Treatment

The RAND Corporation study found that additional domestic law enforcement efforts cost 15 times as much as treatment to achieve the same reduction in societal costs.

"States report spending $2.5 billion a year on treatment. States did not distinguish whether the treatment was for alcohol, illicit drug abuse or nicotine addiction. Of the $2.5 billion total, $695 million is spent through the departments of health and $633 million through the state substance abuse agencies. We believe that virtually all of these funds are spent on alcohol and illegal drug treatment."

"Ibogaine, a natural alkaloid extracted from the root bark of the African shrub Tabernanthe Iboga, has attracted attention because of its reported ability to reverse human addiction to multiple drugs of abuse, including alcohol."

"Studies also suggest that ibogaine attenuates drug- and ethanol-induced behaviors in rodents. For example, ibogaine reduces operant self-administration of heroin in rats, as well as naloxone-precipitated withdrawal in morphine-dependent rats (Glick et al., 1992; Dworkin et al., 1995). Administration of ibogaine decreases cocaine-induced locomotor activity and reduces cocaine self-administration in rats (Cappendijk and Dzoljic, 1993) and mice (Sershen et al., 1994)."

"Despite its attractive properties, ibogaine is not approved as an addiction treatment because of the induction of side effects such as hallucinations. In addition, ibogaine at high doses causes degeneration of cerebellar Purkinje cells (O'Hearn and Molliver, 1993, 1997) and whole-body tremors and ataxia (Glick et al., 1992; O'Hearn and Molliver, 1993) in rats."

"Based on anecdotal reports in humans, ibogaine has been claimed [1] to be effective in interrupting dependence on opioids, stimulants, alcohol and nicotine. Preclinical studies in rats have supported these claims: ibogaine has been reported to decrease the i.v. self-administration of morphine [2] and cocaine [3] and the oral intake of alcohol [4] and nicotine [5]. However, studies in rats have also raised concerns regarding potential adverse effects of ibogaine; most notably, high doses have been shown to be neurotoxic to the cerebellum [6,7]."

"18-MC, a novel iboga alkaloid congener, reduces intravenous methamphetamine and nicotine self-administration in rats. These and previous results with morphine, cocaine and alcohol indicate that 18-MC warrants further development as a potential treatment for multiple forms of drug addiction."

"Although ibogaine has been reported to effectively reduce drug cravings and withdrawal symptoms in addicts (Sheppard, 1994), its tremorigenic, hallucinogenic, neurotoxic, and cardiovascular side effects (see Alper, 2001) have prevented its approval as a treatment for addiction. On the other hand, 18-methoxycoronaridine, although not yet tested in humans, has no apparent side effects in rats, presumably because it is more selective pharmacologically than ibogaine."

"In summary, repeated administration of drugs of abuse and alcohol induces a common pattern of changes in gene expression and protein levels selectively in the VTA. A subset of these changes is reversed by intra-VTA GDNF, as are some of the drug-induced behavioral effects. Endogenous GDNF systems appear to inhibit drug related behaviors, while repeated drug administration appears to inhibit GDIVF signaling itself. Based on these studies, we propose that GDNF is an endogenous anti-addiction agent. This possibility is directly supported by the finding that the activity of the anti-addiction drug, ibogaine, on alcohol consumption is mediated via increased expression of GDNF in the midbrain and the subsequent activation of the GDNF pathway."

"Overall, results indicate that heroin prescription is a very promising approach in reducing any type of drug related crime across all relevant groups analyzed. It affects property crime as well as drug dealing and even use/possession of drugs other than heroin. These results suggest that heroin maintenance does not only have an impact by reducing the acquisitive pressure of treated patients, but also seems to have a broader effect on their entire life-style by stabilizing their daily routine through the commitment to attend the prescription center twice or three times a day, by giving them the opportunity for psychosocial support, and by keeping them away from open drug scenes."

A study of the Swiss heroin prescription program found:
"With respect to the group of those treated uninterruptedly during four years, a strong decrease in the incidence and prevalence rates of overall criminal implication for both intense and moderate offenders was found. As to the type of offense, similar diminutions were observed for all types of offenses related to the use or acquisition of drugs. Not surprisingly, the most pronounced drop was found for use/possession of heroin. In accordance with self-reported and clinical data (Blaettler, Dobler-Mikola, Steffen, & Uchtenhagen, 2002; Uchtenhagen et al., 1999), the analysis of police records suggests that program participants also tend strongly to reduce cocaine and cannabis use probably because program participants dramatically reduced their contacts with the drug scene when entering the program (Uchtenhagen et al., 1999) and were thus less exposed to opportunities to buy drugs. Consequently, their need for money is not only reduced with regard to heroin but also to other substances. Accordingly, the drop in acquisitive crime, such as drug selling or property crime, is also remarkable and related to all kinds of thefts like shoplifting, vehicle theft, burglary, etc. Detailed analyses indicated that the drop found is related to a true diminution in criminal activity rather than a more lenient recording practice of police officers towards program participants.
"On average, males had higher overall rates than females in the pretreatment period. However, no marked gender differences were found with regard to in-treatment rates. Taken as a whole, this suggests that the treatment had a somewhat more beneficial effect on men than women. This result is corroborated by self-report data (Killias et al., 2002). With respect to age and cocaine use, no relevant in-treatment differences were observed. As to program dropout, after one year, about a quarter of the patients had left the program, and after four years, about 50% had left. Considering the high-risk profile of the treated addicts, this retention rate is, at least, promising."

"Heroin misuse in Switzerland was characterised by a substantial decline in heroin incidence and by heroin users entering substitution treatment after a short time, but with a low cessation rate. There are different explanations for the sharp decline in incidence of problematic heroin use. According to Ditton and Frischer, such a steep decline in incidence of heroin use is caused by the quick slow down of the number of non-using friends who are prepared to become users in friendship chains. Musto's generational theory regards the decline in incidence more as a social learning effect whereby the next generation will not use heroin because they have seen the former generation go from pleasant early experiences to devastating circumstances for addicts, families, and communities later on."

A study of the Swiss heroin prescription program found:
"Finally, the analysis of the reasons for interrupting treatment revealed that, even in the group of those treated for less than one year, the majority did not actually drop out of the program but rather changed the type of treatment, mostly either methadone maintenance or abstinence treatment. Knowing that methadone maintenance treatment – and a fortiori abstinence treatment – is able to substantially reduce acquisitive crime, the redirection of heroin maintenance patients toward alternative treatments is probably the main cause for the ongoing reduction or at least stabilization of criminal involvement of most patients after treatment interruption. Thus the principal post-treatment benefit of heroin maintenance seems to be its ability to redirect even briefly treated high-risk patients towards alternative treatments rather than back 'on the street'."

"The harm reduction policy of Switzerland and its emphasis on the medicalisation of the heroin problem seems to have contributed to the image of heroin as unattractive for young people."

"The incidence of regular heroin use in the canton of Zurich started with about 80 new users in 1975, increased to 850 in 1990, and declined to 150 in 2002, and was thus reduced by 82%. Incidence peaked in 1990 at a similar high level to that ever reported in New South Wales, Australia, or in Italy. But only in Zurich has a decline by a factor of four in the number of new users of heroin been observed within a decade. This decline in incidence probably pertains to the whole of Switzerland because the number of patients in substitution treatment is stable, the age of the substituted population is rising, the mortality caused by drugs is declining, and confiscation of heroin is falling. Furthermore, incidence trends did not differ between urban and rural regions of Zurich. This finding is suggestive of a more similar spatial dynamic of heroin use for Switzerland than for other countries."

"The central result of the German model project shows a significant superiority of heroin over methadone treatment for both primary outcome measures. Heroin treatment has significantly higher response rates both in the field of health and the reduction of illicit drug use. According to the study protocol, evidence of the greater efficacy of heroin treatment compared to methadone maintenance treatment has thus been produced. Heroin treatment is also clearly superior to methadone treatment when focusing on patients, who fulfill the two primary outcome measures."

"The German model project for heroin-assisted treatment of opioid dependent patients is so far the largest randomised control group study that investigated the effects of heroin treatment. This fact alone lends particular importance to the results in the (meanwhile worldwide) discussion of effects and benefits of heroin treatment. For the group of so-called most severely dependent patients, heroin treatment proves to be superior to the goals of methadone maintenance based on pharmacological maintenance treatment. This result should not be left without consequences. In accordance with the research results from other countries, it has to be investigated to what extent heroin-assisted treatment can be integrated into the regular treatment offers for severely ill i.v. opioid addicts."

"To conclude, it must be stated that heroin treatment involves a somewhat higher safety risk than methadone treatment. This is mainly due to the intravenous form of application. The rather frequently occurring respiratory depressions and cerebral convulsions are not unexpected and can easily be clinically controlled. Overall, the mortality rate was low during the first study phase, and no death occurred with a causal relationship with the study medication. Compared to much higher health risks related to the i.v. application of street heroin, the safety risk of medically controlled heroin prescription has to be considered as low."

"The UK is exceptional internationally because heroin is included in the range of legally sanctioned treatments for opiate dependence. In practice, this treatment option is rarely utilised: only about 448 heroin users receive heroin on prescription."

"Many countries believe (erroneously) that the international drug conventions prohibit the use of heroin in medical treatment. Furthermore, the International Narcotics Control Board (INCB) has exerted great pressure on countries to cease prescribing heroin for any medical purpose. Nevertheless, a few countries, including the UK, Belgium, the Netherlands, Iceland, Malta, Canada and Switzerland, continue to use heroin (diamorphine) for general medical purposes, mostly in hospital settings (usually for severe pain relief). Until recently, however, Britain was the only country that allowed doctors to prescribe heroin for the treatment of drug dependence."

"The North American Opiate Medication Initiative (NAOMI) is a carefully controlled (clinical trial) that will test whether medically prescribed heroin can successfully attract and retain street-heroin users who have not benefited from previous repeated attempts at methadone maintenance and abstinence programs.
"The NAOMI study will enrol 470 participants at three sites in Vancouver, Montreal and Toronto. The Toronto and Montreal sites are expected to begin recruitment this spring. "Each site will enroll about 157 participants. About half of these volunteers will be assigned to receive pharmaceutical-grade heroin (the experimental group) and half will receive methadone (the control group). The prescribed heroin will be self-administered under careful medical supervision within a specially designed clinic. Those in the heroin group will be treated for 12 months then transitioned, over three months, into either methadone-maintenance therapy or another treatment program. The researchers expect a 6-9 month recruitment period, so that the total time to complete the study will be 21 to 24 months."

"These pilot study findings showed that opiate-dependent injecting drug users with long injecting careers (most started between 1970 and 1982) and for whom opiate treatment had failed multiple times previously were attracted into and retained by therapy with injectable opiates."

"Prescribing injectable opiates is one of many options in a range of treatments for opiate-dependent drug users. In showing that it attracts and retains long term resistant opiate-dependent drug users in treatment and that it is associated with significant and sustained reductions in drug use and improvements in health and social status, our findings endorse the view that it is a feasible option."

Treatment

"While provisions of the Federal Drug law guarantee state assistance to drug addicts, in fact, budgetary restraints have severely limited the capacity of state institutions to provide even a minimum level of support for drug users. Although the state drug-treatment centres are under the guidance of the Ministry of Health, they are, in fact, financed by the various administrative entities of the Federation. Since most of the oblasts and republics have severe financial restraints, in most cases, the drug-treatment centres have not been able to cope with the sudden expansion in the number of drug users requiring assistance. They lack the financial, material and staff resources to carry out the tasks, which are assigned to them by law. There are a few private treatment centres in some of the major cities, but only the wealthy can make use of their facilities. This general lack of treatment and rehabilitation facilities and activities for drug users are some of the reasons why the country has been facing extreme difficulties in attempting to address the very serious problem of HIV/AIDS infection among injecting drug users."

"Substitution (or replacement) therapy such as methadone maintenance therapy, which has been widely credited with controlling HIV transmission among injection drug users in many countries, is illegal in Russia, and the 2003 amendments to the drug law did not change this. Methadone is classified as "illicit" by the terms of the three United Nations conventions on drug control, though most countries that are signatories to the conventions have methadone programs that are successful in substituting injected heroin with noninjected methadone. In this case, neither the SDCC nor the Ministry of Health seems necessarily disposed to review the status quo. Dr. Golyusov of the Ministry of Health said that he is concerned by first-hand accounts from drug users that methadone is more addictive or "harder to get off" than heroin and that other countries' experiences have been "contradictory.""

"Domestic enforcement costs 4 times as much as treatment for a given amount of user reduction, 7 times as much for consumption reduction, and 15 times as much for societal cost reduction."

"An additional cocaine-control dollar generates societal cost savings of 15 cents if used for source-country control, 32 cents if used for interdiction, and 52 cents if used for domestic enforcement. In contrast, the savings from treatment programs are larger than control costs: an additional cocaine-control dollar generates societal cost savings of $7.48 if used for treatment."

The RAND Corporation found that the additional spending needed to achieve a 1% reduction in the number of cocaine users varies according to the sort of program used, and that treatment is the most cost-effective: Control Program Additional spending needed to achieve a 1% reduction in number of cocaine users Source-Country Control $2,062,000,000 Interdiction $964,000,000 Domestic Enforcement $675,000,000 Treatment $155,000,000

The US Office of National Drug Control Strategy estimated that the federal government spent $2.942 billion on treatment and treatment research in 2006 and an estimated $2.943 billion in 2007.

In 2002, federal funding for drug treatment totaled $3,587,500,000, representing 19.1% of the $18,822,800,000 drug war budget. The FY2003 request for treatment funding was $3,811,700,000, which represents 19.9% of the $19,179,700,000 requested drug war budget. Combined, federal prevention and treatment funding -- the demand-side -- totaled $6,136,100,000 in FY2002, and a requested $6,285,100,000 for FY2003. Law enforcement and interdiction -- the supply-side of the equation -- ate up the remaining two-thirds of federal drug war spending, or $12,686,700,000 in FY2002, and $12,894,600,000 requested in FY2003.

"In 2005, an estimated 22.2 million persons aged 12 or older were classified with substance dependence or abuse in the past year (9.1 percent of the population aged 12 or older) (Figure 7.1). Of these, 3.3 million were classified with dependence on or abuse of both alcohol and illicit drugs, 3.6 million were dependent on or abused illicit drugs but not alcohol, and 15.4 million were dependent on or abused alcohol but not illicit drugs. "Between 2002 and 2005, there was no change in the number of persons with substance dependence or abuse (22.0 million in 2002, 21.6 million in 2003, 22.5 million in 2004, and 22.2 million in 2005). "There were 18.7 million persons aged 12 or older classified with dependence on or abuse of alcohol in 2005 (7.7 percent). This estimate has remained stable since 2002."

The National Survey on Drug Use and Health estimated that "In 2005, the number of persons aged 12 or older needing treatment for an illicit drug or alcohol use problem was 23.2 million (9.5 percent of the population aged 12 or older) (Figure 7.6). Of these, 2.3 million (0.9 percent of persons aged 12 or older and 10.0 percent of those who needed treatment) received treatment at a specialty facility. Thus, there were 20.9 million persons (8.6 percent of the population aged 12 or older) who needed treatment for an illicit drug or alcohol use problem but did not receive treatment at a specialty substance abuse facility in the past year."

According to the National Treatment Improvement Evaluation Study (NTIES), "The results show substantial reductions in criminal behavior and arrests after treatment: Selling drugs declined by 78 percent; Those who reported shoplifting declined by almost 82 percent; Before treatment, almost half the respondents reported "beating someone up." Following treatment that number declined to 11 percent; a 78 percent decrease; Changes in arrest rates were less striking than those in self-reported criminal behavior, but the 64 percent reduction in arrests for any crime was still dramatic; and The percentage who largely supported themselves through illegal activity dropped by nearly half - decreasing more than 48 percent."

According to the 1997 National Treatment Improvement Evaluation Study (NTIES), "Treatment appears to be cost effective, particularly when compared to incarceration, which is often the alternative. Treatment costs ranged from a low of about $1,800 per client to a high of approximately $6,800 per client. While the cost of incarceration was not examined by NTIES, widely reported studies such as one reported by the American Correctional Association, gave an estimated 1994 cost of incarceration as $18,330 annually."

In January 2001, the National Center on Addiction and Substance Abuse at Columbia University published an analysis of costs to states from tobacco, alcohol and other drug addiction. According to the report, "States report spending $2.5 billion a year on treatment. States did not distinguish whether the treatment was for alcohol, illicit drug abuse or nicotine addiction. Of the $2.5 billion total, $695 million is spent through the departments of health and $633 million through the state substance abuse agencies. We believe that virtually all of these funds are spent on alcohol and illegal drug treatment."

In January 2001, the National Center on Addiction and Substance Abuse at Columbia University published an analysis of costs to states from tobacco, alcohol and other drug addiction. According to the report, "The justice system spends $433 million on treatment: $149 million for state prison inmates; $103 million for those on probation and parole; $133 million for juvenile offenders; $46 million to help localities treat offenders; $1 million on drug courts. Treatment provided by mental health institutions for co-morbid patients totals $241 million. The remaining $492 million is for the substance abuse portion of state employee assistance programs ($97 million), treatment programs for adults involved in child welfare services ($4.5 million) and capital spending for the construction of treatment facilities ($391 million). (Figure 4.B)"

"The Panel anxiously awaits the time when the disease of addiction is no longer treated as a criminal justice issue, but as a public health problem. Moreover, the Panel embraces the notion of a society that enables any individual with a substance abuse problem, regardless of criminal history, to receive treatment in a safe and respectful environment. The Panel hopes to create a climate in which people who are at risk for, suffering from, or in recovery from alcohol or other drug addiction are valued and treated with dignity."

"According to the ONDCP's 1999 National Drug Control Strategy, there are approximately 4 million chronic drug users in the United States. This closely aligns with the 1998 National Household Survey on Drug Abuse, which found that 4.1 million people were in need of drug treatment. The NIAAA report, Improving the Delivery of Alcohol Treatment and Prevention Services, estimates there are 14 million alcohol abusers, whereas the 1998 National Household Survey on Drug Abuse finds approximately 9.7 million people in need of alcohol treatment. Regardless of the source, a conservative estimate of those in need of substance abuse treatment is between 13 and 16 million people. In contrast, both the 1997 Institute of Medicine (IOM) report, Managing Managed Care, and the 1998 National Household Survey conclude that approximately 3 million people receive care for alcohol or drugs in one year. Although, as previously stated, neither the estimates of need nor the estimates of those in treatment are all inclusive, the picture remains the same - more than 10 million people who need treatment each year are not receiving it."

A study by researchers at Substance Abuse Mental Health Services Administration has indicated that 48% of the need for drug treatment, not including alcohol abuse, is unmet in the United States.

Treatment decreased welfare use by 10.7% and increased employment by 18.7% after one year, according to the 1996 National Treatment Improvement Evaluation Study.

A study of heroin maintenance in Switzerland for the World Health Organization concluded:

1. The health of participants improved.
2. Illicit cocaine and heroin use declined greatly.
3. Housing situation improved and stabilized- most importantly there were no longer any more homeless participants.
4. Fitness for work improved considerably, those with permanent employment more than doubled from 14% to 32%.
5. The number of unemployed fell by half (from 44% to 20%)
6. A third of the patients that were on welfare, left the welfare rolls. But, others went on to welfare to compensate for their lost income from sales of drugs.
7. Income from illegal and semi-legal activities decreased significantly, from 69% of participants to 10%.
8. The number of offenders and offenses decreased by about 60% during the first 6 months of treatment.
9. The retention rate was average for treatment programs. 89% over 6 months, and 69% over 18 months.
10. More than half of the dropouts did so to switch to another form of treatment. 83 of the participants did so to switch to an abstinence-based treatment, and it is expected that this number will grow as the duration of individual treatment increases.
11. There were no overdoses from drugs prescribed by the program.

In 1996, voters in Arizona passed an initiative which mandated drug treatment instead of prison for non-violent drug offenders. At the end of the first year of implementation, Arizona's Supreme Court issued a report which found: A) Arizona taxpayers saved $2.6 million in one year; B) 77.5% of drug possession probationers tested negative for drug use after the program; The Court stated, "The Drug Medicalization, Prevention and Control Act of 1996 has allowed the judicial branch to build an effective probation model to treat and supervise substance abusing offenders... resulting in safer communities and more substance abusing probationers in recovery."

According to CASA (National Center on Addiction and Substance Abuse), the cost of proven treatment for inmates, accompanied by education, job training and health care, would average about $6,500 per inmate. For each inmate that becomes a law-abiding, tax-paying citizen, the economic benefit is $68,800. Even if only one in 10 inmates became a law-abiding citizen after this investment, there would still be a net social gain of $3,800.

"The percentage of recent drug users in State prison who reported participation in a variety of drug abuse programs rose from 34% in 1997 to 39% in 2004 (table 9). This increase was the result of the growing percentage of recent drug users who reported taking part in self-help groups, peer counseling and drug abuse education programs (up from 28% to 34%). Over the same period, the percentage of recent drug users taking part in drug treatment programs with a trained professional was almost unchanged (15% in 1997, 14% in 2004). "Participation in drug abuse programs also increased among Federal inmates who had used drugs in the month before their offense, from 39% in 1997 to 45% in 2004. While there was no change in percentage of these inmates who had undergone drug treatment with a trained professional (15% in both years), the percentage taking part in other drug abuse programs rose from 32% in 1997 to 39% in 2004."

"In 2004, about 642,000 State prisoners were drug dependent or abusing in the year before their admission to prison. An estimated 258,900 of these inmates (or 40%) had taken part in some type of drug abuse program (table 10). These inmates were more than twice as likely to report participation in selfhelp or peer counseling groups and education programs (35%) than to receive drug treatment from a trained professional (15%). "In Federal prison, a higher percentage of drug dependent or abusing inmates (49%) reported taking part in some type of drug abuse programs. Nearly 1 in 3 took part in drug abuse education classes, and 1 in 5 had participated in self-help or peer counseling groups. Overall, 17% took part in drug treatment programs with a trained professional, and 41% had participated in other drug abuse programs."

Among those prisoners who had been using drugs in the month before their offense, 15% of both State and Federal inmates said they had received drug abuse treatment during their current prison term, down from a third of such offenders in 1991. Among those who were using drugs at the time of offense, about 18% of both State and Federal prisoners reported participation in drug treatment since admission, compared to about 40% in 1991.

"Despite the many factors that contribute to the gap, the Panel agrees with many in the field that inadequate funding for substance abuse treatment is a major part of the problem. Over the last decade, spending on substance abuse prevention and treatment has increased, albeit more slowly than overall health spending, to an estimated annual total of $12.6 billion in 1996 (McKusick, Mark, King, Harwood, Buck, Dilonardo, and Genuardi, 1998). Of this amount, public spending is estimated at $7.6 billion (McKusick, et al., 1998). The public spending includes dollars from Medicaid and Medicare, as well as other Federal funds from the Department of Defense, the Department of Veterans Administration, the Department of Justice, and the Substance Abuse Prevention and Treatment (SAPT) Block Grant. The SAPT Block Grant provides Federal support to addiction prevention and treatment services nationally through State and local governments. Private spending includes individual out-of-pocket payment, insurance, and other nonpublic sources, and is estimated at $4.7 billion (McKusick, et al., 1998)."

"One of the main reasons for the higher outlay in public spending is the frequently limited coverage of substance abuse treatment by private insurers. Although 70 percent of drug users are employed and most have private health insurance, 20 percent of public treatment funds were spent on people with private health insurance in 1993, due to limitations on their policy (ONDCP, 1996b). In the view of the Panel, private insurers should serve as the primary source of coverage, with public insurance serving as the safety net."

"'Changing The Conversation' initiated the first intensive exploration of the stigmas and attitudes that affect people with alcohol and drug problems. The Panel addressed stigma as a powerful, shame-based mark of disgrace and reproach that impedes treatment and recovery. Prejudicial attitudes and beliefs generate and perpetuate stigma; therefore, people suffering from alcohol and/or drug problems and those in recovery are often ostracized, discriminated against, and deprived of basic human rights. Their families, treatment providers, and even researchers may face comparable stigmas and attitudes. Ironically, stigmatized individuals often endorse the attitudes and practices that stigmatize them. They may internalize this thinking and behavior, which consequently becomes part of their identity and sense of self-worth. "Public support and public policy are influenced by addiction stigma. Addiction stigma delays acknowledging the disease and inhibits prevention, care, treatment, and research. It diminishes the life opportunities of the stigmatized."