Treating Drug Problems Volume 1 (1990) / Chapter Skim
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3 The Need for Treatment
3 The Need for Treatment
Pages 58-104
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From page 58... ...
Refined diagnostic tools, in combination with treatment effectiveness studies, might further indicate not only whether treatment is needed but also what type is most likely to be beneficial. Diagnostic criteria, which are discussed in detail below, distinguish 58
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From page 59... ...
And as new drugs and ways of administering them appear, the applicability of even well-tested diagnostic criteria must be reestablished. As a basis for understanding the need for treatment, the committee first outlines a conceptual model of the different types and stages of individual drug consumption and its consequences: use, abuse, dependence, recovery, and relapse.
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From page 60... ...
The treatment implications of these drug consumption patterns are quite different, and many individual variations cut across these stereotypes. clarify clinical decisions and permit intelligible estimation of the overall need for treatment in the population, it is necessary to categorize drug
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From page 61... ...
Severe sanctions TREATMENT PROGRAMS consumers based on their current dose, frequency, and method of drug consumption, taking into account their past consumption patterns and weighing the severity of associated problems and consequences including physical, emotional, and social problems. A conceptual paradigm of illicit drug consumption and responses is presented in Figure 3-1.
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From page 62... ...
The shifting normative status of marijuana among young middle-class Americans over the past 25 years is a good illustration. The overall degree of normative chill attached to illicit drug consumption varies from slight to grave depending on the details, gradations similar to the moral index applied to other classes of illegal acts ranging from traffic infractions through mass murder.
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From page 64... ...
The metabolic mechanisms of drug action in humans are shared with some other mammalian species, which has been a basis for developing animal models that have been important sources of scientific insight and testing. Some individuals respond quite positively to their initial drug experience;1 others react quite negatively (experiencing nausea, paranoia, or a 1In dramatic terms: "It's so good, don't even try it once." Although this exhortation mimics current beliefs about crack cocaine, it is actually a quotation about heroin (Smith and Gay, 1972~.
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From page 65... ...
population, even abstainers, can be viewed as incurring some risk from drug consumption: even those who have never used drugs are slightly at risk by virtue of drugs being available to them (in an ever-active market) and by virtue of the behavior of drug users in their environment.
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From page 66... ...
The mixture of drug effects that consumers seek, or are satisfied with, tends to change subtly over time, moving typical from just "getting high" or being sociable in the early stage of use to the achievement of temporary relief from the persistent desire or learned need for a drug (a desire that persists even after short-term withdrawal is completed) in the stage of dependence.
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From page 67... ...
population groups in the overall use of illicit drugs, these differences are much larger for the consumption of specific drugs.
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From page 68... ...
The earlier drug use begins, however, the more likely it is to progress to abuse or dependence; the later it begins, the more likely it is to "tail off" into renewed abstinence without further progression or, if progression occurs, to yield to earlier, more sustained recovery. Cessation without intervention does not necessarily imply a selfcontained decision that "drugs are bad." A convenient source of a favored drug may disappear, and new sources may prove undesirable or too costly.
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From page 69... ...
'typically, the initial voluntary component of drug-seeking behavior is compromised by the cumulative physiological, psychological, and social effects of the dependence process. The conditioning of behavior by physiological and psychological drug effects and by the distribution of rewards and punishments in the proximate social environment can conspire to steadily undermine the individual's ability to control the level and timing of drug consumption.
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From page 70... ...
, published in 1987 by the American Psychiatric Association. In codifying diagnostic criteria for abuse and dependence, both classification systems have converged on formulations that emphasize two fundamental observations.
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From page 71... ...
Evidence of an impaired capacity to control drug taking behavior in terms of its onset, termination, or level of use. A narrowing of the personal repertoire of patterns of drug use, e.g., a tendency to drink alcoholic beverages in the same way on weekdays and weekends and whatever the social constraints regarding appropriate drinking behavior.
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From page 72... ...
The critical commonality in these definitions and measures is that these criteria focus on impairment of control and undesirable functional consequences of excessive drug consumption. These consequences may range from health problems to lost social opportunities, but they are alike in that they are unwanted.
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From page 73... ...
, who followed 100 heroin addicts from New York City who were admitted to Lexington in the early 1950s. For most of the study period, the only form of drug treatment available was detoxification.
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From page 74... ...
continue to have these difficulties (especially if they precede drug involvement) unless specific help is received to deal with them.
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From page 75... ...
If a form of drug treatment contributes effectively to the recovery of various individuals who are so treated, it basically increases the overall group rate of recover over what would have occurred in the absence of treatment. Evaluation of treatment effectiveness therefore depends not only on adequately describing the form of treatment and measuring the outcomes among those treated but also on being able to estimate the untreated recovery rate for that group.
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From page 76... ...
their health and ability to function." More recently, for the September 1989 National Drug Control Strategy document (Office of National Drug Control Policy, 1989) , NIDA used the 1988 household survey conducted by the Research Triangle Institute (NIDA, 1989)
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From page 77... ...
The committee has developed new estimates of the need for treatment by combining information from three data sources: the 1988 NIDA/RTI national household population survey; a number of suIveys and longitudinal studies of criminal justice populations conducted or sponsored by the Bureau of Justice Statistics and the National Institute of Justice; and recent studies of the homeless population. Household Survey Data National drug use surveys to collect data from probability samples of U.S.
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From page 78... ...
Nevertheless, it is possible to use responses to relevant survey items on symptoms of dependence, negative consequences or problems attributed to 17 - a ,_ 1vS 3 1 ,~ 24 J 6 20 _ cot z 0 16 LL o ~~ 12 _ c, ~ 8 c: a: llJ ~ 4 ~ ~ Marijuana /' Stimulants ~ — Eve 1 ~ I I , ~ , , ~ , , , ~ , , I 72 74 76 78 80 YEAR b A Stimulants ~ /_ _ Cocaine ~ _ 82 84 86 88 \ Marijuana 74 76 78 FIGURE 3-5 Continued on next page 80 82 84 86 88 YEAR
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From page 79... ...
The data on each individual in the survey were classified to yield categories of clear, probable, possible, and unlikely need for treatment. Clear need was defined in terms of exceeding thresholds on three distinct criteria: illicit drug consumption at least three times weekly; at least one explicit symptom of dependence (usually two or more were present)
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From page 80... ...
The other 6.9 million recent consumers are unlikely to need drug treatment (Figure 3~. The clear and probable need cases together comprise about 4.6 million individuals, which is one-third of the 14.5 million current-month drug consumers and about 2.3 percent of the total 1988 household population of 198 million individuals aged 12 and older.
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From page 81... ...
of judicial and correctional agencies of the federal government, the 50 states, the District of Columbia, and the nation's 3,000 counties. The sizable proportion of drug treatment clients who are also criminal justice clients far exceeding the 2 percent share of the general population indicates that the need for treatment among populations supervised by the criminal justice system merits a separate accounting.
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From page 82... ...
found that 80 percent had used an illicit drug at least once, 63 percent had used such drugs regularly at some time in the past, 43 percent had used an illicit drug daily in the month prior to their offense, and 35 percent were under the influence of a drug at the time of the offense. State prison inmates typically began illicit drug use at age 15, were first arrested at age 17, and first began regular use of a "major" drug (heroin, cocaine, PCP, LSD [lysergic acid diethylamide]
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From page 83... ...
Judged according to criteria similar to those applied to the household population, prisoners who were daily drug users at the time of their offense are considered to need treatment; in fact, all of them probably meet the diagnostic criteria for drug dependence. This group comprised 43 percent of all inmates responding to the 1986 state prison survey.
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From page 84... ...
need drug treatment is therefore readily made. The much larger probation population is the least well studied of all the criminal justice populations and consequently offers the most difficulty in accurately estimating treatment needs.
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From page 85... ...
These risks from cocaine abuse or dependence appear comparable to the serious risks posed by tobacco or alcohol dependence. It is likely that the greater the severity of maternal abuse or dependence, the greater the risk of fetal damage from the pharmacological effects of the drug consumption itself and the greater the likelihood of maternal complications such as infection (most tragically, infection with the human immunodeficiency virus [HIV]
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From page 86... ...
In finer grain, the survey data indicate that about 1.5 million persons in the household population clearly need treatment; the committee believes this to be a minimum estimate of the prevalence of drug dependence in that group. The survey questions used to estimate treatment needs In the criminal justice population are simpler and cruder than those used In the household survey.
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From page 87... ...
Source: Institute of Medicine analysis of data from the National Household Survey on Drug Abuse conducted by the Research Triangle Institute; Innes (1988) ; Flanagan and Jamieson (1988)
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From page 88... ...
Another 100,000 homeless individuals who are not under criminal justice supervision also need treatment for dependence or abuse. QUANTIFYING THE CONSEQUENCES As a final component in considering the need for treatment, it is important to analyze the adverse effects the burden—of drug abuse and dependence.
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From page 89... ...
The criminal aspect of drug use accounts for more than half of the amount estimated here: $5.5 billion worth of tangible losses to victims of property and violent crimes, $12.8 billion in enforcement costs, and $17.6 billion in productivity lost to legitimate economic enterprises because of time spent instead in prison or in criminal enterprises. Nearly equal in magnitude to the sum of these crime-related costs were the estimated reductions in the productivity of employees whose work performance was impaired by drug consumption.
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From page 90... ...
However, the roughly even division between crime-related losses and employment losses bears a rough correspondence to the estimate made above: those persons who are most clearly in need of treatment for dependence are almost evenly divided between the pool of several million criminal justice clients and the much larger base population, the source of the nation's regular labor force. CONCLUSION Few if any problems in American society are as complicated or as mutable as the issue of drug use, which has been one impetus for the proliferation of policy ideas and instruments.
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From page 91... ...
. It is estimated that about 1.1 million of these individuals are dependent on drugs and are clients of the criminal justice system; another 1.4 million are dependent but not under justice system supervision; and the other 3 million individuals are drug abusers in the household population who probably need less treatment both in terms of quantity and intensity.
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From page 92... ...
, but it includes numerous items that are very similar to them. The survey inquires about the current frequency of illicit drug consumption (days of use in the past month)
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From page 93... ...
Circle the number next to each drug for which you've had withdrawal symptoms, that is, you felt sick because you stopped or cut down on your use of it. Response categories for each of the above: cigarettes; alcohol; sedatives; tranquilizers; stimulants; analgesics; marijuana; inhalants; cocaine; hallucinogens; heroin; other opiates, morphine, codeine; never experienced this.
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From page 94... ...
Consumption Level of Sample Estimated Consumptiona Cases Prevalence Unknown 215 3,744,840 11 141 2,363,026 2-4 192 3,152,013 5-8 79 1,296,743 9-16 82 1,727,539 17-24 55 987,827 25 + 63 1,206,790 Total 827 14,478,778 a Number of times drugs were used In previous month. Source: Institute of Medicine analysis of data from the 1988 National Household Survey on Drug Abuse, performed by Research Triangle Institute for the National Institute on Drug Abuse.
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From page 95... ...
9s an .
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From page 96... ...
Source: Institute of Medicine analysis of data from the 1988 National Household Survey on Drug Abuse, performed by Research Triangle Institute for the National Institute on Drug Abuse. experienced at least two symptoms and two problems.
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From page 97... ...
Source: Institute of Medicine analysis of data from the 1988 National Household Survey on Drug Abuse, performed by Research Triangle Institute for the National Institute on Drug Abuse.
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From page 98... ...
Less than $9,000/year 38 1,000,047 32.2 $9,000-20,000/year 50 1,187,341 38.2 Over $20,000/year 37 920,926 29.6 Subtotal 125 3,108,314 100.0 Total 247 4,632,515 100.0 Source: Institute of Medicine analysis of data from the 1988 National Household Survey on Drug Abuse, performed by Research Triangle Institute for the National Institute on Drug Abuse.
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From page 99... ...
FIGURE 3A-3 Confidence interval of estimates of current illicit drug use by subpopulations. The estimates indicate the illicit use of drugs during any past month for subpopulations (combinations of age, sex, race, and region)
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From page 100... ...
A positive response to one of these items, in conjunction with a positive drug test, is interpreted as indicating a likely need for drug treatment. A positive test but negative verbal responses is interpreted as ambiguous evidence of need for treatment.
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From page 101... ...
The proportion of arrestees needing drug treatment in the DUE cities can be roughly extrapolated to a national basis, adjusting for variations in the number of high-probable-need offenses (burglary, robbery, and drugs) reported in all large cities, smaller cities, suburbs, and rural areas.
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From page 102... ...
The economic value of homicide victims' lost productivity was $1.2 billion. Crime Control Resources The federal government spent $2.5 billion on criminal justice activities specifically directed against the drug trade and drug traffickers in 1988, an increase from the $1.76 billion spent in 1986 (White House Office of Public Affairs, 1988~.
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From page 103... ...
estimated that in 1983 nearly 8 million persons had severe prior histories of drug use (daily consumption of marijuana or other illicit drugs for a minimum of a month at some time in life) that were significantly related to their having a lower household income than their peers.
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From page 104... ...
from the individual to society. Health Costs Most drug treatment and prevention services are government supported, but there is also significant private payment for treatment.
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