HIV                                                           FEBRUARY 2002


   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:


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-


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
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
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
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


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


                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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