Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination
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The Final Report from the White House Conference for a Drug-Free America states (1988): "Our forces are outmanned, outgunned and out-spent . . . Our losses include children born addicted, and other children recruited to crime before their teens by drug lords who use them to build a business of terrible violence and tremendous profit. We have drug dealers on our street corners, in our offices, on our college campuses, and grade school playgrounds." This report was written in 1988, and unfortunately, those conclusions hold true today.
Examining the financial costs of AOD abuse painfully illustrates one aspect of the impact AOD abuse has on our society. Alcohol abuse, the mood-altering drug most frequently abused, costs Americans as much as $85.8 billion each year in lost employment, reduced productivity, and increased health care costs. The cost of other drugs of abuse is estimated at $58.3 billion (Rice et al., 1991a).
When Americans are spending $144.1 billion a year due to AOD abuse, it is absolutely imperative that key players communicate and collaborate when looking for successful methods of dealing with this population. For such a significant and expensive problem, it is clear that coordinated approaches to dealing with AOD abusers have the best chance for success.
State legislators have a vital role in enacting laws that protect members of society from harming each other, and which protect people from harming themselves. The ideas and principles which center around AOD treatment involve rehabilitation and reform. Through these concepts the goal of protection can certainly be advanced.
Armed with knowledge and accurate information about AOD abuse, legislators can ensure that the goals and objectives for the AOD population are advanced in a manner that is productive for a State's entire constituency. By knowing the State's mission and goals for the AOD population, legislation can be enacted which is compatible with these philosophies.
A continuum of sanctions and treatment needs to coexist and provide systemwide benefits. This can only occur if there is an atmosphere of communication and cooperation among systems. Treatment and criminal justice agencies, along with legislators, present a united front to AOD abusers when they send the message that this behavior is unacceptable.
Legislators are on the front lines for States who are trying to cope with shrinking budgets and severe economic problems. A cost-benefit analysis indicates that taxpayers enjoy a $4 return for every $1 spent on treatment programs (NIDA, 1991). For legislators, whose constituents are concerned with the "bottom line," coordination of efforts offers a positive return for a minimal investment.
The purpose of this chapter is to explore the best means for State legislators and the treatment field to coordinate their efforts in dealing with AOD-involved persons. Issues to be discussed include the role of legislators, the high costs of AOD abuse, the cost benefits of AOD treatment, and policy consideration issues.
Legislators have a valuable contribution to make in their use of foresight when handling issues as complex as AOD abuse. Such an issue stretches across economic and societal boundaries and impacts virtually every citizen in some capacity. Foresight is broadly defined as an effort "to address goals and emerging policy issues to provide a longer lead time in decision-making" (Chi, 1991). Some of the principal reasons foresight can be particularly useful to State government include the following (Chi, 1991):
Keeping this concept in mind can be very helpful in any discussion regarding the best ways to have an impact on AOD-involved persons. Legislators have demonstrated their ability to plan ahead; it is a skill that becomes honed as they design budgets, formulate legislation, and respond to the needs of their constituencies. This ability enables them to consider the many complexities of this issue, and to develop long-term and successful options for effectively dealing with this population. Only through educated foresight can decision-making bodies implement the important activities of coordination, allocation of funding, societal protection, and the realization of other worthwhile goals. Implementation of these activities will ultimately save States money, which is often the bottom line for many constituents.
Legislators have a vital role in successfully dealing with AOD-involved persons. They have the opportunity to manage AOD issues and policies through such avenues as establishing Task Forces, or forming issues and coordination committees.
An example of a legislature which has made inroads in dealing with AOD issues is Colorado. The legislature mandated that a committee be formed to develop a strategy for dealing with AOD-involved offenders. House Bill 91-1173 was signed into law May 29, 1991. This bill was formed with the goal of providing comprehensive and continuing services to AOD-involved offenders in the criminal justice system. A section on the standardizing of procedures with regard to substance abuse assessment is particularly innovative. Provisions include that the Judicial Department, the Department of Corrections, the Division of Criminal Justice of the Department of Public Safety, and the Department of Health shall cooperate to develop and implement measures which include the following (House Bill 91-1173, 1991):
(CSAT, 1993.)
Colorado is an excellent example of legislators' ability to mandate coordination, collaboration, and communication efforts. Many other State agencies take their cue from the legislature as to how to deal with a particular State problem, both formally and informally. Legislators are responsible for establishing a State's agenda and are able to take a leadership role in establishing AOD treatment and planning programs–both in the legislation that is developed (with the input from Task Forces and various committees) and in the public messages they send to their constituency.
Rhode Island and Washington also have made landmark strides in the areas of coordination. In Rhode Island, for example, the Office of Substance Abuse was created by the governor after an extensive study had been conducted by the governor's drug program staff. Additional impetus was provided in response to the recommendations of a legislator's two year Special Legislative Commission to Study the Feasibility and Need for a Separate Department of Substance Abuse. The office was created by an executive order in September 1991, and was codified with the passage of House Bill 92-H8784 in July 1992. The creation of this office distinguishes Rhode Island as one of the first States to create a Cabinet level position for the Director of the effort against alcohol and other drugs. The efforts of the office are undertaken on two distinct levels: (1) policy formulation, planning, and coordination of the State system; and (2) provision of services to the community.
Recognizing the need to develop effective working relationships with other State and local government and private sector representatives who are directly concerned with AOD issues, Washington State has created the position of Special Projects Manager within its Division of Alcohol and Substance Abuse (DASA). The DASA Special Projects Manager has primary responsibility for public policy development, collaboration, and legislative coordination. The office also coordinates legislative monitoring and information. The Special Projects Manager is a regular member of the Washington Interagency Network (WIN).
WIN consists of representatives of 13 State agencies who have a stake in AOD issues. Agency representatives are middle managers with program knowledge, and with the capability to support cross-agency strategies and development of approaches. WIN meets monthly, except during legislative session when it meets weekly. The network's goals include information sharing, development of coordinated responses to problems, and resolution of service barriers between entities. WIN member agencies include:
An example of another State which has taken the initiative in coordination of efforts is Alabama. The State is often lauded for having found innovative ways to deal with AOD-involved individuals within its prison system. About half of Alabama prisons have drug treatment programs in place. Merle Friesen, who initiated this program, says that Alabama has "exceeded all expectations of controlling drug use" (Wagar, 1992). He further stated that assaults have also dropped in prisons where drug treatment is available, thereby contributing to a solution for another common problem in correctional institutions. Only 1.3 percent of the prisoners who participate in Alabama's drug treatment program test positive for drugs; this figure is generally much higher in other parts of the country (Wagar, 1992).
Such initiatives, particularly in the areas of implementing a systemwide MIS (critical to effective coordination), and finding creative ways to fund these programmatic changes represent a new way of looking at what can often be a daunting problem facing States. Referral of AOD-involved persons to a continuum of treatment modalities will ultimately save States money. Interrupting the cycle of substance abuse represents an opportunity to help AOD-involved individuals turn their lives around. Morris Thigpen, Alabama Corrections Commissioner, has said of inmates, for example, "If you don't really have some program directed at trying to solve the problems inmates bring with them when they are incarcerated, then you will turn them back out to society with the same problems" (Wagar, 1992). Given that more than half of all prisoners are drug addicts, and that more than two-thirds of them are behind bars for drug-related crimes, it is clear that dealing successfully with this population is an enormous opportunity to positively impact State budgets.
Legislators provide a valuable service to their constituencies when they recognize the importance of placing the needs of an individual component (i.e., the Judiciary, AOD treatment, AOD abusers) within the context of an overall system. This system is dependent on coordination, communication, and collaboration.
A familiar anecdote recounts an interview with a famous bankrobber. When asked why he robbed banks, his droll reply was, "because that's where the money is." Legislators control the purse strings, and that is where constituents are going to turn first for a solution to the problem of AOD abuse.
Legislators establish the priorities for how States are going to spend their money. As such, their leadership enables States to provide adequate economic and human resources for a reasonable quality of life. Investing in efforts to coordinate with the treatment field, with the judiciary, with the criminal justice system, will pay dividends by saving money and lives over the long-term.
AOD abuse is an expensive problem for States. It is expensive in the costs that it generates on a societal, human level, and in terms of actual dollars that States are forced to spend in dealing with this problem.
AOD abuse has many social and human consequences. It contributes to injuries and fatalities at an almost unprecedented level; it is implicated in suicide, homelessness, mental illness, and involvement with the criminal justice system; and it negatively impacts family and employment structures. It has been integrally involved in the spread of HIV/AIDS. HIV (the virus linked to the cause of AIDS) can be directly transmitted through needle sharing and other high risk behavior; intravenous drug users may then transmit the disease to their sexual partners; women who have contracted HIV from needle sharing or from their IV drug-using partners may then infect their infants. Through the Medicaid program, the federal government and States provide some or all of the health care for over 40 percent of patients with AIDS. In 1992, State and federal Medicaid programs spent approximately $2.1 billion on AIDS-related health care (Wilensky, 1991).
(Romig and Rasmussen, 1991.)
The total losses to the economy related to alcohol and drug abuse and mental illness for 1988 were estimated at $273.3 billion. The estimate includes $85.8 billion for alcohol abuse and $58.3 billion for drug abuse. While quantifying the burden is difficult, translating it into economic terms is important to facilitate formulating policy about the use of resources and in making decisions (Rice, Kelman and Miller, 1991a). Total costs include those associated with decreased economic productivity, unemployment, increased health and social welfare costs, law enforcement, and associated costs of criminal trafficking in drugs.
In an Alcohol and Health Report to Congress (1990), studies confirmed that 4 percent–1.1 million of 27.4 million–of short-stay hospital discharges among persons 14 years and older involve an alcohol-related diagnosis, of which 54 percent had an alcohol-related problem as the primary diagnosis. Diseases and medical disorders associated with the consumption of alcohol include liver problems (ninth leading cause of death in 1986); gastrointestinal disorders; cardiovascular system problems; nutritional and metabolic disorders; immune system problems; cancer; endocrine and reproductive problems; and neurologic disorders.
Injection drug users account for 1.2 million persons. The Presidential Commission on the HIV epidemic has reported that only 250,000 drug abusers and 148,000 intravenous drug abusers are in treatment at a given time, meaning that only approximately 10 percent of the nation's IV drug users are being treated, which has serious implications for the AIDS epidemic (NASADAD, 1990). Injection drug users account for more than 20 percent of people infected with AIDS. Care for a person with AIDS can cost as much as $100,000 per year. Many people with AIDS are poor, homeless, and lack traditional family and community supports, relying instead upon public services for assistance (Rua, 1990).
Tuberculosis (TB) rates have increased 16 percent between 1985 and 1990 (Cowley, Leonard & Hager, 1992). There is a proven link between TB and both substance abuse and HIV infection. Alcoholism and intravenous drug use's causative association with TB includes malnutrition, damage to the immune system, poor compliance with treatment regimens, and the poverty which often accompanies AOD abuse.
Alcohol produces defects in fetuses. Treatment of Fetal Alcohol Syndrome was estimated to be one-third of a billion dollars a year in 1988 (Alcohol and Health, 1990).
A close relationship exists between mental disorders and alcohol and drug problems. One study showed that one in three adults with a mental disorder will have an alcohol or drug abuse problem at some point (Alcohol, Drug Abuse, and Mental Health Administration, 1992).
The 1988 estimate for the economic costs of mental illness was $129.3 billion (Rice, Kelman & Miller, 1991). This includes direct costs, such as personal health care (including hospital and nursing home care, physician and other professional services, and prescription drugs), as well as indirect costs such as the value of time spent to care for family members with a mental illness.
The costs to society of crime estimated to be due to drug abuse amounts to $32.5 billion annually. This includes expenditures for police protection, private legal defense, and property destruction, as well as the value of productivity losses for those who engage in crime as a career, as a result of heroin or cocaine addiction, and for people incarcerated in prison as a result of conviction of a drug-related crime (Rice, Kelman & Miller, 1991b). The costs to victims related to AOD-involved offenders is also high, encompassing loss of property and often treatment associated with the trauma of victimization.
Drug abuse morbidity costs, that is, the value of reduced or lost productivity, amounts to $6 billion. A timing model was developed in the estimation of impairment rates (percent of income loss) that was applied to average incomes, including an imputed value of housekeeping services, by age and sex (Rice, Kelman & Miller, 1991b).
Social welfare costs are difficult to compute as the effects of AOD abuse are so far-reaching in this area. Many AOD abusers are in lower income brackets and are eligible for Medicaid benefits, both pertaining to the treatment of addiction and the treatment of the many illnesses associated with AOD abuse. Persons with AIDS (many of whom are intravenous drug abusers) are having a tremendous impact on emergency room services and various public health programs. Aid to Families with Dependent Children is also impacted by the cycle and patterns of poverty and AOD abuse which often go hand-in-hand. States end up with the responsibility of providing health care to the medically indigent. This population is often largely comprised of persons with AOD-involvement.
Treatment offers States the possibility of dealing effectively with the problem of AOD abuse. It is estimated that for every $1 invested in treatment programs, tax-paying citizens enjoy a $4 return in the reduction of drug-related costs (NIDA, 1991). Savings are measured in the decrease of drug-related crime, criminal justice costs, and theft. Increased workplace productivity, while significant, is not calculated in this figure (Hubbard, 1989). Coordinated efforts between legislators and the field of treatment provides a chance to positively impact the cycle of AOD abuse.
Treatment is also a much less costly means of dealing with AOD-involved persons than prison. Outpatient treatment ultimately costs citizens only one-tenth as much as incarceration (NIDA, 1991).
Coordination and systems building provides the best means for States to get the most for their money. When systems communicate, there is less chance for a duplication of effort and an opportunity to make a fragmented system whole. For example, State AOD Directors can provide legislators with valuable information about treatment. They can help States ensure that they are complying with maintenance of effort requirements, as well as all the necessary assurances required by the program. States are eligible for federal financial assistance, but certain conditions apply to, for example, block grant funding. If a State does not comply (through matching funds or other requirements) the money is returned to the federal "pool" and is lost to that State. Legislators who are well-informed about the requirements for their States ensure fiscal responsibility on behalf of their constituents.
When systems collaborate, a comprehensive assessment can follow an AOD abuser throughout the entire system. Such an effort promotes patient-treatment matching, allows a workable continuum which best meets a patient's needs, and provides a means for holding the patient and the involved system(s) accountable. CSAT is working with cities, counties, and States to develop and implement an automated system of case management. Assessment data is translated into treatment plans and related to the courts for their use in referrals, prosecution, and corrections.
As referenced previously, studies show that a $1 investment in treatment programs saves taxpayers $4 in drug-related cost reductions (NIDA, 1991). Treatment provides States with a long-range opportunity to save money. When AOD use is stopped, or interrupted for significant periods of time, the patient has a chance to contribute to society both socially and economically. These financial dividends should not be underestimated. Cessation of AOD use also interrupts the economic drain (e.g., medical, employment, welfare) these patients pose to society.
Treatment also reduces and interrupts patterns of crime, and reduces the rate of recidivism. This results in substantial savings to the criminal justice system. When the costs of crimes attributable to AOD abuse is $32.5 billion, an opportunity to reduce recidivism results in significant savings.
Prevention of the spread of HIV/AIDS is a vital component of treatment. Reducing intravenous drug use alone is an effective means of slowing the spread of HIV. Coupling that with education and information campaigns as a part of the treatment process has great promise in preventing the spread of HIV/AIDS. When costs for treating an AIDS-infected individual can be as high as $100,000 a year, it is vital that education and prevention be a vital part of the campaign to combat this epidemic.
In responding to the needs of citizens, legislators spend a great deal of time carefully evaluating the wisest allocation of State resources. Statistics indicate (NASADAD, 1990) that prevention and treatment save money in the long-term. Interdicting the supply of drugs is a very expensive endeavor, and the payoffs have not been commensurate with this level of expenditure. The process of pyramiding, for example, has turned into a cottage industry that is very difficult to eliminate with traditional, law enforcement methods.
A book called Getting Started in the Illicit Drug Business explains the process:
(Long, 1988.)
Morgan (1992) likens this process to the at-home marketing of cosmetics or kitchen wares. The newly franchised dealer will sell to two or three buyers, make money, and have cocaine for his personal use. The high price of the commodity means the small volume user may become a small volume dealer and recruit other users. States would have to spend a veritable fortune (and they are) to combat this one area of drug trade alone. In addition, merely interdicting the drug supply does not address abuse/addiction issues in any way.
Treatment, on the other hand, reduces the demand for drugs. It is even successful for individuals with the most serious addiction problems. After treatment, recovering addicts are less likely to be involved in crime and more likely to be employed; as employees, they pay more taxes and use fewer social services, helping reduce the overall business tax burden (Rua, 1990).
Manning (1992) has cited at least nine errors in the conventional reasoning about the deterrent effects of police action:
Reallocating a State's resources into prevention, treatment, and related research provides a means of dealing, in a comprehensive fashion, with AOD issues. It also provides States with a means of finding solutions to these problems. There are many areas for a legislature to allocate funding which could have a substantial impact:
Legislators will be key to any solution to the overwhelming problem of AOD abuse. They have the opportunity to take a leadership role in studying this issue; promoting and mandating systems coordination among treatment, health, and criminal justice personnel; and allocating funding to ensure that resources are expended in the most efficient manner.
Insightful leadership is aware of the cost-effectiveness of spending State dollars on treatment. The direct and indirect dividends include reduction in the demand for drugs, decreased morbidity, control of the spread of infectious disease, eventual reduced AOD-related health costs, and reductions in crime.
Developing a strategy which will provide a continuum of treatment services to AOD-involved persons is critical. A coordinated and collaborative effort will save States money in terms of lives saved. When individuals can control their substance abuse, their return to productivity contributes to society rather than creating a drain of resources. Assisting individuals in regaining their health and eliminating their AOD dependency is an effective means for leaders to respond to their citizenry.
Alcohol and health: Seventh special report to the U.S. Congress (January 1990). Washington, DC: U.S. Department of Health and Human Services.
Alcohol, Drug Abuse, and Mental Health Administration (1992, March-April). 1974-1989: The first fifteen years of research on urgent public health problems facing the nation. ADAMHA News, 15(2).
Chi, K. (1991, January-March). Foresight in State government. The Journal of State Government. The Council of State Governments, 3-11.
Center for Substance Abuse Treatment (1993, Spring). TIE Communiqué. Rockville, MD: Treatment Improvement Exchange, U.S. Department of Health and Human Services.
Cowley, G., Leonard, E.A., & Hager, M. (1992, March 16). A deadly return. Newsweek.
House Bill 91-1173 by Representatives Fish, Greenwood, S. Johnson, Kerns, Killian, Mares, Moellenberg, Pankey, Ruddick, Snyder, Swenson, Tanner, Webb, and S. Williams; also Senators Hopper, Allison, Leeds, J. Johnson, McCormick, Meiklejohn, Mendez, Owens, Peterson, Powers, Roberts, Schaffer, Schroeder, Tebedo, Traylor, and Wham (1991: State of Colorado).
Hubbard, R.L. (1989). Drug Abuse Treatment. Chapel Hill: University of North Carolina Press.
Long, H.S. (1988). Getting started in the illicit drug business. Port Townsend, WA: Loompanics Unlimited.
Manning, P.K. (1992). The criminal justice system and the user. In J. Lowinson, P. Ruiz, R.B. Millman & J.G. Langrod (Eds.), Substance abuse: A comprehensive textbook. Baltimore: Williams & Wilkins.
Morgan, J.P. (1992). Prohibition was and is bad for the nation's health. J. Lowinson, P. Ruiz, R.B. Millman & J.G. Langrod (Eds.) Substance abuse: A comprehensive textbook. Baltimore: Williams & Wilkins.
National Institute on Drug Abuse (1991). Drug abuse treatment: An economical approach to addressing the drug problem in America. DHHS Publication No. (ADM) 91-1834.
Rice, D.P., Kelman, S., & Miller, L.S. (1991a, May-June). Estimates of economic costs of alcohol and drug abuse and mental illness, 1985 and 1988. Public Health Reports, 106(3).
Rice, D.P., Kelman, S., & Miller, L.S. (1991b). Economic costs of drug abuse. Economic costs, cost- effectiveness, financing, and community-based drug treatment. U.S. Department of Health and Human Services, Research Monograph 113.
Romig, C.L. & Rasmussen, J.J. (1991). What state legislators need to know about alcohol and other drug abuse. National Conference of State Legislatures.
Rua, J. (1990, March). Treatment works: The tragic cost of undervaluing treatment in the "drug war." Washington, DC: National Association for State Alcohol and Drug Abuse Directors.
Wagar, L. (1992 December). Alabama: Fighting drug addiction in prison. State Government News. Lexington, KY: The Council of State Governments
The White House Conference for a Drug Free America: Final report (1988, June). Washington, DC.
Wilensky, G.R. (1991). Financing care for patients with AIDS. JAMA, the Journal of the American Medical Association, 266(24), 3404.
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