3. Initiatives to Reduce Health and Social Problems
Drug dependence is a chronic, relapsing disorder that exacts an enormous cost on the individual, families, businesses, communities, and nation. Treatment can help individuals end dependence on addictive drugs, thereby reducing consumption. In addition, such programs can reduce the consequences of drug use on our society. Treatment's ultimate goal is to enable a patient to become abstinent. However, reducing drug use, improving the ability of addicts to function, and minimizing medical consequences are valuable and important interim outcomes. SAMHSA's 1997 Services Research Outcome Study, CSAT's 1997 National Treatment Improvement Evaluation Study (NTIES), the 1994 California Drug and Alcohol Treatment Assessment, and other studies demonstrate that treatment can reduce drug use, criminal activity, high-risk behavior, and welfare dependency. Our overall challenge is to help the 3.6 million Americans who are chronic users of illegal drugs to overcome their dependency so that they can lead healthy and productive lives and so that the social consequences of illegal drug abuse are lessened. Initiatives to achieve these ends include:
Effective rehabilitation programs characteristically differentiate by substances, cause addicts to change lifestyles, and provide follow-up services. However, not all treatment programs are equally effective. That is why efforts are underway to raise the standards of practice in treatment to ensure consistency with research findings. ONDCP and NIDA have focused on treatment in national conferences on marijuana, methamphetamine, heroin, and crack cocaine. Additional conferences on treatment modalities and treatment in the criminal-justice system are planned for the spring of 1998. CSAT continues to develop Treatment Improvement Protocols (TIPS), which provide research-based guidance for a wide range of programs. CSAT also supports eleven university-based Addiction Technology Transfer Centers, which cover twenty-four states and Puerto Rico. These centers train substance-abuse counselors and other health, social-service, and criminal-justice professionals.
Closing the Treatment Gap
Drug treatment is available for only 52 percent of people in immediate need of it, despite a 33 percent increase in federal expenditures for treatment since fiscal year 1993. The expansion of managed care and changes in eligibility requirements for Supplemental Security Income and Supplemental Security Disability Income are contributing factors in the continuing "treatment gap." ONDCP and HHS will use substance-abuse block grant funds and other means to expand the nation's treatment capacity. Special emphasis will be given to expanding treatment that meets the needs of young drug abusers, as well as women and intravenous drug users.
Treatment for Opiate Addiction
Although methadone treatment and long-term residential drug-free therapies have demonstrated effectiveness in addressing heroin addiction, only 115,000 of the nation's estimated 810,000 heroin addicts currently are in methadone treatment programs. A major reason for this shortfall is over-regulation of methadone programs. In 1995, the Institute of Medicine (IOM) concluded that existing regulations could be safely reduced. ONDCP, together with HHS and DOJ, are developing guidelines to implement the IOM recommendations. The federal government also supports the use of other pharmacotherapies, like levomethadyl acetate hydrochloride (LAAM) and buprenorphine, to treat opiate addiction.
In the past several years, significant strides have been made in drug abuse research: we have learned not only how drugs affect the brain in ways that affect behavior, but also that behavioral and environmental factors may influence brain function. Research using Positron Emission Tomography (PET) scans shows that when addicts experience cravings for a drug, specific areas of the brain show high levels of activation. Armed with this knowledge, scientists are now determining pre-addiction physiological and psychological characteristics so that "at risk" subjects can be identified before addiction or drug abuse takes place.
Drug-Free Work Place Programs
The Strategy encourages public and private-sector employers, including twenty-two million small businesses, to initiate comprehensive drug-free workplace programs. As the nation's largest employer, the federal government sets the example. Currently, 120 federal agencies have certified drug-free workplace plans. These agencies represent about 1.8 million employees -- the vast majority of the federal civilian workforce. Additionally, the Department of Transportation oversees mandatory drug testing of approximately eight million safety-sensitive employees in the United States. (The program also requires drug testing for operators of commercial motor vehicles from Canada and Mexico.) The Department of Labor's Working Partners program enlists trade associations in encouraging and assisting small businesses to implement programs and disseminates helpful information and materials. To improve the efficacy of these programs, SAMHSA has awarded nine grants to study the impact of comprehensive drug-free workplace programs on productivity and health-care costs in major U.S. corporations.
Welfare Reform and Drug Treatment
Recent legislation requires states to trim welfare roles. However, one in four of the 4.2 million recipients of Temporary Assistance to Needy Families, the federal-state welfare program, require treatment for substance abuse. Clearly, treatment opportunities must be provided to these individuals if they are to join the work force. CSAT conducted workshops in 1997 to develop solutions to this problem. The Department of Labor also recognized this problem. Consequently, its Welfare-to-Work initiative allows the provision of supportive services, such as substance-abuse education, counseling, and non-medical treatment services, to welfare recipients.
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