Download Treatment of Alcohol and Other Substance Use Disorders

i
Treatment of Alcohol and
Other Substance Use Disorders
What Legislators Need to Know
By
Allison C. Colker
Contributing Authors
Sheri Steisel
Tim Whitney
William T. Pound, Executive Director
7700 East First Place
Denver, Colorado 80230
(303) 364-7700
444 North Capitol Street, N.W., Suite 515
Washington, D.C. 20001
(202) 624-5400
January 2004
National Conference of State Legislatures
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Treatment of Alcohol and Other Substance Use Disorders
The National Conference of State Legislatures is the bipartisan organization that serves the legislators and staffs of the states,
commonwealths and territories.
NCSL provides research, technical assistance and opportunities for policymakers to exchange ideas on the most pressing state
issues and is an effective and respected advocate for the interests of the states in the American federal system.
NCSL has three objectives:
•
•
•
To improve the quality and effectiveness of state legislatures.
To promote policy innovation and communication among state legislatures.
To ensure state legislatures a strong, cohesive voice in the federal system.
The Conference operates from offices in Denver, Colorado, and Washington, D.C.
Printed on recycled paper
©2004 by the National Conference of State Legislatures. All rights reserved.
ISBN 1-58024-331-2
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CONTENTS
List of Figures and Tables .................................................................................................................. iv
Acknowledgments ............................................................................................................................. v
About the Authors ............................................................................................................................ vi
NCSL’s Advisory Committee on the Treatment and Prevention of Alcohol and
Other Substance Use Disorders .................................................................................................... viii
Executive Summary .......................................................................................................................... ix
Users’ Guide .................................................................................................................................... xii
1.
What Are Alcohol and Other Substance Use Disorders? ............................................................... 1
Defining Alcohol and Other Substance Use Disorders .......................................................... 1
Chronic, Relapsing Disease .................................................................................................. 3
2.
What Are the Effects of Alcohol and Other Substance Use Disorders? .......................................... 9
National Survey on Drug Use and Health ............................................................................ 9
Standard Methodology for Rate of Alcohol and Other Substance Use Disorders
by Substance, by State .................................................................................................... 10
Healthy People 2010 ......................................................................................................... 13
State-by-State Treatment Gap Table ................................................................................... 16
Profile of a Typical Person with Alcohol and Other Substance Use Disorders ....................... 18
Profiles of People with Alcohol and Other Substance Use Disorders Demonstrate
that all Populations are Addicts ....................................................................................... 18
Use-by-age Charts .............................................................................................................20
Adolescents ....................................................................................................................... 21
3.
Why Should State Legislators be Concerned about Alcohol and Other
Substance Use Disorders? .......................................................................................................23
Economic Costs ................................................................................................................ 23
Health Consequences ........................................................................................................27
Social Consequences .......................................................................................................... 32
Solutions ........................................................................................................................... 36
4.
What Strategies Are Available for the Treatment of Alcohol and Other
Substance Use Disorders? .......................................................................................................37
The Science Behind the Treatment ....................................................................................37
Continuum of Treatment ................................................................................................... 40
Treatment for Specific Populations .....................................................................................49
Culturally Competent Treatment ....................................................................................... 53
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Treatment of Alcohol and Other Substance Use Disorders
Treatment in the Criminal Justice System ........................................................................... 56
Treatment of Co-occurring Mental Illness and Alcohol and Other
Substance Use Disorders .................................................................................................61
Barriers to Recovery ........................................................................................................... 62
Licensing of Providers ........................................................................................................62
Regulating Treatment ........................................................................................................62
Confidentiality ..................................................................................................................62
5.
What Funding Is Available for States to Provide Services to People Affected by
Alcohol and Other Substance Use Disorders? ..........................................................................65
Overview of State and Federal Funding ............................................................................. 65
The State Role in Financing .............................................................................................. 66
Federal Role in Funding Treatment ....................................................................................68
Appendices
A. Legislators’ Checklist .......................................................................................................... 81
B. National Resources ............................................................................................................83
C. “Hot Topic” Drugs ............................................................................................................87
D. PET Scans of Long-term Brain Changes in Abstinence and Brains on Drugs ....................... 89
E. State and Jurisdictional Resources ....................................................................................... 91
F. Center for Substance Abuse Treatment (CSAT) Treatment Improvement Protocols ..............99
G. Quadrant System ........................................................................................................... 101
H. Overview of State Laws Requiring Coverage of Alcohol and Other
Substance Use Disorder Treatment ............................................................................... 105
I. Alcohol Tax, by State ...................................................................................................... 117
Notes .......................................................................................................................................... 123
List of Figures and Tables
Figure
1.
2.
3.
4.
5.
6.
7.
Table
1.
2.
3.
4.
5.
6.
7.
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Activation Patterns to Spatial Working Memory Task for Adolescents .................................... 7
Brain Activation in Young Women ....................................................................................... 7
Use of Alcohol and/or Illicit Drugs, United States, 1994–98 .............................................. 14
Data Measures ..................................................................................................................14
Co-occurring Disorders by Severity ................................................................................. 101
Service Coordination by Severity .................................................................................... 102
Primary Locus of Care by Severity ................................................................................... 103
Rate of Alcohol and Other Substance Use by Substance, by State ....................................... 11
Rate of Substance Abuse and Dependence by Substance, by State ......................................12
Estimated Numbers and Percentages of Persons Aged 12 or Older Needing
But Not Receiving Treatment for an Illicit Drug Problem in the Past Year,
by State: 2000 ............................................................................................................... 17
Rate of Alcohol and Other Substance Use by Substance, by Age ......................................... 20
Rate of Substance Abuse and Dependence by Substance, by Age ....................................... 21
National Averages of Federal Block Grant Allocations and State Appropriations
for Mental Health and Substance Abuse .........................................................................66
Per Capita State Spending on Alcohol and Other Substance Use Prevention,
Treatment and Research ..................................................................................................66
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ACKNOWLEDGMENTS
The following National Conference of State Legislatures (NCSL) staff dedicated many hours
to make this publication possible: Lee Dixon reviewed the summary; Helen Narvasa formatted the tables; Laura Miller planned the marketing, publishing and distribution; and
Leann Stelzer edited the summary.
This publication is made possible through a contract with the Center for Substance Abuse
Treatment, SAMHSA, and a grant from the Robert Wood Johnson Foundation. Special
thanks to Dr. Herman Diesenhaus, Dr. Al Getz, Dr. Rita Vandivort and Dr. Constance
Pechura for reviewing the summary and providing guidance.
NCSL’s Advisory Committee on the Treatment and Prevention of Alcohol and Other Substance Use Disorders oversaw the development of this guidebook from start to finish. Heartfelt thanks go to Rep. Martha Alexander (N.C.), John Coppola, Janice Ford Griffin, Melody
Heaps, Sen. Jim Jensen (Neb.), Kenneth Stark, and First Lady Hope Taft (Ohio).
Every effort was made to ensure the accuracy of this report. Please notify Allison Colker at
NCSL about mistakes or missing information. If you have any questions or requests for
further information, call her at (202) 624-5400.
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Treatment of Alcohol and Other Substance Use Disorders
ABOUT THE AUTHORS
Allison C. Colker, J.D., Esq. is a policy specialist for the National Conference of State
Legislatures (NCSL). Mrs. Colker monitors, tracks and reports on behavioral health legislation and associated issues in the 50 states. Her topic areas include substance abuse
treatment and prevention, parity and insurance benefits for substance abuse, and treatment in lieu of incarceration. This information is published for members—state legislators
and their staff and major national substance abuse associations—in the form of articles,
issue briefs and biweekly Snapshots. In addition, Mrs. Colker frequently provides technical assistance to state legislators and their staff, including state legislative committees that
are directed to assess substance abuse policy issues. She also staffs NCSL’s Advisory Committee on the Treatment and Prevention of Alcohol and Other Substance Use Disorders;
members include two state legislators, a state substance abuse agency director, a state first
lady, an advocate, a lobbyist, a provider association director, and a treatment provider.
Prior to joining NCSL in July 2001, Mrs. Colker worked at the Center for Health Services
Research and Policy of the George Washington University School of Public Health. While
there, she worked on a research project funded by the Substance Abuse and Mental Health
Services Administration (SAMHSA) that was a contract review of child welfare and Medicaid managed care contracts from the 50 states. Mrs. Colker is a member of the Bar of the
State of Maryland. She earned her Juris Doctorate at the George Washington University
Law School, where she focused her course of study on health law and policy. She also holds
a bachelor’s degree in biology from McDaniel College (formerly Western Maryland College).
Sheri Steisel is the senior director of the Human Services Committee of NCSL and has
been on the NCSL staff since 1988. Ms. Steisel plays a key role in the development of
policy and lobbying strategy on state-federal human services issues. Her work with the
Human Services Committee concentrates on four major categories: income security and
social services, food and nutrition, welfare reform and immigration. Currently, Ms. Steisel
serves on the National Public Policy Committee for United Way of America. She received
her master’s of public policy with concentrations in human services policy and press, politics and public opinion from the John F. Kennedy School of Government at Harvard University; her undergraduate degree is from Wellesley College.
Tim Whitney, J.D., is special counsel for policy for Illinois TASC (Treatment Alternatives
for Safe Communities), a statewide social service agency specializing in linking criminal
justice and other public systems with community-based clinical and other resources needed
to support consumers of those systems. Mr. Whitney specializes in the development of
policies and initiatives related to substance abuse, crime and related issues. He also serves as
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About the Authors
legislative liaison, preparing, analyzing and making recommendations on pending legislation, while participating in local, state and federal advocacy in the areas of crime and
substance abuse. In addition to these activities, Mr. Whitney has served as a consultant for
a number of state and federal policy matters. These include participation in the criminal
justice component of the Center for Substance Abuse Treatment’s National Treatment Plan,
the health and public safety transition committee for Illinois governor-elect Rod Blagojevich;
and the advisory committee organized to develop a dedicated, evidence-based treatment
and reentry prison in Illinois. Mr. Whitney earned his Juris Doctor from DePaul University
and his bachelor of science in communication and public relations from Cornell University.
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Treatment of Alcohol and Other Substance Use Disorders
NCSL’S ADVISORY COMMITTEE ON THE
TREATMENT AND PREVENTION OF ALCOHOL
AND OTHER SUBSTANCE USE DISORDERS
Representative Martha Alexander
North Carolina
Senator Jim Jensen
Nebraska
John Coppola, Executive Director
Alcoholism and Substance Abuse Providers
of New York State
Albany, New York
Kenneth Stark, Director
Division of Alcohol and Substance Abuse
Washington State Department of Social
and Health Services
Olympia, Washington
Janice Ford Griffin, Deputy Executive
Director
Join Together
Boston, Massachusetts
Melody Heaps, President
Treatment Alternatives for Safe
Communities-Illinois
Chicago, Illinois
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First Lady Hope Taft
Ohio
Sue Thau, Public Policy Consultant
Community Anti-Drug Coalitions
of America
Alexandria, Virginia
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EXECUTIVE SUMMARY
The term alcohol and other substance use disorders encompasses many disorders, including alcohol abuse, alcoholism, drug abuse and drug addiction. Although key differences
exist between abuse and addiction, the effect on the states, the nature of treatment, and
funding streams are collective; therefore, they are discussed collectively in this book. Addiction is a chronic relapsing disease that causes brain changes in the user. The initial
choice to use alcohol or other drugs may be voluntary, but if a person becomes addicted, he
or she is then suffering from a biological disease, one of the symptoms of which is a necessity to continue using.
The federal government measures the extent of alcohol and other drug use in many ways.
The most comprehensive measure is the annual National Survey on Drug Use and Health.
There are also measurements of use by state, by age, and by other demographic characteristics. Unfortunately, the need for treatment far exceeds the capacity to provide treatment
in this country. The adolescent population is particularly affected by alcohol and other
drug use.
States suffer many economic costs associated with untreated alcohol and other substance
use disorders. Employers also suffer economic consequences. States and the public suffer
many health consequences associated with alcohol and substance use disorders, including
fetal alcohol syndrome and drug-affected babies, infectious diseases, mental health, medical conditions, death, and trauma. They also suffer many social consequences, including
crime, TANF/welfare, accidents, auto crashes, suicide, homelessness, domestic violence,
and child abuse and neglect. Some promising economic solutions for states can lead to cost
avoidance or cost-offset, particularly in the criminal justice area.
To effectively treat alcohol and other substance use disorders, it is important to have available a comprehensive continuum of treatment and a full spectrum of services. The four
steps of addressing alcohol and other substance use disorders are:
•
•
•
•
Identification of the problem,
Assessment of its severity,
Treatment, and
Ongoing recovery management.
Treatment can involve medications (such as methadone), can be coerced by the criminal
justice system, and should involve a variety of intensities and modalities. Detoxification is
not treatment, but it is often a medically necessary first step to stabilize a patient and
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Treatment of Alcohol and Other Substance Use Disorders
prepare him or her for treatment. Treatment should occur in the least restrictive setting
appropriate, and a patient should be continually reassessed and moved through the continuum from most to least restrictive settings. The range of treatment intensities includes
inpatient/residential, therapeutic communities, intensive outpatient, and outpatient.
Ongoing recovery management includes relapse prevention, such as self-help groups; education, job and family support; and, sometimes, special living arrangements, such as sober
living environments. Treatment for some specific populations must be tailored to meet the
unique needs of each population, such as adolescents, women and older adults. It is important to provide culturally competent treatment for minorities, such as Native Americans, Asian and Pacific Islander Americans, Hispanic/Latino populations, African Americans, and rural populations. Treatment in the criminal justice system is a major issue for
states because the majority of offenders have alcohol and other substance use disorders.
Another significant issue is treatment of co-occurring mental illness and alcohol and other
substance use disorders because this population is large and the co-occurring disorders
complicate treatment.
Both state and federal governments fund alcohol and other substance use prevention and
treatment services. States make general fund appropriations for treatment in addition to
appropriating federal funds. Most states require some level of private insurance coverage
for treatment. Parity and mandated benefits are economically advantageous for states because they create a cost shift from the public sector to the private sector. A significant
source of state funds for treatment comes from alcohol taxes on liquor, wine and beer. The
federal government funds alcohol and other substance use prevention and treatment through
various federal agencies.
•
The Substance Abuse and Mental Health Services Administration oversees the Substance Abuse Prevention and Treatment Block Grant and various discretionary grant
programs, which are appropriated to the single state agencies.
•
The Centers for Medicare and Medicaid Services oversee Medicaid, Temporary Assistance to Needy Families, the State Children’s Health Insurance Program, and Medicare, all of which can cover alcohol and other substance use treatment.
•
The Administration for Children and Families oversee Title IVB and Title IVE funds,
which can be used for a behavioral health demonstration program.
•
The Department of Education oversees the Safe and Drug-Free Schools and Communities State Grants Program, which addresses alcohol and other substance use prevention and education.
•
The Department of Justice oversees the Residential Substance Abuse Treatment for
State Prisoners Program, the Drug-Free Communities Program, the Byrne Formula
Grant Program, the Drug Court Discretionary Grant Program, and the Reentry: Serious and Violent Offender Reentry Initiative, all of which address crime related to
alcohol and other substance use disorders.
•
The Department of Veterans Affairs oversees the Veterans Health Administration, which
provides alcohol and other substance use treatment for veterans.
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Executive Summary
•
Housing and Urban Development oversees the Public Housing Drug Elimination
Grants Program, which promotes safety from alcohol and other substance use and
related crime in public housing projects.
•
The Department of Defense oversees TRICARE, which provides alcohol and other
substance use treatment for military personnel.
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Treatment of Alcohol and Other Substance Use Disorders
USERS’ GUIDE
This publication is meant to serve as a guidebook for state legislators and legislative staff. It
is targeted specifically toward health, human services, criminal justice, insurance and appropriations committees; leadership; and legislative services and research staff. The format
makes it a working document. The document is available online at http://www.ncsl.org/
programs/health/forum/SAguidebook.htm.
The purpose for the notebook binder is threefold. First, you will receive quarterly updates
that will instruct you to replace, add or remove pages. Second, you can easily remove pages
for duplication, or to take with you to a hearing or to the floor. Third, you can print out
HPTS Issue Briefs and substance abuse SnapShots, and put them at the back of your binder,
behind the Issue Briefs and SnapShots tabs.
The table of contents and chapter tabs are color-coded by chapter. Therefore, you can skim
the table of contents to find the topic you are interested in and quickly flip to the appropriate chapter.
Updates for your guidebook will be e-mailed to you quarterly so that you can print them
and update your guidebook. If you prefer to have the updates mailed to you, call Allison
Colker at (202) 624-3581. The online version will be updated quarterly.
Appendix A is a legislators’ checklist for your use in evaluating your state’s treatment system.
Appendix B is a list of national resources that you can consult to get more specific information.
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What Are Alcohol and Other Substance Use Disorders?
1. WHAT ARE ALCOHOL AND OTHER
SUBSTANCE USE DISORDERS?
Defining Alcohol and Other Substance Use
Disorders
The terms and definitions associated with alcohol and other
substance use disorders have changed over the years. Although the terms change, the fundamental problems associated with these disorders remain constant. The accepted
Institute of Medicine terminology is “alcohol and other substance use disorders;” therefore, that term will be used
throughout this book.
•
Nearly 14 million adult Americans—one of every 13—meet
the diagnostic criteria for alcohol dependence or alcohol abuse.
•
About 50 percent of adults have or have had a close family
relative with one of those disorders.
•
More than 70 percent of individuals who consume alcohol
exceed moderate drinking guidelines (up to two drinks per
day for men and one drink per day for women and older
people).
•
More than 50 percent of college students who drink alcohol
say that they drink to “get drunk.”
•
Approximately 12.8 percent of men and women experience
Alcohol Abuse
According to the National Institutes of Health, nearly 14
symptoms of alcohol dependence at some time in their lives.
Of those individuals, approximately 700,000 are treated
million adult Americans—one of every 13— meet the diannually.
agnostic criteria for alcohol dependence or alcohol abuse.
About 50 percent of adults have or have had a close family
relative with one of those disorders. In addition, more than 70 percent of individuals who
consume alcohol exceed moderate drinking guidelines (up to two drinks per day for men
and one drink per day for women and older people). More than 50 percent of college
students who drink alcohol say that they drink to “get drunk.”1
Experts use the following definition to identify an individual with an alcohol abuse problem.
•
Alcohol Abuse is defined as a heavy and frequent alcohol problem that involves the
continued use of alcohol—despite social, occupational, psychological or physical problems—in addition to recurrent alcohol use in physically hazardous situations.2
Although alcohol is not an illegal substance for adults, the abuse of alcohol has become a
serious problem in the United States. Approximately 12.8 percent of men and women
experience symptoms of alcohol dependence at some time in their lives. Of those individuals, approximately 700,000 are treated annually.3
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Treatment of Alcohol and Other Substance Use Disorders
Alcoholism
Experts use the following definition to identify an individual with alcoholism.
•
Alcohol Dependence, also termed “alcoholism” or “alcohol dependence syndrome,” is
distinguished by cognitive, behavioral and physiologic symptoms, which indicate that
a person continues to drink despite significant alcohol-related problems. These alcohol-related problems do not necessarily involve heavy drinking.4
Drug Abuse and Addiction
The diagnostic criteria used to identify drug use, similar to the ones used for alcohol use,
are classified in three ways: use, abuse and dependence.
•
Use is characterized by low or infrequent doses and can be considered experimental,
occasional or social; damaging consequences are rare and minor.5
•
Abuse describes higher doses or frequencies that are usually sporadically heavy and
intensive; effects are unpredictable and sometimes severe.6
•
Dependence defines the addiction to drugs and is associated with high or frequent
doses, compulsion, craving and withdrawal; severe consequences are likely.7
Drug addiction involves a loss of control over drug-taking behavior and an overwhelming
compulsion to take drugs. It is a chronic, relapsing disorder; relapse can occur long after
drugs are gone from the body. An addict will ignore the adverse consequences of drug use
and is tolerant, physically dependent and psychologically dependent.
Appendix C is a list of current “hot topic” drugs that you’ve been hearing about in the
news.
DSM-IV-TR
Two common and widely recognized criteria are used by clinicians and researchers to diagnose alcohol and other substance use disorders. The first is the American Psychiatric
Association’s Diagnostic and Statistics Manual of Mental Disorders; the most current is the
fourth edition text revision, commonly referred to as the DSM-IV-TR. The other is the
World Health Organization’s International Classification of Diseases (ICD-9). Both are used
to help identify and classify alcohol and other substance use disorders. The codes contained in them also are used in patient medical records and for claims and billing purposes.
The most common tool used in the United States for diagnosing alcohol and other substance use disorders is the DSM-IV-TR. The ICD-9 is most often used as an international
tool for diagnosing causes of death and disability. An ICD-9 diagnosis is required by
HIPAA and by Medicaid. The DSM-IV-TR classifies alcohol and other substance use
disorders as substance dependence, substance abuse and substance-induced disorders.
Substance dependence is a pattern of substance abuse that leads to impairment or distress;
substance abuse is related to the repeated use of substances; and a substance-induced disorder is a specific syndrome, such as a mood change that is related to ingesting the substance. 8
National Conference of State Legislatures
What Are Alcohol and Other Substance Use Disorders?
Understanding the scope and scale of drug use, abuse and addiction in the United States,
determining its prevalence among various populations, and learning about the many health
and social consequences are critical to solving this complex problem. Epidemiological
research is one method used to identify and examine trends in both drug use and the
attitudes that Americans have toward drug use. Many epidemiological studies—including
a variety of surveys, experimental studies, and field investigations—are conducted on a
continuing basis. These studies provide long-term data trends that can help measure the
nation’s success in preventing and treating drug use.9, 10
Chronic, Relapsing Disease
Many people view alcohol and other substance use disorders as strictly a social problem.
Parents, teens, older adults, and other members of the community tend to characterize
alcohol and other substance users as morally weak or as having criminal tendencies. They
believe that alcohol and other substance users should be able to stop using alcohol and
other drugs if they are willing to change their behavior.11
These myths have stereotyped not only those with alcohol and other substance use disorders, but also their families, their communities, and the health care professionals who work
with them. Alcohol and other substance use disorders comprise a public health problem
that affects many people and has wide-ranging social consequences. The goal of the National Institute on Drug Abuse (NIDA) is to help the public replace its myths and longheld mistaken beliefs about alcohol and other substance use disorders with scientific evidence that addiction is a chronic, relapsing and treatable disease.12
Addiction begins with alcohol and other drug abuse when an individual makes a conscious
choice to use alcohol and other drugs, but addiction is not simply “a lot of alcohol and
other drug use.” Recent scientific research provides overwhelming evidence that not only
do alcohol and other drugs interfere with normal brain functioning by creating powerful
feelings of pleasure, but they also have long-term effects on brain metabolism and activity.
At some point, changes occur in the brain that can turn alcohol and other drug abuse into
addiction—a chronic, relapsing illness. Those addicted to alcohol and other drugs suffer
from a compulsive carving for and use of alcohol and other drugs and cannot quit by
themselves. Treatment is necessary to end this compulsive behavior.13
A variety of approaches are used in treatment programs to help patients deal with these
cravings and possibly avoid alcohol and other drug relapse. NIDA research shows that
addiction is clearly treatable. Through treatment that is tailored to individual needs, patients can learn to control their condition and live relatively normal lives.14
Treatment can have a profound effect not only on alcohol and other drug users, but also on
society as a whole by significantly improving social and psychological functioning, decreasing related criminal behavior and violence, and reducing the spread of AIDS. It can also
dramatically reduce the costs to society of alcohol and other drug abuse.15
A tremendous opportunity exists to effectively change how the public understands alcohol
and other substance use disorders through the wealth of scientific data NIDA has amassed.
Overcoming misconceptions and replacing ideology with scientific knowledge is the best
hope for bridging the gap between the public perception of alcohol and other substance
use disorders and the scientific facts.16
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Treatment of Alcohol and Other Substance Use Disorders
Prevention of alcohol and other drug abuse in a crucial piece of the puzzle. Results from
NIDA-funded prevention research have shown that comprehensive prevention programs
that involve the family, schools, communities and the media are effective in reducing alcohol and other drug abuse. It is necessary to reiterate the message that it is better to not
start at all than to enter rehabilitation if addiction occurs.17
PET Scans of Long-term Brain Changes in Abstinence and Brains on Drugs
The following text and pictures are taken from the National Institute on Drug Abuse
(NIDA) Slide Teaching Packet, Bringing the Power of Science to Bear on Drug Abuse and
Addiction, slides 7-10 and 14.18
This is literally the brain on drugs.
When someone gets “high” on cocaine, where does the cocaine go in the
brain? With the help of a radioactive tracer, this PET scan shows us a
person’s brain on cocaine and the area of the brain, highlighted in yellow, where cocaine is “binding” or attaching itself. This PET scan shows
us minute by minute, in a time-lapsed sequence, just how quickly cocaine begins affecting a particular area of the brain.19
Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and
baboon brain in vivo. Fowler J.S., Volkow N.D., Wolf A.P., Dewey S.L., Schlyer D.J.,
Macgregor, Hitzemann R., Logan J., Bendreim B., Gatley S.T., et al. Synapse
1989;4(4):371-377.
We start in the upper left hand corner. You can see that 1 minute after
cocaine is administered to this subject nothing much happens. All
areas of the brain seem to be functioning normally. But after 3 to 4
minutes, we see areas highlighted in yellow where cocaine is starting to
bind to the striatum of the brain and activate it.20
At the 5- to 8-minute interval, we see that cocaine is affecting a large
area of the brain. After that, the drug’s effects begin to wear off. At the 9- to 10-minute
point, the high feeling is almost gone. Unless the abuser takes more cocaine, the experience
is over in about 20 to 30 minutes.21
Scientists are doing research to find out if the striatum produces the “high feeling” and
controls our feelings of pleasure and motivation. One of the reasons scientists are curious
about specific areas of the brain affected by drugs such as cocaine is to develop treatments
for people who become addicted to these drugs. Scientists hope to find
the most effective way to change an addicted brain back to normal functioning. 22
Long-term effects of drug abuse.
This PET scan shows us that once addicted to a drug like cocaine, the
brain is affected for a long, long time. In other words, once addicted,
the brain is literally changed.23
In this slide, the level of brain function is indicated in yellow. The top
row shows a normal-functioning brain without drugs. You can see a lot
of brain activity. In other words, there is a lot of yellow color.24
Photo courtesy of Nora Volkow, Ph.D. Volkow ND, Hitzemann R, Wang G-J, Fowler
J.S., Wolf A.P., Dewey S.L.. Long-term frontal brain metabolic changes in cocaine abusers.
Synapse 11:184-190, 1992; Volkow ND, Fowler J.S., Wang G-J, Hitzemann R, Logan
J, Schlyer D, Dewey S, Wolf A.P.. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993.
The middle row shows a cocaine addict’s brain after 10 days without
any cocaine use at all. What is happening here? Less yellow means less
National Conference of State Legislatures
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What Are Alcohol and Other Substance Use Disorders?
normal activity occurring in the brain—even after the cocaine abuser has abstained from the
drug for 10 days.25
The third row shows the same addict’s brain after 100 days without any cocaine. We can
see a little more yellow, so there is some improvement—more brain activity—at this point.
But the addict’s brain is still not back to a normal level of functioning ... more than 3
months later. Scientists are concerned that there may be areas in the brain that never fully
recover from drug abuse and addiction.26
Drugs have long-term consequences.
Here is another example of what science has shown us about the longterm effects of drugs. What this PET scan shows us is how just 10 days
of drug use can produce very dramatic and long-term changes in the
brain of a monkey. The drug in these images is amphetamine, or what
some people call “speed.” Remember the previous slide showed us what
the brain of a chronic cocaine abuser looks like. This slide shows us
what using a drug like amphetamine can do in only 10 days to the brain
of a monkey. 27
This slide also gives us a better idea of what methamphetamine, a drug
similar in structure, can do to the brain. Methamphetamine use is
becoming increasingly popular in certain areas of the country.28
Photo courtesy of NIDA from research conducted by Melega W.P., Raleigh M.J.,
Stout D.B., Lacan C., Huang S.C., Phelps M.E. Recovery of striatal dopamine function after acute amphetamine- and methamphetamine-induced neurotoxicity in the
vervet monkey. Brain Res 1997 Aug 22;766(1-2);113-120.
The top row shows us, in white and red, normal brain activity. The
second row shows us that same brain 4 weeks after being given amphetamine for 10 days.
There is a dramatic decrease in brain activity. This decreased brain activity continues for
up to 1 year after amphetamine use. These continuous brain changes often trigger other
changes in social and emotional behavior, too, including a possible increase in aggressiveness, feelings of isolation, and depression.29
The memory of drugs.
This slide demonstrates something really amazing—how just the mention of items associated with drug use may cause an addict to “crave” or
desire drugs. This PET scan is part of a scientific study that compared
recovering addicts, who had stopped using cocaine, with people who
had no history of cocaine use. The study hoped to determine what
parts of the brain are activated when drugs are craved.30
For this study, brain scans were performed while subjects watched two
videos. The first video, a nondrug presentation, showed nature images—mountains, rivers, animals, flowers, trees. The second video showed
cocaine and drug paraphernalia, such as pipes, needles, matches, and
other items familiar to addicts.31
Photo courtesy of Anna Rose Childress, Ph.D.
This is how the memory of drugs works: The yellow area on the upper part of the second
image is the amygdala, a part of the brain’s limbic system, which is critical for memory and
responsible for evoking emotions. For an addict, when a drug craving occurs, the amygdala
becomes active and a craving for cocaine is triggered.32
National Conference of State Legislatures
6
Treatment of Alcohol and Other Substance Use Disorders
So if it’s the middle of the night, raining, snowing, it doesn’t matter. This craving demands
the drug immediately. Rational thoughts are dismissed by the uncontrollable desire for
drugs. At this point, a basic change has occurred in the brain. The person is no longer in
control. This changed brain makes it almost impossible for drug addicts to stay drug-free
without professional help. Because addiction is a brain disease.33
Have you changed your mind?
As we look at side-by-side PET scans of a person who has never used
cocaine compared with a cocaine addict, can you tell which brain is
more active and healthy? Yes, the brain on the left with an abundance
of red is the healthy, active brain.34
With a little bit of knowledge about what drug addiction actually is,
anyone—not just neuroscientists and neurobiologists—can see the
changes in brain activity caused by drug abuse and addiction. The PET
scans we’ve looked at today prove that.35
We’ve seen the scientific facts. We’ve learned that addiction is a brain
disease. And we’ve also learned that scientists are making great strides
in developing treatments for addiction. There will be no magic charm
to make addiction go away. But educated and informed with the scientific facts about
what drugs can do to the brain, we are each in a better position to decide whether or not to
take drugs in the first place. Given the facts, have you changed your mind?36
Photo courtesy of NIDA. If You Change Your Mind. Student magazine. NIH Publication No. 93-3474, 1993.
Appendix D contains more PET scans related to specific drugs.
MRI Scans of Long-term Brain Changes in Alcoholics and Adolescent Brains
on Alcohol
As exhibited in the MRI scans below, the brains of alcoholics shrink. The brain of the
alcoholic has visibly shrunk, compared to the brain of the healthy non-alcoholic. The
brain matter is the lighter gray color. In the alcoholic’s MRI scan, you can see that the
brain has receded (shrunk) around the sides.
Healthy non-alcoholic woman (age 43)
Photos courtesy of Daniel Hommer, M.D., NIAAA.
Alcoholic woman (age 43)
National Conference of State Legislatures
7
What Are Alcohol and Other Substance Use Disorders?
As exhibited in the MRI scans below, alcohol affects adolescents’ brains in several ways.
The first set of MRI scans (figure 1) demonstrates that there is greater activation of a
normal adolescent brain during a spatial working memory task than of an adolescent brain
on alcohol. The second set of MRI scans (figure 2) demonstrates that there is underactivation in the brain of an alcohol-dependent adolescent when compared to the brain of
a light drinker adolescent.
Figure 1. Activation Patterns to Spatial Working Memory Task for Adolescents
Normal
Alcohol
Greater activation
during spatial
working memory
Greater activation
during vigilance
Photos courtesy of Sandra Brown, Ph.D., University of California, San Diego.37
Figure 2. Brain Activation in Young Women
Light Drinker
Female, Age 20
Alcohol-Dependent
Female, Age 20
Greater
activation
Underactivation
Photos courtesy of Sandra Brown, Ph.D., University of California, San Diego.37
National Conference of State Legislatures
8
Treatment of Alcohol and Other Substance Use Disorders
National Conference of State Legislatures
9
What Are the Effects of Alcohol and Other Substance Use Disorders?
2. WHAT ARE THE EFFECTS OF ALCOHOL
AND OTHER SUBSTANCE USE DISORDERS?
Alcohol and other substance use disorders are equal opportunity diseases. The public perception is that they are
largely poor, unemployed persons’ diseases; however, employed persons are also affected.
Alcohol and other substance use disorders disproportionately affect full-time working individuals. Approximately
70 percent of people with alcohol and other substance use
disorders are employed full-time. This is problematic for
employers because even moderate drinking results in lost
productivity.
Although documented rates of heavy alcohol and illicit drug
use are highest for the unemployed, alcohol and other substance use is a problem that disproportionately affects working Americans. Of the 15.2 million Americans age 18 and
older who were heavy drinkers in 2002, 12 million (79
percent) were either full-time or part-time workers.1 Of
the 16.6 million illicit drug users 18 and over, 12.4 million (74.6 percent) were employed either full-time or parttime. 2
The federal government has adopted several means by which
to measure the number of people with alcohol and other
substance use disorders.
•
Approximately 70 percent of people with alcohol and other substance use disorders are employed full-time.
•
Of the 15.2 million Americans age 18 and older who were heavy
drinkers in 2002, 12 million (79 percent) were either full-time or
part-time workers.
•
Of the 16.6 million illicit drug users age 18 and over, 12.4 million (74.6 percent) were employed either full-time or part-time.
•
Approximately 120 million Americans over age 12 were current
drinkers in 2002.
•
Of those who were current drinkers, approximately 54 million
Americans were binge drinkers.
•
Of those who were current or binge drinkers, approximately
15.9 million Americans were heavy drinkers.
•
An estimated 19.5 million Americans over age 12 (8.3 percent)
reported using illicit drugs in the past month during 2002 and
thus are considered current users.
•
Marijuana, the most common illicit drug, was used by 75 percent of current drug users.
•
Of the 15.9 million heavy drinkers, approximately one third—
5.2 million—also were current illicit drug users.
National Survey on Drug Use and Health
The National Survey on Drug Use and Health (NSDUH) indicates that alcohol is the
most common substance use disorder problem. According to the 2002 survey, approximately one of every two Americans over age 12 was a current alcohol user, about one of five
was a binge drinker, and about one of every 15 was a heavy drinker. Current, binge and
heavy alcohol use are defined as follows.
National Conference of State Legislatures
9
10
Treatment of Alcohol and Other Substance Use Disorders
Current use: At least one drink in the past month.
• Approximately 120 million Americans over age 12 were current drinkers in 2002.
Binge use: Five or more drinks on the same occasion at least once in the past month.
• Of those who were current drinkers, approximately 54 million Americans were binge
drinkers.
Heavy use: Five or more drinks on the same occasion on at least five different days in the
past month.
• Of those who were current or binge drinkers, approximately 15.9 million Americans
were heavy drinkers.3
According to the same survey, an estimated 19.5 million Americans over age 12 (8.3 percent) reported using illicit drugs in the past month during 2002 and are thus considered
current users. Marijuana, the most commonly used illicit drug, was used by 75 percent of
current drug users.4 Studies show that some individuals who use alcohol also may use
other drugs. Of the 15.9 million heavy drinkers, approximately one third or 5.2 million
also were current illicit drug users.5
Although documented rates of heavy alcohol and illicit drug use are highest for the unemployed, alcohol and other substance use is a problem that disproportionately affects working Americans. Of the 15.2 million Americans age 18 and older who were heavy drinkers
in 2002, 12 million (79 percent) were either full-time or part-time workers.6 Of the 16.6
million illicit drug users 18 and over, 12.4 million (74.6 percent) were employed either
full-time or part-time.7
Standard Methodology for Rate of Alcohol and Other Substance Use
Disorders by Substance, by State
The 2002 NSDUH does not included state-by-state information. The most current survey to include this information is the 2000 survey. Estimates in the report, State Estimates
of Substance Use from the 2000 National Household Survey on Drug Abuse, have been adjusted
to reflect the probability of selection, record nonresponse, poststratification to known benchmarks, item imputation, and other aspects of the estimation process.8
In the report, state model-based estimates are portrayed in U.S. maps showing all 50 states
and the District of Columbia. These estimates also are provided in tables that include all
50 states and the District of Columbia by four age categories and in individual state tables
arranged to display all of the estimates discussed in this report by the four age categories for
a given state.9
Each table contains a “national” total that represents the (weighted) sum of the estimates
from the 50 states and the District of Columbia. Those totals are generally slightly different
from the corresponding national estimates calculated by summing the sample-weighted records
across the entire sample. The latter estimates are the preferred unbiased estimates for the
nation and are used in the text for comparison with the state-level estimates.10 Tables 1 and
2 show rates of alcohol and other substance use and dependence by substance, by state.
To obtain your state’s need assessments, contact your own single state agency director. For
a listing of single state agency directors, please refer to appendix E.
National Conference of State Legislatures
11
What Are the Effects of Alcohol and Other Substance Use Disorders?
Table 1. Rate of Alcohol and Other Substance Use by Substance, by State
Annual Averages Based on 1999 and 2000 NHSDAs
State/
Jurisdiction
Total
Ala.
Alaska
Ariz.
Ark.
Calif.
Colo.
Conn.
Del.
Fla.
Ga.
Hawaii
Idaho
Ill.
Ind.
Ia.
Kan.
Ky.
La.
Maine
Md.
Mass.
Mich.
Minn.
Miss.
Mo.
Mt.
Neb.
Nev.
N.H.
N.J.
N.M.
N.Y.
N.C.
N.D.
Ohio
Okla.
Ore.
Pa.
R.I.
S.C.
S.D.
Tenn.
Texas
Utah
Vt.
Va.
Wash.
W.V.
Wis.
Wyo.
D.C.
Key:
Past Month
Users of Any
Illicit Drug
Past Month
Users of
Marijuana
#
%
#
13,968
196
43
233
117
1,954
300
196
53
745
396
75
58
612
293
102
110
192
216
72
242
581
545
236
118
239
49
61
114
66
410
105
855
422
22
520
137
212
591
67
160
29
275
774
85
43
271
356
73
293
24
30
6.28
5.38
8.80
6.10
5.44
7.62
8.86
7.26
8.45
5.92
6.28
7.67
5.37
6.27
5.93
4.28
5.12
5.87
6.09
6.88
5.69
11.35
6.89
5.97
5.21
5.27
6.32
4.47
7.49
6.55
6.13
7.13
5.79
6.68
4.19
5.60
4.99
7.52
5.85
8.12
5.15
4.75
5.94
4.86
5.01
8.50
4.82
7.51
4.69
6.68
5.67
7.05
10,675
140
31
173
84
1,459
264
154
45
597
281
59
44
465
219
67
79
138
133
62
190
463
448
187
72
196
38
47
81
60
310
88
665
347
17
399
83
184
451
59
125
23
200
536
54
37
232
267
54
230
19
22
%
Past Month
Users of Any
Illicit Drug
Other Than
Marijuana
#
%
4.80
3.84
6.35
4.53
3.89
5.69
7.80
5.70
7.24
4.74
4.45
6.07
4.12
4.77
4.43
2.79
3.68
4.21
3.74
5.95
4.46
9.03
5.66
4.73
3.16
4.33
4.89
3.45
5.31
5.96
4.63
5.93
4.50
5.50
3.17
4.30
3.02
6.53
4.47
7.20
4.02
3.73
4.31
3.36
3.15
7.26
4.13
5.62
3.49
5.24
4.40
5.23
5,935
96
15
118
55
778
106
76
19
311
174
24
25
250
130
52
54
95
107
28
101
175
213
99
56
98
19
30
49
27
168
42
361
164
11
238
78
84
261
23
73
14
123
409
51
15
113
136
40
125
11
14
2.67
2.63
3.16
3.10
2.56
3.04
3.15
2.83
3.08
2.47
2.75
2.44
2.32
2.57
2.62
2.17
2.52
2.91
3.01
2.67
2.38
3.42
2.69
2.51
2.48
2.16
2.52
2.20
3.21
2.67
2.50
2.83
2.44
2.60
2.14
2.57
2.87
2.97
2.59
2.77
2.33
2.21
2.65
2.56
3.01
3.03
2.01
2.87
2.55
2.87
2.64
3.20
Past Year
Users of
Cocaine
Past Month Users
of Alcohol
#
%
#
3,658
64
11
81
32
443
83
41
16
213
113
18
14
147
71
32
32
54
61
14
55
105
122
65
34
59
12
20
32
14
98
41
221
100
7
140
40
42
145
14
51
10
84
310
25
9
84
71
20
76
6
9
1.64
1.76
2.20
2.11
1.51
1.73
2.45
1.51
2.48
1.69
1.79
1.81
1.33
1.51
1.43
1.33
1.48
1.66
1.71
1.31
1.29
2.06
1.54
1.64
1.49
1.30
1.54
1.46
2.10
1.82
1.27
3.19
1.38
1.41
1.62
1.16
1.39
1.83
1.37
1.47
1.31
2.20
1.67
2.56
1.68
1.77
1.30
2.02
1.62
1.82
1.68
2.08
102,758
1,341
258
1,769
758
11,917
1,975
1,510
328
5,799
2,722
421
444
4,938
1,957
1,230
1,019
1,128
1,558
521
2,097
3,097
3,714
2,115
675
2,024
425
718
798
573
3,446
751
7,314
2,336
303
4,221
1,001
1,387
4,924
435
1,117
312
1,564
6,857
475
287
2,581
2,233
508
2,493
212
191
%
46.25
36.87
52.87
46.36
35.32
46.49
58.51
56.01
52.46
46.08
43.23
43.28
41.54
50.66
39.69
51.60
47.48
34.41
43.88
49.90
49.23
60.33
46.99
53.76
29.83
44.81
55.32
52.44
52.62
57.23
51.47
50.92
49.51
37.01
56.69
45.50
36.62
49.48
48.74
53.10
35.89
50.66
33.81
43.04
28.07
56.50
45.95
47.03
32.70
57.24
50.22
44.90
Past Month
“Binge”
Alcohol Users
#
%
45,349
657
105
786
406
4,913
777
575
140
2,334
1,284
197
199
2,238
915
568
436
632
828
223
738
1,305
1,690
912
379
911
182
326
357
207
1,397
348
2,990
1,064
155
2,033
490
527
2,193
182
576
158
775
3,380
233
113
1,037
843
276
1,176
104
80
20.41
18.05
21.49
20.59
18.91
19.16
22.99
21.34
22.40
18.54
20.39
20.22
18.65
22.96
18.55
23.82
20.30
19.28
23.32
21.29
17.33
25.54
21.37
23.15
16.76
20.15
23.64
23.80
23.55
20.68
20.87
23.54
20.24
16.85
29.06
21.91
17.93
18.78
21.70
22.24
18.50
25.67
16.75
21.22
13.73
22.13
18.46
17.76
17.78
26.95
24.66
18.86
# = Estimated numbers (in thousands)
% = Percentages reporting
Source: “State Estimates of Substance Use from the 2000 National Household Survey on Drug Abuse: Volume I. Findings, Appendix A: Tables of Model-Based Estimates
(50 states and the District of Columbia), by Substance,” http://www.samhsa.gov/oas/2kState/PDF/Vol1/2kSAEv1W.pdf.
National Conference of State Legislatures
12
Treatment of Alcohol and Other Substance Use Disorders
Table 2. Rate of Substance Abuse and Dependence by Substance, by State
Annual Averages Based on 1999 and 2000 NHSDAs
State/
Jurisdiction
Past Year Alcohol
Dependence or
Abuse
#
Total
Ala.
Alaska
Ariz.
Ark.
Calif.
Colo.
Conn.
Del.
Fla.
Ga.
Hawaii
Idaho
Ill.
Ind.
Ia.
Kan.
Ky.
La.
Maine
Md.
Mass.
Mich.
Minn.
Miss.
Mo.
Mt.
Neb.
Nev.
N.H.
N.J.
N.M.
N.Y.
N.C.
N.D.
Ohio
Okla.
Ore.
Pa.
R.I.
S.C.
S.D.
Tenn.
Texas
Utah
Vt.
Va.
Wash.
W.V.
Wis.
Wyo.
D.C.
Key:
12,384
197
34
230
105
1,561
216
183
36
700
319
53
62
610
257
137
122
168
216
52
224
366
441
219
125
237
54
95
89
64
326
97
704
285
40
454
145
167
559
53
144
47
249
913
86
30
268
259
72
264
25
25
%
5.54
5.39
6.91
5.95
4.84
6.07
6.34
6.77
5.69
5.52
5.01
5.40
5.74
6.24
5.18
5.74
5.65
5.12
6.07
4.95
5.23
7.12
5.56
5.52
5.52
5.22
6.96
6.85
5.76
6.33
4.86
6.51
4.76
4.48
7.37
4.89
5.28
5.87
5.52
6.40
4.61
7.52
5.34
5.69
4.98
5.93
4.74
5.41
4.66
6.00
5.97
5.94
Past Year Alcohol
Dependence
#
5,225
94
13
101
48
668
77
73
15
288
159
22
28
243
116
55
50
74
103
22
87
125
171
96
71
98
18
34
34
24
140
43
300
145
13
196
64
71
237
19
74
18
115
361
34
12
116
106
34
98
9
12
%
2.34
2.58
2.74
2.62
2.21
2.59
2.27
2.70
2.33
2.27
2.50
2.30
2.60
2.48
2.33
2.30
2.31
2.26
2.90
2.14
2.03
2.44
2.16
2.43
3.11
2.16
2.36
2.50
2.18
2.36
2.08
2.86
2.03
2.28
2.48
2.11
2.32
2.52
2.34
2.31
2.36
2.83
2.47
2.25
1.96
2.33
2.05
2.21
2.20
2.24
2.20
2.90
Past Year Any
Illicit Drug
Dependence or
Abuse
#
4,504
68
13
111
43
621
82
58
14
226
125
18
21
176
86
33
40
67
77
20
92
125
148
71
45
77
16
24
35
22
119
32
307
114
9
173
62
68
181
16
55
11
89
324
41
11
99
109
28
85
8
10
%
2.01
1.86
2.59
2.87
1.98
2.41
2.42
2.12
2.28
1.78
1.96
1.87
1.90
1.81
1.74
1.37
1.83
2.04
2.16
1.91
2.14
2.43
1.86
1.79
1.95
1.70
2.02
1.70
2.25
2.21
1.78
2.12
2.07
1.80
1.65
1.87
2.27
2.38
1.79
1.93
1.76
1.71
1.90
2.02
2.35
2.10
1.75
2.28
1.83
1.92
1.96
2.46
Past Year Any
Illicit Drug
Dependence
#
2,869
47
6
67
26
410
54
40
10
148
77
11
14
115
58
23
25
41
53
12
60
90
87
46
30
50
8
16
21
13
73
19
195
67
5
102
33
38
128
10
36
7
61
187
24
8
67
68
18
55
5
6
%
1.28
1.28
1.31
1.73
1.18
1.59
1.58
1.48
1.57
1.17
1.20
1.16
1.28
1.17
1.17
0.97
1.14
1.26
1.48
1.15
1.41
1.75
1.10
1.15
1.32
1.11
1.09
1.17
1.34
1.25
1.09
1.25
1.32
1.05
0.98
1.10
1.20
1.33
1.27
1.23
1.15
1.10
1.31
1.17
1.39
1.57
1.18
1.42
1.15
1.24
1.13
1.45
Past Year
Dependence or
Abuse for Any
Illicit Drug or
Alcohol
#
%
14,701
231
39
287
130
1,895
253
217
44
818
394
63
71
665
304
144
145
207
267
64
278
424
526
253
157
286
59
104
106
71
380
118
895
327
45
549
170
201
662
61
174
48
287
1,050
107
37
316
332
80
303
29
30
# = Estimated numbers of persons reporting (in thousands)
% = Percentages reporting
Source: “State Estimates of Substance Use from the 2000 National Household Survey on Drug Abuse: Volume I. Findings, Appendix A: Tables of Model-Based Estimates
(50 states and the District of Columbia), by Substance,” http://www.samhsa.gov/oas/2kState/PDF/Vol1/2kSAEv1W.pdf.
National Conference of State Legislatures
6.58
6.33
7.85
7.43
5.98
7.36
7.42
8.01
6.89
6.45
6.19
6.51
6.51
6.80
6.15
6.04
6.71
6.28
7.50
6.09
6.48
8.26
6.64
6.37
6.92
6.29
7.61
7.51
6.84
7.06
5.65
7.92
6.06
5.14
8.29
5.91
6.21
7.07
6.54
7.36
5.55
7.79
6.14
6.54
6.21
7.24
5.60
6.94
5.16
6.89
6.75
7.11
What Are the Effects of Alcohol and Other Substance Use Disorders?
Healthy People 2010
Healthy People 2010 is a set of health objectives for the nation to achieve over the first
decade of the new century. It can be used by many different people, states, communities,
professional organizations, and others to help them develop programs to improve health.11
Healthy People 2010 builds on initiatives pursued over the past two decades. The 1979
surgeon general’s report, Healthy People, and Healthy People 2000: National Health Promotion and Disease Prevention Objectives both established national health objectives and served
as the basis for the development of state and community plans. Like its predecessors, Healthy
People 2010 was developed through a broad consultation process, built on the best scientific knowledge and designed to measure programs over time.12
Healthy People 2010 is designed to achieve two overarching goals:
•
Goal 1: Increase Quality and Years of Healthy Life
The first goal of Healthy People 2010 is to help individuals of all ages increase life
expectancy and improve their quality of life.
•
Goal 2: Eliminate Health Disparities
The second goal of Healthy People 2010 is to eliminate health disparities among different segments of the population.
Each of the 28 focus area chapters also contains a concise goal statement. This statement
frames the overall purpose of the focus area.13
One of the focus areas is “substance abuse.” Of the 28 focus areas, 10 are also Leading
Health Indicators. The Leading Health Indicators (LHIs) are 10 major health issues for
the nation.14 One LHI is “substance abuse.”
Alcohol and illicit drug use are associated with many of this country’s most serious problems, including violence, injury, and HIV infection. The annual economic costs to the
United States from alcohol abuse were estimated to be $167 billion in 1995, and the costs
from drug abuse were estimated to be $110 billion. 15
In 1998, 79 percent of adolescents between the ages of 12 and 17 reported that they did
not use alcohol or illicit drugs in the past month. In the same year, 6 percent of adults age
18 and older reported using illicit drugs in the past month; 17 percent reported binge
drinking in the past month, which is defined as consuming five or more drinks on one
occasion.16
The objectives selected to measure progress among adolescents and adults for this leading
health indicator are presented below. These are only indicators and do not represent all the
substance abuse objectives in Healthy People 2010.17
National Conference of State Legislatures
13
14
Treatment of Alcohol and Other Substance Use Disorders
Figure 3. Use of Alcohol and/or Illicit Drugs, United States, 1994–1998
Source: Substance Abuse and Mental Health Services Administration, Office of the Assistant Secretary, National Household Survey on Drug Abuse. 1994–98
(Rockville, Md.: SAMHSA, 1994-98).
26-10a. Increase the proportion of adolescents not using alcohol or any illicit drugs during
the past 30 days.
26-10c. Reduce the proportion of adults using any illicit drug during the past 30 days.
26-11c. Reduce the proportion of adults engaging in binge drinking of alcoholic beverages
during the past month.
Figure 4. Data Measures
26-01a
26-01b
26-01c
26-01d
26-02
26-03
26-04
26-05
26-06
26-07
26-08
26-09a
26-09b
26-09c
26-09d
26-10a
26-10b
26-10c
26-11a
26-11b
26-11c
Alcohol-related motor vehicle crash deaths (per 100,000 population)
Alcohol-related motor vehicle crash injuries (per 100,000 population)
Drug-related motor vehicle crash deaths
Drug-related motor vehicle crash injuries
Cirrhosis deaths (age adjusted per 100,000 standard population)
Drug-induced deaths (age adjusted per 100,000 standard population)
Drug-related hospital emergency department visits (thousands)
Alcohol-related hospital emergency department visits
Adolescents riding with a driver who has been drinking alcohol - Students
(grades 9 through 12)
Intentional injuries from alcohol and drug- related violence
Lost productivity due to alcohol and drug use
Average age at first use of alcohol - Adolescents (aged 12 to 17 years)
Average age at first use of marijuana - Adolescents (aged 12 to 17 years)
High school seniors never consuming alcoholic beverages
High school seniors never using illicit drugs
Adolescents not using alcohol or illicit drugs in past 30 days (aged 12 to 17 years)
Adolescents using marijuana in past 30 days (aged 12 to 17 years)
Adults using illicit drugs in past 30 days (aged 18 years and over)
Binge drinking - High school seniors
Binge drinking - College students
Binge drinking - Adults (aged 18 years and over)
National Conference of State Legislatures
What Are the Effects of Alcohol and Other Substance Use Disorders?
Figure 4. Data Measures (continued)
26-11d
26-12
26-13a
26-13b
26-14a
26-14b
26-14c
26-15
26-16a
26-16b
26-16c
26-16d
26-16e
26-16f
26-17a
Binge drinking - Adolescents (aged 12 to 17 years)
Average annual alcohol consumption (gallons per person, aged 14 years and over)
Adult females exceeding guidelines for low-risk drinking (aged 21 years and over)
Adult males exceeding guidelines for low-risk drinking (aged 21 years and over)
Steroid use among adolescents - 8th graders
Steroid use among adolescents - 10th graders
Steroid use among adolescents - 12th graders
Inhalant use among adolescents (aged 12 to 17 years)
Peer disapproval of substance abuse - 8th graders
Peer disapproval of substance abuse - 10th graders
Peer disapproval of substance abuse - 12th graders
Peer disapproval of trying marijuana or hashish once or twice - 8th graders
Peer disapproval of trying marijuana or hashish once or twice - 10th graders
Peer disapproval of trying marijuana or hashish once or twice - 12th graders
Perception of risk associated with consuming 5+ alcoholic drinks once or twice a week Adolescents (aged 12 to 17 years)
26-17b Perception of risk associated with smoking marijuana once per month Adolescents (aged 12 to 17 years)
26-17c Perception of risk associated with using cocaine once per month Adolescents (aged 12 to 17 years)
26-18 Treatment gap for illicit drugs in the general population
26-19 Substance abuse treatment in correctional institutions
26-20 Treatment admissions for injection drug use (thousands)
26-21 Treatment gap for alcohol problems
26-22 Hospital emergency department referrals for alcohol or drug problems and suicide attempts
26-23 Community partnerships and coalitions to prevent substance abuse
26-24 Administrative license revocation laws for persons who drive under the influence of
intoxicants (number of States and D.C.)
26-25 Blood alcohol concentration levels of 0.08 for motor vehicle drivers (number of States
and D.C., aged 21 years and over)18
Source: “DATA2010 ... the Healthy People 2010 Database—October 2003 Edition— 10/20/03—10:16:57AM Focus area: 26-Substance Abuse,”
http://wonder.cdc.gov/scripts/broker.exe.
Trends in Substance Abuse
Adolescents
Alcohol is the drug most frequently used by adolescents between the ages of 12 and 17.
Although the trend from 1994 to 1998 showed some fluctuations, about 77 percent of
adolescents between the ages of 12 and 17 report being both alcohol free and drug free in
the past month. In 1998, 19 percent of adolescents in this age group reported drinking
alcohol in the past month. Alcohol use in the past month for this age group has remained
at about 20 percent since 1992. Eight percent of this age group reported binge drinking,
and 3 percent were heavy drinkers (five or more drinks on the same occasion on each of five
or more days in the past 30 days).19
Data from 1998 show that 10 percent of adolescents between the ages of 12 and 17 reported
using illicit drugs in the past 30 days. This rate remains well below the all-time high of 16
percent in 1979. Current illicit drug use had nearly doubled for those between the ages of 12
and 13 between 1996 and 1997 but then decreased between 1997 and 1998. Youth are
experimenting with a variety of illicit drugs, including marijuana, cocaine, crack, heroin,
National Conference of State Legislatures
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16
Treatment of Alcohol and Other Substance Use Disorders
acid, inhalants and methamphetamines, and also misuse prescription drugs and other “street”
drugs. The younger a person is when he or she becomes a habitual user of illicit drugs, the
stronger the addiction becomes and the more difficult it is to stop use.20
Adults
Binge drinking has remained at the same approximate level of 17 percent for all adults
since 1988, with the highest current rate of 32 percent among adults between the ages of
18 and 25. Illicit drug use has been near the present rate of 6 percent since 1980. Men
continue to have higher rates of illicit drug use than women, and rates of illicit drug use in
urban areas are higher than in rural areas.21
State-by-State Treatment Gap Table
Table 3 presents state estimates of treatment gaps, which are the percentages and numbers
of people who need but do not receive treatment for illicit drug use. It does not include
alcohol. A discussion follows about the methodology used to calculate the state estimates of
the treatment gap.22
For each respondent in the sample, one can determine whether a person needed but did
not receive treatment for an illicit drug problem based on the following definition: An
individual was counted in the treatment gap if he or she was dependent on or had abused
an illicit drug but had not received treatment for his or her illicit drug problem at a “specialty” substance abuse facility in the past 12 months (i.e., in the 12 months before being
interviewed). “Specialty” substance abuse facilities include drug and alcohol rehabilitation
facilities (inpatient or outpatient), hospitals (inpatient only), and mental health centers.23
The state estimates are based on a model that has two components. One component is a
national model using data from the 2000 National Household Survey on Drug Abuse
(NHSDA). The national model includes demographic information (such as age and race),
socioeconomic information on the local area (such as the percentage below the poverty
level), and information specific to drug use (such as the marijuana possession arrest rate for
the county). The information used in the national model is available at the census block,
census tract or county level.24
The second component of the model is the information collected from the NHSDA respondents in each state. This direct sample component adjusts the results to reflect stateand local-level differences. Together, these two components produce the final estimate. In
effect, for each state, two estimates of the treatment gap—one from a national model and
one from the sample data from the state—are combined to make the best estimate for the
state. If a state is represented in the survey by a relatively small sample and the direct
sample estimate from the state is subject to significant sampling variation, more weight is
given to the national component.
When the process is complete, the results are validated by comparing the estimates produced by the model with estimates based entirely on the sample data. This is done for areas
that have very large samples that can be assumed to produce “accurate” estimates without
the need for models. The validation results showed that the model-based estimates for all
those age 12 or older were quite accurate compared with the true state value—on average,
within about 4 percent of the true value. For example, if the true value in a state was 2
percent, the estimate would typically be within 0.08 of a percent of the true value.25
National Conference of State Legislatures
17
What Are the Effects of Alcohol and Other Substance Use Disorders?
Table 3. Estimated Numbers and Percentages of Persons Aged 12 or Older
Needing But Not Receiving Treatment for an Illicit Drug Problem in the Past Year, by State: 2000
State/Jurisdiction
Total
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Estimated Numbers
3,994,321
60,846
10,381
88,686
34,202
563,676
71,131
52,010
11,100
196,128
100,012
16,838
19,700
164,309
82,093
32,845
35,310
53,647
65,208
18,817
80,734
108,669
137,607
75,663
37,181
67,487
12,396
22,267
27,941
19,883
110,186
25,748
285,054
98,671
8,019
150,150
43,449
54,906
160,117
13,983
48,469
9,262
78,992
287,765
36,474
9,810
87,768
94,245
22,959
75,832
6,872
8,820
Estimated Percentages
1.79%
1.66
2.12
2.29
1.58
2.19
2.09
1.92
1.76
1.55
1.73
1.73
1.81
1.68
1.66
1.37
1.63
1.63
1.83
1.80
1.89
2.11
1.74
1.90
1.63
1.48
1.60
1.61
1.81
1.97
1.64
1.73
1.93
1.55
1.49
1.62
1.58
1.92
1.58
1.70
1.54
1.49
1.69
1.79
2.11
1.92
1.55
1.97
1.47
1.71
1.61
2.08
Source: “National and State Estimates of Drug Abuse Treatment Gap, Chapter 3. Estimates of the Treatment Gap, by State,” http://www.samhsa.gov/oas/TXgap/
chapter3.htm.
National Conference of State Legislatures
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Treatment of Alcohol and Other Substance Use Disorders
Profile of a Typical Person with an Alcohol and Other Substance Use
Disorders
Analyses of available statistics reveal that the typical addict is a 35-year-old white male who
is employed full-time. However, many people think that the typical addict is a 16-yearold black female who is unemployed and on welfare. One reason for this misperception is
that an addict who is able to function and go to work is invisible—nobody knows that he
is an addict. This is part of the stigma of addiction.
Profiles of People with Alcohol and Other Substance Use Disorders
Demonstrate that all Populations are Addicts
Lori R.
“I am going to continue being a mom,” Lori R. said as she spoke proudly about her three
children. But, until recently, the idea of parenting created anxiety for Lori. On May 1,
2000, the Department of Children and Family Services (DCFS) took Lori’s children into
custody because she was using drugs. “I just kept going into their empty rooms and crying,” said Lori.
After that day, Lori said she saw the damage that using drugs had inflicted on her life. She
started a treatment program and in October 2000, Lori began to work for JCPenney. As
she progressed in her recovery and became self-sufficient, Lori shifted her focus to her
children’s return.
The reunification process is a difficult one, especially for those who are trying to maintain
their abstinence from alcohol and other drugs. Lori’s recovery coach knows this is true.
“During the process of trying to get their kids back, they are also working to maintain their
sobriety, they are in counseling, and they are going to work every day; it can be really
overwhelming.”
Lori knew she wanted her children home, but they had been away for so long that she was
nervous about their homecoming. “I felt like I had let my children down,” said Lori. Her
recovery coach was there to help guide her through the reunification process. “That’s the
reason I was there—to ensure things went smoothly, like an advocate.”
Lori continues to work at JCPenney, where she has been promoted three times. She hopes
to become a first-time homeowner sometime this summer. But, most importantly, she has
her children back in her life. “I’m a mom now,” she said.
Mari L.
Mari L. is learning a new way of life. Her drug use led to criminal behavior, and a judge
finally ordered treatment overseen by an independent case manager as part of her probation sentence. “I was an addict for 20 years. My case manager set up a treatment plan that
took me through the stages of addiction, but also taught me there’s a difference between
abstinence and sobriety. I stopped using before, once for a couple of years, but now I see I
have to recover from my old way of life.”
National Conference of State Legislatures
What Are the Effects of Alcohol and Other Substance Use Disorders?
For Mari, that meant leaving behind certain friends and family members, many of whom
were in denial about her addiction, while others served as her “enablers.”
“I knew they would give me $20, $30 because they liked me as a person, and in a day I
could get $100.” Even then, Mari was beginning to realize that brief highs weren’t worth
the more enduring consequences of withdrawal, but she couldn’t stop using. “My case
manager got me into treatment that was right for me. I needed structure in my life and not
every program works for everybody.”
Mari went to a recovery home where she underwent four months of residential treatment.
Now, she is living one year of sobriety at the recovery home before getting her own apartment. A telemarketing job, plus some overtime, covers her rent and she looks forward to
parlaying this experience into a higher-level position as an emergency operator.
“I’m learning to come up with solutions to deal with my problems instead of making
excuses,” she says. “Today, I know I have a lot of options and the choices are mine. There’s
nothing I can do about yesterday, except to learn from it.” To people new to the treatment
process, Mari advises, “It will work for you, if you work at it and believe you can be productive for the rest of your life.”
Jim
“I was one of those drunks who never saw the inside of a jail, nor was I ever ticketed for any
offense that I could attribute to alcohol. I have never been hospitalized for any reason.
Drinking never cost me a job or my wife.”26
“My favorite expression was, ‘I can quit drinking any time I want to.’ It got to the point
where I started to believe it. I was able to quit drinking each Lent except for the one just
prior to my coming into the A.A. program. I believed God would punish me more in the
hereafter if I didn’t do some penance for my sins here on earth. Abstaining from alcohol was
the toughest penance I knew of. Sheer determination, bullheadedness, willpower, and egotism carried me through.
Bullheadedness was a part of my nature. When I had made up my mind to do something,
hell or high water couldn’t change it. Many times during Lent, my wife pleaded with me to
drink, just because I was so miserable to her and the kids when I wasn’t drinking.”27
“All my friends knew I always quit during Lent. Their adulation of my willpower sustained
me through those days and nights. The fear of what they might say or think if I happened
to fall off the wagon kept me going till Easter. I lived on the comments of my drinking
buddies’ wives: ‘Oh, how I wish my Jack (or Tom, or Steve) could quit like you.’ My wife
was probably thinking, ‘If they only knew what his sobriety is costing me!’” 28
“I was also the smartest man in the world, in the company I worked for, in the departments
I worked in, and at home as the head of the family.” 29
“I had only one problem that was a little difficult to understand, let alone solve. After
waking so many mornings feeling so terribly lousy and sick, and telling and promising
myself I would not be that stupid again, why would I go right out and be stupid again?
National Conference of State Legislatures
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20
Treatment of Alcohol and Other Substance Use Disorders
Why couldn’t I stop after only one or two, like some guys I knew? Why was I almost always
thinking about booze one way or another? Why couldn’t I fall asleep unless I was at least
half gooned-up?” 30
“What would I do with my time if I quit? What would people say or think if I quit? What
would customers say? What about Christmas, New Year’s, and my birthday without booze?
How come I couldn’t quit when I wanted to, when I’d always said I could? How come I lied
so much? I was tired of lying, I was tired of trying to be someone else. It hurt me to think
I was hooked on booze like an addict on dope.” 31
“One beautiful Saturday afternoon in July, when I was 34 years old, I blurted out to a
priest that alcohol might be the root of my troubles. I had never before admitted such a
thing to anyone. The priest suggested I try A.A.” 32
“I think one of the extraordinary yet simple points of A.A. is that I didn’t have to quit
drinking—in the sense that I understood quitting—before entering the program. I think if the
program had advocated quitting as I understood it, I would not be sober today.” 33
“A.A. teaches us how to live without alcohol, how unnecessary alcohol is, and how it increases our problems.” 34
“It is a perfectly natural thing for most of us to say thank you to other people for whatever
we receive. That’s why it is important that I say thanks for the most precious gift I can
receive—24 hours of sobriety.” 35
Use-by-Age Charts
Tables 4 and 5 quantify rates of alcohol and other substance use, abuse and dependence by
substance, by age.
Table 4. Rate of Alcohol and Other Substance Use by Substance, by Age
(Annual Averages Based on 1999 and 2000 NHSDAs)
Past Month
Users of Any
Illicit Drug
Age
Group
(Yrs.)
Total
12-17
18-25
26 or
older
Past Month
Users of
Marijuana
#
%
#
%
13,968
2,280
4,598
7,091
6.28
9.79
16.01
4.17
10,675
1,687
3,932
5,056
4.80
7.24
13.69
2.97
Past Month
Users of Any
Illicit Drug
Other Than
Marijuana
#
%
5,935
1,058
1,713
3,164
2.67
4.54
5.96
1.86
Past Year
Users of
Cocaine
#
3,658
389
1,358
1,910
%
1.64
1.67
4.73
1.12
Past Month
Users of Alcohol
Past Month
“Binge”
Alcohol Users
#
%
#
%
102,758
3,819
16,318
82,621
46.25
16.40
56.81
48.55
45,349
2,387
10,850
32,112
20.41
10.25
37.78
18.87
Key: # = Estimated Numbers (in Thousands)
% = Percentages Reporting
Source: “State Estimates of Substance Use from the 2000 National Household Survey on Drug Abuse: Volume I. Findings, Appendix A: Tables of Model-Based
Estimates (50 States and the District of Columbia), by Substance,” http://www.samhsa.gov/oas/2kState/PDF/Vol1/2kSAEv1W.pdf.
National Conference of State Legislatures
21
What Are the Effects of Alcohol and Other Substance Use Disorders?
Table 5. Rate of Substance Abuse and Dependence by Substance, by Age
(Annual Averages Based on 1999 and 2000 NHSDAs)
Past Year Alcohol
Dependence or
Abuse
Age
Group
(Yrs.)
Total
12-17
18-25
26 or
older
#
12,384
1,225
3,750
7,409
Past Year Alcohol
Dependence
%
#
5.54
5.24
12.94
4.33
5,225
432
1,337
3,456
%
2.34
1.85
4.61
2.02
Past Year Any
Illicit Drug
Dependence or
Abuse
#
4,504
1,061
1,062
1,841
%
2.01
4.54
5.53
1.08
Past Year Any
Illicit Drug
Dependence
#
2,869
564
1,015
1,289
%
1.28
2.41
3.50
0.75
Past Year
Dependence or
Abuse for Any
Illicit Drug or
Alcohol
#
%
14,701
1,806
4,479
8,416
6.58
7.73
15.45
4.92
Key: # = Estimated Numbers of Persons Reporting (in Thousands)
% = Percentages Reporting
Source: “State Estimates of Substance Use from the 2000 National Household Survey on Drug Abuse: Volume I. Findings, Appendix A: Tables of Model-Based
Estimates (50 States and the District of Columbia), by Substance,” http://www.samhsa.gov/oas/2kState/PDF/Vol1/2kSAEv1W.pdf.
Adolescents
Adolescents are a population that is uniquely affected by alcohol and other substance use
disorders. Many adolescents themselves use alcohol and some use other drugs. Adolescents whose parents use substances are at greater risk of developing alcohol and other substance use disorders. It is important to note that, although it is legal for adults to use
alcohol, it is illegal for adolescents.
Adolescents’ Use
Since 1975, the Institute for Social Research at the University of Michigan has conducted
an annual national survey on drug and alcohol of approximately 16,000 high school seniors. In 1993, the wording of alcohol-related questions was changed to indicate that a
“drink” meant “more than a few sips.”
According to the survey results, the number of seniors who have ever tried alcohol remained stable at 80 percent between 1993 and 1999. However, the number of seniors
who used alcohol in the past year or in the past 30 days both increased slightly between
1993 and 1999. The number of seniors who have been drunk in the last 30 days also rose
by 4 percent from 1993 to 32.9 percent in 1999. The 1998 NHSDA indicates rates of
underage drinking were highest among white males between the ages of 18 and 20.36
The University of Michigan results found more than half (54.7 percent) of high school
seniors surveyed in 1999 had used an illicit drug in their lifetime. This is a marked increase from the 42.9 percent reported in 1993. The number of seniors who had used an
illicit drug in the past 30 days also rose substantially from 18.3 percent in 1993 to 25.9
percent in 1999. Rates of illicit drug use in the 1998 NHSDA were highest among 18- to
20-year-olds and decreased thereafter.37
Youth alcohol and other substance use continues to be a problem that states are attempting
to address. The number of adolescents under age 18 who are receiving alcohol and other
substance use treatment on any given day in the United States almost doubled from 44,000
people in 1991 to 77,000 people in 1996, according to the Substance Abuse and Mental
Health Services Administration’s Office of Applied Studies.
National Conference of State Legislatures
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Treatment of Alcohol and Other Substance Use Disorders
Parents’ or Custodial Adults’ Use
Alcoholism and other drug addiction have genetic and environmental causes. Both have
serious consequences for children who live in homes where parents are involved. More than
28 million Americans are children of alcoholics; nearly 11 million are under age 18. This
figure is magnified by the countless number of others who are affected by parents who are
impaired by other psychoactive drugs. Alcoholism and other drug addiction tend to run in
families. 38
•
Children of addicted parents are more at risk for alcoholism and other drug addiction
than are other children. Family interaction is defined by alcohol and other substance
use or addiction in a family. A relationship between parental addiction and child abuse
has been documented in a large proportion of child abuse and neglect cases.
•
Children of drug addicted parents are at higher risk for placement outside the home.
•
Children of addicted parents exhibit symptoms of depression and anxiety more than
do children from non-addicted families.
•
Children of addicted parents experience greater physical and mental health problems
and higher health and welfare costs than do children from non-addicted families.
•
Children of addicted parents have a high rate of behavior problems.
•
Children of addicted parents score lower on tests measuring school achievement and
they exhibit other difficulties in school. Maternal consumption of alcohol and other
drugs during any time of pregnancy can cause birth defects or neurological deficits.
•
Children of addicted parents may benefit from supportive adult efforts to help them.
National Conference of State Legislatures
Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders?
23
3. WHY SHOULD STATE LEGISLATORS BE
CONCERNED ABOUT ALCOHOL AND
OTHER SUBSTANCE USE DISORDERS?
National expenditures for the treatment of alcohol and other
substance use disorders exceeded $12 billion in 1996. This
amount is relatively low when compared to the $246 billion that alcohol and other substance use cost society.1
State governments spend billions of dollars each year on
alcohol and other substance use treatment. Additional
billions are spent on alcohol and other drug-related crimes,
accidents and social problems that arise in the work place,
the community and the home. Problems include lost
worker productivity, increased homelessness, and mental
health and family problems.
Studies from several states have shown that drug treatment
is cost effective. These state experiences demonstrate that
alcohol and other substance use treatment results in
marked decreases in drug use, medical expenses and illegal
behavior, which translates into savings for employers, for
the health care system and for taxpayers.2
State legislators will want to be aware of the economic,
health and social consequences of alcohol and other substance use disorders in order to make cost-effective public
policy decisions.
•
National expenditures for the treatment of alcohol and other
substance use disorders exceeded $12 billion in 1996.
•
This amount is relatively low when compared to the $246
billion that alcohol and other substance use cost society.
•
The costs of alcohol and other substance use disorders were
estimated in 1992 by the National Institute on Drug Abuse
and the National Institute on Alcohol Abuse and Alcoholism
to be more than $246 billion annually.
•
States spent $81.3 billion in 1998 to deal with this issue—
13.1 percent of their budgets.
•
Furthermore, of every dollar states spent on substance abuse,
96 cents went to shovel up the wreckage in state programs
and only four cents went to prevent and treat the problem.
•
An estimated 8.2 million people were dependent on alcohol
in 2002, and 2.44 million people reported receiving treatment or counseling for their alcohol use.
•
In 2002, 19.5 million Americans were current illicit drug
users. This represents 8.3 percent of the population age 12
and older.
Economic Costs
Alcohol and other substance use disorders place financial burdens on states and taxpayers.
Untreated alcohol and other substance use cost the nation billions of dollars each year as a
result of increasing health care costs, loss of productivity at work, judicial and law enforcement costs, unemployment and the costs of social services. The costs of alcohol and other
substance use disorders were estimated in 1992 by the National Institute on Drug Abuse
and the National Institute on Alcohol Abuse and Alcoholism to be more than $246 billion
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Treatment of Alcohol and Other Substance Use Disorders
annually. The costs of alcoholism are expected to increase every year due to population
growth and inflation.3 States bear the greatest financial burden.
Many ancillary costs also are associated with alcohol and other substance use disorders.
These include health, social service, criminal justice, education, mental health and public
safety. These costs result from untreated alcohol and other substance use disorders because, left untreated, people with alcohol and other substance use disorders are likely to
have medical problems, consume social services, commit crimes, have children with learning disabilities, have co-occurring mental illnesses and impede the safety of the community. States are employing multiple approaches to avoid, shift and offset these costs, particularly in the criminal justice system via treatment in lieu of incarceration, i.e., drug
courts, diversion programs and sentencing reform.
Associated Costs
The National Center on Addiction and Substance Abuse at Columbia University (CASA)
published a January 2001 report, Shoveling Up: The Impact of Substance Abuse on State
Budgets, the first comprehensive analysis of how much substance abuse and addiction cost
each state budget. This analysis shows that states spent $81.3 billion in 1998 to deal with
this issue—13.1 percent of their budgets. Furthermore, of every $1 states spent on substance abuse, 96 cents went to shovel up the wreckage in state programs and only four
cents went to prevent and treat the problem. This report provides state specific estimates
for 45 responding states, the District of Columbia and Puerto Rico for 16 categories of
programs, including health, social service, criminal justice, education, mental health and
public safety. CASA estimated aggregate spending in the five states that did not respond to
the survey (Indiana, Maine, New Hampshire, North Carolina and Texas).4
Among the findings of the report are these.5
•
State governments spent $81.3 billion in 1998 to deal with substance abuse. This
amounts to more than 13 cents of every state budget dollar. Substance abuse is among
the largest cost in state budgets, although its effects are hidden in departments and
activities that typically do not deal with substance abuse.
•
Each American paid $277 per year in state taxes to deal with the burden of substance
abuse and addiction in their social programs, and only $10 per year for prevention and
treatment.
•
Of every $1 states spend on substance abuse:
-
95.8 cents goes to pay for the burden of this problem on public programs. Untreated substance abuse increases, for example, the cost of every state’s criminal
justice system; elementary and secondary schools; Medicaid; child welfare, juvenile justice and mental health systems; highways; and state payrolls. These costs
totaled $77.9 billion in 1998.
-
Only 3.7 cents goes to fund prevention, treatment and research programs aimed at
reducing the incidence and consequences of substance abuse. State spending for
prevention, treatment and research amounted to $3 billion in 1998.
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One-half of one cent covers costs of collecting alcohol and tobacco taxes and regulating alcohol and tobacco products. Regulation and taxation are untapped resources that could help control spending on the consequences of alcohol and tobacco abuse and addiction. State spending on regulation and compliance was $433
million in 1998.
•
States spent $24.9 billion in 1998 on the costs of substance abuse to children—an
amount comparable to the entire state budget of Pennsylvania. For every $113 states
spend on the consequences of substance abuse just for children, they spend only $1 on
prevention or treatment.
•
States spent $30.7 billion in 1998 on the burden of substance abuse on the justice
system—for incarceration, probation and parole, juvenile justice and criminal and family
court costs of substance-involved offenders. These costs total 4.9 percent of state budgets, more than 10 times the total amount that states spent for substance abuse treatment and prevention.
•
Other areas of significant state spending for failing to prevent or treat substance abuse
include:
-
$16.5 billion in education (2.7 percent of state spending),
-
$15.2 billion in health (2.4 percent of state spending),
-
$7.7 billion in child and family assistance (1.2 percent of state spending), and
-
$5.9 billion in mental health and developmental disabilities (0.9 percent of state
spending).
•
States spend more on the consequences of substance abuse than they do on Medicaid
($60.4 billion or 9.7 percent of state budgets) or on transportation ($51.4 billion or
8.3 percent of state budgets). They spend as much on substance abuse as on higher
education ($81.3 billion or 13.1 percent of state budgets).
•
The drug linked to the largest percentage of state substance abuse costs is alcohol. At
least $9.2 billion is spent on alcohol alone, $7.4 billion on tobacco alone and $1.1
billion on illicit drug use only. The remaining spending, $63.6 billion, could not be
differentiated by drug, but most of this amount is linked to both alcohol and illegal
drug abuse.
•
States collected $4 billion in alcohol taxes and $7.4 billion in tobacco taxes in 1998 for
a total of $11.4 billion. For each $1 in alcohol and tobacco taxes that reached state
coffers, states spent $7.13 on the problem of alcoholism and drug addiction—$6.83
to cope with the burden, $0.26 for prevention and treatment and $0.04 to collect
taxes and run licensing boards. Few states dedicate revenues to the burden of untreated
substance abuse or use alcohol and tobacco tax increases as a way to reduce use by
teens.
•
On average, of every $100 states spend on substance abuse, they spend $95.80 on the
burden of substance abuse to public programs, compared to $3.70 for prevention,
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Treatment of Alcohol and Other Substance Use Disorders
treatment and research ($0.50 is spent on regulation and compliance), but state spending
varies widely. The proportion spent on shoveling up the wreckage compared to prevention and treatment ranges from to $89.71 vs. $10.22 in North Dakota to $99.94 vs.
$0.06 in Colorado.
Elements that Measure Associated Costs
To survey states for its Shoveling Up report, CASA identified several elements of state budgets to examine to assess the cost of untreated addiction to the states. Those elements are:6
•
•
•
•
•
•
•
Justice
- Adult Corrections
- Juvenile Justice
- Judiciary
Education
Health
Child and Family Assistance
- Child Welfare
- Income Support Programs
Mental Health/Developmental Disabilities
- Mental Health
- Developmental Disabilities
Public Safety
State Workforce
Employment Consequences
Alcohol and other substance use disorders are generally recognized to be a major, global
public health problem of particular concern. There are many reasons for this concern,
including the likelihood that: 1) employees with alcohol and other substance use disorders
damage their own and others’ health and well being; 2) employee alcohol and other substance use may decrease productivity and contribute to absenteeism, accidents, injuries,
death or violence in the workplace; and 3) a workplace that tolerates or ignores employee
alcohol and other substance use disorders does not reflect the interests of the vast majority
of employees who do not use substances or who are in recovery.7
•
Alcoholism alone accounts for 500 million lost work days each year. Casual drinkers,
in aggregate, account for far more incidents of absenteeism, tardiness, and poor quality
of work than those who are regarded as alcohol dependent.8
•
Between 20 percent and 40 percent of all general hospital patients are admitted for
complications related to alcoholism and other forms of alcohol and other substance use
disorders.9
•
The human costs to the individual, family, and community are incalculable.10
•
Today, almost 73 percent of all current drug users between the ages of 18 and 49 are
full- or part-time employed—more than 8.3 million workers.11
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Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders?
•
About 7 percent of full-time workers use illicit drugs (6.3 million), and about 7 percent are heavy drinkers.12
•
About 1.2 million full-time workers both use illicit drugs and are heavy alcohol users. 13
•
The highest rate of documented or reported illicit drug use and heavy alcohol use is
among those who are between the ages of 18 and 25, males, Caucasian, and those with
less than a high school education.14
Health Consequences
According to the National Household Survey on Drug Abuse, an estimated 8.2 million
people were dependent on alcohol in 2002, and 2.44 million people reported receiving
treatment or counseling for their alcohol use.15 Although alcohol and other drugs are
implicated in deaths caused by motor vehicle crashes, drownings, falls and fires, it is difficult to measure the connection between alcohol and morbidity. Excessive use of alcohol is
harmful to every organ and tissue in the body. Alcohol affects the liver, esophagus, stomach, intestines, heart, brain, nerves, hormones and immune system and also can lead to
other health problems.16 Some studies also show that moderate use of alcohol is good for
an individual’s heart because it boosts HDL cholesterol levels. However, aerobic exercise
and weight loss also provide the same result. Alcohol intake is not recommended solely to
have a healthier heart because alcohol can raise blood pressure and cause many other negative health effects.
The Substance Abuse and Mental Health Services Administration estimates that, in 2002,
19.5 million Americans were current illicit drug users. This represents 8.3 percent of the
population age 12 and older.17 Alcohol and other substance use causes damage to the
health of an alcohol and other substance user and can impede his or her ability to function
at a normal level.
According to a research study conducted by Rutgers University, treatment of alcohol and
other substance use disorders causes sharp reductions in medical care utilization and encourages more appropriate utilization when services are delivered. These cost offsets are a
stable, long-term effect of treatment from which society will reap benefits for a period
longer than any research team has followed to date.18
Fetal Alcohol Syndrome and Drug-Affected Babies
Drinking alcohol during pregnancy can produce infants with fetal alcohol syndrome (FAS)
or infants with fetal alcohol effects (FAE). Characteristics of FAS include prenatal and
postnatal growth retardation, evidence of craniofacial anomalies, central nervous system
dysfunction and malformations in the major organ systems. FAE is a lesser set of the same
symptoms that make up FAS. At least 5,000 infants are born each year with FAS; another
50,000 children show symptoms of FAE.19
Alcohol-related neurodevelopmental disorder (ARND) is a term used to describe individuals who have mental but no physical abnormalities. Alcohol-related birth defects (ARBD)
refers to those who have physical defects of the body from prenatal alcohol exposure.
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Treatment of Alcohol and Other Substance Use Disorders
Studies have examined babies born with FAS at later developmental stages to determine its
long-term effects. Overall improvement could be seen in some areas: the appearance of the
children, their clumsiness, impaired concentration, difficulties with siblings, tantrums,
negativity and phobias. Other factors persisted, however, including hyperactivity, speech
defects and anxiety. There was a greater need for special education for these children as
they reached school age and, the more mentally challenged these children were at birth,
the less improvement they showed as they grew older. Most of these children continue to
need special health, education and social services as they grow older.20
Drug and alcohol use by pregnant women has gained national attention. When pregnant
women use drugs, alcohol or cigarettes, the substances cross the placenta and affect the
developing fetus. Cocaine use can cause miscarriage, fetal stroke, premature delivery, and
maternal and infant hemorrhaging. Narcotics such as opium and heroin can cause fetal
addiction, which can lead to infant withdrawal, respiratory distress and convulsions. In
addition to physical abnormalities, drug-affected babies use costly medical services and a
variety of other support services.
In 1997, the Substance Abuse and Mental Health Services Administration released the
first major analysis of alcohol, illicit drug and tobacco use in a nationally representative
sample of women. The findings indicated:
•
About 21.5 percent of pregnant women under age 44 had used alcohol in the past
month and, of this group, nearly one-third reported having three or more drinks on
the days they drank.
•
An estimated 62,000, or 2.3 percent, of all pregnant women under age 44 reported
using an illicit drug in the past month.21
A 1998 study by the National Institute on Drug Abuse (NIDA) showed an increase from
1997 in the use of illicit drugs by pregnant women who used an illicit drug during pregnancy to 5.5 percent, or 221,000 women.22
Infectious Disease
According to the U.S. Centers for Disease Control and Prevention, although the number of
cases of acute hepatitis C virus (HCV) among injection drug users has declined dramatically since 1989, both incidence and prevalence of HCV infection remain high in this
group. The reasons are not fully understood but may be due to safer injection practices
resulting from intensive HIV prevention programs and to the very high proportion of drug
users who already are infected. Injection drug use currently accounts for most HCV transmission in the United States, and has accounted for a substantial proportion of HCV infections during the past decades. Many people with chronic HCV infection might have acquired their infection 20 to 30 years ago as a result of limited or occasional illegal drug
injecting. Injection drug use leads to HCV transmission in a manner similar to that for
other blood borne pathogens (i.e., through transfer of HCV-infected blood by sharing
syringes and needles either directly or through contamination of drug preparation equipment). However, HCV infection is acquired more rapidly after initiation of injecting than
other viral infections (i.e., hepatitis B virus (HBV) and human immunodeficiency virus
(HIV)), and rates of HCV infection among young injecting drug users are four times higher
than rates of HIV infection. After five years of injecting, as many as 90 percent of users are
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Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders?
infected with HCV. More rapid acquisition of HCV infection, compared with other viral
infections among injection drug users is likely caused by high prevalence of chronic HCV
infection among injecting-drug users, which results in a greater likelihood of exposure to
an HCV-infected person.23
•
A study conducted among volunteer blood donors in the United States documented
that HCV infection has been independently associated with a history of intranasal
cocaine use. (The mode of transmission could be through sharing contaminated straws.)
Data from NHANES III indicated that 14 percent of the general population have used
cocaine at least once. Although NHANES III data also indicated that cocaine use was
associated with HCV infection, injection drug use histories were not ascertained.24
•
Among patients with acute hepatitis C identified in CDC’s sentinel counties viral
hepatitis surveillance system since 1991, intranasal cocaine use in the absence of injection drug use was uncommon.25
Thus, at least in the recent past, intranasal cocaine use rarely appears to have contributed
to transmission. Until more data are available, whether those with a history of noninjecting
illegal drug use alone (e.g., intranasal cocaine use) are likely to be infected with HCV
remains unknown.26
The incidence of reported HIV cases among injection drug users (IDU) is accelerating at
an alarming rate. According to the U.S. Centers for Disease Control and Prevention, sharing syringes and other equipment for drug injection is a well-known route of HIV transmission, yet injection drug use contributes to the epidemic’s spread beyond the circle of
those who inject. Since the epidemic began, injection drug use has directly and indirectly
accounted for more than 36 percent of AIDS cases in the United States. This disturbing
trend appears to be continuing. Of the 48,269 new cases of AIDS reported in 1998, 31
percent were IDU-associated. People who have sex with an IDU also are at risk of infection
through the sexual transmission of HIV. Children born to mothers who contracted HIV
through sharing needles or having sex with an IDU may become infected as well.27
Alcohol and other substance use also places individuals at risk for sexually transmitted
diseases (STDs). While experiencing the effects of the substance, individuals are likely to
engage in unprotected sex. (This also leads to more unintended pregnancies.) Furthermore, substances suppress inhibitions; therefore, individuals are likely to engage in more
risky behaviors.
Mental Health
Estimates suggest that each year up to 10 million people across the nation are suffering
from at least one co-occurring mental health and alcohol and other substance use disorder.28 The National Comorbidity Study results indicate that 41 percent to 65 percent of
individuals with a lifetime alcohol and other substance use disorder also have a lifetime
history of at least one mental disorder. In addition, almost 51 percent of individuals with
one or more lifetime mental disorders also have a history of at least one alcohol and other
substance use disorder.29 Although a causality relationship between alcohol and other
substance use disorders and mental disorders has yet to be established, there are indications that individuals who suffer from mental illnesses may self-medicate with alcohol and
other drugs, leading to alcohol and other substance use disorders.
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Treatment of Alcohol and Other Substance Use Disorders
President George W. Bush established the President’s New Freedom Commission on Mental Health in April 2002. The commission is chaired by Michael F. Hogan, director of the
Ohio Department of Mental Health. The commission submitted its final report to the
president on July 22, 2003. The commission established 15 subcommittees to examine
specific aspects of mental health services and offer recommendations for improvement. The
subcommittee on Co-occurring Disorders, chaired by Rodolfo Arredondo, submitted its
summary report, An Outline for the Draft Report of the Subcommittee on Co-occurring Substance Abuse and Mental Disorders, on Dec. 2, 2002. The report can be found at http://
www.mentalhealthcommission.gov/subcommittee/Co_Occurring_Outline.doc.
Medical Conditions
Alcohol-related problems—such as liver disease, heart disease, certain forms of cancer and
pancreatitis—often develop more gradually and may become evident only after many years
of heavy drinking. Women may develop alcohol-related health problems sooner than men,
and from drinking less alcohol than men. Because alcohol affects nearly every organ in the
body, long-term heavy drinking increases the risk for many serious health problems. More
than 2 million Americans suffer from alcohol-related liver disease.30
•
Some drinkers develop alcoholic hepatitis, or inflammation of the liver, as a result of
heavy drinking over a long period of time. Its symptoms include fever, jaundice (abnormal yellowing of the skin, eyeballs and urine) and abdominal pain. Alcoholic hepatitis
can cause death if drinking continues. If drinking stops, the condition may be reversible. 31
•
About 10 percent to 20 percent of heavy drinkers develop alcoholic cirrhosis, or scarring of the liver. People with cirrhosis should not drink alcohol. Although treatment for
the complications of cirrhosis is available, a liver transplant may be needed for someone
with life-threatening cirrhosis. Alcoholic cirrhosis can cause death if drinking continues. Cirrhosis is not reversible, but if a person with cirrhosis stops drinking, the chances
of survival improve considerably. People with cirrhosis often feel better, and liver function may improve, after they stop drinking.32
•
About 4 million Americans are infected with hepatitis C virus (HCV), which can cause
liver cirrhosis and liver cancer. Some heavy drinkers also have HCV infection. As a
result, their livers may be damaged not only by alcohol but by also HCV-related problems. People with HCV infection are more susceptible to alcohol-related liver damage
and should think carefully about the risks when considering whether to drink alcohol. 33
•
Moderate drinking can have beneficial effects on the heart, especially among those at
greatest risk for heart attacks, such as men over age 45 and women after menopause.
However, heavy drinking over a long period of time increases the risk for heart disease,
high blood pressure, and some kinds of stroke.34
•
Long-term heavy drinking increases the risk of certain forms of cancer, especially cancer
of the esophagus, mouth, throat and larynx (voice box). Research suggests that, in
some women, as little as one drink per day can slightly increase the risk of breast
cancer. Drinking also may increase the risk of developing cancer of the colon and rectum. 35
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Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders?
•
The pancreas helps regulate the body’s blood sugar levels by producing insulin. The
pancreas also has a role in digesting the food we eat. Long-term heavy drinking can lead
to pancreatitis, or inflammation of the pancreas. Acute pancreatitis can cause severe
abdominal pain and can be fatal. Chronic pancreatitis is associated with chronic pain,
diarrhea and weight loss.36
High doses of cocaine and/or prolonged use can trigger paranoia. Smoking crack cocaine
can produce a particularly aggressive paranoid behavior in users. When addicted individuals stop using cocaine, they often become depressed. This also may lead to further cocaine
use to alleviate depression. Prolonged cocaine snorting can result in ulceration of the mucous membrane of the nose and can damage the nasal septum enough to cause it to collapse. Cocaine-related deaths often are a result of cardiac arrest or seizures followed by
respiratory arrest.37
Research findings for long-term marijuana use indicate some changes in the brain similar
to those seen after long-term use of other major drugs of abuse.38
•
A study of 450 individuals found that people who smoke marijuana frequently but do
not smoke tobacco have more health problems and miss more days of work than do
nonsmokers. Many of the extra sick days among the marijuana smokers in the study
were for respiratory illnesses. Even infrequent use can cause burning and stinging of
the mouth and throat, often accompanied by a heavy cough. Someone who smokes
marijuana regularly may have many of the same respiratory problems as tobacco smokers, such as daily cough and phlegm production, more frequent acute chest illness, a
heightened risk of lung infections, and a greater tendency to obstructed airways. Cancer of the respiratory tract and lungs also may be promoted by marijuana smoke.39
•
A study comparing 173 cancer patients and 176 healthy individuals produced strong
evidence that smoking marijuana increases the likelihood of developing cancer of the
head or neck, and the more marijuana smoked the greater the increase. A statistical
analysis of the data suggested that marijuana smoking doubled or tripled the risk of
these cancers. Marijuana use has the potential to promote cancer of the lungs and
other parts of the respiratory tract because it contains irritants and carcinogens. In fact,
marijuana smoke contains 50 percent to 70 percent more carcinogenic hydrocarbons
than does tobacco smoke. It also produces high levels of an enzyme that converts certain hydrocarbons into their carcinogenic form—levels that may accelerate the changes
that ultimately produce malignant cells. Marijuana users usually inhale more deeply
and hold their breath longer than tobacco smokers do, which increases the lungs’ exposure to carcinogenic smoke. These facts suggest that, puff for puff, smoking marijuana
may increase the risk of cancer more than smoking tobacco.40
Death
Alcoholic hepatitis can cause death if drinking continues. Alcoholic cirrhosis can cause
death if drinking continues. Acute pancreatitis can cause severe abdominal pain and can be
fatal. 41
In rare instances, sudden death can occur on the first use of cocaine or unexpectedly thereafter. However, there is no way to determine who is prone to sudden death. Cocainerelated deaths often are a result of cardiac arrest or seizures followed by respiratory arrest.42
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Treatment of Alcohol and Other Substance Use Disorders
One study has indicated that a user’s risk of heart attack more than quadruples in the first
hour after smoking marijuana. The researchers suggest that such an effect might occur from
marijuana’s effects on blood pressure and heart rate and reduced oxygen-carrying capacity
of blood.43
Trauma
Alcohol and other substance use disorders are major contributing factors in thousands of
traumatic injuries each year. The Drug Abuse Warning Network (DAWN) is a national
probability survey of hospital emergency departments (EDs) conducted annually by the
Substance Abuse and Mental Health Services Administration to capture data about emergency department episodes induced by or related to the use of an illegal drug or the nonmedical use of a legal drug. Data for 2001 showed an estimated 638,484 drug-related ED
episodes and 1,165,367 drug mentions.44 (A drug mention refers to a substance that was
mentioned during a drug-related ED episode.) In drug-related ED episodes, overdose
(264,086) was the most frequently cited reason for the visit. The most frequently cited
motives for taking the substance were dependence (228,994) and suicide (194,324).45
Social Consequences
Families, friends, associates and communities—the entire fabric of society—are affected by
the problems associated with alcohol and other substance use disorders. People who misuse drugs and alcohol often are less productive on their jobs than others. Alcohol and other
substance use disorders contribute to crime, TANF/welfare, accidents, auto crashes, suicide, homelessness, domestic violence and child abuse.
Crime
Alcohol and other substance use and crime are inextricably linked. Research conducted in
major cities across the country reveals that an average of 64 percent of arrestees—male and
female, young and old, regardless of the type of offense—used substances in the days leading up to their crime and arrest.46 Throughout the last 20 years of the twentieth century, in
a political and ideological climate that favored tougher penalties, states attempted to curb
alcohol and other substance use and their attendant social harm through the widespread
enactment of determinate and mandatory minimum sentencing provisions and “three strikes
and you’re out” laws.47
The result—a prison population that now stands at more than 1.3 million, and that quadrupled from 1980 to 2000.48 During that same time period, the United States consistently ranked in the top three industrialized nations in rate of incarceration.49 Enhancements to sentences and reductions in access to rehabilitative options, particularly for lowlevel drug offenses, continued unabated, despite little evidence that incarceration had any
meaningful effect on recidivism rates among addicted offenders.50
The single most important cause of the explosive rise in the nation’s prison population is
the burgeoning number of prison inmates admitted for drug offenses.51 From 1980 to
2000, the number of inmates in state and federal prisons for drug offenses increased by
1,222 percent. At the same time, drug offenders went from 6 percent of the total incarcerate population to 20 percent.52 Most state drug offense incarcerations are the result of lowlevel possession or sales violations.
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Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders?
Massive increases in the numbers of incarcerated people have disproportionately involved
minority communities, particularly African Americans.53 African Americans currently constitute 45 percent of the prison population in the United States, and more than 10 percent
of the African American males between the ages of 25 and 29 currently are incarcerated.54
At the beginning of the 1990s, more African American men were under the control of the
criminal justice system than were enrolled in college.55 The likelihood of incarceration for
a male born in 1991 is 29 percent for African Americans, 16 percent for Hispanics, and 4
percent for whites.56 In 1995, nearly one in three African American men between the ages
of 20 and 29 was under some form of correctional supervision on any given day in the
United States.57 Nationwide, the percentages of incarcerated African Americans are higher
than their representations in every state’s general population.58
The massive imprisonment of African American men for drug offenses has taken a toll on
African American communities throughout the United States. Large numbers of incarcerations for drug offenses have undermined the deterrent effects of prison.59 Imprisonment
has led to fewer numbers of African American men available to care for children, leading to
higher rates of children born out of wedlock, single-parent households, and overall family
disruption.60 The continually growing numbers of African American women incarcerated
for drug offenses also has had a devastating effect on family stability and well-being in the
African American community.61 Prison terms for felony drug offense convictions also have
foreclosed employment prospects and disenfranchised millions of African Americans. It is
estimated that 40 percent of African American men will temporarily or permanently lose
their right to vote as the result of a felony conviction.62
The effects of imprisonment are, of course, not limited to minority communities. Research
has demonstrated that the effect of imprisonment on family stability, neighborhood cohesion and employment might actually increase crime rates in some communities.63 Convictions for felony drug offenses also prohibit many ex-offenders from being eligible for student loans, public housing assistance and drivers’ licenses, resulting in deleterious, lifelong
consequences for those who already have served their sentences for drug law violations.64
TANF/Welfare
Alcohol and other substance use disorders are one of the barriers to self-sufficiency for
welfare recipients.65 Alcohol and other substance use pose a particular challenge for state
welfare reform efforts. It is difficult for addicted welfare recipients to follow welfare rules.
It is even more difficult for these recipients to find and retain employment. Failure in work
and job placements also can contribute to an already low self-esteem in these recipients.
Addicted recipients often face sanctions for noncompliance with welfare rules. These sanctions may include a reduced amount of cash assistance or denial of aid, leaving the children
of addicted welfare recipients vulnerable to neglect and abuse.
Welfare caseloads have dramatically declined since welfare reform. Those who remain on
the caseload face multiple barriers to employment because of problems that often include
alcohol and other substance use disorders. Thirty percent of the caseload has an alcohol or
other substance use disorder or a mental health diagnosis. These recipients face time limits—a federal limit of 60 months of assistance and some state time limits of shorter duration. Welfare recipients with alcohol and other substance use disorders jeopardize state
efforts to meet increasingly strict federal work participation requirements, which could
result in federal financial penalties.
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Treatment of Alcohol and Other Substance Use Disorders
Accidents
Alcohol and other drugs have been implicated in the four leading causes of accidents:
motor vehicle collisions, falls, drowning, and burns and fires.
Burns and fires are accountable for at least 5,000 deaths and 1.4 million injuries every
year.66 Further, a review of five recent studies shows that between 33 percent and 61 percent of those who died as a result of burns from fires were drinking.67
Another means of alcohol-related accidental death and injury is drowning. Drownings,
including boating accidents, are the third most common cause of unintended death for all
ages.68 Data from seven general population studies indicated than an average of 34 percent
of 2,151 drownings involved alcohol use.69
Alcohol may increase the risk factors that contribute to injury or death in any of these
activities as a result of slower response time, decreased coordination, desensitization to
pain, and drowsiness. All these are effects of alcohol consumption.
Auto Crashes
Automobile crashes are the leading cause of death by injury in the United States for people
between the ages of 1 and 34. The National Highway Traffic Safety Administration (NHTSA)
estimates alcohol was involved in 39 percent of fatal crashes and 7 percent of all crashes in
1998.70 The 15,935 fatalities in alcohol-related crashes represent an average of one alcohol-related fatality every 33 minutes. Police reported alcohol was a factor in more than
305,000 crashes that resulted in personal injury. This averages to approximately one person injured in an alcohol-related accident every two minutes.71
Suicide
Suicide is the eighth leading cause of death in the United States and the third leading cause
of death for youth, according to a 1997 report released by the American Association of
Suicidology. The results of one such study indicated that almost 36 percent of suicide
victims had a positive blood alcohol content (BAC) level.72 Although the data did not
prove a causal relationship between alcohol and suicide, the authors suggested that, for
some people, alcohol may have contributed to the decision to commit suicide.
Homelessness
Most national surveys involve data taken from households; therefore, alcohol and other
substance use among the homeless population is not captured. The U.S. Census Bureau in
1996 surveyed homeless assistance programs and the clients who use them. These data
indicate that 38 percent of homeless people who sought assistance had an alcohol problem
in the past month and 26 percent had a drug problem in the past month.73 In 1999, the
National Law Center on Homelessness estimated that more than 2 million people are
homeless during a one-year period. Of these, 2 million, or 40 percent, are drug or alcohol
dependent.
Closely related to alcohol and other substance use disorders in the homeless population are
mental health problems. In 1996, more than 20 percent of the homeless population who
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Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders?
sought assistance reported using alcohol and/or other drugs in the past month in conjunction with a mental health problem.74
According to the National Coalition for the Homeless (NCH), surveys of homeless populations conducted during the 1980s found high rates of alcohol and other substance use
disorders. Although there is no “ ... magic number with respect to the prevalence of
addiction disorders among homeless adults,” untreated alcohol and other substance use
disorders are highly correlated with homelessness.75 Homeless and alcohol and other substance use disorders are interrelated because some people are more predisposed to poverty
and homelessness because of their alcohol and other substance use disorders. There are also
indications that some homeless people begin to use substances to escape the reality of their
homelessness and helplessness.
Domestic Violence
Based on victim reports, 183,000 (37 percent) rapes and sexual assaults involve alcohol use
by the offender, as do 661,000 (27 percent) of aggravated assaults and nearly 1.7 million
(25 percent) simple assaults each year.76
Researchers have found that one-fourth to one-half of men who commit acts of domestic
violence also have alcohol and other substance use disorders and that a sizable percentage of
convicted batterers were raised by parents who used drugs or alcohol. Studies also show
that women who use alcohol and other drugs are more likely to be victims of domestic
violence.77
The Joint Commission on Accreditation of Healthcare Associations (JCAHO) requires screening for domestic violence in emergency departments as a condition of accreditation.
Child Abuse and Neglect
Alcohol and other substance use disorders affect the entire family, not only the individual
who suffers from the addiction. Evidence drawn from numerous studies across the nation
indicates that 40 percent to 80 percent of the parents of the families in the child welfare
system (child protection, abuse and neglect, foster care, adoption, family preservation and
support services) have alcohol and other substance use disorders and that those problems
are connected with the abuse and neglect experienced by their children.78 Day-to-day
abuse and neglect can result in long-term emotional and psychological problems. In addition, children of alcoholics are four times more likely to develop alcoholism than are children of non-alcoholics.79 Children who live with a non-recovering alcoholic score lower on
measures of family cohesion, intellectual-cultural orientation, active-recreational orientation and independence. They also usually experience higher levels of conflict within the
family. 80
In addition, a survey conducted by CASA in 1997 revealed that, when children in America
are being abused or neglected, it is likely that their parents are drunk or high from alcohol
or other drugs or suffering from a hangover or withdrawal symptoms.81 Almost three of
four child welfare professionals in the survey cited alcohol and other substance use disorders as one of the top three causes for the dramatic rise in child maltreatment since 1985.
Also, in a study that controlled for income, family size, degree of social support, parental
depression and anti-social personality, children whose parents were using substances were
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Treatment of Alcohol and Other Substance Use Disorders
three times more likely to be abused and four times more likely to be neglected than were
children whose parents were not alcohol and other substance users.82
Children are not the only family members who are affected by alcohol and other substance
use disorders. Separated and divorced men and women were three times as likely to say
that they had been married to an alcoholic or problem drinker.83
Solutions
Cost Avoidance
The value of imprisonment as a crime control tool has yielded diminishing returns because
greater numbers of offenders are being imprisoned for less serious crimes, especially drug
offenses.84 The high costs of building and operating prisons are not offset by dollars saved
in terms of preventing the most serious and costly crimes. Research has shown, however,
that shifting economic resources from prison systems and into community-based programs,
can produce appreciable reductions in crime.85
Funding justice treatment options, particularly those that divert offenders out of prisons
and into community-based treatment, should not be viewed as a direct cost offset. Few
jurisdictions have so few offenders that the diversion of one offender out of prison and into
a treatment alternative will leave that prison bed unfilled. Epidemiological data demonstrate that there are more offenders who need treatment than there are either treatment
slots or prison beds.
Simple Cost-Offset Methodology
An offset occurs if a cost (such as medical utilization or incarceration) decreases as a result
of treatment for alcohol and other substance use disorders. Studies can measure differences
in the cost (such as medical utilization or incarceration) of treated vs. untreated alcohol and
other substance users.
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What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
37
4. WHAT STRATEGIES ARE AVAILABLE FOR
THE TREATMENT OF ALCOHOL AND
OTHER SUBSTANCE USE DISORDERS?
The Science Behind the Treatment
For many years, researchers have been defining the shortand long-term effects of alcohol and other substance use
disorders. Scientific tools and knowledge now exist on how
to best modify the behaviors of addicted individuals to improve treatment strategies and reduce negative health consequences of individuals and, in the long run, society. 1
Researchers now can pinpoint the effects of alcohol and other
substance use disorders on an individual’s cells, nerves, cultural susceptibility, inheritance of disorders and the effects
of genetic influences on future generations.2 Science and
research cross many scientific, social and cultural boundaries. Research must be transferred from the laboratory to
the clinic to the community and back.3 Research, the basic
foundation for advances in treatment, leads the way to more
effective alcohol and other substance use treatment services.
Recent developments in pharmocotherapy also have changed
the future of alcohol and other substance use treatment and
its role is expected to expand in the future. Research into
alcohol and other substance use disorders will continue to
identify new technologies and new avenues for treatment
approaches.
Denial is a common facet of alcohol and other substance
use disorders, as individuals (and often other significant
people in their lives) tend to minimize both the nature and
the amount of their drug or alcohol use. Often, those in
denial actually convince themselves that alcohol and other
substance use is not a serious problem, although objective
indicators suggest serious consequences. Thus, reports from
people in treatment often are more credible than those from
individuals in the criminal justice system. Assurance of con-
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•
The National Institute on Drug Abuse’s Drug Abuse Treatment Outcome Study found that methadone treatment reduced participants’ heroin use by 70 percent and criminal
activity by 57 percent, while increasing full-time employment by 24 percent.
•
Methadone maintenance therapy helps keep more than
100,000 addicts off heroin, off welfare, and on the tax rolls as
law-abiding, productive citizens.
•
According to the Drug Abuse Treatment Outcome Study
(DATOS), follow-up of Therapeutic Community (TC)
graduates showed a 67 percent decrease in the number of
weekly cocaine users and a 53 percent decline in heavy drinkers. Unemployment dropped 13 percent, suicidal ideation
fell by 46 percent and illegal activity declined by 61 percent.
•
A 1987 review of several studies of the outcomes for people
attending AA found that, overall, 46.5 percent to 62 percent
of active AA members had at least one year of continuous
sobriety. Thirty-five percent to 40 percent of subjects reported
abstinence of less than one year. Twenty-six percent to 40
percent were sober from one to five or six years, and 20 percent to 30 percent maintained abstinence five or six years or
more.
•
In 2002, 57.4 percent of men had used alcohol in the past
month, compared with 44.9 percent of women.
•
Men were twice as likely as women to have used illicit drugs,
including marijuana and cocaine, in the past month during
2002 (10.3 percent versus 6.4 percent).
•
In 2002, 0.8 percent of those age 65 and older currently were
using illicit drugs
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Treatment of Alcohol and Other Substance Use Disorders
fidentiality is an important factor that enhances self-reporting, while potential prosecution
and other sanctions are likely to diminish disclosures. Although screening interviews and
instruments may not give a true picture of drug and alcohol use in all cases, some people
will be truthful. Coupled with other screening methods, such as chemical tests, these
measures help distinguish users from nonusers.4
National Institute on Drug Abuse (NIDA) Principles of Effective Treatment
Based on their research, the National Institute on Drug Abuse has developed principles of
effective treatment.5
1. No single treatment is appropriate for all individuals. Matching treatment settings,
interventions, and services to each individual’s particular problems and needs is critical
to his or her ultimate success in returning to productive functioning in the family,
workplace and society.
2. Treatment needs to be readily available. Because individuals who are addicted to drugs
may be uncertain about entering treatment, taking advantage of opportunities when
they are ready for treatment is crucial. Potential treatment applicants can be lost if
treatment is not immediately available or is not readily accessible.
3. Effective treatment attends to multiple needs of the individual, not just to his or her
drug use. To be effective, treatment must address the individual’s drug use and any
associated medical, psychological, social, vocational and legal problems.
4. An individual’s treatment and services plan must be assessed continually and modified
as necessary to ensure that the plan meets the person’s changing needs. A patient may
require varying combinations of services and treatment components during the course
of treatment and recovery. In addition to counseling or psychotherapy, a patient at
times may require medication, other medical services, family therapy, parenting instruction, vocational rehabilitation, and social and legal services. It is critical that the
treatment approach be appropriate to the individual’s age, gender, ethnicity and culture.
5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The appropriate duration for an individual depends on his or her problems
and needs. Research indicates that, for most patients, the threshold of significant improvement is reached at about three months in treatment. After this threshold is reached,
additional treatment can produce further progress toward recovery. Because people
often leave treatment prematurely, programs should include strategies to engage and
keep patients in treatment.
6. Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address issues of
motivation, build skills to resist drug use, replace drug-using activities with constructive and rewarding nondrug-using activities, and improve problem-solving abilities.
Behavioral therapy also facilitates interpersonal relationships and the individual’s ability to function in the family and community.
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What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
7. Medications are an important element of treatment for many patients, especially when
combined with counseling and other behavioral therapies. Methadone is very effective
in helping individuals who are addicted to heroin or other opiates stabilize their lives
and reduce their illicit drug use. Naltrexone also is an effective medication for some
opiate addicts and some patients with co-occurring alcohol dependence. For those who
are addicted to nicotine, a nicotine replacement product (such as patches or gum) or
an oral medication (such as bupropion) can be an effective component of treatment.
For patients with mental disorders, both behavioral treatments and medications can be
critically important. [Buprenorphine is a partial opiate agonist that was approved by
the FDA on Oct. 8, 2002, for the treatment of heroin addiction. The FDA approved
two applications for buprenorphine as a treatment for narcotic addiction in a tablet
form. A recent federal law will allow qualified physicians to dispense buprenorphine
from their offices.]
8. Addicted or drug-abusing individuals with coexisting mental disorders should have
both disorders treated in an integrated way. Because addictive disorders and mental
disorders often occur in the same individual, patients who present for either condition
should be assessed and treated for the co-occurrence of the other type of disorder.
9. Medical detoxification is only the first stage of addiction treatment and, by itself, does
little to change long-term drug use. Medical detoxification safely manages the acute
physical symptoms of withdrawal associated with stopping drug use. Although detoxification alone is rarely sufficient to help addicts achieve long-term abstinence, for some
individuals it is a strongly indicated precursor to effective drug addiction treatment.
10. Treatment does not need to be voluntary to be effective. Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or criminal justice system can significantly increase both treatment entry and
retention rates and the success of drug treatment interventions.
11. Possible drug use during treatment must be monitored continuously. Lapses to drug
use can occur during treatment. The objective monitoring of a patient’s drug and
alcohol use during treatment, through urinalysis or other tests, can help the patient
withstand urges to use drugs. Such monitoring also can provide early evidence of drug
use so that the individual’s treatment plan can be adjusted. Feedback to patients who
test positive for illicit drug use is an important element of monitoring.
12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C,
tuberculosis and other infectious diseases, and counseling to help patients modify or
change behaviors that place themselves or others at risk of infection. Counseling can
help patients avoid high-risk behavior. Counseling also can help people who are already infected manage their illness.
13. Recovery from drug addiction can be a long-term process and frequently requires
multiple episodes of treatment. As with other chronic illnesses, relapses to drug use
can occur during or after successful treatment episodes. Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term
abstinence and fully restored functioning. Participation in self-help support programs
during and following treatment often is helpful in maintaining abstinence.
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Treatment of Alcohol and Other Substance Use Disorders
To share the results of this extensive body of research and foster more widespread use of
scientifically based treatment components, the National Institute on Drug Abuse held the
National Conference on Drug Addiction Treatment: From Research to Practice in April
1998 and prepared this guide. The first section of the guide summarizes basic, overarching
principles that characterize effective treatment. The next section elaborates on these principles by providing answers to frequently raised questions, as supported by the available
scientific literature. The next section describes the types of treatment, and is followed by
examples of scientifically based and tested treatment components.6
Center for Substance Abuse Treatment (CSAT) Treatment Improvement
Protocols
The Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of alcohol and other substance use disorders. CSAT’s Office of Evaluation, Scientific
Analysis, and Synthesis draws on the experience and knowledge of clinical, research and
administrative experts to produce the TIPs, which are distributed to a growing number of
facilities and individuals across the country. The audience for the TIPs is expanding beyond
public and private alcohol and other substance use treatment facilities as alcohol and other
substance use disorders are increasingly recognized as a major problem.7 (For more information on CSAT TIPs, please refer to appendix F.)
Continuum of Treatment
The word “treatment” may be a misnomer as applied to substance use and addiction because it implies a one-time strategy to eliminate the adverse effects of a physiological condition. Like other chronic and potentially fatal conditions such as heart disease or diabetes,
treatment of substance use and addiction actually refers to an extended process of diagnosis, treatment of acute symptoms, identification and management of circumstances that
may have promoted the drug use in the first place, and development of life-long strategies
to minimize the likelihood of ongoing use and its attendant consequences. In this context,
treatment is best viewed as a continuum of different types and intensities of services over a
long period of time. A phrase commonly used in the current treatment field is “recovery
management,” referring to the structured process of accessing and completing the range of
services on the road to health and self-sufficiency.
Under the continuum of care model, individuals with alcohol and other substance use
disorders move through the spectrum of treatment and other social services. A service network of different programs that provide a multifaceted and multidisciplinary approach is
ideal. These services should encompass the various types of alcohol and other substance use
occurring in the community, should account for differences in client characteristics (e.g.,
age, gender, racial or ethnic group identification, socioeconomic level), and should be formally linked with other agencies that provide other supportive services—such as health
care, education and housing programs—to ensure that patients can obtain help with associated physical, social and psychological problems.8 In fact, measures of success in treatment systems should be based not only reduction or elimination of drug use, but also on
the ability of the individual to gain access to and make progress in other types of services
(job training, housing, family skills, etc.) to minimize future reliance on public systems.
Some agencies and organizations are comprehensive enough to provide several types and
modalities of treatment; however, most treatment providers specialize in one or a few treat-
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What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
ment modalities. Clinical case management can be an effective tool for ensuring linkages
with various agencies and for ensuring that individuals have access to the most appropriate
types of services to meet their needs.9
Research clearly indicates that treatment for alcohol and other substance use does work.
With treatment, substance-dependent people enjoy healthy and productive lives. Instead
of creating health risks, committing crimes and requiring public support, individuals in
recovery can and do make positive contributions to their communities. Recovery is a viable
goal, but also is complex and challenging, requiring personal and relational changes and a
significant investment of effort. Whether an individual is addicted to or abusing alcohol,
illegal drugs, prescription drugs, or a combination of these, the most important goal is to
discontinue the use of alcohol and/or drugs.10
The continuum of treatment involves four key stages:
1.
2.
3.
4.
Identification,
Assessment,
Treatment, and
Ongoing recovery management.
Stage 1: Identification
For an individual with an alcohol and other substance use disorder to receive treatment, the
disorder must first be identified. Many individuals and professionals who come into contact with potential clients are in a position to set them on the road to recovery. Some may
self-identify their disorder, but commonly spouses, parents, employers and teachers are the
first line of identification. In other cases, health care institutions, the criminal justice system, or the child welfare system will identify potential clients as a result of adverse consequences stemming from substance or alcohol use. An important principle that has emerged
in the treatment field is “no wrong door to treatment,” meaning that, regardless of the
source or type of identification, clients will be given access to the full continuum of treatment and recovery management. This is absolutely critical, as many public and private
institutions will address alcohol or substance use disorders only to the extent that they
affect the client’s present involvement in those institutions. This acute, episodic approach
cannot appropriately address the range of complex issues facing clients with these disorders. As a result, they are much less likely to demonstrate long-term effectiveness.
Screening, Brief Intervention, and Referral
Screening, brief intervention, and referral (SBIR) is a model of identification that can occur
in any setting, including physicians’ offices, hospitals, community health centers, schoolbased health clinics and student assistance programs, occupational health clinics, hospitals, emergency departments, the criminal justice system, children’s services and TANF.11
Screening refers to brief procedures used to determine the presence of a problem, substantiate
that there is reason for concern, or identify the need for further evaluation. Interview techniques and screening instruments may be designed to attempt to get alcohol- or other druginvolved people to reveal information about their alcohol and other substance use. These selfreports can be helpful in determining whether there is a need for further assessment and
intervention. Screening interviews and instruments may be developed by a given agency, or
they may be obtained from other sources that provide them as a service or for profit.12
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Treatment of Alcohol and Other Substance Use Disorders
Screening, whether via interviews or written instruments, relies on the self-report of the
potential client to prompt further action.13 Screening does not need to be identified as
such. It might include something as simple as a few brief questions asked during physician
intake procedures that query the individual about the use of alcohol or other drugs.
The final steps of SBIR are brief intervention and referral. If a screening results in a determination that an individual has an alcohol or other substance use disorder, then the screening entity intervenes to the extent of their authority and either refers the individual to
treatment or engages the services of an independent clinical referral agent who will conduct
a comprehensive clinical assessment and make a referral to the appropriate level of treatment. The screening entity may even help place the individual in treatment and follow up
to ensure that the individual received treatment.
Uniform Accident and Sickness Policy Provision Law (UPPL)
The prevalence of alcohol problems is higher in trauma patients than in any other medical
setting. The leading cause of death for substance abusers is injury, not cirrhosis, pancreatitis, or other related disease. Trauma patients with alcohol problems have high reinjury
rates and deaths due to reinjury. Opportunistic screening and intervention in health care
settings where there is a high proportion of patients with alcohol problems is perhaps the
most promising means of closing the gap between the number of patients who might
benefit from treatment and the number who actually receive it. Studies demonstrate that
routine alcohol screening and intervention in trauma centers and emergency rooms reduce
both subsequent alcohol intake and the risk of injury recurrence. A variety of federal,
expert and consensus panels recommend routine screening and intervention in trauma
centers.
Currently, most trauma centers treat the patient’s injuries and ignore the underlying alcohol problem. This would be similar to the case of a 55-year-old male with a myocardial
infarction due to hypertension who receives therapy for his heart attack but not for his high
blood pressure, who is discharged with a high expectation of having another myocardial
event.
In most states, if a trauma or emergency room physician screens a patient for an alcohol
problem and the patient screens positive, the insurance company can deny responsibility
for the medical bill. This not only affects trauma centers, but it also affects patients, who
may have to declare bankruptcy due to the costs of major medical treatment.
The UPPL started as a model law adopted by the National Association of Insurance Commissioners (NAIC) in 1947. Its intent is to decrease insurance costs. It has not had that
effect. Instead, physicians counteract it by simply refusing to screen. Thus, the insurance
company pays anyway. The only effect of the law is to cause the problem to be ignored. In
testimony to the NAIC and the National Conference of Insurance Legislators (NCOIL),
insurers were unable to provide claims data to demonstrate any savings. That is because,
where the law is in effect and enforced, physicians have nullified it by refusing to screen.
Surveys demonstrate that trauma centers are willing to institute alcohol screening and
intervention programs, and trauma clinicians support it. However, they cannot do this
due to the financial consequences of the UPPL.
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What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
One does not need to be breaking a law to be affected by the UPPL. A person can go out
to dinner to celebrate an anniversary or birthday, have a few drinks, and take a cab home. If
there is a crash and the person is found to be under the influence of alcohol (not even
defined as intoxicated in a legal sense), the insurer can deny payment.
There are approximately 2 million hospital discharges for trauma each year, and 25 million
emergency department visits for injury treatment. Of these patients, 25 percent to 40
percent meet criteria for an alcohol problem and may benefit from treatment. Currently,
about 1 million people receive treatment for an alcohol problem each year in the United
States. The implementation of routine alcohol screening and intervention in emergency
rooms and trauma centers could dramatically increase both case detection and the number
of people who receive counseling or a referral to counseling. Implementation of such a plan
would require removal of the severe financial penalties to trauma centers and to patients
that the UPPL represents.14
Stage 2: Assessment
Clinical assessment is the first stage of formal intervention with those who are chemically
dependent. A comprehensive appraisal of the individual’s alcohol and other substance use
disorder, how it affects his or her health and functioning, and the other types of social
services required are vital for selecting treatment resources that best meet his or her needs.
Assessment includes a determination of many factors, including:
•
•
•
•
The severity of the problem;
Possible influences that have perpetuated chemical use, culminating in addiction;
Related difficulties; and
The individual’s perceptions of and attitude toward treatment.15
When an individual is assessed, an initial treatment plan is devised, placing the individual
in the appropriate treatment setting for the appropriate time frame and securing services
that match his or her needs and strengths. Under the care model, the individual is continually reassessed throughout treatment, and any necessary changes in the treatment setting,
time frame and/or services are made. Use of the care model ensures that individuals are
receiving the most appropriate treatment in the least restrictive treatment setting and the
services that address their needs and strengths.
American Society of Addiction Medicine (ASAM) Patient Placement Criteria
The American Society of Addiction Medicine published the ASAM Patient Placement Criteria
for the Treatment of Substance-Related Disorders, (Second Edition-Revised ): (ASAM PPC-2R) in
April 2001. It is the most widely used and comprehensive national guidelines for placement,
continued stay and discharge of patients with alcohol and other substance use disorders. It
was written in response to requests for criteria that better meet the needs of patients with cooccurring mental and alcohol and other substance use disorders (“dual diagnosis”), for revised
adolescent criteria and for clarification of the residential levels of care.16
The ASAM PPC-2R provides two sets of guidelines, one for adults and one for adolescents,
and five broad levels of care for each group. The levels of care are: Level 0.5, Early Intervention; Level I, Outpatient Treatment; Level II, Intensive Outpatient/Partial Hospitalization;
Level III, Residential/Inpatient Treatment; and Level IV, Medically-Managed Intensive Inpatient Treatment. Within these broad levels of service is a range of specific levels of care.17
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Treatment of Alcohol and Other Substance Use Disorders
For each level of care, a brief overview of the services available for particular severities of
addiction and related problems is presented, as is a structured description of the settings,
staff and services, and admission criteria for the following six dimensions: acute intoxication/withdrawal potential; biomedical conditions and complications; emotional, behavioral or cognitive conditions and complications; readiness to change; relapse, continued use
or continued problem potential; and recovery environment.18
The diagnostic terminology used in the ASAM PPC-2R is consistent with the most recent
language of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV). The “unbundling” of clinical services is addressed, recognizing that
these services can be and often are provided separately from environmental supports. With
unbundling, the type and intensity of treatment are based on the patient’s needs, not on
limitations imposed by the treatment setting. Criteria also are included that attempt to
match a patient’s severity of illness along dimension 1 (acute intoxication and/or withdrawal potential) with five intensities of detoxification service.19
Many states have adopted ASAM or ASAM-modified patient placement criteria in rules of
licensure for treatment.
Stage 3: Treatment
Treatment is designed to help the patient reduce his or her dependence on alcohol or other
drugs and attain a higher level of physical, psychological and social functioning. A successful program may involve a combination of specific treatments and may change over time,
depending on the individual. Incorporating management of psychological problems as a
component of any rehabilitation program is crucial to the ongoing success of a patient’s
treatment.
Successful outcomes depend on retaining patients in treatment programs for a sufficient
length of time. Whether a patient stays in a program can be attributed to individual factors—such as motivation and support from family or friends-and factors associated with
the treatment program—such as positive relationships between counselors and patients.
Counselors who establish such a relationship will be better equipped to identify and address patients’ needs and ensure successful treatment.20
The availability of different treatment options is important in achieving the overall goal of
rehabilitation for the patient. Because each patient is different, a particular modality of
treatment that may work best for one individual will not work for another. Because new
research is being conducted daily, treatment strategies and options for patients are improving.21 Rehabilitation and treatment can occur in both residential and outpatient settings,
depending on the needs of the patient.
The medical component of treatment settings has implications for funding. For instance,
health insurance procedures require medical control. Funding for community service agencies
does not necessarily require medical involvement. In order to increase accessibility and
broaden the range of reimbursement mechanisms, some states have developed new licensing standards to permit reimbursement of detoxification and rehabilitation services for
ambulatory patients in non-hospital settings.
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The Role of Medications in Treatment
Scientific research has advanced to the degree that the underlying effects of alcohol and
other drugs can be identified. Different pharmaceuticals are being used effectively to target different neurotransmitter systems. Physicians now are able to prescribe medications
for patients to manage withdrawal, foster sobriety, decrease alcohol and other substance use
by managing effects related to psychological disorders, and weaken problem behaviors.
Prescriptions for benzodiazepines such as Valium or Xanax have been widely used for the
manage alcohol withdrawal. Research continues on the use of benzodiazepines for the
effective management of withdrawal delirium. Because benzodiazepines are known for
their sedative effects, research continues on the possible use of other classes of drugs. Medications such as ReVia (naltrexone) and Antabuse (disulfiram) also are also being used as
anti-craving agents in the treatment of alcoholism.22
Using pharmacotherapies is an effective way to maximize efficacy in other drug use treatment programs. The most widely used medication for opioid addicts is methadone.
Buphenorphine and naltrexone are the other major medications that are available for opiate
dependence. Because of the lack of reimbursement, however, buphenorphine and naltrexone
are under utilized. Methadone often is prescribed for drug users as an alternative to heroin
addiction and has proven effective for many people. The National Institute on Drug Abuse’s
Drug Abuse Treatment Outcome Study found that methadone treatment reduced participants’ heroin use by 70 percent and criminal activity by 57 percent, while increasing fulltime employment by 24 percent.23
Methadone maintenance programs usually are more successful at retaining clients with
opiate dependence than are therapeutic communities, which, in turn, are more successful
than outpatient programs that provide only psychotherapy and counseling. Methadone
maintenance therapy helps keep more than 100,000 addicts off heroin, off welfare, and on
the tax rolls as law-abiding, productive citizens.24 Within various methadone programs,
those that provide higher doses of methadone (usually a minimum of 60 mg.) have better
retention rates. Also, those that provide the full range of other services—such as counseling, therapy and medical care—along with methadone generally achieve better results than
the programs that provide minimal services.25
Methadone maintenance, naltrexone, buprenorphine and disulfiram assist individuals with
alcohol and other substance use disorders to maintain a drug-free existence. Reducing
alcohol and other substance use through pharmacological therapies diminishes the spread
of infectious diseases, reduces the level of criminal activity, improves the rate of employment, reduces intake and affects the demand for drugs.26 New medications are still being
studied and researched and will continue to make great inroads into the treatment of
alcohol and other substance use disorders. In the future, the role of pharmacologic interventions is expected to greatly expand and revolutionize treatment for individuals with
alcohol and other substance use disorders.
Coerced vs. Voluntary Treatment
Coerced participation in drug or alcohol treatment is just as effective—or more effective—
than non-coerced treatment.27 The most visible type of coercion is criminal justice involvement. However, the most common type of coercion is family member insistence. A RAND
study has shown that many individuals who enter treatment voluntarily are actually being
coerced by one or more family members and/or by supervisors or employers. Research
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indicates that compulsory treatment in the form of civil commitment increases treatment
retention for intravenous drug abusers.28
Treatment Intensities and Modalities
Detoxification. Detoxification seeks to provide safe withdrawal from alcohol or other drugs
in a dignified and humane manner during which the patient becomes free from toxins
under controlled conditions. It is not a treatment in and of itself, but sometimes is the first
step in a comprehensive treatment strategy. The process of detoxification from alcohol and
other drugs includes removing toxins from the body and the period of time when a person’s
physiology is adjusting to the absence of alcohol or other drugs. For most patients, detoxification from alcohol takes three to five days. The time frame for detoxification from other
drugs varies depending on the drug and the severity of addiction.29 Detoxification can be
provided in residential or outpatient settings.
Inpatient/Residential. Inpatient treatment may be comprised of a combination of the
following: medical treatment, nursing and supportive services, including counseling and
other daily activities, on a 24-hour basis in a hospital or other licensed medical facility.30
Inpatient hospitalization is the most expensive, closely supervised, restrictive service and
the one with the highest percentage of medical staff. It is reserved for individuals with
medical complications such as short-term treatment and crisis stabilization, for individuals
in acute distress, or for comprehensive evaluations of people with multiple disorders.
Therapeutic Communities. In some areas, therapeutic communities (TCs) are a popular
form of rehabilitation in the longer term, community-based residential settings for individuals who need this level of care to work toward increased levels of responsibility in the
community over time. The populations that a TC program targets are individuals who
need a safe environment in which to function, including, but not limited to, individuals
with serious, chronic, recurring alcohol and other substance use disorders; parents; pregnant women; homeless people; and juveniles. The basic goal of a TC is to offer a lifestyle
that includes abstinence from drugs; elimination of anti-social (criminal) behavior; development of employable skills; and development of positive attitudes, values and behaviors.31
The TC model is based on the assumption that successful rehabilitation is best achieved in
a “community” where socially acceptable behaviors will be learned to replace the antisocial
behaviors, lifestyles involved with addictions, and criminal behaviors. The support often
includes:
•
Self-help through learning stages and gradual assumption of responsibility;
•
A self-help network that replaces the gangs and/or antisocial peers with a new healthier
community of peers;
•
Prescribed rewards and punishments to reinforce socially acceptable behavior;
•
Individual commitment to the “community,” in which members accept the idea that
their individual problems have an effect on others;
•
Role modeling accomplished through the clinical and other staff, who might include
successfully rehabilitated ex-offenders or ex-drug addicts; and
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What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
•
Links with support programs for continuing care, as well as employment as a means of
assisting the individual to become established outside the residential program.32
TC clients demonstrate less criminal activity during treatment and after discharge. Length
of stay in programs remains the strongest predictor of success. Attrition is high and rates
are below participation rates in outpatient, non-methadone programs but are higher than
methadone programs. However, TC graduates demonstrate more positive outcomes than
those who did not enter the programs and have better outcomes than those individuals
who dropped out of the program.
According to the Drug Abuse Treatment Outcome Study (DATOS), follow-up of TC graduates showed a 67 percent decrease in the number of weekly cocaine users and a 53 percent
decline in heavy drinkers. Unemployment dropped 13 percent, suicidal ideation fell by 46
percent and illegal activity declined by 61 percent.33
Outpatient. Outpatient treatment may be comprised of a combination of the following:
treatment services, as needed, including medical services, nursing services, counseling, and
supportive services for those who can live independently and benefit from ambulatory care
settings. 34
Intensive Outpatient. Intensive outpatient treatment, or day treatment programs, is comprised of the services described for inpatient treatment for those who require care or support in a treatment or recovery setting for less than 24-hour a day supervision; this generally means more intensive care, treatment and support during the day in a special setting
and sometimes is referred to as partial day treatment.35
Stage 4: Ongoing Recovery Management
Relapse Prevention
Addiction is a chronic, relapsing disorder, making prevention of relapse a critical element of
effective treatment. It is not unusual for addicts to relapse within one month following
treatment, nor is it unusual for addicts to relapse 12 months after treatment; 47 percent
will relapse within the first year after treatment. Although relapse is a symptom of addiction, it is preventable. Relapse prevention methodologies are critical to the success of alcohol and other substance use treatment.36 Principles underlying relapse prevention therapy
include:
•
Self-regulation and stabilization. As the patient’s capacity to self-regulate thinking, feeling, memory, judgment and behavior increases, the risk of relapse will decrease. Selfregulation can be achieved through stabilization. Stabilization may include:
- Detoxification from alcohol and other drugs;
- Recuperation from the effects of stress that preceded the chemical use;
- Resolution of immediate interpersonal and situational crises that threaten sobriety; or
- Establishment of a daily structure including proper diet, exercise, stress management and regular contact with both treatment personnel and self-help groups.37
Chemical addiction is a disease and, like many diseases, the possibility of relapse always
exists. The process of alcohol and other drug use is complex, and is affected by social,
clinical and medical factors. The solutions to the problem of chemical addiction are multi-
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Treatment of Alcohol and Other Substance Use Disorders
faceted. Treatment strategies benefit from a relapse prevention component in virtually every case. It is a definite means of stretching the effectiveness of state treatment funds. For
relapse prevention to work, agencies and systems must cooperate and communicate in their
search for the best means of successfully intervening with substance using patients.38
Self-Help
Self-help or 12-step organizations involve mutual help among peers who are experiencing
similar problems. With the development of the first Alcoholics Anonymous group in 1935,
a long tradition of the use of self-help groups for alcohol and other substance users was
launched. Self-help groups often meet in churches, community facilities, prisons and other
locations, but they generally claim no political or religious affiliation. Alcoholics Anonymous (AA) describes itself as a voluntary, self-run fellowship. An important characteristic
for many people is its promise of anonymity, protecting the right to privacy of its members. 39
Members of AA believe that addiction is a disease that can never be cured. However, they
maintain that progression of the disease can be arrested, and those in remission are recovering alcoholics. Groups function to reinforce social and cognitive behaviors that are incompatible with addictive behaviors.40 The primary goals of AA and similar self-help groups
are to:
•
•
•
Achieve total abstinence from alcohol or other drugs;
Effect changes in personal values and interpersonal behavior; and
Continue participation in the fellowship to both give and receive help from others with
similar problems.41
Self-help groups may be the only intervention used by some people to end chemical dependency. However, self-help groups often are used in tandem with other treatment modalities, such as residential or outpatient treatment programs.42 Often, experienced members act as “sponsors” to newer members, creating a person-to-person guidance system in
times of crisis and creating bonds between members.43
Narcotics Anonymous (NA) is modeled on the Alcoholics Anonymous concept and, although the two programs are not affiliated, they use the same 12-step program. NA is a
different organization with diverse jargon, style, substance and social traditions. It is concerned with the problem of addiction, and members may have had experience with any or
all of the entire range of abusable psychoactive substances.44
Alcoholics Anonymous is now a worldwide organization with groups in the United States
and 114 other countries. Its membership is estimated at 1.5 million. Narcotics Anonymous is international as well, with groups in at least 36 countries. Estimates of its membership total approximately 250,000.45
Although there is ample anecdotal testimony to the effectiveness of self-help organizations,
especially Alcoholics Anonymous, there is little in the way of objective data to support
these claims. However, opinions of many clinicians and individuals who have been helped
by the approach strongly support it for the recovery of some alcohol and other substance
users. 46
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What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
A 1987 review of several studies of the outcomes for people attending AA found that,
overall, 46.5 percent to 62 percent of active AA members had at least one year of continuous sobriety. Thirty-five percent to 40 percent of subjects reported abstinence of less than
one year. Twenty-six percent to 40 percent were sober from one to five or six years, and 20
percent to 30 percent maintained abstinence five or six years or more.47
Education
Effective recovery management involves education. Many recovering individuals obtain
their high school graduation equivalency degrees (GED) and/or embark upon higher education.
Jobs
Effective recovery management involves job training and employment. Many recovering
individuals receive job skills training and/or employment placement services.
Family
Although continuing research is needed, available data support the efficacy of family therapy
interventions. Adolescents involved in family therapy have been shown to have half the
recidivism rate of those who do not receive this service. Evidence also exists that family
therapy improves adolescent retention in residential treatment programs. Family treatment also has been favorably correlated with days free of methadone, illegal opiates and
marijuana. A 1986 study found that alcoholics who received treatment with their spouses,
including both alcohol-related interventions and marital therapy, were more compliant,
decreased their drinking more rapidly, and relapsed more slowly than did study participants who received only alcohol-focused treatment with their spouses. They also maintained better marital satisfaction and were more likely to stay in treatment than were those
who received treatment with minimal spouse involvement. In general, family involvement
enhances assessment and intervention and increases motivation in treatment.48
Special Living Arrangements
Maintenance consists of relapse prevention and other continuing care services. To maintain
the gains of rehabilitation, a plan of therapeutic services to help a person stabilize is critical
to full recovery. Continued contact and therapeutic activities are essential to avoid a return
to negative patterns of drinking and other alcohol and other substance use. In some instances, people who are too disabled by alcohol and other substance use disorders to live
independently can be provided with supported housing to ensure the continuance of necessary supportive services in a structured environment. This prevents dangerous relapses to
addictive behavior.
Sober Living Environments. Sober living environments (SLEs) are housing for individuals
in recovery from alcohol and other substance use disorders. SLEs offer a stable, supportive
and sober environment that is conducive to sobriety and recovery and serves as a bridge to
independent living. They typically do not provide any type of treatment or recovery services. These environments are referred to as supportive living environments, halfway houses,
recovery homes, sober living homes or sober living housing.
Treatment for Specific Populations
Most alcohol and other substance use disorders are multidimensional. An individual may
be a member of several different population groups, which makes the identification of an
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Treatment of Alcohol and Other Substance Use Disorders
appropriate treatment group more difficult. Brief descriptions of several populations that
may require special consideration for treatment are included below.
Adolescents
Although drug use in the general population of adolescents who are attending school and
living at home has declined in recent years, there is sufficient justification to be concerned
about youth. Dropouts constitute an estimated 15 percent to 20 percent of youth the age
of high school seniors, and these youth tend to be at high risk for alcohol and other substance use and delinquency.49
Youth who become involved in delinquent behaviors and the use of drugs and alcohol come
from all social strata, from both large and small communities, and from healthy as well as
dysfunctional families. They may be gifted or limited in intellectual abilities, have few or
many talents, and vary markedly in personality. There is no easy predictor of delinquency
or alcohol and other substance use.50
Indeed, research indicates that a complex array of cognitive, psychological, attitudinal,
social, personality, pharmacological and developmental factors foster initiation of adolescent drug use. Some characteristics that are typical of adolescent development appear to
increase the chances that some youth will at least begin the process of experimenting and
taking risks with drugs, alcohol and illegal behaviors. Young people are establishing their
identity and independence. As part of this process, they need to explore different behaviors
and values. Experimentation and opposition to adult norms and values, within limits, is
typical adolescent behavior. For some youth, however, these behaviors plunge them into a
world of activities that can become very dangerous. The pleasure, thrill or excitement may
be so stimulating that they continue to seek it. For some, the acts of rebellion against
parents or society are particularly satisfying. Others acquiesce to peer influences from youth
who offer friendship and acceptance to those who will engage in similar activities.51
As with other special populations, alcohol- and drug-involved youth need treatment programs that are sensitive to their needs and appropriate for their developmental stage. Assessment is the first critical phase of treatment. The multiple assessment approach—including interviews, observations, specialized testing, and written reports—is recommended
for obtaining the most valuable information for informed treatment planning. Treatment
programs for youth should not merely duplicate programs that have been successful with
adult groups. They need to be formulated with particular attention to adolescent developmental levels, family situations, educational needs, and many other factors. Appropriate
interventions for youth may include:
•
•
•
•
•
School-based prevention;
Drug education classes;
Outpatient treatment;
Partial hospitalization; and
Residential treatment.52
Drug Strategies’ Treating Teens: A Guide to Adolescent Drug Treatment is a guide to the
following nine key elements of effective teen treatment:
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What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
•
•
•
•
•
•
•
•
•
Assessment and treatment matching;
Comprehensive, integrated treatment approach;
Family involvement in treatment;
Developmentally appropriate program;
Engage and retain teens in treatment;
Qualified staff;
Gender and cultural competence;
Continuing care; and
Treatment outcomes.
Women
Women’s roles of child-bearer and mother complicate treatment for women. Many women
need to bring their children to treatment with them. Many inpatient treatment programs
are designed specifically for women with their children. When treating pregnant users,
treatment providers have the extra liability of addressing the effect of drugs on the fetus.
Many women lose custody of their children due to their alcohol and other substance use.
However, treatment works, restores children to their families and produces healthy babies.
In 2002, 57.4 percent of men had used alcohol in the past month compared with 44.9
percent of women.53 Men are more likely to drive drunk or be involved in an alcoholrelated fatal traffic crash.54
The above figures indicate that women drink less frequently and less heavily than men.
However, it is important to note that women metabolize alcohol differently than men and
are likely to feel a stronger effect from the same amount of alcohol. They become intoxicated faster and are addicted more easily.55 In addition, women develop alcoholic liver
disease at a lower cumulative dose of alcohol than men.56 Risk factors for problem drinking
in women include a partner or spouse who drinks, depression, and sexual dysfunction or
abuse. 57
Men were twice as likely as women to have used illicit drugs, including marijuana and
cocaine, in the past month during 2002 (10.3 percent verses 6.4 percent).58
Women, especially pregnant women, have a difficult time obtaining treatment for alcohol
and other substance use disorders. Very few public treatment programs accept pregnant
women or mothers with children, largely because these facilities are not equipped to deal
with the health, housing and education needs of mothers and their families.
Pregnant women who are alcohol and other substance users are a difficult population to
treat. They often are afraid to admit to alcohol and other substance use and seek treatment
for their illness because they fear they will be prosecuted for child abuse and will lose their
children once they are born. In addition, many treatment programs do not provide day
care for children, which places a burden on mothers who are seeking to receive treatment
for their illness.59
No state currently has a law that can be specifically used to prosecute a mother for using
drugs or alcohol during pregnancy. However, existing laws that apply to child abuse and
neglect, assault, murder or drug dealing have been used to attempt to penalize these mothers for their alcohol and other substance use. Despite various attempts to apply these laws
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Treatment of Alcohol and Other Substance Use Disorders
to women’s prenatal conduct, all appellate courts have held these statutes inapplicable to
women’s prenatal conduct.
•
The lone exception is Whitner vs. the State of South Carolina, in which the state prosecuted two women for using crack while pregnant. The case was based on the South
Carolina law that makes it a crime to neglect or refuse to provide a child with proper
care and attention so that the child is or is likely to be endangered. In May 1998, the
U.S. Supreme Court refused to hear, on appeal, arguments by the two women that
South Carolina should not be able to use this child endangerment law for their unborn
children. 60
Among the important questions raised by the option of incarceration are: Who will care for
these children while their mothers are in jail and how will incarceration provide or lead to
treatment and recovery?
On the other side of the criminalization vs. treatment issue are the two states—Wisconsin
and South Dakota—that currently have laws that provide for pregnant alcohol and other
substance users to be involuntarily ordered into treatment.
•
In 1997, Wisconsin enacted the first law in the nation to allow judges to issue a court
order for treatment of pregnant women.61 The law, which became effective July 1,
1998, allows an individual who believes an expectant mother has harmed or may harm
her unborn child through alcohol and other substance use to file a report. Local law
enforcement and child protection workers must immediately investigate the report
and may take the expectant mother into custody. The county social services department may offer services to the mother and, if the services are refused, the department
may request the district attorney to file a petition with the juvenile court. The juvenile
court has jurisdiction over both the mother and her unborn child, and it may order her
into custody if she refuses treatment. The court may order counseling, supervision by
a social services agency, out-of-home placement, or participation in an inpatient or
outpatient treatment program.62
•
A South Dakota law enacted in 1998 briefly states that any pregnant drug user may be
committed by the circuit court upon the petition of the person’s spouse or guardian, a
relative, a physician, the administrator of any approved treatment facility or any other
responsible person.
Older Adults
Older Americans consume more prescribed and over-the-counter medication than any other
age group in the United States. In combination with an aging body that is more vulnerable
to the effects of medication, this often leads to misuse of prescription drugs among the
elderly. Health care providers often overlook this misuse or abuse because of insufficient
knowledge, limited research data and short primary care visits.63
Research consistently shows that, as people age, consumption of alcohol decreases and
there is less alcohol use. Longitudinal studies indicate alcohol use may decrease slightly as
light drinkers grow older, and abstinence becomes more prevalent. Heavy drinking also
declines with increasing age.64 Use of illicit drugs follows similar trends. In 2002, 0.8
percent of those age 65 and older currently were using illicit drugs.65
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What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
Although the rate of alcohol and other substance use is low among older Americans as
compared to the total population, abuse of alcohol and prescription drugs among adults
age 60 and older is one of the fastest growing problems in the country. Until relatively
recently, alcohol and prescription drug abuse, which affects up to 17 percent of older
adults, was not discussed in either alcohol and other substance use or gerontological literature. 66
A recent study suggests that alcohol and other substance use for women over age 59 is a
serious problem that does not receive adequate attention. Abuse of alcohol and psychoactive prescription drugs are most common among older, affluent white women.67
Culturally Competent Treatment
Available data reveal different patterns of alcohol and other substance use among various
racial and ethnic groups. Black and Hispanic alcohol and other substance users tend to use
heroin and cocaine more than white addicts; whites tend to abuse a greater variety of
substances. The results of some studies have led to the hypothesis that whites’ use of drugs
tends to be the result of emotional problems or deviance.68
Native Americans
There is considerable variation in the settings in which Native Americans live. Some live in
urban areas, while others reside on isolated reservations. These factors influence the rates
and types of alcohol and other drug addiction found among Native Americans. Treatment
approaches must be sensitive to the particular cultural heritage of people who enter programs. 69
There is a significant problem of alcohol and other substance use among Native Americans
in the United States. The age at first involvement with alcohol is younger for Indian
youths, and the frequency and amount of drinking are greater. Well-established during
adolescence, these trends continue into young adulthood.70
Although alcohol and marijuana use are common among Native American youth, inhalant
use is almost twice as high as among all other youth between the ages of 12 and 17. Use of
inhalants peaks during the early and middle teens, then tapers off in later years as the
availability of marijuana, alcohol and other substances increases.71
The serious consequences of inhalants make this trend alarming. Use of inhalants can
result in organic brain damage, a condition that can be very severe, and possibly permanent. Other risks include respiratory depression; cardiac arrhythmia; and irreversible damage to the kidneys, liver and bone marrow. Sniffing of gasoline has caused lead poisoning,
which can have lasting adverse effects on an individual’s physical and emotional development. 72
It is theorized that these high rates of alcohol and other substance use among Native Americans are related to socioeconomic conditions, including poverty; prejudice; and lack of
economic, educational and social opportunities. Family influences also are conjectured to
play a significant role in early use of substances. 73
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Treatment of Alcohol and Other Substance Use Disorders
Available research suggests that intervention efforts need to be aimed at enhancing the
health of Native American families. Successful programs have included key elements of
community ownership, agency collaboration and tribal determination.74
Asian and Pacific Islander Americans
Statistical evidence of alcohol and other drug use among Asian Americans is generally low
compared with other subgroups of the population. However, alcohol and other substance
use may be greater than survey reports indicate because Asian Americans tend to handle
problems within the family and community. They are not as likely to use public treatment
services, due to the stigma attached to seeking professional help in their culture.75
Overall, Asian Americans have fewer alcohol-related problems than any other major ethnic
group. However, there are indications that the use of alcohol and other drugs may be
increasing. Traditionally, drinking takes place in controlled settings, rarely alone. However,
drinking patterns among various groups of Asian Americans differ greatly.76
Hispanic/Latino Populations
Spanish speaking people are not a homogeneous group, and Hispanic/Latino populations
from each country bring with them distinctive habits, customs, values and cultural traditions. 77
Drug use among Hispanic/Latino youth has been significantly associated with high school
dropout rates.78 Hispanic/Latino youth appear to use alcohol at a rate similar to that of
Anglo youth. Boys are more likely to begin drinking at a younger age and to drink more
than girls. For other drugs, the level of use among Hispanic/Latino youth is comparable to,
or slightly less than, that of Anglo youth. Hispanic/Latino youth between the ages of 12
and 17 are more likely than Anglo or African American youth to have used cocaine.79
Specific recommendations for treatment planning for this population include:
•
Targeting the entire family and religious leaders because of the strong ties and influences these entities have;
•
Developing materials and programs in Spanish and making them culturally appropriate; and
•
Targeting efforts through community leaders and organizations to increase the acceptability of programs.80
African Americans
African American high school students have lower levels of reported drug and alcohol use
compared to other groups. African American youth also begin the use of alcohol and other
drugs at later ages than the general population.81
Yet, alcohol and other drug use is a leading health and social problem for African Americans. When alcohol-related health problems—such as cirrhosis of the liver and certain
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What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
types of cancer—are examined, there is a greater prevalence among African American men
than among white men. 82
Although African Americans are more likely to abstain from using alcohol, studies have
found that those who do use also are more likely to use other drugs concurrently. The
relative availability of illegal drugs in the inner city may play a role in drug use among
African American youth.83
The relationship between alcohol use among African American youth and crime is welldocumented. Delinquent behavior appears to begin before drug use. However, those who
use alcohol are more likely to engage in delinquent behavior than are those who do not
drink. Cocaine use, which is on the rise in some African American neighborhoods, appears
to be associated with higher crime rates.84
Rural Populations
The U.S. General Accounting Office (GAO) conducted a study of several issues related to
substance abuse in rural areas in preparing a report for Congress. In 1990, the GAO found
that:
•
Alcohol is by far the most widely used drug in rural areas.
•
Prevalence rates for some drugs (such as cocaine) appear to be lower in rural than
nonrural areas. Prevalence rates for other drugs (such as inhalants) may be higher in
rural areas than elsewhere.
•
Total alcohol and other substance use (alcohol use plus other drug use) rates in rural
states are about as high as in nonrural States. 85
Treatment of alcohol and other substance users in rural settings presents a variety of special
issues and problems.
•
Rural treatment programs may be more expensive to administer than metropolitan
programs. Although fewer people may need a particular program or service, the cost of
operation may be similar because comparable staff, facilities and supplies are needed.
This results in higher per-patient treatment costs.
•
Treatment may not be as accessible due to the distance patients and program staff must
travel to meet.
•
Programs may not be accepted by the community or community agencies. In some
rural communities, there may be a stigma related to alcohol and other drug addiction
that is not as noticeable in urban areas. Those who need treatment may be more visible
than they would be in a more populated area; therefore, there may be more concern
about confidentiality on the part of those who need treatment. The importance of
treatment may not be understood or supported as well as in metropolitan areas that
have greater resources.
•
There may be a lack of trained and experienced staff in the area of alcohol and other
substance issues. Rural areas may have a difficult time attracting and holding such
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Treatment of Alcohol and Other Substance Use Disorders
professionals. Limited resources mean professionals in many agencies must perform a
variety of tasks. Individuals in education and health care may not have sufficient time
or expertise to devote specifically to drug issues. 86
It is clear that treatment has as vital a role to play in rural areas as it does in metropolitan,
urban areas.87 There are special challenges to developing a continuum of care in rural areas.
This is not unique to alcohol and other substance use treatment, but is true for all rural
health care.
Methamphetamine and prescription drug abuse are significant problems in rural areas.
Treatment in the Criminal Justice System
In most jurisdictions, “criminal justice” refers not to a singular, all-encompassing system,
but to a continuum of often independent entities and subsystems, including police departments, state or district attorneys, public and private defenders, county jails, courts, probation, state corrections, community corrections, and parole or supervised release. In most
cases, as a defendant/offender proceeds through the justice process, he or she will come
under the supervision of the local municipality, the county and the state, all within several
months.
The last two decades of the twentieth century saw escalation in the punishment of drug
offenders that, in turn, has led to an over-burdened justice system. However, drug offenders are not the only offenders for whom alcohol and other substance use is a problem. Up to
three-fourths or more of all offenders may demonstrate problems related to alcohol and
other substance use issues.
The approaches to dealing with the complex challenges of substance-involved offenders are
as varied as the jurisdictions in which they are employed. Research has demonstrated the
need for five key constructs in developing treatment programs for justice populations.
Principle #1: Active Collaboration between Justice and Treatment Systems
At the intersection of the justice and treatment systems, the overarching goals of the
two systems often appear inconsistent—i.e., public safety vs. rehabilitation. Yet, the
goals of both systems are equally important in reducing drug use and criminal behavior. As a result, active collaboration is the cornerstone of any successful drug and crime
reduction strategy. Partnerships ensure maximum availability of services, capitalizing
on existing programs, inter-system efforts and other community strengths.88 The partners are able to leverage existing knowledge and expertise and direct resources through
a unified strategy.89 Partnerships also increase ownership and accountability for success90 and can more effectively influence public policy and open or gain access to funding streams without duplicating effort.91
Principle #2: Formal Systemic and Programmatic Infrastructure
Systemic approaches require a solid foundation of procedure, protocols, information
management and exchange, and standards of performance to support long-term effectiveness.92 Some measure of formality is critical, regardless of the size of the jurisdiction. The specifics of the infrastructure should remain the purview of the systems,
based on the needs and nuances of their jurisdiction.
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What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
Principle #3: Clinical Case Management Linking Justice and Treatment
Case management of drug-involved offenders through the treatment milieu has been
demonstrated to effectively assist offenders as they move through the continuum of
care. It also has been proven to result in more rapid access to necessary services, longer
lengths of stay, and more positive long-term outcomes.93 This is particularly important
for offenders who demonstrate an array of behavioral and social needs over an extended
period of time and who otherwise would likely be unable to gain access to those services.94 The case manager can play a critical role in the ongoing determination of client
need, in securing services suitable for the individual client, and in coordinating and
engaging of multiple service systems.95
Principle #4: Appropriate and Effective Use of Treatment
Once the treatment needs have been identified via a comprehensive clinical assessment, referrals must be made to treatment programs that employ the most recent
evidence-based methodologies structured to the unique needs of the offender. For justice populations, length and continuity of treatment can be a major determinant of
long-term success.96 It also is important to recognize addiction as chronic disease, subject to frequent relapses, that often may require multiple interventions over an extended period of time.97
Principle #5: Commitment to Science-Based Models of Treatment Delivery and Mechanisms for Ongoing Knowledge Transfer
New research is continually emerging that helps us better understand the nature of
drug use, its effect on criminal behavior, the special needs of offender populations, and
strategies for effective treatment and other interventions. A formal system for ongoing
inter- and intra-disciplinary education is key to ensuring that the partnership between
the systems is continually operating with the most relevant and most recent information.
General discussions follow of the types of strategies that currently are being employed
across the country. These strategies include sentencing reform, prosecutorial and courtordered diversion, corrections-based treatment, reentry and reintegration, and juvenile justice.
Sentencing Reform
Many states recognize that enhancements in penalties for drug offenses have had little
effect on the commission of substance-related crimes or on stemming the tide of recidivism. Some states are now reversing the trend of enhancing drug law violations by adjusting or eliminating mandatory minimum sentences and other penalties in order to create a
more appropriate sentencing response. Although these changes may ultimately result in
smaller prison populations, they do not in and of themselves address the root of the problem—the alcohol and other substance use. They are therefore best used in conjunction
with a treatment intervention.
Some states—such as Arizona,98 California,99 Illinois100 and New York—have enacted legislation that requires access to treatment interventions for drug or drug-involved offenders.
In some cases, sentences may be stayed pending the outcome of treatment. In others, a
guilty plea is required, usually prompting a sentence of probation and treatment supervision. These legislative strategies reflect a wholesale reversal of earlier policies and, as such,
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may be difficult to enact. However, they do result in systemic responses, meaning that
prosecutors, public defenders, judges, probation agencies and the community treatment
providers who deliver the services must work together.
Prosecutorial and Court-Ordered Diversion
Diversion programs usually refer to those programs that halt a given defendant’s/offender’s
progression through the justice system or remove him or her from the justice system altogether. These programs are based on established research that clearly demonstrates the
benefits of treatment or drug education over incarceration. Examples include the following.
Prosecutorial Diversion or Deferment. The local prosecuting office will defer pressing of
formal charges pending successful completion of drug education or other type of treatment intervention.
Drug Courts/Sentencing. Drug courts are based on a non-adversarial, team-oriented approach. Defendants are selected for the drug court by virtue of their charge or demonstrated substance use. The judge generally will mandate the offender to treatment, and
all the court professionals will monitor progress and contribute to ongoing supervision
and compliance. Drug courts may be pre- or post-sentence, and the judge may use the
leverage of additional justice sanctions to compel compliance with treatment. Initial
research on drug courts suggests positive outcomes in terms of reduction of alcohol and
other substance use and recidivism.101
TASC. Originally known as Treatment Alternatives to Street Crime, TASC is a model
for providing independent clinical assessment, treatment referral and case monitoring
functions as a link between the justice systems and community treatment. The independent nature allows for objective assessment of each defendant’s needs and for a
balance between the justice system’s goals and priorities and the offender’s clinical
concerns. The clinical expertise of the TASC case manager complements the public
safety role of the probation or parole officer. TASC programs may be pre- or postsentence, and may be statewide or local.102
Breaking the Cycle. Breaking the Cycle is built upon the TASC model of independent
evaluation and case management, employing judicial review and sanctions, but without the eligibility requirements present in other diversion programs. Evaluation of the
Breaking the Cycle program revealed some challenges to implementation but also demonstrated positive outcomes.103
Corrections-Based Treatment
During the last decade, access to treatment options among inmates has dropped sharply.
In 1991, 34 percent of offenders who reported drug use prior to incarceration reported
access to treatment in a prison environment. In 1997, that number had dropped to 13
percent. Among the factors contributing to this drop are ever-increasing numbers of offenders, limited staff expertise, and lack of coordination among the necessary agencies.
Among the most common and promising approaches for prison-based treatment is the use
of the therapeutic community, modified to include the unique issues facing inmate popu-
National Conference of State Legislatures
What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
lations. A “Therapeutic Community” (TC)104 is a model of treatment that is based on
social learning theory.105 The TC addresses the whole person, not only the substance abuse.
It creates a highly structured environment with norms, language, rules, expectations, sanctions for negative behaviors, and rewards for positive behaviors. In a TC, everyone involved
becomes part of the treatment, including the inmates, treatment staff and correctional
officers. Mistakes are confronted and used as learning experiences; similarly, good behaviors
are recognized, reinforced and rewarded. Research on the effectiveness of TCs demonstrates
that those who complete the programs are significantly less likely to relapse or recidivate.106
Reentry and Reintegration
Research clearly demonstrates that the most positive long-term results in reducing alcohol
and other substance use and recidivism occur when prison-based treatment is matched
with strategic transition and reentry services. Federally funded studies with measured longterm results show that three states—California, Delaware and Texas—have reduced recidivism and improved cost-effectiveness through a three-phase treatment continuum that
includes in-prison TCs, a community-based transitional living center with substance abuse
treatment, and community-based aftercare. In each case, the research has shown that the
best results occur with participants who complete all stages of programming.107
Here again, the models and strategies are as unique as the jurisdictions in which they are
implemented. Some of the models employed successfully include:
Transitional Housing. Transitional housing may be operated by state corrections or an
independent agency. The goal is to provide a continuum of services after release and to
continue the TC strategy until the releasee demonstrates some measure of self sufficiency. Other services—such as job training and readiness, general education, family
skills, gang and violence intervention, and others targeted to specific needs of the local
community—may be provided.
Independent Clinical Reentry Management. Very similar to the TASC court and probation strategy, independent clinical reentry management involves a third party that
conducts comprehensive clinical assessments of returning offenders, designs individualized case plans to help them navigate the range of services they need to access, then
helps them through the process of achieving stability and self-sufficiency. The case
manager maintains links with all the necessary community providers and works closely
with the releasee, the community, and the supervisory authority (usually parole or
similar entity) to balance the releasee’s restorative needs with the community’s public
safety concerns.
Winners Circle Support Groups. Developed in Texas, the Winners Circle is a peer-led
support group for ex-offenders, most of whom also demonstrate alcohol and other
substance use issues. The groups create a safe, non-judgmental environment for sharing challenges and concerns and creates opportunities for mentorship relationships
wherein ex-offenders who have overcome the barriers to reintegration forge personal
support and guidance relationships with those just being released.
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Treatment of Alcohol and Other Substance Use Disorders
Juvenile Justice
For juvenile offenders, the principles of delivering effective treatment programs and alternatives are the same as those described above. Likewise, the range of opportunities for
intervention mirrors the adult justice system, although generally with different terminology. As with the adult system, the juvenile justice system involves law enforcement agencies, the courts, detention or probation agencies, and community reintegration. As a result,
the types of strategies—whether they be statutory, diversion, institutional treatment or
reentry—also can be applied.
The one distinct difference is the enhanced complexity of the juvenile client. Many juveniles come from abusive situations or broken families, and thus have few prospects for
returning to their community. Some may even be wards of the state. Many are ganginvolved. Their juvenile status also affects the course of their education. Their ability to
achieve any measure of stability may be tenuous, but their juvenile involvement also offers
the opportunity to address issues that may manifest themselves more seriously later in life
if they remain unaddressed.
Options for treatment of juveniles generally will occur in one of two settings—non-detention or detention. Options such as 12-step groups, outpatient treatment or day treatment
are the most widely used programs to address alcohol and other substance use in a nondetention setting.108 Models such as drug courts, TASC and intensive case management
also have been employed in a number of jurisdictions. Within these programs, treatment
modalities may include family or individual therapy, skills training, conflict resolution and
violence prevention, peer mediation or adult mentoring programs.109 Research indicates
interpersonal skills training, family therapy and individual counseling have the most positive effect on reducing adverse outcomes such as police contacts and recidivism.110
Detention serves one of two roles in the juvenile justice system. First, a juvenile offender
may be held in a detention facility while a case is being processed (similar to an adult jail)
if it is believed he or she is a threat to the community, will be at risk if returned to the
community or may fail to reappear at a hearing. About one-quarter of these cases involved
a drug offense,111 but alcohol and other substance use treatment in this type of detention
setting is not common.
A juvenile offender may receive a mandatory referral for treatment while in a longer-term
detention setting, used much in the same way as a prison for adults. Options include inpatient treatment and residential therapeutic communities (TCs).112 TCs provide 24-hour
settings where a variety of rehabilitation services are provided, including personality restructuring, social education, and economic and survival skills. Research indicates adolescents who
are involved in these programs exhibit significantly reduced alcohol and other substance use,
as well as a reduction of criminal activity and improvement in educational achievement. The
most significant predictor of successful treatment is the amount of time spent in the treatment program. Positive outcomes are associated with stays of 90 days or more.113
Short-term residential programs have more questionable outcomes than long-term alternatives. The recent trend in the juvenile justice system is to place youths in large, frequently
crowded short-term programs. Evidence suggests these programs serve primarily to isolate
youth from society and inadequately address rehabilitation needs. As a result, their effectiveness in reducing recidivism is limited.114
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What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
As with adults, the process of reentry into the community following detention is often the
most critical in determining long-term success; it may be exacerbated by additional challenges in home, school and social settings. These settings require full cooperation by a
collaborative team of stakeholders to design individualized reentry strategies to leverage the
strengths of the youth and the services available in the community.115
Treatment of Co-occurring Mental Illness and Alcohol and Other
Substance Use Disorders
An estimated 10 million people in the nation have combinations of co-occurring mental
illnesses and alcohol and other substance use disorders. This population is especially difficult to treat because of the complexity of issues that face them and the system of care
provided to them. According to the National Association of State Alcohol and Drug Abuse
Directors (NASADAD), numerous barriers exist to providing appropriate treatment to
dually diagnosed individuals. Most troubling is the fact that no single point of responsibility for treatment exists. Mental health and alcohol and other substance use treatment
systems operate independently of each other, almost as separate cultures. Each has its own
treatment methods and philosophies, administrative structures and funding. The lack of
coordination that often occurs makes it difficult for providers and consumers caught between the two systems.116 One possible solution involves the concept of a “no wrong door”
system that is available and accessible no matter where and how the individual enters the
system. In addition, the use of common data and assessment tools, staff who are trained in
each other’s disciplines, and flexible funding mechanisms will lead to the comprehensive,
coordinated system of care that is critical for success in treating co-occurring disorders.
One issue is funding, whether mental health or substance abuse money should be used.
Another issue is the cross-training on mental health and substance abuse providers.
Quadrant System
A conceptual framework for treatment that is flexible, cost-effective, client-centered and
evidence-driven was developed by the NASMHPD-NASADAD Task Force on Co-occurring Mental Health and Substance Use Disorders. Use of the framework helps key stakeholders speak the same language about symptom severity, locus of care, and the level of
service coordination needed to address co-occurring disorders. The vast majority of the
research literature and the bulk of the money invested tends to focus on people with serious
mental illnesses who also have alcohol and other substance use disorders. This framework,
which takes a much broader approach, is designed to ensure enough flexibility to address
the needs of all individuals with co-occurring disorders; to fit into any service setting; and
to allow policymakers, providers and funders to plan and fund services for individuals
regardless of the current structure of a state’s or community’s health care delivery system.117 More information about the quadrant system is contained in appendix G.
Mental illness is only one of several illnesses that co-occur with alcohol and other substance
use disorders. Many physical illnesses commonly co-occur, such as fetal alcohol syndrome
(FAS), Hepatitis C virus (HCV), human immunodeficiency virus (HIV), sexually transmitted diseases (STDs), liver disease, heart disease, certain forms of cancer and pancreatitis.
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Treatment of Alcohol and Other Substance Use Disorders
Barriers to Recovery
Many consequences of former alcohol and other substance use, particularly if a crime was
involved, act as barriers to recovery. Sanctions for various crimes include losing Medicaid
and/or social security disability insurance (SSDI) benefits. Ex-felons are barred from public housing. There are many job restrictions; ex-convicts are not permitted to have certain
jobs. Most job applications and higher education applications ask whether the applicant
has ever been convicted of a crime.
Licensing of Providers
State legislators may establish licensing requirements for treatment facilities, including
standards for the physical plant and requirements for services provided. State legislators
also may establish licensing requirements for individual providers, such as education requirements and supervised work experience requirements.
Regulating Treatment
State legislators set regulations regarding quality of care at state-run treatment facilities.
State legislators legislate on certificate of need requirements (CON) that often apply to
treatment facilities, particularly methadone clinics.
Confidentiality
The federal confidentiality laws and regulations prohibit disclosure of information about
patients who have applied for or received any alcohol or other drug use-related services—
including assessment, diagnosis, counseling, group counseling, treatment, or referral for
treatment—from a covered program. The restrictions on disclosure apply to any information that would identify a patient as an alcohol or other drug user, either directly or by
implication. The general rule applies from the time the patient makes an appointment. It
also applies to patients who are civilly or involuntarily committed, minor patients, patients
who are mandated into treatment by the criminal justice system, and former patients. The
rule applies whether the person making an inquiry already has the information, has other
ways of getting it, has official status, is authorized by state law, or has a subpoena or search
warrant. 118
Any program that specializes, in whole or in part, in providing treatment, counseling and/
or assessment, and referral services for patients with alcohol or other drug problems must
comply with the federal confidentiality regulations (§§2.12(e)). The federal regulations
apply only to programs that receive federal assistance, including indirect forms of federal
aid such as tax-exempt status, or state or local government funding coming (in whole or in
part) from the federal government.119
The federal confidentiality regulations provide three ways by which researchers can obtain
information from AOD programs:120
•
The regulations permit AOD use treatment programs to give researchers access to
information about patients when no patient identifying information is revealed.
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What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?
•
The regulations permit AOD programs to give researchers patient identifying information without patients’ consent when certain criteria are met.
•
Researchers also may obtain information that is protected by the federal confidentiality regulations if patients sign proper consent forms.
The federal regulations permit programs to disclose information about patients if the programs reveal no patient identifying information. Patient identifying information is information that identifies an individual as an alcohol or other drug user. Thus, a program can
give researchers aggregate data about its population or some portion of its population. For
example, a program staff member could tell a researcher engaged in outcomes monitoring
that, during the last year, 42 patients completed the treatment program, 67 dropped out
in less than six months, and 25 left the program between six and 12 months. 121
The confidentiality regulations permit programs to disclose patient identifying information to researchers, auditors and evaluators without patient consent, providing certain safeguards are met (§§2.52, 2.53). 122
Alcohol and other substance programs can disclose patient identifying information to those
who are conducting “scientific research” if the program director determines that the researcher 1) is qualified to conduct the research, 2) has a protocol under which patient
identifying information will be kept in accordance with the regulations’ security provisions
(see §§2.16),6 and 3) has provided a written statement from a group of three or more
independent individuals who have reviewed the protocol and determined that it protects
patients’ rights. 123
Researchers are prohibited from identifying any individual patient in any report or otherwise disclosing any patient identities except to the program. This provision is addressed
more fully below, because it is particularly important when a research design calls for
follow-up research with the patient or collateral sources or for tracking patients in other
health, social welfare or criminal justice systems. 124
Patient records may be reviewed on the program’s premises for the purposes of conducting
an audit or evaluation by the following entities: 125
•
Federal, state and local government agencies that fund or are authorized to regulate a
program;
•
Private entities that fund or provide third-party payments to a program; and
•
Peer review entities that are performing utilization or quality control review in order to
conduct an audit or evaluation.
Any person or entity reviewing patient records to perform an audit or conduct an evaluation must agree in writing that the information will be used only to carry out the audit or
evaluation and that patient information will be disclosed only 1) back to the program, 2)
in accordance with a court order to investigate or prosecute the program (§§2.66), or 3) to
a government agency overseeing a Medicare or Medicaid audit or evaluation (§§2.53(a),
(c), (d)). Any other person or entity that is determined by the program director to be
qualified to conduct an audit or evaluation and that agrees in writing to abide by the
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Treatment of Alcohol and Other Substance Use Disorders
restrictions on redisclosure also can review patient records. Again, the prohibition on
redisclosure is particularly important when research designs include follow-up. 126
When a researcher who seeks to interview patients or former patients meets the requirements of §§2.52 or 2.53, the federal confidentiality regulations do not require that a
program obtain a patient’s consent under §§2.31 to release his or her name to the researcher. However, it is always better practice to obtain patients’ consent to the release of
their names to researchers, auditors, or evaluators who are seeking to approach them for
interviews. 127
Researchers also can obtain patient identifying information if the patient has agreed to the
release of the information by signing a valid consent form that has not expired or been
revoked (§§2.31). The regulations’ requirements regarding consent are somewhat unusual
and strict and must be carefully followed. 128
A proper consent form must be in writing and must contain each of the items contained in
§2.31: 129
•
The name or general description of the program or person making the disclosure;
•
The name or title of the individual or organization that will receive the disclosure;
•
The name of the patient who is the subject of the disclosure;
•
The purpose or need for the disclosure;
•
How much and what kind of information will be disclosed;
•
A statement that the patient may revoke the consent at any time, except to the extent
that the program or person authorized to make a disclosure has already acted in reliance on it;
•
The date, event, or condition upon which the consent expires, if not previously revoked;
•
The signature of the patient (and, in some states, his or her parent); and
•
The date on which the consent is signed.
A general medical release form or any consent form that does not contain all the elements
listed above is not acceptable. 130
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What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders?
65
5. WHAT FUNDING IS AVAILABLE FOR STATES
TO PROVIDE SERVICES TO PEOPLE
AFFECTED BY ALCOHOL AND OTHER
SUBSTANCE USE DISORDERS?
The Substance Abuse Prevention and Treatment Block Grant
• The Substance Abuse Prevention and Treatment Block Grant
provides approximately 40 percent of the public funds spent
provides approximately 40 percent of the public funds spent
on treatment and prevention in the states. Entitlement
on treatment and prevention in the states.
programs, such as Medicaid, are another important source
of funding. Funding of alcohol and other substance use
• In FY 1996, $12.6 billion was spent on treatment for alcoprevention and treatment services for alcohol and other subhol and other substance use disorders.
stance use disorders is provided by federal, state and local
governments. State and federal governments share finan• Between 1987 and 1997, the average annual growth rate of
cial responsibility in the area of Medicaid, where states are
expenditures for alcohol and other substance use disorders
increasingly using managed care systems to administer benwas 2.5 percent.
efits. Coverage of alcohol and other substance use treatment varies widely among private insurers. However, many
states have laws that mandate coverage of some level of benefits for the treatment of alcohol
and other substance use disorders. A small number of states require at least an offering of
benefits, while still others do not address the issue at all. Federally funded programs
primarily operate as block grants, entitlements or categorical grants, and research grants.
Overview of State and Federal Funding
In FY 1997, $11.9 billion was spent on treatment for alcohol and other substance use
disorders. Between 1987 and 1997, the average annual growth rate of expenditures for
alcohol and other substance use disorders was 2.5 percent.1
The Substance Abuse and Mental Health Administration (SAMSHA) data for FY 1997
shows that the majority of funding for alcohol and other substance use treatment expenditures was from public sector funding (64 percent).2 Table 6 shows national averages of
federal block grant allocations and state appropriations for mental health and substance
abuse.
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Treatment of Alcohol and Other Substance Use Disorders
Table 6. National Averages of Federal Block Grant Allocations and State Appropriations
for Mental Health and Substance Abuse
FY 02/03 Mental Health
Block Grant Allocation
$8,162,127
FY 02/03 Substance
Abuse Block Grant
Allocation
$32,684,766
FY 01 State
Appropriation for
Mental Health
$448,518,107
FY 98 State
Appropriation for
Substance Abuse
$24,080,673
Sources: “SAMHSA Grant Awards FY 2002/FY 2003,” http://www.samhsa.gov/funding/funding.html.
“Table 1: SMHA Mental Health Actual Dollar and Per Capita Expenditures by State, Fiscal Year 2001,” http://www.nri-inc.org/RevExp01/Table1.htm.
“Table 1: Expenditures Reported for State Supported Alcohol and Other Drug Services By State and Funding Source, For Fiscal Year 1998,” State Alcohol and Drug Abuse
Profile (SADAP), FY 1998; data included for ONLY THOSE PROGRAMS that received at least some funds administered by the State Alcohol and Other Drug Abuse Agency
during the State’s FY 1998.
The State Role in Financing
Each state has designated a single state agency (see appendix E for state contacts) to be
responsible for effective allocation and utilization of federal and state sources that are specifically targeted for alcohol and other substance use treatment services. Funding from
state government sources include, but are not limited to:
•
•
•
•
•
State general fund revenues;
Medicaid funds that are used for drug and alcohol treatment;
Earmarked taxes;
Seized assets, money or property that is derived from drug crimes and specifically
appropriated for support of drug and alcohol treatment programs; and
Fines, fees and/or assessments earmarked for drug and alcohol treatment.
State Funds for Treatment
Each state appropriates money to its substance abuse agency for the prevention and treatment of alcohol and other substance use disorders. States also
appropriate money to other agencies for purposes related to alTable 7. Per Capita State Spending on Alcohol and
cohol and other substance use disorders, such as Medicaid for
Other Substance Use Prevention, Treatment and Research
treatment, children and families for screening and treatment,
State
Per Capita
State
Per Capita
education for prevention, housing for screening and referral, jusSpending
Spending
Alabama
$7.40
Montana
$8.21
tice for treatment and drug courts, and so forth. Table 7 shows
Alaska
$26.51
Nebraska
$5.40
state per capita spending on alcohol and other substance use
Arizona
$12.32
Nevada
$3.61
Arkansas
$1.81
New Hampshire
*
prevention, treatment and research.
California
$14.66
New Jersey
$6.17
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
$0.14
$8.34
$31.34
$5.28
NA
$7.31
$5.74
$8.17
*
$4.00
$3.20
$3.37
$3.32
*
$6.87
$15.86
$0.19
$12.23
$4.54
$7.71
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
$6.39
$27.77
*
$15.79
$3.74
$10.37
$23.96
$8.50
$0.74
$0.41
$5.16
$1.66
*
$4.89
$5.14
$4.20
$10.21
$4.30
$1.51
$5.81
Note: Indiana, Maine, New Hampshire, North Carolina and Texas did not respond to the survey.
Source: “Shoveling Up: The Impact of Substance Abuse on State Budgets, State-By-State Tables,”
http://www.casacolumbia.org/usr_doc/statebystate.html.
Private Insurance Coverage
Many private insurance companies are providing benefits for
the treatment of alcohol and other substance use disorders. These
benefits can vary greatly from one insurance company to the
next. Benefits also vary across the types of plans that are offered
by employer/purchasers of insurance coverage and other services.
Standard health maintenance organization (HMO) plans offer
more benefits than do traditional or preferred provider organization plans (PPOs) because HMO plans are more tightly managed and can control use of and access to services. Some plans
cover medical, inpatient detoxification only for alcohol and other
substance use disorders. Other plans may cover outpatient services but not inpatient or residential care. Some plans greatly
National Conference of State Legislatures
What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders?
limit the amount of visits or inpatient days for the treatment of alcohol and other substance
use disorders. Plans vary widely in access and the extent of services available to the insured,
and in the minimum and maximum amounts of services available to patients and insureds.
Four common treatment settings are associated with alcohol and other substance use disorders. Managed care organizations and other insurance entities define these levels of care
differently, based on the level and type of benefits they offer, the utilization management
guidelines they are using, and their medical necessity criteria. However, certain basic
components must be available in each treatment setting.
Parity and Mandated Benefits
Mandating benefits for the treatment of alcohol and other substance use disorders is controversial. Insurers and employers—especially small group employers—oppose mandated
benefits because they believe these mandates increase costs and force employers to lower
other health insurance benefits for their employees. Supporters of alcohol and other substance use treatment mandates believe that mandates are the only way people who need
treatment can obtain the services they need without being discriminated against. The
ultimate mandate for the equality of treatment for alcohol and other substance use services
can be found in state parity laws. These laws require that the benefits for the treatment of
mental health and alcohol and other substance use must be provided under the same terms
and conditions as the benefits for the treatment of any other physical illness. Benefits
include equality in lifetime and annual limits, deductibles and co-insurance, and visit
limits for inpatient and outpatient treatment. Parity for mental health has gained momentum during the past 10 years, and 21 states now require full parity for the treatment of
mental illness. However of those 21, only nine—Connecticut, Delaware, Maine, Minnesota, North Carolina, South Carolina, Vermont, Virginia and West Virginia—include treatment for alcohol and other substance use disorders. Parity benefits in North Carolina and
South Carolina apply only to state employee plans.3
Forty-five states require that some level of benefits be provided for the treatment of alcohol
and other substance use disorders (see appendix H).
Finally, mandates—even parity mandates—do not cover all third-party payers. Medicare
and Medicaid are exempt from many state mandates, unless explicitly required to provide
coverage under the law. Also exempt from many mandated benefits laws are small group
employers, self-insured and individual health plans, and those covered under the federal
Employee Retirement Income and Security Act (ERISA).4
On June 7, 1999, the White House announced its intent to provide federal employees
with parity benefit coverage in the Federal Employee Health Benefit Plan (FEHBP) for the
treatment of mental illness and alcohol and other substance use disorders and other medical health problems by 2001. The largest employer-sponsored health insurance program
in the country, FEHBP covers about 9 million people, including federal employees, retirees and their families. This benefit coverage program could serve as a national model.
The Office of Personnel Management (OPM) has taken the lead in making mental health
coverage more affordable and accessible for all federal employees. During the past few
years, OPM, working with benefit providers in the FEHBP, have:
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Treatment of Alcohol and Other Substance Use Disorders
•
Eliminated lifetime and annual maximums for mental health care.
•
Moved away from contractual day and visit limitations and high out-of-pocket costs
for mental health care.
•
Covered medical visits and testing to monitor drug treatment for mental conditions as
pharmaceutical disease management.5
Following President Clinton’s directive, OPM issued a call letter to all 285 health plans
that participate in the FEHBP to enlist their support in achieving parity for mental health
and substance abuse coverage.
Cost Shift to Private Sector. Parity and mandated benefits shift the cost of treatment from
the public system to the private sector. Many privately insured individuals require alcohol
and other substance use treatment, but their insurance does not cover such treatment.
Therefore, many of those individuals receive publicly funded treatment. Parity and mandated benefit laws require private insurance to cover the cost of alcohol and other substance
use treatment; therefore, privately insured individuals who require alcohol and other substance use treatment have that treatment paid for by their insurers.
Alcohol Tax
An alcohol tax serves the dual purposes of primary prevention and revenue enhancement
for the state. The additional cost deters some individuals from purchasing alcohol. Teenagers are particularly sensitive to price. Everyone who uses alcohol contributes toward a tax
fund used for the prevention and treatment of alcoholism and alcohol abuse. The majority
of people favor the tax, particularly if it is tied to prevention and treatment. (Appendix I
contains alcohol taxes by state.)
Federal Role in Funding Treatment
Medicaid, Medicare, TRICARE, supplemental security income (SSI) and social security
disability insurance (SSDI) are entitlement programs that enable eligible recipients or states
to receive income support maintenance and health care. All these programs have services
that can be used for alcohol and other substance use treatment and services. P.L. 104-121,
signed by President Clinton in 1996, eliminated addictions as a qualified disability for
SSI/SSDI. As a result, SSI as a mandatory Medicaid eligible was not available for those
with addictions. SSDI and its link to Medicare was lost. However, those with addictions
were not excluded from Medicaid and Medicare per se. The denial applied immediately to
any new or preceding claim for benefits. Benefits were terminated on January 1, 1997, for
individuals who were receiving benefits based on alcohol and other substance use disorders;
costs were shifted to state and local programs.
Many other grants are available from the federal government through various federal agencies, including the military, the Department of Education, and the Administration for
Children and Families. Some of the federal programs are discussed below.
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What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders?
Substance Abuse and Mental Health Services Administration (SAMHSA)
State government is the largest single purchaser of treatment services for alcohol and other
substance use disorders through block grants in most states. SAMSHA is the lead agency
for alcohol and other substance use treatment and prevention programs.
Substance Abuse Prevention and Treatment (SAPT) Block Grant
The Center for Substance Abuse Treatment within the Substance Abuse and Mental Health
Services Administration is the lead agency to administer the block grant. The grant funds
represent approximately 40 percent of the funds flowing through the single state agencies.
The block grant contains several mandatory distributions and set-asides:
•
20 percent must be used for prevention activities;
•
2 percent to 5 percent must be spent on AIDS-related drug use programs in states with
an AIDS case rate of 10 per 100,000 population;
•
States must spend from their allocation an amount “equal to fiscal year 1994 spending
levels” on programs for pregnant women and women with dependent children; and
•
Up to 5 percent of a state’s allocation may be used for state administration.6
Of the funds allocated to the block grant program, 95 percent are distributed to states
through a formula prescribed by the authorizing legislation. Factors used to calculate the
allotments include total personal income; state population data by age groups (total population data for territories); total taxable resources; and a cost of services index factor.7
Performance Partnership Grants
The Substance Abuse and Mental Health Services Administration (SAMHSA) published
for comments in the Federal Register on December 23, 2002, its plans to create two new
Performance Partnership Grant programs with states. The new Performance Partnership
Grant programs will replace the current Substance Abuse Prevention and Treatment Block
Grant and the Community Mental Health Services Block Grant to states.8
The announcement was the culmination of years of discussion with the National Association of State Alcohol and Drug Abuse Directors and the National Association of State
Mental Health Program Directors. The request for comments provided an opportunity for
interested organizations and individuals to help ensure that the Performance Partnership
Program meets its long-term goals. SAMHSA was particularly interested in learning whether
the proposed performance measures are the most appropriate to help SAMHSA track program performance in relation to those goals.9
“The Performance Partnership approach builds on the principles of partnership, flexibility,
and accountability based on performance,” said SAMHSA Administrator Charles G. Curie.
“We expect these new proposals to bring continuous quality improvement to the provision
of substance abuse treatment and prevention services; and community-based mental health
services for adults with serious mental illness, and children with serious emotional disturbance.”10
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Treatment of Alcohol and Other Substance Use Disorders
He explained that, “We are not proposing any changes that would alter eligibility for
funding under the two programs, nor are we changing the formula for distribution of those
funds. We are changing the relationship between the federal and state governments to
achieve our goal of improved services for those with mental health and/or substance abuse
disorders.”11
The Performance Partnership Program will change the thrust of the block grants from state
expenditure reports and accountability based on documentation of compliance to reliance
on evidence of performance. States would gain more flexibility to use block grant funds to
address their specific needs. States and the federal government would work together to
identify the strengths of a state’s service system and areas where it could be improved to
benefit those in need of alcohol and other substance use and mental health services. The
goal of the new program is to promote an atmosphere where best practices are integrated
into state programs as part of a continuing cycle of quality improvement.12
Congress ordered a plan to change block grant programs to a performance-based system in
the Children’s Health Act of 2000.13
Maintenance of Effort (MOE) Funds
The SAPT Block Grant has a maintenance of effort (MOE) requirement. With respect to
the principal agency of a state for carrying out authorized activities, such agency will for
such year maintain aggregate state expenditures for authorized activities at a level that is
not less than the average level of such expenditures maintained by the state for the two-year
period preceding the fiscal year for which the state is applying for the grant.14
Upon the request of a state, the secretary may waive all or part of the requirement for the
agency if the secretary determines that extraordinary economic conditions in the state justify the waiver. The secretary shall approve or deny a request for a waiver not later than 120
days after the date on which the request is made. Any waiver provided by the secretary
shall be applicable only to the fiscal year involved.15 (See Federal Regulations, 45 CFR
96.134(b) Maintenance of Effort Regarding State Expenditures.)
In making a grant to a state for a fiscal year, the secretary shall make a determination of
whether, for the previous fiscal year, the state maintained material compliance with any
agreement made by the agency. If the secretary determines that a state has failed to maintain such compliance, the secretary shall reduce the amount of the allotment for the state
for the fiscal year for which the grant is being made by an amount equal to the amount
constituting such failure for the previous fiscal year. The secretary may make a grant for a
fiscal year only if the state involved submits to the secretary information sufficient for the
secretary to make the determination. 16
Discretionary Grant Programs
A discretionary grant permits the federal government, according to specific authorizing
legislation, to exercise judgment (discretion) in selecting the applicant/recipient organization, through a competitive grant process. Types of activities commonly supported by discretionary grants include demonstration, training, service and programs. Discretionary grants
are sometimes referred to as a project grants.17
Discretionary grant funds are made available and awarded by the Center for Mental Health
Services (CMHS), the Center for Substance Abuse Prevention (CSAP), and the Center for
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What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders?
Substance Abuse Treatment (CSAT) in accordance with the mission and purpose of
SAMHSA.18
Programs of Regional and National Significance (PRNS) is a type of discretionary grant
included in SAMHSA’s authorizing legislation (P.L. 102-321, as amended by P.L. 106310). PRNS grants complement SAMHSA’s block grants to the states in many ways. They
enable SAMHSA to target funds to priority populations or health concerns, respond quickly
to emerging needs, and implement and promote adoption of evidence-based practices.
Evaluation of the PRNS grants further helps SAMHSA ensure that federal service funds are
well spent.19 These grants are not always coordinated with state programs.
SAMHSA’s PRNS grants fall into two categories, knowledge application (KA) programs
and targeted capacity expansion/response (TCE) programs. KA programs are designed to
bridge the gap between scientific knowledge and community-based practice. Knowledge
application grants provide support for wide-scale adoption of new research tested effective
practices. TCE programs provide targeted funding to implement focused responses to emerging needs using proven practices. Projects address treatment and prevention issues unique
to a population or geographic area.20
Centers for Medicare and Medicaid Services (CMS)
Medicaid
Medicaid is a federal-state partnership that provides required and optional health care
services to millions of low-income Americans. Funds that are given to the states using an
open-ended formula, provide a minimum of 50 percent federal share in the cost of medical
services covered and part of administrative costs. As a result, Medicaid provides a useful
way for states to maximize funding resources.
The number of Medicaid recipients has increased from approximately 10 million in 1967
to an estimated 48.9 million in FY 2002, an increase of 389 percent. This has meant rapid
growth in Medicaid expenditures, although the rate of increase has subsided recently.21
Between 1990 and 2002, Medicaid recipients as a percent of the total U.S. population
increased from 10.2 percent to 16.9 percent, an increase of approximately 66 percent.22
Medicaid spending on alcohol and other substance use disorders rose rapidly at an inflation-adjusted rate of 9.8 percent yearly between 1987 and 1992, still slower than the 11.8
percent annual increase in Medicaid spending on all health care during that period. In the
second five-year period, Medicaid programs slowed the rate of increase of spending on
alcohol and other substance use treatment to an annual 5.7 percent increase between 1992
and 1997. 23
Federal Medicaid guidelines require a core of basic services, including hospital inpatient
and outpatient care; early and periodic screening, diagnosis and treatment of physical and
mental illnesses for individuals under age 21; rural health clinic services; physicians’ services; and nurse-midwife services. States have discretion to cover additional services, such
as alcohol and other substance use treatment programs and inpatient hospital care in mental institutions for individuals under age 21; services of state-licensed practitioners, such as
psychologists, alcohol and other substance use counselors, and medical social workers; rehabilitation option to expand to 10 people; clinic services, such as those offered by outpatient alcohol and other substance use clinics; prescription drugs; and transportation and
emergency hospital services.
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Treatment of Alcohol and Other Substance Use Disorders
Medicaid does not provide coverage for individuals between the ages of 21 and 65 who
receive alcohol and other substance use or mental illness treatment from an institution for
mental disease (IMD). (An IMD is defined as any hospital, nursing facility or other institution with more than 16 beds whose primary business is mental health, which includes
alcohol and other substance use disorders.) The IMD exclusion effectively denies Medicaid funding to residential, community-based alcohol and other substance use treatment
services, such as therapeutic communities. This policy has particularly adverse effects for
substance using women who are pregnant or have dependent children and may require
residential treatment services. The IMD exclusion is viewed as a barrier to appropriate
alcohol and other substance use treatment for vulnerable populations and effectively shifts
the cost of serving these populations to the states and to block grant funded programs.
Section 1115 of the Social Security Act allows states to apply for waivers for demonstration
projects as long as the programs are “budget neutral.” Several states have used the 1115
waiver to implement projects that waive the IMD exclusion. In addition, states that are
experimenting with managed care delivery systems (some no longer require a waiver, according to the Balanced Budget Act of 1997) and under 1915b waivers can circumvent the
IMD exclusion. Because Medicaid pays managed care systems flat rates with an agreed
upon capitation fee, CMS does not require information about the actual services provided.
Therefore, Medicaid-approved managed care systems may provide alcohol and other substance use treatment services, provided the costs for these services fall within the agreed
upon capitation fee.
To obtain your state’s coverage of alcohol and other substance use disorder treatment under
Medicaid, contact your single state agency director or the Medicaid office. (A listing of
single state agency directors is contained in appendix E.)
Mental Health vs. Alcohol and Other Substance Use Disorders Spending. States can
choose, under Medicaid, to expand alcohol and other substance use disorders services and
expand the list of those eligible. If a state chooses to include the medically needy population under Medicaid, the State plan must provide, as a minimum, particular services. If
the state plan includes services (only two ways: 1115 IMD waiver or use DSH or cost
savings fund) either in institutions for mental diseases or in intermediate care facilities for
the mentally retarded (ICF/MRs), it must offer either of the following to each of the medically needy groups: the services contained in 42 CFR sections 440.10 through 440.50 and
440.165 (to the extent that nurse-midwives are authorized to practice under state law or
regulations); or the services contained in any seven of the sections in 42 CFR 440.10
through 440.165. States also may receive federal funding if they elect to provide other
optional services. The most commonly covered optional services under the Medicaid program include intermediate care facility/mentally retarded services.24
Sanctions. Medicaid sanctions involve cutting people off of treatment for various crimes.
Medicaid and Managed Care
States increasingly rely on managed care as an alternative to traditional fee-for-service delivery systems. Under managed care systems, health maintenance organizations (HMOs),
prepaid health plans (PHPs) or comparable entities provide a specific set of services to
Medicaid enrollees, usually in return for a predetermined periodic payment per enrollee.
Managed care programs seek to enhance access to quality care in a more cost-effective
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What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders?
manner.25 The percentage of Medicaid enrollees participating in a managed care plan
increased from 14 percent in 1993 to 54 percent in 1998.26
States employ four approaches to providing mental health and/or alcohol and other substance use treatment in a managed care model.
•
Integrated managed care programs include alcohol and other substance use treatment
as a component of an overall physical health plan. Three approaches are models that
are designed specifically to serve mental health and/or alcohol and other substance use
needs. 27
•
Integrated models provide alcohol and other substance use services as part of a comprehensive physical health managed care plan. Health maintenance organizations (HMOs)
and managed care organizations (MCOs) typically run these programs. The HMO or
MCO may subcontract with a specialty organization to provide alcohol and other
substance use treatment services. However, payment for services by state Medicaid
remains integrated. Another variation of integrated programs is known as a carve-in,
where states require the specialty organization that provides treatment services to have
a clinical relationship with the primary managed care organization.28
•
Partial carve-out programs offer a basic set of benefits under a comprehensive physical
health plan, but supplement these benefits under a separate managed care program
that offers services targeted toward specific populations or high users (e.g., pregnant
women with alcohol and other substance use disorders).
•
Full carve-out programs go a step further and separate all mental health or alcohol and
other substance use services from physical health managed care programs. In standalone programs, alcohol and other substance use treatment services are completely
independent of any other program. In other words, these programs are not carved out
of a physical health program. Stand-alone programs typically are not associated with
Medicaid.29
Temporary Assistance to Needy Families (TANF)
The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of
1996 replaced the Aid to Families with Dependent Children (AFDC) program with the
TANF block grant. To receive the TANF block grant, states must meet a maintenance of
effort (MOE) requirement each year. The law delinked Medicaid eligibility from eligibility for TANF services. As a result, a new Medicaid eligibility category was created to cover
families that would have been covered under AFDC eligibility in 1997.30
States can use welfare funds as a funding source for different approaches to alcohol and
other substance use treatment and services. States can maximize the flexibility of the welfare block grant by separating the different funding streams. State MOE for TANF can be
used for “medical services,” including treatment by a physician or medical professional, the
cost of medication, and health insurance premiums. Federal TANF funds are restricted to
“non-medical” services. The state can maximize TANF spending for alcohol and other
substance use disorders by setting a narrow definition of “medical services.” Many aspects
of alcohol and other substance use services and treatment are considered “non-medical.”
These include screening, assessment, treatment, and residential and child care costs associated with treatment.
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Treatment of Alcohol and Other Substance Use Disorders
At least 40 percent of the states have allocated some TANF funds for alcohol and other
substance use services, including integrating alcohol and other substance use education
into job readiness programs; providing screening services and treatment for welfare clients
through mental health programs; providing counseling services; developing a plan to address the alcohol and other substance use needs of the entire welfare family through a
comprehensive approach to treatment; and beginning pilot programs that provide financial incentives to businesses that hire welfare recipients.31
All TANF and TANF MOE spending must meet one of the four goals of the 1996 Personal
Responsibility and Work Opportunity Act:
•
To provide assistance to needy families so that children may be cared for in their own
homes or in the homes of relatives;
•
To end the dependence of needy parents on government benefits by promoting job
preparation, work and marriage;
•
To prevent and reduce the incidence of out-of-wedlock pregnancies and establish annual numerical goals for preventing and reducing the incidence of these pregnancies;
and
•
To encourage the formation and maintenance of two-parent families.
Alcohol and other substance use services and treatment can be effective in meeting each of
the four goals.
Many states are using TANF funds to provide “non-medical assistance,” including:
•
Screening and assessment of welfare recipients for alcohol and other substance use;
•
Placing qualified alcohol and other substance use professionals in every welfare office;
•
Reimbursing the room and board costs of residential care;
•
Providing counseling by social workers;
•
Integrating alcohol and other substance use education into job readiness programs;
•
Teaching welfare recipients about alcohol and other substance use disorders and how
to recognize them;
•
Developing comprehensive plans to address the alcohol and other substance use treatment needs of the entire family;
•
Providing screening and referring individuals to treatment services provided by mental
health programs; and
•
Providing child care and transportation to facilitate treatment.
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States are using their TANF MOE funds to expand “medical services” for alcohol and other
substance use treatment, including treatment by a physician, medication and reimbursing
the cost of health insurance premiums. The 1996 federal welfare law also gives states the
option of universal drug testing of welfare recipients.
State Children’s Health Insurance Program (SCHIP)
Under the State Children’s Health Insurance Program (SCHIP), states can choose to expand Medicaid, establish a new separate program such as employer-sponsored health care,
or create a combination program. A state’s choice of whether to expand Medicaid often
affects the alcohol and other substance use benefits children will receive.
Regardless of whether states choose to expand Medicaid or establish a private/combination
program, coverage of alcohol and other substance use treatment services is “optional” except for children who are to be given any Medicaid service they need even if it is not on the
state’s usual benefits.32 When SCHIP is a Medicaid expansion, SCHIP children also get
this entitlement. This is not true for separate SCHIP. Adolescent alcohol and other substance use treatment also raises different issues regarding confidentiality of treatment and
involvement of family members. Although many programs seek to involve families in
treatment, adolescents may view family involvement as a deterrent to seeking treatment.33
Also, the IMD restriction does not affect children.
Early Prevention, Screening, Detection and Treatment (EPSDT) Funds
The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) service is Medicaid’s
comprehensive and preventive child health program for individuals under age 21. It requires that any medically necessary health care service listed as a possible Medicaid service
be provided to an EPSDT recipient even if the service is not available under the state’s
Medicaid plan to the rest of the Medicaid population.34 If managed care does not cover,
the state must pay for it in fee for service.
The EPSDT program consists of two mutually supportive, operational components:
1) Assuring the availability and accessibility of required health care resources; and
2) Helping Medicaid recipients and their parents or guardians effectively use these resources.
All Medicaid children are periodically screened and are screened if they need diagnosis or
treatment.
Medicare
Alcohol and other substance use— particularly alcohol and prescription drug abuse—
among the elderly is one of the fastest growing problems in the country. The problem is
expected to continue to grow as baby boomers reach retirement.35 Medicare is a public
health insurance program that covers most people over age 65, people who are entitled to
Social Security or Railroad Retirement disability benefits for 24 months or more, people
with end-stage renal disease who require continuing dialysis or kidney transplant, and
certain otherwise non-covered elderly people who elect to buy into Medicare. Like Medicaid, Medicare includes alcohol and other substance use disorders as mental disorders.36
To qualify for Medicare under age 65, a disabled person must be over age 18 and have
incurred the disability prior to age 22. Since these individuals first must qualify for Social
Security Disability Insurance (SSDI) and SSDI is not awarded on the basis of alcohol and
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Treatment of Alcohol and Other Substance Use Disorders
other substance use disorders alone, only alcohol and other substance users with physical
or mental impairments are eligible for Medicare on the basis of disability. Even then, SSDI
beneficiaries must receive 24 months of SSDI payments before they become eligible for
Medicare.
The number of people enrolled in Medicare grew significantly, from 19.5 million in 1967
to a projected 39.2 million in 1998, an increase of 101 percent.37 In 1997, Medicare
spending accounted for only 8 percent of expenditures for alcohol and other substance use
treatment. The growth of Medicare alcohol and other substance use disorders expenditures
more than doubled over the two five-year intervals, from a growth rate of 4.7 percent per
year between 1987 and 1992 to a rate of 10.7 percent per year between 1992 and 1997,
on average.38
Social Security Administration (SSA)
Supplemental Security Income (SSI)
The SSI program provides monthly income to people who are age 65 or older, or are blind
or disabled, and have limited income and financial resources.39 SSI does not cover alcohol
and other substance use disorder treatment.
Social Security Disability Insurance (SSDI)
The Social Security Disability Insurance program pays benefits to a person with a work
history if he or she is disabled or blind insured under the act; the child of an insured
worker; or the widow, widower, or surviving divorced spouse of an insured worker.40 SSDI
does not cover alcohol and other substance use disorder treatment.
Administration for Children and Families (ACF)
Title IVB and Title IVE Funds
To provide states flexibility to design innovative child welfare programs, Congress enacted
a provision in 1994 (Public Law 103-432) authorizing the secretary of the U.S. Department of Health and Human Services (DHHS) to approve up to 10 demonstration projects
requiring waivers of provisions under titles IV-B and IV-E. This authority, established by
section 1130 of the Social Security Act, was subsequently amended by the Adoption and
Safe Families Act in 1997, allowing DHHS to approve an additional 10 demonstration
projects in each of fiscal years 1998-2002. The secretary may waive any provision of either
Title IV-B or Title IV-E if necessary to enable the state to carry out its demonstration
project, with some exceptions. Demonstrations are limited to five years and must include
an evaluation component and be cost-neutral to the federal government.41
As of April 2000, almost half the states had had demonstration projects approved, with
some states operating more than one project. For new waivers, DHHS is especially interested in proposals that would examine the following: performance-based systems, integrated systems for behavioral health (substance abuse and mental health), effective prevention and early intervention, adoption and postadoption services, service improvements for
children in the placement and care responsibility of tribes, service improvements for adolescent youth, and reunification services for adolescent youth.42
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Department of Education (DOE)
The Safe and Drug-Free Schools and Communities State Grants Program
Run by the Department of Education, this program provides funds primarily to the state
education agencies and governors’ offices for anti-alcohol and other substance use education, prevention, early intervention and treatment referral programs. This money cannot
be used for treatment services. In 1996, 97 percent of all school districts in the country
participated in the program.43
The program provides support to state educational agencies (SEAs) for a variety of drug
and violence prevention activities focused primarily on school-age youth. SEAs are required
to distribute 91 percent of funds to local education agencies (LEAs) for drug and violence
prevention activities authorized under the statute, which may include developing instructional materials; providing counseling services; developing professional development programs for school personnel, students, law enforcement officials, judicial officials or community leaders; implementing conflict resolution, peer meditation and mentoring programs;
implementing character education programs and community service projects; establishing
safe zones of passage for students to and from school; and acquiring and installing metal
detectors and hiring security personnel. Of the funds distributed to LEAs, 30 percent
must be awarded to LEAs that have the greatest need for additional funds for drug and
violence prevention; the remaining 70 percent of funds must be awarded to LEAs based on
enrollment. 44
The governor has 20 percent of the money. This program provides support to governors for
a variety of drug and violence prevention activities focused primarily on school-age youth.
Governors use their program funds to provide support to parent groups, community-based
organizations, and other public and private nonprofit entities for drug and violence prevention activities that complement the state education agency (SEA) and local education agency
(LEA) portion of the Safe and Drug-Free Schools and Communities Program.45
Department of Justice (DOJ)
The Residential Substance Abuse Treatment for State Prisoners Program
Administered by the Corrections Program Office in the Office of Justice Programs, this
program provides funds for individual and group alcohol and other substance use treatment activities for offenders in residential facilities operated by state and local correctional
agencies. To receive funding, state and local correctional agencies must:
•
Provide treatment that lasts between six and 12 months;
•
Provide treatment in residential treatment facilities set apart from the general correctional population;
•
Focus on the alcohol and other substance use disorders of the inmate;
•
Develop the inmates’ cognitive, behavioral, social, vocational and other skills to solve
the alcohol and other substance use disorders; and
•
Implement or continue to require urinalysis and other reliable forms of drug and alcohol testing.
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Treatment of Alcohol and Other Substance Use Disorders
Each state that participates in the program receives a base of 4 percent of the total funds
available for the program. The remaining funds are distributed to the participating states
based on their prison populations, as compared to the prison populations of all participating states.46
The Drug-Free Communities Program
This program, created by the Drug-Free Communities Act of 1997, is administered for the
Office of National Drug Control Policy. Under the program, agreements are entered into
with national drug control agencies to delegate authority for the execution of grants. The
grants are awarded to coalitions that meet specified criteria, including those that:
•
Have as a principal mission the comprehensive and long-term reduction of alcohol and
other substance use with a primary focus on youth in the community;
•
Describe and document the nature and extent of the alcohol and other substance use
problem in the community;
•
Provide a description of alcohol and other substance use prevention and treatment
programs and activities in the community at the time of the grant application;
•
Identify alcohol and other substance use programs and service gaps in the community;
and
•
Develop a strategic plan for comprehensive, long-term reduction of alcohol and other
substance use among youth and work to develop a consensus regarding the priorities of
the community to combat alcohol and other substance use among youth.47
Byrne Formula Grant Program
The Edward Byrne Memorial State and Local Law Enforcement Assistance Grant Program
(Byrne Formula Grant Program) is a partnership among federal, state and local governments to create safer communities. The Bureau of Justice Assistance (BJA) is authorized to
award grants to states for use by states and units of local government to improve the functioning of the criminal justice system—with emphasis on violent crime and serious offenders—and enforce state and local laws that establish offenses similar to those in the federal
Controlled Substances Act (21 U.S.C. 802(6) et seq.).48
Grants may be used to provide personnel, equipment, training, technical assistance and
information systems for more widespread apprehension, prosecution, adjudication, detention and rehabilitation of offenders who violate such state and local laws. Grants also may
be used to provide assistance (other than compensation) to victims of these offenders. Twentynine legislatively authorized purpose areas were established to define the nature and scope
of programs and projects that may be funded under the Byrne Formula Grant Program. 49
Chemical dependency assessments, treatment and prevention are allowable uses of the
money.
Drug Court Discretionary Grant Program
The Drug Court Discretionary Grant Program (DCDG) provides financial and technical
assistance to states, state courts, local courts, units of local government and American Indian tribal governments to develop and implement treatment drug courts that effectively
integrate substance abuse treatment, mandatory drug testing, sanctions and incentives,
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What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders?
and transitional services in a judicially supervised court setting with jurisdiction over nonviolent, substance-abusing offenders. Programs funded by DCDG are required by law to
target nonviolent offenders and must implement a drug court based on 10 key components. This program supports the following drug court activity:50
•
•
•
•
•
Adult drug court implementation,
Juvenile drug court implementation,
Family drug court implementation,
Single jurisdiction drug court enhancement, and
Statewide drug court enhancement.
Training and Technical Assistance. The National Drug Court Training and Technical Assistance Program (NDCTTAP) supports DCDG by increasing the knowledge and skills of drug
court practitioners to plan, implement and sustain effective drug court programs. It also
builds capacity at the state and local levels to provide comprehensive practitioner-based training and technical assistance. Following are the three components of NDCTTAP. 51
•
The goal of the Drug Court Planning Initiative (DCPI) is to provide communities
with the knowledge, skills and tools necessary to implement a drug court. Particular
emphasis is placed on learning new roles, cross training, and developing both a team
and a coordinated strategy across justice and treatment systems.
•
The goal of the Drug Court Training Initiative (DCTI) is to provide state-of-the-art
training on a variety of subjects to operational adult, juvenile or tribal drug courts and
state agencies.
•
The goal of the Drug Court Technical Assistance Initiative (DCTAI) is to provide
technical assistance on a variety of subjects to operational adult, juvenile or tribal drug
courts and state agencies.
Reentry: Serious and Violent Offender Reentry Initiative
The Serious and Violent Offender Reentry Initiative is supported by the Department of
Justice’s Office of Justice Programs (OJP) and its federal partners, the U.S. departments of
Education, Health and Human Services, Housing and Urban Development, and Labor.
This initiative is a comprehensive effort that addresses both juvenile and adult populations
of serious, high-risk offenders. It provides funding to develop, implement, enhance and
evaluate reentry strategies that will ensure the safety of the community and the reduction
of serious, violent crime. This is accomplished by preparing targeted offenders to successfully return to their communities after having served a significant period of secure confinement in a state training school, juvenile or adult correctional facility, or other secure institution. 52
The Reentry Initiative envisions the development of model reentry programs that begin in
correctional institutions and continue throughout an offender’s transition to and stabilization in the community. These programs will provide for individual reentry plans that address issues confronting offenders as they return to the community. The initiative will
encompass three phases and be implemented through appropriate programs:53
Phase 1—Protect and Prepare: Institution-Based Programs. These programs are designed to prepare offenders to reenter society. Services provided in this phase will in-
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Treatment of Alcohol and Other Substance Use Disorders
clude education, mental health and alcohol and other substance use treatment, job
training, mentoring, and full diagnostic and risk assessment.
Phase 2—Control and Restore: Community-Based Transition Programs. These programs will work with offenders prior to and immediately following their release from
correctional institutions. Services provided in this phase will include, as appropriate,
education, monitoring, mentoring, life-skills training, assessment, job-skills development, and mental health and alcohol and other substance use treatment.
Phase 3—Sustain and Support: Community-Based Long-Term Support Programs.
These programs will connect individuals who have left the supervision of the justice
system with a network of social services agencies and community-based organizations
to provide ongoing services and mentoring relationships.
Department of Veterans Affairs (VA)
Veterans Health Administration (VHA)
People who receive treatment from the Veterans Health Administration (VHA) are not
captured in the single state agency’s data because they are considered to receive treatment
directly from the federal government. It is important for states to determine how many
veterans they are treating who are eligible for VHA so they can shift them to VHA and have
more money to treat other people.
Housing and Urban Development (HUD)
The Public Housing Drug Elimination Grants Program
This program, run through the Department of Housing and Urban Development and
created through the 1988 Anti-Drug Abuse Act, provides grants to public and Indian
housing authorities to eliminate drug-related crime in public housing projects. The funds
may be used for a variety of actions, including enhancing security; making physical improvements to improve security; or developing and implementing prevention, intervention
and treatment programs to help curtail the use of drugs in public and Indian housing
projects. 54
Department of Defense (DOD)
TRICARE
TRICARE is a medical program that provides coverage for active duty military personnel
and their dependents, non-Medicare eligible retirees and their family members, and survivors of all uniformed services. The program offers eligible enrollees a choice between managed health care programs. TRICARE Standard is the new name for the traditional standard CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), which
is perhaps the largest federal program outside the block grants and entitlement programs.55
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Appendices
APPENDIX A. LEGISLATORS’ CHECKLIST
What strategies are available for the treatment of alcohol and other substance use disorders IN MY
STATE?
Does MY STATE:
YES NO
Have a comprehensive continuum of treatment?
Have the infrastructure for identification?
Use the screening, brief intervention, and referral model for identification?
Have the Uniform Accident and Sickness Policy Provision Law?
Have the infrastructure to conduct assessment?
Use the American Society of Addiction Medicine (ASAM) patient placement
criteria?
Have the infrastructure to provide comprehensive treatment?
Use medications in treatment?
Use coerced treatment in the criminal justice system?
Have a spectrum of treatment intensities and modalities?
Have inpatient and outpatient detoxification?
Have inpatient/residential treatment facilities?
Have therapeutic communities?
Have outpatient treatment facilities?
Have intensive outpatient treatment facilities?
Have the infrastructure for ongoing recovery management?
Have the infrastructure for relapse prevention?
Have a spectrum of self-help groups?
Have special living arrangements for people in recovery?
Have sober living environments?
Have targeted treatment for specific populations?
Have treatment programs for adolescents?
Have treatment programs for women?
Have treatment programs for older adults?
Provide culturally competent treatment?
Meet the needs of Native Americans in treatment?
Meet the needs of Asian and Pacific Islander Americans in treatment?
Meet the needs of Hispanic/Latino populations in treatment?
Meet the needs of African Americans in treatment?
Meet the needs of rural populations in treatment?
Have a spectrum of treatment in the criminal justice system?
Address the treatment of co-occurring mental illness and alcohol and other
substance use disorders?
Use the quadrant system model for co-occurring disorders?
Have barriers to recovery, such as sanctions for various crimes?
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Appendix A. Legislators’ Checklist (continued)
YES NO
Have standards for the licensing of providers?
Have standards for regulating treatment?
Have standards to protect the confidentiality of people in treatment?
Have the infrastructure to make the transition from the SAPT Block Grant to
Performance Partnership Grants?
What Funding is Available for States to Provide Services to People Affected by Alcohol and Other Substance
Use Disorders IN MY STATE?
What is MY STATE’S role in financing treatment?
What is MY STATE’S appropriation of state funds for treatment?
What is MY STATE’S per capita spending for treatment?
What does MY STATE mandate in private insurance coverage for treatment?
What are MY STATE’S parity and mandated benefits laws?
What are MY STATE’S alcohol taxes?
What is the federal role in funding treatment in MY STATE?
What funding does MY STATE receive from the Substance Abuse and Mental Health Services
Agency?
What is the amount of MY STATE’S Substance Abuse Prevention and Treatment Block Grant?
What are the amounts of MY STATE’S discretionary grants?
What funding does MY STATE receive from the Centers for Medicare and Medicaid Services?
What treatment services does MY STATE cover under Medicaid?
What treatment services do MY STATE’S Medicaid Managed Care plans cover?
What treatment services does MY STATE cover under Temporary Assistance to Needy Families?
What treatment services does MY STATE cover under the State Children’s Health Insurance
Program?
What treatment services does MY STATE cover with Early Prevention, Screening, Detection, and
Treatment Funds?
What funding does MY STATE receive from the Administration for Children and Families?
What treatment services does MY STATE provide under a demonstration program with Title IVB
and Title IVE funds?
What funding does MY STATE receive from the Department of Education?
What is the amount of MY STATE’S Safe and Drug-Free Schools and Communities State Grant?
What funding does MY STATE receive from the Department of Justice?
What is the amount of MY STATE’S Residential Substance Abuse Treatment for State Prisoners
Grant?
What is the amount of MY STATE’S Drug-Free Communities Grant?
What is the amount of MY STATE’S Byrne Formula Grant?
What is the amount of MY STATE’S Drug Court Discretionary Grant?
What is the amount of MY STATE’S Reentry: Serious and Violent Offender Reentry Initiative
Grant?
What funding does MY STATE receive from Housing and Urban Development?
What is the amount of MY STATE’S Public Housing Drug Elimination Grant?
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Appendices
APPENDIX B. NATIONAL RESOURCES
American Council for Drug Education
164 West 74th Street
New York, N.Y. 10023
(800) 488-DRUG
http://www.acde.org/
The White House Office of National Drug
Control Policy, Drug Policy Information
Clearinghouse
2277 Research Boulevard
Rockville, Md. 20849
(800) 666-3332
http://www.whitehousedrugpolicy.gov/about/
clearinghouse.html
National Institute of Mental Health
NIMH Public Inquiries
6001 Executive Boulevard, Room 8184
MSC 9663
Bethesda, Md. 20892-9663
(301) 443-4513
http://www.nimh.nih.gov/
National Council on Alcoholism and Drug
Dependence Inc.
20 Exchange Place, Suite 2902
New York, N.Y. 10005
(212) 269-7797
http://www.ncadd.org/
Justice Information Center
National Criminal Justice Reference Service
P.O. Box 6000
Rockville, Md. 20849-6000
(800) 851-3420
http://www.ncjrs.org/
National Highway Traffic Safety
Administration
400 Seventh Street, S.W.
Washington, D.C. 20590
(800) 424-9393
http://www.nhtsa.dot.gov/
National Association of State Alcohol and
Drug Abuse Directors
808 17th Street N.W., Suite 410
Washington, D.C. 20006
http://www.nasadad.org/
National Institute on Alcohol Abuse and
Alcoholism
6000 Executive Boulevard, Willco Building
Bethesda, Md. 20892-7003
(301) 443-6371
http://www.niaaa.nih.gov/
National Clearinghouse for Alcohol and Drug
Information
P.O. Box 2345
Rockville, Md. 20847-2345
(800) 729-6686
http://www.health.org/
National Institute on Drug Abuse
6001 Executive Boulevard, Room 5213
Bethesda, Md. 20892
(301) 443-1124
http://www.nida.nih.gov/NIDAHome1.html
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Appendix B. National Resources (continued)
Center for Substance Abuse Treatment
Substance Abuse and Mental Health
Services Administration
Room 12-105, Parklawn Building
5600 Fishers Lane
Rockville, Md. 20857
(301) 443-4795
http://www.samhsa.gov/index.htm
American Society of Addiction Medicine
4601 North Park Avenue, Arcade Suite 101
Chevy Chase, Md. 20815
(301) 656-3920
http://www.asam.org/
Alcoholics Anonymous
A.A. World Services Inc.
P.O. Box 459
New York, N.Y. 10163
(212) 870-3400
http://www.aa.org/
The Robert Wood Johnson Foundation
College Road East and Route 1
P.O. Box 2316
Princeton, N.J. 08543
(888) 631-9989
http://www.rwjf.org/
NIAAA Alcohol Policy Information Service
http://alcoholpolicy.niaaa.nih.gov/
National Association of Drug Court
Professionals
National Drug Court Institute
4900 Seminary Road, Suite 320
Alexandria, Va. 22311
(703) 575-9400
http://www.nadcp.org
http://www.ndci.org
National Treatment Accountability for Safer
Communities (TASC)
2204 Mt. Vernon Avenue, Suite 200
Alexandria, Va. 22301
(703) 836-8272
http://www.nationaltasc.org
Narcotics Anonymous
World Service Office
P.O. Box 9999
Van Nuys, Calif. 91409
(818) 773-9999
http://www.na.org/
Parents Corps
c/o National Families in Action
http://www.nationalfamilies.org
Join Together
One Appleton Street, 4th Floor
Boston, Mass. 02116-5223
(617) 437-1500
http://www.jointogether.org/
Community Anti-Drug Coalitions of America
901 North Pitt Street, Suite 300
Alexandria, Va. 22314
(800) 54-CADCA
http://www.cadca.org/
Faces and Voices of Recovery
901 North Washington Street, Suite 601
Alexandria, Va. 22314
(703) 299-6760
http://www.facesandvoicesofrecovery.org/
Center for Substance Abuse Prevention
Substance Abuse and Mental Health
Services Administration
Room 12-105, Parklawn Building
5600 Fishers Lane
Rockville, Md. 20857
(301) 443-4795
http://www.samhsa.gov/index.htm
Center for Mental Health Services
Substance Abuse and Mental Health
Services Administration
Room 12-105, Parklawn Building
5600 Fishers Lane
Rockville, Md. 20857
(301) 443-4795
http://www.samhsa.gov/index.htm
Drug Strategies
1150 Connecticut Avenue, N.W., Suite 800
Washington, D.C. 20036
(202) 289-9070
http://www.drugstrategies.org/
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Appendices
Appendix B. National Resources (continued)
National Center on Addiction and Substance
Abuse at Columbia University
633 Third Avenue, 19th Floor
New York, N.Y. 10017-6706
(212) 841-5200
http://www.casacolumbia.org
Adult Children of Alcoholics
ASA WSO
P.O. Box 3216
Torrance, Calif. 90510
(310) 534-1815
http://www.adultchildren.org
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Appendices
APPENDIX C. “HOT TOPIC” DRUGS
Substance
Alcohol
Marijuana
Methamphetamine
Other Names
Route of
Medical Uses
Administration
Alcohol
Oral
None
Marijuana
Smoked
Glaucoma, pain
Methamphetamine
Booze, Sauce, Juice
Pot, Weed, Dope
Crank, Crystal, Glass, Ice,
Speed
Injected, oral, smoked,
sniffed
Possible Effects
ADHD, obesity, narcolepsy
Inhalants
Volatile Solvents
Adhesives
Aerosols
Solvents and gases
Cleaning agents
Food products
Gases
Model airplane glue,
Rubber cement,
Household glue
Spray paint, hairspray, air
freshener, deodorant,
fabric protector
Nail polish remover, paint
thinner, type correction
fluid and thinner, toxic
markers, pure toluene,
cigar lighter fluid,
gasoline, carburetor
cleaner, octane booster
Dry cleaning fluid, spot
remover, degreaser
Vegetable cooking spray,
dessert topping spray
(whipped cream, whippets
Nitrous oxide, butane,
propane, helium
Sniffed
None
Sniffed
None
Sniffed
None
Sniffed
None
Sniffed
None
Sniffed
None
Nitrous oxide, ether,
chloroform
Sniffed
Anesthetics
Anesthetic
None
Nitrites (Nitrite room deodorizers)
Amyl
Butyl
“Poppers,” “Snappers”
“Rush,” “Locker room,”
“Bolt,” “Climax,” also
marketed in head shops as
“Video head cleaner”
Sniffed
Sniffed
Amphetamine
variants
Adam, Ecstasy, STP, XTC
Oral
None
None
Ecstacy
None
Prescription Narcotics/Opiates/Barbituates
Codeine
Methadone
Morphine
Opium
Tylenol w/codeine,
Robitussin A-C
Amidone, Dolophine,
Methadose
Roxanol, Duramorph
Laudanum, Paregoric,
Dover’s Powder
Injected, oral
Injected, oral
Oral, smoked
Oral, smoked
Analgesic, antitussive (relieves or
prevents cough)
Analgesic, treatment for opiate
dependence
Analgesic
Analgesic,
Antidiarrheal
Opiods and morphine
derivatives are used
medicinally to relieve
pain. Users experience
relaxation with an
immediate rush or
euphoria.
Illegal Narcotics/Opiates
Heroin
Horse, Smack
Injected, smoked, sniffed
None
Sources: National Institute on Drug Abuse, Drug Abuse and Addiction: The Sixth Triennial Report; The National Clearinghouse for Alcohol and
Drug Information, Web page: www.health.org, September 1999; “Products Abused as Inhalants,” http://www.inhalants.org/.
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Appendices
APPENDIX D. PET SCANS OF LONG-TERM
BRAIN CHANGES IN ABSTINENCE AND BRAINS
ON DRUGS
The following text and pictures are taken from the National Institute on Drug Abuse
(NIDA) Slide Teaching Packet, “Understanding Drug Abuse and Addiction: What Science
Says,” slides 9-11.1
Measuring Brain Activity in Response to Drug Use
Position Emission Tomography (PET) measures emissions from radioactively-labeled chemicals that have been injected into the bloodstream and uses the data to produce images of the distribution of
the chemicals in the body.2
In alcohol and other substance use disorders research, PET is being
used for a variety of reasons including: to identify the brain sites
where drugs and naturally occurring neurotransmitters act; to show
how quickly drugs reach and activate receptors; to determine how
long drugs occupy these receptors; and to find out how long they
take to leave the brain. PET is also being used to show brain changes
following chronic drug use, during withdrawal from drug use, and
during the experience of drug craving. In addition, PET can be used to assess the effects of
pharmacological and behavioral therapies for drug addiction on the brain.3
Positron Emission Tomography (PET) Scan of a Person Using
Cocaine
Cocaine has other actions in the brain in addition to activating the
brain’s reward circuitry. Using brain imaging technologies, such as
PET scans, scientists can see how cocaine actually affects brain function in people. PET allows scientists to see which areas of the brain
are more or less active by measuring the amount of glucose that is
used by different brain regions. Glucose is the main energy source
for the brain. When brain regions are more active, they will use
more glucose and when they are less active they will use less. The
amount of glucose that is used by the brain can be measured with
PET scans. The left scan is taken from a normal, awake person. The
red color shows the highest level of glucose utilization (yellow repNational Conference of State Legislatures
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resents less utilization and blue indicated the least). The right scan is taken from someone
who is on cocaine. The loss of red areas in the right scan compared to the left (normal)
scan indicates that the brain is using less glucose and therefore is less active. This reduction in activity results in disruption of many brain functions. 4
MDMA (Ecstasy) and Brain Changes
This slide shows brain PET scans of an individual who has never
used MDMA (seen at the top of slide marked “control”) and those
of an individual who used MDMA for an extended period of time
up until 3 weeks prior to the images being taken. Specifically, the
PET scans show the brain’s ability to transport a neurotransmitter
called “serotonin” from the synapse back into the releasing neuron.
Serotonin is fundamental to the brain’s integration of information
and emotion.5
Brighter colors in the PET scans indicate that more serotonin is
being transported than do duller colors. As seen in the slide, the
brain of the MDMA user shows duller colors compared to the control, indicating a decrease in the MDMA abuser’s ability to remove serotonin from the
synapse. Such findings are leading researchers to conclude that MDMA may increase the
risk of long-term, perhaps permanent, problems with learning and memory.6
The following text and picture are taken from the National Institute on Drug Abuse (NIDA)
Slide Teaching Packet, “Bringing the Power of Science to Bear on Drug Abuse and Addiction,” slide 6.7
A positron emission tomography (PET) scanner.
One of the tools that scientists use to see the effects of drugs on the
brain is called positron emission tomography or a PET scan. Similar to an x-ray, but much more sophisticated, a PET scan is used to
examine many different organs including the heart, liver, lungs,
and bones, as well as the brain. A PET scan shows much more
than the physical structure of bone and tissue. A PET scan shows
how well (or how little) an organ is functioning. 8
Using a PET scan, a doctor or a scientist can see what is actually
happening in a person’s brain and see the effects of drugs. The
PET scan shows areas of the brain that are active and also areas that
are inactive or not functioning at all. Typically, a PET scan takes 1
to 2 hours with the person lying completely still so that the PET
images will be clear.9
Notes
1. “Understanding Drug Abuse and Addiction: What Science Says,” http://www.drugabuse.gov/pubs/teaching/Teaching3/Teaching.html, Dec. 18, 2003.
2. “Understanding Drug Abuse and Addiction: What Science Says, Slide 9: Measuring Brain Activity in Response to Drug Use,” http://www.drugabuse.gov/pubs/teachingTeaching3/
Teaching3.html, Dec. 18, 2003.
3. Ibid.
4. “Understanding Drug Abuse and Addiction: What Science Says, Slide 10: Positron Emission Tomography (PET) Scan of a Person Using Cocaine,” http://www.drugabuse.gov/
pubs/teaching/Teaching3/Teaching3.html, Dec. 18, 2003.
5. “Understanding Drug Abuse and Addiction: What Science Says, Slide 11: MDMA (Ecstasy) and Brain Changes,” http://www.drugabuse.gov/pubs/teaching/Teaching3/
Teaching3.html, Dec. 18, 2003.
6. Ibid.
7. “Bringing the Power of Science to Bear on Drug Abuse and Addiction,” http://www.drugabuse.gov/pubs/teaching/Teaching5/Teaching.html, Dec. 18, 2003.
8. “Bringing the Power of Science to Bear on Drug Abuse and Addiction, Slide 6: A positron emission tomography (PET) scanner,” http://www.drugabuse.gov/pubs/teaching/
Teaching5/Teaching3.html, Dec. 18, 2003.
9. Ibid.
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Appendices
APPENDIX E. STATE AND JURISDICTIONAL
RESOURCES
This directory is taken from the Treatment Improvement Exchange, a resource sponsored by the Division of
State and Community Assistance of the Center for Substance Abuse Treatment (CSAT) to provide information exchange between CSAT staff and state and local single state agencies. This list is subject to change. It
is current as of Nov. 9, 2003.
Alabama
J. Kent Hunt, Associate Commissioner for
Substance Abuse
Alabama Department of Mental Health and
Mental Retardation
RSA Union Building
100 North Union Street
Montgomery, Ala. 36130-1410
Phone: (334) 242-3953
Fax: (334) 242-0759
Alaska
Karen Pearson, Director
Division of Alcoholism and Drug Abuse
Alaska Department of Health and Social
Services
P.O. Box 110607
Juneau, Alaska 99811-0607
Phone: (907) 465-5808
Fax: (907) 465-2185
http://www.hss.state.ak.us/dada/
Arizona
Christy Dye, Program Manager
Bureau of Substance Abuse Treatment and
Prevention
Division of Behavioral Health Services
Arizona Department of Health Services
150 North 18th Avenue, Suite 220
Phoenix, Ariz. 85007
Phone: (602) 364-4558
Fax: (602) 364-4763
http://www.hs.state.az.us/bhs/
Arkansas
Joe M. Hill, Director
Alcohol and Drug Abuse Prevention
Division of Behavioral Health Services
Arkansas Department of Human Services
4313 West Markham, Third Floor
Administration
Little Rock, Ark. 72205
Phone: (501) 686-9871
Fax: (501) 686-9035
http://www.healthyarkansas.com
California
Kathryn Jett, Director
Department of Alcohol and Drug Programs
1700 K Street, Fifth Floor
Executive Office
Sacramento, Calif. 95814-4037
Phone: (916) 445-1943
Fax: (916) 323-5873
http://www.adp.cahwnet.gov/
Colorado
Janet Wood, Director
Alcohol and Drug Abuse Division
Colorado Department of Human Services
4055 South Lowell Boulevard, Building K-8
Denver, Colo. 80236-3120
Phone: (303) 866-7480
Fax: (303) 866-7481
http://www.cdhs.state.co.us/ohr/adad/index.html
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Appendix E. State and Jurisdictional Resources (continued)
Connecticut
Thomas Kirk, Commissioner
Department of Mental Health and Addiction
Services
P.O. Box 341431
Hartford, Conn. 06134
Phone: (860) 418-6969
Fax: (860) 418-6691
http://www.dmhas.state.ct.us/
Hawaii
Elaine Wilson, Chief
Alcohol and Drug Abuse Division
Hawaii Department of Health
Kakuhihewa Building
601 Kamokila Boulevard, Room 360
Kabolei, Hawaii 96707
Phone: (808) 692-7507
Fax: (808) 692-7521
Delaware
Renata Henry, Director
Division of Alcoholism, Drug Abuse and
Mental Health
Delaware Health and Social Services
DHH Campus, Room 192
1901 North DuPont Highway, Administration
Building
Newcastle, Del. 19720
Phone: (302) 255-9426
Fax: (302) 255-4428
http://www.state.de.us/
Idaho
Pharis Stanger, Substance Abuse Project
Manager
Bureau of Mental Health and Substance
Abuse
Division of Family and Community Services
Idaho Department of Health and Welfare
450 West State Street, Fifth Floor
Boise, Idaho 83720-0036
Phone: (208) 334-4944
Fax: (208) 332-7305
http://www2.state.id.us/dhw/mentalhealth/
index.htm
Florida
Ken DeCherchio, Director
Substance Abuse Program Office
Department of Children and Families
Building 6, Third Floor
1317 Winewood Boulevard
Tallahassee, Fla. 32399-0700
Phone: (850) 921-2495
Fax: (850) 487-2627
http://www.state.fl.us/cf_web/topics/substance/
Georgia
Bruce Hoopes, Chief
Substance Abuse Program
Division of Mental Health, Developmental
Disabilities and Addictive Disease
Georgia Department of Human Resources
2 Peachtree Street, N.W., Fourth Floor
Atlanta, Ga. 30303-3171
Phone: (404) 657-2135
Fax: (404) 657-2160
http://www2.state.ga.us/Departments/DHR/
mhmrsa.html
Illinois
Theodora Binion-Taylor, Associate Director
Office of Alcoholism and Substance Abuse
Illinois Department of Human Services
James R. Thompson Center
100 West Randolph, Suite 5-600
Chicago, Ill. 60601
Phone: (312) 814-2300
Fax: (312) 814-2419
http://www.state.il.us/agency/dhs/
Indiana
John Viernes, Director
Division of Mental Health
Indiana Family and Social Services
Administration
Indiana Government Building, Room W353
402 West Washington Street
Indianapolis, Ind. 46204
Phone: (317) 232-7844
Fax: (317) 233-3472
http://www.ai.org/fssa/HTML/PROGRAMS/
2c.html
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Appendices
Appendix E. State and Jurisdictional Resources (continued)
Iowa
Janet Zwick, Director
Division of Health Promotion, Prevention
and Addictive Behaviors
Iowa Department of Public Health
Lucas State Office Building, Fourth Floor
321 East 12th Street
Des Moines, Ia. 50319-0075
Phone: (515) 281-4417
Fax: (515) 281-4535
http://idph.state.ia.us/sa.htm
Kansas
Donna Doolin, Acting Director
Division of Health Care Policy, Addiction and
Prevention Services
Kansas Department of Social and
Rehabilitation Services
Docking State Office Building, Tenth Floor,
North
915 S.W. Harrison Street
Topeka, Kan. 66612
Phone: (785) 296-7272
Fax: (785) 296-5507
http://www.srskansas.org
Kentucky
Michael Townsend, Director
Division of Substance Abuse
Kentucky Department of Mental Health and
Mental Retardation Services
100 Fair Oaks Lane
Frankfort, Ky. 40621-0001
Phone: (502) 564-2880
Fax: (502) 564-7152
http://dmhmrs.chr.state.ky.us/
Louisiana
Michael Duffy, Assistant Secretary
Office for Addictive Disorders
Louisiana Department of Health and
Hospitals
P.O. Box 2790, BIN #18
Baton Rouge, La. 70821-2790
Phone: (225) 342-6717
Fax: (225) 342-3875
http://www.dhh.state.la.us/OADA/Index.htm
Maine
Kimberly Johnson, Director
Maine Office of Substance Abuse
Augusta Mental Health Complex
Marquardt Building, Third Floor
159 State House Station
Augusta, Maine 04333-0519
Phone: (207) 287-6330
Fax: (207) 287-4334
http://www.state.me.us/dmhmrsa/osa/
Maryland
Peter Luongo, Director
Alcohol and Drug Abuse Administration
Maryland Department of Health and Mental
Hygiene
55 Wade Avenue
Catonsville, Md. 21228
Phone: (410) 402-8600
Fax: (410) 402-8601
maryland-adaa.org/
Massachusetts
Michael Botticelli, Associate Commissioner
Bureau of Substance Abuse Services
Massachusetts Department of Public Health
250 Washington Street, Third Floor
Boston, Mass. 02108
Phone: (617) 624-5111
Fax: (617) 624-5185
http://www.state.ma.us/dph/bsas/bsas.htm
Michigan
Yvonne Blackmond, Director
Bureau of Mental Health and Substance
Abuse
Michigan Department of Community Health
Lewis Cass Building
320 South Walnut Street, Sixth Floor
Lansing, Mich. 48909
Phone: (517) 373-4726
Fax: (517) 373-4288
http://www.mdch.state.mi.us/mdch2/mhsub.htm
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Appendix E. State and Jurisdictional Resources (continued)
Minnesota
Donald R. Eubanks, Director
Chemical Health Division
Minnesota Department of Human Services
444 Lafayette Road North
St. Paul, Minn. 55155-3823
Phone: (651) 582-1856
Fax: (651) 582-1865
http://www.dhs.state.mn.us/
Mississippi
Herbert L. Loving, Director
Division of Alcohol and Drug Abuse
Mississippi Department of Mental Health
1101 Robert E. Lee State Building
239 North Lamar Street
Jackson, Miss. 39201
Phone: (601) 359-6220
Fax: (601) 359-6295
http://www.dmh.state.ms.us/
Missouri
Michael Couty, Director
Division of Alcohol and Drug Abuse
Missouri Department of Mental Health
1706 East Elm Street
Jefferson City, Mo. 65102-0687
Phone: (573) 751-4942
Fax: (573) 751-7814
http://www.modmh.state.mo.us/ada/ada.html
Montana
Roland Mena, Bureau Chief
Addictive and Mental Disorders Division
Chemical Dependency Bureau
P.O. Box 202905
Helena, Mont. 59620-2905
Phone: (406) 444-3964
Fax: (406) 444-9389
http://www.dphhs.state.mt.us/divisions/
Nebraska
Ron Sorensen, Director
Division of Mental Health, Substance Abuse
and Addictions Services
Nebraska Department of Health and Human
Services Systems
Folsom Street and West Prospector Place,
Building 14, West Campus
P.O. Box 98925
Lincoln, Neb. 68509-8925
Phone: (402) 479-5583
Fax: (402) 479-5162
http://www.hhs.state.ne.us/beh/dadaas.htm
Nevada
Maria Canfield, Chief
Bureau of Alcohol and Drug Abuse, Health
Division
Department of Human Resources
505 East King Street, Room 500
Carson City, Nev. 89701-3703
Phone: (775) 684-4190
Fax: (775) 684-4185
http://www.health2k.state.nv.us/bada/
New Hampshire
Riley Regan, Director
Division of Alcohol and Drug Abuse
Prevention and Recovery
New Hampshire Department of Health and
Human Services
State Office Park South
105 Pleasant Street
Concord, N.H. 03301
Phone: (603) 271-6100
Fax: (603) 271-6116
http://www.dhhs.state.nh.us/Index.nsf?Open
New Jersey
Carolann Kane-Cavaiola, Assistant
Commissioner
Division of Addiction Services
New Jersey Department of Health and
Senior Services
120 South Stockton Street, Third Floor
P.O. Box 362
Trenton, N.J. 08625
Phone: (609) 292-5760
Fax: (609) 292-3816
http://www.state.nj.us/health/as/addsrvs.htm
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Appendix E. State and Jurisdictional Resources (continued)
New Mexico
Pamela Martin, Director
Behavioral Health Services Division
New Mexico Department of Health
Harold Runnels Building, Room 3200 North
1190 St. Francis Street
Santa Fe, N.M. 87502-6110
Phone: (505) 827-2658
Fax: (505) 827-0097
New York
William Gorman, Commissioner
New York State Office of Alcoholism and
Substance Abuse Services
1450 Western Avenue
Albany, N.Y. 12203-3526
Phone: (518) 457-2061
Fax: (518) 457-5474
http://www.oasas.state.ny.us/
North Carolina
Flo Stein, Chief
Community Policy Management
Division of Mental Health, Developmental
Disabilities and Substance Abuse Services
North Carolina Department of Health and
Human Services
3007 Mail Service Center
Raleigh, N.C. 27603-3007
Phone: (919) 733-4670
Fax: (919) 733-9455
http://www.state.nc.us/DHR/docs/divinfo/
dmh.htm
North Dakota
Don Wright, Unit Manager
Substance Abuse Services
Division of Mental Health and Substance
Abuse Services
North Dakota Department of HumanServices
Professional Building
600 South 2nd Street, Suite 1E
Bismarck, N.D. 58504-5729
Phone: (701) 328-8922
Fax: (701) 328-8969
http://207.108.104.74/dhs/dhsweb.nsf/
ServicePages/MentalHealthandSubstanceAbuse
Services
Ohio
Gary Q. Tester, Director
Ohio Department of Alcohol and Drug
Addiction Services
Two Nationwide Plaza, 12th Floor
280 North High Street
Columbus, Ohio 43215-2537
Phone: (614) 466-3445
Fax: (614) 752-8645
http://www.state.oh.us/ada/main.html
Oklahoma
Ben Brown, Deputy Commissioner
Substance Abuse Services
Oklahoma Department of Mental Health and
Substance Abuse Services
P.O. Box 53277
Oklahoma City, Okla. 73152-3277
Phone: (405) 522-3877
Fax: (405) 522-0637
http://www.state.ok.us/~dmhsas/
Oregon
Bob Nikkel, Administrator
Office of Mental Health and Addiction
Services
Department of Human Services
Health Services Building
2575 Bittern Street, N.E.
P.O. Box 14250
Salem, Ore. 97309-0740
Phone: (503) 945-9700
Fax: (503) 373-7327
http://www.oadap.hr.state.or.us
Pennsylvania
Gene Boyle, Director
Bureau of Drug and Alcohol Programs
Pennsylvania Department of Health
02 Klein Plaza, Suite B
Harrisburg, Pa. 17014
Phone: (717) 783-8200
Fax: (717) 787-6285
http://www.health.state.pa.us/php/SCA/
default.htm
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Appendix E. State and Jurisdictional Resources (continued)
Rhode Island
Craig Stenning, Executive Director
Behavioral Health Care Services
Department of Mental Health, Retardation
and Hospitals
14 Harrington Road-Barry Hall
Cranston, R.I. 02920
Phone: (401) 462-2339
Fax: (401) 462-3204
http://www.mhrh.state.ri.us/
South Carolina
W. Lee Catoe, Director
South Carolina Department of Alcohol and
Other Drug Abuse Services
101 Business Park Boulevard
Columbia, S.C. 29203-9498
Phone: (803) 896-5551
Fax: (803) 896-5557
http://www.daodas.state.sc.us
http://www.scprevents.org
South Dakota
Gilbert Sudbeck, Director
Division of Alcohol and Drug Abuse
South Dakota Department of Human
Services
East Highway 34, Hillsview Plaza
c/o 500 East Capitol
Pierre, S.D. 57501-5070
Phone: (605) 773-3123/5990
Fax: (605) 773-5483
http://www.state.sd.us/dhs/ada
Tennessee
Stephanie W. Perry, Assistant
Commissioner
Bureau of Alcohol and Drug Abuse Services
Tennessee Department of Health
Cordell Hull Building, Third Floor
425 Fifth Avenue, North
Nashville, Tenn. 37247-4401
Phone: (615) 741-1921
Fax: (615) 532-2419
http://www.state.tn.us/health/badas/
Texas
Dave Wanser, Executive Director
Texas Commission on Alcohol and Drug
Abuse
P.O. Box 80529
Austin, Texas 78708-0529
Phone: (512) 349-6602
Fax: (512) 837-4123
http://www.tcada.state.tx.us
Utah
Randall Bachman, Director
Division of Substance Abuse and Mental
Health
Utah Department of Human Services
120 North 200 West, Room 201
Salt Lake City, Utah 84103
Phone: (801) 538-3939
Fax: (801) 538-4696
http://www.hsdsa.state.ut.us/
Vermont
Linda Piasecki and Peter Lee, Interim
Directors
Office of Alcohol and Drug Abuse Programs
Vermont Department of Health
108 Cherry Street
Burlington, Vt. 05402
Phone: (802) 651-1550
Fax: (802) 651-1573
http://www.state.vt.us/adap
Virginia
Robert Johnson, Director
Substance Abuse Specialty Services
Virginia Department of Mental Health,
Mental Retardation and Substance Abuse
Services
1220 Bank Street, Eighth Floor
Richmond, Va. 23218
Phone: (804) 786-3906
Fax: (804) 786-4320
http://www.dmhmrsas.state.va.us/
National Conference of State Legislatures
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Appendices
Appendix E. State and Jurisdictional Resources (continued)
Washington
Kenneth D. Stark, Director
Division of Alcohol and Substance Abuse
Washington Department of Social and
Health Services
P.O. Box 45330
Olympia, Wash. 98504-5330
Phone: (360) 438-8200
Fax: (360) 438-8078
http://www.wa.gov/dshs/hrsa/hrsa3ov.html#
DASA
West Virginia
Steve Mason, Director
Division of Alcohol and Drug Abuse
Office of Behavioral Health Services
West Virginia Department of Health and
Human Services
Building 6, Room 738
1900 Kanawha Boulevard, Capitol Complex
Charleston, W.V. 25305
Phone: (304) 558-2276
Fax: (304) 558-1008
http://www.wvdhhr.org/bhhf/
Wisconsin
Keith Lang, Director
Bureau of Substance Abuse Services
Division of Supportive Living
Department of Health and Family Services
P.O. Box 7851
Madison, Wis. 53707-7851
Phone: (608) 266-2717
Fax: (608) 266-1533
http://www.dhfs.state.wi.us/SubstAbuse/
index.htm
Wyoming
Diane Galloway, Administrator
Substance Abuse Division
Department of Health
2424 Pioneer Avenue, Suite 306
Cheyenne, Wyo. 82002
Phone: (307) 777-6494
Fax: (307) 777-7006
http://wbdh.state.wy.us/services/psa/index.htm
http://www.wyowins.net
American Samoa
Uiagalelei Lealofi, Director
Department of Human and Social Services
P.O. Box 997534
997534 Utulei Street
Pago Pago, A.S. 96799
Phone: (011-684) 633-2696
Fax: (011-684) 699-7449
District of Columbia
William Steward, Acting Administrator
Senior Deputy Director for Substance Abuse
Services
Department of Operations
Addiction Prevention and Recovery
Administration
825 North Capitol Street, N.E., Suite 3125
Washington, D.C. 20002
Phone: (202) 442-9155
Fax: (202) 442-9427
Guam
Peter Roberto, Director
Department of Mental Health and Substance
Abuse
Government of Guam
790 Governor Carlos G. Camacho Road
Tamuning, Guam 96911
Phone: (011-671) 647-5445
Fax: (011-671) 649-6948
Marshall Islands
Saeko Shoniber
Ministry of Finance
Office of the SSA Director
P.O. Box D
Majuro, MH 96960
Phone: (011-692) 625-8311/8320
Fax: (011-692) 625-3607
Micronesia
Eliuel K. Pretrick, Secretary
Department of Health, Education and Social
Affairs
Federated States of Micronesia
P.O. Box PS 70
Palikir, Pohnpei FM 96941
Phone: (691) 320-2619
Fax: (691) 320-5263
National Conference of State Legislatures
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Treatment of Alcohol and Other Substance Use Disorders
Appendix E. State and Jurisdictional Resources (continued)
Northern Mariana Islands
James Hofschneider, Secretary of Health
Department of Public Health
Commonwealth of the Northern Mariana Islands
P.O. Box 409 CK
Saipan, MP 96950
Phone: (011-670) 234-8950 ext. 2001
Fax: (011-670) 234-8930
Palau
Sandra S. Pierantozzi, Minister of Health
Ministry of Human Services
Palau National Hospital
P.O. Box 6027
Koro, Republic of Palau 96940-0504
Phone: (011-680) 488-2813
Fax: (011-680) 488-1211
Red Lake
Judy Roy, Acting Chairman
Tribal Council
RedLake Band of the Chippewa Indian Tribe
P.O. Box 574
RedLake, MN 56671
Phone: (218) 679-3341
Fax: (218) 679-3378
Virgin Islands
Jaslene Williams, Acting Director
Division of Mental Health
Department of Health
3500 Richmond, Christiansted
St. Croix, U.S. VI 00802-4370
Phone: (340) 773-1311, ext. 3011 or 3012
Fax: (340) 773-7900
Puerto Rico
Johnny Rullan, Acting Administrator
Puerto Rico Mental Health and Anti-Addiction
Services Administration
G.P.O. Box 70184
San Juan, PR 00928-1414
Phone: (787) 274-7676
Fax: (787) 274-7604
National Conference of State Legislatures
99
Appendices
APPENDIX F. CENTER FOR SUBSTANCE
ABUSE TREATMENT (CSAT) TREATMENT
IMPROVEMENT PROTOCOLS
The Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of alcohol and other substance use disorders. CSAT’s Office of Evaluation, Scientific
Analysis, and Synthesis draws on the experience and knowledge of clinical, research and
administrative experts to produce the TIPs, which are distributed to a growing number of
facilities and individuals across the country. The audience for the TIPs is expanding beyond
public and private alcohol and other substance use treatment facilities as alcohol and other
substance use disorders are increasingly recognized as a major problem.1
The TIPs Editorial Advisory Board, a distinguished group of substance use disorders experts and professionals in such related fields as primary care, mental health, and social
services, and the state alcohol and other drug abuse directors generate topics for the TIPs
based on the field’s current needs for information and guidance.2
After selecting a topic, CSAT invites staff from pertinent federal agencies and national
organizations to a resource panel that recommends specific areas of focus as well as resources that should be considered in developing the content for the TIP. Soon after that, a
consensus panel is held: non-federal experts who are familiar with the topic and are nominated by their peers participate in panel discussions over five days. The information and
recommendations on which they reach consensus form the foundation of the TIP. The
members of each consensus panel represent substance use treatment programs, hospitals,
community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A panel chair ensures that the guidelines mirror the results
of the group’s collaboration.3
A large and diverse group of experts closely reviews the draft document. Once the changes
recommended by the field reviewers have been incorporated, the TIP is prepared for publication. Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each
TIP is to convey “front-line” information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either panelists’ clinical experience or the
literature. If there is research to suggest a particular approach, citations are provided.4
Notes
1. “Treatment Improvement Protocol Series, CSAT TIPs,” http://www.treatment.org/Externals/tips.html, Dec. 18, 2003.
2. Ibid.
3. Ibid.
4. Ibid.
National Conference of State Legislatures
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100
Treatment of Alcohol and Other Substance Use Disorders
TIP 1: State Methadone Treatment Guidelines
TIP 2: Pregnant, Substance-Using Women
TIP 3: Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents
TIP 4: Guidelines for the Treatment of Alcohol and Other Drug-Abusing Adolescents
TIP 5: Improving Treatment for Drug-Exposed Infants
TIP 6: Screening for Infectious Diseases Among Substance Abusers
TIP 7: Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal
Justice System
TIP 8: Intensive Outpatient Treatment for Alcohol and Other Drug Abuse
TIP 9: Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other
Drug
TIP 10: Assessment and Treatment of Cocaine-Abusing, Methadone-Maintained Patients
TIP 11: Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious
Diseases
TIP 12: Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal
Justice System
TIP 13: The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use
Disorders
TIP 14: Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment
TIP 15: Treatment for HIV-Infected Alcohol and Other Drug Abusers
TIP 16: Alcohol and Other Drug Screening of Hospitalized Trauma Patients
TIP 17: Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice
System
TIP 18: The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Abuse
Treatment Providers
TIP 19: Detoxification From Alcohol and Other Drugs
TIP 20: Matching Treatment to Patient Needs in Opioid Substitution Therapy
TIP 21: Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the
Justice System
TIP 22: LAAM in the Treatment of Opiate Addiction
TIP 23: Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing
TIP 24: A Guide to Substance Abuse Services for Primary Care Physicians
TIP 25: Substance Abuse Treatment and Domestic Violence
TIP 26: Substance Abuse Among Older Adults
TIP 27: Comprehensive Case Management for Substance Abuse Treatment
TIP 28: Naltrexone and Alcoholism Treatment
TIP 29: Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities
TIP 30: Continuity of Offender Treatment for Substance Use Disorders From Institution to Community
TIP 31: Screening and Assessing Adolescents For Substance Use Disorders
TIP 32: Treatment of Adolescents With Substance Use Disorders
TIP 33: Treatment for Stimulant Use Disorders
TIP 34: Brief Interventions And Brief Therapies for Substance Abuse Treatment
TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment
TIP 36: Substance Abuse Treatment Responding to Child Abuse and Neglect Issues
TIP 37: Substance Abuse Treatment for Persons With HIV/AIDS
TIP 38: Integrating Substance Abuse Treatment and Vocational Services
National Conference of State Legislatures
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Appendices
APPENDIX G. QUADRANT SYSTEM
A conceptual framework for treatment that is flexible, cost-effective, client-centered and evidence-driven was developed by the NASMHPD-NASADAD Task Force on Co-occurring
Mental Health and Substance Use Disorders. Use of the framework helps key stakeholders
speak the same language about symptom severity, locus of care, and the level of service coordination needed to address co-occurring disorders. The vast majority of the research literature
and the bulk of the money invested tend to focus on people with serious mental illnesses who
also have alcohol and other substance use disorders. This framework, which takes a much
broader approach, is designed to ensure enough flexibility to address the needs of all individuals with co-occurring disorders; to fit into any service setting; and to allow policymakers,
providers and funders to plan and fund services for individuals regardless of the current structure of a state’s or community’s health care delivery system.1
Finally, the framework points to the need for special attention to three groups of individuals:
1) individuals, especially children and adolescents, who are at risk of developing serious disease; 2) individuals engaged in one of the two treatment systems where the other, less severe,
aspect of the co-occurring disorder remains a lower priority for treatment; and 3) individuals
with more severe mental and alcohol and other substance use disorders, who are found in
inappropriate settings—including jails, emergency rooms, or living on
the streets—who use the most resources and have the worst outcomes.2
Figure 5. Co-occurring Disorders by Severity
Levels of Illness Severity
The underlying assumption of the model is that the severity of an
individual’s mental illness and/or alcohol and other substance use disorder may vary from high severity to low severity at any given time. The
model uses four major categories of illness severity (see figure 5):
•
Category I. Less severe mental disorder/less severe substance disorder.
•
Category II. More severe mental disorder/less severe substance
disorder.
•
Category III. Less severe mental disorder/more severe substance
disorder.
•
Category IV. More severe mental disorder/more severe substance
disorder.3
National Conference of State Legislatures
Source: NASMHPD and NASADAD, National Dialogue on Co-Occurring Mental Health
and Substance Abuse Disorders (Alexandria, Va. and Washington, D.C.: NASMHPD and
NASADAD, March 1999).
101
102
Treatment of Alcohol and Other Substance Use Disorders
Because of the opportunity for prevention, Category I, which includes many children and
adolescents, is arguably one of the most important categories of individuals upon which
states should focus their treatment resources and funding. It is believed that early intervention can prevent the development of more serious disorders that if left inadequately
treated, will result in much greater financial and human costs to society. At the other end
of the scale, Category IV represents the group of individuals who currently use a disproportionate share of service funding because their illnesses are the most severe and because they
are found in the most expensive treatment and institutional settings, including inpatient
hospital settings, emergency rooms and jails. This group also represents a priority population upon which states should arguably focus treatment resources and funding because
they exact the greatest human and financial tolls on society.4
Levels of Service Coordination by Illness Severity
Based on the severity of their disorders and the location of their care, the following levels of
coordination among the substance abuse, mental health and primary health care systems
are recommended to address the needs of individuals with co-occurring mental health and
substance abuse disorders (see figure 6):
Figure 6. Service Coordination by Severity
• Level I. Consultation. Those informal relationships among providers
that ensure both mental illness and alcohol and other substance
use disorders are addressed, especially with regard to identification, engagement, prevention and early intervention. An example
of such consultation might include a telephone request for information or advice regarding the etiology and clinical course of
depression in a person using alcohol or other drugs. 5
• Levels II/III. Collaboration. Those more formal relationships among
providers that ensure both mental illness and alcohol and other
substance use disorders are included in the treatment regimen.
An example of such collaboration might include interagency
staffing conferences where representatives of both substance abuse
and mental health agencies specifically contribute to the design
of a treatment program for individuals with co-occurring disorders and contribute to service delivery. 6
•
Source: NASMHPD and NASADAD, National Dialogue on Co-Occurring Mental Health
and Substance Abuse Disorders (Alexandria, Va. and Washington, D.C.: NASMHPD and
NASADAD, March 1999).
Level IV. Integrated Services. Those relationships among mental health and alcohol and other substance use providers in which
the contributions of professionals in both fields are merged into
a single treatment setting and treatment regimen.7
Locus of Care by Illness Severity
Based on the severity of their disorders, people with co-occurring mental health and alcohol and other substance use disorders currently tend to receive their care in the following
settings (see figure 7):
•
Setting I. Primary health care settings, school-based clinics, community programs; no
care.
National Conference of State Legislatures
103
Appendices
•
Setting II. Mental health system.
•
Setting III. Substance abuse system.
•
Setting IV. State hospitals, jails, prisons, forensic units, emergency rooms, homeless service programs, mental health and/or
substance abuse system; no care.8
Figure 7. Primary Locus of Care by Severity
As with categories of illness, the use of such clearly delineated settings is for ease of discussion. In reality, there is a great deal of overlap between and among these settings; individuals with different
combinations of severity are served in all of the systems highlighted
above. In addition, individuals may move back and forth throughout the system of care based on their level of recovery at any given
time. 9
Financing of Services by Illness Severity
Source: NASMHPD and NASADAD, National Dialogue on Co-Occurring Mental
Health and Substance Abuse Disorders (Alexandria, Va. and Washington, D.C.:
Creating coordinated funding streams at the state, federal and local
NASMHPD and NASADAD, March 1999).
program levels for a comprehensive system of care is also a challenge.
Numerous barriers to funding the treatment of co-occurring disorders exist. One such
barrier is the absence of shared systems for co-occurring disorders that would be driven by
shared funding. There is also institutional resistance to merging funding streams. Furthermore, statutes and regulations frequently create barriers to the development of creative and
effective treatment models by limiting program flexibility (e.g., in most states, a co-occurring treatment program must choose to be licensed either as a substance abuse treatment
provider or a mental health treatment provider, but not as both). Coordination of funding
streams at the local or county level is essential to providing the most effective treatment,
but often is lacking. In light of current budgetary restraints, obtaining significant levels of
new funding dedicated to the treatment of co-occurring disorders is unlikely. States and
communities may need to consider a mixed model that combines different streams of existing funds and also leverages some new resources.10
Block Grant Funds
State and local mental health and substance abuse agencies currently depend on similar
sources of revenue, including CMHS and SAPT block grant funds, Medicaid, state general
revenue and local taxes, among others; the proportion of funds available for both systems
varies widely, however. For example, many state substance abuse agencies depend almost
completely on SAPT funds, while CMHS Block Grant funds make up a very small percentage of most state mental health budgets. Medicaid generally is used more often to fund
mental health services. In addition, the total state budget for mental health services is
usually much larger than for substance abuse services. In Massachusetts, for example, Medicaid funding makes available $1 for substance abuse treatment for every $9 allocated for
mental health services.11
The specific form that a state’s participation in Medicaid managed care takes, as well as any
consent decrees or lawsuits that determine which populations can be served, also will affect
the type and amount of funding available to serve people with co-occurring disorders. All
National Conference of State Legislatures
104
Treatment of Alcohol and Other Substance Use Disorders
state substance abuse agencies devote significant resources to the areas of prevention and
early intervention.12
To insist that new resources must be available to serve people with co-occurring disorders is
likely to be unrealistic. States and communities may need to consider a mixed model that
combines different streams of existing funds while leveraging some new resources. Task
force members described joint projects for people with co-occurring disorders that use
SAPT Block Grant and state mental health general revenue funds, block grant funds from
both mental health and substance abuse agencies, and block grant funds and resources
from the Temporary Assistance to Needy Families (TANF) program. It was noted that
SAMHSA had recently issued a position statement acknowledging that SAPT and Mental
Health Block Grant funds can be used to provide services for individuals with co-occurring
substance abuse disorders and mental illnesses in a variety of treatment settings, including
settings where integrated services are delivered. Although each of these programs specifies a
certain set of services that can and cannot be funded, together they can be used to support
a wide range of needs.13
Notes
1. NASMHPD and NASADAD, National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders
(Alexandria, Va., and Washington, D.C.: NASMHPD and NASADAD, March 1999).
2. Ibid.
3. Ibid.
4. Ibid.
5. Ibid.
6. Ibid.
7. Ibid.
8. Ibid.
9. Ibid.
10. NASMHPD and NASADAD, Financing and Marketing the New Conceptual Framework for Co-Occurring Mental
Health and Substance Abuse Disorders: A Blueprint for Systems Change (Alexandria, Va., and Washington, D.C.:
NASMHPD and NASADAD, April 2000).
11. Ibid.
12. Ibid.
13. Ibid.
National Conference of State Legislatures
1990
1994
January 2000
July 2001
Conn.
National Conference of State Legislatures
Del.
Yes (1997)
No
No
No
No
1997
Calif.
Colo.
N/A
No
Yes (1997)
Adopted
Federal
Parity? Year
No
N/A
1987
1997
Alaska
Ariz.
Ark.
1979
Effective
Date
Ala.
State
Group, HMO,
individual and
state employee
plans
Group: small
employer
exemption 50 or
less; cost increase
1.5% or more
Group
Group 2003
amendment:
Provides an option
for small
employers of 50 or
less to purchase
plans w/o mandate
Group and
individual
Group- five
employees or less
exempt; 20 or less
must offer
coverage
N/A
Group and HMO
Group and HMO
Insurance Policies
Affected by Law
Mental or nervous
condi-tions,
including
alcoholism and
drug addiction (3)
Drug and alcohol
dependencies
Alcoholism
Alcoholism
Chemical
dependency (2)
N/A
Alcoholism and
drug dependency
Alcoholism and
drug abuse
Alcoholism
Illnesses
Covered (1)
Parity
Parity
Mandated offering
Mandated offering
Mandated offering
Minimum
mandated benefits
or mandated
offering for small
group
N/A
Mandated offering
Mandated offering
Type of Benefit
Must be equal
Must be equal
Not specified
45 days
Must be equal
N/A
Not less favorable
generally
Not specified
30 days
Scope of Inpatient
Must be equal
Must be equal
Not specified
$500 annually
Must be equal
N/A
Not less favorable
generally
Not specified
One day of
inpatient converts
to three sessions of
outpatient
Scope of
Outpatient
Must be equal
Must be equal
Not specified
Not specified
Must be equal
N/A
Not less favorable
generally
One day of
inpatient converts
to two days of
partial/
residential
Not specified
Scope of Partial/
Residential
Must be equal
Must be equal
Not specified
Shall not exceed
50% of the
payment;
deductible shall
not differ
Must be equal
N/A
Not less favorable
generally
Must be equal to
other illnesses
Not specified
Copayments and
Co-insurance
Must be equal
Must be equal
Not specified
Not specified
As of 1/02, at least
$12,715 over two
consecutive benefit
years and $25,425
lifetime
N/A
$6,000 every two
years;
$12,000 lifetime
Must be equal
Not specified
Lifetime/Annual
Dollar Limits
Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder
Treatment
Appendices
105
105
Yes (1997)
Yes (1997)
January 2001
June 2003
Ind.
N/A
No
No
N/A
1995
January 2002
Idaho
Ill.
No
No
1988
1998
Ga.
Adopted
Federal
Parity? Year
Yes (1998)
Hawaii
1993
Effective
Date
Fla.
State
National Conference of State Legislatures
Groups,
individuals and
HMOs
State employees
with an exemption
for a cost increase
of 4% or more
N/A
Group
Group with a
small employer
exemption of 50
or less
Individual, group
and HMO
Group and
individual
Group and HMO
Insurance Policies
Affected by Law
Substance abuse
and chemical
dependency
Substance abuse
and chemical
dependency
N/A
Alcoholism
Mental illnesses
other than serious
mental illnesses
Mental disorders,
including
substance abuse
(4)
Alcohol and drug
dependence
Substance abuse
Illnesses
Covered (1)
Mandate for plans
that offer benefits,
when the services
are required in the
treatment of a
mental illness
Mandate for plans
that offer benefits,
when the services
are required in the
treatment of a
mental illness
N/A
Mandated benefits
Mandated offering
for mental illnesses
other than serious
mental illnesses
Mandated benefits
Mandated offering
Mandated offering
Type of Benefit
Must be equal
Must be equal
No less than two
treatment episodes
per lifetime
N/A
Not specified (12)
45 days
30 days
Not specified
Scope of Inpatient
Must be equal
Must be equal
No less than two
treatment episodes
per lifetime
N/A
Not specified
35 days
44 visit maximum;
$35 maximum
reimbursement per
visit
48 visits
Scope of
Outpatient
Must be equal
Must be equal
No less than two
treatment episodes
per lifetime
N/A
Not specified
Not specified
Not specified
Not specified
Scope of Partial/
Residential
Must be equal
Must be equal
N/A
Not specified
Insured may be
required to pay up
to 50% of the
expenses incurred
Must be
comparable
Must be equal
Not specified
Copayments and
Co-insurance
Must be equal
N/A
Not specified
Annual benefit
may be limited to
the lesser of
$10,000 or 25%
of lifetime policy
limit
Must be equal
Must be
comparable
Minimum lifetime
benefit of $2,000;
annual limits not
specified
Must be equal
Lifetime/Annual
Dollar Limits
Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder
Treatment (continued)
106
Treatment of Alcohol and Other Substance Use Disorders
National Conference of State Legislatures
La.
Ky.
Ia.
Kan.
State
1982
Yes (1997)
No
July 2000
April 2002
No
Yes (1997)
Adopted
Federal
Parity? Year
N/A
Yes (1997)
1980
The section
of law that
requires
group plans
that offer
mental
health
benefits to
comply with
the federal
Mental
Health Parity
Act sunsets
December
31, 2003
January 2002
N/A
1998
Effective
Date
Group with small
employer
exemption of 50
or less
Amends the law to
exempt group
health benefit
plans covering
fewer than 51
(previously 50),
employees
Group
Group
Group and
individual
N/A
Group, individual,
HMO and state
employee plans
Insurance Policies
Affected by Law
Alcoholism and
drug abuse
Mental illness and
alcohol and other
drug abuse (6)
Alcoholism
Alcoholism, drug
abuse, or nervous
or mental
condition
N/A
Alcoholism or
drug abuse or
mental conditions
(5)
Illnesses
Covered (1)
Mandated offering
Mandate for plans
that offer benefits
Mandated offering
Mandated benefits
N/A
Mandated benefits
Type of Benefit
Not specified
Emergency
detoxification- 3
days reimbursed at
$40 per day
Equal if offered
30 days
N/A
30 days
Scope of Inpatient
Not specified
Equal if offered
Not less than
100% of the first
$100, 80% of the
next $100 and
50% of the next
$1,640 per year
and not less than
$7,500 per
lifetime
10 visits
reimbursed at $10
per visit
N/A
Not less than
100% of the first
$100, 80% of the
next $100 and
50% of the next
$1,640 per year
and not less than
$7,500 per
lifetime
Scope of
Outpatient
Not specified
Equal if offered
10 days
reimbursed at $50
per day
Not specified
N/A
Not specified
Scope of Partial/
Residential
Not specified
Equal if offered
Not specified
Not specified
N/A
Not specified
Copayments and
Co-insurance
Not specified
Equal if offered
Not specified
Specified only for
outpatient
treatment
N/A
Specified only for
outpatient
treatment
Lifetime/Annual
Dollar Limits
Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder
Treatment (continued)
Appendices
107
Mich.
Mass.
Md.
Maine
State
No
No
January 2001
No
January 2001
1988
No
No
No
Adopted
Federal
Parity? Year
Yes
1991
1994
1984
2003
Effective
Date
Individual, group,
HMO and state
employee plans;
small employer
exemption of 50
or less that expired
1/1/2001
Group for
inpatient; group
and individual for
other levels;
exemption for cost
increase of 3% or
more
HMOs only,
group and
individual
contracts, with a
cost exemption for
substance abuse
services, if the fees
increase by 3% or
more
Individual, group
and HMO
Individual and
group
Group with a
small employer
exemption for 20
or less
Group and HMO
with a small
employer
exemption for 20
or less
Insurance Policies
Affected by Law
Mandated offering
of inpatient and
mandated benefits
for other levels
Minimum
mandated benefits
Mental health and
substance abuse
Mandated benefits
Mandated benefits
Minimum
mandated benefit
Mandated benefit
Parity
Type of Benefit
Substance abuse
All DSM
diagnoses not
covered under the
parity provision
(mental illness and
substance abuse)
Alcoholism
Mental illness,
emotional
disorder, drug
abuse or alcohol
abuse disorder
Mental illness; (7)
expands coverage
under 1996 law to
11 categories of
mental illness,
including
substance abuserelated disorders
Alcoholism and
drug dependency
Illnesses
Covered (1)
National Conference of State Legislatures
None.
To the extent
agreed upon
60 days
30 days
Must be equal
Not specified
Must be equal
Scope of Inpatient
Not fewer than 20
visits per year for
mental illness and
$2,968 for
substance abuse
$1,500 per year
for outpatient and
intermediate
treatment
24 visits
$500 per year
Unlimited visits
Not specified
Must be equal
Scope of
Outpatient
$2,968 for
substance abuse
$1,500 per year
for outpatient and
intermediate
treatment
May convert two
days of partial/
residential to one
day of inpatient
60 days
Not specified
Must be equal
Scope of Partial/
Residential
Charges, terms,
and conditions for
the services shall
not be less
favorable than the
maximum for any
other comparable
service
Charges terms and
conditions shall
not be less
favorable
May place a
maximum limit on
benefits as long as
they are consistent
with the law
Must be equal,
except outpatient
80% -visits 1-5,
65% - visits 6-30,
50% visits 31 and
above
Not specified
Must be equal
Copayments and
Co-insurance
Lifetime not
specified $2,968
annual limit for
outpatient and
intermediate care
for substance
abuse treatment
$1,500 per year
for outpatient and
intermediate
treatment
Not specified
May place a
maximum limit on
benefits as long as
they are consistent
with the law
Must be equal
Must be equal
Lifetime/Annual
Dollar Limits
Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder
Treatment (continued)
108
Treatment of Alcohol and Other Substance Use Disorders
No
No
No
1995
1997
January 2000
Mo.
No
No
Adopted
Federal
Parity? Year
No
1975
1986
1995
Effective
Date
Miss.
Minn.
State
National Conference of State Legislatures
Group and
individual
Group, individual
and HMO
Group and
individual
Group
Mental illness
including alcohol
and drug abuse
(10)
Mental (8)
disorders and
chemical
dependency (9)
Alcoholism,
chemical
dependency or
drug addiction
Alcoholism
Mental health and
chemical
dependency
Alcoholism,
chemical
dependency or
drug addiction
Group and
individual
Group and
individual
Mental health and
chemical
dependency
Illnesses
Covered (1)
HMOs
Insurance Policies
Affected by Law
Mandate for plans
that offer benefits
Mandated offering
Mandated benefit
for alcoholism;
mandated offering
for others
Mandated benefit
Mandated benefit
Mandated offering
Parity
Type of Benefit
Equal for mental
illness, at least 30
days for alcohol
and drug abuse if
offered
30 days for
alcoholism; 80%
of reasonable
charges, $2,000
maximum
90 days for mental
disorders and six
days for
detoxification
At least 20% of
the total days
allowed but not
less than 28 days
yearly
Not specified
Must be equal
Must be equal
Scope of Inpatient
Equal for mental
illness, at least 20
visits for alcohol
and drug abuse if
offered
Two visits for
mental disorders,
26 visits for
chemical
dependency
30 days for all
levels of care total,
not for each level
Not specified
At least 130 hours
of treatment per
year
Must be equal
Must be equal
Scope of
Outpatient
Not specified
Must be equal for
mental disorders,
21 days for
chemical
dependency
30 days for all
levels of care total,
not for each level
At least 20% of
the inpatient days
allowed but not
less than 28 days
yearly
Not specified
Must be equal
Must be equal
Scope of Partial/
Residential
Shall not be
unreasonable in
relation to the cost
of services
provided for
mental illness
Must be equal
Not specified
Not specified
Not specified
Must be equal
Must be equal
Copayments and
Co-insurance
Must be equal for
mental illness;
chemical
dependency may
not be limited to
less than 10
episodes of
treatment
A lifetime limit
equal to four times
the annual limit
may be imposed
for alcohol and
drug abuse
Annual limit of
$1,000 per year,
lifetime limit not
specified
Not specified
Not specified
Must be equal
Must be equal
Lifetime/Annual
Dollar Limits
Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder
Treatment (continued)
Appendices
109
Effective
Date
July 1997
law
terminated
9/30/01,
then law
below
became
effective
October 1,
2001;
replaces July
1997 law
that sunset
Sept. 30,
2001, see
supra.
1989
1997
2003
State
Mont.
Neb.
Nev.
N.H.
No
Yes (1997)
No
Yes (1997)
Adopted
Federal
Parity? Year
Yes (1997)
Group and
blanket accident
or health insurers,
HMOs (unless the
HMO elects to
provide coverage
under the federal
"HMO Act"),
state employee
plans and, with
respect to coverage
of biologically
based mental
illnesses, nonprofit
health service
corporations
Group, individual
and HMO
Group and HMO
Group
Group with a
small group
exemption
(number not
specified) or a cost
increase of 1% or
more
Insurance Policies
Affected by Law
Mandated benefits
Minimum
mandated benefits
Chemical
dependency,
including
alcoholism
Mandated offering
Mandated benefits
Mandated benefits
Type of Benefit
Abuse of alcohol
or drugs
Alcoholism
Mental illness
alcoholism and
drug addiction
Mental illness,
alcoholism and
drug addiction
Illnesses
Covered (1)
May be limited;
must include
benefits for
detoxification and
rehabilitation
21 days each, with
a $4,000
maximum every
two years and a
$8,000 maximum
lifetime for alcohol
and drug
addiction only
21 days for mental
illness only.
$6,000 maximum
every 12 months
and until $12,000
maximum lifetime
is met, then
annual benefit
may be reduced to
$2,000 for alcohol
and drug
addiction only
30 days per year
with at least two
treatment periods
in a lifetime
$9,000 inpatient
and $1,500 for
detoxification per
year
Scope of Inpatient
May be limited;
must include
benefits for
detoxification and
rehabilitation
$2,500 per year
Not specified
Not specified
Not specified
One day of
inpatient
treatment for
mental illness may
be traded for two
days of partial
No less than
$2,000 for mental
illness
60 visits during
the lifetime of the
policy
One day of
inpatient
treatment for
mental illness may
be traded for two
days of partial
Scope of Partial/
Residential
No less than
$2,000 for mental
illness and $1,000
for alcohol and
drug addiction per
year
Scope of
Outpatient
Not specified
Must be paid in
same manner
No less favorable
generally than for
physical illness
No less favorable
up to maximums
No less favorable
up to maximums
Copayments and
Co-insurance
Must be paid in
same manner to
maximum benefit;
lifetime maximum
not specified
May be limited
No less favorable
generally than for
physical illness
See specified
maximums under
inpatient and
outpatient
benefits; aggregate
limits may not be
imposed more
restrictively
Not specified
Lifetime/Annual
Dollar Limits
Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder
Treatment (continued)
110
Treatment of Alcohol and Other Substance Use Disorders
National Conference of State Legislatures
Yes (1997)
Yes (1997)
1985
1997
N.C.
No
1998
N.Y.
Yes (1998)
No
Adopted
Federal
Parity? Year
No
1987
October
2002
1985
Effective
Date
N.M.
N.J.
State
National Conference of State Legislatures
State employee
plans
Group
Group
Group
Individual
Group and
Individual
Insurance Policies
Affected by Law
Mental illness and
chemical
dependency (11)
Chemical
dependency (11)
Mental, nervous,
or emotional
disorders and
alcoholism and
substance abuse
Alcoholism
Biologically based
mental illness and
alcohol and
substance abuse
Alcoholism
Illnesses
Covered (1)
Parity
Mandated offering
Mandated offering
Mandated offering
(Does not replace
laws that mandate
greater coverage;
provides a less
expensive
alternative to these
policies, for
individual plans)
Mandated offering
Mandated benefits
for care prescribed
by a doctor
Type of Benefit
$8,000 per year
and $16,000 per
lifetime
Must be equal
$8,000 per year
and $16,000 per
lifetime
Must be equal
Not specified
Not specified
30 days for alcohol
and substance
abuse treatment
(30 days total for
inpatient and/or
outpatient
treatment)
30 days for alcohol
and substance
abuse treatment
(30 days total for
inpatient and/or
outpatient
treatment)
30 visits per year,
limited to no less
than two episodes
per lifetime
$700-mental
illness and 60
visits for
alcoholism or
substance abuse
Not specified.
30 days for
biologically based
mental illnesses
90 days for
biologically based
mental illnesses
30 days per year,
limited to no less
than two episodes
per lifetime
30 days-mental
illness, 30 daysalcoholism or
substance abuse,
seven daysdetoxification
$8,000 per year
and $16,000 per
lifetime
Must be equal
Must be equal
Scope of Partial/
Residential
Must be equal
Scope of
Outpatient
Must be equal
Scope of Inpatient
As deemed
appropriate by the
superintend-ent
and consistent
with those for
other benefits
$8000 per year
and $16,000 per
lifetime
Must be equal
Alcohol and
substance abuse:
30% coinsurance
Consistent with
those imposed on
other benefits
Benefits shall be
provided to the
same extent as
benefits for any
other sickness
Biologically based
mental illnesses:
no coinsurance,
but $500 copayment per
inpatient stay; 30
% coinsurance for
outpatient stay;
Copayments and
Co-insurance
As deemed
appropriate by the
superinten-dent
and consistent
with those for
other benefits
$8,000 per year
and $16,000 per
lifetime
Must be equal
Consistent with
those imposed on
other benefits
Benefits shall be
provided to the
same extent as
benefits for any
other sickness
Not specified
Lifetime/Annual
Dollar Limits
Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder
Treatment (continued)
Appendices
111
National Conference of State Legislatures
1989
No
No
July 2000
Pa.
N/A
No
N/A
1981
Okla.
Ore.
No
No
Adopted
Federal
Parity? Year
No
1985
August 1,
2003
1995
Effective
Date
Ohio
N.D.
State
Group and HMO
Group and HMO
N/A
Individual
Group and selfinsured
Group and HMO
Group and HMO.
Insurance Policies
Affected by Law
Alcoholism or
drug addiction
Mental or nervous
conditions,
including
alcoholism and
chemical
dependency (12)
N/A
Alcoholism
Mental or nervous
disorders and
alcoholism
Alcoholism and
drug addiction
Mental disorders,
alcoholism and
drug addiction
Illnesses
Covered (1)
Mandated benefits
Mandated benefits
Mandate for plans
that offer mental
health coverage;
mandated benefits
for alcoholism
N/A
Mandated offering
Amends inpatient
and residential
treatment limits
for alcoholism and
drug addiction.
(see 1995 law,
supra)
Mandated benefits
Mandated benefits
Type of Benefit
7 days of
detoxification per
year, 28 per
lifetime
Substance abuse =
$5,625 for adults
and $5,000 for
children; mental
health = $5,000
for adults and
$7,500 for
children per 24
months
30 visits per year,
120 per lifetime
Substance abuse =
$1,875 for adults
and $2,500 for
children; mental
health = $2,500
for both per 24
months
At least $550 for
mental illness and
$550 for
alcoholism per
year
N/A
$4,500 in a 24month period
No change
45 days
At least $550 for
mental illness and
$550 for
alcoholism per
year
N/A
$4,500 for in a 24month period
30 hours for
mental illness and
20 visits for
substance abuse
Scope of
Outpatient
45 days for mental
illness and 60 days
for substance
abuse
Scope of Inpatient
30 days per year,
90 days per
lifetime
Substance abuse =
$4,375 for adults
and $3,750 for
children; mental
health = $1,250
for adults and
$3,125 for
children per 24
months
If more than 60
days of residential
treatment is
required, up to 23
days of unused
inpatient
treatment may be
traded at a rate of
one inpatient day
for two residential
days
At least $550 for
mental illness and
$550 for
alcoholism per
year
N/A
$4,500 in a 24month period
60 days
120 days for
mental illness and
120 days for
substance abuse
Scope of Partial/
Residential
For the first course
of treatment shall
be no greater than
those for other
illnesses
Benefits are
subject to
reasonable
deductibles and
co-insurance
N/A
Coverage must be
no less than 80%
of total
Shall be no greater
than those for
other illnesses
No deductible or
copayment for first
five hours not to
exceed 20% for
remaining hours
No change
Copayments and
Co-insurance
Dual diagnosis
mental health/
substance abuse =
$13,125 for adults
and $15,625 for
children;
substance abuse
only = $8,125 for
adults and
$13,125 for
children per 24
months
Dollar limits not
specified; day and
visit limits as
specified for each
level of care
N/A
Lifetime not
specified
Lifetime dollar
limits are not
specified
No change
Lifetime and
annual dollar
limits not specified
Lifetime/Annual
Dollar Limits
Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder
Treatment (continued)
112
Treatment of Alcohol and Other Substance Use Disorders
National Conference of State Legislatures
1982
Tenn.
Yes (1997)
No
Yes (97)
1/1/2002
1979
Yes (1997)
No
Adopted
Federal
Parity? Year
No
1994
January 2002
1995
Effective
Date
S.D.
S.C.
R.I.
State
Group with a
small employer
exemption 50 or
less, or cost
increase of 1% or
more
Group, individual
and HMO
State employee
insurance plan
with cost increase
exemptions
Group
Individual, group,
self-insured and
HMO
Individual, group
and self-insured
Insurance Policies
Affected by Law
Alcohol and drug
dependency
Psychiatric
conditions,
including
substance abuse
(14)
Mental health
condition or
alcohol or
substance abuse
(15)
Alcoholism
Mental illness,
including
substance abuse
Substance
dependency and
abuse (13)
Illnesses
Covered (1)
Mandated offering
Mandated offering
Parity
Mandated offering
Minimum
mandated benefit
Mandated benefits
Type of Benefit
30 days care
overall each six
months; 90 days
lifetime
Must be equal
Must be equal
$2,000 per year
total overall
Three episodes of
detoxification or
21 days, whichever
comes first, per
year
Must be equal
Scope of Inpatient
30 days care
overall each six
months; 90 days
lifetime
Must be equal
Must be equal
30 hours for each
individual under
treatment and 20
hours for family
per year
30 visits for
mental illness
only; 30 hours for
substance abuse
only; five
detoxification
occurrences or 30
days, whichever
comes first
$2,000 per year
total overall
Scope of
Outpatient
30 days care
overall each six
months; 90 days
lifetime
Must be equal
Must be equal
On the same basis
as benefits
provided for other
illnesses
Must be equal
Must be equal
May be different
Must be equal
Must be equal
$2,000 per year
total overall
Not specified
Copayments and
Co-insurance
30 days per year,
not to exceed
lifetime limit of 90
days.
Scope of Partial/
Residential
On the same basis
as benefits
provided for other
illnesses
Must be equal
Must be equal
Lifetime
maximum of
$10,000
Must be equal
Not specified
Lifetime/Annual
Dollar Limits
Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder
Treatment (continued)
Appendices
113
No
No
Effective
January 1,
2000 to July
1, 2004
Effective
until January
2000 and
after July 1,
2004
Va.
No
No
Yes
Yes
Adopted
Federal
Parity? Year
No
1998
Repealed July
1, 2001
1994
Jan. 1, 2001HMO July 1,
2001- Group
September 1,
2001
1981
Effective
Date
Vt.
Utah
Texas
State
National Conference of State Legislatures
Group and
individual with a
small group
exemption 25 or
less
Group, individual
and HMO
Group, individual
and state employee
plans
Group
Group and HMOs
State employee
plans
Group and selfinsured with an
exemption for selfinsured plans of
250 or less
Insurance Policies
Affected by Law
Alcohol and drug
dependency
Mental health
condition
including alcohol
and substance
abuse (18)
Biologically based
mental illness,
including drug
and alcohol
addiction (19)
Mental health and
substance abuse
Mental illness as
defined by the
Diagnostic and
Statistical Manual
Serious mental
illness (17)
Chemical
dependency (16)
Illnesses
Covered (1)
Mandated benefits
Parity
Parity
Mandated offering
Mandated offering
Law effective Jan.
1, 2004, allows
insurers and
HMOs to offer
policies without
this mandate, in
addition to at least
one policy with
the mandate, to
provide a less
expensive
alternative
Minimum
Mandated benefit
Mandated benefit
with a mandated
offering for selfinsured of 250 or
less
Type of Benefit
Must be equal to
achieve the same
outcome as
treatment for any
other illness
25 days for adults
and children
Must be equal
Not specified
May include a
restriction
Must be equal to
achieve the same
outcome as
treatment for any
other illness
20 visits for adults
and children
Must be equal
Not specified
May include a
restriction
60 visits
Must be equal to
achieve the same
outcome as
treatment for any
other illness.
Up to 10 days of
inpatient can be
converted for
children to 1.5
days of partial for
one day of
inpatient
Must be equal
Not specified
May include a
restriction
Not specified
Must be equal to
achieve the same
outcome as
treatment for any
other illness
Co-insurance for
outpatient can be
no more than 50%
after fifth visit; all
others must be
equal
Must be equal
Not specified
May include a
restriction
Must be equal
Must be equal to
achieve the same
outcome as
treatment for any
other illness
Benefits shall be
no more restrictive
than for other
illnesses except as
specified
Must be equal
Not specified
May not include a
lifetime limit;
annual limit must
be equal
May include a
restriction
Must be sufficient
to provide
appropriate care
Must be sufficient
to provide
appropriate care
Lifetime
maximum of three
separate series of
treatments,
including all levels
of medically
necessary care in
each episode
Lifetime
maximum of three
separate series of
treatments,
including all levels
of medically
necessary care in
each episode
Lifetime
maximum of three
separate series of
treatments,
including all levels
of medically
necessary care in
each episode
45 days
Lifetime/Annual
Dollar Limits
Copayments and
Co-insurance
Scope of Partial/
Residential
Scope of
Outpatient
Scope of Inpatient
Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder
Treatment (continued)
114
Treatment of Alcohol and Other Substance Use Disorders
1998
W.V.
1985
N/A
Wis.
Wyo.
2002
1990
Effective
Date
Wash.
State
National Conference of State Legislatures
No
No
Yes (1997)
Yes (1997)
Adopted
Federal
Parity? Year
No
N/A
State employees
with 2% cost
increase
exemption/ Group
accident and sick
insurance plans
with 1% cost
increase
exemption for
plans of 25 or less
and 2% for larger
plans/ HMOs
Group or blanket
disability
insurance policies
Group
Group
Insurance Policies
Affected by Law
N/A
Nervous and
mental disorders,
alcoholism, and
other drug abuse
Serious mental
illness, including
substance-related
disorders (21)
Chemical
dependency
Alcoholism (20)
Illnesses
Covered (1)
N/A
Mandated offering
Parity
Mandated offering
Mandated benefit
Type of Benefit
N/A
Not less than the
lesser of 30 days or
$7,000 minus any
cost sharing or the
equivalent benefits
measured in
services rendered
or, if the policy
does not use cost
sharing, $6,300 in
equivalent benefits
measured in
services rendered
Must be equal
30 days
Not specified
Scope of Inpatient
N/A
N/A
May apply same
deductible and/or
copayment to
mental health and
alcohol and other
drug abuse services
that apply to all
benefits; may
apply deductibles,
copayments, or
co-insurance to
inpatient,
outpatient and
transitional
services
Transitional
treatment: Not
less than $3,000
minus any
applicable cost
sharing at the level
charged under the
policy for the
equivalent benefits
measured in
services rendered
or, if the policy
does not use cost
sharing, $2,700 in
equivalent benefits
measured in
services rendered
N/A
Not less than
$2,000 minus any
cost sharing or the
equivalent benefits
measured in
services rendered
or, if the policy
does not use cost
sharing, $1,800 in
equivalent benefits
measured in
services rendered
N/A
Annual benefits
need not exceed
$7,000 or the
equivalent benefits
measured in
services rendered;
the amount may
be reduced if the
policy is written in
combination with
major medical
coverage, if the
combined
coverage complies
with the mandate
Must be equal
Not less than $750
annually and not
less than an
amount equal to
the lesser of
$10,000 or 25%
of the lifetime
limit
Must be equal
Not specified
Lifetime/Annual
Dollar Limits
Must be equal up
to 30 days; cannot
exceed 50% for
out- patient
Not specified
Copayments and
Co-insurance
Must be equal
Not specified
Not specified
Scope of Partial/
Residential
Must be equal
Not specified
Not specified
Scope of
Outpatient
Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder
Treatment (continued)
Appendices
115
116
Treatment of Alcohol and Other Substance Use Disorders
Appendix H. Overview of State Laws Requiring Coverage of Alcohol
and Other Substance Use Disorder Treatment (continued)
Notes
1. Thirteen Diagnostic and Statistical Manual diagnoses are commonly referred to as biologically based mental illnesses by mental health
providers and consumer organizations. Between three and 13 of these diagnoses are referred to in various state parity laws.
2. Mental illnesses and developmental disorders are defined in Arizona as disorders listed in the Internal Classification of Disease Manual and
the Diagnostic and Statistics Manual of the American Psychiatric Association (DSM)
3. Connecticut defines mental or nervous condition as mental disorders, as defined in the most recent edition of the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders and includes alcoholism and drug addiction as defined by the DSM.
4. In Georgia, mental disorders are defined by the Internal Classification of Disease Manual or the Diagnostic and Statistics Manual of the
American Psychiatric Association (DSM).
5. Kansas defines nervous or mental conditions to mean disorders specified in the Diagnostic and Statistics Manual of mental disorders, fourth
edition (DSM-IV), but shall not include conditions not attributable to a mental disorder that are a focus of attention or treatment.
6. Kentucky defines mental health condition to mean any condition or disorder that involves mental illness or alcohol and other drug abuse that
falls under any of the diagnostic categories listed in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) or that is listed
in the mental disorders section of the international classification of disease, or the most recent subsequent editions.
7. Expands coverage to the following 11 categories of mental illness in the American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders, except for those that are designated as “V” codes: substance abuse-related disorder; psychotic disorders such
as schizophrenia; dissociative disorders; mood disorders; anxiety disorders; personality disorders; paraphilias; attention deficit and
disruptive behavior disorders; pervasive developmental disorders; tic disorders; eating disorders, including bulimia and anorexia; and
substance abuse-related disorders.
8. Missouri defines recognized mental illness as those conditions classified as “mental disorders” in the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders, but shall not include mental retardation.
9. Missouri defines chemical dependency as the psychological or physiological dependence upon and abuse of drugs, including alcohol,
characterized by drug tolerance or withdrawal and impairment of social or occupational role functioning or both.
10. Missouri defines mental illness as the following disorders contained in the International Classification of Diseases (ICD-9-CM): 1)
schizophrenic disorders and paranoid states (295 and 297, except 297.3); 2) major depression, bipolar disorder and other affective
psychoses (296); 3) obsessive compulsive disorder, post-traumatic stress disorder and other major anxiety disorders (300.0, 300.21,
300.22, 300.23, 300.3 and 309.81); 4) early childhood psychoses and other disorders first diagnosed in childhood or adolescence (299.8,
312.8, 313.81 and 314); 5) alcohol and drug abuse (291, 292, 303, 304, and 305, except 305.1); 6) anorexia nervosa, bulimia and other
severe eating disorders (307.1, 307.51, 307.52 and 307.53); and 7) senile organic psychotic conditions (290).
11. North Carolina defines “mental illness” to mean: “(i) when applied to an adult, an illness which so lessens the capacity of the individual to
use self-control, judgment, and discretion in the conduct of his affairs and social relations as to make it necessary or advisable for him to be
under treatment, care, supervision, guidance, or control; and (ii) when applied to a minor, a mental condition, other than mental
retardation alone, that so impairs the youth’s capacity to exercise age adequate self-control or judgment in the conduct of his activities and
social relationships so that he is in need of treatment. NC defines chemical dependency to mean the pathological use or abuse of alcohol or
other drugs in a manner or to a degree that produces an impairment in personal, social or occupational functioning and which may, but
need not, include a pattern of tolerance and withdrawal.”
12. Oregon defines chemical dependency to mean the addictive relationship with any drug or alcohol characterized by either a physical or
psychological relationship, or both, that interferes with the individual’s social, psychological or physical adjustment to common problems on
a recurring basis. For purposes of this section, chemical dependency does not include addiction to, or dependency on, tobacco, tobacco
products or foods. It does not provide a specific definition for mental or nervous conditions.
13. Rhode Island defines substance dependency and substance abuse as the pattern of pathological use of alcohol or other psychoactive
drugs characterized by impairments in social and/or occupational functioning, debilitating physical condition, inability to abstain from or
reduce consumption of the substance, or the need for daily substance use for adequate functioning.
14. South Carolina defines psychiatric conditions to mean those mental and nervous conditions, drug and substance addiction or abuse,
alcoholism, or other conditions that are defined, described, or classified as psychiatric disorders or conditions in the most current
publication of the American Psychiatric Association entitled The Diagnostic and Statistical Manual of Mental Disorders.
15. South Carolina defines mental health condition to mean; schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder,
pervasive developmental disorder or autism, panic disorder, obsessive-compulsive disorder, social anxiety disorder, anorexia, bulimia,
asperger’s disorder, intermittent explosive disorder, post-traumatic stress disorder, psychosis not otherwise specified when diagnosed in a
child under age 17, Rett’s disorder, or Tourette’s disorder.
16. Texas defines chemical dependency to mean the abuse of or psychological or physical dependence on or addiction to alcohol or a
controlled substance.
17. Texas defines serious mental illness to mean the following psychiatric illnesses as defined by the American Psychiatric Association in the
Diagnostic and Statistical Manual (DSM): 1) schizophrenia, 2) paranoid and other psychotic disorders, 3) bipolar disorders (hypomanic,
manic, depressive, and mixed), 4) major depressive disorders (single episode or recurrent), 5) schizoaffective disorders (bipolar or
depressive), 6) pervasive developmental disorders, 7) obsessive-compulsive disorder, and 8) depression in childhood and adolescence.
18. Vermont defines mental health condition as any condition or disorder involving mental illness or alcohol or substance abuse that falls
under any of the diagnostic categories listed in the mental disorders section of the International Classification of Diseases, as periodically
revised.
19. Virginia defines biologically based mental illness as any mental or nervous condition caused by a biological disorder of the brain that results
in a clinically significant syndrome that substantially limits the person’s functioning; specifically, the following diagnoses are defined as
biologically based mental illness as they apply to adults and children: 1) schizophrenia, 2) schizoaffective disorder, 3) bipolar disorder, 4)
major depressive disorder, 5) panic disorder, 6) obsessive-compulsive disorder, 7) attention deficit hyperactivity disorder, 8) autism, and 9)
drug and alcoholism addiction.
20. West Virginia defines alcoholism as a chronic disorder or illness in which the individual is unable, for psychological or physical reasons, or
both, to refrain from the frequent consumption of alcohol in quantities sufficient to produce intoxication and, ultimately, injury to health
and effective functioning.
21. West Virginia Defines serious mental illness as (i) schizophrenia and other psychotic disorders; (ii) bipolar disorders; (iii) depressive
disorders; (iv) substance-related disorders with the exception of caffeine-related disorders and nicotine-related disorders; (v) anxiety
disorders; and (vi) anorexia and bulimia, as defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental
Disorders, as periodically revised. For employee plans, also includes attention deficit hyperactivity disorder, separation anxiety disorder, and
conduct disorder, for individuals under age 19.
Source: National Conference of State Legislatures, Health Policy Tracking Service, October 2003.
National Conference of State Legislatures
117
Appendices
APPENDIX I. ALCOHOL TAX, BY STATE
State Liquor Excise Tax Rates (as of Jan. 1, 2003)
State/
Jurisdiction
Alabama
Excise Tax Rates
($ Per Gallon)
Sales Taxes
Applied
Other Taxes
(1)
Yes
$12.80
N/A
Arizona
3.00
Yes
Arkansas
2.50
Yes
under 5% - $0.50/gallon, under 21% - $1.00/gallon; $0.20/case and 3% offpremise 14% on-premise retail taxes
over 50% - $6.60/gallon
Alaska
California
3.30
Yes
Colorado
2.28
Yes
under 21% - $2.50/gallon
Connecticut
4.50
Yes
under 7% - $2.05/gallon
Delaware
3.75
N/A
under 25% - $2.50/gallon
Florida
6.50
Yes
under 17.259% - $2.25/gallon, over 55.780% - $9.53/gallon 6.67¢/ounce onpremise retail tax
Georgia
3.79
Yes
$0.83/gallon local tax
Hawaii
5.92
Yes
Idaho
(1)
Yes
Illinois
4.50
Yes
under 20% - $0.73/gallon; $0.50/gallon in Chicago and $1.00/gallon in Cook
County
Indiana
2.68
Yes
under 15% - $0.47/gallon
(1)
Yes
Iowa
Kansas
2.50
No
Kentucky
1.92
Yes (2)
Louisiana
2.50
Yes
(1)
Yes
Maryland
1.50
Yes
Massachusetts
4.05
Yes (2)
Maine
Michigan
(1)
Yes
Minnesota
5.03
--
(1)
Yes
Mississippi
Missouri
2.00
Yes
Montana
(1)
N/A
Nebraska
3.00
Yes
Nevada
2.05
Yes
(1)
N/A
4.40
Yes
New Mexico
6.06
Yes
New York
6.44
Yes
New Hampshire
New Jersey
8% off-premise and 10% on-premise retail tax
under 6% - $0.25/gallon; $0.05/case and 9% wholesale tax
under 6% - $0.32/gallon
under 15% - $1.10/gallon, over 50% alcohol - $4.05/proof gallon; 0.57% on
private club sales
$0.01/bottle (except miniatures) and 9.0% sales tax
under 14% - $0.40/gallon and under 21% - $0.75/gallon.
under 24% - $2.54/gallon; $1.00/gallon New York City
National Conference of State Legislatures
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118
Treatment of Alcohol and Other Substance Use Disorders
Appendix I. State Liquor Excise Tax Rates (as of Jan. 1, 2003)—
(continued)
State/
Jurisdiction
Excise Tax Rates
($ Per Gallon)
Sales Taxes
Applied
North Carolina
(1)
Yes (2)
North Dakota
2.50
--
(1)
Yes
Ohio
Oklahoma
Other Taxes
7% state sales tax
5.56
Yes
(1)
N/A
Pennsylvania
(1)
Yes
Rhode Island
3.75
Yes
South Carolina
2.72
Yes
$5.36/case and 9% surtax
South Dakota
3.93
Yes
under 14% - $0.93/gallon, 2% wholesale tax
Tennessee
4.40
Yes
$0.15/case and 15% on-premise; under 7% - $1.21/gallon.
Texas
2.40
Yes
14% on-premise and $0.05/drink on airline sales
Utah
(1)
Yes
Vermont
(1)
No
Virginia
(1)
Yes
Washington
(1)
Yes (2)
(1)
Yes
Oregon
West Virginia
Wisconsin
3.25
Yes
Wyoming
(1)
Yes
Dist. of Columbia
1.50
Yes
U.S. Median
3.30
$1.00/bottle on-premise and 12% on-premise
10% on-premise sales tax
8% off- and 10% on-premise sales tax
Notes:
1. In 18 states, the government directly controls the sales of distilled spirits. Revenue in these states is generated from
various taxes, fees and net liquor profits.
2. Sales tax is applied to on-premise sales only.
Source: Compiled by FTA from various sources.
National Conference of State Legislatures
119
Appendices
Appendix I. State Wine Excise Tax Rates (as of Jan. 1, 2003)
State/
Jurisdiction
Alabama
Excise Tax Rates
($ Per Gallon)
Sales Taxes
Applied
Other Taxes
$1.70
Yes
Alaska
2.50
N/A
Arizona
0.84
Yes
Arkansas
0.75
Yes
under 5% - $0.25/gallon; $0.05/case; and 3% off-premise and 10% onpremise
sparkling wine - $0.30/gallon
California
0.20
Yes
Colorado
0.32
Yes
Connecticut
0.60
Yes
Delaware
0.97
N/A
Florida
2.25
Yes
over 14% - sold through state store
over 21% and sparkling wine - $1.50/gallon
over 17.259% - $3.00/gallon, sparkling wine $3.50/gallon 6.67¢/4 ounces onpremise retail tax
Georgia
1.51
Yes
over 14% - $2.54/gallon; $0.83/gallon local tax
Hawaii
1.36
Yes
sparkling wine - $2.09/gallon and wine coolers - $0.84/gallon
Idaho
0.45
Yes
Illinois
0.73
Yes
over 20% - $4.50/gallon; $0.30/gallon in Chicago and ($0.16-$0.30)/gallon
in Cook County
Indiana
0.47
Yes
over 21% - $2.68/gallon
Iowa
1.75
Yes
under 5% - $0.19/gallon
Kansas
0.30
No
over 14% - $0.75/gallon; 8% off-premise and 10% on-premise
Kentucky
0.50
Yes (1)
Louisiana
0.11
Yes
14% to 24% - $0.23/gallon, over 24% and sparkling wine - $1.59/gallon
over 15.5% - sold through state stores, sparkling wine - $1.25/gallon;
additional 5% on-premise sales tax
Maine
0.60
Yes
Maryland
0.40
Yes
Massachusetts
0.55
Yes (1)
Michigan
0.51
Yes
Minnesota
0.30
--
Mississippi
0.35
Yes
9% wholesale
sparkling wine - $0.70/gallon;
over 16% - $0.76/gallon
14% to 21% - $0.95/gallon, under 24% and sparkling wine - $1.82/gallon;
$0.01/bottle (except miniatures) and 9.0% sales tax
over 14% and sparkling wine - sold through the state
Missouri
0.36
Yes
Montana
1.06
N/A
over 16% - sold through state stores
Nebraska
0.75
Yes
over 14% - $1.35/gallon
Nevada
0.40
Yes
14% to 22% - $0.75/gallon, over 22% - $2.05/gallon
(2)
N/A
0.70
Yes
New Hampshire
New Jersey
New Mexico
1.70
Yes
New York
0.19
Yes
North Carolina
0.79
Yes
over 14% - $6.06/gallon
over 17% - $0.91/gallon
National Conference of State Legislatures
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Treatment of Alcohol and Other Substance Use Disorders
Appendix I. State Wine Excise Tax Rates (as of Jan. 1, 2003)—
(continued)
State/
Jurisdiction
North Dakota
Excise Tax Rates
($ Per Gallon)
Sales Taxes
Applied
Other Taxes
$0.50
--
over 17% - $0.60/gallon, Sparkling wine - $1.00/gallon; 7% state sales tax
Ohio
0.32
Yes
over 14% - $1.00/gallon, vermouth - $1.10/gallon and sparkling wine $1.50/gallon
Oklahoma
0.72
Yes
over 14% - $1.44/gallon, sparkling wine - $2.08/gallon; $1.00/bottle onpremise and 12% on-premise
Oregon
over 14% - $0.77/gallon
0.67
N/A
Pennsylvania
(2)
Yes
Rhode Island
0.60
Yes
sparkling wine - $0.75/gallon
South Carolina
0.90
Yes
$0.18/gallon additional tax
South Dakota
0.93
Yes
14% to 20% - $1.45/gallon, over 21% and sparkling wine - $2.07/gallon; 2%
wholesale tax
Tennessee
1.21
Yes
$0.15/case and 15% on-premise.
Texas
0.20
Yes
over 14% - $0.408/gallon and sparkling wine - $0.516/gallon; 14% onpremise and $0.05/drink on airline sales
Utah
(2)
Yes
Vermont
0.55
Yes
over 16% - sold through state store, 10% on-premise sales tax
Virginia
1.51
Yes
under 4% - $0.2565/gallon and over 14% - sold through state store
Washington
0.87
Yes
over 14% - $1.72/gallon
West Virginia
1.00
Yes
5% local tax
Wisconsin
0.25
Yes
over 14% - $0.45/gallon
Wyoming
(2)
Yes
Dist. of Columbia
0.30
Yes
U.S. Median
0.60
8% off-premise and 10% on-premise sales tax, over 14% - $0.40/gallon and
Sparkling - $0.45/gallon.
Notes:
1. Sales tax is applied to on-premise sales only.
2. All wine sales are through state stores. Revenue in these states is generated from various taxes, fees and net profits.
Source: Compiled by FTA from various sources.
National Conference of State Legislatures
121
Appendices
Appendix I. State Beer Excise Tax Rates (as of Jan. 1, 2003)
State/
Jurisdiction
Alabama
Excise Tax Rates
($ Per Gallon)
Sales Taxes
Applied
Other Taxes
$0.53
Yes
$0.52/gallon local tax
Alaska
1.07
N/A
$0.35/gallon small breweries
Arizona
0.16
Yes
Arkansas
0.23
Yes
California
0.20
Yes
Colorado
0.08
Yes
Connecticut
0.19
Yes
Delaware
0.16
N/A
Florida
0.48
Yes
under 3.2% - $0.16/gallon; $0.008/gallon and 3% off-premise 10% onpremise tax
$.0267/12 ounces on-premise retail tax
Georgia
0.48
Yes
$0.53/gallon local tax
Hawaii
0.92
Yes
$0.53/gallon draft beer
Idaho
0.15
Yes
over 4% - $0.45/gallon
Illinois
0.185
Yes
$0.16/gallon in Chicago and $0.06/gallon in Cook County
Indiana
0.12
Yes
Iowa
0.19
Yes
Kansas
0.18
--
Kentucky
0.08
Yes (1)
Louisiana
0.32
Yes
$0.048/gallon local tax
Maine
0.35
Yes
additional 5% on-premise tax
Yes
over 3.2% - {8% off-premise and 10% on-premise}, under 3.2% - 4.25% sales
tax.
9% wholesale tax
Maryland
0.09
Massachusetts
0.11
Michigan
0.20
Minnesota
0.15
--
Mississippi
0.43
Yes
Missouri
0.06
Yes
Montana
0.14
N/A
Nebraska
0.23
Yes
Nevada
0.09
Yes
New Hampshire
0.30
N/A
New Jersey
0.12
Yes
New Mexico
0.41
Yes
New York (2)
0.125
Yes
North Carolina
0.53
Yes
$0.48/gallon bulk beer
North Dakota
0.16
--
7% state sales tax, bulk beer $0.08/gal.
Ohio
0.18
Yes
Yes (1)
$0.2333/gallon in Garrett County
0.57% on private club sales
Yes
under 3.2% - $0.077/gallon, 9.0% sales tax
$0.12/gallon in New York City
National Conference of State Legislatures
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Treatment of Alcohol and Other Substance Use Disorders
Appendix I. State Beer Excise Tax Rates (as of Jan. 1, 2003)—
(continued)
State/
Jurisdiction
Oklahoma
Excise Tax Rates
($ Per Gallon)
Sales Taxes
Applied
Other Taxes
$0.40
Yes
Oregon
0.08
N/A
Pennsylvania
0.08
Yes
Rhode Island
0.10
Yes
South Carolina
0.77
Yes
South Dakota
0.27
Yes
Tennessee
0.14
Yes
17% wholesale tax
Texas
0.19
Yes
over 4% - $0.198/gallon, 14% on-premise and $0.05/drink on airline sales
Utah
under 3.2% - $0.36/gallon; $1.00/case on-premise and 12% on-premise
$0.04/case wholesale tax
0.35
Yes
over 3.2% - sold through state store
Vermont
0.265
No
6% to 8% alcohol - $0.55; 10% on-premise sales tax
Virginia
0.26
Yes
0.261
Yes
West Virginia
0.18
Yes
Wisconsin
0.06
Yes
Wyoming
0.02
Yes
0.09
Yes
Washington
Dist. of Columbia
U.S. Median
8% off-premise and 10% on-premise sales tax
0.185
Notes:
1. Sales tax is applied to on-premise sales only.
2. Tax rate scheduled to decrease to 11.5 cents per gallon on Sept. 1, 2003.
Source: Compiled by FTA from various sources.
National Conference of State Legislatures
123
Notes
NOTES
Chapter 1. What Are Alcohol and Other Substance Abuse Disorders?
1. News Advisory: Surgeon General Helps to Launch First Ever National Alcohol Screening Day (Washington D.C.: National Institutes of Health, April 3, 1999).
2. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (Washington, D.C.: APA, 2000).
3. U.S. Department of Health and Human Services, Alcohol and Health: Ninth Special
Report to the U.S. Congress (Washington, D.C.: DHHS, June 1997), 337.
4. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision.
5. Dean R. Gerstein and Henrick J. Harwood, eds., Treating Drug Problems, vol. 1
(Washington, D.C.: National Academy Press, 1990), 59.
6. Ibid.
7. Ibid.
8. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision.
9. National Institutes of Health, National Institute on Drug Abuse, 25 Years of Discovery to Advance the Health of the Public (Bethesda, Md.: NIH, 1999).
10. Department of Health and Human Services, Substance Abuse and Mental Health
Services Administration, Summary of Findings from the 1998 National Household Survey on
Drug Abuse (Washington, D.C.: DHHS, August 1999).
11. “NIDA InfoFacts: Science-Based Facts on Drug Abuse and Addiction, Understanding
Drug Abuse and Addiction,” http://www.drugabuse.gov/Infofax/understand.html, Dec.
18, 2003.
12. Ibid.
National Conference of State Legislatures
123
124
Treatment of Alcohol and Other Substance Use Disorders
13. Ibid.
14. Ibid.
15. Ibid.
16. Ibid.
17. Ibid.
18. “Bringing the Power of Science to Bear on Drug Abuse and Addiction,” http://
www.drugabuse.gov/pubs/teaching/Teaching5/Teaching.html, Dec. 18, 2003.
19. “Bringing the Power of Science to Bear on Drug Abuse and Addiction, Slide 7:
This is Literally the Brain on Drugs,” http://www.drugabuse.gov/pubs/teaching/Teaching5/Teaching3.html, Dec. 18, 2003.
20. Ibid.
21. Ibid.
22. Ibid.
23. “Bringing the Power of Science to Bear on Drug Abuse and Addiction, Slide 8:
Long-term Effects of Drug Abuse,” http://www.drugabuse.gov/pubs/teaching/Teaching5/
Teaching3.html, Dec. 18, 2003.
24. Ibid.
25. Ibid.
26. Ibid.
27. “Bringing the Power of Science to Bear on Drug Abuse and Addiction, Slide 9:
Drugs Have Long-term Consequences,” http://www.drugabuse.gov/pubs/teaching/Teaching5/Teaching4.html, Dec. 18, 2003.
28. Ibid.
29. Ibid.
30. “Bringing the Power of Science to Bear on Drug Abuse and Addiction, Slide 10:
The Memory of Drugs,” http://www.drugabuse.gov/pubs/teaching/Teaching5/
Teaching4.html, Dec. 18, 2003.
31. Ibid.
32. Ibid.
National Conference of State Legislatures
125
Notes
33. Ibid.
34. “Bringing the Power of Science to Bear on Drug Abuse and Addiction, Slide 14:
Have You Changed Your Mind?,” http://www.drugabuse.gov/pubs/teaching/Teaching5/
Teaching5.html, Dec. 18, 2003.
35. Ibid.
36. Ibid.
37. A.D. Dager, et al., “Effects of Alcohol and Marijuana Use on fMRI Response in
Adolescents,” Alcoholism: Clinical and Experimental Research 26, no. 5 (May 2002): 36A.
S.F. Tapert, et al., “fMRI BOLD response to alcohol stimuli in alcohol dependent
young women,” Addictive Behaviors (in press).
S.F. Tapert, et al, “Neural response to alcohol stimuli in alcohol use disordered adolescents,” Archives of General Psychology 60 (2003): 727-735.
Chapter 2. What Are the Effects of Alcohol and Other Substance
Use Disorders?
1. “Results from the 2002 National Survey on Drug Use and Health (NSDUH),
Chapter 3. Alcohol Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/
2k2Results.htm#chap3, Dec. 18, 2003.
2. “Results from the 2002 National Survey on Drug Use and Health (NSDUH),
Chapter 2. Illicit Drug Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/
2k2Results.htm#chap2, Dec. 18, 2003.
3. “Results from the 2002 National Survey on Drug Use and Health (NSDUH),
Chapter 3. Alcohol Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/
2k2Results.htm#chap3, Dec. 18, 2003.
4. “Results from the 2002 National Survey on Drug Use and Health (NSDUH),
Chapter 2. Illicit Drug Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/
2k2Results.htm#chap2, Dec. 18, 2003.
5. “Results from the 2002 National Survey on Drug Use and Health (NSDUH),
Chapter 3. Alcohol Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/
2k2Results.htm#chap3, Dec. 18, 2003.
6. Ibid.
7. “Results from the 2002 National Survey on Drug Use and Health (NSDUH),
Chapter 2. Illicit Drug Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/
2k2Results.htm#chap2, Dec. 18, 2003.
National Conference of State Legislatures
126
Treatment of Alcohol and Other Substance Use Disorders
8. Ibid.
9. “State Estimates of Substance Use from the 2000 National Household Survey on
Drug Abuse: Volume I. Findings, 1.3. Format of Report and Presentation of Data,” http:/
/www.samhsa.gov/oas/2kState/PDF/Vol1/2kSAEv1W.pdf, Dec. 18, 2003.
10. Ibid.
11. “What Is Healthy People?,” http://www.healthypeople.gov/About/whatis.htm,
Dec. 18, 2003.
12. Ibid.
13. “What Are Its Goals?,” http://www.healthypeople.gov/About/whatis.htm, Dec.
18, 2003.
14. “Fact Sheet,” http://www.healthypeople.gov/About/hpfact.htm, Dec. 18, 2003.
15. Healthy People 2010: Understanding and Improving Health (second edition, fourcolor version), “Substance Abuse: Leading Health Indicator,” http://www.healthypeople.gov/
Document/html/uih/uih_4.htm#subsabuse, Dec. 18, 2003.
16. Ibid.
17. Ibid.
18. “DATA2010 ... the Healthy People 2010 Database—October 2003 Edition—
10/20/03—10:16:57AM Focus area: 26-Substance Abuse,” http://wonder.cdc.gov/scripts/
broker.exe, Dec. 18, 2003.
19. Healthy People 2010: Understanding and Improving Health (second edition, fourcolor version), “Substance Abuse: Leading Health Indicator,” http://www.healthypeople.gov/
Document/html/uih/uih_4.htm#subsabuse, Dec. 18, 2003.
20. Ibid.
21. Ibid.
22. “National and State Estimates of Drug Abuse Treatment Gap, Chapter 3. Estimates of the Treatment Gap, by State,” http://www.samhsa.gov/oas/TXgap/chapter3.htm,
Dec. 18, 2003.
23. Ibid.
24. Ibid.
25. Ibid.
26. “My Name is Jim, and I’m an Alcoholic,” http://www.alcoholics-anonymous.org/
default/en_about_aa_sub.cfm?subpageid=73&pageid=12, Dec. 18, 2003.
National Conference of State Legislatures
127
Notes
27. Ibid.
28. Ibid.
29. Ibid.
30. Ibid.
31. Ibid.
32. Ibid.
33. Ibid.
34. Ibid.
35. Ibid.
36. Ibid., 20.
37. Ibid., 11.
38. “Children of Addicted Parents: Important Facts,” http://www.nacoa.net/pdfs/
addicted.pdf, Dec. 18, 2003.
Chapter 3. Why Should State Legislators Be Concerned About
Alcohol and Other Substance Use Disorders?
1. Substance Abuse and Mental Health Services Administration, National Expenditures for Mental Health Alcohol and Other Drug Treatment (Washington, D.C.: SAMSHA,
September 1998).
2. Center for Substance Abuse Treatment, Although the Costs of Increased Substance
Abuse Benefits Are Low, the Advantages Are Significant (Washington D.C.: Office of Managed Care, Center for Substance Abuse Treatment, February 1999).
3. The National Institute on Drug Abuse and The National Institute on Alcohol
Abuse and Alcoholism, The Economic Costs of Alcohol and Drug Abuse in the United States1992 (Washington D.C.: NIDA, NIAAA, 1992).
4. “Shoveling Up: The Impact of Substance Abuse on State Budgets,” http://
www.casacolumbia.org/publications1456/publications_show.htm?doc_id=47299, Dec. 18,
2003.
5. “Shoveling Up: The Impact of Substance Abuse on State Budgets,” http://
www.casacolumbia.org/usr_doc/47299a.pdf, Dec. 18, 2003.
6. Ibid.
National Conference of State Legislatures
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Treatment of Alcohol and Other Substance Use Disorders
7. “Substance Abuse, Workplace Concerns,” http://www.drugfreeworkplace.gov/
SubstanceAbuse/SADefined/SBDefined.htm#Concerns, Dec. 18, 2003.
8. “Substance Abuse Prevention in Workplaces is Good Business,” http://
www.drugfreeworkplace.gov/WPResearch/CollaborativeResearch/GoodBusiness.pdf, Dec.
18, 2003.
9. Ibid.
10. Ibid.
11. Ibid.
12. Ibid.
13. Ibid.
14. Ibid.
15. “Results from the 2002 National Survey on Drug Use and Health (NSDUH),
Chapter 8. Substance Dependence, Abuse, and Treatment,” http://www.samhsa.gov/oas/
nhsda/2k2nsduh/Results/2k2Results.htm#chap8, Dec. 18, 2003.
16. Ibid.
17. “Results from the 2002 National Survey on Drug Use and Health (NSDUH),
Chapter 2. Illicit Drug Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/
2k2Results.htm#chap2, Dec. 18, 2003.
18. J.W. Langenbucher, B.S. McCrady, J. Brick, and R. Esterly, Socioeconomic Evaluations of Addictions Treatment (Piscataway, N.J.: Center of Alcohol Studies, Rutgers University, 1994).
19. The National Organization on Fetal Alcohol Syndrome, NO FAS (Washington,
D.C.: NOFAS, 1998).
20. Ibid.
21. Substance Abuse and Mental Health Services Administration, New National Study
on Substance Use Among Women in the United States (Washington D.C.: SAMHSA, September 22, 1997); http://www.samhsa.gov/press/97.
22. Substance Abuse Policy Research Program, Backgrounder on Substance Abuse During Pregnancy (Winston-Salem, N.C.: SAPRP, August, 1998).
23. “Hepatitis C: What Clinicians and Other Health Professionals Need To Know,
Transmission Modes, Injection and Other Illegal Drug Use,” http://www.cdc.gov/ncidod/
diseases/hepatitis/c_training/edu/1/epidem-trans-3.htm, Dec. 18, 2003.
National Conference of State Legislatures
129
Notes
24. Ibid.
25. Ibid.
26. Ibid.
27. U.S. Centers For Disease Control and Prevention, Division of HIV/AIDS Prevention, Drug Associated HIV Transmission Continues in the United States (Atlanta: Ga.: CDCP,
1999).
28. National Association of State Alcohol and Drug Abuse Directors, National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders (Washington, D.C.:
NASADAD, 1998).
29. R.C. Kessler et al., “Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric
Disorders in the United States: Results from the National Comorbidity Survey,” Archives of
General Psychiatry 51 (January 1994): 8-19.
30. “Alcohol: What You Don’t Know Can Harm You,” http://www.niaaa.nih.gov/publications/harm-al.htm, Dec. 18, 2003.
31. Ibid.
32. Ibid.
33. Ibid.
34. Ibid.
35. Ibid.
36. Ibid.
37. “NIDA InfoFacts: Crack and Cocaine,” http://www.drugabuse.gov/Infofax/
cocaine.html, Dec. 18, 2003.
38. “NIDA InfoFacts: Marijuana,” http://www.drugabuse.gov/Infofax/marijuana.html,
Dec. 18, 2003.
39. Ibid.
40. Ibid.
41. “Alcohol: What You Don’t Know Can Harm You,” http://www.niaaa.nih.gov/publications/harm-al.htm, Dec. 18, 2003.
42. “NIDA InfoFacts: Crack and Cocaine,” http://www.drugabuse.gov/Infofax/
cocaine.html, Dec. 18, 2003.
National Conference of State Legislatures
130
Treatment of Alcohol and Other Substance Use Disorders
43. “NIDA InfoFacts: Marijuana,” http://www.drugabuse.gov/Infofax/marijuana.htm,
Dec. 18, 2003.
44. “Detailed Emergency Department Tables from the Drug Abuse Warning Network
2001, Table 2.2—ED Drug Abuse Episodes: Episode Characteristics by Demographic
Characteristics: Estimates, 2001,” http://dawninfo.samhsa.gov/pubs_94_02/edpubs/
2001detailed/Tables/DT2001_2.2.xls, Dec. 18, 2003.
45. Ibid.
46. National Institute of Justice, ADAM 1999: Annual Report on Drug Use Among
Adult and Juvenile Arrestees (Washington, D.C.: U.S. Department of Justice, 2000). Descriptions of the ADAM program and links to the latest publications and data, are at http:
//www.adam-nj.net.
47. M. Mauer and M. Chesney-Lind, eds., “Introduction,” (In M. Mauer & M.
Chesney-Lind (Eds.), Invisible Punishment: The Collateral Consequences of Mass Imprisonment (pp. 1-12). New York: The New Press, 2001).
48. Bureau of Justice Statistics, Number of Persons in Custody of State Correctional Authorities by Most Serious Offense, 1980-1999 (Washington, DC: U.S. Department of Justice,
2002).
49. M. Mauer, Americans Behind Bars: U.S. and International Use of Incarceration, 1995
(Washington, D.C.: The Sentencing Project, 1997).
50. R.J. MacCoun and P. Reuter, Drug War Heresies (New York: Cambridge University
Press, 2001).
51. M. Tonry, Malign Neglect: Race, Crime, and Punishment in America (New York:
Oxford University Press, 1995).
52. Bureau of Justice Statistics, Number of Persons in Custody of State Correctional Authorities by Most Serious Offense, 1980-1999 (Washington, D.C.: U.S. Department of Justice, 2002).
53. J.P. Lynch and W.J. Sabol. “Prison use and social control,” In J. Horney (ed.),
Criminal Justice 2000: Policies, Processes, and Decisions of the Criminal Justice System (Washington, D.C.: U.S. Department of Justice, National Institute of Justice, 2000), 7-44.
54. Bureau of Justice Statistics, Prisoners in 2002 (Washington, D.C.: U.S. Department of Justice, 2003).
55. C. Haney and P. Zimbardo. “The Past and Future of U.S. Prison Policy: TwentyFive Years After the Stanford Prison Experiment” American Psychologist 53 (1999): 711720.
56. T.P. Bonczar and A.J. Beck, Lifetime Likelihood of Going to State or Federal Prison
(Washington, D.C.: U.S. Department of Justice, Bureau of Justice Statistics, 1997).
National Conference of State Legislatures
131
Notes
57. Mauer, 1999.
58. Human Rights Watch, Punishment and Prejudice: Racial Disparities in the War on
Drugs (New York: Human Rights Watch, 2000).
59. T. Clear, “The Problem with ‘Addition by Subtraction:’ The Prison-Crime Relationship in Low-Income Communities,” In M. Mauer and M. Chesney-Lind (eds.), Invisible Punishment: The Collateral Consequences of Mass Imprisonment (New York: The New
Press, 2001): 181-194.
60. D.T. Courtwright, “The Drug War’s Hidden Toll,” Issues in Science and Technology
14 (1996): 69-78.
61. B. Bloom and D. Steinhart, Why Punish the Children? (San Francisco, Calif.: National Council on Crime and Delinquency, 1993).
62. J. Fellner and M. Mauer, Losing the Vote: The Impact of Felony Disenfranchisement
Laws in the United States (New York: The Sentencing Project and Human Rights Watch,
1998).
63. Clear, 2001; Mauer, 1999.
64. J. Travis, “Invisible Punishment: An Instrument of Social Exclusion,” in M. Mauer
and M. Chesney-Lind (eds.), Invisible Punishment: The Collateral Consequences of Mass Imprisonment (New York: The New Press, 2001): 15-36.
65. “CASAWORKS for Families: A Promising Approach to Welfare Reform and Substance-Abusing Women,” http://www.casacolumbia.org/usr_doc/68773.pdf, Dec. 18, 2003.
66. S.P. Baker, B. O’Neill, and R.S. Karpf, The Injury Fact Book, 2nd edition (New
York, N.Y..: Oxford University Press, 1992), as referenced in DHHS, Alcohol and Health,
254.
67. R. Hingson and J. Howland, “Alcohol and Non-traffic Unintended Injuries,” Addiction 88, no. 7 (1993): 877-883, as referenced in DHHS, Alcohol and Health, 254.
68. S. P. Baker, et al., Injury Fact Book, 254.
69. Hingson and Howard, “Unintended Injuries,” 254.
70. U.S. Department of Transportation, National Highway Traffic Safety Administration, Traffic Safety Facts 1998: Alcohol (Washington, D.C.: NHTSA, 1998).
71. Ibid.
72. L. Hayward, S.R. Zubrick and S. Silburn, “Blood Alcohol Levels in Suicide Cases“
Journal of Epidemiol Community Health 46, no. 3 (1992): 256-260, as referenced in DHHS,
Alcohol and Health, 259.
73. Martha R. Burt et al., Homelessness: Programs and the People They Serve, 24.
National Conference of State Legislatures
132
Treatment of Alcohol and Other Substance Use Disorders
74. Ibid., 48.
75. National Coalition for the Homeless, Addiction Disorders and Homelessness, Fact
Sheet 6 (Washington, D.C.: NCH, 1999).
76. U.S. Department of Justice. Alcohol and Crime: An Analysis of National Data on the
Prevalence of Alcohol Involvement in Crime (Washington, D.C.: DOJ, 1998).
77. “Substance Abuse Treatment and Domestic Violence: Treatment Improvement
Protocol (TIP) Series 25, Executive Summary and Recommendations,” http://
ncadi.samhsa.gov/govpubs/BKD239/25c.aspx, Dec. 18, 2003.
78. Nancy K. Young; Sidney L. Gardner, and Kimberly Dennis, Responding to Alcohol
and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy (Washington,
D.C.: Child Welfare League of America, 1998).
79. National Association for Children of Alcoholics, Children of Alcoholics: Important
Facts (Rockville, Md.: NACOA, 1999).
80. Ibid.
81. National Center on Addiction and Substance Abuse at Columbia University, Survey of Child Welfare Professionals (New York, N.Y.: CASA, 1997).
82. Ibid.
83. Department of Justice, Alcohol and Crime.
84. M. Mauer, Race to Incarcerate (New York: The New Press, 1999).
85. J.J. Donohue and P. Siegelman, “Allocating Resources Among Prisons and Social
Programs in the Battle Against Crime,” Journal of Legal Studies 27 (1998): 30-43.
Chapter 4. What Strategies Are Available for the Treatment of
Alcohol and Other Substance Use Disorders?
1. National Institutes of Health, National Institute on Drug Abuse, 25 Years of Discovery to Advance the Health of the Public (Bethesda, Md.: NIH, 1999), vii.
2. DHHS, Alcohol and Health, chapter 2.
3. National Institutes of Health, 25 Years of Discovery, 13.
4. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination,
Technical Assistance Publication Series 11, Chapter 4-Screening and Assessment,” http://
www.treatment.org/Taps/Tap11/tap11chap4.html, Dec. 18, 2003.
5. “Principles of Drug Addiction Treatment, Principles of Effective Treatment,”
http://www.nida.nih.gov/PODAT/PODAT1.html, Dec. 18, 2003.
National Conference of State Legislatures
133
Notes
6. “Principles of Drug Addiction Treatment: A Research Based Guide,” http://
www.nida.nih.gov/PODAT/PODAT2.html, Dec. 18, 2003.
7. “Treatment Improvement Protocol Series, CSAT TIPs,” http://www.treatment.org/
Externals/tips.html, Dec. 18, 2003.
8. Ibid.
9. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination,
Technical Assistance Publication Series 11, Chapter 5-The Importance of Patient-Treatment Matching,” http://www.treatment.org/Taps/Tap11/tap11chap5.html, Dec. 18, 2003.
10. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination,
Technical Assistance Publication Series 11, Chapter 1-Who Needs Treatment: An Overview of Addiction and Its Treatment, Recovery,” http://www.treatment.org/Taps/Tap11/
tap11chap1.html#recovery, Dec. 18, 2003.
11. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination,
Technical Assistance Publication Series 11, Chapter 4-Screening and Assessment,” http://
www.treatment.org/Taps/Tap11/tap11chap4.html, Dec. 18, 2003.
12. Ibid.
13. Ibid.
14. States and jurisdictions with laws that give insurers the option to deny medical
reimbursements to patients under the influence of alcohol are Alabama, Alaska, Arizona,
Arkansas, California, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa,
Kansas, Kentucky, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, Nevada,
New Jersey, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina,
Tennessee, Texas, Virginia, Washington, West Virginia, Wyoming and the District of Columbia; states with laws that give insurers the option to deny medical reimbursements to
patients under the influence of narcotics are Minnesota, New York, Oklahoma and South
Dakota; states that have repealed laws are Maryland, North Carolina and Vermont.
15. Ibid.
16. “Patient Placement Criteria, Second Edition Revised,” http://www.asam.org/ppc/
ppc2.htm, Dec. 18, 2003.
17. Ibid.
18. Ibid.
19. Ibid.
20. National Institutes of Health, National Institute on Drug Abuse, Principles of Drug
Addiction Treatment (Rockville, Md.: NIH, October 1999), FAQ section.
21. Ibid.
National Conference of State Legislatures
134
Treatment of Alcohol and Other Substance Use Disorders
22. DHHS, Alcohol and Health, 348–350.
23. Office of the National Drug Control Policy, The National Drug Control Strategy,
1999 (Washington D.C.: ONDCP, 1999) 61.
24. Ibid., 61.
25. U.S. Department of Health and Human Services, The National Institutes on Drug
Abuse, Infofax Treatment Methods (Washington, D.C.: DHHS, 1999).
26. Department of Health and Human Services, Treatment for Alcohol and Other Drug
Abuse: Opportunities for Coordination (Washington, D.C.: DHHS, 1994).
27. Institutes of Medicine, Treating Drug Problems, Volume 1-A Study of the Evolution,
Effectiveness, and Financing of Public and Private Drug Treatment Systems (PLACE, PUBLISHER, 1990), 10-11.
28. “Compulsory Treatment of Drug Abuse: Research and Clinical Practice, NIDA
Research Monograph Series 86,” http://165.112.78.61/pdf/monographs/86.pdf, Dec. 18,
2003.
29. Department of Health and Human Services, Substance Abuse and Mental Health
Services Administration, Detoxification From Alcohol and Other Drugs Treatment Improvement Protocol (TIP) Series 19 (Rockville, Md.: SAMHSA, 1995), chapters 1 and 3.
30. Margaret A.E. Jarvis, Michael F. Weaver, and Sidney H. Schnoll, Role of the Primary
Care Physician in Problems of Substance Abuse (vol. 159, no. 9) (Chicago, Ill.: American
Medical Association, May 1999).
31. Therapeutic Communities of America, TCA News, Therapeutic Communities of
America, About TCA (Washington, D.C.: TCA, 1999).
32. Ibid., 2.
33. R.L. Hubbard et al., “Overview of 1-year Follow-up Outcomes in the Drug Abuse
Treatment Outcome Study (DATOS),” Psychology of Addictive Behaviors 11, no. 4 (1997):
261-278.
34. Margaret A.E. Jarvis, Michael F. Weaver, and Sidney H. Schnoll, Role of the Primary
Care Physician in Problems of Substance Abuse.
35. Ibid.
36. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination,
Technical Assistance Publication Series 11, Chapter 9-Relapse Prevention,” http://
www.treatment.org/Taps/Tap11/tap11chap9.html, Dec. 18, 2003.
37. Ibid.
National Conference of State Legislatures
135
Notes
38. Ibid.
39. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination,
Technical Assistance Publication Series 11, Chapter 3-Causes of Addiction and Modalities
for Treatment, Treatment Components,” http://www.treatment.org/Taps/Tap11/
tap11chap3.html#components, Dec. 18, 2003.
40. Ibid.
41. Ibid.
42. Ibid.
43. Ibid.
44. Ibid.
45. Ibid.
46. Ibid.
47. Ibid.
48. Ibid.
49. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination,
Technical Assistance Publication Series 11, Chapter 6-Special Populations, Juveniles,”
http://www.treatment.org/Taps/Tap11/tap11chap6.html#juveniles, Dec. 18, 2003.
50. Ibid.
51. Ibid.
52. Ibid.
53. “Results from the 2002 National Survey on Drug Use and Health (NSDUH),
Chapter 3. Alcohol Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/
2k2Results.htm#chap3, Dec. 18, 2003.
54. DHHS, Alcohol and Health, 251-253.
55. The National Center on Addiction and Substance Abuse at Columbia University,
Substance Abuse and The American Woman (New York, N.Y.: CASA, June 1996), vi.
56. DHHS, Alcohol and Health, 137.
57. Ibid., 22.
National Conference of State Legislatures
136
Treatment of Alcohol and Other Substance Use Disorders
58. “Results from the 2002 National Survey on Drug Use and Health (NSDUH),
Chapter 2. Illicit Drug Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/
2k2Results.htm#chap2, Dec. 18, 2003.
59. Dan Steinberg and Shelly Gehshan, State Responses to Maternal Drug and Alcohol
Use: An Update (Washington D.C.: National Conference of State Legislatures, 2000).
60. Ibid.
61. State of Wisconsin, Office of the Governor, New Law Protects Unborn Babies From
Alcohol and Cocaine Abuse (June 16, 1998).
62. Wisconsin Legislative Reference Bureau, Unborn Children in Need of Protection (Brief
98-9) (Madison: Wisconsin Legislative Reference Bureau, June 1998).
63. Department of Health and Human Services, Substance Abuse and Mental Health
Services Administration, Substance Abuse Among Older Adults (Washington, D.C.: DHHS,
1998), executive summary and chapter 1.
64. DHHS, Alcohol and Health, 24.
65. “Results from the 2002 National Survey on Drug Use and Health (NSDUH),
Chapter 2. Illicit Drug Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/
2k2Results.htm#chap2, December 18, 2003.
66. Department of Health and Human Services, Substance Abuse and Mental Health
Services Administration, Substance Abuse Among Older Adults (Washington, D.C.: DHHS,
1998), chapter 1.
67. The National Center on Addiction and Substance Abuse at Columbia University,
Under the Rug: Substance Abuse and The Mature Woman (New York, N.Y.: CASA, June
1998), 3-5.
68. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination,
Technical Assistance Publication Series 11, Chapter 6-Special Populations, Ethnic and Racial
Minority Populations,” http://www.treatment.org/Taps/Tap11/tap11chap6.html#ethnic,
Dec. 18, 2003.
69. Ibid.
70. Ibid.
71. Ibid.
72. Ibid.
73. Ibid.
74. Ibid.
National Conference of State Legislatures
137
Notes
75. Ibid.
76. Ibid.
77. Ibid.
78. Ibid.
79. Ibid.
80. Ibid.
81. Ibid.
82. Ibid.
83. Ibid.
84. Ibid.
85. Ibid.
86. Ibid.
87. Ibid.
88. North Central Regional Educational Laboratory, Human Services Coordination: Who
Cares? (Policy Briefs, Report No. 1) (Oak Brook, Ill.: Evaluation and Policy Information
Center of NCREL, 1996).
89. D.C. McBride, Curtis J. VanderWaal, Yvonne M. Terry, and Holly VanBuren,
Breaking the Cycle of Drug Abuse Among Juvenile Offenders, Office of Juvenile Justice and Delinquency Prevention (November 1999).
90. NCREL, 1996.
91. D. Bailey and K. Koney, “Interorganizational Community-Based Collaboratives: A
Strategic Response to Shape the Social Work Agenda,” Social Work 41 (1996): 602-611.
92. See National Institute on Drug Abuse, Principles of Drug Addiction Treatment: A
Research-Based Guide (Washington, D.C.: National Institutes of Health, 1999); (see also
National Institute of Justice, Case Management in the Criminal Justice System: Research in
Action (Washington, D.C.: NIJ, 1999); see also A.H. Crowe and R. Reeves, 1994.
93. Office of Juvenile Justice and Delinquency Prevention, 1999. Citing others.
94. Office of Juvenile Justice and Delinquency Prevention, Duane C. McBride, Curtis
J. VanderWaal, Yvonne M. Terry, and Holly VanBuren, November 1999.
National Conference of State Legislatures
138
Treatment of Alcohol and Other Substance Use Disorders
95. NIJ, 1999.
96. A.T. McLellan and James R. McKay, “Components of Successful Treatment Programs: Lessons from the Research Literature,” in Allen W. Graham and Terry K. Schultz
(eds.), (1998) Principles of Addiction Medicine (Chevy Chase, Md.: American Society of
Addiction Medicine Inc., 1998).
97. See NIDA, 1999.
98. Also known as the Drug Medicalization, Prevention and Control Act of 1996; see
Arizona Revised Statutes section 13-901.01 et. seq.
99. Known as the Substance Abuse Crime and Prevention Act of 2000; see
www.adp.ca.gov for additional information.
100. See Illinois Compiled Statutes, Chapter 20, section 301/40-5 et. seq.
101. For more information about drug courts and related materials, see the National
Association of Drug Court Professional/National Drug Court Institute, at www.ndci.org.
102. For more information about the TASC model and TASC programs around the
country, see the National Association of TASC Programs, at www.nationaltasc.org.
103. A. Harrell, O. Mitchel, A. Hirst, D. Marlowe and J. Merrill, “Breaking the
Cycle of Drugs and Crime: Findings from the Birmingham BTC Demonstration” Criminology & Public Policy 1, no. 2 (2002): 189-216.
104. For general information on therapeutic communities, see Therapeutic Communities of America, Therapeutic Communities in Correctional Settings: The Prison Based TC
Standards Development Project, Final Report of Phase II (Washington D.C.: The White House
Office of National Drug Control Policy, 1999).
105. G. Melnick, G. De Leon, G. Thomas, D. Kressel and H.K. Wexler, “Treatment
Process in Prison Therapeutic Communities: Motivation, Participation and Outcome,”
American Journal of Drug and Alcohol Abuse 27, no. 4 (2001): 633-50.
106. H.K. Wexler, G. Melnick, L. Lowe and J. Peters, “Three-Year Reincarceration
Outcomes for Amity In-Prison Therapeutic Community and Aftercare in California,” The
Prison Journal 79, no. 3 (1999).
107. California. A National Institute of Drug Abuse (NIDA)-funded study evaluated
outcomes for inmates who participated in nine to 12 months of TC programming operated
by a private agency in a 200-bed unit at the R. J. Donovan Correctional Facility in San
Diego. Upon completion of the TC in the prison, graduates could participate in a TC
treatment program for up to one year in a community-based facility that included services
for the residents’ wives and children. The recidivism rate at 36 months for those who
completed the aftercare component was 27 percent versus 75 percent for other groups.
Texas. In the Texas model, inmates participated in a 500-bed, nine-month modified
TC in Kyle, Texas. Following in-prison TC treatment (ITC), offenders are paroled and
transferred to a community-based residential facility near to their home city where they
National Conference of State Legislatures
139
Notes
continue to participate in TC programming for three months. The transitional centers use
a work-release model and are designed to reintegrate the offender into the community,
while providing ongoing treatment support. Following their stay in the transitional center,
the men are required to participate in up to one year of outpatient counseling. The study
found that “return rates for ITC treated and untreated offenders were not significantly
different (41 percent vs. 42 percent, respectively). However, it was found that 25 percent
of the aftercare completers were returned to custody, significantly less than the rate for the
comparison group”
Delaware. This 1997 study showed that offenders who received TC treatment both in
prison and in the work release center did “by far the best in terms of avoiding relapse and
recidivism” in a one-year follow-up. The NIDA and NIJ-funded three-year follow-up study
showed that clients who also participated in the community aftercare outpatient program
did even better in remaining arrest- and drug-free. After three years, the non-treatment
group had re-arrest rates of 71 percent, those who completed the prison and work release
programs had a re-arrest rate of 45 percent, and those who completed all three steps,
including the community aftercare, had a re-arrest rate of only 31 percent.
108. National Institute of Justice, Breaking the Cycle of Drug Use Among Juvenile Offenders (Washington, D.C.: NIJ, November 1999), 46.
109. Ibid., 50.
110. Ibid., 56.
111. U.S. Department of Justice, Juvenile Offenders and Victims: 1999 National Report
(Washington D.C.: DOJ, 1999), 152.
112. NIJ, Breaking the Cycle of Drug Use Among Juvenile Offenders, 35.
113. Ibid., 47-48.
114. Ibid., 49.
115. Ibid.
116. National Association of State Alcohol and Drug Abuse Directors, National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders (Washington, D.C.:
NASADAD, 1998).
117. NASMHPD and NASADAD, National Dialogue on Co-Occurring Mental Health
and Substance Abuse Disorders (Alexandria, Va., and Washington, D.C.: NASMHPD and
NASADAD, March 1999).
118. “Developing State Outcomes Monitoring Systems for Alcohol and Other Drug
Abuse Treatment: Treatment Improvement Protocol (TIP) Series 14, Chapter 6-Legal Issues in Outcomes Monitoring, Overview of the Federal Confidentiality Laws,” http://
www.treatment.org/Externals/Tip-14/tip-14ch6.htm#_ch6a, Dec. 18, 2003.
119. Ibid.
National Conference of State Legislatures
140
Treatment of Alcohol and Other Substance Use Disorders
120. Ibid.
121. Ibid.
122. Ibid.
123. Ibid.
124. Ibid.
125. Ibid.
126. Ibid.
127. Ibid.
128. Ibid.
129. Ibid.
130. Ibid.
Chapter 5. What Funding Is Available for States to Provide Services
to People Affected by Alcohol and Other Substance Use Disorders?
1. “National Estimates of Expenditures for Substance Abuse Treatment,” http://
www.samhsa.gov/centers/csat/content/idbse.htm, Dec. 18, 2003.
2. Ibid.
3. National Conference of State Legislatures, Health Policy Tracking Service, Issue
Brief: Parity and Other Insurance Mandates for the Treatment of Mental Illness and Substance
Abuse (Washington, D.C.: NCSL, 2003), v.
4. Ibid.
5. “Parity in Mental Health and Substance Abuse Coverage: Expanding Health Benefit Opportunities for Federal Employees,” http://www.opm.gov/insure/mental/html/
parity.htm, Dec. 18, 2003.
6. U.S. Department of Health and Human Services, Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection (Washington, D.C.: DHHS, April 1999), appendix C.
7. “Substance Abuse Prevention and Treatment Block Grant,” http://www.samhsa.gov/
budget/content/2004/2004budget-14a.htm, Dec. 18, 2003.
National Conference of State Legislatures
141
Notes
8. “SAMHSA Proposes Change in Block Grants: Comments Sought on Performance
Partnership Plans,” http://www.samhsa.gov/news/newsreleases/021219nr_perfpartners.htm,
Dec. 18, 2003.
9. Ibid.
10. Ibid.
11. Ibid.
12. Ibid.
13. Ibid.
14. “PUBLIC LAW 102–321, Subpart II, Block Grants for Prevention and Treatment
of Substance Abuse, Sec. 1930. Maintenance of Effort Regarding State Expenditures, Sec.
1930. Maintenance of Effort Regarding State Expenditures,” http://www.treatment.org/
legis/pl102sc1.html#Sec1930, Dec. 18, 2003.
15. Ibid.
16. Ibid.
17. “Developing Competitive SAMHSA Grant Applications, Participant Manual, April
2003, Glossary of Terms,” http://www.samhsa.gov/grants/TAManual/TAmanual_frame.
html, Dec. 18, 2003.
18. “Developing Competitive SAMHSA Grant Applications, Participant Manual, April
2003, Module 1: Know SAMHSA and Its Centers, SAMHSA Organization Chart,” http:/
/www.samhsa.gov/grants/TAManual/TAmanual_frame.htm, Dec. 18, 2003.
19. “SAMHSA Grants Snapshot, A Word From The Administrator,” http://
www.samhsa.gov/grants/content/snapshot/intro.html, Dec. 18, 2003.
20. Ibid.
21. ”Medicaid Enrollment and Beneficiaries: Selected Fiscal Years,” http://
www.cms.hhs.gov/researchers/pubs/datacompendium/2002/02pg34.pdf, Dec. 18, 2003.
22. “U.S. Census Bureau: Population Estimates,” http://eire.census.gov/popest/data/
states/ST-EST2002-ASRO-01.php, Dec. 18, 2003.
23. “National Estimates of Expenditures for Substance Abuse Treatment,” http://
www.samhsa.gov/centers/csat/content/idbse.htm, Dec. 18, 2003.
24. “Medicaid Services,” http://www.cms.gov/medicaid/mservice.asp, December 18,
2003.
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25. U.S. Department of Health and Human Services, Health Care Financing Administration, Brief Summaries of Medicare and Medicaid, July 31, 1997, www.hcfa.gov/pubforms/
mmsum1.htm, Dec. 18, 2003.
26. U.S. Department of Health and Human Services, Health Care Financing Administration, National Summary of Medicaid Managed Care Programs and Enrollment (Washington, D.C.: DHHS, June 30, 1998), http://www.hcfa.gov/medicaid/trends98.htm.
27. U.S. Department of Health and Human Services, Substance Abuse and Mental
Health Services Administration, Managed Care Tracking System (Washington D.C.: DHHS,
July 1998), section V.
28. Ibid.
29. Ibid.
30. U.S. Department of Health and Human Services, Health Care Financing Administration and Administration for Children and Families, Supporting Families in Transition:
A Guide to Expanding Health Coverage in the Post-Welfare Reform World (Washington, D.C.:
DHHS, 1999).
31. “Window of Opportunity for Welfare Reform,” State Legislatures (National Conference of State Legislatures) (April 1999).
32. H. Westley Clark, The Children’s Health Insurance Program: Are Substance Abuse
Treatment Services For Youth Really Optional? (Washington D.C.: Center for Substance Abuse
Treatment, 1999).
33. Shelly Geshan, Substance Abuse Treatment in State Children’s Health Insurance Programs.
34. “Medicaid and EPSDT,” http://cms.hhs.gov/medicaid/epsdt/default.asp, Dec. 18,
2003.
35. DHHS, Substance Abuse Among Older Adults, chapter 1.
36. DHHS, Brief Summaries of Medicare and Medicaid.
37. U.S. Department of Health and Human Services Health Care Financing Administration, HCFA Statistics: Highlights, www.hcfa.gov/stats/hstats98/highli98.htm, Dec. 18,
2003.
38. “National Estimates of Expenditures for Substance Abuse Treatment,” http://
www.samhsa.gov/centers/csat/content/idbse.htm, Dec. 18, 2003.
39. “Answers to Your Questions, What is Supplemental Security Income (SSI)?”
http://ssa-custhelp.ssa.gov/cgi-bin/ssa.cfg/php/enduser/std_adp.php?p_sid=z-U*NOg&p_lva=&p_faqid=93&p_created=955552221&p_sp=cF9zcmNoPTEmcF9ncmlkc29ydD0mc
F9yb3dfY250PTM1JnBfY2F0X2x2bDE9NDgmcF9jYXRfbHZsMj1_YW55fiZwX3BhZ2U
9MQ**&p_li=, Dec. 18, 2003.
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Notes
40. “Answers to Your Questions, What kind of disability benefits does Social Security
pay?”http://ssa-custhelp.ssa.gov/cgi-bin/ssa.cfg/php/enduser/
std_adp.php?p_sid=g2Bi2OOg&p_lva=&p_faqid=153&p_created=955633203&p_sp=cF9zcm
NoPTEmcF9ncmlkc29ydD0mcF9yb3dfY250PTI4JnBfc2VhcmNoX3RleHQ9JnBfc2Vhcm
NoX3R5cGU9MyZwX2NhdF9sdmwxPTEwNSZwX2NhdF9sdmwyPTg4JnBfcGFnZT0x&p_li=,
Dec. 18, 2003.
41. “Green Book—Section 11. Child Protection, Foster Care, and Adoption Assistance, Federal Waivers of Title IV-B and IV-E Provisions,” http://www.acf.hhs.gov/programs/cb/dis/tables/sec11gb/waivers.htm, Dec. 18, 2003.
42. Ibid.
43. Executive Office of the President, Responding to Drug Use and Violence: A Directory
and Resource Guide of Public- and Private-Sector Drug Control Grants, The Safe and Drug-Free
Schools and Communities State Grants Program (Washington D.C.: EOP, 1997).
44. “Safe and Drug-Free Schools State Formula Grants,” http://www.ed.gov/programs/
dvpformula/index.html, Dec. 18, 2003.
45. “Safe and Drug-Free Schools Governors’ Grants,” http://www.ed.gov/programs/
dvpgovgrants/index.html, Dec. 18, 2003.
46. U.S. Department of Justice, Office of Justice Programs/Corrections Program Office, Residential Substance Abuse Treatment for State Prisoners FY 1999 Program Guidance and
Application Kit (Washington D.C.: DOJ, 1999).
47. Office of National Drug Control Policy, Drug Free Communities Grant Program,
November 1998, http://www.whitehousedrugpolicy.gov/prevent/support.html, Dec. 18,
2003.
48. “Programs, Edward Byrne Memorial State and Local Law Enforcement Assistance
(Byrne Formula Grant Program),” http://www.ojp.usdoj.gov/BJA/grant/byrne.html, Dec.
18, 2003.
49. Ibid.
50. “Programs, Drug Court Discretionary Grant Program,” http://www.ojp.usdoj.gov/
BJA/grant/drugcourts.html, Dec. 18, 2003.
51. Ibid.
52. “Reentry: Serious and Violent Offender Reentry Initiative,” http://
www.ojp.usdoj.gov/BJA/grant/reentry.html, Dec. 18, 2003.
53. Ibid.
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54. U.S. Department of Housing and Urban Development, Funding Availability for the
Public Housing Drug Elimination Program, www.hud.gov/nofa/suprnofa/supnofa1/
4340sec10.html, Dec. 18, 2003.
55. U.S. Navy, TRICARE, www.ndw.navy.mil/html/tricare.html, Dec. 18, 2003.
National Conference of State Legislatures