Drug Treatment

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Drug Treatment

DRUG ABUSE AND ADDICTION

Psychiatric Definition

Though not all experts agree on a single definition of drug addiction, the Diagnostic and Statistical Manual of Mental Disorders-IV Text Revision (DSM-IV-TR ; 2000) is the most widely used reference for diagnosing and treating mental illness and substance-related disorders. In the DSM-IV-TR, the nation's psychiatrists draw a distinction between substance abuse and substance dependence. They stress that these terms should not be used interchangeably.

As also discussed in Chapter 1, the DSM-IV-TR requires that at least one of the following conditions be met within the year prior before a person can be diagnosed as a substance abuser: the person has repeatedly failed to live up to major obligations, such as on the job, at school, or in the family, because of drug use; the person has used the substance in dangerous situations, such as before driving; the person has had multiple legal problems because of drug use; or the person continued to use drugs in the face of interpersonal problems, such as arguments or fights caused by substance use.

The DSM-IV-TR requires that at least three of the following conditions be met in the previous year before a person can be said to be substance dependent: the patient has experienced increased tolerance; the patient experienced withdrawal; the patient had a loss of control over quantity or duration of use; the patient had a continuing wish or inability to decrease use; the patient spent inordinate amounts of time procuring or consuming drugs or recovering from substance use; the patient has given up important goals or activities because of substance use; or the patient has continued to use the substance despite knowledge that he or she has experienced damaging effects.

Essence of Drug Abuse

Alan I. Leshner, the director of the National Institute of Drug Abuse (NIDA), notes in his article "The Essence of Drug Abuse" (June 14, 2005, http://www.drugabuse.gov/Published_Articles/Essence.html), that:

What does matter tremendously is whether or not a drug causes what we now know to be the essence of addiction: uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences. This is the crux of how many professional organizations all define addiction, and how we all should use the term. It is really only this expression of addictionuncontrollable, compulsive craving, seeking and use of drugsthat matters to the addict and to his or her family, and that should matter to society as a whole. These are the elements responsible for the massive health and social problems caused by drug addiction.

Disease Model of Addiction

In the last twenty years of the twentieth century, advances in neuroscience led to new understanding of how people become addicted and why they stay that way. The disease model of addiction has been proposed by psychiatric and medical researchers. Addicts, they say, respond to drugs differently than people who are not addicted. Much of the difference is associated with differences in brain functioning and can be linked to genetic factors. Approaches to treatment emphasize that addiction must be treated in the same way as other chronic diseases.

A. Thomas McLellan et al., in "Drug Dependence, a Chronic Medical Illness" (Journal of the American Medical Association, October 4, 2000), liken drug dependence to chronic illnesses such as diabetes, hypertension, and asthma. McLellan et al. review scientific studies of twins and children of parents who were dependent on alcohol or other drugs. They report high degrees of correlation between parental and sibling dependence, suggesting a strong genetic component in addiction and alcoholism. In addition, people who used drugs over long periods had different patterns of brain function, which seemed to lead them to continue to use drugs. Furthermore, in "Molecular Genetics of Addiction Vulnerability" (NeuroRx, July 2006), George R. Uhl posits that "classical genetic studies document strong complex genetic contributions to abuse of multiple addictive substances."

NIDA also views drug addiction (if not all substance abuse) as a disease. On its "Frequently Asked Questions" Web page (October 10, 2006, http://www.nida.nih.gov/tools/FAQ.html), the agency answers the question, "What is drug addiction?":

Drug addiction is a complex brain disease. It is characterized by drug craving, seeking, and use that can persist even in the face of extremely negative consequences. Drug-seeking may become compulsive in large part as a result of the effects of prolonged drug use on brain functioning and, thus, on behavior. For many people, relapses are possible even after long periods of abstinence.

In Principles of Drug Addiction Treatment: A Research-Based Guide (October 1999, http://www.nida.nih.gov/PDF/PODAT/PODAT.pdf), NIDA points out that drug addiction is not only a brain disease but also leads to social "illness" and other diseases:

Addiction often involves not only compulsive drug taking but also a wide range of dysfunctional behaviors that can interfere with normal functioning in the family, the workplace, and the broader community. Addiction also can place people at increased risk for a wide variety of other illnesses. These illnesses can be brought on by behaviors, such as poor living and health habits, that often accompany life as an addict, or because of [the] toxic effects of the drugs themselves.

An Integrated Approach to Treatment

The modern approach to treatment has come to reflect the complexity of the drug abuse-addiction spectrum and combines medical approaches, behavior modification, education, and social support functions intended to redress imbalances in the patient's total environment. Components of a comprehensive drug treatment approach are shown in Figure 6.1. Arrayed in the center are categories of treatment used alone or in combination and, on the periphery, social service functions that may have to be deployed to solve some of the patient's problems that led to drug use or addiction in the first place.

HOW MANY PEOPLE ARE BEING TREATED?

UFDS/N-SSATS Data

The Substance Abuse and Mental Health Services Administration (SAMHSA), an agency of the U.S. Department of Health and Human Services, has been collecting data on substance abuse facilities since 1976. The program has had various names throughout its history; it was called the Uniform Facility Data Set (UFDS) survey until 2000, when the name was changed to the National Survey of Substance Abuse Treatment Services (N-SSATS). In the course of this program's history, the data collected have changed, introducing discontinuities in reporting. Until 1998, under the UFDS, data on clients of treatment services were reported in some detail, were omitted in 1999, and reintroduced in limited format in 2000. The most recent UFDS data on the gender, racial, ethnic, and age characteristics of people in treatment were reported in 1998. Data on these breakdowns of admissions, however, have continued to be available from another SAMHSA source: the Treatment Episode Data Set, which is discussed later in this chapter.

N-SSATS numbers represent a snapshot of the treatment units on a particular day and do not indicate how many people were being treated over the course of the entire year. As of March 31, 2004, N-SSATS reported in the National Survey of Substance Abuse Treatment Services (N-SSATS): 2004Data on Substance Abuse Treatment Facilities (2005, http://wwwdasis.samhsa.gov/04nssats/index.htm) that the number of people in the treatment facilities who responded to the survey stood at slightly over 1.07 million, representing a slight increase since the 1998 figure of nearly 1.04 million. (See Table 6.1.)

NSDUH Data

The SAMHSA also included questions about treatment in its 2005 National Survey on Drug Use and Health (NSDUH) to collect data from people who sought and received substance abuse treatment. Figure 6.2 shows the results of asking recipients where they received treatment for substance use in the past year at any location. People could report receiving treatment at more than one location. (This definition of treatment location is different from the specific treatment facilities reporting to the SAMHSA for N-SSATS.) The NSDUH determines that self-help groups, outpatient rehabilitation facilities, inpatient rehabilitation facilities, outpatient mental health centers, and hospital inpatient facilities are where people say they most commonly receive treatment.

The NSDUH also asked substance abusers why they did not receive the treatment they needed. SAMHSA data show that 7.6 million people needed treatment in 2005, but only a fraction of these people (the 1.07 million mentioned previously) received treatment at a specialty facility. Figure 6.3 shows that most people (44.4%) cited financial reasons for not receiving treatment. One out of five admitted that they were not yet ready to give up drugs.

Treatment Episode Data Set Data

Another source of data for the drug-treatment population comes from the SAMHSA's Treatment Episode Data Set (TEDS). This program counts admissions over the period of a year rather than the number of people in treatment on a particular date during the year. When the same person is admitted twice during the same year, he or she is counted twice, whereas in the UFDS/N-SSATS survey individuals are counted only once. As reported in Treatment Episode Data Set (TEDS) 19942004: National Admissions to Substance Abuse Treatment Services (July 2006, http://wwwdasis.samhsa.gov/teds04/tedsad2k4web.pdf), TEDS data for 1998 showed over 1.7 million admissions (versus UFDS's nearly 1.04 million). TEDS admissions in 2004 were over 1.8 million.

CHARACTERISTICS OF THOSE ADMITTED

TEDS data from 1994 to 2004 on admissions by sex, race/ethnicity, and age are presented in Table 6.2 and Table 6.3.

Gender

As shown in Table 6.2, males represented most of those admitted for drug and/or alcohol treatment, although the percentage of men dropped slightly between 1994 and 2004 (from 71.4% to 68.5%) and that of women increased (from 28.6% to 31.5%). The number of males admitted for treatment in 2004 was nearly 1.3 million versus just over 590,000 female admissions. (See Table 6.3.) These results and data from the NSDUH reflect that a greater proportion of men abuse drugs than women in the United States. According to Table 4.1 in Chapter 4, 9.9% of males were past-month users in 2004, compared with 6.1% of females.

Race and Ethnicity

In 2004 whites were most of those admitted to substance abuse treatment facilities (60%; see Table 6.2) and were those admitted in the greatest numbers (1.1 million; see Table 6.3). They were followed by African-Americans at 22.5% (419,099). Compared with data from 1994, whites increased from 58.3% (963,257) and African-Americans decreased from 27.1% (447,945). Hispanics

TABLE 6.1
Persons admitted into substance abuse treatment, by state or region and type of care received, March 31, 2004
State or jurjsdiction * Number
Total Type of care offered
Total outpatient Outpatient Total residential Residential Total hospital inpatient Hospital inpatient
Regular Intensive Day treatment or partial hospitalization Detox Methadone maintenance Short-term Long-term Detox Treatment Detox
Total 1,072,251 954,551 564,300 121,862 28,133 12,064 228,192 101,713 21,758 72,934 7,021 15,987 9,773 6,214
Alabama 12,106 10,931 1,359 4,350 280 76 4,866 1,123 381 647 95 52 32 20
Alaska 2,503 2,097 1,480 404 110 20 83 388 106 249 33 18 7 11
Arizona 23,527 21,563 13,328 2,679 469 701 4,386 1,743 438 1,163 142 221 112 109
Arkansas 3,165 2,507 1,583 436 62 124 302 555 221 288 46 103 66 37
California 140,401 121,676 71,976 16,610 3,890 2,597 26,603 17,567 2,229 14,287 1,051 1,158 733 425
Colorado 30,501 28,602 24,177 1,879 398 125 2,023 1,762 229 1,238 295 137 104 33
Connecticut 21,363 18,960 8,023 1,715 666 302 8,254 1,778 573 1,084 121 625 239 386
Delaware 3,977 3,735 2,103 228 52 23 1,329 162 10 108 44 80 68 12
District of Columbia 5,365 4,426 1,256 1,012 237 35 1,886 861 278 459 124 78 66 12
Fed. of Micronesia
Florida 45,215 38,737 25,097 2,876 1,424 262 9,078 5,487 783 4,282 422 991 595 396
Georgia 17,238 14,576 6,235 2,168 2,191 240 3,742 2,162 235 1,719 208 500 309 191
Guam 178 178 100 78
Hawaii 3,618 3,005 1,581 629 163 21 611 386 70 306 10 227 200 27
Idaho 4,017 3,768 2,907 830 17 14 193 70 95 28 56 28 28
Illinois 42,709 39,055 21,968 4,652 640 157 11,638 3,385 711 2,427 247 269 116 153
Indiana 25,396 24,102 15,022 5,020 393 256 3,411 998 218 715 65 296 160 136
Iowa 8,220 7,579 5,819 1,271 216 20 253 620 200 400 20 21 5 16
Kansas 9,796 8,969 6,352 1,591 157 53 816 752 318 363 71 75 54 21
Kentucky 18,261 17,001 14,157 1,409 116 14 1,305 1,021 241 686 94 239 168 71
Louisiana 12,313 10,432 5,746 1,631 215 98 2,742 1,515 427 960 128 366 213 153
Maine 7,109 6,693 4,359 434 173 121 1,606 326 52 274 90 40 50
Maryland 34,449 32,192 15,567 3,269 491 614 12,251 2,078 558 1,416 104 179 149 30
Massachusetts 35,998 31,866 19,958 779 582 829 9,718 3,158 477 2,342 339 974 274 700
Michigan 42,121 38,615 28,315 2,469 235 546 7,050 3,255 1,071 1,955 229 251 172 79
Minnesota 9,679 6,714 2,075 2,542 388 25 1,684 2,632 846 1,633 153 333 287 46
Mississippi 6,095 4,649 3,636 559 452 2 1,113 218 886 9 333 240 93
Missouri 17,566 15,593 9,541 3,520 846 36 1,650 1,653 1,083 474 96 320 235 85
Montana 2,715 2,491 2,087 377 12 15 165 61 45 59 59 43 16
Nebraska 4,976 4,174 3,226 720 25 17 186 744 224 473 47 58 56 2
Nevada 8,335 7,458 4,885 613 59 73 1,828 795 109 633 53 82 18 64
New Hampshire 3,517 3,211 2,604 90 6 115 396 288 103 147 38 18 6 12
New Jersey 29,687 26,609 9,259 3,599 1,259 1,815 10,677 2,482 364 2,046 72 596 433 163
New Mexico 11,517 10,802 7,518 830 165 144 2,145 622 141 367 114 93 70 23
New York 120,451 107,399 46,147 13,115 5,471 358 42,308 10,723 1,503 8,607 613 2,329 1,318 1,011
North Carolina 26,169 24,024 15,013 3,099 241 185 5,486 1,757 393 1,245 119 388 257 131
North Dakota 2,383 2,045 1,147 431 447 20 282 70 206 6 56 52 4
Ohio 36,133 33,417 24,225 5,654 475 218 2,845 2,262 410 1,754 98 454 288 166
Oklahoma 8,738 7,593 6,014 801 90 226 462 1,056 274 688 94 89 39 50
Oregon 18,735 17,553 11,430 3,253 102 84 2,684 1,160 218 859 83 22 9 13
Palau 42 39 29 10 3 3
Pennsylvania 38,796 33,744 18,206 4,863 825 92 9,758 4,271 1,466 2,548 257 781 640 141
Puerto Rico 10,974 6,312 1,876 204 379 98 3,755 4,222 112 3,818 292 440 345 95
Rhode Island 6,590 6,237 2,642 118 64 164 3,249 329 27 272 30 24 24
TABLE 6.1
Persons admitted into substance abuse treatment, by state or region and type of care received, March 31, 2004 [continued]
State or jurjsdiction * Number
Total Type of care offered
Total outpatient Outpatient Total residential Residential Total hospital inpatient Hospital inpatient
Regular Intensive Day treatment or partial hospitalization Detox Methadone maintenance Short-term Long-term Detox Treatment Detox
*Facilities operated by federal agencies are included in the states in which the facilities are located.
Quantity is zero.
Source: "Table 6.24a. Clients in Treatment, according to Type of Care Received, by State or Jurisdiction: March 31, 2004, Number," in National Survey of Substance Abuse Treatment Services (N-SSATS): 2004, Data on Substance Abuse Treatment Facilities, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, August 2005, http://wwwdasis.samhsa.gov/04nssats/nssats_rpt_04.pdf (accessed October 17, 2006)
South Carolina 13,641 13,019 9,570 1,070 89 44 2,246 341 96 206 39 281 152 129
South Dakota 1,991 1,495 1,026 402 51 16 452 139 253 60 44 44
Tennessee 13,139 10,949 6,738 1,414 211 32 2,554 1,823 917 819 87 367 208 159
Texas 33,820 27,278 13,363 4,013 1,117 218 8,567 5,581 1,589 3,758 234 961 586 375
Utah 9,732 8,695 5,784 987 471 105 1,348 991 68 849 74 46 29 17
Vermont 2,668 2,522 2,142 219 49 3 109 106 43 52 11 40 16 24
Virgin Islands 135 116 84 32 19 19
Virginia 22,298 20,919 15,775 1,536 575 171 2,862 1,228 348 747 133 151 66 85
Washington 34,839 32,940 22,468 6,631 166 329 3,346 1,730 750 859 121 169 119 50
West Virginia 7,103 6,677 3,226 701 176 105 2,469 371 75 277 19 55 22 33
Wisconsin 17,354 15,918 12,164 1,430 655 44 1,625 1,068 207 773 88 368 266 102
Wyoming 2,887 2,694 1,932 620 80 62 172 8 158 6 21 19 2

increased their proportion of admissions to drug treatment facilities from 11% (181,168) in 1994 to 12.7% (235,793) in 2004. American Indians and Alaskan Natives dropped in share of those treated from 2.3% to 2.1% during this period. Asian and Pacific Islanders increased by 0.3% but remained less than 1% of the total admissions.

Age

In 1994 the age group with the largest number receiving substance abuse treatment was twenty-five- to thirty-four-year-olds (37.8% of total), followed by those aged thirty-five to forty-four years (29.1%). Ten years later, these were still the two largest groups receiving treatment, but the order was reversed: those aged thirty-five to forty-four were in the group having the highest percentage receiving substance abuse treatment and those aged twenty-five to thirty-four were in the group having the second-highest percentage. The percentage of the younger group decreased to 24.7% in 2004, whereas the percentage of the older group stayed about the same (29%), thus causing the order reversal. Those aged sixty-five and older were least represented (after those under the age of twelve), accounting for 0.8% in 1994 and 0.6% in 2004. (See Table 6.2.)

TYPES OF TREATMENT

The treatment that recovering drug addicts receive depends on the types of drugs to which they are addicted. Regardless of the substance they are addicted to, most treatment programs involve some form of rehabilitation ("rehab"). Drug rehab refers to processes that assist a drug-addicted person in discontinuing drug use and returning to a drug-free life. For many types of addiction, rehab is the only form of treatment that is needed. However, those who are addicted to opiates typically must undergo a period of detoxification ("detox") before rehab can begin. In some cases opiate addicts are given opioid substitutes to help them with their addiction.

Detox

Individuals addicted to opium-based drugs must usually undergo medical detox in an outpatient facility, a residential center, or a hospital. Medical help, including sedation, is provided to manage the painful physical and psychic symptoms of withdrawal. Counseling is always available as well; in many detox centers group therapy is available. NIDA, however, describes detoxification as a precursor to rehabilitation because that process cannot begin until the individual's body has been cleared of the drug and a certain physiological equilibrium has been established. Rehabilitation usually follows detoxification.

Rehabilitation

Rehab has many forms, but it is always designed to change the behavior of the drug abuser. Changed behaviorachieving independence of drugs or alcoholrequires understanding the circumstances that led to dependence, confidence that the individual can succeed, and changes in lifestyle so that the individual avoids occasions that produced drug-using behavior. Individual counseling, interaction with support groups, and formal education are used in combination with close supervision, incentives, and disincentives. Certain individuals require a new socialization that is achieved by living for an extended time in a structured and supportive environment in which new life skills can be acquired. Treatment may involve guiding the individual to seek help from other social agencies (as shown in the circle in Figure 6.1) to reorder his or her life.

Individuals, of course, may be mentally ill and will then receive, as part of drug rehab, mental health services in outpatient or hospital settings. Most treatment takes place in outpatient settings, with the individual reporting daily, weekly, or less frequently for periodic treatment and assessment.

OPIOID SUBSTITUTE PROGRAMS

Heroin addicts and those habituated to other opium-based substances follow usual treatment programs but may, in addition, be prescribed what are known as opioid substitutes. The best known of the opioid substitutes is methadone, which is an agonist, a chemical substance that activates brain receptors. In the case of methadone, the brain receptors it activates are the same receptors that respond to heroin. However, heroin addiction disrupts many physiological functions, whereas methadone normalizes those functions. Many studies show methadone to be effective; likewise, many thousands lead normal lives using this heroin substitute. Methadone was approved for use in 1972.

Levo-alpha-acetylmethadol (LAAM), which was approved in 1993, is another agonist used in treating drug dependency. Whereas methadone must be taken daily, LAAM can be taken three times per week. Use of LAAM and methadone is not without risk. It is possible to become dependent on them just as it is with heroin and other opioids. However, clinical experience with both methadone and LAAM indicates that these medications have a much lower potential for abuse than heroin.

Naltrexone is an antagonist, a chemical substance that reduces the effect of another chemical substance on the body. Naltrexone blocks the effect of heroin on the brain's receptors and can reduce involuntary compulsive drug craving. It can be prescribed by physicians and is effective both against alcohol dependency and in detox. As reported in "Subutex and Suboxone Approved to Treat Opiate Dependence" (FDA Talk Paper, October 2, 2002), buprenorphine, which was approved for use by the U.S. Food and Drug Administration in 2002, acts as an agonist at lower doses and as an antagonist at higher doses.

Distribution of Patients

The great majority of patients undergoing treatment in 2004 were receiving outpatient care, 954,551 (89%) of nearly 1.1 million patients on March 31 of that year. (See Table 6.1.) Of the remainder, 101,713 (9.5%) were in residential facilities and 15,987 (1.5%) received hospital inpatient treatment. Of those under outpatient treatment but not in detox, the majority were receiving what the SAMHSA labels regular, or nonintensive, treatment.

Of the total treatment population, 25,299 individuals (2.4% of all patients) were undergoing detox, most in outpatient settings (12,064), the rest in residential facilities (7,021) and hospitals (6,214). Among all patients under treatment, 228,192 (21.3%) were receiving methadone. (See Table 6.1.)

TABLE 6.2
Percentage of persons admitted into substance abuse treatment, by gender, ethnicity, and age at admission, 19942004
Sex, race/ethnicity, and age at admission TEDS admissions * U.S. population
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2004
*Treatment episode data set
Source: "Table 2.9b. Admissions by Sex, Race/Ethnicity, and Age at Admission: TEDS 19942004 and U.S. Population 2004 Percent Distribution," in Treatment Episode Data Set (TEDS) 19942004: National Admissions to Substance Abuse Treatment Services, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, July 2006, http://wwwdasis.samhsa.gov/teds04/tedsad2k4web.pdf (accessed October 17, 2006)
Sex
Male 71.4 70.7 70.5 70.4 70.5 70.5 70.0 69.8 69.8 69.1 68.5 48.9
Female 28.6 29.3 29.5 29.6 29.5 29.5 30.0 30.2 30.2 30.9 31.5 51.1
   Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Race/ethnicity
White (non-Hispanic) 58.3 59.0 59.8 59.6 59.5 59.2 58.5 59.1 58.8 58.7 60.0 70.2
Black (non-Hispanic) 27.1 26.7 25.7 25.3 24.9 24.3 24.9 24.4 24.2 24.0 22.5 12.4
Hispanic 11.0 10.7 10.4 10.9 11.3 12.0 12.0 12.0 12.6 12.7 12.7 12.0
American Indian/Alaska Native 2.3 2.3 2.5 2.4 2.4 2.4 2.3 2.2 2.1 2.0 2.1 0.8
Asian/Pacific Islander 0.6 0.6 0.6 0.7 0.7 0.8 0.8 0.8 0.9 1.0 0.9 4.3
Other 0.8 0.8 1.0 1.1 1.2 1.4 1.6 1.5 1.4 1.6 1.8 0.4
   Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Age at admission
Under 12 years 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.1 0.1 0.2 0.2 16.4
12 to 17 years 6.6 7.4 7.9 8.2 8.1 8.0 7.8 8.2 8.3 8.4 8.3 8.8
18 to 24 years 14.0 13.8 13.4 13.8 14.4 15.0 15.8 16.6 17.1 17.4 18.1 9.9
25 to 34 years 37.8 36.1 33.9 32.2 30.3 28.4 27.0 26.0 25.1 24.7 24.7 12.8
35 to 44 years 29.1 29.9 31.0 31.6 32.2 32.6 32.6 31.9 31.1 30.3 29.0 15.0
45 to 54 years 9.1 9.5 10.3 10.8 11.5 12.4 13.2 13.8 14.7 15.3 15.8 14.3
55 to 64 years 2.5 2.4 2.5 2.5 2.6 2.7 2.8 2.7 3.0 3.1 3.2 10.0
65 years and older 0.8 0.7 0.7 0.7 0.7 0.7 0.7 0.6 0.6 0.6 0.6 12.6
   Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

STATISTICS ON ADMITTED PATIENTS

Admissions by Substance

Data on admissions by the primary substance of abuse provided by TEDS for 2004 are shown in Table 6.4. In that year alcohol alone and with a secondary drug is the primary substance for which the greatest number of people received treatment (753,464, or 40.2%, of all admissions), followed by opiates (329,138, or 17.6%, mainly heroin), marijuana (298,317, or 15.9%), cocaine (256,387, or 13.7%), and stimulants (151,404, or 8.1%, primarily methamphetamine).

The 2004 admissions for alcohol abuse (either alone or in combination with a secondary substance) of 40.2% is down from 52.8% reported by TEDS in 1994. Total alcohol-related admissions have been declining annually, largely accounting for the decreasing trend in total admissions.

The category showing the largest growth has been stimulants. In 1994 stimulants accounted for 2.7% of all admissions, whereas in 2004 they accounted for 8.1%, as indicated by the admissions numbers in Table 6.4. Within the stimulant category, admissions caused by amphetamine (particularly methamphetamine) accounted for the vast majority. Methamphetamine is addictive and is produced in illicit makeshift laboratories around the country. Marijuana-related admissions have had the second most rapid growth, representing 15.9% of cases in 2004, up from 8.5% as reported by TEDS in 1994.

Opiate-related admissions have been growing, and cocaine-related admissions have been declining. In 1994 opiate-caused admissions were 13.8% and cocaine-caused admissions were 17.8% of the total; ten years later their percentages were reversed, with opiates accounting for 17.5% and cocaine for 13.7% of admissions, as indicated by the admissions numbers in Table 6.4. The largest decline of admissions from 1994 to 2004 has been for cases involving inhalants, declining to 0.06% of all admissions in 2004, down from 0.16% in 1994.

Demographics by Substance

A detailed examination of admissions in 2004 is provided in Table 6.4, which shows the distribution of people admitted by major drug categories, gender, race/ethnicity, and age at admission.

GENDER

As noted previously in this chapter, total male admissions (68.5%) were higher than total female admissions (31.5%) in 2004. As Table 6.4 shows, this trend held in all but two substance categories: sedatives (54.4% females versus 45.6% males) and tranquilizers

TABLE 6.3
Persons admitted into substance abuse treatment, by gender, ethnicity, and age at admission, 19942004
Sex, race/ethnicity, and age at admission 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Source: "Table 2.9a. Admissions by Sex, Race/Ethnicity, and Age at Admission: TEDS 19942004, Number," in Treatment Episode Data Set (TEDS) 19942004: National Admissions to Substance Abuse Treatment Services, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, July 2006, http://wwwdasis.samhsa.gov/teds04/tedsad2k4web.pdf (accessed October 17, 2006)
   Total 1,665,331 1,675,380 1,639,064 1,607,957 1,712,268 1,725,885 1,802,807 1,824,254 1,938,846 1,892,733 1,872,784
Sex
Male 1,182,286 1,179,563 1,151,527 1,128,154 1,202,608 1,212,676 1,258,788 1,271,668 1,352,419 1,307,112 1,281,888
Female 473,884 488,715 481,191 474,350 502,961 507,136 538,888 550,169 585,538 584,984 590,043
No. of admissions 1,656,170 1,668,278 1,632,718 1,602,504 1,705,569 1,719,812 1,797,676 1,821,837 1,937,957 1,892,096 1,871,931
Race/ethnicity
White (non-Hispanic) 963,257 981,359 973,808 948,992 1,004,115 1,008,503 1,044,157 1,069,476 1,131,619 1,103,598 1,116,708
Black (non-Hispanic) 447,945 443,964 418,514 402,619 419,784 413,754 443,894 441,260 465,187 451,247 419,099
Hispanic 181,168 178,269 169,285 173,347 191,484 203,750 213,508 217,017 242,683 238,481 235,793
American Indian/Alaska Native 38,404 37,704 40,082 38,333 40,511 40,138 40,618 40,296 41,266 37,208 38,141
Asian/Pacific Islander 9,873 9,870 10,197 10,893 11,515 13,610 14,980 14,405 16,802 17,940 16,371
Other 12,896 13,193 16,606 18,263 20,351 23,467 27,999 26,354 27,255 30,604 34,213
No. of admissions 1,653,543 1,664,359 1,628,492 1,592,447 1,687,760 1,703,222 1,785,156 1,808,808 1,924,812 1,879,078 1,860,325
Age at admission
Under 12 years 3,211 3,616 3,469 3,704 3,390 2,987 3,050 2,484 2,486 2,931 3,677
12 to 17 years 109,122 122,909 129,858 131,194 139,129 137,596 140,996 148,848 160,856 158,397 155,585
18 to 24 years 232,063 230,645 219,406 220,714 245,508 258,208 283,375 302,548 330,298 329,178 338,295
25 to 34 years 628,260 603,148 555,300 516,346 517,297 488,394 485,287 472,698 485,505 467,386 462,148
35 to 44 years 482,401 499,650 507,067 506,624 549,754 559,649 585,376 580,546 601,594 571,839 541,498
45 to 54 years 151,320 159,111 167,899 173,335 197,211 213,538 237,555 251,555 285,247 289,284 295,039
55 to 64 years 41,052 40,390 41,377 40,736 44,096 46,299 49,505 49,704 57,087 58,701 60,432
65 years and older 12,967 11,938 11,535 11,381 11,611 11,652 12,297 11,554 11,650 11,412 11,713
No. of admissions 1,660,396 1,671,407 1,635,911 1,604,034 1,707,996 1,718,323 1,797,441 1,819,937 1,934,723 1,889,128 1,868,387
TABLE 6.4
Percentage of persons admitted into substance abuse treatment, by gender, ethnicity, and primary substance abused, 2004
Sex, race/ethnicity All admissions Primary substance at admission
Alcohol Opiates Cocaine Marijuana/hashish Stimulants Trahquilizers Sedatives Hallucinogens PCP Inhalants Other/none specified
Alcohol only With secondary drug Heroin Other opiates Smoked cocaine Other route Methamphetamine/smphetamine Other stimulants
*Less than 0.05 percent.
Quantity is zero.
Source: "Table 3.1a. Admissions by Primary Substance of Abuse, according to Sex and Race/Ethnicity: TEDS 2004 Column Percent Distribution," in Treatment Episode Data Set (TEDS) 19942004: National Admissions to Substance Abuse Treatment Services, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, July 2006, http://wwwdasis.samhsa.gov/teds04/tedsad2k4web.pdf (accessed October 17, 2006)
   Total 1,875,026 416,510 336,954 265,895 63,243 184,949 71,438 298,317 150,402 1,007 8,558 4,487 2,708 3,272 1,209 66,377
Sex
Male 68.5 74.9 73.8 68.0 52.8 58.6 66.1 74.2 54.8 57.4 47.6 45.6 71.5 66.5 68.7 58.7
Female 31.5 25.1 26.2 32.0 47.2 41.4 33.9 25.8 45.2 42.6 52.4 54.4 28.5 33.5 31.3 41.3
   Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
No. of admissions 1,874,173 416,336 336,808 265,842 63,212 184,895 71,403 298,139 150,343 1,006 8,556 4,485 2,403 3,272 1,207 66,266
Race/ethnicity
White (non-Hispanic) 60.0 70.4 60.4 50.4 88.8 37.8 51.5 54.3 72.6 62.3 85.0 82.9 69.8 19.9 67.4 67.3
Black (non-Hispanic) 22.5 12.4 24.6 23.6 4.7 53.0 28.9 28.6 2.5 21.0 5.3 6.7 16.9 50.3 6.2 16.2
Hispanic origin 12.8 11.7 10.2 23.0 3.4 6.7 15.9 12.2 15.8 10.2 7.6 6.9 8.2 22.8 18.7 10.9
    Mexican 5.2 6.2 3.3 5.4 1.2 2.2 5.6 5.6 12.3 4.0 1.4 3.3 2.8 11.8 13.5 1.1
    Puerto Rican 3.9 1.7 3.6 12.7 1.0 2.3 5.3 3.0 0.3 2.4 3.9 1.9 2.0 6.5 1.7 1.5
    Cuban 0.3 0.3 0.2 0.4 0.1 0.5 0.9 0.4 0.2 0.4 0.2 0.2 0.2 0.6 0.1 0.3
    Other/not specified 3.4 3.4 3.0 4.5 1.1 1.8 4.1 3.3 3.0 3.5 2.0 1.6 3.1 3.9 3.5 8.1
Other 4.8 5.6 4.8 3.0 3.1 2.5 3.7 4.8 9.1 6.5 2.1 3.4 5.2 7.0 7.6 5.6
Alaska Native 0.1 0.1 0.1 0.2 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.2 0.1 0.4 *
American Indian 1.9 3.0 2.6 0.6 1.5 0.7 1.0 1.6 2.2 1.7 0.7 1.2 1.0 1.0 4.9 3.1
Asian/Pacific Islander 0.9 0.8 0.6 0.4 0.6 0.5 0.5 1.1 3.0 1.4 0.3 0.6 1.7 0.5 0.8 0.7
Other 1.8 1.6 1.5 1.8 1.0 1.2 2.1 2.0 3.8 3.3 1.0 1.4 2.4 5.1 1.8 1.8
   Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
No. of admissions 1,862,567 414,176 335,298 264,017 62,798 184,211 70,899 296,331 149,696 1,006 8,538 4,469 2,391 3,252 1,201 64,284

(52.4% females versus 47.6% males). The greatest male-female differences were noted in alcohol-only admissions (74.9% males versus 25.1% females), marijuana-related admissions (74.2% males versus 25.8% females), and alcohol admissions with a secondary drug (73.8% males versus 26.2% females).

RACE AND ETHNICITY

In 2004 whites made up 60% of the substance abuse treatment admissions, African-Americans 22.5%, Hispanics 12.8%, American Indians 1.9%, and Asians and Pacific Islanders 0.9%. Whites had the highest admission rates for all drug categories except smoked cocaine and phencyclidine (PCP). African-Americans had the highest smoked-cocaine admissions (53%) and PCP-related admissions (50.3%). African-Americans were second in admission rates for all other substances of abuse except methamphetamine/amphetamine-, tran-quilizer-, and sedative-related admissions. Hispanics were generally third in admission rates but were second in methamphetamine/amphetamine-, tranquilizer-, and sedative-related admissions. (See Table 6.4.) It is important to note that the Hispanics category is treated as an "ethnicity" rather than as a race and includes both white and black individuals of Hispanic origin.

It is, however, important to consider these rates of substance abuse treatment by race in the context of the overall racial composition of the United States. The 2004 TEDS data indicate that 70% of whites, 13% of Hispanics, and 12% of African-Americans made up the population. When substance abuse treatment rates are compared to these population statistics, whites were underrepresented in treatment (60% in treatment versus 70% in the population), the proportion of Hispanics in treatment was comparable to Hispanics in the population (12.8% in treatment versus 13% in the population), and African-Americans were disproportionately admitted for treatment (22.5% in treatment versus 12% in the population).

AGE AT ADMISSION

The 2004 TEDS data show that 85.4% of people admitted for alcohol-only abuse that year were between the ages of twenty and fifty-four and had an average age of thirty-nine years. Crack cocaine treatment recipients (74.9%) clustered in the thirty- to forty-nine-year-old age group and had an average age of thirty-eight years. In contrast, 46.1% of those admitted for using inhalants were aged seventeen or younger and had an average age of twenty-four years. Those being treated for marijuana abuse were another "young" group. Nearly three-quarters (73.3%) were between the ages of fifteen and twenty-nine. The marijuana treatment group had an average age of twenty-four years.

Type of Treatment

In 2004, 62.5% of those admitted to treatment were admitted into ambulatory (nonresidential) treatment facilities; of the remainder, 17.3% went into residential facilities and 20.2% went into residential-type (twenty-four-hour) detoxification. (See Table 6.5.)

Among those going into drug-related detoxification, the largest percentages had been admitted for tranquilizer use (33%) and heroin (33.1%). Those using marijuana had the highest percentage entering ambulatory care (83.5%). The largest proportions of substance abusers assigned to residential treatment were cocaine users at 54.6%. (See Table 6.5.)

Referring Source

Table 6.6 shows the source of referral of patients to substance abuse treatment in 2004. Just over one-third of all people admitted came to get treatment at their own volition (33.7%). The largest referral source (sending 36.3% of individuals) was the criminal justice system, referring people for drug use or driving under the influence of alcohol. Much of the remaining third of all referrals came from substance abuse treatment providers and other health care agencies (10.7% and 6.9% of referrals, respectively), referring individuals for specific services. Other referrals came from schools, employers, and community agencies.

Regarding the source of referral based on the drug of abuse, Table 6.6 data show that most heroin users (57.8%) and other opiate users (49.8%) sought treatment of their own accord. Justice system sources sent most marijuana users (57%), meth users (50.4%), and PCP users (58.9%), along with many hallucinogen users (49.5%) and alcohol-only users (41.6%) to treatment.

HOW EFFECTIVE IS TREATMENT?

During the 1960s there was an opioid epidemic in the United States, and the federal government released substantial funds to substance abuse treatment programs. This funding has continued over the decades and is supplemented by state governments and private sources. Table 9.2 in Chapter 9 shows that the 2007 federal budget request for drug abuse treatment was $2.4 billion, and the request for treatment research was $605 million.

With so much money devoted to substance abuse treatment, there has been considerable research conducted on the effectiveness of the programs. The bulk of this research began in the late 1960s and extended into the 1990s.

In "New Research Documents Success of Drug Abuse Treatments" (December 15, 1997, http://www.nih.gov/news/pr/dec97/nida-15.htm), the National Institutes of Health notes that the first major study of drug-treatment effectiveness was the Drug Abuse Reporting Program (DARP), which studied more than forty-four thousand clients in more than fifty treatment centers from 1969 to 1973. Program staff then studied a smaller group of these clients

TABLE 6.5
Percentage of persons admitted into substance abuse treatment, by primary substance of abuse and type of care received, 2004
Type of service and planned use of opioid treatment All admissions Primary substance at admission
Alcohol Opiates Cocaine Marijuana/hashish Stimulants Tranquilizers Sedatives Hallucinogens PCP Inhalants Other/none specified
Alcohol only With secondary drug Heroin Other opiates Smoked cocaine Other route Methamphetamine/smphetamine Other stimulants
Source: Adapted from "Table 3.6. Admissions by Primary Substance of Abuse, according to Type of Service and Opioid Replacement Therapy: TEDS 2004, Percent Distribution," in Treatment Episode Data Set (TEDS) 19942004: National Admissions to Substance Abuse Treatment Services, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, July 2006, http://wwwdasis.samhsa.gov/teds04/tedsad2k4web.pdf (accessed October 17, 2006)
   Total 1,875,026 416,510 336,954 265,895 63,243 184,949 71,438 298,317 150,402 1,007 8,558 4,487 2,408 3,272 1,209 66,377
Type of service
Ambulatory 62.5 59.1 58.6 51.3 56.8 52.4 63.3 83.5 65.0 68.4 49.0 59.1 71.9 70.6 68.2 81.3
   Outpatient 50.2 49.2 47.6 37.4 42.1 39.0 47.9 68.3 51.7 59.0 37.0 46.9 60.1 58.9 56.2 76.9
   Intensive outpatient 10.6 9.3 10.5 5.3 11.3 13.0 14.9 14.8 13.2 8.7 10.9 10.6 11.3 11.7 11.0 3.8
   Detoxification 1.7 0.6 0.4 8.6 3.4 0.4 0.5 0.4 0.2 0.7 1.1 1.6 0.5 * 0.9 0.6
Detoxification (24-hour service) 20.2 29.5 22.4 33.1 25.9 19.2 10.5 2.6 9.7 13.0 33.0 20.1 7.7 5.0 13.4 10.2
   Free-standing residential 16.0 24.5 16.7 22.8 20.6 17.4 9.1 2.4 9.4 11.8 19.6 15.2 6.5 4.3 12.7 7.4
   Hospital inpatient 4.2 5.0 5.7 10.3 5.3 1.8 1.5 0.1 0.2 1.2 13.5 4.8 1.2 0.6 0.7 2.8
Rehabilitation/residential 17.3 11.4 19.0 15.6 17.3 28.4 26.2 13.9 25.3 18.6 18.0 20.8 20.3 24.4 18.4 8.6
   Short-term (<31 days) 8.3 6.4 10.8 6.6 10.5 12.9 11.9 5.8 9.8 7.2 9.9 12.3 8.7 7.4 8.7 2.4
   Long-term (31+ days) 8.0 3.9 7.2 7.6 5.4 14.7 12.7 7.6 14.9 9.5 5.9 7.2 11.0 16.4 8.7 4.5
   Hospital (non-detox) 1.0 1.1 1.1 1.4 1.5 0.7 1.5 0.5 0.6 1.8 2.2 1.3 0.7 0.7 1.1 1.7
   Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
No. of admissions 1,875,026 416,510 336,954 265,895 63,243 184,949 71,438 298,317 150,402 1,007 8,558 4,487 2,408 3,272 1,209 66,377
TABLE 6.6
Percentage of persons admitted into substance abuse treatment, by primary substance of abuse and type of care received, 2004
Source of referral to treatment and number of prior treatment episodes All admissions Primary substance at admission
Alcohol Opiates Cocaine Marijuana/hashish Stimulants Tranquilizers Sedatives Hallucinogens PCP Inhalants Other/none specified
Alcohol only With secondary drug Heroin Other opiates Smoked cocaine Other route Methamphetamine/amphetamine Other stimulants
aDriving under the influence.
bEmployee Assistance Program.
Source: "Table 3.5. Admissions by Primary Substance of Abuse, according to Source of Referral to Treatment and Number of Prior Treatment Episodes: TEDS 2004, Percent Distribution," in Treatment Episode Data Set (TEDS) 19942004: National Admissions to Substance Abuse Treatment Services, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, July 2006, http://wwwdasis.samhsa.gov/teds04/tedsad2k4web.pdf (accessed October 17, 2006)
   Total 1,875,026 416,510 336,954 265,895 63,243 184,949 71,438 298,317 150,402 1,007 8,558 4,487 2,408 3,272 1,209 66,377
Source of referral to treatment
Criminal justice/DUIa 36.3 41.6 35.0 14.5 16.1 26.8 34.3 57.0 50.4 38.4 19.6 27.0 49.5 58.9 28.1 19.9
Self or individual 33.7 29.4 30.9 57.8 49.8 37.8 31.8 16.3 24.5 31.3 39.6 35.8 24.2 19.5 32.4 53.0
Substance abuse provider 10.7 9.1 13.3 16.2 14.5 15.3 12.9 5.5 5.1 8.8 17.2 12.9 8.5 7.6 8.4 2.2
Other health care provider 6.9 8.5 7.7 4.9 10.1 7.6 6.9 4.7 4.6 8.0 13.7 10.2 5.2 2.7 11.8 8.9
School (educational) 1.2 0.7 0.9 0.1 0.3 0.1 0.4 4.1 0.4 2.2 0.8 1.3 1.5 0.1 7.6 3.5
Employer/EAPb 0.9 1.3 1.0 0.3 1.1 0.7 1.8 1.2 0.4 0.8 0.8 1.4 0.4 0.6 0.7 0.5
Other community referral 10.4 9.4 11.3 6.3 8.1 11.6 11.9 11.2 14.6 10.5 8.2 11.4 10.7 10.6 10.9 11.9
   Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
No. of admissions 1,809,407 404,574 325,665 258,776 61,241 178,777 68,268 288,179 144,552 982 8,280 4,247 2,327 3,169 1,169 59,201
No. of prior treatment episodes
None 43.5 50.7 38.2 22.0 39.5 32.5 40.4 57.6 49.9 47.6 43.3 46.3 48.2 42.0 55.1 73.5
1 23.2 22.4 23.5 20.1 25.4 23.6 25.7 24.6 26.6 26.4 23.2 24.0 24.8 24.7 19.2 12.1
2 12.4 10.7 13.5 15.7 13.9 15.4 14.2 9.6 11.7 12.0 12.0 13.5 12.3 15.0 8.6 5.2
3 6.9 5.8 8.0 10.6 7.6 9.5 7.7 3.9 5.2 5.5 6.3 5.9 5.6 6.8 4.9 2.5
4 3.9 3.1 4.7 7.0 4.3 5.6 4.1 1.6 2.4 1.9 4.1 3.2 2.9 3.7 3.2 1.3
5 or more 10.2 7.3 12.1 24.6 9.3 13.4 7.9 2.8 4.0 6.5 11.1 7.1 6.4 7.8 9.1 5.5
   Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
No. of admissions 1,531,474 333,988 262,052 210,367 53,550 164,230 58,612 262,744 131,827 890 6,569 3,879 2,000 2,929 1,059 36,778

six and twelve years after their treatment. A second important study was the Treatment Outcome Prospective Study (TOPS), which followed eleven thousand clients admitted to forty-one treatment centers between 1979 and 1981. Both DARP and TOPS found major reductions in both drug abuse and criminal activity after treatment.

Services Research Outcomes Study

The SAMHSA's Services Research Outcomes Study (SROS) confirmed that both drug use and criminal behavior are reduced after drug treatment. Because it conducted a five-year follow-up, the SROS provided the best nationally representative data to answer the question: "Does treatment work?" This study, although now several years old and reporting on even older data, has not been repeated and is the most recent assessment available based on a national sample.

In this nationally representative sample, alcohol use decreased 14% and drug use 21%, leading to the following conclusion in the SAMHSA's SROS report (1998, http://oas.samhsa.gov/Sros/sros8006.htm): "A nationally representative survey of 1,799 persons confirms that both drug use and criminal behavior are reduced following inpatient, outpatient and residential treatment for drug abuse."

According to the SROS report (1998, http://oas.samhsa.gov/Sros/httoc.htm), decreases varied from drug to drug, with heroin use decreasing the least. It went down 13.2%, suggesting that heroin use continued for just under 87% of users. Crack use declined 16.4%, but those treated for snorting cocaine powder did better: 45.4% had abandoned the drug after treatment and continued to do so five years laterbut 54.6% were still snorting cocaine. Among marijuana users 28% had given up the drug, whereas 72% continued. Results were better in all the other drug categories, but these are also the drugs of limited use by the study sample (and the population at large). The study also showed that success of treatment is higher when users are older. The exception was crack cocaine.

TYPE AND LENGTH OF TREATMENT

According to the SROS report, results by type of treatment were variable. Overall results for any illicit drug show that best results (25% decrease in drug use) were obtained by inpatient (hospital) treatment, followed by residential treatment. Outpatient methadone treatment had less favorable results (10% decrease) than outpatient drug-free treatment (19%). Outpatient methadone treatment consists of receiving methadone during visits to a treatment center; the center may also provide other services, such as counseling. Outpatient drug-free treatment consists of counseling, group therapy, and other services, but individuals receive no pharmaceutical support.

Marijuana users who were treated in inpatient facilities had better results (35% stopped using the drug) than those in residential (32%) and in methadone treatment (33%). Drug-free outpatient treatment had the lowest success rate (19%). By contrast, those using powdered cocaine benefited almost as much from drug-free outpatient treatment (42% decrease) as from inpatient treatment (47%) and did best in residential settings (55%). Crack users also did best with residential treatment (32% decrease) but had a low response to inpatient care and showed no significant decrease in use from outpatient treatment, whether with methadone or free of drugs. Heroin users responded only to methadone treatment in statistically significant numbers; 27% of those surveyed had stopped using the drug as a consequence of outpatient methadone treatment.

On average, the best results for decreasing use of all drugs, especially cocaine, were achieved with treatment that lasted six months or more; this length of treatment was also nearly the top category for marijuana use. The second length with good results (and with the best result for marijuana) was treatment lasting at least one week but less than one month. Results for crack cocaine show statistically significant results only for the "one-week-to-less-than-one-month" category. For heroin, only the "six-months-or-more" treatment duration produced significant decrease in use. Most heroin addicts require long-term methadone treatment (or treatment with a similar prescription drug) to control their habits.

CRIMINAL BEHAVIOR

The SROS report shows that treatment for substance abuse can significantly reduce crime. Criminal activities such as breaking and entering, drug sales, prostitution, driving under the influence, and theft/larceny decreased between 23% and 38% after drug treatment. However, incarceration and parole/probation violations actually increased, by 17% and 26%, respectively. Data in the study on those incarcerated or detained were less reliable than other data because of nonresponse to the survey.

More Recent Studies on Effectiveness and Cost Effectiveness of Treatment

Using data from the SROS report, Ramin Mojtabai and Joshua Graff Zivin, in "Effectiveness and Cost-Effectiveness of Four Treatment Modalities for Substance Disorders: A Propensity Score Analysis" (Health Services Research, February 2003), compare both the effectiveness and the cost-effectiveness of inpatient, residential, outpatient detox/methadone, and outpatient drug-free substance abuse treatment programs. They determine that there are only minor differences in effectiveness among these four types of programs. (Effectiveness or success is defined as abstinence and any reduction in substance use.) Mojtabai and Graff Zivin also determine that outpatient drug-free programs are the most cost-effective type of program.

More recently, Matilde P. Machado, in "Substance Abuse Treatment, What Do We Know? An Economist's Perspective" (European Journal of Health Economics, March 2005), compared the effectiveness and cost-effectiveness of substance abuse treatment programs by conducting a literature review and summarizing the results. Machado notes that there is no common definition of "effectiveness" but that three objectives represent most expectations about substance abuse treatment: reducing alcohol and/or drug use, improving personal and social functioning, and improving public health. Machado notes, "The evidence largely indicates that treatment is effective in each of these aspects." Drug abusers appear to agree with the research. In the 2005 NSDUH, when drug abusers were asked why they did not receive the substance abuse treatment they sought, only 0.4% answered that treatment would not help them. (See Figure 6.3.)

Nonetheless, Machado suggests that although drug treatment programs are effective, not all treatment programs are equally effective. Some may work better for patients with certain characteristics. For example, notes Machado, "stable alcoholic patients do well in short inexpensive programs while patients with more serious conditions benefit from additional services and longer treatment."

In analyzing cost-effectiveness of drug abuse treatment programs, Machado finds that most cost-effectiveness studies limited their analyses to treatment costs. She suggests that cost-effectiveness can only be determined by including all resources needed to provide treatment, such as patient costs (for example, transportation and day care) and societal costs (for example, crime and unemployment).

DRUG COURTS

Figure 6.4 shows the inception and recent increase in the use of drug courts nationwide. According to the Office of National Drug Control Policy (June 21, 2006, http://www.whitehousedrugpolicy.gov/enforce/drugcourt.html), there were 1,557 drug courts operating in the United States as of April 2006 and 394 more were in the planning stages.

Drug courts are programs that use the court's authority to offer certain drug addicted offenders to have their charges dismissed or their sentences reduced if they participate in drug court substance abuse treatment programs. Drug court programs vary across the nation, but most programs offer a range of treatment options and generally require one year of commitment from the defendant.

In Adult Drug Courts: Evidence Indicates Recidivism Reductions and Mixed Results for Other Outcomes (February 2005, http://www.gao.gov/new.items/d05219.pdf), the U.S. Government Accountability Office (GAO) notes that drug court programs reduce the recidivism rate (rate of reoffenses) during the time that drug abusers are enrolled in drug court treatment programs. The GAO does, however, find limited and mixed evidence of substance use relapse outcomes. Nonetheless, the GAO concludes that:

Overall, positive findings from relatively rigorous evaluations in relation to recidivism, coupled with positive net benefit results indicate that drug court programs can be an effective means to deal with some offenders. These programs appear to provide an opportunity for some individuals to take advantage of a structured program to help them reduce their criminal involvement and their substance abuse problems, as well as potentially provide a benefit to society in general.

C. West Huddleston, Karen Freeman-Wilson, and Donna L. Boone, in Painting the Current Picture: A National Report Card on Drug Courts and Other Problem Solving Court Programs in the United States (May 2004, http://www.ndci.org/publications/paintingcurrentpicture.pdf), assert that drug courts decrease criminal recidivism, save money, increase retention in treatment, and provide affordable treatment.

WHERE TO GO FOR HELP

God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.

Invocation used in most 12-Step programs

Many organizations provide assistance for addicts, their families, and friends. Most of the self-help groups are based on the 12-Step program of Alcoholics Anonymous (AA). Whereas AA is a support group for problem drinkers, Al-Anon/Alateen is for friends and families of alcoholics. Families Anonymous provides support for family members and friends concerned about a loved one's problems with drugs and/or alcohol. Other organizations include Adult Children of Alcoholics, Cocaine Anonymous, and Narcotics Anonymous. For an addict, many of these organizations can provide immediate help. For families and friends, they can provide knowledge, understanding, and support. For contact information for some of these organizations, see the Important Names and Addresses section at the back of this book.

A chief barrier to seeking help for many people habitually taking drugs is the recognition that they need help. Users often underestimate the problem and assume that they can manage without seeking professional assistance. Another barrier is the cost of drug abuse treatment, which is not always covered by a person's health insurance. Recognition of these problems has led to new programs both to help individuals recognize the need for help and to fund it.

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