Fact Sheet Series > Substance Abuse Treatment

Policy Issues and Challenges in Substance Abuse Treatment
February 2002

Current Knowledge Leads to Conclusions about the Usefulness of Substance Abuse Treatment

Thirty years of research on the biological, genetic, molecular, and social aspects of addiction and on substance abuse treatment strategies have resulted in some clear messages about addiction and treatment:

• Addiction is compulsive drug seeking and using, even in the face of terrible personal and social consequences. It is not the result of character flaws or moral failings but of profound changes in the brain's structure and function. Addiction is a chronic and complex, but treatable, brain disease.

• Addiction has powerful biological and behavioral dimensions. As a result, most injection drug users (IDUs) cannot quit on their own. Substance abuse treatment offers the medical, psychological, and behavioral support that individuals need to stop using drugs. For many, treatment is a long-term process that involves multiple interventions and attempts at abstinence.

• Even the most severely addicted individuals can participate in treatment and reduce their drug use. The best treatment programs offer a combination of treatment and support strategies. Overall, substance abuse treatment is as effective as treatment for other chronic conditions, including diabetes, hypertension, and asthma.

• Widespread availability of and easy access to treatment has broad social benefits. Every $1 invested in treatment reduces the costs of drug-related crime, criminal justice costs, and theft by $4 to $7. When health care savings are added in, total estimated savings can exceed costs by a ratio of 12 to 1. By helping people reduce or stop injecting drugs, substance abuse treatment reduces the transmission of blood-borne diseases, such as HIV and hepatitis B and C. Treatment can also improve the stability of family and community life and improve a person's prospects for employment.

A Big Gap Exists Between Need for Treatment and Availability of Services

A gulf exists between the number of people who want or could benefit from substance abuse treatment and the number of people who actually receive services:

• Citing estimates drawn from several national data sources, the Office of National Drug Control Policy's National Drug Control Strategy 2001 states that about five million drug users needed immediate treatment in 1998, while only 2.1 million received it.

• In a 1997 consensus statement on the effectiveness of medical treatment for opiate addiction, a National Institutes of Health (NIH) expert panel noted that despite the effectiveness of methadone maintenance treatment, less than 20 percent of the estimated 600,000 opiate addicts were participating in methadone treatment programs.

• The National Center on Addiction and Substance Abuse at Columbia University (CASA) estimates that more than 800,000 people in the criminal justice system would benefit from substance abuse treatment, but fewer than 150,000 receive it. U.S. Bureau of Justice surveys conducted in 1997 and 1998 show that only about 12% of state and 10% of federal prisoners had participated in programs focusing on substance abuse treatment.

Efforts to Close this Gap Face Policy Challenges

Negative attitudes and limited understanding give substance abuse treatment a low priority.

Public, provider, and policymaker attitudes and perceptions about drug use and users shape the importance given to substance abuse treatment versus other possible responses to drug use. A national inclination to respond punitively toward drug users, mistaken beliefs about the nature of addiction and recovery, and bias against drugs users and professionals who provide services to them have resulted in:

• a greater emphasis on criminal sanctions for drug use, leading to a surge in the number of people in prisons and jails (between 1980 and 1996, the U.S. prison population tripled, in large part because of convictions associated with drugs); and

• community resistance to substance abuse treatment facilities and programs, on the grounds that they contribute to increased crime, attract undesirable groups of people, and encourage the drug trade.

Substance abuse treatment's low priority is reflected in limited insurance coverage.

Despite the fact that managing addiction is similar to managing other chronic diseases, most employer-provided health insurance policies place greater burdens on patients of substance abuse treatment programs in terms of cost-sharing, co-payments, and deductibles. At the same time, many plans provide less coverage for the number of visits or days of coverage and annual dollar expenditures for treatment. Many health insurance companies have lower lifetime limits on amounts that can be spent on drug and alcohol treatment than on other illnesses.

Public and private funding for substance abuse treatment is far less than what is needed.

Limited funding is an important reason why the availability of substance abuse treatment is restricted:

• An exhaustive analysis of the impact of substance abuse on state budgets published in 2001 by CASA showed that of every dollar states spent on substance abuse and addiction, 96 cents went toward dealing with the consequences and only 4 cents was used for prevention and treatment. The report also notes that "Each American paid $277 per year in state taxes to deal with the burden of substance abuse and addiction in their social programs and only $10 a year for prevention and treatment."

• Over the last decade federal spending on substance abuse prevention and treatment has increased yet it still lags far behind spending on programs to stop drugs from entering the country and on domestic law enforcement of drug laws and regulations.

• As substance abuse treatment increasingly comes under managed care, resources are being more tightly controlled. This has resulted in decreases in the types, duration, and intensity of services provided and a decline in essential complementary services, such as psychological counseling and help with medical, legal, financial, and employment issues.

Substance abuse treatment has historically operated outside the health care mainstream.

Substance abuse treatment facilities and programs have evolved separately for several reasons. One is that many programs have been created by individuals who have overcome their own addiction and gone on to build systems to help others. For example, individuals in recovery have been key to the formation of successful "12-step" groups and therapeutic communities. Peer support has long been an important therapeutic strategy. Lack of insurance coverage for treatment, stigma attached to substance abuse and addicted individuals, and lack of training and expertise in substance abuse issues on the part of mainstream medical practitioners also contribute to the isolation of substance abuse treatment from other health care services.

This lack of integration with other health care services and providers is a problem because so many individuals who need substance abuse treatment services also need other services. For example:

• More than 40 percent of people with drug addictions also have mental health disorders. About 10 million Americans have both substance abuse and mental health problems.

• More than half of the 40,000 people who became infected with hepatitis C in 1999 were injection drug users; injection drug use is also a major risk factor for transmission of HIV.

This problem is particularly severe for vulnerable groups who have limited or no contacts with health care providers or who have no health insurance. Many of these individuals need primary health care services as well as care for particular health problems.

A Number of Initiatives are Addressing These Policy Challenges

Across the country, federal, state, and local agencies and organizations are recognizing the value of substance abuse treatment and the importance of expanding its availability to all those who need it. Here are just a few of the initiatives underway to change the policy environment.

Choosing treatment over incarceration. In November 2000, California voters approved a measure that requires substance abuse treatment, not jail, for drug possession or use. It also provides for treatment instead of prison for non-violent parolees who test positive for drug use. For details, visit: "Legislative Analyst's Office Analysis of the 2001-02 Budget Bill".

In June 2001, the Louisiana legislature passed a measure that permits judges to allow probation or sentence suspension for more than a dozen non-violent crimes, including theft, simple possession of small amounts of drugs, bribery, and prostitution. Jail time for more serious drug distribution convictions remains mandatory, but sentences are shortened. In an editorial praising the legislation, The Advocate newspaper urged the state to focus on substance abuse treatment: "If there are significant savings under the new rules, they ought to be spent on the programs that prevent offenders from returning to a life of crime: more probation and parole officers, and drug-treatment programs."

Revamping methadone maintenance treatment (MMT) regulations. In May 2001, the U.S. Department of Health and Human Services (DHHS) announced a fundamental shift in the federal government's role in regulating and monitoring MMT. The new system relies on accreditation of substance abuse treatment programs that use methadone and other medications by independent organizations and states, in accordance with treatment standards that have been developed by the Center for Substance Abuse Treatment (CSAT) over the last 10 years. The standards are based on "best practice guidelines" and emphasize improving quality of care in areas such as individualized treatment planning, increased medical supervision, and assessment of patients. In December 2001, DHHS announced the selection of four accreditation organizations that will be used in this new approach. For details, visit: SAMHSA What's New (click on Archives of News Releases and scroll down to the two May 18, 2001 releases)

Improving the scientific underpinnings of substance abuse treatment. In 1999, the National Institute on Drug Abuse (NIDA) established the National Drug Abuse Treatment Clinical Trials Network (CTN). The CTN provides a research infrastructure that allows investigators to conduct rigorous multi-site clinical trials to test whether new treatment approaches are effective in community settings. The CTN currently includes 14 research centers, each of which is linked to a number of community-based programs representing diverse treatment settings and patient populations in that region of the country. This network structure allows effective, science-based behavioral and pharmacological treatment approaches to be rapidly disseminated across the country. For details, visit: National Institute on Drug Abuse.

Increasing parity for substance abuse treatment. Beginning in 2001, the Federal Employees Health Benefits Program, which covers 9 million people, requires coverage for substance abuse and mental health services equal to that for medical, surgical, and hospital services. Both types of coverage will have the same cost-sharing features, such as deductibles, coinsurance, and copays. For details, visit: "Mental Health and Substance Abuse Parity Questions and Answers."

Improving opportunities for collaboration across health care, public health, and substance abuse treatment settings. Since 1998, CSAT, the CDC, and the Health Resources and Services Administration (HRSA) have sponsored a series of cross-training workshops across the country. These workshops give providers who work in a variety of settings (such as sexually transmitted disease/HIV prevention, substance abuse treatment, primary health care, mental health services, and criminal justice) an opportunity to improve their ability to respond to the interwoven health and behavior problems of their drug-using patients. The training also fosters personal connections across agency disciplines, cultures, and bureaucracies. These connections encourage staff to develop regular communications and collaborative working relationships with other agencies and organizations. For details, visit: "Substance Abuse and Infectious Disease: Cross-Training for Collaborative Systems of Prevention, Treatment, and Care."

To Learn More About This Topic

Read the overview fact sheet in this series on drug users and substance abuse treatment - "Substance Abuse Treatment for Injection Drug Users: A Strategy with Many Benefits." It provides basic information, links to the other fact sheets in this series, and links to other useful information (both print and web).

Visit websites of the Centers for Disease Control and Prevention and the Academy for Educational Development for these and related materials:

• Preventing Blood-borne Infections Among Injection Drug Users: A Comprehensive Approach, which provides extensive information on HIV and viral hepatitis infection in IDUs and the legal, social, and policy environment, and describes strategies and principles of a comprehensive approach to addressing these issues.

• Interventions to Increase IDUs' Access to Sterile Syringes, a series of six fact sheets.

• Drug Use, HIV, and the Criminal Justice System, a series of eight fact sheets.

Check out these sources of information:

Amaro H. An expensive policy: the impact of inadequate funding for substance abuse treatment. [Editorial] American Journal of Public Health 1999;89:657-659.

Leshner A. Addiction is a brain disease. Issues in Science and Technology 2001;17(3).

Leshner AI. National study offers strong evidence of the effectiveness of drug abuse treatment. NIDA Notes 1997;12(5). (This article also provides links to other articles describing findings from NIDA's Drug Abuse Treatment Outcome Study [DATOS]).

National Center on Addiction and Substance Abuse at Columbia University (CASA). Shoveling up: the impact of substance abuse on state budgets. New York: CASA; 2001.

National Institute on Drug Abuse. Principles of drug addiction treatment: a research-based guide. Rockville (MD): NIDA; 1999. NIH Publication No. 99-4180.

National Institutes of Health. Effective medical treatment of opiate addiction. NIH Consensus Statement Online. Bethesda (MD): NIH; 1997, Nov 17-19;15(6):1-38.

Schneider Institute for Health Policy, Brandeis University. Substance abuse: the nation's number one health problem. Prepared for The Robert Wood Johnson Foundation. Princeton (NJ): Robert Wood Johnson Foundation; February 2001.

White House Office of National Drug Control Policy. National Drug Control Strategy 2001. Chapter 3. Report on programs and initiatives, Part 2. Treating addicted individuals.

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