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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 theseto 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

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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

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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 monthsabstaining 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

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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 termsfor example, those used by the National Commission on Marijuana and Drug Abuse [1973] and Siegel [1990]are related to this

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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 goodsserious crimes but much lower on the scale. In a 1986 opinion

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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

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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~.

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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 individualcriminal penalties, job-related or family sanctions, prevention programs, and treatment programscontribute 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 syndromesor they may be moods, thoughts, or sensations that were associated in time or meaning with taking drugs. These phenomena are as varied as individual

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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.

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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.

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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.

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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

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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;

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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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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~.