Drug Treatment

DRUG ABUSE AND ADDICTION

Psychiatric Definition

Though not all experts agree on a single definition of drug addiction, the Diagnostic and Statistical Manual of Mental Disorders-IV Text Revision (DSM-IV-TR ; 2000) is the most widely used reference for diagnosing and treating mental illness and substance-related disorders. In the DSM-IV-TR, the nation's psychiatrists draw a distinction between substance abuse and substance dependence. They stress that these terms should not be used interchangeably.

As also discussed in Chapter 1, the DSM-IV-TR requires that at least one of the following conditions be met within the year prior before a person can be diagnosed as a substance abuser: the person has repeatedly failed to live up to major obligations, such as on the job, at school, or in the family, because of drug use; the person has used the substance in dangerous situations, such as before driving; the person has had multiple legal problems because of drug use; or the person continued to use drugs in the face of interpersonal problems, such as arguments or fights caused by substance use.

The DSM-IV-TR requires that at least three of the following conditions be met in the previous year before a person can be said to be substance dependent: the patient has experienced increased tolerance; the patient experienced withdrawal; the patient had a loss of control over quantity or duration of use; the patient had a continuing wish or inability to decrease use; the patient spent inordinate amounts of time procuring or consuming drugs or recovering from substance use; the patient has given up important goals or activities because of substance use; or the patient has continued to use the substance despite knowledge that he or she has experienced damaging effects.

Essence of Drug Abuse

Alan I. Leshner, the director of the National Institute of Drug Abuse (NIDA), notes in his article "The Essence of Drug Abuse" (June 14, 2005, http://www.drugabuse.gov/Published_Articles/Essence.html), that:

What does matter tremendously is whether or not a drug causes what we now know to be the essence of addiction: uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences. This is the crux of how many professional organizations all define addiction, and how we all should use the term. It is really only this expression of addiction—uncontrollable, compulsive craving, seeking and use of drugs—that matters to the addict and to his or her family, and that should matter to society as a whole. These are the elements responsible for the massive health and social problems caused by drug addiction.

Disease Model of Addiction

In the last twenty years of the twentieth century, advances in neuroscience led to new understanding of how people become addicted and why they stay that way. The disease model of addiction has been proposed by psychiatric and medical researchers. Addicts, they say, respond to drugs differently than people who are not addicted. Much of the difference is associated with differences in brain functioning and can be linked to genetic factors. Approaches to treatment emphasize that addiction must be treated in the same way as other chronic diseases.

A. Thomas McLellan et al., in "Drug Dependence, a Chronic Medical Illness" (Journal of the American Medical Association, October 4, 2000), liken drug dependence to chronic illnesses such as diabetes, hypertension, and asthma. McLellan et al. review scientific studies of twins and children of parents who were dependent on alcohol or other drugs. They report high degrees of correlation between parental and sibling dependence, suggesting a strong genetic component in addiction and alcoholism. In addition, people who used drugs over long periods had different patterns of brain function, which seemed to lead them to continue to use drugs. Furthermore, in "Molecular Genetics of Addiction Vulnerability" (NeuroRx, July 2006), George R. Uhl posits that "classical genetic studies document strong complex genetic contributions to abuse of multiple addictive substances."

NIDA also views drug addiction (if not all substance abuse) as a disease. On its "Frequently Asked Questions" Web page (October 10, 2006, http://www.nida.nih.gov/tools/FAQ.html), the agency answers the question, "What is drug addiction?":

Drug addiction is a complex brain disease. It is characterized by drug craving, seeking, and use that can persist even in the face of extremely negative consequences. Drug-seeking may become compulsive in large part as a result of the effects of prolonged drug use on brain functioning and, thus, on behavior. For many people, relapses are possible even after long periods of abstinence.

In Principles of Drug Addiction Treatment: A Research-Based Guide (October 1999, http://www.nida.nih.gov/PDF/PODAT/PODAT.pdf), NIDA points out that drug addiction is not only a brain disease but also leads to social "illness" and other diseases:

Addiction often involves not only compulsive drug taking but also a wide range of dysfunctional behaviors that can interfere with normal functioning in the family, the workplace, and the broader community. Addiction also can place people at increased risk for a wide variety of other illnesses. These illnesses can be brought on by behaviors, such as poor living and health habits, that often accompany life as an addict, or because of [the] toxic effects of the drugs themselves.

An Integrated Approach to Treatment

The modern approach to treatment has come to reflect the complexity of the drug abuse-addiction spectrum and combines medical approaches, behavior modification, education, and social support functions intended to redress imbalances in the patient's total environment. Components of a comprehensive drug treatment approach are shown in Figure 6.1. Arrayed in the center are categories of treatment used alone or in combination and, on the periphery, social service functions that may have to be deployed to solve some of the patient's problems that led to drug use or addiction in the first place.

HOW MANY PEOPLE ARE BEING TREATED?

UFDS/N-SSATS Data

The Substance Abuse and Mental Health Services Administration (SAMHSA), an agency of the U.S. Department of Health and Human Services, has been collecting data on substance abuse facilities since 1976. The program has had various names throughout its history; it was called the Uniform Facility Data Set (UFDS) survey until 2000, when the name was changed to the National Survey of Substance Abuse Treatment Services (N-SSATS). In the course of this program's history, the data collected have changed, introducing discontinuities in reporting. Until 1998, under the UFDS, data on clients of treatment services were reported in some detail, were omitted in 1999, and reintroduced in limited format in 2000. The most recent UFDS data on the gender, racial, ethnic, and age characteristics of people in treatment were reported in 1998. Data on these breakdowns of admissions, however, have continued to be available from another SAMHSA source: the Treatment Episode Data Set, which is discussed later in this chapter.

N-SSATS numbers represent a snapshot of the treatment units on a particular day and do not indicate how many people were being treated over the course of the entire year. As of March 31, 2004, N-SSATS reported in the National Survey of Substance Abuse Treatment Services (N-SSATS): 2004—Data on Substance Abuse Treatment Facilities (2005, http://wwwdasis.samhsa.gov/04nssats/index.htm) that the number of people in the treatment facilities who responded to the survey stood at slightly over 1.07 million, representing a slight increase since the 1998 figure of nearly 1.04 million. (See Table 6.1.)

NSDUH Data

The SAMHSA also included questions about treatment in its 2005 National Survey on Drug Use and Health (NSDUH) to collect data from people who sought and received substance abuse treatment. Figure 6.2 shows the results of asking recipients where they received treatment for substance use in the past year at any location. People could report receiving treatment at more than one location. (This definition of treatment location is different from the specific treatment facilities reporting to the SAMHSA for N-SSATS.) The NSDUH determines that self-help groups, outpatient rehabilitation facilities, inpatient rehabilitation facilities, outpatient mental health centers, and hospital inpatient facilities are where people say they most commonly receive treatment.

The NSDUH also asked substance abusers why they did not receive the treatment they needed. SAMHSA data show that 7.6 million people needed treatment in 2005, but only a fraction of these people (the 1.07 million mentioned previously) received treatment at a specialty facility. Figure 6.3 shows that most people (44.4%) cited financial reasons for not receiving treatment. One out of five admitted that they were not yet ready to give up drugs.

Treatment Episode Data Set Data

Another source of data for the drug-treatment population comes from the SAMHSA's Treatment Episode Data Set (TEDS). This program counts admissions over the period of a year rather than the number of people in treatment on a particular date during the year. When the same person is admitted twice during the same year, he or she is counted twice, whereas in the UFDS/N-SSATS survey individuals are counted only once. As reported in Treatment Episode Data Set (TEDS) 1994–2004: National Admissions to Substance Abuse Treatment Services (July 2006, http://wwwdasis.samhsa.gov/teds04/tedsad2k4web.pdf), TEDS data for 1998 showed over 1.7 million admissions (versus UFDS's nearly 1.04 million). TEDS admissions in 2004 were over 1.8 million.

CHARACTERISTICS OF THOSE ADMITTED

TEDS data from 1994 to 2004 on admissions by sex, race/ethnicity, and age are presented in Table 6.2 and Table 6.3.

Gender

As shown in Table 6.2, males represented most of those admitted for drug and/or alcohol treatment, although the percentage of men dropped slightly between 1994 and 2004 (from 71.4% to 68.5%) and that of women increased (from 28.6% to 31.5%). The number of males admitted for treatment in 2004 was nearly 1.3 million versus just over 590,000 female admissions. (See Table 6.3.) These results and data from the NSDUH reflect that a greater proportion of men abuse drugs than women in the United States. According to Table 4.1 in Chapter 4, 9.9% of males were past-month users in 2004, compared with 6.1% of females.

Race and Ethnicity

In 2004 whites were most of those admitted to substance abuse treatment facilities (60%; see Table 6.2) and were those admitted in the greatest numbers (1.1 million; see Table 6.3). They were followed by African-Americans at 22.5% (419,099). Compared with data from 1994, whites increased from 58.3% (963,257) and African-Americans decreased from 27.1% (447,945). Hispanics

increased their proportion of admissions to drug treatment facilities from 11% (181,168) in 1994 to 12.7% (235,793) in 2004. American Indians and Alaskan Natives dropped in share of those treated from 2.3% to 2.1% during this period. Asian and Pacific Islanders increased by 0.3% but remained less than 1% of the total admissions.

Age

In 1994 the age group with the largest number receiving substance abuse treatment was twenty-five- to thirty-four-year-olds (37.8% of total), followed by those aged thirty-five to forty-four years (29.1%). Ten years later, these were still the two largest groups receiving treatment, but the order was reversed: those aged thirty-five to forty-four were in the group having the highest percentage receiving substance abuse treatment and those aged twenty-five to thirty-four were in the group having the second-highest percentage. The percentage of the younger group decreased to 24.7% in 2004, whereas the percentage of the older group stayed about the same (29%), thus causing the order reversal. Those aged sixty-five and older were least represented (after those under the age of twelve), accounting for 0.8% in 1994 and 0.6% in 2004. (See Table 6.2.)

TYPES OF TREATMENT

The treatment that recovering drug addicts receive depends on the types of drugs to which they are addicted. Regardless of the substance they are addicted to, most treatment programs involve some form of rehabilitation ("rehab"). Drug rehab refers to processes that assist a drug-addicted person in discontinuing drug use and returning to a drug-free life. For many types of addiction, rehab is the only form of treatment that is needed. However, those who are addicted to opiates typically must undergo a period of detoxification ("detox") before rehab can begin. In some cases opiate addicts are given opioid substitutes to help them with their addiction.

Detox

Individuals addicted to opium-based drugs must usually undergo medical detox in an outpatient facility, a residential center, or a hospital. Medical help, including sedation, is provided to manage the painful physical and psychic symptoms of withdrawal. Counseling is always available as well; in many detox centers group therapy is available. NIDA, however, describes detoxification as a precursor to rehabilitation because that process cannot begin until the individual's body has been cleared of the drug and a certain physiological equilibrium has been established. Rehabilitation usually follows detoxification.

Rehabilitation

Rehab has many forms, but it is always designed to change the behavior of the drug abuser. Changed behavior—achieving independence of drugs or alcohol—requires understanding the circumstances that led to dependence, confidence that the individual can succeed, and changes in lifestyle so that the individual avoids occasions that produced drug-using behavior. Individual counseling, interaction with support groups, and formal education are used in combination with close supervision, incentives, and disincentives. Certain individuals require a new socialization that is achieved by living for an extended time in a structured and supportive environment in which new life skills can be acquired. Treatment may involve guiding the individual to seek help from other social agencies (as shown in the circle in Figure 6.1) to reorder his or her life.

Individuals, of course, may be mentally ill and will then receive, as part of drug rehab, mental health services in outpatient or hospital settings. Most treatment takes place in outpatient settings, with the individual reporting daily, weekly, or less frequently for periodic treatment and assessment.

OPIOID SUBSTITUTE PROGRAMS

Heroin addicts and those habituated to other opium-based substances follow usual treatment programs but may, in addition, be prescribed what are known as opioid substitutes. The best known of the opioid substitutes is methadone, which is an agonist, a chemical substance that activates brain receptors. In the case of methadone, the brain receptors it activates are the same receptors that respond to heroin. However, heroin addiction disrupts many physiological functions, whereas methadone normalizes those functions. Many studies show methadone to be effective; likewise, many thousands lead normal lives using this heroin substitute. Methadone was approved for use in 1972.

Levo-alpha-acetylmethadol (LAAM), which was approved in 1993, is another agonist used in treating drug dependency. Whereas methadone must be taken daily, LAAM can be taken three times per week. Use of LAAM and methadone is not without risk. It is possible to become dependent on them just as it is with heroin and other opioids. However, clinical experience with both methadone and LAAM indicates that these medications have a much lower potential for abuse than heroin.

Naltrexone is an antagonist, a chemical substance that reduces the effect of another chemical substance on the body. Naltrexone blocks the effect of heroin on the brain's receptors and can reduce involuntary compulsive drug craving. It can be prescribed by physicians and is effective both against alcohol dependency and in detox. As reported in "Subutex and Suboxone Approved to Treat Opiate Dependence" (FDA Talk Paper, October 2, 2002), buprenorphine, which was approved for use by the U.S. Food and Drug Administration in 2002, acts as an agonist at lower doses and as an antagonist at higher doses.

Distribution of Patients

The great majority of patients undergoing treatment in 2004 were receiving outpatient care, 954,551 (89%) of nearly 1.1 million patients on March 31 of that year. (See Table 6.1.) Of the remainder, 101,713 (9.5%) were in residential facilities and 15,987 (1.5%) received hospital inpatient treatment. Of those under outpatient treatment but not in detox, the majority were receiving what the SAMHSA labels regular, or nonintensive, treatment.

Of the total treatment population, 25,299 individuals (2.4% of all patients) were undergoing detox, most in outpatient settings (12,064), the rest in residential facilities (7,021) and hospitals (6,214). Among all patients under treatment, 228,192 (21.3%) were receiving methadone. (See Table 6.1.)

STATISTICS ON ADMITTED PATIENTS

Admissions by Substance

Data on admissions by the primary substance of abuse provided by TEDS for 2004 are shown in Table 6.4. In that year alcohol alone and with a secondary drug is the primary substance for which the greatest number of people received treatment (753,464, or 40.2%, of all admissions), followed by opiates (329,138, or 17.6%, mainly heroin), marijuana (298,317, or 15.9%), cocaine (256,387, or 13.7%), and stimulants (151,404, or 8.1%, primarily methamphetamine).

The 2004 admissions for alcohol abuse (either alone or in combination with a secondary substance) of 40.2% is down from 52.8% reported by TEDS in 1994. Total alcohol-related admissions have been declining annually, largely accounting for the decreasing trend in total admissions.

The category showing the largest growth has been stimulants. In 1994 stimulants accounted for 2.7% of all admissions, whereas in 2004 they accounted for 8.1%, as indicated by the admissions numbers in Table 6.4. Within the stimulant category, admissions caused by amphetamine (particularly methamphetamine) accounted for the vast majority. Methamphetamine is addictive and is produced in illicit makeshift laboratories around the country. Marijuana-related admissions have had the second most rapid growth, representing 15.9% of cases in 2004, up from 8.5% as reported by TEDS in 1994.

Opiate-related admissions have been growing, and cocaine-related admissions have been declining. In 1994 opiate-caused admissions were 13.8% and cocaine-caused admissions were 17.8% of the total; ten years later their percentages were reversed, with opiates accounting for 17.5% and cocaine for 13.7% of admissions, as indicated by the admissions numbers in Table 6.4. The largest decline of admissions from 1994 to 2004 has been for cases involving inhalants, declining to 0.06% of all admissions in 2004, down from 0.16% in 1994.

Demographics by Substance

A detailed examination of admissions in 2004 is provided in Table 6.4, which shows the distribution of people admitted by major drug categories, gender, race/ethnicity, and age at admission.

GENDER

As noted previously in this chapter, total male admissions (68.5%) were higher than total female admissions (31.5%) in 2004. As Table 6.4 shows, this trend held in all but two substance categories: sedatives (54.4% females versus 45.6% males) and tranquilizers

(52.4% females versus 47.6% males). The greatest male-female differences were noted in alcohol-only admissions (74.9% males versus 25.1% females), marijuana-related admissions (74.2% males versus 25.8% females), and alcohol admissions with a secondary drug (73.8% males versus 26.2% females).

RACE AND ETHNICITY

In 2004 whites made up 60% of the substance abuse treatment admissions, African-Americans 22.5%, Hispanics 12.8%, American Indians 1.9%, and Asians and Pacific Islanders 0.9%. Whites had the highest admission rates for all drug categories except smoked cocaine and phencyclidine (PCP). African-Americans had the highest smoked-cocaine admissions (53%) and PCP-related admissions (50.3%). African-Americans were second in admission rates for all other substances of abuse except methamphetamine/amphetamine-, tran-quilizer-, and sedative-related admissions. Hispanics were generally third in admission rates but were second in methamphetamine/amphetamine-, tranquilizer-, and sedative-related admissions. (See Table 6.4.) It is important to note that the Hispanics category is treated as an "ethnicity" rather than as a race and includes both white and black individuals of Hispanic origin.

It is, however, important to consider these rates of substance abuse treatment by race in the context of the overall racial composition of the United States. The 2004 TEDS data indicate that 70% of whites, 13% of Hispanics, and 12% of African-Americans made up the population. When substance abuse treatment rates are compared to these population statistics, whites were underrepresented in treatment (60% in treatment versus 70% in the population), the proportion of Hispanics in treatment was comparable to Hispanics in the population (12.8% in treatment versus 13% in the population), and African-Americans were disproportionately admitted for treatment (22.5% in treatment versus 12% in the population).

AGE AT ADMISSION

The 2004 TEDS data show that 85.4% of people admitted for alcohol-only abuse that year were between the ages of twenty and fifty-four and had an average age of thirty-nine years. Crack cocaine treatment recipients (74.9%) clustered in the thirty- to forty-nine-year-old age group and had an average age of thirty-eight years. In contrast, 46.1% of those admitted for using inhalants were aged seventeen or younger and had an average age of twenty-four years. Those being treated for marijuana abuse were another "young" group. Nearly three-quarters (73.3%) were between the ages of fifteen and twenty-nine. The marijuana treatment group had an average age of twenty-four years.

Type of Treatment

In 2004, 62.5% of those admitted to treatment were admitted into ambulatory (nonresidential) treatment facilities; of the remainder, 17.3% went into residential facilities and 20.2% went into residential-type (twenty-four-hour) detoxification. (See Table 6.5.)

Among those going into drug-related detoxification, the largest percentages had been admitted for tranquilizer use (33%) and heroin (33.1%). Those using marijuana had the highest percentage entering ambulatory care (83.5%). The largest proportions of substance abusers assigned to residential treatment were cocaine users at 54.6%. (See Table 6.5.)

Referring Source

Table 6.6 shows the source of referral of patients to substance abuse treatment in 2004. Just over one-third of all people admitted came to get treatment at their own volition (33.7%). The largest referral source (sending 36.3% of individuals) was the criminal justice system, referring people for drug use or driving under the influence of alcohol. Much of the remaining third of all referrals came from substance abuse treatment providers and other health care agencies (10.7% and 6.9% of referrals, respectively), referring individuals for specific services. Other referrals came from schools, employers, and community agencies.

Regarding the source of referral based on the drug of abuse, Table 6.6 data show that most heroin users (57.8%) and other opiate users (49.8%) sought treatment of their own accord. Justice system sources sent most marijuana users (57%), meth users (50.4%), and PCP users (58.9%), along with many hallucinogen users (49.5%) and alcohol-only users (41.6%) to treatment.

HOW EFFECTIVE IS TREATMENT?

During the 1960s there was an opioid epidemic in the United States, and the federal government released substantial funds to substance abuse treatment programs. This funding has continued over the decades and is supplemented by state governments and private sources. Table 9.2 in Chapter 9 shows that the 2007 federal budget request for drug abuse treatment was $2.4 billion, and the request for treatment research was $605 million.

With so much money devoted to substance abuse treatment, there has been considerable research conducted on the effectiveness of the programs. The bulk of this research began in the late 1960s and extended into the 1990s.

In "New Research Documents Success of Drug Abuse Treatments" (December 15, 1997, http://www.nih.gov/news/pr/dec97/nida-15.htm), the National Institutes of Health notes that the first major study of drug-treatment effectiveness was the Drug Abuse Reporting Program (DARP), which studied more than forty-four thousand clients in more than fifty treatment centers from 1969 to 1973. Program staff then studied a smaller group of these clients

six and twelve years after their treatment. A second important study was the Treatment Outcome Prospective Study (TOPS), which followed eleven thousand clients admitted to forty-one treatment centers between 1979 and 1981. Both DARP and TOPS found major reductions in both drug abuse and criminal activity after treatment.

Services Research Outcomes Study

The SAMHSA's Services Research Outcomes Study (SROS) confirmed that both drug use and criminal behavior are reduced after drug treatment. Because it conducted a five-year follow-up, the SROS provided the best nationally representative data to answer the question: "Does treatment work?" This study, although now several years old and reporting on even older data, has not been repeated and is the most recent assessment available based on a national sample.

In this nationally representative sample, alcohol use decreased 14% and drug use 21%, leading to the following conclusion in the SAMHSA's SROS report (1998, http://oas.samhsa.gov/Sros/sros8006.htm): "A nationally representative survey of 1,799 persons confirms that both drug use and criminal behavior are reduced following inpatient, outpatient and residential treatment for drug abuse."

According to the SROS report (1998, http://oas.samhsa.gov/Sros/httoc.htm), decreases varied from drug to drug, with heroin use decreasing the least. It went down 13.2%, suggesting that heroin use continued for just under 87% of users. Crack use declined 16.4%, but those treated for snorting cocaine powder did better: 45.4% had abandoned the drug after treatment and continued to do so five years later—but 54.6% were still snorting cocaine. Among marijuana users 28% had given up the drug, whereas 72% continued. Results were better in all the other drug categories, but these are also the drugs of limited use by the study sample (and the population at large). The study also showed that success of treatment is higher when users are older. The exception was crack cocaine.

TYPE AND LENGTH OF TREATMENT

According to the SROS report, results by type of treatment were variable. Overall results for any illicit drug show that best results (25% decrease in drug use) were obtained by inpatient (hospital) treatment, followed by residential treatment. Outpatient methadone treatment had less favorable results (10% decrease) than outpatient drug-free treatment (19%). Outpatient methadone treatment consists of receiving methadone during visits to a treatment center; the center may also provide other services, such as counseling. Outpatient drug-free treatment consists of counseling, group therapy, and other services, but individuals receive no pharmaceutical support.

Marijuana users who were treated in inpatient facilities had better results (35% stopped using the drug) than those in residential (32%) and in methadone treatment (33%). Drug-free outpatient treatment had the lowest success rate (19%). By contrast, those using powdered cocaine benefited almost as much from drug-free outpatient treatment (42% decrease) as from inpatient treatment (47%) and did best in residential settings (55%). Crack users also did best with residential treatment (32% decrease) but had a low response to inpatient care and showed no significant decrease in use from outpatient treatment, whether with methadone or free of drugs. Heroin users responded only to methadone treatment in statistically significant numbers; 27% of those surveyed had stopped using the drug as a consequence of outpatient methadone treatment.

On average, the best results for decreasing use of all drugs, especially cocaine, were achieved with treatment that lasted six months or more; this length of treatment was also nearly the top category for marijuana use. The second length with good results (and with the best result for marijuana) was treatment lasting at least one week but less than one month. Results for crack cocaine show statistically significant results only for the "one-week-to-less-than-one-month" category. For heroin, only the "six-months-or-more" treatment duration produced significant decrease in use. Most heroin addicts require long-term methadone treatment (or treatment with a similar prescription drug) to control their habits.

CRIMINAL BEHAVIOR

The SROS report shows that treatment for substance abuse can significantly reduce crime. Criminal activities such as breaking and entering, drug sales, prostitution, driving under the influence, and theft/larceny decreased between 23% and 38% after drug treatment. However, incarceration and parole/probation violations actually increased, by 17% and 26%, respectively. Data in the study on those incarcerated or detained were less reliable than other data because of nonresponse to the survey.

More Recent Studies on Effectiveness and Cost Effectiveness of Treatment

Using data from the SROS report, Ramin Mojtabai and Joshua Graff Zivin, in "Effectiveness and Cost-Effectiveness of Four Treatment Modalities for Substance Disorders: A Propensity Score Analysis" (Health Services Research, February 2003), compare both the effectiveness and the cost-effectiveness of inpatient, residential, outpatient detox/methadone, and outpatient drug-free substance abuse treatment programs. They determine that there are only minor differences in effectiveness among these four types of programs. (Effectiveness or success is defined as abstinence and any reduction in substance use.) Mojtabai and Graff Zivin also determine that outpatient drug-free programs are the most cost-effective type of program.

More recently, Matilde P. Machado, in "Substance Abuse Treatment, What Do We Know? An Economist's Perspective" (European Journal of Health Economics, March 2005), compared the effectiveness and cost-effectiveness of substance abuse treatment programs by conducting a literature review and summarizing the results. Machado notes that there is no common definition of "effectiveness" but that three objectives represent most expectations about substance abuse treatment: reducing alcohol and/or drug use, improving personal and social functioning, and improving public health. Machado notes, "The evidence largely indicates that treatment is effective in each of these aspects." Drug abusers appear to agree with the research. In the 2005 NSDUH, when drug abusers were asked why they did not receive the substance abuse treatment they sought, only 0.4% answered that treatment would not help them. (See Figure 6.3.)

Nonetheless, Machado suggests that although drug treatment programs are effective, not all treatment programs are equally effective. Some may work better for patients with certain characteristics. For example, notes Machado, "stable alcoholic patients do well in short inexpensive programs while patients with more serious conditions benefit from additional services and longer treatment."

In analyzing cost-effectiveness of drug abuse treatment programs, Machado finds that most cost-effectiveness studies limited their analyses to treatment costs. She suggests that cost-effectiveness can only be determined by including all resources needed to provide treatment, such as patient costs (for example, transportation and day care) and societal costs (for example, crime and unemployment).

DRUG COURTS

Figure 6.4 shows the inception and recent increase in the use of drug courts nationwide. According to the Office of National Drug Control Policy (June 21, 2006, http://www.whitehousedrugpolicy.gov/enforce/drugcourt.html), there were 1,557 drug courts operating in the United States as of April 2006 and 394 more were in the planning stages.

Drug courts are programs that use the court's authority to offer certain drug addicted offenders to have their charges dismissed or their sentences reduced if they participate in drug court substance abuse treatment programs. Drug court programs vary across the nation, but most programs offer a range of treatment options and generally require one year of commitment from the defendant.

In Adult Drug Courts: Evidence Indicates Recidivism Reductions and Mixed Results for Other Outcomes (February 2005, http://www.gao.gov/new.items/d05219.pdf), the U.S. Government Accountability Office (GAO) notes that drug court programs reduce the recidivism rate (rate of reoffenses) during the time that drug abusers are enrolled in drug court treatment programs. The GAO does, however, find limited and mixed evidence of substance use relapse outcomes. Nonetheless, the GAO concludes that:

Overall, positive findings from relatively rigorous evaluations in relation to recidivism, coupled with positive net benefit results … indicate that drug court programs can be an effective means to deal with some offenders. These programs appear to provide an opportunity for some individuals to take advantage of a structured program to help them reduce their criminal involvement and their substance abuse problems, as well as potentially provide a benefit to society in general.

C. West Huddleston, Karen Freeman-Wilson, and Donna L. Boone, in Painting the Current Picture: A National Report Card on Drug Courts and Other Problem Solving Court Programs in the United States (May 2004, http://www.ndci.org/publications/paintingcurrentpicture.pdf), assert that drug courts decrease criminal recidivism, save money, increase retention in treatment, and provide affordable treatment.

WHERE TO GO FOR HELP

God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.

—Invocation used in most 12-Step programs

Many organizations provide assistance for addicts, their families, and friends. Most of the self-help groups are based on the 12-Step program of Alcoholics Anonymous (AA). Whereas AA is a support group for problem drinkers, Al-Anon/Alateen is for friends and families of alcoholics. Families Anonymous provides support for family members and friends concerned about a loved one's problems with drugs and/or alcohol. Other organizations include Adult Children of Alcoholics, Cocaine Anonymous, and Narcotics Anonymous. For an addict, many of these organizations can provide immediate help. For families and friends, they can provide knowledge, understanding, and support. For contact information for some of these organizations, see the Important Names and Addresses section at the back of this book.

A chief barrier to seeking help for many people habitually taking drugs is the recognition that they need help. Users often underestimate the problem and assume that they can manage without seeking professional assistance. Another barrier is the cost of drug abuse treatment, which is not always covered by a person's health insurance. Recognition of these problems has led to new programs both to help individuals recognize the need for help and to fund it.