From Screening to Recovery Support: A Continuum of Care

Despite recent reductions in drug use, Americans continue to drink to excess, abuse prescription drugs, and use illegal drugs. Many Americans have some experience with substance abuse and its devastating effects on the individual, the family, and the community.

For the thousands of Americans already suffering from substance use disorders, Federal initiatives such as the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Substance Abuse Prevention and Treatment Block Grant and discretionary grant programs, and researched sponsored by the National Institute on Drug Abuse (NIDA) support State and community efforts to deliver the treatment services needed to achieve and maintain recovery.

Recognizing that addiction to substances is a treatable disease and that recovery is possible, the Administration has supported innovative and effective programs designed to help expand treatment options, enhance treatment delivery, and improve treatment outcomes. By screening for substance use in the medical system, more Americans who are in need of interventions or treatment are receiving services. Identifying substance use early may also stop the disease from progressing to addiction and reduce the need for intense treatment—a costly and complex process involving long-term interaction with counselors, agencies, and professional services. Through the President’s Access to Recovery Program, approximately $400 million in Federal funds have delivered a comprehensive spectrum of services tailored to the individual, including recovery support services.

Detecting Drug Use Early Saves Lives

Today, there are more than 20 million Americans who meet the medical definition of abuse or addiction to alcohol and illicit drugs. This means nearly 10 percent of the U.S. population over age 12 has a diagnosable substance abuse disorder. Yet the vast majority of these people—more than 94 percent—do not realize they need help and have not sought treatment or other professional care.

Although a significant number of drug users fit the medical profile of an addict, most users fall into a much broader category of people whose use has not yet progressed to addiction. For many of these users, an accident or serious trauma may be just around the corner.

An often overlooked group of people with undiagnosed drug problems are those who abuse prescription drugs. Many do so in the erroneous belief that prescribed medications are safe even if used for unintended purposes and outside the boundaries and directions of a doctor’s prescription.

Health professionals hold a key to increasing awareness and bringing help to millions of Americans with drug and alcohol problems. It is estimated that 180 million Americans age 18 or older see a healthcare provider at least once a year. These visits provide a very valuable opportunity for drug and alcohol screening. With a few carefully worded questions using an evidence-based questionnaire, healthcare providers can learn a great deal about whether a patient is at risk for problems related to substance abuse.

Verbal screening is a simple diagnostic tool, administered as a questionnaire through personal interviews or selfreporting. It can be incorporated into routine practice in medical settings. If the score on the screen test exceeds a certain value, suggesting a likely substance abuse problem, the provider decides the level of intensity for followup assistance. For a score showing moderate risk, a “brief intervention” may be the most appropriate response.

Brief interventions are nonjudgmental motivational conversations between providers and patients. The purpose is to increase patients’ insight into their substance abuse and its consequences, and to provide patients with a workable strategy for reducing or stopping their drug use. Sometimes a meaningful discussion with a healthcare provider is all it takes to convince a patient to stop using drugs. Other times, a brief intervention is the first in as many as six follow-up sessions aimed at modifying the patient’s risky behavior. If a score falls in the range consistent with addiction, the patient is referred to specialty treatment for a more extensive and longer period of care.

In 2003, the Federal Government began providing funding to support screening and brief intervention programs in States and tribal communities through Screening, Brief Intervention, and Referral to Treatment (SBIRT) cooperative agreements administered by SAMHSA. As of December 2007, more than 577,436 clients in 11 States had been screened. Approximately 23 percent received a score that triggered the need for further assistance. Of this number, 15.9 percent received a brief intervention, 3.1 percent received brief drug treatment, and only 3.6 percent required referral to specialized drug treatment programs. Outcome measures from the Federal program reveal that screening and brief intervention helps reduce substance abuse and related consequences, including emergency room and trauma center visits and deaths. Screening and brief interventions also increase the percentage of people who enter specialized treatment; have a positive impact on factors that enhance overall health, including improvements in general and mental health, employment, housing, and a reduction in arrests; and may provide a shield from further drug use. Federal program outcomes indicate that these results persist even 6 months after a brief intervention. Moreover, cost-benefit analyses of Federal programs have demonstrated net healthcare cost savings from screening and brief interventions.

Federal funds provided by SAMHSA are also helping colleges and universities identify young adults at risk for substance use and mental health disorders. Since 2005, Targeted Capacity Expansion Campus Screening and Brief Intervention (TCE-SBI) grants have been awarded to 12 colleges and universities. Grantees vary widely in setting, population, and operational model. For example, Bristol Community College (BCC) in Fall River, Massachusetts, chose to add questions from a mental health screening tool to their drug and alcohol campus outreach efforts. BCC is a public community commuter college with a student population of approximately 21,000. Residents from Fall River are admitted to publicly funded treatment programs at double the average rate for other Massachusetts communities. Students with positive screens receive a brief intervention. Students assessed as needing more intensive treatment or treatment for behavioral or health issues are referred to appropriate resources.

These grants identify the specific substance abuse problems and associated mental health issues on a given campus so that schools can be responsive to the needs of their students. Like random student drug testing, screening can also be used to identify students who abuse prescription drugs, a growing problem in this age group. The models created through the TCE-SBI grants are replicable and could have a significant impact on the mental and physical well-being of the Nation's young adults.

Medical Education on Substance Abuse

In December 2004, the Office of National Drug Control Policy (ONDCP) hosted a Leadership Conference on Medical Education in Substance Abuse. The conference brought together leaders of private sector organizations, Federal agencies, organized medicine, and licensure and certification bodies to discuss ways to enhance the training of physicians in the prevention, diagnosis, and management of alcohol and drug use disorders, including prescription drug abuse.

Cosponsored by SAMHSA's Center for Substance Abuse Treatment, as well as the National Institute on Alcohol Abuse and Alcoholism and NIDA, the conferences addressed such topics as how to increase the limited training physicians receive in the diagnosis, management, and underlying science of addiction; how to overcome physicians' attitudes about substance use disorders and the patients who have them; and the effectiveness of treatment protocols. Conference participants identified several evidence-based strategies to address these issues, including the development of educational programs and clinical protocols and guidelines.

In January 2008, ONDCP hosted a third Leadership Conference to address sustainability and institutionalization of screening and brief interventions and the promotion and adoption of new healthcare codes for these procedures.

Developments in reimbursement procedures are some of the greatest successes to come out of these collaborations. In January 2007, the Centers for Medicaid and Medicare Services (CMS) adopted new Healthcare Common Procedure Coding System (HCPCS) procedural codes for Medicaid Services for screening and brief interventions. These codes make it possible for State Medicaid plans to reimburse medical claims for these services. CMS is educating States on the value of offering these services. CMS also announced reimbursable “G” codes for alcohol and drug assessment and brief intervention.

The American Medical Association Board also adopted codes for screening and brief intervention, which became effective in January 2008. The National Association of Letter Carriers Health Benefit Plan approved the coding for these services and accepts the HCPCS codes as a covered expense for eligible employees enrolled in their plan.

Support for screening and brief intervention within the medical community reflects an increasing awareness of the importance of addressing substance use. In 2007, the Accreditation Council for Continuing Medical Education, the organization that accredits providers of continuing medical education (CME) courses in the United States, used the concept of screening and brief intervention to illustrate their new CME requirements. Moreover, the Federation of State Medical Boards and the American Medical Association have adopted policies aimed at educating medical professionals on screening and brief interventions and on prescription drug abuse.

Screening is also an integral component of the U.S. Department of Veterans Affairs (VA) Health System. The Indian Health Service has initiated a program to instruct all its healthcare centers on screening and brief interventions.

Nationwide adoption of screening and brief interventions, in a range of healthcare settings, can help us better understand substance abuse, how it is treated, and how treatment services are delivered.

Breaking the Cycle of Addiction: Maintaining Recovery

Screening helps identify a large group of Americans at risk for substance abuse disorders, particularly those who are unaware of or reluctant to acknowledge the consequences of their drug using behavior. For those who are referred to specialized treatment services as a result of screening, involvement with the criminal justice system, or their own initiative, the Administration has engaged in targeted efforts to provide services to underserved populations and to increase the number of treatment slots, providers, and modalities.

Figure 13. States with Access to Recovery Grants as of September 2007

Figure 14. ATR Client Outcomes 2005-2007

Concerned about treatment for Americans whose "fight against drugs is a fight for their own lives," the President launched Access to Recovery (ATR) in his 2003 State of the Union address. Starting in 2004, Congress appropriated approximately $98 million per year over 3 years for the first ATR grants in 14 States and 1 tribal organization.

ATR expands substance abuse treatment capacity, promotes choices in both recovery paths and services, increases the number and types of providers, uses voucher systems to allow clients to play a more significant role in the development of their treatment plans, and links clinical treatment with important recovery support services such as childcare, transportation, and mentoring. As of September 30, 2007, more than 190,000 people with substance use disorders have received clinical treatment and/or recovery support services through ATR, exceeding the 3-year target of 125,000. Approximately 65 percent of the clients for whom status and discharge data are available have received recovery support services, which, though critical for recovery, are not typically funded through the Substance Abuse Prevention and Treatment (SAPT) block grant.

The SAMHSA-administered grant program allows States and tribal organizations to tailor programs to meet their primary treatment needs. In Texas, ATR has been used to target the State's criminal justice population, which generally has been underserved in the area of drug treatment services. Tennessee has used its ATR funds to target those whose primary addiction is methamphetamine. The voucher component of the program, which affords individuals an unprecedented degree of flexibility to choose among eligible clinical treatment and recovery support providers, empowers Americans to be active in their recovery and may contribute to higher treatment retention and completion rates.

As a result of ATR, States and tribal organizations have expanded the number of providers of treatment and recovery support services. Faith-based organizations, which generally do not receive funding from State governments for substance abuse treatment, have received approximately 32 percent of the ATR dollars. These organizations offer a unique and compassionate approach to people in need.

In 2007, with continued funding for the ATR program, the Administration announced new grants, which expanded the number of grantees to 24. Funds for FY07 grants total $98 million, of which $25 million is targeted to methamphetamine. The new 3-year target for clients served is 160,000. These grants will continue to transform and expand the treatment system, helping Americans struggling with addiction rebuild their lives.

Co-occurring substance abuse and mental health disorders are more common than most professional counselors, medical personnel, or the general public realize. Providers typically report 50-75 percent of patients in substance abuse treatment programs suffer a co-occurring mental illness, while 20-25 percent of those treated in mental health settings have a co-occurring substance abuse problem. Often, individuals with co-occurring disorders receive sequential or parallel treatment from the traditionally separate substance abuse and mental health service systems. Many do not receive treatment of any kind.

Studies of mental health and substance abuse have demonstrated that integrated treatment is successful in retaining individuals with co-occurring disorders in treatment, reducing substance abuse disorders, and ameliorating symptoms of mental disorders.

In response to the President’s New Freedom Commission Report on Mental Health, which recommends screening for co-occurring mental and substance use disorders and linking integrated treatment strategies, the VA is required to annually screen for depression, post-traumatic stress disorder, and substance abuse and to develop screening instruments that can be self-administered.

Since March 2003, the VA Medical Center in Philadelphia and its clinics can refer patients who screen positive for depression to a Behavioral Health Lab (BHL) for further assessment. There are BHLs in approximately 30 VA medical sites, with plans to expand. Assessments include an evaluation of alcohol and drug use and a diagnosis of current psychiatric disorders and severity ratings. Patients identified as having severe mental health or substance use problems are automatically referred for care.

As they implement this intervention, the BHL affords an opportunity to educate primary care practitioners on detection and treatment of depression and other psychiatric disorders.

The BHL model is a particularly valuable tool for helping veterans gain access to care for misuse of prescription drugs or abuse of illicit drugs. This broad-based approach provides a practical, low-cost method of assessing, monitoring, and treating patients identified in primary care as having mental health and substance abuse needs.

A Chance to Heal: Treating Substance Abusing Offenders

For many Americans, substance abuse can lead to involvement in the criminal justice system. With 32 percent of State prisoners and 26 percent of Federal prisoners reporting in 2004 that they had committed their crimes while under the influence of drugs, connecting offenders with substance abuse treatment through drug courts, during incarceration, or after release back into the community is an important component of the Nation's strategy to heal drug users.

For nonviolent drug offenders whose underlying problem is substance use, drug treatment courts combine the power of the justice system with effective treatment services to break the cycle of criminal behavior, alcohol and drug use, child abuse and neglect, and incarceration. A decade of drug court research indicates that it reduces crime by lowering rearrest and conviction rates, improving substance abuse treatment outcomes, and reuniting families, while also producing measurable cost benefits.

A recent study in Suffolk County, Massachusetts, found that drug court participants were 13 percent less likely to be rearrested, 34 percent less likely to be reconvicted, and 24 percent less likely to be reincarcerated compared to probationers.

In line with their effects on crime rates, drug courts have proven to be cost-effective. One analysis in Washington State concluded that drug courts cost an average of $4,333 per client, but save $4,705 for taxpayers and $4,395 for potential crime victims, thus yielding a net cost-benefit of $4,767 per client. An analysis in California concluded that drug courts cost an average of about $3,000 per client but save an average of $11,000 per client over the long term.

Since 1995, the Office of Justice Programs at the U.S. Department of Justice has provided grants to fund the planning, implementation, and enhancement of juvenile, adult, family and tribal drug treatment courts across the country. There are currently more than 2,000 such courts in operation, with more in development. With the number of treatment drug courts sometimes outpacing treatment capacity, Federal resources provided through SAMHSA/CSAT Family and Juvenile Treatment Drug Courts grants help close the treatment gap by supporting the efforts of treatment drug courts to expand and/ or enhance treatment services. The Family and Juvenile Treatment Drug Courts program began in FY02 and continues today.

In order to coordinate Federal criminal justice treatment initiatives such as drug courts, SAMHSA and the Department of Justice, Bureau of Justice Assistance (BJA), have established interagency agreements and memoranda of understanding and have held joint information exchanges to eliminate duplication and increase technical assistance and training efforts as well as utilize the expertise of the National Association of Drug Court Professionals (NA- DCP) and the National Drug Court Institute (NDCI). SAMHSA, BJA, and NDCI are also helping to raise awareness of the drug court model, increase the number of non-Federally supported drug courts, and promote the routine implementation of evidence-based practices that can standardize treatment protocols and improve treatment outcomes.

Recognizing the success of drug treatment courts in addressing the chronic, acute, and long-term effects of drug abuse, the Administration requested resources in FY08 for drug courts within overall funding for SAMHSA's criminal justice activities. This funding would increase treatment capacity by supporting treatment and wrap-around services, case management, drug testing, and program coordination, which are vital for the recovering drug user.

The drug treatment court approach is being adopted by nations around the world to effectively deliver drug treatment for those under criminal justice supervision. To date, 10 other countries have instituted drug courts, and several more plan to establish them. Every year, the number of international participants who attend the NA- DCP's Annual Training Conference increases. In 2006, the June meeting, held in Washington, D.C., included representatives from England, Ireland, Scotland, Chile, the British Virgin Islands, Canada, the Organization of American States/Inter-American Drug Abuse Control Commission (CICAD), and the United Nations Office on Drugs and Crime. ONDCP is working with partners around the world to further broaden international participation in 2008.

To disseminate research findings related to treating the addicted offender and to begin to effect system wide change, in July 2006 NIDA released a publication titled Principles of Drug Abuse Treatment for Criminal Justice Populations. The publication advances the concept of addiction as a brain disease and the importance of treating it as such, emphasizing the need for customized strategies that include behavioral therapies, medication, and consideration of other mental and physical illnesses. The key message is that treatment works, reducing drug abuse, criminal recidivism, and relapses to addiction.

Figure 15. The Number of Drug Courts Continues to Increase Nationwide (1989-2007)

Understanding Addiction

NIDA plays a critical role in helping to shape effective, evidence-based prevention and treatment strategies. In support of this effort, the Administration has requested nearly $6 billion from Congress since FY03. In that time, much progress has been made in understanding how drugs of abuse affect the brain and behavior, including the roles played by genetics, environment, age, gender, and other factors. Understanding these roles can assist in devising more effective prevention and treatment strategies.

Neuroscientists have been testing and improving new approaches to harness the power of genetics to understand, prevent, and treat addiction. Investigators from the NIDA Intramural Research Program have shown the effectiveness of using a powerful method of identifying genes to determine a person’s predisposition to substance abuse and addiction.

Results from screenings of DNA samples of heavy substance abusers revealed that as many as 38 genes may play a role. Identifying candidate genes for vulnerability to drug abuse provides scientists with new insight into how people may be biologically vulnerable to addiction.

NIDA-supported research is also contributing to advances in treatment. Key discoveries about the safety and efficacy of medications such as buprenorphine to treat opiate addiction have helped thousands of heroin users reduce the urge to use opiates. Research on how marijuana affects the brain and the body has led to a better understanding of the drug’s dangers, as well as the development of synthetic chemicals with the therapeutic potential to target the areas of the brain and body affected by THC, the most active component of marijuana.

Drugs of abuse exert powerful influences over human behavior through their actions on the brain. An approach that prevents a drug from entering the brain could have tremendous potential to treat addiction. Immunization could achieve this goal by chemically “locking up” drugs while they are in the bloodstream, thereby blocking entry into the brain. Seven years ago, NIDA embraced this concept and decided to support a nicotine vaccine effort in collaboration with a pharmaceutical company. Early studies show it to be safe and capable of generating antibodies that block nicotine’s entry into the brain. Current results show that the vaccine helped prevent smoking relapse for up to 2 months in about a quarter of the study participants.

The same approach has been undertaken for cocaine addiction, with a small clinical trial suggesting its safety and promise. NIDA is also supporting the potential development of vaccines for methamphetamine addiction. NIDA’s support of this research is part of the Administration’s continuing commitment to encourage innovative research that could have a significant impact on the Nation’s health.