The President's National Drug Control Strategy
March 2004II. Healing America’s Drug Users: Getting Treatment Resources Where They Are Needed
Budget Highlights
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The Strategy uses the public health model as a way to understand the epidemiology of drug use and control its spread. The public health model is the only understanding of addiction that can explain why people continue to use drugs when the consequences are a devastating disease of the brain and a terrible loss of human potential.
Conventional wisdom on the topic suggests that young adults use drugs because they think they are invincible. Adults, presumably wiser but also selfdestructive or simply optimistic, are thought to recognize the dangers but use drugs anyway. They watch an addict and tell themselves that things will be different for them.
But the conventional wisdom only explains so much. Why, for instance, do people initiate the use of methamphetaminea drug that can cause a complete unraveling of home life, work, and social connections in a matter of months?
The public health model suggests a deeper explanation, one touched upon in the previous chapter’s discussion of prevention and the role of newly drug-using teens in proselytizing their peers to join in the fun, and seeking to normalize their own drug using behavior. Simply put, many people use drugs because they know someone who is using and not suffering any apparent consequences. The disease of drug dependence spreads because the vectors of contagion are “asymptomatic” users who do not yet show the consequences of their drug habit, and who do not have the slightest awareness of their need to seek help.
It is especially important to intervene with users during this “honeymoon” phase. A new approach suggests a way ahead, using the existing medical infrastructurewhich already has extensive experience in identifying problem drinkersto screen for drug use and offer appropriate and often brief interventions. The Department of Health and Human Services has awarded seven grants in the past year to advance our understanding of screening and brief intervention in treatment. In Chicago, for example, Cook County Hospital emergency room staff as well as doctors and nurses in other areas of the hospital will be trained to detect the signs of developing drug use and direct users into treatment.
Expanding Access to Recovery
Screening and brief interventions hold promise for cutting short the drug problems of millions of Americans. Yet 20 million Americans are past month, or current, users of at least one illegal drug, and seven million Americans need drug treatment, according to diagnostic criteria developed by the American Psychiatric Association.
More than one million Americans receive treatment each year and start on the road to recovery. In recent years, however, an average of 100,000 of those who seek treatment each year have not been able to receive it. They have an immediate need, and we have launched a new program to address itAccess to Recovery. Begun in fiscal year 2004, with an additional $100 million requested in fiscal year 2005, the program will expand access to clinical substance abuse treatment, including recovery support services, while encouraging accountability in the treatment delivery system.
The program will work as follows: Those without the means to pay for treatment will be assessed and issued a voucher for the cost of treatment or recovery services as appropriate.
Recognizing that there are many routes to recovery, this initiative envisions a pathway to help that is direct and open on a nondiscriminatory basis to all, including services provided by faithbased organizations. For many Americans, the transforming powers of faith are crucial resources in overcoming dependency, and this new program will work to ensure that treatment vouchers are available to the programs that work the best, including those that are faith-based (see box below).
KEY ELEMENTS OF ACCESS TO RECOVERY:
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From Waiting to Denial
Most policy analyses of drug treatment begin and end with a discussion of waiting lists. Although such lists are a staple of journalistic accounts of the drug treatment system, even the roughly 100,000 individuals seeking but unable to obtain treatment represent a tiny fractionperhaps one in 70of the number in need of help. The real problem is that a much larger number of Americans—some six millionare dependent on an illicit drug and are not seeking treatment (see Figure 7). Thus the central problem is not waiting lists, but waiting for individuals who are in denial about their need for drug treatment to recognize that need.
A voucher system, for the first time, offers those seeking drug treatment a consumer-driven path to the services they need; yet, the larger challenge for our society is to direct drug-dependent individualsone in five of whom also suffers from a serious “co-occurring” mental illnessto the help they so desperately need but fail to consider.
Closing this “denial gap” is a vast undertaking. Helping our brothers and sisters in need and staring down the social discomfort and risk of alienation to offer the hope of recovery requires the energy and commitment of all Americans.We must create a climate in which Americans confront drug use honestly and directly, offering the compassionate coercion of family, friends, and the community, including colleagues in the workplace, to motivate the change that brings recovery.
When such efforts fail, and when individuals run afoul of the criminal justice system, we must make all reasonable efforts to identify and direct individuals in need into court-supervised drug treatment. In this connection, the Administration has requested a $32 million increase in Federal support for the drug courts program in fiscal year 2005.
Drug courts use the authority of a judge to require abstinence and altered behavior through a combination of clear expectations, graduated sanctions, mandatory drug testing, case management, supervised treatment, and aftercare programsa remarkable example of a public health approach linked to a public safety strategy. Carefully modulated programs like drug courts are often the only way to free a drug user from the grip of addiction. More than 1,183 drug courts operate in all 50 states, with an additional 414 courts in the planning stages (see Figure 8).
Figure 7: Most of Those in Need of Drug Treatment Do Not Seek It
Source: National Survey of Drug Use and Health, 2002
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Figure 8: Number of Drug Courts Nationwide
Source: National Drug Court Institute
Focus on Prescription Drug Safety
Traditional drug threats involve illicit substances grown or produced abroad and smuggled across America’s borders by traffickers. By contrast, with few exceptions, prescription drugs are legal medicines, legitimately manufactured, distributed by licensed pharmacists, and prescribed in good faith by physicians. And while most Americans understand the risks of addiction or even death from drugs like heroin or cocaine, they are less likely to appreciate the risks associated with prescription drugs, which are approved and certified by the government. Yet, through negligence, theft, fraud, or forgery, these addictive substances are being diverted and abused with alarming frequency.
Surveys confirm that the nonmedical use of prescription drugs has emerged in the last decade as a major problem. The illegal diversion, theft, and medical mismanagement of prescription drugs (particularly opioid pain medications) have increased and, in some areas, present a larger public health and law enforcement challenge than cocaine or heroin.
According to the most recent National Survey of Drug Use and Health, the misuse of psychotherapeutic drugspain relievers, tranquilizers, stimulants, and sedativeswas the second leading category of illicit drug use in 2002, following marijuana. An estimated 6.2 million Americans (approximately 2.6 percent of the population age 12 and older) had used a psychotherapeutic drug for nonmedical reasons in the month prior to the survey.
The bulk of this abuse involves narcotic analgesicsan estimated 4.4 million Americans are past-month (so-called current) nonmedical users of pain relievers. OxyContin, a powerful time-release painkiller with an addiction potential similar to morphine, was used nonmedically at least once by 1.9 million Americans in 2002. The rate of OxyContin abuse in 2002 was ten times higher than in 1999.
The University of Michigan’s Monitoring the Future survey for 2003 finds a similar pattern among young people, with the nonmedical use of prescription drugs second only to marijuana. The abuse by high-school seniors of the brand-name narcotic Vicodin is more than double their use of cocaine, Ecstasy, or methamphetamine. This drug has become a deadly youth fad, with one out of every ten high-school seniors reporting nonmedical use. Some 5 percent of seniors report nonmedical use of OxyContin.
Additionally, according to the Drug Abuse Warning Network (DAWN), a nationwide sentinel system that monitors drug-related emergency room episodes, nonmedical use of narcotic analgesics as a reason for an emergency room visit rose 163 percent between 1995 and 2002. More alarming, trend data from DAWN for the years 1995–2002 shows a dramatic rise in emergency room mentions of single-entity oxycodone (formulations of the narcotic without other drug combinations), from 100 mentions in 1996 to nearly 15,000 mentions in 2002.
Curtailing Doctor Shopping
Pharmaceuticals can be diverted in multiple ways. The most popular form of diversion is known as doctor shoppingvisiting many doctors to acquire large amounts of controlled substances. Other diversion methods focus on the pharmacies themselves, which may experience theft or inappropriate distribution of controlled drugs by pharmacists or employees or may receive forged prescriptions. Physicians may inappropriately prescribe controlled substances through either insufficient risk-management of patients with a potential for abuse or outright fraudulent medical practice. Those who acquire diverted substances may themselves abuse them or sell them to others at enormous profit.
The most alarming form of prescription drug abuse involves substances classified under the Controlled Substances Act as Schedule II or III drugs. By definition, these drugs have a high potential for abuse, but also an accepted medical use. Simply to ban such substances would undermine the legitimate medical purposes that they serve and would increase the suffering of many. The challenge for policymakers is to suppress the abuse of prescription drugs without infringing unnecessarily on legitimate medical practice.
The Federal Government has sophisticated systems in place for tracking and controlling drugs with high potential for abuse, from the manufacturer down to the wholesale level. The Drug Enforcement Administration (DEA) has regulatory and investigative jurisdiction over the diversion of controlled pharmaceuticals, and accomplishes its control and monitoring functions through a nationwide database. As a result, relatively little of the diversion problem originates in the manufacturing-to-wholesaling system.
It is at the retail level, the most frequent site of diversion, where the need for increased monitoring is greatest.We are now closing this gap in part through the development of something most Americans assume already exists—state-level prescription monitoring programs. PMPs, as they are known, are designed to facilitate the collection, analysis, and reporting of information on the prescribing, dispensing, and use of pharmaceuticals.
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The data generated by PMPs is analyzed by licensing, regulatory, or law enforcement agencies to track a patient’s use of prescription medicines. When cases of inappropriate prescribing or dispensing of controlled substances appear, regulatory and law enforcement officials are alerted. PMPs also offer physicians a way to obtain information on whether their patients or prospective patients have obtained the same or similar prescription drugs from other doctors.
State programs like these do not interfere with legitimate prescribing and dispensing of pharmaceuticals. Nor do they violate patient confidentiality requirements. Currently, 21 states have some form of reporting mechanism, with additional states in the development stage.
The effectiveness of PMPs can be seen in a simple statistic: in 2000, the five states with the lowest number of OxyContin prescriptions per capita all had PMPs. According to DEA, the five states with the highest number of prescriptions per capita all lacked them.
An important feature of successful PMPs is developing the authority to share data across state lines to combat border-crossing abusers trying to avoid detection. The startup cost of a PMP is surprisingly modest—approximately $300,000 per state, with most states able to operate them continually for between $150,000 and $1 million per year. Internet monitoring tools are essential for establishing an effective system. DEA is also currently developing a method to track and monitor illegitimate Internet prescription offers.
Prescription monitoring programs offer real hope for effective diversion control and restoring prescription safety, but they cannot succeed in isolation. The pharmaceutical industry itself must become a part of this partnership in a constructive way. Manufacturers must commit to responsible advertising and risk announcements involving their products.
The Food and Drug Administration (FDA) will continue to monitor promotional materials for controlled substances, particularly for sustainedrelease products, to ensure that false and potentially misleading claims are not made. The FDA Office of Criminal Investigations is working with DEA on investigations involving the illegal sale, use, and diversion of controlled substances, including illegal sales over the Internet. DEA will improve its training on the recognition and pursuit of diversion cases so that they can pursue cases aggressively without limiting proper pain management by physicians.
Finally, physicians must perform risk assessments on patients at risk for potential abuse. This is particularly true for patients entering opiate therapy for chronic pain. Physician licensing boards must insist on more effective education for future doctors, and on remedial courses in risk management and awareness of dangerous new drugs for existing practitioners. State licensing boards must exercise appropriate oversight and take action against physicians who undermine the integrity of medical practice.
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