Treating Drug Problems Volume 1 (1990) / Chapter Skim
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Summary
Pages 1-32
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From page 1... ...
Why do the results of treatment programs vary? What are their respective benefits and costs?
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The most urgent unanswered questions in this regard are the following: · With sufficient resources and related services, would different drug treatment modalities than the ones now available be more effective for adolescents and mothers of younger children? How efficient and effective Is the current distribution of criminal justice responses to the drug problem?
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From page 3... ...
During 1965-1975, a national medical-criminal treatment policy was made viable chiefly by the emergence of promising new treatment modalities: methadone maintenance and therapeutic communities for heroin and outpatient nonmethadone programs oriented toward nonopiate drugs. In the same period the federal government sponsored the buildup of a substantial public tier of community-based drug treatment programs.
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Modalities of treatment attuned to medical-criminal ideas again seem increasingly attractive. It is becoming widely appreciated that the drug problem does not lend itself to simple characterization or solution, that a combination of ideas and policies is the most fruitful way to respond to it, and that treatment programs can and should reflect this principle of combination.
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Recovely and Relapse Drug dependence is characteristically a chronic, relapsing disorder. Drug abuse often assumes this character as well, but not as often.
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Treatment of drug problems, therefore, often addresses itself not only to drug consumption as such but also to the chronic personal impairments and social and economic deficits that often characterize those who enter treatment. Individuals without accompanying problems, who have longterm assets such as a stable job and supportive family, are not likely to need specific adjunctive services and have been found to be intrinsically less likely to relapse.
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Formal diagnostic criteria for determining the appropriateness of treatment have evolved over the years and now encompass a constellation of drug-related problems rather than focusing exclusively on classical signs such as tolerance and withdrawal symptoms. Practice in diagnosis is highly variable; nevertheless, the majority of individuals entering drug treatment programs are dependent or severe abusers by any reasonably discriminating a -- r criteria.
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Total social costs are especially difficult to estimate, being subject to many uncertainties of measurement. The costs of drug problems in the form of treatment for AIDS, prevention programs, and drug treatment programs are not insubstantial, but they are clearly much smaller than the costs incurred as a result of drug-related crime.
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Individuals often enter treatment as a strategy of partial rather than full recovery that is, to help manage serious problems with the law, their family, their mental or physical health, other drug consumers or dealers, a threat involving criminal justice supervision, or an abrupt loss of customary income. In other words, they may enter treatment to establish better control over their drug behavior or its consequences but not necessarily to extinguish the behavior entirely.
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Half or more of the admissions to typical community-based residential and outpatient drug treatment programs (except perhaps for methadone) are on probation or parole when they enter treatment.
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Yet the most important reason to consider these or related schemes to compel more of the criminal justice population to seek treatment is not that coercion may improve the results of treatment but that treatment may improve the rather dismal record of plain coercion particularly imprisonment—in reducing the level of intensively criminal behavior that ensues when the coercive grip is relaxed.
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The most extensive and scientifically best-developed evidence concerns methadone maintenance. A lower although still suggestive level of evidence is available for therapeutic communities and outpatient nonmethadone programs.
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Regarding behavior and treatment, the extensive evaluation literature on methadone maintenance yields firm conclusions as follows: · There is strong evidence from clinical trials and similar study designs that opiate-dependent individuals have better outcomes on average in terms of illicit drug consumption and other criminal behavior when maintained on methadone than when not treated at all, when simply detoxified and released, or when methadone is tapered down and terminated as a result of client request, program expulsion, or program closure. · Methadone clinics have significantly higher retention rates for opiate-dependent populations than do other treatment modalities for similar clients.
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In the later 1980s, cocaine dependence began to predominate in many programs. Therapeutic communities are designed for individuals with major impairments and social deficits, including histories of serious criminal behavior.
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· Attrition from TCs is typically high above the rates for methadone maintenance but below the rates for outpatient nonmethadone treatment. Outpatient Nonmethadone Programs Outpatient nonmethadone programs display a great deal of heterogeneity in their treatment processes, philosophies, and staffing.
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From page 16... ...
Detoxification episodes are often hospital based and may begin with emergency treatment of an overdose. However, clinicians generally advocate that, because of the narrow and short-term focus and very poor outcomes in terms of relapse to drug dependence, detoxification not be considered a modality of treatment in the same sense as methadone, TCs, outpatient nonmethadone, and CD programs.
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Most prison drug treatment programs studied, including specialized "boot camp" or "shock incarceration" facilities, have not reduced the typically high postrelease rates of recidivism (return to criminal behavior) among untreated prisoners.
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Methadone has received far more analysis than any other modality, followed by therapeutic communities and outpatient nonmethadone. Chemical dependency programs have had by far the least study.
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Methadone maintenance has been studied much more extensively than any other modality, has the smallest annual revenues of the four major modalities, and is appropriate only for long-term treatment of opiate-dependent individuals. Therapeutic communities have been studied much more than outpatient nonmethadone programs but substantially less than methadone programs.
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Chemical dependency programs are the least well studied of the drug treatment modalities. The aggressive marketing that many such programs have deployed has created suspicion about these programs in many quarters that cannot be allayed without investment in objective treatment research and evaluation.
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It is operating short of current demand in some but not all parts of the country. The private tier in 1987 supplied 212,000 drug treatment episodes with revenues of $521 million, three-fourths from privately paid fees and reimbursements; it comprised 801 proprietary and not-for-profit hospital programs (offering in almost all cases chemical dependency treatment)
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From page 22... ...
In selected regions, the public tier needs greater investments in both intensity and capacity. The private tier appears at this time to be heavily committed to acute care hospital treatment for cocaine and marijuana problems and may benefit most from either a shift toward greater use of nonhospital residential and outpatient modalities or, if such a shift cannot be effected, a move toward cost or charge structures that will permit and encourage the more extended periods of care typical of these modalities, in contrast to the short stays and high per diem charges now characteristic of hospital-based chemical dependency treatment.
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From page 23... ...
The recent decade-long hollowing-out of treatment programs through resource attrition, together with research findings about substantial variations in program performance, and the consistent importance of retention in predicting outcome all support the need for restoration of funding and quality levels in treatment. The upgrading of staff capabilities and morale and modest but critically needed renovation of decrepit facilities and furnishings have multiple significance.
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From page 24... ...
Federal and State Roles State governments have played the major role in financial administration and quality control of drug treatment programs in recent years, but there has also been cyclical movement between state and federal leadership. The federal government originally built most of the public tier of providers and then transferred responsibility for regulating and supporting this tier largely to the states; it is now moving back into the lead role.
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From page 25... ...
Mechanisms for Providing Public Support At present, the public sector provides access to drug treatment through two distinctly different financial mechanisms: direct program financing through service contracts and grants to formally defined and certified addiction treatment programs, versus individual insurance financing through Medicaid and similar programs. The largest and most important guarantee of access to drug treatment is the program of public grants or contracts with public-tier treatment providers, who serve virtually all of the medically indigent population (the poor, uninsured, or underinsured)
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From page 26... ...
There are five steps that would be particularly useful as incentives tot ward a larger role for Medicaid in treating drug problems and that would not compromise the efficiency of the direct service support mechanism. The first step is to require all parties to cooperative agreements, grants, or contracts involving federal funds to develop and display evidence of progress toward the long-term goal of increasing the receipt of funds from the Medicaid system.
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From page 27... ...
The fourth step is to reduce gross inconsistencies in the way drug problems are handled in eligibility determinations for Medicaid, Aid to Families with Dependent Children, Medicare, Supplemental Security Income, and other income maintenance, education, and housing assistance entitlement programs. These inconsistencies create a bureaucratic nightmare for the drug treatment programs and state agencies that draw on more than one such source of funds which most of them try to do.
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From page 28... ...
to determine the appropriate length of stay; and · history of failure to complete earlier ambulatory or residential detoxification versus completion in inpatient settings. As perhaps the most important and immediately needed utilization management requirement, the committee recommends that all drug treatment programs receiving public support be required to participate in a client-oriented data system that reports client characteristics, retention, and progress indicators at admission, during treatment, at discharge, and (on a reasonable sampling basis)
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PRIVATE COVERAGE OF DRUG TREATMENT (CHAPTER 8) Extent, Costs, and lYends of Coverage The private tier of drug treatment providers is largely oriented toward treating the employed population and their family members.
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From page 30... ...
Although residential drug treatment, including hospital treatment, often serves clinically important functions such as permitting intensive therapy and isolating the patient from an adverse environment or treating concurrent psychiatric or medical complications, hospital-specific components (e.g., 24-hour onsite medical coverage) do not seem to be the therapeutically important elements in drug treatment programs that are sited there, even though the availability of these components is used to justify charging acute care hospital rates for all clients.
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From page 31... ...
Sound utilization management that includes reliable performance and outcome measurements is likely to obviate the need for separate length-of-stay and dollar caps on coverage. Nonhospital residential and outpatient treatment delivered in state-certified treatment programs should be covered.
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From page 32... ...
CODA The drug problem is not a fixed constellation but a restless, everchanging composite. Within this pharmacological and sociological diversity, treatment addresses the chronic, relapsing disorders of drug dependence and abuse.
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