IDU HIV FEBRUARY 2002 PREVENTION POLICY ISSUES AND CHALLENGES IN SUBSTANCE ABUSE TREATMENT Despite the current scientific consensus on the importance and effectiveness of substance abuse treatment, barriers persist to providing it to all who need or want it. A number of creative national initiatives and many other efforts on a local and individual level are breaking down these barriers. Current Knowledge Leads to treatment programs offer a combina- • Citing estimates drawn from several Conclusions about the Usefulness tion of treatment and support strate- national data sources, the Office of Substance Abuse Treatment gies. Overall, substance abuse treatment of National Drug Control Policy’s is as effective as treatment for other National Drug Control Strategy Thirty years of research on the biological, chronic conditions, including 2001 states that about five million genetic, molecular, and social aspects of diabetes, hypertension, and asthma. drug users needed immediate treatment addiction and on substance abuse treatment in 1998, while only 2.1 million strategies have resulted in some clear • Widespread availability of and easy received it. messages about addiction and treatment: access to treatment has broad social benefits. Every $1 invested in treatment • In a 1997 consensus statement on the • Addiction is compulsive drug seeking reduces the costs of drug-related effectiveness of medical treatment for and using, even in the face of terrible crime, criminal justice costs, and theft opiate addiction, a National Institutes personal and social consequences. It by $4 to $7. When health care of Health (NIH) expert panel noted is not the result of character flaws savings are added in, total estimated that despite the effectiveness of meth- or moral failings but of profound savings can exceed costs by a ratio of adone maintenance treatment, less than changes in the brain’s structure and 12 to 1. By helping people reduce or 20 percent of the estimated 600,000 function. Addiction is a chronic and stop injecting drugs, substance abuse opiate addicts were participating in complex, but treatable, brain disease. treatment reduces the transmission of methadone treatment programs. • Addiction has powerful biological blood-borne diseases, such as HIV • The National Center on Addiction and behavioral dimensions. As a result, and hepatitis B and C. Treatment can and Substance Abuse at Columbia most injection drug users (IDUs) also improve the stability of family University (CASA) estimates that more cannot quit on their own. Substance and community life and improve a than 800,000 people in the criminal abuse treatment offers the medical, person’s prospects for employment. justice system would benefit from psychological, and behavioral support A Big Gap Exists Between Need substance abuse treatment, but fewer that individuals need to stop using than 150,000 receive it. U.S. Bureau drugs. For many, treatment is a long- for Treatment and Availability of Justice surveys conducted in 1997 term process that involves multiple of Services and 1998 show that only about 12% interventions and attempts at abstinence. of state and 10% of federal prisoners A gulf exists between the number of • Even the most severely addicted indi- people who want or could benefit from had participated in programs focusing viduals can participate in treatment substance abuse treatment and the number on substance abuse treatment. and reduce their drug use. The best of people who actually receive services: 1 IDU HIV PREVENTION Efforts to Close this Gap Face Public and private funding for substance abuse has long been an important therapeutic Policy Challenges treatment is far less than what is needed. strategy. Lack of insurance coverage for treatment, stigma attached to substance Negative attitudes and limited understanding Limited funding is an important reason abuse and addicted individuals, and lack give substance abuse treatment a low priority. why the availability of substance abuse of training and expertise in substance treatment is restricted: Public, provider, and policymaker atti- abuse issues on the part of mainstream • An exhaustive analysis of the impact medical practitioners also contribute to tudes and perceptions about drug use of substance abuse on state budgets the isolation of substance abuse treatment and users shape the importance given to published in 2001 by CASA showed from other health care services. substance abuse treatment versus other that of every dollar states spent on possible responses to drug use. A national This lack of integration with other health substance abuse and addiction, 96 inclination to respond punitively toward care services and providers is a problem cents went toward dealing with the drug users, mistaken beliefs about the because so many individuals who need consequences and only 4 cents was nature of addiction and recovery, and bias substance abuse treatment services also used for prevention and treatment. against drugs users and professionals who need other services. For example: The report also notes that “Each provide services to them have resulted in: American paid $277 per year in • More than 40 percent of people • a greater emphasis on criminal sanc- state taxes to deal with the burden with drug addictions also have mental tions for drug use, leading to a surge of substance abuse and addiction in health disorders. About 10 million in the number of people in prisons their social programs and only $10 a Americans have both substance abuse and jails (between 1980 and 1996, year for prevention and treatment.” and mental health problems. the U.S. prison population tripled, in large part because of convictions • Over the last decade federal spending • More than half of the 40,000 people associated with drugs); and on substance abuse prevention and who became infected with hepatitis treatment has increased yet it still lags C in 1999 were injection drug users; • community resistance to substance far behind spending on programs to injection drug use is also a major risk abuse treatment facilities and programs, stop drugs from entering the country factor for transmission of HIV. on the grounds that they contribute and on domestic law enforcement of to increased crime, attract undesirable drug laws and regulations. This problem is particularly severe for groups of people, and encourage the vulnerable groups who have limited or drug trade. • As substance abuse treatment increas- no contacts with health care providers ingly comes under managed care, or who have no health insurance. Many Substance abuse treatment’s low priority is resources are being more tightly of these individuals need primary health reflected in limited insurance coverage. controlled. This has resulted in care services as well as care for particular Despite the fact that managing addiction decreases in the types, duration, and health problems. is similar to managing other chronic intensity of services provided and a decline in essential complementary A Number of Initiatives are diseases, most employer-provided health insurance policies place greater burdens services, such as psychological coun- Addressing These Policy Challenges on patients of substance abuse treatment seling and help with medical, legal, Across the country, federal, state, and programs in terms of cost-sharing, financial, and employment issues. local agencies and organizations are co-payments, and deductibles. At the Substance abuse treatment has historically recognizing the value of substance same time, many plans provide less operated outside the health care mainstream. abuse treatment and the importance of coverage for the number of visits or expanding its availability to all those days of coverage and annual dollar Substance abuse treatment facilities and who need it. Here are just a few of the expenditures for treatment. Many health programs have evolved separately for initiatives underway to change the policy insurance companies have lower lifetime several reasons. One is that many pro- environment. limits on amounts that can be spent grams have been created by individuals who have overcome their own addiction Choosing treatment over incarceration. on drug and alcohol treatment than on and gone on to build systems to help In November 2000, California voters other illnesses. others. For example, individuals in approved a measure that requires sub- recovery have been key to the formation stance abuse treatment, not jail, for drug of successful “12-step” groups and possession or use. It also provides for therapeutic communities. Peer support treatment instead of prison for non- 2 IDU HIV PREVENTION violent parolees who test positive for Improving the scientific underpinnings fosters personal connections across drug use. For details, visit: of substance abuse treatment. In 1999, agency disciplines, cultures, and bureau- www.lao.ca.gov/analysis%5F2001/health%5 the National Institute on Drug Abuse cracies. These connections encourage Fss/hss%5Fcc%5Fprop36.htm (NIDA) established the National Drug staff to develop regular communications Abuse Treatment Clinical Trials and collaborative working relationships In June 2001, the Louisiana legislature Network (CTN). The CTN provides with other agencies and organizations. passed a measure that permits judges to a research infrastructure that allows For details, visit: allow probation or sentence suspension investigators to conduct rigorous multi- www.treatment.org/Topics/infectious.html for more than a dozen non-violent site clinical trials to test whether new crimes, including theft, simple possession To Learn More About This Topic treatment approaches are effective in of small amounts of drugs, bribery, and community settings. The CTN currently Read the overview fact sheet in this prostitution. Jail time for more serious includes 14 research centers, each series on drug users and substance abuse drug distribution convictions remains of which is linked to a number of treatment – “Substance Abuse Treatment mandatory, but sentences are shortened. community-based programs representing for Injection Drug Users: A Strategy In an editorial praising the legislation, The diverse treatment settings and patient with Many Benefits.” It provides basic Advocate newspaper urged the state to focus populations in that region of the information, links to the other fact on substance abuse treatment: “If there country. This network structure allows sheets in this series, and links to other are significant savings under the new rules, effective, science-based behavioral and useful information (both print and web). they ought to be spent on the programs pharmacological treatment approaches that prevent offenders from returning to Visit websites of the Centers for to be rapidly disseminated across the a life of crime: more probation and parole Disease Control and Prevention country. For details, visit: officers, and drug-treatment programs.” (www.cdc.gov/idu) and the Academy for http://188.8.131.52/CTN/index.htm For details, visit: www.theadvocate.com/ Educational Development (www.health- opinion/story.asp?storyid=3280 Increasing parity for substance abuse strategies.org/pubs/publications.htm) treatment. Beginning in 2001, the for these and related materials: Revamping methadone maintenance Federal Employees Health Benefits • Preventing Blood-borne Infections Among treatment (MMT) regulations. In Program, which covers 9 million people, Injection Drug Users: A Comprehensive May 2001, the U.S. Department of requires coverage for substance abuse Approach, which provides extensive Health and Human Services (DHHS) and mental health services equal to background information on HIV announced a fundamental shift in the that for medical, surgical, and hospital and viral hepatitis infection in IDUs federal government’s role in regulating services. Both types of coverage will and the legal, social, and policy and monitoring MMT. The new system have the same cost-sharing features, such environment, and describes strategies relies on accreditation of substance as deductibles, coinsurance, and copays. and principles of a comprehensive abuse treatment programs that use For details, visit: approach to addressing these issues. methadone and other medications by www.opm.gov/insure/health/parity/qanda.htm independent organizations and states, • Interventions to Increase IDUs’ Access to in accordance with treatment standards Improving opportunities for collabora- Sterile Syringes, a series of six fact sheets. that have been developed by the Center tion across health care, public health, for Substance Abuse Treatment (CSAT) and substance abuse treatment , • Drug Use, HIV and the Criminal Justice over the last 10 years. The standards are settings. Since 1998, CSAT, the CDC, System, a series of eight fact sheets. based on “best practice guidelines” and and the Health Resources and Services emphasize improving quality of care in Administration (HRSA) have sponsored Check out these sources of information: areas such as individualized treatment a series of cross-training workshops Amaro H. An expensive policy: the planning, increased medical supervision, across the country. These workshops impact of inadequate funding for and assessment of patients. In December give providers who work in a variety of substance abuse treatment. [Editorial] 2001, DHHS announced the selection settings (such as sexually transmitted American Journal of Public Health of four accreditation organizations that disease/HIV prevention, substance 1999;89:657-659. will be used in this new approach. For abuse treatment, primary health care, Leshner A. Addiction is a brain disease. details, visit: www.samhsa.gov/news/news.html mental health services, and criminal Issues in Science and Technology 2001;17(3). (click on Archives of News Releases justice) an opportunity to improve their www.eiconline.org/braindisease.html and scroll down to the two May 18, ability to respond to the interwoven 2001 releases) health and behavior problems of their Leshner AI. National study offers drug-using patients. The training also strong evidence of the effectiveness 3 IDU HIV PREVENTION of drug abuse treatment. NIDA Notes National Institute on Drug Abuse. Schneider Institute for Health Policy, 1997;12(5). www.nida.nih.gov/NIDA_Notes Principles of drug addiction treatment: Brandeis University. Substance abuse: /NNVol12N5/DirRepVol12N5.html a research-based guide. Rockville (MD): the nation’s number one health problem. (This article also provides links to other NIDA; 1999. NIH Publication Prepared for The Robert Wood Johnson articles describing findings from NIDA’s No. 99-4180. http://165.112.78. Foundation. Princeton (NJ): Robert Wood Drug Abuse Treatment Outcome Study 61/PODAT/PODATindex.html Johnson Foundation; February 2001. [DATOS]). www.rwjfliterature.org/chartbook/chartbook.htm National Institutes of Health. Effective National Center on Addiction and medical treatment of opiate addiction. White House Office of National Drug Substance Abuse at Columbia NIH Consensus Statement Online. Control Policy. National Drug Control University (CASA). Shoveling up: the Bethesda (MD): NIH; 1997, Nov Strategy 2001. Chapter 3. Report on impact of substance abuse on state 17-19;15(6):1-38. http://odp.od.nih.gov/ programs and initiatives, Part 2. budgets. New York: CASA; 2001. consensus/cons/108/ 108_intro.htm Treating addicted individuals. www.casacolumbia.org/publications1456/ www.whitehousedrugpolicy.gov/publications/ publications_show.htm?doc_id=47299 policy/ndcs01/index.html Produced by the Academy for Educational Development, with funding from CDC. Department of Health and Human Services http://www.cdc.gov/idu Through the Academy for Educational Development (AED), IDU-related technical assistance is available to health departments funded by CDC to conduct HIV prevention and to HIV prevention community planning groups (CPGs). For more information, contact your CDC HIV prevention project officer at 404-639-5230 or AED at (202) 884-8952.
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