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OCR for page 58
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
OCR for page 59
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
OCR for page 60
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
OCR for page 61
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
OCR for page 62
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
OCR for page 63
63
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OCR for page 64
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~.
OCR for page 65
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
OCR for page 66
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.
OCR for page 67
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.
OCR for page 68
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.
OCR for page 94
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
OCR for page 95
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OCR for page 96
96
TREATING DRUG PROBLEMS
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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;
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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.
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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.
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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
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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).
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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
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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
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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.
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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~.
Representative terms from entire chapter:
drug consumption
