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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Federal Leadership in Building the National Drug Treatment System Karst J. Besteman This paper is meant to highlight some of the knottier questions that the national policy community must answer to bring the drug treatment system into the 1990s. These questions are not new; they have been faced before and answered at different points in various ways. The nation's present multilayered system is in part the result of those decisions and carries within it trenchant lessons about the operational consequences that flow from philosophical and political choices at the highest levels. This paper outlines the history and development of the federally supported drug treatment system from the 1960s to the present. First, it notes the role of new therapeutic ideas in the 1960s. At the outset, the federal system consisted of two prison-based hospitals that had been established for narcotic addiction treatment in the 1920s and 1930s in Lexington, Kentucky, and Fort Worth, Texas. These prison-hospitals were the basic federal foundations on which new, independent treatment services were grafted as the government began to respond to the rising tide of drug problems in the 1960s. The first of these innovative modalities was the TC, or therapeutic community, which began with the California-based Synanon, followed by New York's Daytop Village, Odyssey House, and Phoenix House. As these modalities were becoming refined, the states of California and New York were taking the first steps toward mandating commitment to treatment through the criminal justice system. These state plans and other therapeutic approaches round out the early period. The next section of the paper deals with legislative reform. It first discusses President Kennedy's Commission on Narcotics and Drug Abuse and the national climate that brought it about. Although the commissions' recommendations were not acted upon because of the abrupt change of Karst J. Besteman is director of the Substance Abuse Center at the Institutes for Behavior Resources, Washington, D.C.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment administrations in the aftermath of November 1963, Congress later enacted one of its key recommendations in the form of the Narcotic Addict Rehabilitation Act (NARA) of 1966, which established a federal program of civil commitment of narcotic addicts. This section of the paper describes the implementation of NARA and the treatment programs it developed, programs that departed significantly from the concepts embodied in the act. The next section details the administrative moves and comprehensive legislation of the early 1970s that arose in response to an explosion of concern over drug addiction in connection with the rapidly rising crime rate. The Nixon administration acted decisively with the establishment of the Special Action Office for Drug Abuse Prevention (SAODAP) in 1972. The National Institute of Mental Health was subsequently reorganized into the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), giving birth to the National Institute on Drug Abuse (NIDA), which took in previously scattered authorities and dollar pools. Management procedures in SAODAP and NIDA, and changes that began to take place in the federal drug treatment system in the middle 1970s, conclude this section. The paper then treats the phase of consolidation of federal programs, changes that took place during the Carter and Reagan administrations. There was a shift in the outlook on the drug "problem" during the Carter years, and inflationary effects badly eroded the funding of programs. The section then details Reagan administration policies—in particular, the conversion to block grants—that gave states much greater responsibility for maintaining treatment programs. The paper's final section examines the overall federal role in funding drug abuse treatment and outlines some conclusions about how the federal government might best fulfill its leading role. It stresses the need for experienced clinical personnel and for the federal government to have sufficient manpower and experience on hand to rebuild the national data system. It also emphasizes the importance of experienced leadership to deal with other interests at the federal level. EARLY PROGRAMS From the mid-1930s until the mid-1960s, the entire federal drug treatment system consisted of two prison-hospitals: Fort Worth and Lexington. At these facilities the primary patients were federal prisoners transferred to the custody of the Public Health Service (PHS). Subject to available capacity of the hospitals, voluntary patients were also accepted for treatment. The programs and contributions of these two facilities are
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment recognized as laying important groundwork in the understanding and treatment of addiction (Maddux, 1978). Aside from these two programs, however, drug treatment facilities and regimens prior to the 1970s were quite limited. Even more significant than the rudimentary treatment were the study opportunities provided by PHS residencies, fellowships, and research agreements. A cadre of psychiatric clinicians and social researchers were schooled at Lexington and Fort Worth in the 1950s and 1960s, and their clinical and research work became the foundation on which a great deal of the treatment expansion of the 1960s and 1970s was based. In the late 1950s, a small group of ex-addicts, most with long criminal records and previously failed treatment attempts, joined together under the guidance of a recovering alcoholic, Charles Diedrich, to form Synanon, the first self-help therapeutic community. Synanon established the early pattern for programs that today provide the majority of community-based residential treatment for drug abuse and addiction (Yablonski, 1965). The Synanon experience was the tap root for several other treatment programs that began in the 1960s, such as Daytop Lodge, Odyssey House, and Phoenix House. These organizations differed from Synanon in that the staff were a mix of professional and ex-addict counselors and directors (compared with the all-ex-addict staff at Synanon). The Synanon leadership was hostile and critical of these new programs and their reliance on certified professionals in the treatment field (Maddux, 1978). Between these two types of therapeutic communities there arose rivalries that in the very early stages of treatment service development caused confusion in public understanding and support (Densen-Gerber, 1973). In the early 1960s, California and New York adopted a mandated treatment system using commitment by the courts to an enforced term of treatment. In California, the Civil Addict Program was administered by a separate authority within the criminal justice system using a large facility at Corona for the inpatient phase (Wood, 1966). Under the supervision of a specially chartered parole authority, the patient was closely supervised (through urine testing) after release. Failure to remain drug free resulted in a return to the correctional facility for further treatment. In New York, a distinct independent agency, the Narcotic Addiction Control Commission, was established to administer treatment to persons committed from the civil and criminal courts. Its procedures allowed narcotic addicts to be treated within the corrections department and within mental health facilities. There was extensive supervision with a greater emphasis than in other correctional units on returning the addict to his home community. The early optimism of these two programs, with their ability to retain patient contact through court orders, was an important factor in the federal decision to promote civil commitment. The California and New
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment York programs were instrumental in paving the way for later federal initiatives (Meiselas, 1966). Also in the 1960s, Drs. Vincent Dole and Marie Nyswander, working in New York City, began to treat heroin addicts by experimenting with sustained drug substitution and maintenance. After unsatisfactory results with morphine and other narcotics, they were impressed by the results of methadone. (This synthetic opiate was developed in Germany during World War II; it was later studied at Lexington and used there for detoxification purposes. Methadone's therapeutic safety and efficacy were established for detoxification and as a postoperative analgesic by the mid-1950s [Dole and Nyswander, 1965].) By carefully selecting their early subjects, establishing a strong therapeutic rapport with and commitment to the patients, and risking professional criticisms and even prosecution for unorthodox and legally uncertain practices in prescription of a narcotic, Dole and Nyswander were able to gather remarkable cumulative anecdotal and statistical evidence of a new use for this already approved pharmaceutical drug. Not only did the methadone program receive a great deal of interest within New York City but a series of annual conferences sponsored by the National Association for the Prevention of Addiction to Narcotics (NAPAN) resulted in rapid dissemination of the details of the early clinical experiences to other localities and the development of a close professional network to promote the use of methadone in treating heroin addiction (see, for example, National Association for the Prevention of Addiction to Narcotics, 1970, 1972, 1973). All of the major decisions and issues of dispute regarding methadone maintenance were framed during the annual meetings of NAPAN. Dr. Jerome H. Jaffe, who was later named the Nixon administration's "drug czar," stated clearly that, given fiscal constraints and the need to choose between dispensing methadone to many addicts and providing rehabilitative services to a few, he would opt for prescribing the drug [methadone] (Jaffe, 1970). Dr. William Martin, director of the National Institute of Mental Health (NIMH) Addiction Research Center at Lexington, in writing a summary of the Second National Conference on Methadone Treatment in 1970, noted with disappointment that established clinical research criteria were not being met by proponents of the modality in their evaluation of the treatment (Martin, 1970). Additionally, during this period in the early 1960s, a variety of small demonstration programs sprang up across the country with the help of very modest federal funding. Basically, these programs applied known intervention and rehabilitative services to an addicted population, with rigorous evaluation of the outcomes. None of these early demonstration programs were highly publicized. Most of the program leaders labored in widely
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment scattered communities, each experiencing some limited success. One program in particular, under the joint sponsorship of the Public Health Service, the Vocational Rehabilitation Administration, and the Texas Christian University, brought representatives from local programs together to define the state of the art in drug abuse treatment and to provide guidelines for future treatment programs (U.S. Department of Health, Education and Welfare, 1966). At about this same time, Attorney General Nicholas Katzenbach testified to the Senate Judiciary Committee that, in order to reform the federal courts and to better serve the many narcotic addicts across the country, he was proposing a civil commitment procedure that could be invoked in lieu of prosecuting drug-related crimes. The Public Health Service, which had initially opposed the creation of the two federal treatment centers at Lexington and Fort Worth, now endorsed Katzenbach's proposal as helping to strengthen the treatment system by ensuring an intense and lengthy aftercare (Maddux, 1978). No data were produced by witnesses, but there was unanimous professional agreement in favor of civil commitment. Another important development occurred in Puerto Rico in 1961. An addiction treatment program was instituted that had as its major component a recognition of the need for social retraining and long-term efforts at reintegrating addicts into the community. The addicted patient would benefit from a long-term regimen that had four distinct phases: induction, intensive treatment, reentry into the community, and prevention. The program assumed that the addict's behavior derived over the years from a value system and attitude toward life that was not compatible with society's demands. Much of the treatment offered in the program was a highly structured re-education process (Ramirez, 1966). During this period there were also ongoing efforts to achieve improvements in program evaluation and treatment outcome studies as a means of determining which elements of treatment were effective in changing the addicted patient's behavior. EARLY LEGISLATIVE REFORM National Addict Rehabilitation Act In 1962 the convening of the Presidential Commission on Narcotics and Drug Abuse was an important step at the policy and legislative levels. Judge E. Barrett Prettymen headed the commission, which was chartered by President Kennedy to examine the issues and recommend new approaches. (Commissions were a standard tool for examining issues on
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment which the Kennedy administration had no clear policy position.) This presidential commission was proposed by Attorney General Robert Kennedy who may have been responding to the reviews by professional associations that were completed shortly before the commission was formed. During its tenure the commission heard extensive testimony about all aspects of the narcotics problem and ultimately offered 25 recommendations in its report, which was presented to the President a few days before his assassination. Most of the commission's recommendations were never acted upon. One recommendation however, later became law—that is, the recommendation calling for a federal civil commitment law that would be designed particularly to deal with federal offenders within the sentencing process of the federal courts. This law was implemented by legislation known as the Narcotic Addict Rehabilitation Act (NARA) of 1966 (Public Law 89-793). In developing this legislation, Congress added two titles: the first enabled a person to voluntarily seek federally funded treatment by self-commitment in a federal court, and the other authorized federal government support of state and local programs through a grant-in-aid program. NARA, in its final form, laid the groundwork for a federally funded national drug treatment system, although the decision to proceed with such a system was not made until 1971. As proposed by the Johnson administration, NARA had two basic concepts. First, defendants without prior convictions or without a charge involving a violent act who appeared before a federal judge could request that the charges be held in abeyance while they received treatment for addiction. If the individual successfully completed treatment—including an extended period (2-1/2 years) of community supervision—the courts had the authority to drop the charge. If the individual was unsuccessful in completing the inpatient treatment and aftercare programs, the charges could be reinstated and a trial scheduled. Second, if a defendant was found guilty and a determination made that he or she was in need of treatment for an addiction, the court could order that treatment to be provided during incarceration. In Attorney General Katzenbach's testimony before the Senate Judiciary Committee in 1966, he stated, ''I would not be speaking here in support of this bill if I did not consider it an essential part of our fight against crime." Later he added, "The real question is how much longer we can allow the public safety to be endangered by continuing the primitive, strictly punitive approach to addiction which has spread like a plague through one areas even as penalties against it have stiffened" (Martin and Isbell, 1978). The law and its intent, as reflected in this testimony, were substantially different from what was being implemented. The legislative history of NARA depicts the proposed arrangement as
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment an entirely closed-ended system of federal courts, federal prisons, federal hospitals, and a small number of federal clinics providing locally supervised aftercare. The implementation was very different. There was virtually no lead time to implement the act before commitments began, there were sharp federal manpower restraints, and the geographic distribution of patients entering the system was much greater than expected. As a result, the treatment system consisted of federal facilities providing primary inpatient services and private contractors providing outpatient aftercare services. The National Institute of Mental Health (NIMH) was given the responsibility to implement NARA. In a speech in February 1967, the director of NIMH, Stanley Yolles, proposed a network of 11 Public Health Service clinics in those cities having the largest numbers of narcotic addicts (Boston, Buffalo, Chicago, Cleveland, Detroit, Los Angeles, New Orleans, New York, Philadelphia, San Francisco, Washington, D.C.). This network would require between 80 and 90 full-time clinicians and would use Public Health Service clinics, which were then providing primary health care to American seamen. The plan assumed that all patients for these civil commitment programs would come from the metropolitan areas with the largest known heroin addict populations. However, when it was finally implemented, the NARA program followed none of these specifications. One reason for the change was that only 15 full-time employees were allocated to NARA activity for the first year. NIMH had developed an implementation plan that envisioned the gradual initiation of the inpatient phase of treatment, which in turn would enable new staff to be recruited, and allow the identification of treatment agencies that would provide aftercare services in the addicts' home communities. The U.S. District Court, however, began committing patients to these programs before they were officially opened, forcing a rapid revision of the concept. These factors generated a series of management decisions that in the end would have a major impact on the ability of the federal government to implement a national treatment system. Without fully appreciating the long-term implications of these decisions, the staff at NIMH had set in motion the ideas that led eventually to the provision of all phases of treatment within patients' home communities. Under the program's early pattern, virtually all services were provided on an outpatient basis, a decision originally driven by budget constraints. Later, however, outpatient service became the model treatment setting. These developments coincided with a rapid infusion of money and demands for expansion of the national treatment capacity. NARA's implementation was an important step toward a national drug treatment system for three reasons. First, it brought together within
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment the government a group of people who were experienced in treating narcotic addicts and who were free to try ideas that were impossible to test in the isolation of the two existing federal hospitals. Second, the new law required that treatment be available no matter where the patient lived. This requirement forced agencies and individuals to address addiction treatment in communities that had not yet admitted that they had residents who were addicts. Third, the critical need to train personnel was recognized early on, and hundreds of professionals were introduced to the clinical skills needed to deal with narcotic addicts. The NARA treatment system consisted of three phases: examination and evaluation, inpatient treatment, and aftercare. The examination and evaluation of applicants to NARA programs was contracted out during the second year of the program to enable the two Public Health Service hospitals to concentrate their efforts on the inpatient task. From the beginning, aftercare was provided by contracting for these services in the patient's home community. There was a concerted effort by NARA staff to design, provide, and require training for the clinicians employed by the contract treatment agencies. Training programs were designed by experienced professional treatment staff of the Narcotic Addict Rehabilitation Branch of NIMH. Most of these individuals had experience with heroin addicts at Lexington or Fort Worth, and some had experience from early community demonstration projects supported by the Vocational Rehabilitation Administration or the Office of Economic Opportunity (OEO). The training was delivered with the help of a small group of ex-addicts who were working in the earliest community grants programs. The training consisted of lectures and demonstrations, often with the ex-addicts role-playing the part of active street-wise addicts. This program was the forerunner of the federal role as a major training resource in the addiction field. There was a fourth critical element in NARA: federal contract management. NARA/NIMH produced a standard contract governing its treatment agencies, which specified the frequency and purposes of patient contact. It covered the number of weekly counseling sessions (three), frequency of urine tests (one per week), allowable dental services (only restoration), psychological consultations, vocational training (state eligibility criteria were used), and accepted treatment modalities (drug-free outpatient, therapeutic community, methadone maintenance). Exceptions to these general contractual terms could be approved on special request to a central clinical review board. The number of exceptions requested in the NARA system was remarkably small. Most counselors had little depth of experience in treating narcotic addicts and initially simply followed the contract terms to the letter. Early exception requests were to purchase cosmetic surgery,
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment watches, and used cars. Although the authority to purchase these items was available, the requests were refused. As the counselors became more knowledgeable, their requests were more likely to be for expanded use of residential treatment or methadone maintenance rather than outpatient drug-free regimens. Other Legislation In retrospect, this sequence of events has the progression and the nature of a planned strategy. The reality was that, from 1967 to 1971, the greater political community and the perceived public threat of a drug abuse epidemic kept pressure on NIMH to increase its commitment to support drug abuse treatment. One of the actions taken by the institute in this regard was the formation of the Division of Narcotic Addiction and Drug Abuse (DNADA). NIMH consolidated all elements of its programs related to drug abuse into this one organization. It encompassed intra-and extramural research and treatment, as well as the provision of public information and training. The consolidation of these functions prepared for the establishment of the National Institute on Drug Abuse in late 1973. During the late 1960s there were also other related events that prepared the treatment system for an all-out expansion effort. The amendment of the Community Mental Health Centers Act (Public Law 91-513) mandating and supporting the provision of drug abuse and alcoholism treatment within community health facilities helped influence the service delivery field to address drug addiction treatment. Furthermore, the initiative by the Office of Economic Opportunity in supporting community-based treatment of alcoholism and drug abuse, along with the requirement that people within the services community be part of the care-giving staff, enabled some nontraditional treatment agencies to win federal support and achieve financial stability. Both of these efforts, although limited in size and scope, expanded the numbers and locations of people able and willing to provide services to narcotic addicts. The combination of approximately 150 NARA contractors, 25 community mental health centers (CMHCs), and 20 OEO service centers formed the early provider base for the rapid expansion of federal support for drug abuse treatment. In addition to these programs, there were other groups that were growing at the same time but outside of federal support. For example, the state of New York was funding community treatment programs within the methadone maintenance and therapeutic community modalities, and Illinois had initiated a modest community treatment effort at the University of Chicago. These programs also proved useful during this era of rapid expansion.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment During 1968-1969, NIMH's Division of Narcotic Addiction and Drug Abuse (DNADA) made a decision regarding methadone treatment that had profound effects on later events. Over the objection of both the Food and Drug Administration and against the advice of the NIMH director, the director of DNADA, Dr. Sidney Cohen, submitted an investigative new drug (IND) application for methadone as a maintenance treatment for narcotic addiction. Methadone was already approved as an analgesic and could be prescribed to assist in the withdrawal from heroin. However, its use in treating heroin addiction had as yet no standing or approval from the Food and Drug Administration, which became a bureaucratic impediment to its wider use in treating heroin addiction. Nevertheless, all DNADA grantees and contract care providers were encouraged to participate in methadone programs, a policy that in a relatively short period of time produced a large body of data about the use and effectiveness of methadone maintenance. The data also documented the relative safety of using methadone with heroin addicts. Without these extensive data files, the government's decision in 1972 to produce the regulatory guidance and approval of methadone as a maintenance therapy might have been frustrated. (The regulations were published in 1972 in the Federal Register, Vol. 37, No. 242, Part 3.) Before the 1972 approval of methadone maintenance, there was serious concern among NIMH professional staff that methadone would not deliver the positive therapeutic impact being claimed by its supporters. There was a strong desire to delay its approval subject to more extensive evaluation coupled with the fear that the public was being sold a ''magic bullet." All of these concerns had some validity, but that validity was ignored by those in the Nixon Administration who advocated the rapid expansion of the capacity of methadone clinics. NIMH was characterized as opposing President Nixon's program, and this perception generated tension and hostility between the staff of the White House Special Action Office and NIMH's Division of Narcotic Addiction and Drug Abuse during 1971 and 1972. The end result was a period of micromanagement by the Special Action Office of NIMH drug abuse grant awards. LEGISLATIVE EXPANSION Special Action Office for Drug Abuse Prevention The period from 1971 to 1975 was the most fruitful and productive in federal history in establishing and expanding drug treatment services. The reasons for this expansion are diverse, and they spring from very different concerns and decisions. During the 1968 presidential campaign,
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment both Nixon and Humphrey committed themselves to expanding support for the NARA programs, in part because of increasing concern among the general public over the spread of drug abuse. The use of marijuana and other nonopiate drugs had become a symbol of rebellion among the nation's youth, and communities that heretofore had not experienced drug addiction were reporting known narcotic users. Furthermore, a rising number of addicted people were being arrested for property crime. The emerging treatment modalities offered hope that the treatment of addiction would have positive outcomes. In addition, there was a growing commitment to community-based treatment. Early in 1971, President Nixon announced a program to address the drug problem. Drug abuse, according to his advisors, was a major influence on the escalating crime rate (Ehrlichman et al., 1971). The President was determined to address "crime on the streets," and he wished to make the District of Columbia an example of an effective response to crime. The available information seemed to indicate that, without some significant intervention in the pattern and frequency of the abuse of illicit drugs, crime would continue unabated. Consequently, the President's antidrug strategy was for the most part a more aggressive approach to federal support and leadership of law enforcement activities. The literature and data compiled by the District of Columbia's criminal justice system promoted the concept that methadone maintenance programs successfully demonstrated a reduction in criminal behavior by addicts who were in treatment. There was also other research coming to light that concluded that sustaining a patient on an outpatient basis with close supervision and daily contact was more cost-effective than full-time incarceration (Sells, 1972). These findings led the President to the decision that federal investment in drug treatment would reduce crime and save money. Consequently, on June 17, 1971, President Nixon issued Executive Order 11599 in which he established the Special Action Office for Drug Abuse Prevention (SAODAP). Dr. Jerome Jaffe, who was appointed its director, came to the post from the Illinois Drug Abuse Program in Chicago. The President spelled out in broad outline how this office, over a three-year life span, would organize, direct, and evaluate the entire federal effort to solve this difficult problem. Concurrently, the President asked Congress for significant increases in funding for the support of community-based treatment programs. In addition, he also sent legislation to Congress requesting speedy establishment of SAODAP. The establishment of SAODAP came at a crucial time because the Special Action Office was able to initiate actions with specific goals and within time frames that usually were not realistic within the federal system. Almost immediately SAODAP required that hospital treatment beds be reduced to 2 percent of the treatment slots in any community. (Approxi-
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment by the mayors of many large cities that, because of the expansion of the block grant, their interests were not well served in the new bill.) The Ford Administration—A Turning Point The issuance of a white paper on drug abuse in 1975 marked a turning point from increased federal presence to one of a steady maintenance of the system. In this role as head of the Domestic Council, Vice-President Nelson Rockefeller initiated a major review of policy and program priorities that attempted to set a new course for federal action after six years of emphasis on heroin addiction and the development of treatment capacity. This policy review incorporated the concepts of a relationship between alcohol and drug abuse and relative risk among the drugs of abuse, raising the issue of the need for more attention to prevention in future federal policy. The ideas of these discussions, however, were rendered moot by the outcome of the presidential election of 1976. In 1975, a budget decision marked the beginning of a decline in federal support for treatment that was not reversed for more than a decade. Early in that year, NIDA had, at the direction of the Department of Health, Education and Welfare, converted the statewide services contract mechanism to a statewide services grant. The change loosened the control of the federal government on drug treatment management and was followed by a major reduction in the level of federal support within the grant structure. Because of a budgetary shortfall in fiscal year 1976, NIDA notified all grantees that there would be no cost-of-living adjustments and no new awards. It also announced a national review of all inpatient services and a tightening of policies regarding admission eligibility to federally-sponsored programs. CONSOLIDATION Jimmy Carter's inauguration as president in 1977 brought a significant shift in the environment in which drug treatment issues were examined. The drug treatment system had been initiated in reaction to concern about crime. Therefore, as the system was built, the priority was rapid implementation of treatment capacity, with little attention given to the relationship of drug abuse treatment to other components of the health care system. Many people saw drug treatment as an adjunct to the criminal justice system; others saw it as part of the social service system. The
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Carter administration framed the issues within the health care arena, but although drug treatment was not unimportant, it was not considered a high domestic priority. Therefore, resource levels during this era remained stagnant at a time when the rate of inflation in the health care system was accelerating dramatically. As a result, there was a retrenchment of programs, with the weaker organizations disappearing and a few agencies becoming stronger. In particular, agencies that did not have the corporate capacity to capture nonfederal funds were unable to continue delivering the kinds of services that were still required of federal grantees that were no longer being fully funded. A period of program integration thus began. The states, when they were able, began to invest in drug treatment, although the proportion of federal support to the system continued to decline. As the statewide grant mechanism matured, the application of the program matrix became more difficult, direct technical assistance became less available, and federal involvement in the day-to-day management of programs was reduced. An addition, some of the data requirements were modified so that there was less information immediately available to the program managers in Washington. Increasingly, the state agencies found themselves depending on their own resources to solve problems. This was also a period of transition at the National Institute on Drug Abuse. Robert Dupont, the founding director who had come from a clinical program background and had been part of the growth and establishment of the national treatment system, resigned. One year later his successor was determined: the institute's research director, William Pollin, chosen principally for his strong record of research involvement in the neurosciences. His commitment to sustaining a federal role in services was minimal, and the emphasis within the institute consequently shifted operationally to research. This change in emphasis was encouraged by Secretary of Health and Human Services Joseph Califano and resulted in a shift of personnel throughout NIDA. It also started a reduction in the knowledge and information base for services, a trend that continued into the Reagan administration. Block Grants With the installation of the Reagan administration in 1981, the states received a clear policy message: they were to have prime responsibility for all service systems; despite the actions of previous administrations, the federal government now assumed no special responsibility for drug treatment services. After a period of assessment, the proposal to initiate the block grant funding mechanism for alcohol, drug abuse, and mental health
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment services was sent to Congress. Because the states had a decade of experience in managing the federal funds in drug treatment services, there were few protests raised against the block grant. However, there were concerns raised about the 25 percent reduction in funds for treatment services that was a key part of the proposal. Soon after the passage of the block grant, the federal government stopped collecting baseline data on admissions to federally funded projects. Again, drug abuse activities became part of a major redefinition by the federal government of its role and responsibilities. These major program shifts also brought about personnel reductions at the National Institute on Drug Abuse. In December 1981, as part of a Public Health Service-wide reduction in force (RIF) and reduction in service, the National Institute on Drug Abuse removed from its rolls the personnel who had built, sustained, and supervised the national drug treatment service system. With this action, the institute was stripped of the senior professional leadership to whom the states had historically turned for help in the solution of their drug treatment problems. Initially, there was excitement at the state level with the freedom and independence of action given them by the block grant. Very shortly, however, the state agencies discovered the difficulty of sustaining a service when there is no focused authority for the activity at the national level. Many changes occurred as a result of the decision not to include the federal government in drug treatment services. First, common data elements disappeared. Moreover, states gave drug treatment a lower priority than had been the case with the former federal commitment, producing less total revenue for the system. In many states a single administrative organization was established to handle both drug and alcohol treatment services and prevention. By 1983 the states had begun to allocate more tax revenues to local treatment programs. Starting as early as 1984, there was strong advocacy by the states for the federal government to restore its leadership in the drug treatment endeavor. During this period, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and NIDA entered into a series of contracts and grants with the National Association of State Alcohol and Drug Abuse Directors to provide data and some of the services that had formerly been provided by federal agencies. This included the collection of data on sources of fiscal support for treatment and the collection of information on the patients being served by federally funded treatment programs. In 1986, Congress added a new block grant for alcohol and drug treatment to the base alcohol, drug abuse, and mental health block grant. The appropriation of funds with that authority replaced the dollars that had been deleted when the block grant was passed in 1981. This restor-
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment ation of funds was the first increase in treatment funding since the mid-1970s; however, the new legislation also raised some important issues regarding federal mandates placed on block grant funds. For example, while agreeing to the block grant approach, Congress was adamant on set-asides within it, thus injecting categorical support into this new funding mechanism. In the 1988 Anti-Drug Abuse Act, Congress put a clearer categorical stamp on the initiatives by building in a mechanism for local communities to receive funds outside the block grant. This change in approach is particularly important because ADAMHA and its institutes had earlier in the decade RIFed the expertise and infrastructure needed to review and award project grants properly. In addition, the 1988 legislation placed greater requirements on the states to adopt federally mandated priorities with the block grant monies. Today, the philosophical struggle between the executive and legislative branches of government is being fought directly within the drug treatment authorities. The Bush administration is interested in continuing the trend toward deregulation and greater freedom for the states. Congress is interested in having a greater voice in how local communities address the drug problem and has been much more responsive to special-interest constituencies within the addiction field. Women, high-risk youth, prevention, and specified programs have all been singled out and given special authorization by various committees. Stipulations in the Anti-Drug Abuse Act of 1988 specifying that ''no less than X percent of block grant funds be spent" on a particular service or population actually total more than 100 percent of the funds; to comply with the law a significant proportion of program expenditures must meet at least two priority stipulations. Because of the numerous changes inserted in the 1988 legislation, ADAMHA has not as yet issued definitive decisions as to the exact implementation rules. There is no doubt that the sections to address treatment waiting list problems provide ample authority to bypass the state drug abuse agencies and initiate individual project grants. The early decision was to allow both patterns while encouraging the states to be aggressive and prompt in applying for and spending the funds. Subsequently, ADAMHA seems to be having problems developing a new grant application and appears concerned about its ability to accept, review, award, and monitor local project grants. Therefore, the emphasis is on prompt action by the states. The ability of the states to implement the new requirements of the 1988 legislation quickly and effectively will be an important factor in the short term in influencing the trend toward a more categorical approach in federal legislation. If this new initiative is slowly or unevenly executed, it will again fuel the desire to return to a federally managed categorical grant
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment program authority. When the additional block grant for alcohol and drug treatment was implemented after the 1986 anti-drug bill, there were such long delays in the money flow that congressional committees were skeptical of the ability of the treatment system to absorb additional funds in 1988. Some of the flexibility in the 1988 anti-drug bill is designed to bypass the slower acting states and allow communities to deal directly with the federal government. In fact, the long-term stability of the block grant is at stake with these new initiatives. Congressional interest in a return to categorical funding will intensify if the $100 million for emergency expansion of the nation's treatment capacity is not distributed promptly. CONCLUSIONS The tension between expectations and reality reinforces the continuing need to examine the federal role in funding drug abuse treatment. Assuming agreement that the federal government has a legitimate role in such funding, there remains the large question of how to execute that role. Several mechanisms have been used: contracts with service providers or community agencies, categorical grants to community providers or agencies, statewide contracts with specified subcontractors, statewide grants with specified grantees, cooperative agreements, statewide formula grants, and statewide block grants. These mechanisms are listed in a sequence of descending federal control and ascending state management obligations. Direct contract and categorical grant programs demand a substantial federal work force of substantive experts and technical managers of contracts and grants. There are substantial demands on personnel for site visits to assure performance by the contractor or grantee and build relationships between the individual program and the federal program managers. With the 1981 advent of the block grant and the reduction in force that followed, the federal establishment is no longer capable of managing categorical grants or contract programs in drug abuse without first undergoing a period of rebuilding internal competence and personnel Because of limited personnel resources, the legislative mandate of the 1988 anti-drug bill to establish a national data system offering a national perspective on the size and performance of the drug treatment system is also being implemented slowly. Prior to the block grants, the federal
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment government had more personnel assigned to data collection and analysis, and there is currently a critical need to rebuild this function. A seminal issue for treatment professionals and program managers is the disparity between the need for experienced leadership at the federal level on treatment issues and the insufficiency of experienced, committed clinical personnel in the federal agencies who can play this role. ADAMHA leadership has emerged from the research and parent/advocacy group constituencies; NIDA's operational leadership has been largely research oriented since 1979. The treatment needs of the nation and the requirements to effectively implement the mandates of the policy statements of the Anti-Drug Abuse Act of 1988 highlight the difficulty of maintaining an effective federal resource between perceived emergencies. Resource commitments to address drug abuse and addiction with solutions other than law enforcement erode during periods of relative public calm about these problems. With another declared emergency situation and a legislative infusion of federal funds, federal executives need to devise and follow a strategy to ensure the sustained ability of the Public Health Service to provide leadership for the drug treatment services community. With the large numbers of dysfunctional drug abusers and addicts in our cities and states, the demand for more effective treatment can only increase in the near future. As critical and important as the federal role in research on drug abuse is, it is not the sole focus of the federal effort. As in the early 1970s, there is no alternative or substitute for federal leadership as a way to build and manage an effective treatment effort. ACKNOWLEDGMENT I wish to thank the members of the Substance Abuse Coverage Study for their thorough review and critique of this document, which was largely completed in the spring of 1989. I am especially grateful to David Deitch for his commentary and insights into this era and Dean Gerstein and Elaine McGarraugh for numerous editorial and substantive contributions. REFERENCES Davis, C., and I.C. Ford (1980) Preparing a Drug Abuse Workforce: A National Training System. Washington, D.C.: Career Development, Center for Human Services. Densen-Gerber, J. (1973) We Mainline Dreams. Garden City, N.Y.:
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Doubleday & Company, Inc. Dole, V.P., and M. Nyswander (1965) A medical treatment of diacetylmorphine (heroin) addiction. Journal of the American Medical Association 193:646-650. Ehrlichman, J.D., E. Krogh, and J.H. Jaffe (1971) Special message to the Congress on drug abuse prevention and control, June 17. In Public Papers of the President of the United States: Richard Nixon, 1971. Washington, D.C.: U.S. Government Printing Office. Jaffe, J. (1970) Further experience with methadone. International Journal of the Addictions 5(3):386-387. Jaffe, J.H. (1978) Reminiscences of a drug czar. In W.R. Martin and H. Isbell, eds., Drug Addiction and the U.S. Public Health Service: Proceedings of a Symposium Commemorating the 40th Anniversary of the Addiction Research Center at Lexington, Kentucky. DHEW Pub. No. ADM 77-434. Washington, D.C.: U.S. Department of Health, Education and Welfare. Maddux, J.F. (1978) History of the hospital treatment programs, 1935-1974. In W.R. Martin and H. Isbell, eds., Drug Addiction and the U.S. Public Health Service: Proceedings of a Symposium Commemorating the 40th Anniversary of the Addiction Research Center at Lexington, Kentucky. DHEW Pub. No. ADM 77-434. Washington, D.C.: U.S. Department of Health, Education and Welfare. Martin, W.R. (1970) Commentary on the Second National Conference on Methadone Treatment. International Journal of the Addictions 5(3):545-551. Martin, W.R., and H. Isbell, eds. (1978) Drug Addiction and the U.S. Public Health Service: Proceedings of a Symposium Commemorating the 40th Anniversary of the Addiction Research Center at Lexington, Kentucky. DHEW Pub. No. ADM 77-434. Washington, D.C.: U.S. Department of Health, Education and Welfare. Meiselas, H. (1966) Narcotic addiction program of the New York Department of Mental Hygiene. In Rehabilitating the Narcotic Addict. Washington, D.C.: U.S. Department of Health, Education and Welfare. National Association for the Prevention of Addiction to Narcotics (1970) Proceedings: Third National Conference in Methadone Maintenance. Rockville, Md.: National Institute of Mental Health. National Association for the Prevention of Addiction to Narcotics (1972) Proceedings: Fourth National Conference in Methadone Maintenance. Rockville, Md.: National Institute of Mental Health. National Association for the Prevention of Addiction to Narcotics (1973) Proceedings: Fifth National Conference in Methadone Maintenance. Rockville, Md.: National Institute of Mental Health.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Ramirez, E. (1966) Mental health program of the Commonwealth of Puerto Rico. In Rehabilitating the Narcotic Addict. Washington, D.C.: U.S. Department of Health, Education and Welfare. Sells, S.B. (1972) The Effectiveness of Drug Abuse Treatment, Vols. 1-5. Cambridge, Mass.: Ballinger Publishing Co. Special Action Office for Drug Abuse Prevention (1974a) Central Intake Unit Manual. Series C, No. 1, February. Special Action Office for Drug Abuse Prevention (1974b) Drug Free Treatment Manual. Series C, No. 5, October. Special Action Office for Drug Abuse Prevention (1974c) Outpatient Drug Free Treatment Manual. Series C, No. 4, September. Special Action Office for Drug Abuse Prevention (1974d) Outpatient Methadone Treatment Manual. Series C, No. 2, August. Special Action Office for Drug Abuse Prevention (1974e) Residential Methadone Treatment Manual. Series C, No. 3, August. U.S. Department of Health, Education and Welfare (1966) Rehabilitating the Narcotic Addict. Washington, D.C.: U.S. Department of Health, Education and Welfare. Wood, R.W. (1966) California rehabilitation center. In Rehabilitating the Narcotic Addict. Washington, D.C.: U.S. Department of Health, Education and Welfare. Yablonski, L (1965) The Tunnel Back. Synanon. New York: Macmillan and Company . APPENDIX: FEDERAL FUNDING POLICIES FROM 1967 TO 1980 Early in this period, these policies were the product of the National Institute of Mental Health and the Department of Health, Education, and Welfare. Starting with the President's executive order on June 17, 1971, until July of 1975, all funding policies were the product of the Special Action Office for Drug Abuse Prevention. From 1975 to the present, federal funding policies have evolved from the regular budget process involving the proposals and review between the Department of Health and Human Services and the Office of Management and Budget. Since 1981 and the advent of the block grant, federal funding policy has been the function of the congressional budget process.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment 1967-1972 Narcotic Addict Rehabilitation Act program: 100 percent funding by the federal government including overhead for the contract care program. Limited to narcotic addicts committed by a federal district court to the care of the surgeon general. Community Mental Health Centers (CMHC) program: Authorized by P.L. 91-211 and P.L. 91-513; covers staffing costs only. Eight-year support with gradually diminishing rates of federal support: nonpoverty, 80 percent down to 30 percent; poverty, 90 percent down to 70 percent. Office of Economic Opportunity programs: Community grants to provide care for alcoholics and drug addicts. Two main purposes: to treat alcoholism and addiction, and employ and train members of the community. 1972 P.L. 92-255: Vastly expanded the authority and flexibility of federal support for community-based treatment. Section 410 permitted grants and contracts to cover all operational costs including overhead. SAODAP mandated the following mix on the site of treatment: 2 percent or less in a hospital-based program; 18 percent or less in residential-based programs; and 80 percent or more treated in outpatient programs. Three-year awards: nonpoverty, 80 percent down to 70 percent; poverty, 90 percent down to 80 percent. 1973 SAODAP directive: All treatment grants converted to performance contracts. The concept of the treatment matrix and the requirement to maintain patient services at a certain percentage of total capacity became contractual requirements. There was an additional requirement that 10 percent of patients be referred from the criminal justice system. 1974 With the Division of Community Assistance, the National Institute on Drug Abuse became operational. SAODAP directed other federally funded community treatment service grants to be transferred to NIDA, which received approximately $40 million worth of projects and a $20 million increase in budget to fund and administer these projects. The task was to
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment eliminate poorly performing programs and to consolidate duplicative programs. Also, NIDA reduced out-year funding on all programs. In the end, although programs were eliminated and consolidated, there were other impacts that appeared. 1975 At the insistence of DHEW, NIDA converted all statewide services contracts to statewide services grants. This move firmly placed the single state agency in charge of the treatment system management. States could request new awards of grants at the following federal support levels: year 1—federal, 80 percent, and state, 20 percent; year 2—federal, 50 percent, and state, 50 percent; year 3—federal, 20 percent, and state, 80 percent. In July 1975, the shortfall in the FY 1976 budget was made public, leading to NIDA policies of no cost-of-living adjustments, no new awards, review of the need for inpatient ''slows" (no inpatient support permitted), and reaffirmation of the need to serve the addicted and the criminal justice system. In September 1976, federal funding policy revisions were announced: federal funding would be reduced to a flat 60 percent, a policy that included administrative costs; poverty areas would continue to have a benefit. No new poverty areas would be designated. The 1975 amendments to the CMHC authority funding would be limited to two years unless all requirements of the law were met. (Drug grants chose to become part of the statewide grant rather than comply with the CMHC legislation.) Eight-year project grants were brought into compliance with the first policy noted above. 1977 NIDA made further treatment slot cost adjustments. 1978 All outreach and central intake services were eliminated from any federal support.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment 1979 NIDA permitted a reduction—from 95,000 to 84,000—in the number of federally supported treatment slots. These funding policies remained in effect until the block grant era began in 1981. TABLE A-1 Treatment Slot Costs Designated by SAODAP and NIDA, 1972-1981 FY FY FY FY FY FY Type 72 73-76 77 78 79 80-81 Inpatient 30,000 36,000 40,000 Elim. — — Residential 4,200 4,400 5,150 5,400 5,670 5,840 Outpatient 1,500 1,500 1,750 1,850 1,940 2,000 Day care — — 2,370 2,500 2,620 2,700 Residential detox — — — — 15,000 15,450
Representative terms from entire chapter: