Innovations in Substance Abuse Treatment and Policy: Conference Findings
and Future Directions
Prepared by: Sarah J. Bray, Kim M. Blankenship, PhD and Joan Altman
Introduction
In June 2000, CIRA’s Law, Policy, and Ethics Core co-sponsored, with the Connecticut State
Department of Mental Health and Addiction Services (DMHAS), a conference entitled ―Recent
Innovations in Substance Abuse Treatment: Implications for Connecticut and Beyond.‖ Several
purposes converged in the organizing of this conference.
From the perspective of HIV prevention, drug treatment is a promising point of focus. It has been
shown to reduce drug use, needle sharing, and drug-related sexual risk [1-12]. It also has an
impact on non-HIV outcomes. For example, it reduces crime and arrests, improves employment
opportunities, and generally increases the quality of life for drug users, including reducing
homelessness [13-15]. Even some of these ―non-HIV‖ outcomes are associated with varying
levels of HIV risk, although the direction of causation is not certain. For example, people who
are homeless, particularly those also suffering from mental illness, have been shown to have
increased levels of substance abuse HIV risk relative to the general population [16-17].
Although it could be presumed that substance use brings about homelessness, research suggests
that homelessness also increases substance use [18].
To completely characterize the potential for drug treatment as an HIV prevention strategy, and to
understand how to promote the most accessible and effective forms of drug treatment, it must be
recognized as part of a complex system of social services, structures and processes. Even if drug
treatment is relatively available, it may not be accessible to all of those who need it. Drug users
must frequently rely on public insurance to cover the costs of programs, so regulations and
policies relating to insurance must be taken into consideration in assessing the HIV prevention
potential of drug treatment. Access to housing and income may also affect the ability of drug
users both to access drug treatment and to gain the greatest benefits from it. So any discussion of
drug treatment and of HIV risk in drug users must acknowledge the social circumstances faced
by drug users. It must also consider the criminal justice system, with which many drug users
eventually have contact.
We wanted to organize a conference that acknowledged the role of drug treatment in HIV
prevention, as well as the location of drug treatment in this larger social system. This intent was
reflected substantively in the themes of the conference sessions. In the first session, speakers
discussed pharmacological innovations in drug treatment, a number of which have been shown to
have considerable effect on substance use problems. In the second session, we considered
innovations in delivery of drug treatment, recognizing that pharmacological solutions are only as
good as the delivery systems available to get them to drug users. The third session examined
diversion programs, which acknowledge that many drug users come in contact with the criminal
justice system and that under some conditions, there is much to gain from diverting them from
prison to drug treatment. Lastly, we organized a session to discuss integrative strategies to drug
treatment: approaches that recognize and that are structured to account for the circumstances of
drug users lives, such as homelessness, mental health problems, and domestic violence.
The recognition that substance abuse treatment is itself embedded in a broader social system was
also reflected in the composition of our audience and panelists, and in our approach to
conference organizing. In the state of Connecticut, the many components that make up this
complex system come under the jurisdiction of different departments: Department of Correction
(DOC), Department of Children and Families (DCF), Department of Public Health (DPH),
Department of Mental Health and Addiction Services (DMHAS), Department of Social Services
(DSS), and the Chief Court Administrator’s Office. To ensure that we discussed the feasibility
and acceptability of different innovations in substance abuse treatment from these varying
perspectives, we invited those who make and implement policy, including Commissioners and
staff from each of the Departments listed above, as well as the Chief Court Administrator, and
local legislators. In this policy update, we summarize the different presentations at the
conference, report on the discussion at a lunchtime Commissioners panel, and describe some
recent developments in drug treatment since the conclusion of this conference.
Conference summary
The conference addressed four subjects: pharmacological innovations in substance abuse
treatment, innovations in treatment delivery, diversionary programs, and integrative approaches
that address not only substance abuse but also problems such as homelessness and mental illness.
A list of all panels and panel participants appears as an appendix at the end of this report.
Pharmacological Innovations:
In the first panel, Richard Schottenfeld discussed research on the cocaine vaccine, a vaccine that
causes the body to produce antibodies to cocaine that then prevent the drug from entering the
brain. Animal studies indicate that the vaccine is likely to be effective in blocking the effects of
cocaine, and human studies are currently being conducted [19-22]. Schottenfeld pointed out,
however, that the long-term efficacy of the vaccine is not known. To date, studies suggest that it
works for about two months. Nor is it known how many times the vaccine can safely be
administered. These limitations suggest that the vaccine will be used for treatment, not
prevention of use.
Schottenfeld also indicated that new onset use of heroin is increasing, in part, as a result of the
increased purity of the drug, which increases the rates of intranasal use and smoking. The U.S.
treats only 25% of its heroin addicts as compared to Scotland, which treats 60-80% of its heroin
addicts. Methadone treatment is the most effective form of treatment for heroin use. It effects
are enhanced when accompanied by contingency management services, in which abstinence
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from illicit drugs or achievement of other goals is rewarded with vouchers or other incentives
(e.g. entertainment or restaurant vouchers) or use of illicit drugs is met with sanctions such as
reduced program privileges. Provision of adequate doses of methadone and of necessary social
services and counseling alongside treatment also increase its effectiveness. But in addition to
improving the efficacy of methadone treatment, Schottenfeld suggested it is important to
continue to develop alternative maintenance therapies, such as buprenorphine, a combination of
buprenorphine and Naltrexone, or a sustained-release depo version of naltrexone [23]. Research
suggests that buprenorphine is slightly less effective than methadone [24], but it is easier to
withdraw from [25]. Naltrexone works by binding to opiate receptors 100 times more tightly
than heroin, but it creates no activity and blocks the effects of heroin. It is highly unpopular with
drug users however, because it causes almost immediate withdrawal. Depo-naltrexone, which
lasts over a 30-day period, has been developed as an alternative. These alternatives may be most
appropriate for certain drug users, but they raise a number of policy questions including how to
make buprenorphine widely available through primary care physicians while avoiding diversion
of the drug.
Also on this panel, Robert Heimer discussed another type of maintenance therapy: heroin
maintenance for individuals who are unable or unwilling to stop using heroin and enter
treatment. In heroin maintenance programs implemented in Switzerland in 1994, more than
1,100 heroin addicts registered as addicts and entered a program in which they were provided
with heroin for self-administration within a clinic, under the supervision of medical
professionals, on an on-going basis. Although the program was not designed as a controlled
clinical trial, a trial in which participants were randomized to immediate entry into the program
or entry after 6 months was conducted in Geneva. In both trials as a whole and within the
randomized cohort in Geneva, those receiving heroin reported less illicit heroin use, improved
their health and social functioning, and reduced their criminal activity. Heroin maintenance is
now policy, rather than an experiment, in Switzerland. Heimer discussed the need for a trial of
heroin maintenance in the United States. Obstacles to the implementation of such a trial include
public attitudes regarding drug treatment programs that do not have abstinence as their central
goal, and the view that maintenance of drug addicts should not be necessary since effective
forms of treatment exist.
Innovations in Delivery:
In the second panel, speakers discussed innovations in delivery such as provision of methadone
in prison, physician prescription of methadone, and treatment on demand.
Peter Tenore provided information on the experience of the Riker's Island facility with provision
of methadone maintenance treatment to inmates. His data indicate that individuals who are
provided with methadone treatment during incarceration have a lower recidivism rate upon
release. Methadone treatment in prison also reduces drug use in prison and thereby reduces
threats to safety and security within these settings. Tenore indicated that in order to get
treatment into the prisons, advocates emphasized that substance use is a medical problem;
inmates with diabetes would not be denied insulin, and inmates with addiction problems should
not be denied methadone.
3
Schottenfeld discussed efforts to expand the availability of methadone through physician
prescription. In the current system of clinic-dispensed methadone, patients encounter problems
such as stigmatization and marginalization, lack of privacy, and unfriendly treatment from
service providers. In addition, they frequently interact with active drug users at methadone
clinics. A system of physician prescription of methadone would reduce these problems, but
would raise the question of how to balance the risk of methadone diversion with the potential
benefits of improved treatment. Schottenfeld described different possible models of physician
prescription, including one that has been applied in Connecticut.
Edward Kaplan discussed a model he had developed to determine the number of treatment slots
that would have to be added to achieve a system that provides "treatment on demand," and what
the associated costs and benefits of doing so would be [26]. Using data from San Francisco, he
noted that although the length of wait lists for drug treatment may suggest that only a small
portion of drug users are seeking treatment (7% in the case of San Francisco), there is also
"latent demand:" desire for treatment among people who do not actively seek treatment as long
as they know it is not available. When San Francisco expanded the availability of drug
treatment, the waiting list actually grew longer. This was because more people started trying to
get treatment, knowing their chances of entering treatment had improved; but it was portrayed by
the media as evidence of the policy's failure.
Diversionary Programs:
In this panel, speakers described programs that divert drug offenders and people with mental
illness from the criminal justice system into appropriate treatment programs. They also
discussed some of the political and social obstacles to diversion.
William Carbone described Connecticut's system of diversion programs, including Alternative to
Incarceration (AIC) programs, the Jail Reinterview Program, and drug courts. He provided
evidence that these programs reduce substance use and recidivism and do not pose a threat to
public safety. He also discussed how they not only enable people to reduce their drug use, but
also help them get GEDs and find employment. According to Carbone, these programs generally
have support from judges, who want to tailor the sentences they mandate to the needs of the
offender and the seriousness of the offense. Nicholas Pastore similarly advocated AIC programs,
describing them in the context of a criminal justice system that expands yearly to incarcerate
greater and greater numbers of individuals, primarily people of color. Jelani Lawson stated that
the real question, since we know that AIC programs work, is how to reverse our current policy of
spending much more on incarceration than on AICs . He advocated a grass-roots approach to
increasing public support for AICs. Senator John Martinez pointed out that the problem is much
deeper than one of funding priorities, and needs much more than research to be resolved. In fact,
he argued, the communities in need of substance abuse treatment and diversion programs are
over-researched. What is needed are programs that prevent substance use, not just treat it, and
programs that address people's multiple needs, not only their substance addiction.
Madelon Baranoski described diversion programs for people with mental illness. For these
populations, lack of access to drug treatment may be a lower priority than the general disarray of
their lives and their inability to access mental health services. Mental health diversion programs
4
are similar to diversion programs for drug offenders both in some of the barriers encountered
when attempting to implement them, and in some of the social aspects of implementation. Each
attaches stigma to populations in need, and each must address the multiple needs of individuals.
She asserted that future goals of the diversion programs for mentally ill offenders in Connecticut
should include identifying and involving stakeholders, and creating a seamless network of
services within the criminal justice system so that mentally ill offenders do not fall between the
cracks at any stage of the process.
Integrative Approaches:
In this panel, speakers discussed approaches to substance abuse treatment that include attention
to some of the contextual barriers to drug treatment, such as homelessness, poverty, and
violence.
Janice Elliot reported findings on the impact of providing supportive housing services to people
with substance abuse and mental health needs. Some of these programs provide housing along
with case management and clinical services, and they do not require tenants to abstain from drug
or alcohol use to remain in housing. An independent evaluation conducted by the state last year
found that tenants liked being in the housing programs, the average cost per person in use of
mental health and substance abuse services decreased significantly with the program, and there
was a strong level of peer support in the program. Other research has found similarly positive
results. Elliot pointed out that the association between housing and decreases in drug use
suggests that having affordable housing available will be critical to the success of diversionary
programs. Pilot supportive housing programs, funded through DMHAS, are being created with
the goal of providing 500 units in the next four years.
Linda Frisman described the Homeless Families Initiative, a program for mothers who are
homeless, at risk of homelessness, or in unsafe housing (poor conditions, or violence) with
substance abuse problems, and women who also have children under 10. Case managers,
including a peer in recovery, help program participants with finding a home, transportation
assistance, money management, and parenting. The program utilizes contingency management
techniques (as described above) but does not give rewards in exchange for specific actions;
instead, rewards are given when women feel they have made a positive change in their lives.
Michael Rowe discussed the practice of assertive mental health outreach, which starts with the
recognition that individuals who are homeless and have a mental illness may not be willing or
able to go to a clinic. Outreach workers -- clinicians, case managers, and other specialists -- leave
their offices to look for mentally ill and substance using homeless persons on the streets, in soup
kitchens, and in emergency shelters. They try to slowly build trust with individuals and offer a
wide range of services such as shelter, housing, help in finding work or being approved for
disability income support payments, and other assistance in addition to mental health and
substance abuse treatment. Eventually, they hope to persuade people to accept treatment and to
place them in affordable housing, with the necessary supports to remain housed. The program
rejects the notion that people have to hit "rock bottom" before they will be ready for treatment
and that only those who demonstrate motivation should be offered treatment. Instead, the
program adopts a model of starting "where the client is," both geographically and existentially.
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New Haven, through the Connecticut Mental Health Center at the School of Medicine, has
participated in the most extensive evaluation of assertive mental health outreach and
coordination of services (systems integration), as one of 18 sites for the national ACCESS
(Access to Community Care and Effective Services and Supports) research demonstration
project through the federal Center for Mental Health Services. Assessments have been conducted
of the programs' impact on mental health and substance abuse, and other outcomes. These
assessments show significant improvement in mental health, housing, and substance abuse for
individuals in the program. Rowe argued that successful treatment requires seeing people in their
context, including the context of poverty and lack of opportunity.
Commissioners Panel
Comprised of commissioners from DMHAS, the Department of Public Health (DPH), the
Department of Children and Families (DCF), the Department of Correction (DOC), and the
Department of Social Services (DSS), as well as the Chief Court Administrator, this lunchtime
panel session discussed barriers to implementing innovative substance abuse policies and
programs. In particular, commissioners singled out four different, but related kinds of obstacles:
paradigmatic, economic, attitudinal, and political.
Each of the commissioners represented a department that, while it must deal with substance use
in some capacity, must do so in the context of an operating paradigm; and several commissioners
stressed that innovative or alternative approaches to substance use must be consistent with these
paradigms. For example, Commissioner Thomas Kirk, of DMHAS, argued that substance use
must be addressed as a public health problem if new approaches to substance abuse treatment are
to be implemented. While this framework may work within DMHAS and DPH, Dr. Brett
Rayford noted it may not be as effective within the DOC, where the operative paradigm focuses
on security; or, in the judicial system, observed Judge Robert Leuba, where the operative
paradigm focuses on sanctions. There was general agreement that paradigmatic barriers were all
the more difficult to confront because of the extensive stigmatization of substance abuse and
drug users. In addition, both David Parella, from DSS, and Thomas Gilman, from DCF, noted
that various regulations restrict the amount of funding available to pay for the drug treatment
needs of those in prison or receiving public assistance, posing yet another barrier to expanding
substance abuse treatment options for some groups. Political barriers to implementing
innovative substance abuse programs and policies were also discussed at the lunchtime panel.
Legislators in the audience, such as State Rep. Bill Dyson, emphasized that constituent interest
and demand often influences their choices as to which issues to devote their time and energy.
They do not receive the same credit from constituents for helping to establish a drug treatment
program as they might for programs addressing such health problems as asthma, or Down’s
Syndrome. In part, this is because drug use is stigmatized. They emphasized that to confront
these political barriers, they need both scientific evidence of the efficacy of different programs,
and a message that stresses the value of drug treatment for communities.
Recent developments
6
In the months that have passed since CIRA's June 2000 conference, important developments in
substance abuse treatment policy have occurred around the nation. Most notable have been the
developments in the realm of alternatives to incarceration, which was one focus of the
conference. Over the summer, an administrative decree in New York called for drug treatment
in place of incarceration for first- and second-time non-violent offenders. Some related
initiatives were considered by states on November 7th. California voters passed Proposition 36,
which provides that first- and second-time non-violent drug offenders, as well as individuals who
violate parole or probation on drug-related charges, be offered drug treatment rather than
incarceration. A similar bill was defeated in Massachusetts, however. Oregon passed an
initiative requiring proceeds from asset forfeitures in drug cases to go into a fund to pay for drug
treatment, rather than being used for law enforcement.
Other areas of focus at the conference were pharmacological innovations and innovations in
delivery of substance abuse treatment. Among the topics discussed were buprenorphine studies
and physician prescribed methadone. A Federal law relating to these two topics was passed in
October, 2000. The law allows physicians to prescribe buprenorphine to their patients, which is
expected to expand drug treatment access and allow for treatment that avoids some of the
barriers to participation in methadone maintenance treatment, such as the difficulties of meeting
restrictive clinic hours while maintaining a job. Currently, Federal regulations of methadone
maintenance treatment are being revised to allow for greater flexibility in provision of
methadone maintenance services. Although it is too early to gauge the projected impact of the
revisions, it is likely that changes in service provision will begin to occur next year.
During the summer and fall, we have also witnessed continuation of the ongoing gradual shift in
public opinion regarding drug use and addiction. This summer's "Shadow Conventions"
addressing the War on Drugs helped to increase public awareness that drug addiction and drug-
related harm have not been diminished by the strategies of the War on Drugs, but rather, have
apparently been exacerbated. This awareness was also helped by the various public figures, such
as Governor Gary Johnson of New Mexico, who have come forward to criticize current drug
policies. Although much public opposition to drug policy reform still remains, public support for
reform has been sufficient to allow initiatives such as those mentioned above to be implemented.
Finally, research further elucidating the extent of drug addiction and the efficacy of treatment has
been published in the months since the conference. For the first time, the Substance Abuse and
Mental Health Administration released state-level estimates of substance use and addiction,
which revealed that an estimated 52,000 Connecticut residents were "dependent" on illicit drugs
in the year preceding the survey, and an estimated 208,000 used illicit drugs in the month
preceding the survey. Statistics such as these help to estimate the need for substance abuse
services in Connecticut. Research demonstrating the benefits of drug treatment has also
continued to accumulate. A study published in July, for example, investigated the cost-
effectiveness of expanding availability of methadone maintenance treatment, particularly in
reference to its impact on HIV transmission. The researchers found that additional methadone
maintenance capacity meets standards for cost-effectiveness, and would remain cost-effective
even if it were twice as expensive and half as effective as current methadone maintenance slots.
In addition, they found that more than half of the benefits of methadone maintenance are gained
by individuals who do not inject drugs [27]. A recent study comparing efficacy of levomethadyl
7
acetate, buprenorphine, and high- and low-dose methadone found that abstinence from opiate use
was as high or higher for participants taking levomethadyl acetate and buprenorphine as for those
taking high-dose methadone, but much lower among participants taking low-dose methadone
[28]. Drug use in prison recently became the subject of public discussion when a widely
publicized survey found that 88% of former inmates said they found it easy to obtain drugs in
prison, and 46% reported that their time in prison made them more likely to use drugs than had
they not been incarcerated [29].
These recent developments and findings speak to many of the questions raised at the drug
treatment conference this summer. Which forms of drug treatment provide the greatest benefits,
not only to substance users but also to the community more generally? How can effective forms
of drug treatment, including new pharmacological methods, be made more accessible? How can
we ensure that people with substance abuse problems in the criminal justice system are offered
effective treatment? What legal changes are needed to turn our goals of providing effective and
accessible treatment into a reality?
Future directions
As indicated above, progress has been made toward implementing some of the interventions
called for by conference participants – e.g. increased use of new pharmacological treatments,
diversion from prison to treatment for drug offenders, and improved access to methadone
maintenance treatment. However, much remains to be done to realize the potential for drug
treatment to promote HIV prevention. There are some significant gaps in research that could
help further this goal. For example, research on the connection among social welfare policies,
drug use, and HIV risk, is necessary, as are concomitant interventions to address the social
factors placing people at risk of substance use or exacerbating their substance use problems, such
as homelessness, lack of stable income, and unemployment. Conference participants advocated
interventions addressing such factors and discussed evidence of their impact. Unfortunately,
numerous laws and policies work to reinforce the disadvantages that drug users face when
attempting to obtain housing and social services.
Further research on the barriers to making substance use treatment more available are also
necessary. Significant expansion of alternatives to incarceration programs, for example, will
require an expanded number of treatment slots if clients within the criminal justice system are
not to compete with those in need of drug treatment outside the system. Zoning laws and other
policies that impact on the establishment of such facilities need examination.
This conference has also made clear that research on the benefits of drug treatment may not
alone be sufficient to ensure that reforms intended to expand its availability and accessibility will
be implemented. We must also develop a better understanding of the best strategies for
translating research findings into political and policy action. It is likely that one component of
such a strategy will be an integrated approach to addressing drug use—a problem that cuts across
many sectors of society and of state government. The Recent Innovations in Substance Abuse
conference was a first step in developing such an integrated approach that we hope can develop
into a long-term collaboration.
8
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Appendix: Conference panels and participants
Welcome
Michael Merson, Yale University School of Medicine, Department of Epidemiology and Public Health
(EPH) – Center for Interdisciplinary Research on AIDS (CIRA)
Barbara Geller, Department of Mental Health and Addiction Services (DMHAS)
Kim Blankenship, Yale University School of Medicine, EPH-CIRA
Panel 1: Pharmacological Innovations
―Comments on Cocaine Vaccine Research,‖ and ―Buprenorphine Studies,‖ Richard Schottenfeld, Yale
University School of Medicine, Department of Psychiatry; Connecticut Mental Health Center
(CMHC)
Video: Excerpt from 60 Minutes: ―Where Have all the Addicts Gone‖
―Alternative Opiate Therapies,‖ Robert Heimer, Yale University School of Medicine, EPH-CIRA
Panel Chair: Kaveh Khoshnood, Yale University School of Medicine, EPH-CIRA
Discussant: Mark Kinzly, Corporation for Supportive Housing
Panel 2: Innovations in Delivery
―Methadone: A Medical Model, Prison Issues, and Impact on HIV Transmission,‖ Peter Tenore, Albert
Einstein College of Medicine, Riker's Island Correctional Facility
―Physician Prescribed Methadone,‖ Richard Schottenfeld, Yale University School of Medicine,
Department of Psychiatry; CMHC
―Treatment on Demand: Expanding Public Capacity for Substance Abuse Treatment,‖ Edward Kaplan,
Yale University School of Management; EPH-CIRA
Panel Chair: Jody Sindelar, Yale University School of Medicine, EPH
Discussants: David Biklen, CT Law Revision Commission; Mary Barr, MotivationalMovement
Commissioners Panel
Thomas Kirk, Commissioner, Department of Mental Health and Addiction Services
???Elise Kramer, Department of Public Health
Judge Robert Leuba, Chief Court Administrator, Judicial Branch of the State of Connecticut
David Parrella, Director of Medical Care Administration, Department of Social Services
Brett Rayford, Director of Health, Mental Health and Addiction Services, Department of Corrections
Thomas Gilman, Deputy Commissioner, Department of Children & Families
Panel Chair: Michael Merson, Yale University School of Medicine, EPH-CIRA
Panel 3: Diversionary Programs
―Court Supported Diversionary Programming,‖ William Carbone, Court Support Services Division,
Judicial Branch of the State of Connecticut
―Alternatives to Arrest and Re-Arrest,‖ Nicholas Pastore, Criminal Justice Policy Foundation,
Washington, DC
―Connecticut’s Jail Diversion Program: Creating Partnerships Between Mental Health Services and the
Criminal Justice System,‖ Madelon Baranoski, Yale University School of Medicine, Department of
Psychiatry; CMHC
Panel Chair: Barbara Geller, DMHAS
Discussants: Jelani Lawson, Connecticut Drug Policy Leadership Council; Representative John Martinez,
95th District
Panel 4: Integrative Approaches
―Supportive Housing and Substance Use,‖ Janice Elliot, Corporation for Supportive Housing
―Project SAFE Homeless Families Initiative,‖ Linda Frisman, DMHAS
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―Assertive Mental Health Outreach: What is it and Does it Work with Substance Users,‖ Michael Rowe,
Yale University School of Medicine, Department of Psychiatry; CMHC
Panel Chair: Kim Blankenship, Yale University School of Medicine, EPH-CIRA
Discussants: Representative Patricia Dillon, 92nd District; David Martineau, Immaculate Conception
Shelter & Housing Corporation
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