends for marijuana and cocaine across the 1980s, particularly among adolescents and young adults. The committee has developed new estimates of the need for treatment by combining information from three data sources: the 1988 NIDA/RTI national household population survey; a number of suIveys and longitudinal studies of criminal justice populations conducted or sponsored by the Bureau of Justice Statistics and the National Institute of Justice; and recent studies of the homeless population. Household Survey Data National drug use surveys to collect data from probability samples of U.S. household residents have been conducted at inteIvals of from one to three years since 1972. The 1988 survey of 5,719 adults and 3,095 adolescents, conducted by the Research Triangle Institute for NIDA, was the

78 TREATING DRUG PROBLEMS first to collect information on items that are part of the ICD-10 and DSM- III-R criteria for drug dependence and abuse. A thorough assessment of the reliability and validity of these survey items, including cross-validation with clinical workups or diagnostic interviews, has not been performed. Nevertheless, it is possible to use responses to relevant survey items on symptoms of dependence, negative consequences or problems attributed to 17 - a ,_ 1vS 3 1 ,~ 24 J 6 20 _ cot z 0 16 LL o ~~ 12 _ c, ~ 8 c: a: llJ ~ 4 ~ ~ Marijuana /' Stimulants ~ — Eve 1 ~ I I , ~ , , ~ , , , ~ , , I 72 74 76 78 80 YEAR b A Stimulants ~ /_ _ Cocaine ~ _ 82 84 86 88 \ Marijuana 74 76 78 FIGURE 3-5 Continued on next page 80 82 84 86 88 YEAR

THE NEED FOR TREATMENT c:, 6 or: LL 5 9= 4 so LIZ 3 °t at> LL em ~ ~ 1 ~7 ii O G LLJ 72 74 76 79 r Cocaine _— _ — \ 78 80 82 84 86 88 YEAR FIGURE 3-5 Mends in past-month drug use, 197~1988, for ~a' adolescents aged 12 to 17 years; Abe young adults aged 18 to 25 years; Icy adults aged 26 and older. Note: The stimulant line is missing in the figures where frequencies were too low for statistical reliability. source: National Institute on Drug Abuse `1988b, 1989~. a drug, and levels of drug consumption to estimate more precisely than in previous efforts the need for treatment among household residents. The data on each individual in the survey were classified to yield categories of clear, probable, possible, and unlikely need for treatment. Clear need was defined in terms of exceeding thresholds on three distinct criteria: illicit drug consumption at least three times weekly; at least one explicit symptom of dependence (usually two or more were present); and at least one other kind of functional problem attributed to drug use (usually two or more were evident). If an individual's level of consumption, number of symptoms, or number of problems fell below one threshold value but exceeded the other thresholds, a probable need for treatment was imputed. If there were at least monthly use and some indication of symptoms or problems, the individual's need was classified as possible. In all other cases, the need for treatment was deemed unlikely. The committee believes that all of those individuals classified as having a clear need for treatment exceed the minimum diagnostic criteria for dependence. Those with a probable need for treatment exceed the criteria for abuse and, in some proportion of the cases, for dependence. Some of those with a possible need may meet the criteria for abuse most will not. Appendix 3A details the procedures used to arrive at these estimates. On this basis, out of an estimated 14.5 million individuals (about 7.3 percent of the household population 12 years of age or older) who consumed an illicit drug at least once in the month before the su~vey,4 1.5 million (0.7 percent of the population) can be categorized as having a clear 4The survey further revealed that an additional 13.5 million persons had used an illicit drug in the past year but not in the past month and 44.5 million individuals had used an illicit drug at least once but not in the past year.

80 TREATING DRUG PROBLEMS Clear Probable Possible Unlikely (47.7%) FIGURE 3~ The estimated need for treatment among the 1988 household drug-consuming population (14.5 million individuals in the household population who had used drugs at least once in the past 30 days). Source: Institute of Medicine analysis of data from the 1988 National Household Survey on Drug Abuse, performed by Research Triangle Institute for the National Institute on Drug Abuse. need for drug treatment at the time of the survey. Another 3.1 million individuals (1.6 percent) have a probable need; 2.9 million (1.5 percent) have a possible need. The other 6.9 million recent consumers are unlikely to need drug treatment (Figure 3~. The clear and probable need cases together comprise about 4.6 million individuals, which is one-third of the 14.5 million current-month drug consumers and about 2.3 percent of the total 1988 household population of 198 million individuals aged 12 and older. The clear and probable cases are two-thirds male and heavily concentrated among younger adults (aged 18 to 34~; youths under the age of 18 make up 9 percent of the total (about 396,000 persons), and adults 34 years of age and older constitute another 16 percent (727,000 persons). Most of the adults participate in the labor force: 75 percent hold jobs, and 10 percent are unemployed. The IS percent not in the labor force are primarily in school, retired, disabled, or have household responsibilities. The unemployment rate among clear and probable need cases is about double the 1988 national unemployment rate. Although a substantial majority of the household residents needing treatment maintain jobs in the legitimate economy, many have low incomes: 32 percent earn less than $9,000 per year, 38 percent earn $9,000 to $20,000, and 30 percent earn more than $20,000 per year.

THE NEED FOR TREATMENT 81 Criminal Justice Populations Among those groups that may not be well represented in the national household surveys are the nearly 2 percent of U.S. adults who are under the supervision (as inmates, probationers, or parolees) of judicial and correctional agencies of the federal government, the 50 states, the District of Columbia, and the nation's 3,000 counties. The sizable proportion of drug treatment clients who are also criminal justice clients far exceeding the 2 percent share of the general population indicates that the need for treatment among populations supervised by the criminal justice system merits a separate accounting. Moreover, the number of persons under such supervision has been growing at a steady rate (5 to 8 percent annually since 1973) that shows no sign of diminishing. Any future growth in the treatment sector, particularly on the public side, seems bound to involve an expanded interface with criminal justice populations. On any given day in 1987, the last year for which complete counts are available, nearly 3.7 million adults were under criminal justice supervision or in custody (Allen-Hager, 1988; Beck et al., 1988; Hester, 1988; Kline, 1988; Greenfeld, 1989~. A minority of this group were serving sentences in state and federal prisons (580,000) or county jails (140,000) or were in jail awaiting prosecution (150,000~; three out of four were under supervision in the community while on probation (2.24 million) or parole (360,000~. About 50,000 minors were in juvenile justice or correctional institutions. An even larger number of individuals were arrested during 1987 and thus came into contact with the criminal justice system for short periods. Of the 1~7 million arrests leading to 8.7 million jail admissions, 2.6 million arrests were for violent or property (income-generating) crimes and 937,000 were for drug law violations (Jamieson and Flanagan, 1989~. A large proportion of other kinds of arrests (e.g., prostitution, gambling, weapons violations, simple assaults) involved drug consumers. At any one time, the bunts of these arrestees were in the community on bail or on recognizance while awaiting disposition of charges. The estimates presented in Appendix 3B suggest that more than a million of these 1987 arrestees clearly or probably needed drug treatment. However, there are better data available on individuals already under criminal justice supervision when arrested or those who come under that jurisdiction following arrest and disposition of charges. These data fall into two categories: those related to individuals in jails or prisons and those related to- persons under community supervision (on probation or parole). The prison and jail inmate population numbered 874,000 at the end of 1987. Inmates are not supposed to be consuming drugs while in custody (although there is clearly substantial leakage of drugs into correctional settings). Many have long prior histories of drug abuse or dependence,

82 TREATING DRUG PROBLEMS however, and enforced abstinence during incarceration hardly ensures con- tinued abstinence after release. Prior drug problems are quite common among state prison inmates.5 A 1986 survey of inmates (Innes, 1988) found that 80 percent had used an illicit drug at least once, 63 percent had used such drugs regularly at some time in the past, 43 percent had used an illicit drug daily in the month prior to their offense, and 35 percent were under the influence of a drug at the time of the offense. State prison inmates typically began illicit drug use at age 15, were first arrested at age 17, and first began regular use of a "major" drug (heroin, cocaine, PCP, LSD [lysergic acid diethylamide], methadone) at age 18. The median age of the prison population was 28 years. Confidential surveys conducted among prisoners demonstrate how drug involvement patterns have changed both in character and quantity over the past 15 years6 (1kble 3-3~. In state prisons in 1974, one in four inmates reported having been under the influence of one or more drugs when he (or she, although 19 out of 20 inmates were male) committed the crime that prompted his incarceration. Heroin was the principal drug mentioned; marijuana was less common, and cocaine was rare. In 1979, with a third more prisoners in custody altogether, one in three prisoners had been under the influence of a drug. Heroin, however, was mentioned less frequently and thus was much lower in proportion and numbers. Marijuana had risen substantially on both counts, and cocaine prevalence had risen dramatically, although it was still less common than heroin. In 1986, with two-and-a-half times as many prisoners in custody as in 1974, the number of heroin mentions had increased and was again 5Regarding prisons versus jails: generally, sentences that will involve a minimum of one year actually behind bars are served in prisons (state penitentiaries); those with shorter minimum confinements are served in county jails. (A few states have a single custodial system rather than separate county and state facilities.) There are also regular exceptions to this rule. The overall length of a sentence is almost always longer (generally by a factor of two to three [see Hester, 1988; State Statistical Programs Branch, 19893) than the time to be served in custody; the actual amount of time served in prison depends on the state's mandatory release policies, the degree of prison overcrowding, the convict's behavior while in prison and on parole, and other consid- erations that affect correctional and parole policy. 6Prisoners serve sentences of varying lengths, and those with the longest sentences—generally for murder or rape—constitute a much larger share of a prison census than their entering num- bers would suggest. Because of the length of sentences, a prison population, in reporting on pre-arrest drug patterns, is like a series of sedimentary layers that reflect criminal drug involve- ment in earlier periods. The pattern is complicated by the fact that many prison admissions are returned parole violators. At the end of 1988, about 43 percent of state prisoners had been newly admitted during the year, 18 percent had been returned during the year on parole revocations (about half of these with new sentences on top of the old ones), and 39 percent had been contin- uously in prison for a year or longer (Lawrence Greenfeld, Bureau of Justice Statistics, personal communication, July 1989~.

THE NEED FOR TREATMENT TABLE 3-3 Trends in Numbers and Percentages of Prison Inmates Who Reported Being Under the Influence of One or More Drugs at the Time of the Convicted Offense Inmate 1974 1979 1986 Drug Smms No. % No. % No % No drug 163,000 74.7 2W,000 67.7 338,000 64.6 Any drug 55,000 25.3 97,000 32.3 185,000 35.4 Heroin 35,000 16.2 26,000 8.7 36,000 7.0 Cocaine 2,000 1.0 14,000 4.6 56,000 10.7 Marijuana 22,000 10.3 53,000 17.6 97,000 18.6 Toud 218,000 100.0 301,000 100.0 523,000 100.0 Sources: Innes (1988); Flanagan and Ja~rneson (1988). 83 comparable to 1974, although the proportion had not kept pace with the overall increase in the prison population. Cocaine prevalence now exceeded heroin by a large margin, and the marijuana figures continued to increase at a pace slightly ahead of the increase in all offenders imprisoned. Based on questions about drug histories, it appears that most of those who were under the influence of a drug at the time of their offense also stated that they had histories of drug dependence and were using drugs on a daily basis when the offense occurred. The great majority of those who were under the influence of drugs were not arrested for a drug offense per se (possession, sales, etc.~. Of all those who reported being under drug influence, 26 percent were in prison for robbery, 21 percent for burglary, 20 percent for a violent crime other than robbery, and only 14 percent for a drug offense. About the same percentage (42 to 43 percent) of all those incarcerated for robbery, burglary, or drug offenses indicated they were under the influence of a drug when the offense occurred; about 30 percent of all other imprisoned offenders reported drug influence as well. Judged according to criteria similar to those applied to the household population, prisoners who were daily drug users at the time of their offense are considered to need treatment; in fact, all of them probably meet the diagnostic criteria for drug dependence. This group comprised 43 percent of all inmates responding to the 1986 state prison survey. Applying this finding to the 1987 state and federal7 prison census of 584,000 (Greenfeld, 1989) results in about 250,000 inmates who need treatment. Inking a We federal prison population is around so,ooo. These institutions were not surveyed with the state prisons, but at least the same proportion of these prisoners as of the state prison populations may be assumed to need treatment. Wore than two-thirds of those confined in federal prisons are sentenced for proper or violent crimes. In state prisons these offended have the highest reported drug use, including one~uarter of the total who are serving time for drug offenses.y

84 TREATING DRUG PROBLEMS similar proportion of convicted inmates serving time in county jails (0.43 x 140,000 ~ 60,000) and juveniles in long-term custody institutions (0.43 x 25,000 ~ 10,000) yields an overall daily estimate of 320,000 individuals in correctional institutions who need treatment. At the end of 1987, probation and parole offices were supervising 2.6 million unincarcerated persons. The mix of offenses among parolees closely approximated that Of the prison population from which they were drawn (and to which, in a large proportion of cases, they return following parole violations). An estimate that 43 percent of parolees (150,000) need drug treatment is therefore readily made. The much larger probation population is the least well studied of all the criminal justice populations and consequently offers the most difficulty in accurately estimating treatment needs. For one thing, it includes a high proportion of less serious (nonfelony) offenses. But in general, one would expect there to be a significant number of probationers with drug problems. The prison- and parole-based figure of 43 percent would seem to be an upper bound; the estimate (see Appendix 3B) that 10 percent of all arrestees need drug treatment provides a lower bound. The midpoint of these two boundaries, 26 percent, represents about 580,000 probationers. Combining this figure with that for parolees (150,000) produces an estimate of approximately 730,000 individuals in the community under supervision of the criminal justice system who need treatment for drug problems. The Homeless Population Recent studies have estimated that from 200,000 to 700,000 people in the United States are homeless on any given night and as many as 2 million experience homelessness at some point during a year, staying temporarily in the intervals with family, friends, or acquaintances. About three-quarters of all homeless people are unattached adults; the balance are mostly women with children. There is evidence that the homeless suffer from a high prevalence of drug disorders; several recent studies have found prevalence rates of 10 to 33.5 percent, with a median value of 20 percent (Institute of Medicine, 1988b). The homeless are by definition excluded from household population studies, as are individuals or families who are temporarily staying in some- one else's household. The need for treatment in this otherwise unrepre- sented population could thus range from a minimum of 20,000 (10 percent of 200,000) to a maximum of 670,000 (33.5 percent of 2 million). For its estimate, the committee applied the median prevalence value of 20 percent of individuals having drug disorders to the midpoint one-night homelessness estimate of 450,00~, however, it applied the lower prevalence estimate of 10 percent to an additional 775,()00 "hidden homeless" or nonchronically -

THE NEED FOR TREATMENT 85 transient (the midpoint of the difference between 2 million and 450,000~. Adding the two prevalence figures yields a treatment-needing homeless population of about 170,000. Pregnant Women Pregnant women who are consuming illegal drugs, especially those with high rates of consumption, are of special epidemiological concern. Fetuses are vulnerable to maternal consumption of drugs during pregnancy, and there has been great concern about potentially serious consequences of maternal cocaine abuse and dependence for unborn babies in terms of premature delivery, small size at term birth, developmental somatic defects, and impacts on cognitive and behavioral development (Chavez et al., 1989; Zuckerman et al., 1989, Chasnoff et al., 1990~. These risks from cocaine abuse or dependence appear comparable to the serious risks posed by tobacco or alcohol dependence. It is likely that the greater the severity of maternal abuse or dependence, the greater the risk of fetal damage from the pharmacological effects of the drug consumption itself and the greater the likelihood of maternal complications such as infection (most tragically, infection with the human immunodeficiency virus [HIV], which causes AIDS), malnutrition, and trauma. The risks to children of drug-abusing or dependent mothers do not necessarily stop accumulating at birth. If maternal drug abuse or depen- dence continues, the future of these babies is further compromised or threatened on a day-to-day basis unless competent and loving care-giving by someone else can be arranged—often not an easy matter. The best al- ternative, therefore, is for the pregnant and postpartum mother to abstain from drug taking, and treatment may be an appropriate means toward this end. The 1988 RTI/NID A national household survey indicated that about 9.3 million women in high-fertility age brackets (15 to 35 years) used an illicit drug at least once in the previous year; 4.9 million did so within the past month. The overall expected birth rate for a group in this age bracket would be about 9 percent annually, with 7 percent pregnant in a given month. These numbers imply a probable range of 350,000 to 625,000 annual fetal exposures to one or more episodes of illicit maternal drug consumption. Of course, estimates of potential maternal drug exposure ex- pressed as annual or monthly prevalence rates are not especially informative concerning the scope of risks of such fetal effects as low birth weight; more drug-specific, frequency-specific, and recency-specific analyses are needed for these determinations (cf. Zuckerman et al., 1989; Petitti and Coleman, 1990~. In terms of the classification methods used in this chapter, about 10

86 TREATING DRUG PROBLEMS percent of all past-month users clearly need treatment (i.e., are dependent), and another 20 percent probably need treatment (most are classifiable as drug abusers). This implies that about 105,000 pregnant women annually are in need of drug treatment, based on the same diagnostic criteria applied to the general population. These statistical estimates assume that women who consume illicit drugs are on average just as likely as non-drug-taking age peers to give birth. No published studies shed direct light on this assumption, which may be too generous, considering that birth rates are much higher among married versus unmarried women and that married women are a much more abstemious group; on the other hand, it may not be generous enough, given that drug consumers, at least among teenagers, are more sexually active and more often pregnant than abstainers. At any rate, the estimate of 105,000 pregnant women needing drug treatment annually is a subset rather than an addition to the estimated numbers in need of treatment noted in previous sections.8 Summary The committee's combined estimate of the point-in-time need for treat- ment on a typical day in 1987/1988 is approximately 5.5 million individuals (liable 3-4~. This number includes about 1 in 50 household residents older than 12 years of age, more than one-third of all prison and jail inmates, and more than one-fourth of all parolees and probationers. The total estimate is about 2.7 percent of the U.S. population aged 12 years or older. In finer grain, the survey data indicate that about 1.5 million persons in the household population clearly need treatment; the committee believes this to be a minimum estimate of the prevalence of drug dependence in that group. The survey questions used to estimate treatment needs In the criminal justice population are simpler and cruder than those used In the household survey. The criteria provided by these survey items are much more like the "clear" (that is, more severely impaired) than the "probable" householder treatment criteria; In other words, the individuals meeting these criteria (daily-user criminals) are likely to be drug dependent rather Working from a different base studies among obstetrical patients—Chasnoff and associates have estimated that about 375,000 babies in the United States (more than 10 percent of live births) may be exposed annually to illicit drugs. This figure is within the committee's estimated range, although it is based on samples of uncertain representativeness that use a variety of meth- ods. The major study (Chasnoff, 1989) involves 36 hospitals across the country. Nearly all of them are urban core medical centers serving large proportions of the innercity poor, who are likely to display illicit drug prevalence rates well in excess of the national average. In another study by Chasnoff and coworkers (1990), however, which covers a highly urbanized county in Florida, these investigators found rates of positive drug tests among prenatal clinic patients that approached those in some central cities, even among cases observed in private obstetrical prac- tices.

THE NEED FOR TREATMENT TABLE 3-4 Estimated Need for Drug Treatment (in thousands) Among Surveyed Adult and Adolescent Populations, 1987-1988 87 Those Who Population Total Need Treatment Household 198,000 Clear need 1,500 Probable need 3,100 Homeless (sheltered, street, and transient) 1,225 170 Criminal justice clients Correctional custody 925 320 Probation and parole 2,600 730 Pregnancies (live births) 3,875 105 (Less overlaps)a ( - 470) Total needing treatment 5,455 aIn theory, the need for treatment among parolees and probationers should be counted in the household surveys because it is generally a condition of parole and probation that certain signs of social stability, such as a fixed address in the community, be maintained. However, enforcement of such conditions is spotty. The efficiency of coverage of parolees and probationers in the national drug abuse household survey has not been examined. It would be simple to do so, however, by asking respondents whether they were currently on probation or parole. Such an item should be no more subject to nonresponse or validity problems than questions about illicit drugs. In the 1988 national survey on drug abuse, at least 70 of 5,800 adult respondents (including oversampled subgroups) would have been on probation or under parole supervision in the event of standard demographic likelihoods of participation. There is some basis for estimating the efficiency of sampling probationers and parolees in the household survey. Criminal recidivism among parolees is very high; around two-thirds of all parolees are rearrested within a few years, and the figure is higher for those needing treatment. On this evidence, parolees have much reason to conceal themselves and are not likely to be residentially stable or accessible enough for complete enumeration and good representation in a household survey. The committee estimates that only 30 percent of those needing treatment, or 45,000 persons, are represented. About 20 percent of all probationers do not successfully complete probation. Those needing treatment clearly fail at a higher rate, probably 40 to 50 percent (see, e.g., Toborg and Kirby, 1984). This recidivism rate is not as high as for parolees, but it does suggest a reduced likelihood of being identified for participation in a household survey. The committee estimates that 50 percent, or 270,000 probationers needing treatment, may be represented there. Overlap with the homeless estimate seems to require reasoning in the other direction. No data were located on rates of probation or parole status among the homeless. Yet the incidence of such status in this group seems likely to be higher than among the residentially stable. With the latter proportion placed at about 15 percent, doubling that yields 30 percent of the homeless drug-dependent or drug-abusing individuals on parole or probation—50,000 individuals. The overlap of women who are pregnant (and give birth to live babies) with the household and other population figures is virtually total. The overlap of pregnancy, probation, and parole groups with homeless and household populations needing treatment is thus estimated at 470,000 persons. Source: Institute of Medicine analysis of data from the National Household Survey on Drug Abuse conducted by the Research Triangle Institute; Innes (1988); Flanagan and Jamieson (1988); Greenfeld (1989); and Institute of Medicine (1988b).

88 TREATING DRUG PROBLEMS than drug abusing. Considering the overlap in estimates, the committee therefore judges that at least 1.3 million household residents who are not currently under criminal justice supervision need treatment for drug dependence; 1.1 million individuals who are under justice supervision also need such treatment (one-third of these individuals are currently in jail or prison). About 3 million additional household residents probably need treatment; most of them would be diagnosed with the less severe condition of drug abuse. Another 100,000 homeless individuals who are not under criminal justice supervision also need treatment for dependence or abuse. QUANTIFYING THE CONSEQUENCES As a final component in considering the need for treatment, it is important to analyze the adverse effects the burden—of drug abuse and dependence. In particular, to gauge the extent of this burden, it is im- portant to use the same scale of measurement as that usually used to address the problem, namely, monetary cost. This approach, of course, is strictly economic and is not the ultimate measure of policy: in particular, the moral and emotional dimensions of the drug problem are virtually impossible to calibrate in monetary terms. But there is value in signaling the overall economic consequences of drug abuse and dependence, and this approach is a precursor to cost-effectiveness and cost/benefit studies that more closely assess the economic payoffs and merits of alternative responses and strategies (cf. Grant et al., 1983~. Most studies of the cost or burden of drug abuse (N D. Little Co., 1975; Lemkau et al., 1974; Rufener et al., 1977b; Cruze et al., 1981; Harwood et al., 1984) have used a "human capital" approach, which has become fairly standard in estimating the costs of health problems (Rice, 1966; Cooper and Rice, 1976; Hodgson and Meiners, 1979~. This method is conservative in that it measures only those dimensions of a problem that can be expressed as tangible losses from the stock of potentially productive labor and property in society. In so doing, it ignores the possibility that the actual or potential loss victims, as a group, might be willing to pay more to avoid these losses than the equivalent tangible costs alone. In other words, the pain, suffering, fear, and demoralization that accompany the tangible losses reflected in economic measures of drug problems are not fully accounted for by the human capital approach. There is also as yet no good analytical basis for quantifying the downstream costs of necrologic and other deficits of drug-dependent infants or the neglect and abuse of children by drug-impaired parents. The last thorough estimate of the societal cost of drug problems, which covered 1983, was published several years ago (Harwood et al., 1984~. Since then, a number of statistical updates and revisions have become available.

THE NEED FOR TREATMENT TABLE 3-5 Approximate Societal Costs (in billions of dollars) of the Drug Problem Category Victims of drug-related crime (1986) Lost work time Stolen property Lost lives/earnings Cost of property repairs, medical services Cost 1.5 2.6 1.2 0.2 Total Cnme control resources Federal anti-drug (1988) State and local drug law enforcement (1986) State and local drug offense adjudication, corrections (1986) State and local crime control costs from drug-related crimes (1985) Total Criminal careers lost productivity (1986) Employee productivity losses (1983) Drug-related AIDS (1985) Drug treatment and prevention (1987) 5.5 2.5 3.8 2.0 4.5 12.8 17.6 33.3 1.0 1.7 Source: Institute of Medicine analysis of victimization costs using the methods described in Harwood and coworkers (1984; cf. Harwood et al., 1988). The figures for criminal victimization in 1986 are taken from Shim and DeBerry (1988). See Appendix 3C for additional description of sources. 89 The committee's more contemporary estimate, based on the most recently published data, is presented in Table 3-5. The costs are of several types. The criminal aspect of drug use accounts for more than half of the amount estimated here: $5.5 billion worth of tangible losses to victims of property and violent crimes, $12.8 billion in enforcement costs, and $17.6 billion in productivity lost to legitimate economic enterprises because of time spent instead in prison or in criminal enterprises. Nearly equal in magnitude to the sum of these crime-related costs were the estimated reductions in the productivity of employees whose work performance was impaired by drug consumption. The health costs of drug problems in relation to AIDS and expenditures for drug treatment and prevention programs are other, not insubstantial costs, but they are much smaller than the costs incurred as a result of drug-related crime. Further details concerning the generation of estimates in Table 3-5 are provided in Appendix 3C. More elaborate new estimation analyses are currently being prepared by Dorothy Rice and colleagues for NIDA, referenced to

go TREATING DRUG PROBLEMS index year 1985 (cf. Rice and Kelman, 1989), and by the Research Triangle Institute for the Bureau of Justice Statistics; neither set of results are yet available. These cost estimates cannot be quantitatively disaggregated to show costs for drug use, abuse, and dependence, although it is certain that drug use as such is a small direct contributor to these costs. However, the roughly even division between crime-related losses and employment losses bears a rough correspondence to the estimate made above: those persons who are most clearly in need of treatment for dependence are almost evenly divided between the pool of several million criminal justice clients and the much larger base population, the source of the nation's regular labor force. CONCLUSION Few if any problems in American society are as complicated or as mutable as the issue of drug use, which has been one impetus for the proliferation of policy ideas and instruments. Because drug treatment is only one of several accepted policy instruments, the dominant question is how to calibrate its role to determine how much treatment is needed, by whom, of what kinds, for how long, and at whose cost. In trying to make these kinds of policy decisions, particularly for the future, there are three important implications of the problem's complexity. Me first implication, which is elaborated in this chapter, is that careful methods and sophisticated knowledge are required to grasp the nature and quantify the extent of the need for treatment. A clear understanding of this aspect of the problem is particularly important when concepts such as "treatment on demand" or "required coverage" become the focus of debate. Those who are expected to underwrite the costs reflected by these concepts justifiably worry about stepping into a murky and bottomless pit of financial obligation. The need for treatment is great and probably still expanding, but the pit does have a bottom, and the murk can be cleared. Measures of the raw prevalence of drug taking usually expressed in such terms as the 28 million Americans who took an illegal drug one or more times in the past year are not good gauges of the extent of the need for treatment. Current prevalence statistics measure the pool of drug involvement for which some type of response but not necessarily treatment may be needed. The extent of the need for treatment becomes clearer if one focuses on two particular features that simultaneously have biological, psychological, and social significance: the level and pattern of consumption behavior, and the number and severity of functional problems an individual is experiencing or causing as a result of this behavior. The overall prevalence of drug use is a poor absolute measure and an

THE NEED FOR TREATMENT 91 imperfect correlate of the extent and severity of problems, probably because different subgroups of the population have different trajectories of drug in- volvement. Although the number of users that is, lighter consumers may dip or soar over the short term, heavy consumers usually require some time to reach that level and are slower to change. Even good information about the distribution of drug consumption across the population leaves a margin of uncertainty about the need for treatment because a few individuals can consume heavily or regularly with seeming impunity while others have se- vere trouble at much lower doses and frequencies. These differences have much to do with the kind of social advantages and supports available to the individual. This chapter outlines an analytical model to distinguish different types and stages of individual drug consumption and consequences: from absti- nence through use, abuse, and dependence, and on to recovery and relapse. The two outstanding points about this model are the specific identification of a need for treatment with drug abuse and (especially) dependence, and the recognition that individuals continually move into and out of these con- ditions. The factors that propel individuals through the stages of this model are mainly learning and conditioning processes, which are strongly shaped by the economic, social, and cultural dimensions of a person's environment. D=g abuse and dependence are distinguished from drug use through diagnostic criteria; in turn, these criteria, when applied to sample surveys of the population, permit moderately accurate estimates of the aggregate need for treatment. The committee analyzed a number of surveys of the general and special populations that contained questions similar to the diagnostic criteria and arrived at a new estimate of about 5.5 million people who need drug treatment (slightly more than 2.5 percent of the overall adolescent and adult U.S. population of more than 200 million people). It is estimated that about 1.1 million of these individuals are dependent on drugs and are clients of the criminal justice system; another 1.4 million are dependent but not under justice system supervision; and the other 3 million individuals are drug abusers in the household population who probably need less treatment both in terms of quantity and intensity. The above breakdown leads directly to the second implication of the complex nature of the drug problem: different forms of treatment are needed. A wide variety of specific drug problems (some of which are in fact psychosocial or health problems) may precede drug abuse or dependence and exist apart from them; nevertheless, such problems contribute to drug- seeking behavior and affect opportunities for recovery and the chances of relapse. Many of these issues come to a head in selecting or negotiating the goals of treatment, which are the principal subject of Chapter 4. The third implication of the complexity of the problem of drug con- sumption is that evaluating the costs and benefits of treatment is a very

92 TREATING DRUG PROBLEMS demanding task. The course of drug problems is diverse and full of branch- ing probabilities, and it seems to be affected by many things about which scientific knowledge is still quite limited. Even though a single intervention may have little effect on an individual at the time it is delivered, the effects of serial interventions may accumulate significantly over a period of time. Determining how treatment affects the course of drug problems what its incremental benefits may be requires sophisticated analysis; considering current data limitations and analytical capabilities, such analyses cannot escape uncertainties. These uncertainties might be greatly reduced in the event of a miracle cure for drug dependence. But none exists as yet, nor is such a cure a prospect for the immediate future. As with heart disease and cancer in the health domain, theft and assaultive behavior in the realm of crime, or homelessness and family dissolution in the area of social welfare, even the best interventions work only partially some of the time and for some of the people. In none of these cases does the absence of a panacea excuse society from responding to the best of its ability or from working to find and improve the best ideas (even if they are only partially successful). The costs of drug problems are so high that reducing them even modestly is worthwhile. The complexity, uncertainty, and costs associated with drug abuse and dependence, as noted in this chapter, undergird the analysis of treatment effectiveness and costs and benefits in Chapter 5. APPENDIX 3A ESTIMATING THE NEED FOR TREATMENT IN THE HOUSEHOLD POPULATION Special analyses of the 198% National Household Survey of Drug Abuse were conducted to Institute of Medicine specifications at the Research lli- angle Institute to quantify the need for drug abuse treatment among the household population. Previous estimates using the national household surveys were based on the frequency of drug consumption only. Yet the diagnostic algorithms developed in DSM-III-R, ICD-10, and their prede- cessors refer to physiological and psychological symptoms of dependence and abuse and to psychosocial problems and consequences of consumption. These may be correlated with consumption frequency, but they are not simply isomorphic with frequency. The household survey instrument does not directly employ all of the DSM or ICD criteria (see Table 3-2), but it includes numerous items that are very similar to them. The survey inquires about the current frequency of illicit drug consumption (days of use in the past month), symptoms of dependence in the past year, and problems and consequences of drug use

THE NEED FOR TREATMENT 93 in the past year. In this analysis, frequency of drug consumption was coded into eight ranges: · no current illicit use of any drug; · current use of unknown intensity; [Most frequent use of any one drug in the past month:] once; 2 to 8 times; 5 to 8 times; 9 to 16 times; 17 to 24 times; and 25 to 30 times. The symptoms of dependence were coded into three ranges: no re- ported symptoms from any drug; one reported symptom from any drug; and two or more symptoms from any drug. The survey questions used to elicit information on dependence were as follows: In the past year: Have you ever tried to cut down on your use of any of these drugs? Circle the number next to each drug for which you have ever needed larger amounts to get the same effect or that you could no longer get high on the amount you used to use. Circle the number next to each drug you have ever used each day or almost daily for two or more weeks in a row. Circle the number of each drug you felt that you needed or were dependent on. Circle the number next to each drug for which you've had with- drawal symptoms, that is, you felt sick because you stopped or cut down on your use of it. Response categories for each of the above: cigarettes; alcohol; seda- tives; tranquilizers; stimulants; analgesics; marijuana; inhalants; co- caine; hallucinogens; heroin; other opiates, morphine, codeine; never experienced this. The problems and consequences of drug use were coded into three ranges: no reported problems from any drug; one reported consequence from any drug; and two or more consequences from any drug~s). The questions below were used to elicit information on drug problems; the drugs listed above (see the questions on dependence) were also used as response categories for these questions. Have you had any of these problems in the past 12 months from your use of any of the substances on this card? If yes, write in which substances you think probably caused the problem.

94 TREATING DRUG PROBLEMS TABLE 3A-1 Frequency of Illicit Drug Consumption (for one month) and Estimated Prevalence by Level of. Consumption Level of Sample Estimated Consumptiona Cases Prevalence Unknown 215 3,744,840 11 141 2,363,026 2-4 192 3,152,013 5-8 79 1,296,743 9-16 82 1,727,539 17-24 55 987,827 25 + 63 1,206,790 Total 827 14,478,778 a Number of times drugs were used In previous month. Source: Institute of Medicine analysis of data from the 1988 National Household Survey on Drug Abuse, performed by Research Triangle Institute for the National Institute on Drug Abuse. Became depressed or lost interest in things. Had arguments and fights with family or friends. Had trouble at school or on the job. Drove unsafely. At times, I could not remember what happened to me. Felt completely alone and isolated. Felt very nervous and anxious. Had health problems. Found it difficult to think clearly. Had serious money problems. Felt irritable and upset. Got less work done than usual at school or on the job. Felt suspicious and distrustful of people. Had trouble with the police. Skipped four or more regular meals in a row. Found it harder to handle my problems. Had to get emergency medical help. Tabulations of these three variables are reported in Table 3A-1 (levels of consumption) and Table 3A-2 (cross-tabulations of the symptom and problem indexes). Cigarettes and alcohol were excluded from the tabula- tions into categories. The symptom and consequence indexes (each with values of 0, 1, or 2) were summed to yield a symptom/problem scale with values of O through 4. Those individuals with a value of zero reported neither symptoms nor problems in the past year; those with a value of 4

9s an . - 'e A .= At 3 Do cat oo AL ~ Cat V ~ O ~ ~ .= _ ~ Cal ~ Ct c., ~ O O ~ ~ O Hi an ~ .s ~ Cal ~ o - 1 <) ¢ ~ At m ~ V C) V' V C) ~4 O Cal C) =: U' C) .> Ct C) Z ~ O EN Z + Z z; Z O U: O V' ~ ~ oo ~ ~ ~ oo ~ ~ - ~ oo o ~ ~ o ~ o ~ o ~ ~ ~ - o as ~ a~ ~ u~ ~ ~ ~ ~ - ~ ~ ~ ~ ~ - oo ~ ~ ~ . . . . - - - ) t— - - - ~ ~ o ~ ~ oo c~ ~ ~ ~ v~ - ~ ~ c~ ~ c~ c~ ~ ~ oo - o oN o O ~ ~ ~ - - . . . . cr ~o oo ~ - ) - - ~ a~ ~ ~ ~ ~ ~ ~ o r~ ~ ~ ~ o u, U2 'e c) ~ + o ~ o - cn ce o .— 'e z c) ~c o - c~ C4 .c ce cD u, ~: D C) C) C~ D 6 o~ Z ~: o CD V' - a~ CO o c - z x oo - ao Ct Ct ~o o C~ ._ C~ Ct CG ._ .O ~o C) ~o ._ C _ . C) O D ~ 6 o 04 ~ Z

96 TREATING DRUG PROBLEMS 100 By O 50 UJ AL o ~ 1 o ~1 ~11~2 ~ 4+ Symptom/Problem Scale Year N.R. 1 2-4 5-8 9-16 17-24 25+ DAYS OF USE IN PAST MONTH FIGURE 3A-1 Problems by frequency of drug use in the household population, 1988. Year = no use in past month but at least once in past year; N.R. = no response on frequency items. Source: Institute of Medicine analysis of data from the 1988 National Household Survey on Drug Abuse, performed by Research Triangle Institute for the National Institute on Drug Abuse. experienced at least two symptoms and two problems. A value of 2 means two or more symptoms with no problems, two or more problems with no symptoms, or one of each. Similar interpretations apply to the indicator values 1 and 3. The symptom/problem scale was then cross-tabulated with the level of current use. The resulting matrix (Figure 3A-1) can be readily transformed into relative need for treatment. In an ordinal sense, those with the least need would be expected to be in the upper left of the matrix (very low use, few or no symptoms/problems), whereas those with the greatest need would be in the lower right corner (highest use, highest symptoms/problems). The categories of "clear," "probable," "possible," and "unlikely" need for treatment are used to indicate the likelihood that the respondent would require treatment (Figure 3A-2. "Clear" need is defined as a consumption frequency exceeding twice weekly and a value of 3 or 4 on the problem/symptom scale. More-than-twice-weekly consumers with two or fewer symptoms/problems are assigned to the "probable" category. Also "probable" are those with a maximum use of any single drug of from two to eight days per month and a scale value of 3 or 4. The frequency index measures only the drug that is taken most frequently;

THE NEED FOR TREATMENT 97 because many respondents take more than one substance, however, an individual may be taking other drugs less frequently and at different times. For relatively infrequent consumers, the major clinical sign is clearly the elevated symptom/problem count. An individual who consumes an illicit drug five to eight times a month with a low problem/symptom count is classified as having a "possible" need for treatment. In the same class are consumption levels of two to four episodes per month and a scale value of 1 or 2, once-a-month consumption with scale values of 3 or 4, and unknown levels of use. All other individuals are considered relatively "unlikely" to need treatment. Out of 14.5 million current-month drug consumers, the committee classified 1.S million as clear candidates for treatment, 3.1 million as prob- able, 2.9 million as possible, and 6.9 million as unlikely. For purposes of estimating the need for treatment in the household population the clear and probable groups total 4.6 million. Sex, age, labor force participation, and earnings of this combined group are reported in liable 3A-3. 100 90 80 70 60 50 40 30 20 10 JO ~~t,~'~ [~ Unlikely _. 38 _ Possible Probable O Clear \~ FIGURE 3A-2 Need for treatment by frequency of use in the household population, 1988. Source: Institute of Medicine analysis of data from the 1988 National Household Survey on Drug Abuse, performed by Research Triangle Institute for the National Institute on Drug Abuse.

98 TREATING DRUG PROBI FMS The statistical properties of these estimates (standard errors) are com- plex and have not yet been computed. Research Triangle Institute staff consider estimates based on fewer than 15 to 20 case observations to have unacceptably high standard errors. Most of the estimated population char- acter~stics presented here, however, have more than adequate sample cases. (For example, the estimate of 4.6 million persons with clear or probable need for treatment Is based on 247 cases meeting the defined criteria.) provide a sense of the likely statistical properties of these estimates, 95 percent confidence intervals for past-month drug use In subpopulations with estimated use by 5 million or fewer individuals are presented in Figure 3A-3. Larger population estimates have better statistical properties. (Note that the 95 percent confidence Atonal is generally smaller, relative to the TABLE 3A-3 Estimated Need for Treatment (clear plus probable) in the Household Population by Gender, Age, Labor Force Status, and Earnings, 1988 Sample Estimated Characteristic Cases Prevalence Percentage Gender Male 154 3,169,412 68.4 Female 93 1,463,103 31.6 Subtotal 247 4,632,515 100.0 Age 12-17 years 58 395,736 8.8 18-25 84 1,882,855 41.8 26-34 73 1,501,764 33.3 35 and over 19 726,788 16.1 Subtotal 234 4,507,143 100.0 Labor force status of adults (aged 18 and older) Employed 125 3,108,314 75.6 Unemployed 19 389,174 9.5 Not participating 32 613,919 14.9 Subtotal 176 4,111,407 100.0 Unemployment rate 144 3,497,488 11.1 Earnings of adults (those employed) Less than $9,000/year 38 1,000,047 32.2 $9,000-20,000/year 50 1,187,341 38.2 Over $20,000/year 37 920,926 29.6 Subtotal 125 3,108,314 100.0 Total 247 4,632,515 100.0 Source: Institute of Medicine analysis of data from the 1988 National Household Survey on Drug Abuse, performed by Research Triangle Institute for the National Institute on Drug Abuse.

THE NEED FOR TREATMENT 2.6 2.4 2.2 > cO 2 loll HI 1 .8 Z ~ 1.6 C/) 1 .4 Z LL 1.2 ~ O O ~ 0.8 G 0.6 0.4 0.2 o 99 ~ ~ A_ _ ~ . as _ ~ GD6D I,., wit O rev ~ O as ~ ~ ~ ~ _ ~ Q ~ ~ Ah ~ ~ ~ 0. ~ rat 95% Lower OF ~ 0 1 2 3 4 5 ESTIMATES OF CURRENT DRUG USE (in millions) FIGURE 3A-3 Confidence interval of estimates of current illicit drug use by subpopulations. The estimates indicate the illicit use of drugs during any past month for subpopulations (combinations of age, sex, race, and region) with fewer than 5 million users. The reported 95 percent confidence intervals are divided by the estimates to produce ratios. Source: National Institute on Drug Abuse (1989~. value of the estimate, for larger estimates.) Smaller estimates have lower reliability. The plot demonstrates scatter because various subpopulations were sampled at differential rates (e.g., youth and Hispanics were sampled at relatively higher rates, whereas adults aged 35 and older and whites were sampled at lower rates). Therefore, identical estimates for two different subpopulations can have very different statistical properties: an estimate of 500,000 youths needing treatment is much more reliable than an identical estimate for older adults because the estimate for youth is based on about 70 to 80 cases, whereas the estimate for adults aged 35 and older is based on only 10 to 15 cases. APPENDIX 3B ESTIMATING THE NEED FOR TREATMENT AMONG ARRESTEES Information about drug use by arrestees is collected by the Drug Abuse Forecasting (DUF) system created by the National Institute of Justice. This program reports on a quarterly basis urinalysis results collected from arrestees in a dozen or more cities or urban areas ranging in size from Indianapolis to Chicago, Manhattan, and Los Angeles. Urinalysis can detect opiate or cocaine doses (for 48 to 72 hours), marijuana (for ~ to

100 TREATING DRUG PROBLEMS 4 weeks), and other drugs (for varying lengths of time; see Hawks and Chiang, 1986~. The DUF samples are not random but purposive, concentrating on drug charges and violent and property crimes according to individual strat- ified sampling schemes in each city. For this reason, the DUF results are not directly representative of all arrestees nationwide or even in the cities represented. For example, about 35 percent of DUF sample arrests in mid-1988 were for drug offenses, burglary, and robbery, exceeding the percentage of arrests for these charges in 53 U.S. cities of comparable size (more than 250,000 residents) by a factor of about 2.5 and exceeding their percentage of all U.S. arrests by about a factor of 3. Drug use is pervasive among DUF arresters. In the most recently reported summary statistics for the fall of 1989 (O'Neil et al., 1990), about two-thirds of male and female arrestees screened positive for at least one drug, ranging from 53 to 84 percent for men (in San Antonio and New York, respectively) and from 42 to 90 percent for women (in Indianapolis and Philadelphia). More specifically, cocaine traces were found in about one-half of the men (28 to 77 percent) and the women (22 to 79 percent), marijuana traces were found in about one-fourth of the men (13 to 48 percent) and one-fifth of the women (8 to 27 percent), and opiates were found in one-tenth of the men (2 to 23 percent) and the women (1 to 27 percent). About one-fourth of the sample were positive for more than one illegal drug. Additional information is obtained from DUF interviews. Arrestees are asked whether they consider themselves dependent on drugs, whether they could benefit from treatment, or whether they are enrolled in treat- ment. A positive response to one of these items, in conjunction with a positive drug test, is interpreted as indicating a likely need for drug treatment. A positive test but negative verbal responses is interpreted as ambiguous evidence of need for treatment. Table 3B-1 indicates findings for early 1988. About 29 percent of DUF arrestees were classified as likely to need treatment, another 48 percent as possibly needing treatment (am- biguous results), and the final 24 percent as unlikely because they tested negative (some of these individuals may nonetheless have drug problems that require treatment, but they were not detected). Summary statistics on need for treatment in the DUF sample in early 1989 were published by Wish and O'Neil (1989). There is some variation in these rates across different offense types, as reported in Table 3B-2. Probable need for treatment was higher for those committing income-generating crimes (robbery, 40 percent; burglary and larceny, 34 percent) and drug offenses (37 percent) than for those committing violent crimes (homicide, 16 percent; sex offenses, 21 percent; assaults, 25 percent).

THE NEED FOR TREATMENT TABLE 3B-1 Arrestees' Potential Need for Treatment (percentage of total cases) by City, Spring 1988, based on Drug Use Forecasting Data Potential Need For Treatment City Probable Ambiguous Unlikely Cases Total 29.0 47.5 23.6 2,428 New York 51.0 39.7 9.3 257 Portland 26.6 51.3 22.1 263 Indianapolis 32.3 26.9 40.8 130 Houston 11.3 58.8 29.9 204 Detroit 29.9 41.9 28.1 167 New Orleans 15.2 60.7 24.1 191 Phoenix 21.9 46.2 31.9 251 Chicago 29.3 52.7 18.0 283 Los Angeles 41.0 39.0 20.0 446 Other 15.7 57.6 26.7 236 Source: Unpublished Drug Use Forecasting system statistics provided by Dr. Eric Wish, National Institute of Justice. 101 TABLE 3B-2 Arrestees' Potential Need for Treatment (percentage of total cases) by Charge at Arrest, Spring 1988, based on Drug Use Forecasting Data . Potential Need for Treatment Charge Probable Ambiguous Unlikely Cases . Total 29.0 47.5 23.6 2,428 Assault 25.4 42.0 32.6 264 Burglary 33.6 52.2 14.2 247 Drug sale/possession 36.6 54.8 8.6 465 Weapons 18.6 50.0 31.4 70 Homicide/manslaughter 16.2 40.5 43.2 37 Robbery 40.0 41.8 18.2 165 Stolen property/vehicles 25.0 52.8 22.2 176 Sex offenses 20.9 38.4 40.7 86 Larceny/pickpocketing 34.1 41.1 24.7 287 Other 21.3 47.0 31.7 624 Source: Unpublished Drug Use Forecasting system statistics provided by Dr. Eric Wish, National Institute of Justice. The proportion of arrestees needing drug treatment in the DUE cities can be roughly extrapolated to a national basis, adjusting for variations in the number of high-probable-need offenses (burglary, robbery, and drugs) reported in all large cities, smaller cities, suburbs, and rural areas. After this adjustment, about 700,000 arrestees nationwide would be likely to need treatment. If the ambiguous cases are added to this estimate, another 1.2 million arrestees might need drug abuse treatment. The number of

102 TREATING DRUG PROBLEMS individuals represented by arrests would likely be 10 to 20 percent lower owing to multiple arrests per year. APPENDIX 3C ESTIMATING THE COSTS OF DRUG PROBLEMS Drug-related Crim~Victim Losses There were 34.1 million personal and household victimizations in the United States in 1986 (Shim and DeBerry, 1988~. These crimes cause injury, property damage and personal inconvenience worth billions of dollars per year, as well as forcibly transferring further billions of dollars from victims to perpetrators. It is conservatively estimated that more than 25 percent of property crime and about 15 percent of violent crime a total of 9 million crimes are related to drug abuse by the criminal. In other words, without the criminals' current and prior involvement with drugs, these crimes would not have been committed. Using the methods of Harwood and coworkers (1984, 1988), victim losses from the drug-related crimes have been estimated at $1.7 billion, of which the largest proportions were for lost work time ($1.5 billion), property damage ($150 million) and medical care costs ($50 million). Further losses experienced by victims were attributable to the value of the property stolen, which for the 9 million drug-related crimes noted above was $2.6 billion. Homicide is strongly linked to drug trafficking. Surveys of homicide arrestees have found that more than 50 percent are positive for drugs and 16 percent claim they are addicted to illicit drugs (Innes, 1988~. Twenty-eight percent of inmates convicted of homicide or nonnegligent manslaughter claim to have been under the influence of illicit drugs at the time of the crime, and 12 percent admit to being daily users of heroin or cocaine (Innes, 1988~. Conservatively, averaging the 12 percent who admit daily use and the 16 percent who claim addiction yields a causal involvement for drugs in homicide of 14 percent. This implies that 2,900 homicide deaths (out of the 20,600 total estimated by the Bureau of Justice Statistics) were drug related. The economic value of homicide victims' lost productivity was $1.2 billion. Crime Control Resources The federal government spent $2.5 billion on criminal justice activities specifically directed against the drug trade and drug traffickers in 1988, an increase from the $1.76 billion spent in 1986 (White House Office of Public Affairs, 1988~. U.S. contributions to efforts to interrupt the international drug trade consumed $1.2 billion, whereas federal domestic investigations

THE NEED FOR TREATMENT 103 received $584 million. Federal prosecutions and corrections efforts cost $150 and $560 million, respectively. Federal drug enforcement efforts have grown from $36 million in 1969 to $2.5 billion in 198S, with projected 1989 expenditures of $3.8 billion (Strategy Council on Drug Abuse, 1975; Office of National Drug Control Policy, 1989~. State and local governments devote even more resources specifically to fighting the drug trade. A national survey of law enforcement agencies found that, in 1986, 18.2 percent of total expenditures were for this purpose (Godshaw et al., 1987), amounting to $3.8 billion out of nearly $21 billion in state and local law enforcement (police) efforts. Adjudication, legal, and correctional services dedicated specifically to fighting the drug trade cost a further $2 billion. In addition, much violent and property crime is believed to be moti- vated by drug abuse (drug-related crime). Using conservative assumptions about the causal role of drug abuse in violent and property crime (about 15 percent and 25 percent, respectively, as discussed above), state and local criminal justice efforts against drug-related crime probably cost $4.5 billion in 1985. Employee Productivity Losses The largest economic impact of drug abusers derives from their aban- doning the legitimate economy for the underground one and their po- tentially impaired performance in legitimate jobs. These impacts represent losses of potential legitimate productivity- services that are never delivered to the workplace because the drug abusers have entered criminal careers or been incarcerated or because they do not perform in jobs as well as their non-drug-abusing peers. Crime career and incarceration losses to the economy were $12.2 and $5.4 billion in 1986, which arise from significant commitments to crime career endeavors by 1.1 million persons and the incarceration of 200,000 persons on drug charges or drug-related offenses (updated estimates from Cruze et al., 1981, and Harwood et al., 1984~. Reduced productivity among those in the work force is the most complicated calculation; it may also be the largest burden resulting from drug abuse. Harwood and colleagues (1984) estimated that in 1983 nearly 8 million persons had severe prior histories of drug use (daily consumption of marijuana or other illicit drugs for a minimum of a month at some time in life) that were significantly related to their having a lower household income than their peers. The losses of legitimate potential productivity so estimated were $33.3 billion in 1983. The lost income represented by this cost directly affects the well-being of drug-involved individuals and their family members, who may be doubly afflicted (as may the drug abusers themselves) because of theft and partial or total reliance on social welfare.

104 TREATING DRUG PROBLEMS Failure to earn a legitimate income affects public revenues through losses in tax contributions on earnings and expenditures. These costs are thus spread in various ways (that are difficult to quantify) from the individual to society. Health Costs Most drug treatment and prevention services are government sup- ported, but there is also significant private payment for treatment. These services have received an enormous boost since the 1986 Anti-Drug Abuse Act, with the federal commitment escalating markedly in 1987, 1988, and 1989. Expenditures for drug treatment were at least $1.3 billion in 1987 (see Chapter 6~; prevention activities (which target both drugs and alcohol) were $212 million in 1987 (Butynsld and Canova, 1988~. Drug abuse-related AIDS costs in 1985 were estimated to be $967 million (Rice et al., 1990~. About 25 percent of all AIDS cases to date have a history of intravenous drug abuse (Institute of Medicine/National Academy of Sciences, 1988), a figure that represents a steady rise throughout the 1980s (Miller et al., 1990~.

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The large federal role in the drug treatment system was substantially reduced in the early 1980s, undercutting its ability to help communities respond to new challenges such as the crack-cocaine epidemic and the growing violence in drug markets.

How can drug treatment dollars be spent most equitably with the highest likelihood of beneficial results? With this basic question as its focus, Treating Drug Problems, Volume 1 provides specific recommendations on how to organize and fund the drug treatment system. Detailed attention is given to both public and private sources and their programs.

The book presents the latest data and analysis on these topics and more:

  • How specific approaches to drug treatment fit into drug policy, including the different perspectives of the medical and criminal-justice communities.
  • What is known about drug consumption behavior and what treatment approaches have proven most cost-beneficial.
  • What areas need further research—including specifications for increased study of treatment effectiveness and drug use by adolescents and young women.
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