Archival Content: 1999-2005
Despite the current scientific consensus on the importance and effectiveness of substance abuse treatment, barriers persist to providing it to all who need or want it. A number of creative national initiatives and many other efforts on a local and individual level are breaking down these barriers.
Current Knowledge Leads to Conclusions about the Usefulness of Substance Abuse Treatment
Thirty years of research on the biological, genetic, molecular, and social aspects of addiction and on substance abuse treatment strategies have resulted in some clear messages about addiction and treatment:
A Big Gap Exists Between Need for Treatment and Availability of Services
A gulf exists between the number of people who want or could benefit from substance abuse treatment and the number of people who actually receive services:
Efforts to Close this Gap Face Policy Challenges
Negative attitudes and limited understanding give substance abuse treatment a low priority.
Public, provider, and policymaker attitudes and perceptions about drug use and users shape the importance given to substance abuse treatment versus other possible responses to drug use. A national inclination to respond punitively toward drug users, mistaken beliefs about the nature of addiction and recovery, and bias against drugs users and professionals who provide services to them have resulted in:
Substance abuse treatment's low priority is reflected in limited insurance coverage.
Despite the fact that managing addiction is similar to managing other chronic diseases, most employer-provided health insurance policies place greater burdens on patients of substance abuse treatment programs in terms of cost-sharing, co-payments, and deductibles. At the same time, many plans provide less coverage for the number of visits or days of coverage and annual dollar expenditures for treatment. Many health insurance companies have lower lifetime limits on amounts that can be spent on drug and alcohol treatment than on other illnesses.
Public and private funding for substance abuse treatment is far less than what is needed.
Limited funding is an important reason why the availability of substance abuse treatment is restricted:
Substance abuse treatment has historically operated outside the health care mainstream.
Substance abuse treatment facilities and programs have evolved separately for several reasons. One is that many programs have been created by individuals who have overcome their own addiction and gone on to build systems to help others. For example, individuals in recovery have been key to the formation of successful "12-step" groups and therapeutic communities. Peer support has long been an important therapeutic strategy. Lack of insurance coverage for treatment, stigma attached to substance abuse and addicted individuals, and lack of training and expertise in substance abuse issues on the part of mainstream medical practitioners also contribute to the isolation of substance abuse treatment from other health care services.
This lack of integration with other health care services and providers is a problem because so many individuals who need substance abuse treatment services also need other services. For example:
This problem is particularly severe for vulnerable groups who have limited or no contacts with health care providers or who have no health insurance. Many of these individuals need primary health care services as well as care for particular health problems.
A Number of Initiatives are Addressing These Policy Challenges
Across the country, federal, state, and local agencies and organizations are recognizing the value of substance abuse treatment and the importance of expanding its availability to all those who need it. Here are just a few of the initiatives underway to change the policy environment.
Choosing treatment over incarceration. In November 2000, California voters approved a measure that requires substance abuse treatment, not jail, for drug possession or use. It also provides for treatment instead of prison for non-violent parolees who test positive for drug use. For details, visit: "Legislative Analyst's Office Analysis of the 2001-02 Budget Bill".
In June 2001, the Louisiana legislature passed a measure that permits judges to allow probation or sentence suspension for more than a dozen non-violent crimes, including theft, simple possession of small amounts of drugs, bribery, and prostitution. Jail time for more serious drug distribution convictions remains mandatory, but sentences are shortened. In an editorial praising the legislation, The Advocate newspaper urged the state to focus on substance abuse treatment: "If there are significant savings under the new rules, they ought to be spent on the programs that prevent offenders from returning to a life of crime: more probation and parole officers, and drug-treatment programs."
Revamping methadone maintenance treatment (MMT) regulations. In May 2001, the U.S. Department of Health and Human Services (DHHS) announced a fundamental shift in the federal government's role in regulating and monitoring MMT. The new system relies on accreditation of substance abuse treatment programs that use methadone and other medications by independent organizations and states, in accordance with treatment standards that have been developed by the Center for Substance Abuse Treatment (CSAT) over the last 10 years. The standards are based on "best practice guidelines" and emphasize improving quality of care in areas such as individualized treatment planning, increased medical supervision, and assessment of patients. In December 2001, DHHS announced the selection of four accreditation organizations that will be used in this new approach. For details, visit: SAMHSA What's New (click on Archives of News Releases and scroll down to the two May 18, 2001 releases)
Improving the scientific underpinnings of substance abuse treatment. In 1999, the National Institute on Drug Abuse (NIDA) established the National Drug Abuse Treatment Clinical Trials Network (CTN). The CTN provides a research infrastructure that allows investigators to conduct rigorous multi-site clinical trials to test whether new treatment approaches are effective in community settings. The CTN currently includes 14 research centers, each of which is linked to a number of community-based programs representing diverse treatment settings and patient populations in that region of the country. This network structure allows effective, science-based behavioral and pharmacological treatment approaches to be rapidly disseminated across the country. For details, visit: National Institute on Drug Abuse.
Increasing parity for substance abuse treatment. Beginning in 2001, the Federal Employees Health Benefits Program, which covers 9 million people, requires coverage for substance abuse and mental health services equal to that for medical, surgical, and hospital services. Both types of coverage will have the same cost-sharing features, such as deductibles, coinsurance, and copays. For details, visit: "Mental Health and Substance Abuse Parity Questions and Answers."
Improving opportunities for collaboration across health care, public health, and substance abuse treatment settings. Since 1998, CSAT, the CDC, and the Health Resources and Services Administration (HRSA) have sponsored a series of cross-training workshops across the country. These workshops give providers who work in a variety of settings (such as sexually transmitted disease/HIV prevention, substance abuse treatment, primary health care, mental health services, and criminal justice) an opportunity to improve their ability to respond to the interwoven health and behavior problems of their drug-using patients. The training also fosters personal connections across agency disciplines, cultures, and bureaucracies. These connections encourage staff to develop regular communications and collaborative working relationships with other agencies and organizations. For details, visit: "Substance Abuse and Infectious Disease: Cross-Training for Collaborative Systems of Prevention, Treatment, and Care."
To Learn More About This Topic
Read the overview fact sheet in this series on drug users and substance abuse treatment - "Substance Abuse Treatment for Injection Drug Users: A Strategy with Many Benefits." It provides basic information, links to the other fact sheets in this series, and links to other useful information (both print and web).
Check out these sources of information:
Amaro H. An expensive policy: the impact of inadequate funding for substance abuse treatment. [Editorial] American Journal of Public Health 1999;89:657-659.
Leshner A. Addiction is a brain disease. Issues in Science and Technology 2001;17(3).
Leshner AI. National study offers strong evidence of the effectiveness of drug abuse treatment. NIDA Notes 1997;12(5). (This article also provides links to other articles describing findings from NIDA's Drug Abuse Treatment Outcome Study [DATOS]).
National Center on Addiction and Substance Abuse at Columbia University (CASA). Shoveling up: the impact of substance abuse on state budgets. New York: CASA; 2001.
National Institute on Drug Abuse. Principles of drug addiction treatment: a research-based guide. Rockville (MD): NIDA; 1999. NIH Publication No. 99-4180.
National Institutes of Health. Effective medical treatment of opiate addiction. NIH Consensus Statement Online. Bethesda (MD): NIH; 1997, Nov 17-19;15(6):1-38.
Schneider Institute for Health Policy, Brandeis University. Substance abuse: the nation's number one health problem. Prepared for The Robert Wood Johnson Foundation. Princeton (NJ): Robert Wood Johnson Foundation; February 2001.
White House Office of National Drug Control Policy. National Drug Control Strategy 2001. Chapter 3. Report on programs and initiatives, Part 2. Treating addicted individuals.
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