|A Wiser Course: Ending Drug Prohibition
The vast majority of resources in the United States available to meet this country's "drug problem" have been utilized for interdiction rather than education and treatment. This allocation of resources has skewed the public's perception of the problem, which is seen largely as one of law enforcement. However, drug abuse and drug addiction are fundamentally a public health problem.
Reallocation of resources away from interdiction and into education and treatment is essential to the successful management of this problem. Drug abuse and drug addiction are health problems that can be treated. Dr. Herbert D. Kleber, former Deputy Director of the Office of National Drug Control Policy, now Medical Director of the Center on Addiction and Substance Abuse and lecturer in psychiatry at Columbia University College of Physicians and Surgeons, has identified a basic fallacy responsible for the predominant pessimistic outlook:
Drug dependence has been viewed as a chronic relapsing illness with an unfavorable prognosis. However, there are thousands of formerly dependent individuals in the United States and elsewhere who have remained off both illicit drugs and excess use of licit drugs like alcohol for decades, functioning as productive citizens.... [T]here are already effective methods of treatment if the right approach [and] the right person can be brought together. .
No one should conclude that treatment is not effective just because drug abuse, like alcohol abuse and cigarette smoking, often cannot be "cured" with a single treatment effort. Most people who do conquer drug addiction succeed only after multiple efforts and relapses. Because effective treatment depends on finding the best method of helping a particular person at a particular time, several attempts may be needed to discover what will work.
Some substance abusers manage their problem with the help of Alcoholics Anonymous ("AA"), Narcotics Anonymous ("NA") or similar groups. These voluntary self-help associations offer the structure of a program following "twelve steps" to sobriety and the support of fellow abusers in different stages of recovery. Since these groups maintain members' confidentiality and do not keep records of attendance at meetings, their success has not been measured statistically; however, anecdotal evidence of their effectiveness is strong. Additionally, many respected treatment programs rely on methods developed by the self-help groups and prescribe attendance at AA and NA meetings for their patients.
One of the best-known methods of professional treatment for drug abuse is a highly structured, long-term residential inpatient program known as a therapeutic community. The Committee visited three therapeutic community facilities in New York City---programs operated by Daytop Village, Project Return and Phoenix House. Patients in therapeutic communities generally spend one to two years, sometimes more, living and working in the facility. Through individual counseling and group therapy, the patients address the causes and effects of their substance abuse and other problems and attempt to rebuild their lives free of drugs. Education, vocational training and work experience are important components of the treatment, because therapeutic community patients frequently lack necessary skills for making their own way in society. Successful patients gradually re-enter the outside world, first obtaining jobs and ultimately moving to homes outside the program.
While many patients drop out of these challenging and restrictive programs, research has shown that three-quarters of the patients who stay for the prescribed course of treatment remained drug-free seven years later. One study found that 56% of the individuals entering residential treatment (including those who dropped out) no longer used heroin or cocaine one year later. By the end of the study, more than 80% of the patients no longer used any prohibited drug other than marijuana. Another different national study that focused on opiate addicts revealed that nearly three quarters (74%) of the addicts who entered therapeutic communities were not using opiates regularly (i.e., on a daily basis) three years later.
Substance abusers with health insurance or other means of payment often seek residential treatment in less restrictive settings and for shorter periods of time. Two of the best-known programs providing this sort of inpatient treatment are the Betty Ford Center in Palm Springs, California, and the Hazelden program in Minnesota. Patients usually participate in intensive individual counseling, group therapy, and AA or NA meetings. Patients most commonly stay for four weeks and are then discharged to "aftercare" programs for continuing outpatient treatment or are advised to seek AA or NA meetings in the community. Many prominent citizens have testified publicly to the efficacy and value of these sorts of treatment programs.
Methadone maintenance is the most widely used treatment for narcotics addiction in the United States. Drs. Vincent P. Dole and Marie Nyswander developed the treatment at Rockefeller University in the early 1960s. Heroin addicts who are medicated with an appropriate daily dose of methadone, a long-acting synthetic opiate, lose the desire to use heroin but do not experience either withdrawal symptoms or the euphoric or impairing effects of narcotic use. Methadone patients can function normally and perform successfully in the workplace in jobs ranging from attorney to architect to bus driver.
In the early stages of treatment, methadone patients visit the program daily to receive their doses. They are granted more flexible schedules as they show progress in treatment by remaining free of other drugs, maintaining steady employment, and making progress in other areas. Methadone programs also provide counseling and other health care and usually arrange for vocational rehabilitation, education, and other services. Successful methadone patients may remain in treatment for many years, often at reduced doses; and some eventually leave treatment entirely.
A high proportion of methadone patients stay in treatment (more than two-thirds, by many reports), and more than 85% of those remaining in treatment for a year never use heroin again. A substantial proportion also stop using alcohol and other drugs. The results of research assessing the effectiveness of methadone maintenance have been strikingly consistent. One major study found that, within a year of beginning treatment, 70% of those who had entered methadone treatment were no longer using heroin. After three years, use by patients who had remained with the program for at least three months had declined by almost 85%. Another study examining AIDS infection among injection drug users found that methadone maintenance treatment effectively reduced intravenous drug use by 71%. An earlier study had found that more than three quarters of the patients who entered methadone maintenance treatment were still not regularly using opiates three years later.
Substance abusers who cannot commit themselves to inpatient treatment and do not want methadone treatment (or would not benefit from it because their primary drug of abuse is not heroin) can participate in a variety of outpatient drug-free therapies, including the full range of "talk" therapies, supervised twelve-step programs, and programs that use acupuncture to reduce the craving for drugs. Outpatient programs often are recommended as follow-ups to short-term hospital-based "detoxification" programs, which generally are effective only for short-term crisis intervention purposes.
The Committee visited the Lincoln Hospital Substance Abuse Division in New York City, which has been treating drug abuse patients with acupuncture for more than 15 years. Acupuncture treatment, which involves the insertion of five needles in the outer ear while the patients sit quietly in a common room for 30 to 45 minutes, is meant to control withdrawal symptoms and the craving for drugs and to have a general calming effect. At Lincoln Hospital it is used in combination with group counseling on the Narcotics Anonymous model, as well as urinalysis monitoring. Like methadone treatment, acupuncture begins as a daily treatment, with successful patients "graduating" to less frequent schedules. Outpatient drug-free treatment programs, whether they employ acupuncture or not, differ in the nature, length and frequency of treatment sessions. The usefulness of acupuncture treatment for substance abuse has been demonstrated in several studies.
Outpatient programs, generally, have demonstrated a fair amount of success in treating substance abusers. One national study found that nearly three-quarters of the patients who entered outpatient drug-free programs for opiate abuse were not using opiates regularly three years later. A later study of similar scope revealed that, after a year in treatment, 42% of the regular cocaine users who stayed in outpatient drug-free treatment for at least three months had stopped using cocaine completely. Over three to five years, regular heroin use by patients who had received treatment for at least three months fell by half, and fewer than 20% of the patients who stayed in treatment for at least three months were regular users of any prohibited drug except marijuana.
Virtually all studies conducted over the last 20 years show that the most commonly practiced methods of treatment do work. Treatment has been shown to reduce substance abuse and ameliorate its consequences. The outcome of treatment has not been found to differ significantly with the type of treatment received. Methadone programs, inpatient residential programs, and outpatient drug-free programs all show dramatic results.
The most comprehensive study of the effectiveness of drug treatment, the Treatment Outcomes Prospective Survey ("TOPS") funded by the National Institute on Drug Abuse ("NIDA"), strongly confirmed the efficacy of treatment in reducing drug use. For up to five years after their treatment, TOPS followed 10,000 substance abusers who had been admitted to 37 different treatment programs across the country. The programs included residential and outpatient drug-free programs and outpatient methadone maintenance programs. Heroin and cocaine use declined significantly for patients in all treatment modalities. After a year in treatment, heroin use by patients in methadone maintenance programs declined by 70%, while 75% of outpatient drug-free patients and 56% of residential treatment patients had stopped using heroin or cocaine. By the end of the study, fewer than 20% of the patients regularly used any illegal drug except marijuana, and 40% to 50% of the patients abstained altogether.
Other studies have reached virtually identical conclusions. A study sponsored by NIDA to address the risk of AIDS infection for injection drug users found that methadone maintenance treatment effectively reduced intravenous drug use by 71% among those who remained in the program for one year. An earlier NIDA study based on the Drug Abuse Report Program ("DARP") tracked the drug use of 44,000 opiate addicts admitted to treatment between 1969 and 1974. The study found that most patients stopped using opiates daily and had not resumed daily use three years after they were discharged from treatment. More than three quarters of the patients who entered methadone maintenance treatment (76%) and nearly three quarters of the patients who entered therapeutic communities (74%) or outpatient drug-free programs (72%) were still not using opiates regularly three years later. A recent follow-up study of 405 of the original 44,000 addicts found that 74% were not using heroin regularly twelve years after their treatment ended.
Researchers have uniformly concluded that the three most common forms of treatment are effective despite "the variety of problems suffered by clients, their long histories of deviant and debilitating lifestyles, and a lack of support in the community" that lead so many addicts not to complete treatment programs at all. Researchers also agree that the longer addicts remain in treatment, the better their chances of success. National studies of the behavior of thousands of addicts have shown that, while one-third of the patients who stay in treatment for more than three months are still not using drugs a year later, two-thirds of those who stay in treatment for a year or more stay off drugs.
Researchers have studied the impact of drug treatment on many of the health and social problems that drug abuse contributes to---the spread of AIDS and other diseases, premature death, crime, unemployment, costly medical care---as one way of assessing the success of drug treatment. Their studies have shown that treatment reduces these associated consequences of drug abuse.
Treatment prevents the transmission of HIV and other blood-borne diseases that spread when addicts share needles or sell sex for drugs. Two studies have shown that the rate of HIV infection among heroin addicts in New York City not in treatment (46%-47%) is twice the rate of infection among addicts in methadone treatment programs (23%-27%), and a recent study found that none of a group of methadone patients with ten or more years in treatment tested positive for HIV.
Research has shown that treatment also prevents crime. The TOPS survey found that, in the six months following treatment, 97% of the residential therapeutic community clients and 70% of the outpatient clients who had admitted committing predatory crimes in the year before they entered treatment engaged in no criminal activity at all. Three to five years after treatment, the proportion of addicts involved in predatory crimes had fallen by one half to two-thirds. The DARP study found that arrest rates fell by 74% after treatment, for all treatment modalities.
Research reveals that treatment helps recovering addicts work, as well. Only 33% of the 44,000 patients in the DARP study worked in the year before admission to treatment, but 57% were employed in the year following their discharge. Two-thirds of therapeutic community patients were gainfully employed after discharge. The employment rate of clients tracked in the TOPS study also surged. Three to five years after patients entered treatment, the employment of patients admitted to residential programs had doubled over pre-treatment levels, while the employment of addicts receiving outpatient treatment rose by more than half.
The costs of medical treatment for all sorts of health problems decline when addicts receive treatment. As noted earlier in this report, addicts themselves suffer many costly illnesses as a result of drug use, ranging from hepatitis, syphilis and tuberculosis to shingles, malnutrition and psychiatric problems. In 1989, general hospital stays in which drugs or alcohol were identified as a major factor accounted for 1.9 million days of hospitalization in New York State alone. Using a conservatively estimated average cost of $500 a day, that amounts to $9.5 billion worth of medical care. Successful drug treatment starts addicts on their way to physical recovery and therefore reduces these medical costs. Successful drug treatment also prevents the spread of diseases to others, such as children born to addicted mothers, and stems the cost of medical care for them, as well as the cost of foster care for children whose addicted parents cannot care for them.
Other benefits of treatment flow from its effects on criminal behavior and employment. Treated addicts are much more likely to be employed and therefore to contribute to the public coffers rather than receive welfare. They make more productive employees and are less likely to have accidents at work. Treated addicts are far less likely to commit crimes and therefore will save society the cost of property loss and prosecuting criminal activity. One study that calculated the cost of crime, poor employment activity, and medical treatment attributable to drug addiction found that the total of these costs was ten to twenty-five times the cost of treating drug addiction, depending on the cost of the treatment chosen. The cost of treating an addict in a long-term residential drug-free program, for example, was found to amount to only four percent of the cost to society of not treating the addict.
A comparison of costs also shows that treatment is much more cost-effective than incarceration. In New York City, residential drug treatment costs approximately $17,000 a year per treatment bed, and outpatient treatment costs only $2,300-$4,000 a year per treatment slot; the annual operating cost of a prison bed is about $40,000, and the cost of building new prison cells exceeds $100,000 each. Diverting drug abusers from prison to treatment therefore saves New York State or City half the operating costs of incarceration. It also alleviates the need to build expensive new prisons. If the proven effect of treatment on criminal recidivism is included, the savings to the criminal justice system in the future would be even more substantial.
Treatment works and is, in fact, a much more cost-effective way of dealing with substance abuse than arresting drug offenders and locking them in prison. Successfully treated drug addicts give up crime, become productive and more healthy citizens, and ultimately make fewer demands on the public for social and medical services throughout their lives. Their cure also reduces the overall demand for drugs.
One way to reduce the demand for illegal drugs is to prevent individuals at an early and impressionable age from initiating drug use. Using the school system and community programs to educate children about drug use and its destructive consequences is an idea that would undoubtedly be supported by many segments of society. Logic suggests that education programs should be effective in diverting young people from experimenting with drugs.
Mathea Falco, in her book The Making of a Drug Free America, details both school-based and community-based educational programs which have proven results in preventing drug, alcohol and tobacco use. Education has been shown to be effective in preventing and reducing drug as well as tobacco and alcohol use among children and teenagers. Simply to advocate "education," however, may not be enough; the assumption that "education," and any type of education program, will be effective may be erroneous.
Studies of the effectiveness of drug education and prevention strategies seem to suggest that long-term programs geared towards examining the "social influences" leading to drug, alcohol, and tobacco use are more successful in diverting and reducing subsequent use of drugs, alcohol, and tobacco. These successful educational programs are generally coupled with community and home prevention and education programs. In contrast, certain short-term education programs, which lack the corresponding community programs, have not proven effective in actually reducing drug use.
This 15 session curriculum, which is geared towards junior high school students, is designed to teach students personal coping skills so that they may be better able to make decisions and feel more confident in social situations. Evaluations of this program, which has been taught in 150 junior high schools in New York and New Jersey for the past ten years, show that rates of smoking and marijuana use are one-half to three-quarters lower among students who have participated in this program than those who have not.
This program, taught to first-year high school students, combines a thirteen session classroom curriculum with coordinating community, media, and family programs in an effort to teach resistance skills to teenagers and reinforce the social desirability of not using drugs. The program is followed-up with a five-session booster course the following school year. This program, in a five-year follow-up study, has been proven effective in reducing the rate of tobacco, marijuana, and alcohol use by 20% to 40% and cocaine use by 50%.
This program, geared towards sixth and seventh graders, integrates discussions about drugs and alcohol into the everyday curriculum by training teachers to incorporate the discussion of drugs and alcohol into their teaching of academic subjects. This program is currently implemented in approximately one hundred New York City schools. It is believed that this approach will reinforce prevention messages as the students will hear this discussion as part of their learning on a wide variety of subjects. The long-range effectiveness of this approach has not yet been determined.
This program, which has been implemented in junior and senior high schools in twenty states, offers counseling during the school day on a voluntary, confidential basis. A study of the Westchester County, New York school system where the program was originally implemented showed a significant reduction in alcohol and marijuana use. More significantly, studies showed that the rates of drinking and drug use were 30% lower among students at schools which implemented the SAP program.
"Smart Moves" is a program operated out of Boys and Girls Clubs in the inner-cities where children live in high crime neighborhoods. By offering after-school prevention programs and recreational, educational, and vocational activities, this program attempts to teach children to recognize the pressures to use drugs and how to develop the verbal and social skills to resist these pressures. Again, studies have shown that this type of program can reduce cocaine and crack use and improve school behavior and parental involvement.
This comprehensive program seeks to strengthen the bond between children from high crime neighborhoods and their families and schools. The program provides to parents techniques to monitor their children better; teachers get better training to maintain order and resolve conflicts; and children, as in the other programs, are taught skills to resist peer pressure. Interestingly, while the program has shown results in deterring girls from alcohol, tobacco, and drug use, it has not shown similar effectiveness with boys.
Finally, a number of cities are attempting to develop prevention programs geared towards the children of drug addicts. These programs attempt to teach parents communication and parenting skills and provide children with support and social skills. Two such programs are "Strengthening Families," which has been implemented in Salt Lake City, Detroit, and Selma, Alabama, and the "Safe Haven" program in Detroit. Evaluations of the "Strengthening Families" program suggest it strengthens family and school relationships and affects attitudes towards alcohol and tobacco use.
This provides a summary of the types of successful programs already available in the communities. Their success depends upon a school and community commitment to implementing comprehensive programs geared towards preventing drug use by children. The diversity of the structure of the programs illustrates the complexity of the problem. In addition to reaching out to the "average" school age youth and warning them about the dangers of substance abuse, there are children in high-risk homes and crime-ridden neighborhoods who need additional support structures to resist the pressures of drug use.
A Wiser Course: Ending Drug Prohibition
A Report of The Special Committee on Drugs and the Law
of the Association of the Bar of the City of New York
June 14, 1994
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