November 6,2000 Work-in-Progress Draft Report

“Effective Medical Treatment of Heroin Addiction in Office-Based Practices with A Focus on Methadone Maintenance”

Draft Report

April 5, 2001

When the Physician Leadership on National Drug Policy first met in the summer of 1997, we identified a number of key issues on which we wanted the PLNDP to focus. The attached report relates to the section of our consensus statement that recommends, "It is time for a new emphasis in our national drug policy by substantially refocusing our investment in the prevention and treatment of harmful drug use reallocating resources toward drug treatment and prevention, utilizing criminal justice procedures which are shown to be effective in reducing supply and demand, and REDUCING THE DISABLING REGULATION OF ADDICTION TREATMENT PROGRAMS. "

In our initial discussions at the New York Academy of Medicine, one of our primary concerns was the over-regulation of methadone maintenance treatment. Since that time, through an NIH Consensus Conference (in which PLNDP members Howard Hiatt and Robert Petersdorf participated) and subsequent HHS initiatives, there has been a shift from FDA regulation of methadone maintenance programs to an accreditation style of regulation at the Center for Substance Abuse Treatment. Coincident with these events, several clinical researchers have become active in testing the usefulness of methadone maintenance treatment in office-based practices.

With the recent expansion of methadone maintenance treatment into medical practice settings beyond large clinic settings, several PLNDP members felt that it was time to review the policies that both support and retard this development. Therefore, a PLNDP meeting was assembled at the New York Academy of Medicine on November 6, 2000 with clinicians, researchers and regulators in order to discuss their experiences in expanding methadone treatment. We were surprised to learn that, prior to this meeting, the investigators had never met.

This meeting, initiated by the Physician Leadership on National Drug Policy, was co-sponsored by PLNDP member Dr. Spencer Foreman, MontefioreMedicalCenter and Dr. Robert Newman, Continuum Health Partners, and in cooperation with PLNDP member Dr. Jeremiah Barondess, New York Academy of Medicine. In addition to the PLNDP National Office’s involvement with the project, PLNDP Chair Dr. June Osborn participated in the meeting.

Our ability to convene such groups and to facilitate communication among such leaders in medicine and public health is extremely valuable according to the positive feedback that we received from this meeting.

This "work-in-progress" report is being circulated to the participants of the meeting and is the first of what I hope will be several such PLNDP-sponsored reports on clinical demonstrations and current research that support our consensus and contribute to enlightened policies.

David C. Lewis, MD
Project Director

Work-in-progress report

November 6, 2000 at the New York Academy of Medicine, NY.

Present: Jeremiah Barondess, Craig Burridge, Holly Catania, Edmund Drew, Ernie Drucker, Michael Glet, Marc Gourevitch, Herman Joseph, David Fiellin, Spencer Foreman, David Lewis, Martin Livenstein, Robert Lubran, Ira Marion, Vince Marrone, John McCarthy, Laura McNicholas, Joseph Merrill, Robert Newman, June Osborn, Hermenia Palacio, Mark Parrino, Ed Salsitz, Robert Schwartz, Janet Stein, Ellen Tuchman, Peter Vanderkloot, David Vlahov, and staff: Avi Astor, Kathryn Cates-Wessel.

In hopes of capturing some of the historical perspective of office-based methadone maintenance practices, Dr. Lewis opened the meeting by asking Dr. Herman Joseph to summarize the work of New York OASAS programs as they have supported these models since 1983. Dr. Joseph provided an overview of their four models in operation in New YorkState: the hospital based physician model at Beth Israel, the Program Pharmacy Model at Albert Einstein College of Medicine, the Nurse Practitioner/Physician model in NassauCounty and recently the Suburban Medical Office Model located in the Buffalo area opened. In the very near future two additional models with new innovations of medical maintenance will be opened.

Dr. Joseph continued saying that the New York System also fosters the integration of methadone maintenance treatment in other treatment environments such as the alcohol treatment centers which have been renamed Addiction Treatment Centers (ATCs). These ATCs include on-site treatment of methadone patients with alcohol problems. Methadone is now dispensed within most of these facilities from the ATC pharmacies. This innovation was preceded by staff education since staff held strong anti-methadone attitudes.

Dr. Joseph discussed how methadone programs within the criminal justice system have remained resistant. In spite of the success of the well known Rikers Jail KEEP methadone program in New York City, they have not been able to expand statewide because of resistance by correctional staff. According to Dr. Joseph, the major resistances to expanding methadone are the misunderstandings, ignorance, and stigma associated with the treatment, the medication and the patients. He feels that education is an essential factor and that new innovations cannot be implemented without addressing community concerns, professional biases and ignorance. He also commented that with methadone patients, the stigma associated with methadone treatment is the major social problem they face.

Following Dr Joseph’s presentation, Dr Edwin Salsitz expanded on his experience at BethIsraelHospital’s ongoing 15-year program, which now has worked with about 300 patients.

The meeting then turned to the experience of a new generation of office-based practice programs to provide an overview of their work.

Presentation 1:
D. Fiellin, Office-based Medical Maintenance in a Network of Primary Care Practitioners, Yale University

In this model 6 community practitioners are prescribing 46 patients using a medical maintenance model with monthly visits and weekly pickup from the practitioners’ offices.

Results: There was a very low percentage of patients that became clinically unstable during the six-month period of the program. Patient satisfaction with the medical maintenance was very high, and the majority expressed that, if given the option, they would prefer to receive methadone maintenance in their physicians’ offices. The benefits mentioned by patients expressing satisfaction with office-based treatment included: only having to come in three times a week, not having to be around “junkies,” increased privacy, enjoyment of relations with staff, convenience of location, and being treated in a more agreeable atmosphere. The dissatisfaction revolved around issues that all patients in the primary care clinic complain about (i.e. having to wait too long, having to come in too much, the parking situation, etc.). Most patients who showed concern during the program were concerned about returning to narcotic treatment centers rather than continuing with methadone maintenance. For a minority of patients, having to pick up medication in the doctor’s office would be problematic just as dispensing insulin in the office for many diabetics. Overall, physicians and staff made a paradigm shift in their feelings/attitudes about dealing with and treating methadone patients.

In general, patients who experienced relapses felt comfortable speaking to clinicians about such episodes.These consultations provided opportunities for clinicians to strengthen their skills in dealing with relapse episodes. In general, clinicians were extremely satisfied with the treatment model and did not feel as though methadone patients had more or less psychosocial issues than other patients. Moreover, they did not take issue with on-site storage of methadone, except for the administrative requirement of having somebody from the DEA continually coming in to check records.

Presentation 2:
Joseph Merrill, Methadone Treatment through an Outpatient Medial Clinic, Harborview Medical Center, University of Washington, Seattle

In this model, 31 stable methadone patients have been transferred to a unit of the Harborview Outpatient Medical Clinic, where they receive their methadone through a pharmacy unit located within the medical clinic that provides their primary medical care. This is a transitional Medical Maintenance model with weekly and bi-weekly pickup.

Results: In this medical model, methadone is distributed through a pharmacy unit, which keeps separate records for methadone patients. Up to a one month supply of methadone is given to patients. Patients also have the option of continuing with psychosocial services at narcotic treatment clinics. In this medical maintenance model, patients undergo transition gradually up to a one-month supply of take-home methadone.

Keeping two separate charts for purposes of confidentiality (i.e. separate methadone record because of extra privacy regulations), one for medical problems and another for methadone maintenance, has lead to complications as well. If a patient comes in with a medical problem that might be related to methadone use, clinicians and patients are often confused as to where the information should be stored. How should methadone information be segregated from medical information? After all, one of the great strengths of the medical maintenance model is integrating medical, psychiatric, and substance abuse care. However, separate charts split up these different forms of care, and thus defeat the purpose. The solution might not lie in lowering the standards for confidentiality in methadone maintenance, but rather in raising the standards for all medical care.

One circumstance where the issue of confidentiality comes up is regarding insurance needs. Patients may not want to release information about their use of methadone to insurance agencies, though they obviously need to release medical information. In addition, you are forbidden to produce methadone records to respond to a subpoena in a methadone program, though you are required to respond in a medical setting. However, clinicians in medical settings might not be forced to respond to a supine regarding records of methadone maintenance. Nevertheless, they would be in an awkward situation as they might claim that federal regulations prohibit them from disclosing certain information, though they may not be able to claim why. Clarifying these issues before the movement to private practice begins is of the utmost importance.

With regards to training, it is necessary for physicians to undergo a short program detailing the basics of methadone maintenance as well as what patients on methadone have gone through. Physicians learned the most from talking to patients eligible for treatment. Lastly, a source of mentorship or clinical support to which physicians may turn with patient-specific questions is key. Such is the model for other clinical practices, so why not for methadone maintenance?

The goal of the program was to implement medical maintenance outside of the experimental context that prevented previous medical maintenance programs from being replicated widely. They were able to obtain regulatory approval from the FDA, DEA, Washington State and the Washington State Board of Pharmacy, and the FDA and CSAT have cited this program as a model for others wishing to use medical maintenance as a mechanism to improve quality and expand access to methadone treatment.

Overall, the patients feel that they lead a more productive life outside of treatment with some requesting decreases in their levels of methadone, but most patients requested increases (>100 mg) to require them coming in less often. Clinicians learned about treating this population with a noticeable decrease in stigma. Even with a one-year criterion of stability, there is a problem with only 10% qualifying – logistics from a policy and a treatment perspective have been very challenging. Medical Maintenance integrated with general medical care is challenging with overlapping and sometimes conflicting medical issues i.e. problem with insomnia.

Discussion:

• D. Lewis was interested in the training aspects for the clinicians – how much is needed and who should train?

• J. Merrill commented that training needed for physicians included one short session about methadone in addition to mentorship or clinical support to ensure patients get the right answers, highly recommending this as well. He felt overall it shouldn’t be very different from training for any other illness.

• J. Barondess asked if there were IRB issues? Any information about social support systems – effective or ineffective? Any data?

• J. Merrill – With regard to IRB we designed the program to be approved as a part of regular methadone treatment through Evergreen Treatment Services and Harborview Medical Center, not as an experimental trial. The program evaluation approved by the University of Washington IRB included only evaluation interviews with patients and physicians and not the treatment protocol themselves.

• M. Gourevitch suggested that he thought the model should be broadened integrating drug and other substance abuse charts with primary care treatment charts – keeping confidentiality of patient rights upheld.

There was quite a lot of discussion about the pros and cons of dual chart keeping –

• R. Newman – we don’t have dual charts in a hospital setting, as it is awkward to have different rules for methadone patients from all other patients.

• D. Fiellin – often patients request it since many of them pay for services out of their pockets to maintain their confidentiality.

• J. Barondess – under current rules – federal law prohibits the release of patient records without consent of the patients and there should be no difference related to methadone patients. What effect does the electronic format have on this?

• C. Burridge commented from the perspective of a practicing pharmacist that they’ve been maintaining electronic records for 5 years.

• S. Foreman mentioned their practice at Montefiore MedicalCenter was to have physicians log in to access patient records – it sets up barriers to penetrate this information. They audit these records periodically to determine if inappropriate log-ins have been made, etc.

• R. Lubran suggested that any guidance toward this issue related to confidentiality of patient rights would be extremely helpful for CSAT to be further informed.

• D. Fiellin – a major factor in this issue is stigma and this could be an important issue for the PLNDP to take on.

• I.Marion – PLNDP could also address insurance issues as patients pay for their own treatment, their employers should not have access to patient records.

• M. Parrino – FDA/CSAT allow every MTP access to medical maintenance treatment and every patient should be covered under patient confidentiality rights.

• D. Lewis commented that a working group should be developed from the meeting to discuss the need for broadening the expansion of treatment related to patient confidentiality rights.

Presentation 3:
Ernest Drucker, Office-based Prescribing and Community Pharmacy Dispensing, Montefiore Medical Center / Albert Einstein College of Medicine (New York)

This is a randomized clinical trial comparing Office-based Practice to usual care in MMTPs. The subjects are 150 women stabilized in methadone treatment, and 15 primary care practitioners have been trained as new prescribers while the women continue to pick up methadone at their MMTP clinics. The first 3 years have demonstrated equivalence to MMTPs for treatment retention and rates of illicit drug use. The next 5 years of funding will incorporate dispensing through four community pharmacies in the Bronx and Manhattan.

Results: Most of their patients do not have primary care physicians of their own and it’s also one of the criteria for being in the program. They found that the key was not training as much as it was ongoing support for medical staff. He also commented that initially there was a little conflict or friction experienced between the prescribers and the MMTPs in the transition stage. He also found physicians willing to learn to deal with the addicted population and the issues around it in their daily practice. Over the next five years they hope to incorporate community pharmacies into the program. More recently he’s found that Pharmacists are becoming more a part of the medical profession once again, and are being integrated into care and treatment. E. Drucker also commented that he felt a need to establish Best Practice Standards and attempt to reverse the 75 years old problem of the medical profession not wanting to get involved in addiction treatment using maintenance drugs.

Stage One of this study involved recruiting physicians and patients to participate in the office-based treatment program. In general, the doctors recruited were experienced in dealing with its population in their practices and open to learning more about methadone and to prescribing methadone. Patients were eager to find a way to manage their addictions outside of the methadone clinic.

Stage Two involves laying out a framework to incorporate community pharmacies into treatment. These pharmacists, unlike those in many large urban pharmacy chains, are a more constant figure who may get to know patients. Integrating community pharmacies into care would also help to reestablish pharmacists as healthcare professionals and would provide a key partner in the effort to treat addiction at the local level. It is essential to facilitate communication between a patient’s doctor, pharmacist, and case manager if the new clinic model that we are proposing is to be effective. We are working on a computerized system that would do just that.

Is there any rationale for including in a protocol that patients should return to the clinical setting if they show evidence of the disease for which they are being treated? Sometimes it might be useful for a patient to return to a specialist if their clinicians feel that the private office is not providing adequate care. This model of taking patients out of specialty treatment and placing them in primary care and possibly returning them to specialty treatment is a model with which doctors are already familiar – e.g. in psychiatric care. How do we determine patients’ needs in primary care settings, and how do we envision the connection between primary care and specialty care? How will patients be moved back and forth between the two? The challenge will be to match the level and intensity of services to the needs of the patient.

Recent legislation allows physicians to prescribe new drugs, like buprenorphine, without statutory or regulatory requirements for counseling. Methadone, has its own set of legal regulations that make it more difficult to prescribe. It seems strange to base a patient’s need for counseling on the legal requirements surrounding the type of drug used rather than on the patient’s individual needs. However, this does not change the fact that buprenorphine would be easier to prescribe. There is a strong political desire to keep buprenorphine and methadone in separate legal camps, and this might have an impact on future addiction treatment. Strong federal regulations on methadone and loose regulations on buprenorphine may lead physicians to prescribe the less satisfactory drugs. Buprenorphine does not reach high tolerance levels and might not be a satisfactory drug in many cases. One role the PLNDP might play would be to look at the effect of legislation on the impact of methadone and buprenorphine distribution.

A broader and more pressing issue is that drug addiction continues to be treated separately from other diseases. R. Newman: It is unheard of for Congress to control the number of patients seen with a given disease, the training that physicians might have, etc. This recent Federal bill reinforces the stereotype that doctors cannot be trusted to treat addiction like other diseases. With regard to the claim that drug addicts are too hard to handle, the same goes for patients with other diseases that suffer at the same time from psychosocial difficulties. We cannot set a double standard for patients who are addicted to drugs and for those who suffer from other diseases. Such action only reinforces the idea that addiction should not be treated in a similar manner to other chronic diseases.

Discussion:

• J. McCarthy inquired as to whether patients will go to hospitals for counseling?

• E. Drucker commented that there’s one MSW counselor/case manager for every 50 people (as NY state regulations require) and we propose to have the medical worker see patients at the pharmacy (which all have private consultation rooms) or at the site of the medical practice (networks of numerous clinics).

• C. Burridge added that in NY they are required to provide counseling and pharmacists are seen as an excellent resource for many referrals – 12 hours/day – 6 days/week.

• E. Drucker talked about the counseling requirement suggesting the need to go beyond the “watchdog” approach and serve as a case manager that coordinates care with the prescriber and pharmacy.

• R. Newman felt that it would be a concern for physicians to eliminate the counseling.

• I. Marion said that services are available that anyone in the program can access as they need guidance (anxious or depressed, etc.)

• L. McNicholas felt that we should move out of specialty treatment and more into primary care – invert the medical model. How much counseling is needed? Connect specialty care with primary care and determine what’s most appropriate for the patient.

• R. Schwartz added that the level of treatment services offered to patients should be based on their needs, much like with the treatment of depression. A newly admitted methadone patient might need more counseling services than a general primary care setting can offer. However, as patients progress, a physician’s office-based practice can manage more stable patients quite well. In addition, Dr. Van King of John Hopkins University is conducting a study in which patients from two methadone clinics in Baltimore, who have obtained at least one year of abstinence, are randomized to one of three conditions: treatment as usual, monthly physician visits and medication pick-up at a doctor's office, or monthly physician visits and medication pick-up at a methadone clinic. Preliminary results indicate that medical maintenance in either setting has high patient satisfaction, low urine positive rates and no detectable medication diversion.

• R. Lubran mentioned pending approval of FDA for drug but deals with no standards – sponsoring of that bill viewed methadone different from other drugs – newer drugs seen as very safe in contrast to methadone.

• R. Newman commented that he felt it was irrational to have legislatures define a patient’s need for counseling or not.

• R. Lubran said that standards for methadone are different and are established by legislature.

• M. Parrino spoke about the recent Federal bill and they felt if methadone was mentioned it would stall approval of buprenorphrine. He also said that patients with co-morbidity (psychiatric plus addiction) do better with counseling but the issue is what level and degree of counseling is needed. On the subject of the length of patient stability in the hub MMTP, Parrino noted that, in general, presenters indicated to him that the average length of pre-referral stability exceeded the 3-5 year range.

• D. Fiellin added that compared with diabetic patients their progress would improve with more counseling and that it’s an opportunity for primary care physicians and narcotics provided with buprenorphine and it’s office-based practice.

• J. Stein felt that it’s not always necessary to refer someone for specialty care but more as a resource for the healthcare professional vs. the patient

Presentation 4:
Jack McCarthy, Director, Rural Network of Office-based Prescribers. BiValley MMTP and UC Davis, Sacramento Cal. (awaiting CSAT funding)

This program has recruited approximately 7 practitioners and 3 pharmacies in rural Shasta County in a network that will serve 130 patients.

Dr. McCarthy began by referencing SB1807 - OBOT Bill; the two main aspects of the bill are: 1) allows methadone programs to contract with physicians in rural agencies to provide for methadone patients in their clinic settings, and 2) mandates drug courts to accept methadone patients.

Difficulty was encountered in rural counties where there was strong opposition to methadone programs, mainly resulting from the denial that a drug problem even exists. In some areas, the DEA opposed storage of methadone in patient offices, citing that such policy caused all sorts of trouble in the 1970’s. However, they cooperated, and we received support from the National DEA, the California Bureau of Narcotics, and police and sheriff organizations, presumably because they were beginning to realize the importance of treatment.

The program involves a dual record system. The patient in the Narcotic Treatment Program will have to have a duplicate record of NTP services to prove that the methadone they are taking is legitimate.

The bill is geared to serve unstable patients, so intensive counseling services will be necessary. Among physicians attending a course sponsored by the California Society of Addiction Medicine, there was a high interest in office-based treatment, so recruitment does not seem to pose a problem. Buprenorphine may be a problem for patients that want methadone in that doctors will find it much easier to prescribe. One difficulty will be distributing methadone on weekends, when offices are closed. Pharmacies may be able to make up for some of the problem, but the difficulty remains.

Drug court judges opposed the proviso to make methadone accepted in drug courts, but the bill passed. Criminal justice may interfere with treatment, and it is difficult in this new practice setting to counteract such interference. In addition, the criminal justice system itself is a neglected place for opioid treatment. Methadone is not distributed in jails, mainly resulting from the fear that it will not be able to be controlled and from the lack of recognition of heroin addiction as a legitimate disease. The result is that detoxification is the "treatment" of choice.

Additional funding will be needed for research on outcomes.

Discussion:

• D. Lewis questioned if judges were against pharmacotherapy in general.

• J. McCarthy felt that judges, in general, promote a drug free model.

• R. Schwartz discussed issues related to criminal justice system. Incarceration of patients receiving opioid agonist therapy often interferes with treatment since methadone and LAAM are generally not available in jails in the United States.

• I.Marion – other medications are provided for those incarcerated but not for heroin addicts.

• M. Parrino suggested this would be something the PLNDP could help with in coordination with National Drug Court Association – help distinguish between buprenorphine and methadone treatment. State by state simultaneously with feds can help move policies to protect the incarcerated patients. Legal strategy is very expensive and difficult.

• H. Catania – when incarcerated they have a right to be treated but not to their treatment of choice.

• E. Drucker suggested that we build a medical constituency to move the criminal justice system along on methadone treatment.

• H. Joseph encouraged the PLNDP to get involved with this issue.

Presentation 5:

Herminia Palacio, PI, Treatment on Demand — Expanding Access to Methadone Treatment, City of San Francisco, Dept of Health. Funded by CSAT, OSI, and SF/ DOH

This municipal program is recruiting practitioners and pharmacists to expand access to methadone treatment.

Results: The primary goal of this program is to expand access to methadone treatment. The project also aims to accommodate patient choice by finding out what patients think would be the most beneficial setting for treatment. Patients have the option to present to old or new programs. We encourage a team approach to treatment that includes the nurse practitioner, doctor, counselor, and pharmacist.

The results of a study aimed at determining clinician interest indicated that pharmacists are excited at the prospect of professional development in this area, though a great deal of mythology still remains regarding who drug addicts are and how they are likely to behave. The more pharmacists are educated, the more enthusiastic they become. Many providers are eager to integrate substance abuse issues with other medical problems. This is especially the case with HIV and AIDS, since much overlap exists between patients who suffer from these diseases and those who suffer from heroine addiction. It is difficult for a clinician to manage anti-retroviral medication when unaware of a patient’s methadone dosage. There is also much overlap between the incidence of Hepatitis C and heroin addiction. Integrated care would greatly facilitate treatment of patients who suffer from these diseases. The complex medical management issues in the care of Hepatitis C patients may not be able to be fully addressed in the narcotic treatment programs as presently structured and might be better cared for in a medical maintenance model.

Another point in need of emphasis is that engaging people in care is more than writing a prescription. Sometimes methadone is not the best option, but this does not mean that patients for whom methadone does not work need be referred to a higher level of care.

General Discussion:

• M. Parrino – when will this program be put into motion?

• H. Palacio – summer 2001 pilot project will begin with a primary care model.

There was quite a bit of discussion about training healthcare professionals about addiction in general and specifically dealing with methadone. A big issue seems to be certifications and who should be doing this if any. E.Salsitz felt that training should emphasize stigma and stigma related to methadone treatment specifically. He commented that with methadone patients there’s even more stigma and 33% request increases in their dose because they are afraid.

•I.Marion – accreditation will help the mainstream deal with stigma.

• D. Fiellin – success breeds confidence and similar to primary care docs dealing with depression so will happen with buprenorphrine and methadone.

• L. McNicholas – specialty organizations (AAAP and ASAM) need to get involved. Many docs within the specialty organizations don’t want to deal with opiate dependence. She felt a need to put effective treatment and effective training before physicians.

• H. Palacio – PLNDP can help with Medical Education aspects – stress medical institutions focus on addiction in a substantial way. Have to trust physicians to come up to speed and to refer to specialist when they are over their heads.

• J. Merrill – effective treatment can truly change the way both physicians and patients view the way methadone treatment is perceived.

• E. Drucker felt that physicians need support from their institutions for working in addiction care and that the more physicians providing care the better.

• R. Lubran commented on CSAT’s priorities-

1. training physicians – addiction and buprenorphrine – all specialty groups based on curriculum are being developed.

2. Anticipate new regulations to help programs meet accreditation and best practice guidelines.

3. Expand access to treatment through innovative treatment models – virtual clinics

• R. Newman – Training is important – why is the government emphasizing newly trained physicians vs. majority of all physicians?

• R. Lubran – methadone treatment as well as buprehnorphrine – raising standards in treatment systems through training existing physicians or retraining existing treatment communities.

• M. Parrino – perceived quality is coming to surface – treatment experience in general is not just the physician’s problem. PLNDP can potentially move these issues along.

List of participants

Jeremiah Barondess, MD
PLNDP Member
President, NY Academy of Medicine
1216 Fifth Avenue
New York, NY 10029
Telephone: (212) 822-7201
Fax: (212) 996-7826

Craig M. Burridge, M.S., CAE
Executive Director
Pharmacists Society of the State of New York
210 Washington Avenue
Albany, New York 12203
Telephone: (800) 632-8822, (518) 869-6595
Fax: (518) 464-0618
craigb@pssny.org

Holly Catania
Director, Methadone Policy Project
The Lindesmith Center
925 Ninth Avenue
New York, NY 10019
Telephone: (212) 548-0165
Fax: (212) 548-4670
hcatania@sorosny.org

Edmund Drew
215 Park Avenue South
New York, N.Y, 10003
edrew@bethisraelny.org

Ernest Drucker, PhD
680 West End Avenue
New York, NY 10025
Drucker@aecom.yu.edu

David Fiellin, MD
Assistant Professor of Medicine
Yale University School of Medicine
333 Cedar Street
P.O. Box 208025
New Haven, CT 06520-8025
Telephone: (203) 688-2984
David.Fiellin@yale.edu

Spencer Foreman, MD
PLNDP Member
President, Montefiore Medical Center
111 East 210 Street
Bronx, NY 10467-2490
Telephone: (718) 920-2001
Fax: (718) 652-2161

Michael Glet
Elm Pharmacy
298 First Avenue
NY, NY 10009
Telephone: (212) 777-0740

Marc Gourevitch
Director, Addiction Medicine
Montefiore Medical Center/Albert Einstein College of Medicine
1500 Waters Place
ParkerBuilding, 6th Floor, Ward 20
Bronx, NY 10461
Telephone: (718) 409-9450
Fax: (718) 823-0883
Mgourevi@montefiore.org

Herman Joseph, PhD
NY State OASAS
501-7th Avenue, 8th floor
New York, NY 10018
Telephone: (646) 728-4523
Fax: (646) 728-4687
Hermanjoseph@oasas.state.ny.us

Mary Jeanne Kreek, Ph.D. (invited)
Professor
Kreek Lab
Kreek@mail.rockefeller.edu

David Lewis, MD
Project Director, PLNDP
BrownUniversity
Box G-BH
Providence, RI 02912
Telephone: (401) 444-1816
Fax: (401) 444-1850
David_Lewis@brown.edu

Martin Livenstein
Executive Director
Committee of Methadone Program Administrators, Inc.
250 Fifth Avenue, Suite 210
New York, NY 10001
Telephone: (212) 447-6682
Fax: (212) 447-6576
Mlivenstein@compa-ny.org

Joyce Lowinson, MD
Adjunct Faculty
RockefellerUniversity
111 East 56 St.
NY, NY 10022
Telephone: (212) 753-8600, (718) 409-1916
Fax: (212) 754-5683
Lowinsj@mail.rockefeller.edu

Robert Lubran
Acting Director
Office of Pharmacologic & Alternative Therapies (OPAT)
Center for Substance Abuse Treatment (CSAT)
RLubran@samhsa.gov

John McCarthy, MD
Executive Medical Director
Bi-Valley Medical Clinic
2100 Capitol Avenue
Sacramento, CA 95816
Jjm_md@pacbell.net

Laura McNicholas, MD, PhD
University of Pennsylvania School of Medicine
Philadelphia VAMC
Behavioral Health 7 East (116)
University & Woodland Avenue
Philadelphia, PA 19104
Telephone: (215) 823-6085
Mcnicholas@research.trc.upenn.edu

Jeff Merrill, MD, MPH
Acting Instructor of Medicine
University of Washington
Harborview Medica Center
325 Ninth Avenue, Box 359780
Seattle, WA 98104
Telephone: (206) 341-4432
Fax: (206) 731-8247
Joem@u.washington.edu

Ira Marion, MD
Associate Executive Director
Albert Einstein College of Medicine
1500 Waters Place
Bronx, NY 10461
Telephone: (718) 409-9450
Fax: (718) 893-7115

Vince Marrone
Vmarrone@tascorp.org

Robert Newman, MD
President & CEO
Continuum Health Partner
555 West 57th St, 19th Fl
New York, NY
Telephone (212) 523-8390
Fax: (212) 523-8433
RGNEWMANMD@aol.com

June Osborn, MD
Chair, PLNDP
President, Josiah Macy, Jr. Foundation|
44 East 64th Street
New York, NY 10021
Telephone: (212) 486-2424
Fax: (212) 644-0765

Hermina Palacio
Special Policy Advisor to the Director
San Francisco Dept o101 Grove Street, Room 324
San Francisco, CA 94102
Herminia_palacio@dph.sf.ca.us

Mark Parrino
President
American Methadone Treatment Assoc.
217 Broadway, Suite 304
New York, NY 10007
Telephone: (212) 566-5555
Fax: (212) 349-1073

Ed Salsitz, MD
Beth Israel Medicine
1st Avenue East 16th St
New York, NY 10003
Telephone: (212) 420-4400.
Fax: (212) 420-2469
Fsalagi@montefiore.org

Robert Schwatz, M.D.
Medical Director
Friends Research Institute
505 Baltimore Avenue
PO Box 10676
Baltimore, MD 21285
Telephone: (410) 923-5116
Fax: (410) 823-5131
rschwartz@sorosny.org

Dr Janet Stein
Beth Israel Medical Ctr.
BAIRD HALL
350 E 17th St
NY, NY 10003
Telephone: (212) 420 4236
JStein@bethisraelny.org

Ellen Tuchman, CSW, PhD
Director, Office Based Methadone Prescribing
Beth Israel Medical Center
215 Park Avenue South, 15th floor
New York, NY
Telephone: (212) 387-3768
Fax: (212) 387-3752
Et288@is9.nyu.edu

Peter Vanderkloot
100 Cooper Street, #4A
New York, NY 10034
Telephone: 212-387-3929
Fax: 212-473-2444
clueless@escape.com

November 1998 Research Report

“Health, Addiction Treatment, and the Criminal Justice System”

November 1998 Press Release

New Studies Find Drug Courts and Drug Treatment of Prisoners, Parolees & Teens Cut Crime and Drug Use

Nov. 10, 1998

WASHINGTON, D.C. --- A major new series of research studies on drug courts and drug treatment programs for prisoners, parolees, and teenage drug users finds that the best new programs reduce drug use, crime, and re-arrest rates.

In analyzing this new level of success, a core component cited in the studies is the need for close collaboration among components of the criminal justice system, community public health agencies, cognitive and behavioral counselors, drug treatment specialists, health care providers and employment specialists.

"These drug court and prison and teen treatment studies show a critically important alternative to strictly punitive approaches. Drug arrests, which have increased about 150% between 1980 and 1995, have overloaded our prisons and done little to cut substance abuse," said David Lewis, M.D., Project Director for Physician Leadership on National Drug Policy (PLNDP) and Director of the Center for Alcohol and Addiction Studies at Brown University.

"A major concern is that drug abusers, with little access to treatment, simply repeat the pattern of drug use, arrest and incarceration. "

"The good news is that when drug treatment is available in the Criminal Justice System, it works," Dr. Lewis added. "The bad news is that it's usually not available."

PLNDP, which is a non-partisan group of 37 physicians organized to do a policy review of the nation's anti-drug efforts, commissioned the studies. Funds for the project come primarily from the John D. and Catherine T. MacArthur Foundation and the Robert Wood Johnson Foundation.

An important finding is that aggressive policing and incarceration have had little effect on drug usage, while greatly increasing the state and federal prison populations. Meanwhile, enforcement costs continue to rise, along with the negative impact on society from drug related crimes and the serious health problems, with related treatment costs, common to many drug abusers.

"There is a growing awareness that effective rehabilitation programs must be developed to reduce the high recidivism rates which are a primary cause of prison overcrowding," according to the study by Douglas S. Lipton, Ph.D. and Frank S. Pearson, Ph.D. of the National Development and Research Institutes, Inc. in New York City.

"These studies show us how to save the nation major enforcement costs, greatly reduce crime rates and illegal drug use, and return more people to positive, healthy lifestyles. That means optimizing drug treatment through the drug courts, through in-prison treatment and parolee treatment, and by treating teenagers," said June Osborn, M.D., who is Chair of PLNDP and President of the Josiah Macy, Jr. Foundation in New York City.

"Still," said Lonnie Bristow, M.D., the Vice Chair of PLNDP and a past President of the American Medical Association, "This field is in an evolving stage. We need more serious research, and ongoing evaluations of existing programs, to determine which programs work best, for who, and how to sustain them."

Dr. Lewis added that the "working relationships between the Criminal Justice system and the mainstream of the health system are still few and far between. But where they have been established the results are very promising."

As said in "The Effectiveness of Correctional Treatment Revisited" study by Drs. Lipton and Pearson of the National Development and Research Institutes, Inc., more research is needed "to provide correctional administrators, policy makers, legislators, service providers and social scientists with answers to the questions 'what works? with whom? and under what circumstances?'"

However, a baseline conclusion comes from researchers at the Drug Abuse Research Center at the University of California, Los Angeles. The study by M. Douglas Anglin, Ph.D., David Farabee, Ph.D., and Michael Prendergast, Ph.D., said, "The drug abuse research literature provides overall support for the coercion of offenders into treatment for their drug problems." Their study "provides empirically based recommendations for enhancing the use of coercion to increase the effectiveness of offender drug treatment."

DRUG COURTS

According to the drug court study prepared by Steven Belenko, Ph.D., of the National Center on Addiction and Substance Abuse at Columbia University, "All evaluations that have compared post-program recidivism for drug court graduates and comparison groups find much lower recidivism rates...

"A few evaluations have gathered employment data, and these generally found that drug court participants are more likely to gain employment while participating and upon graduation," the study said.

Relative to the importance of collaboration between drug courts and their communities, Dr. Belenko's study also said, "Drug courts have been quite successful in bridging the gap between the court and the treatment/public health systems and spurring greater cooperation among the various agencies and personnel with the criminal justice system, as well as between the criminal justice system and the community."

As to the cost savings, the Belenko study said, "Research by the RAND Corporation on the relative cost-effectiveness of treatment, domestic enforcement, interdiction and source country control found that for heavy users of cocaine, treatment interventions would cost one-seventh as much as enforcement to achieve the same reduction in cocaine use."

A comprehensive study of 440 drug court clients in Multnomah County, Cal. found a two-year savings to the state of $10.2 million. This includes savings in the criminal justice system, victimization, theft reduction, public assistance and medical claims.

The studies indicate that the most important components of the most successful drug courts, which now exist in more than 275 jurisdictions, include close, efficient, team-based collaboration between the drug court and the community's drug abuse treatment systems. This includes the coercive power of the court to promote abstinence and prosocial behavior. But as important, this also means personalized problem-solving efforts to include skilled drug counseling, job referral counseling, personal psychological problems, and meeting the drug abuser's sometimes significant health care needs. Substantive involvement of a drug abusers family can also be critical in the success of treatment, according to an independent study by Carol Shapiro, MSS, who is Project Director of La Bodega de la Familia in New York City. While some drug abusers do not have the family structure or relationships for such efforts, many do.

"If parole and probation officers could turn to families as natural case managers, there would be an additional resource from which to draw to help an offender stay the course," Ms. Shapiro's study says. "When supported, families can offer instrumental and emotional support; can serve as supervisors, mentors, and confidants; and can operate as a check on negative health behaviors."

Research shows that a substantial portion of drug or alcohol-abusing offenders enter prison with various infections, nutritional deficiencies, liver problems, sexually transmitted diseases, HIV/AIDS, violence related injuries, dental problems, and other physical and mental trauma.

A national review of drug courts by researchers at American University found that the best organized ones, with judges who reach out and effectively engage their community's best resources, have produced major reductions in drug use, recidivism and crime.

A key marker of success is the drug abuser remaining in the program. "Retention rates for drug courts are much greater than the retention rates typically observed for criminal justice offenders specifically, and treatment clients in general," the Belenko report says.

The best long-term residential treatment (LTR) is similar to the services offered by the drug courts, and the outcomes in the LTR circumstances are very similar. For instance the study on "Correctional Treatment in Community Settings," by D. Dwayne Simpson, Ph.D. and Kevin Knight, Ph.D. of Texas Christian University, said, "Drug use rates following LTR treatment declined by 67% from pretreatment levels for weekly cocaine use, 65% for weekly heroin use, and 53% for heavy drinking."

In short, the best drug courts provide more comprehensive and closer supervision of the offender than other forms of community supervision. And successful drug courts can work as well with the more common first-time offenders as they do with those with a chronic history of drug use and arrests.

PRISON DRUG TREATMENT

An important factor in prison-based treatment success is a prisoner's self-selection for the program. "The Effectiveness of Correctional Treatment Revisited" study by Douglas S. Lipton, Ph.D. and Frank S. Pearson, Ph.D., of the National Development and Research Institutes, said, "Among those persons who opt for treatment, self selection contributes to retention in and compliance with the treatment regimen, and thereby to treatment efficacy."

"Prior research suggests an ideal treatment of three to nine months and several episodes of primary treatment, aftercare, and relapse should be expected," according to the Drug Abuse Research Center study by Drs. Anglin, Farabee and Prendergast. One reason is that drug dependency tends to be a relapsing condition. Still, according to their study, "approximately 50 percent reported that they would be willing to participate in an in-prison drug or alcohol program even if it meant extending their stay in prison for three months."

A serious problem is that for many prisons there is a greater demand for treatment than there are qualified professionals to provide it.

Drs. Lipton and Pearson point out in their study that two modalities stand out as successful treatments for prison inmates who have very serious predatory behavior or are hard-core users of cocaine and other drugs. Therapeutic communities and cognitive behavioral treatments appear to produce consistent, positive outcomes in terms of reduced recidivism.

They also note the importance of the continuity of treatment after prison release.

An analysis by The National Center on Addiction and Substance Abuse at (CASA) Columbia University "estimated that each inmate who successfully completes a one-year prison-based treatment program and remains drug-free and employed after release, generates $68,800 in economic benefits, compared to a treatment and aftercare cost of $6,500."

PAROLEES AND COMMUNITY AFTERCARE

While two-thirds of probationers have had serious drug and alcohol problems, only 17% of these probationers have access to substance abuse treatment once they leave prison and return to their communities.

However, according to the "Correctional Treatment in Community Settings" study by Drs. Simpson and Knight at Texas Christian University, long term residential (LTR) treatment for these former prisoners can make major improvements. According to their study of the best LTR programs, weekly cocaine use dropped by 67%, weekly heroin use by 65% and heavy drinking by 53%.

Particularly dramatic were their findings that 27% of "aftercare completers" returned to custody, compared to 75-84% returning to custody from comparison groups.

Their study also reflected the findings of other studies, that those who stayed in treatment for 3 months or more had significantly better outcomes. And like the positive outcomes in drug courts, parolees who had legal pressure to stay in the program had much better outcomes. Again, like the drug courts, this is accomplished by positive organizational connections between the community treatment system and the criminal justice system, where there is genuine concern for the enrollee.

"Better therapeutic engagement and retention rates are needed," Drs. Simpson and Knight said, if we hope to sustain these important improvements in patient outcomes. While passage of the 1994 Crime Act produced an increase in emphasis and resources for adjudication and treatment for drug cases, much more remains to be done.

This includes more work "to establish standards and procedures for effective treatment protocols" for those who leave prison, their study said.

JUVENILE SUBSTANCE ABUSE TREATMENT

The growing body of research on juvenile drug treatment indicates that the best programs can cut recidivism by 30% or more.

In the "Substance Abuse and Juvenile Centers" study by Ken C. Winters, Ph.D., he said, "This is a rather substantial drop and rather impressive given that the juveniles involved exhibited delinquency at the upper end of the severity continuum."

Dr. Winters points out that conduct and delinquency problems "have shown a deep, pervasive and long-standing association with youth drug involvement." While there is a complex relationship between substance abuse and delinquency, most studies indicate that the conduct problems usually precede the development of substance abuse problems. Thus delinquency is a key risk factor for adolescent substance use and abuse, rather than drugs triggering delinquency.

His study points out that there are "preliminary indications that desistance of delinquency behaviors during adolescence and young adulthood is associated with a discontinuation of substance abuse over time." In contrast, onset of substance abuse early in adolescence is a predictor or ongoing drug abuse and later criminality.

The Winters study offers a list of program components for which there is "clear and credible evidence" that they will reduce substance abuse, violence and disruptive behaviors among youth in grades K-12.

These include: targeting high risk youth; increased involvement/supervision with an adult; increased accountability to an adult role model; sustained length of program across early years and through high-risk period of puberty; skill enhancement of youth and parents and/or guardians; not a punishment model; not solely peer-lead; multiple components, preferably with the flexibility to address individual- specific needs.

Dr. Winters' study said that "the increasingly complex nature of both delinquency among juveniles and drug abuse has contributed to more serious and violent criminal activity and escalating degrees of substance abuse." The factors that bring a youth into the courts include family issues, community factors, peer issues, and other individual and environmental variables.

Problematic youth drug abuse can trigger serious consequences including psychiatric co-morbidity and suicide, mortality from drug-related traffic crashes, risky sexual practices, and substantial health care costs.

Since conventional approaches, such as high levels of arrest, are having little effect on juvenile substance abuse, a growing number of jurisdictions are considering adaptation of adult drug court practices to juveniles.

One of the many challenges to this approach is the fact that most adolescent substance abusers have rarely "hit bottom" like many long-term adult substance abusers have, which gives teenagers much less motivation to engage in a recovery process.

In the new adolescent model, which has some parallels with adult drug courts, "treatment personnel and representatives of health and social service agencies in the community participate from the beginning and function as partners with juvenile justice system in designing the program." These partners collaborate to agree on a strategy to "maximize the safety needs of the community and to address the treatment needs of the drug-abusing offender."

In closing, the Winters report said, "Judges report impressive sustained turnaround by juveniles who were otherwise at high risk for continued, escalating criminal involvement and drug abuse. It has also been observed that the juvenile drug court and diversion programs exercise closer supervision over the juvenile offender than would be provided in the traditional court process."

In conclusion, these various studies should help develop the effectiveness of drug treatment in drug courts, in prison, for parolees, and for adolescents. Without such progress the national trend is likely to continue for more apprehension of low-level street dealers, stronger penalties for drug sales and possession, and a proliferation of mandatory sentencing laws for drug related crimes.

The outcome will be increasing overcrowding of jails and prisons, increasing law enforcement costs, and little impact on drug usage, related crime, health and social problems.

List of Lead Researchers

M. Douglas Anglin, Ph.D. is Director of the University of California at Los Angeles Drug Abuse Research Center and Professor in Residence of Medical Psychology in the Department of Psychiatry and Biobehavioral Sciences, at the University of California. He has devoted over twenty-five years to research in the area of drug use research with a special focus on drug epidemiology, evaluation of treatment, and the social and individual consequences related to drug use. Dr. Anglin has written over 150 articles for policymaking, practitioner, and other professional journals. He has also served as a member of several advisory and task force panels on drug use and drug user treatment.

Steven Belenko, Ph.D. is a Senior Research Associate at The National Center on Addiction and Substance Abuse at Columbia University. Previous research and management positions were at the New York City Criminal Justice Agency, the Mayor's Criminal Justice Coordinating Council, Mathematica Policy Research, and the Vera Institute of Justice. He has directed a number of research projects on the impact of drug offenders on the criminal justice system, substance abuse treatment for criminal offenders, crack cocaine, and drug courts.

David Farabee, Ph.D. has served as lead analyst for criminal justice research at the Texas Commission on Alcohol and Drug Abuse (1992-1995), Assistant Professor of Psychiatry, and Research Scientist at the University of Kentucky Center on Drug and Alcohol Research (1995-1997). He is presently study director of a five-year evaluation of the California Substance Abuse Treatment Facility (funded by the California Department of Corrections) and Principal Investigator for a multisite evaluation of three residential substance abuse treatment facilities for youth offenders (funded by the California Youth Authority). He has published in the areas of substance misuse, crime, and offender treatment.

Kevin Knight, Ph.D. is a Research Scientist at the Institute of Behavioral Research (IBR) at Texas Christian University. His research, reported in over 30 publications, centers on evaluating corrections-based treatment effectiveness. His recent work emphasizes the assessment of treatment process and the development of evaluation systems for correctional settings. Since joining the IBR faculty in 1991, he has been centrally involved in the design and implementation of several longitudinal evaluations for treatment of probation and prison populations. As a result, he has worked closely with criminal justice agencies and data systems at national and regional levels. Dr. Knight also has served as an advisor to a variety of organizations which address drug abuse and related policy issues.

Douglas S. Lipton, Ph.D. is a Senior Research Fellow at National Development and Research Institutes, Inc. (NDRI) in New York City. From 1988 to 1992, he was Director of Research at NDRI (then Narcotic and Drug Research, Inc.). Dr. Lipton is currently conducting a NIDA-funded comprehensive meta-analysis of all correctional treatment studies from 1968-1996, measuring substance abuse and mental health within the Deaf population, and is conducting a national evaluation of residential substance abuse treatment in correctional settings (with a cooperative agreement grant from the National Institute of Justice). He has evaluated drug abuse control and treatment programs around the world for the UN, consults regularly with HM Prison Service in GB and the CSC in Ottawa, and served as expert consultant to the Partnership for a Drug Free America since its origin. He has taught at several universities and co-authored or edited 6 books and almost 200 publications.

Frank S. Pearson, Ph.D. is Project Director of the National Institute on Drug Abuse funded meta-analytical review of evaluation research on correctional treatment programs, reported from 1968 to the present. He is also Project Director on a project funded by the National Institute of Justice (NIJ) to provide a national evaluation of the Residential Substance Abuse Treatment (RSAT) programs being funded by the Corrections Program Office. Previously, while an Associate Research Professor at Rutgers University from 1983 to 1994, he conducted a variety of research projects, including the following: Co-Principal Investigator and Study Director of a four-year project to conduct a research evaluation of the State of New Jersey's Intensive Supervision Program; Co-Principal Investigator and Study Director of a research project examining urinalysis-based deterrence of drug use by convicted felons while they are under supervision in the community; Co-Principal Investigator on a research project to analyze national survey data, collected by the U. S. Census Bureau, focusing on the relation of school-system efforts at control and discipline to rates of criminal victimization.

D. Dwayne Simpson, Ph.D. is Director of the Institute of Behavioral Research (IBR) and the S.B. Sells Professor of Psychology at Texas Christian University. His research on drug addiction and treatment effectiveness (reported in over 200 publications) has included several large-scale longitudinal evaluations in national and regional multisite projects. His recent work emphasizes assessment of patient functioning and service delivery process, and how these factors influence treatment engagement and retention rates, stages of recovery, and long-term outcomes of addicts. It includes the development of cognitive and behavioral interventions that can enhance patient services and improvements in program management, both in community-based and correctional treatment settings.

Ken Winters, Ph.D. is the Director of the Center for Adolescent Substance Abuse and an Associate Professor in the Department of Psychiatry at the University of Minnesota. Dr. Winters and his colleagues have developed a widely-used assessment system for the evaluation and referral of adolescents suspected of problems due to drug abuse. His research interests include the assessment and treatment of adolescent drug abuse, the role of attention deficit/hyperactivity disorder and conduct disorder as a risk for early drug involvement, and the prevalence and etiology of the spectrum of addictive disorders. Support for Dr. Winters' research is primarily provided by NIDA.

List of Respondents

Paul Gendreau, Ph.D. is Professor of Psychology and Director of the Criminal Justice Studies Centre at the Saint John Campus of the University of New Brunswick. He is also a licensed clinical psychologist. The main thrust of his research over the years has been concerned with the prediction and treatment of criminal behavior and the effects of prison life.

Carol Shapiro is Director of La Bodega de la Familia, a neighborhood drug crisis center and a project of the Vera Institute of Justice. Previously, she served as a consultant to Her Majesty's Home Office in London, an Assistant Commissioner for the NYC Department of Correction, and an administrator for an applied research center at Rutgers University Graduate School of Criminal Justice. For over 20 years, Ms. Shapiro has been a catalyst for criminal justice reform, focusing specifically on the development of alternatives to custody, victim/offender services, and substance abuse policy. Both her professional experiences and writing reflect her commitment to working in partnership with communities and criminal justice, health, and social service systems to reduce reliance on incarceration while addressing concomitant victim, offender, and neighborhood issues.

Donald S. Shepard, Ph.D. is Research Professor at the Institute for Health Policy at the Heller School, Brandeis University. A health economist, his research focuses on cost-effectiveness analysis and financing of substance abuse treatment and other health services. Dr. Shepard is currently principal investigator of a multi-site NIDA study on cost-effectiveness of drug treatment and a NIAAA evaluation of the impact of managed care programs for substance abuse for Medicaid recipients in Massachusetts and Michigan. He also leads the cost and cost-effectiveness analyses in a major national study of substance treatment (the Alcohol and Drug Services Study) and in an analysis of substance abuse treatment in Connecticut prisons.

Constance Weisner, Ph.D. is Area Director for Health Services Research at the Alcohol Research Group and Adjunct Professor at the School of Public Health, University of California, Berkeley. She is on the National Advisory Council of the Center for Substance Abuse Treatment and a member of the World Health Organization's Expert Advisory Panel on Drug Dependence and Alcohol Problems. She conducts research on substance abuse problems in health and human service populations, access to treatment, and treatment outcome.

Selected Slides

March 1998 Research Report

“Addiction and Addiction Treatment”

March 1998 Press Release

Major New Study Finds Drug Treatment as Good as Treatments for Diabetes, Asthma, etc., and Better and Cheaper Than Prison

March 17, 1998

WASHINGTON, D.C.--- A major review of more than 600 peer reviewed research articles, plus original data analyses, show conclusively that drug addiction treatment is very effective and that it works as well as other established medical treatments for illnesses such as diabetes, asthma and hypertension.

The study also compared the outcome of treatment of a drug addict with imprisonment and found that treatment is an effective anti-crime measure and less costly than prison.

These improved outcomes include greatly reduced medical costs to society, returning many more drug addicts to normal, healthy lifestyles and gainful employment, major crime reductions and savings that would otherwise be spent on new prisons and law enforcement.

The study released today was sponsored by Physician Leadership on National Drug Policy (PLNDP), a group of 37 distinguished physicians that includes high ranking officials from the Administrations of Presidents Reagan, Bush and Clinton. They include David Kessler, M.D., immediate past Commissioner of the Food and Drug Administration (FDA), Louis Sullivan, M.D., Secretary of Health and Human Services (HHS) under President Bush, and Edward Brandt, M.D. and Philip Lee, M.D., who were Assistant Secretaries of HHS under Presidents Reagan and Clinton, respectively.

Other members of the PLNDP include Lonnie Bristow, M.D., Past President of the American Medical Association (AMA), Richard Corlin, M.D., Speaker of the House of Delegates of the AMA, June Osborn, M.D., former chair of the Congressionally appointed National Commission on AIDS, former U.S. Surgeon General Antonia Novello, M.D., Frederick Robbins, M.D., a Nobel Laureate, as well as the editors of the JAMA, The New England Journal of Medicine and Science.

"The good news is that today's scientific findings will help us select and fund the best methods to reduce drug addiction. This will result in greatly reduced medical costs and many more people back to gainful employment. The reduction in crime also means less spent on jails and police work," said David Lewis, M.D., Project Director for PLNDP.

"The bad news is that most Americans don't yet understand how well drug treatment works. We all want a healthier society and safer streets, and now we have the scientific research showing us how to get there," Dr. Lewis added. He is also Director of the Center for Alcohol and Addiction Studies at Brown University.

Another new study to be released in the March 18 edition of the Journal of the American Medical Association (JAMA), and distributed at today's press conference with the permission of JAMA, found diminishing public support for drug treatment, and increased support for "more severe penalties for the possession and sale of drugs."

The survey of more than 100 public opinion polls taken between 1951 and 1997 found that the majority of respondents also favored more anti drug education in schools and more funding for police. The JAMAstudy by Robert Blendon, Sc.D., of the Harvard School of Public Health, says that 78% of Americans "see the War on Drugs as having failed thus far..."

According to Dr. Blendon's study, "public support for increased spending for drug treatment has declined from a high of 65% in 1990 to 53% in 1996."

June Osborn, M.D., the Chair of PLNDP who is also President of the Josiah Macy, Jr. Foundation in New York City, said, "Dr. Blendon's study is of real value because it tells us what we have to do. Doctors, members of Congress, law enforcement officials and public health experts must reach out to the public with the message of drug treatment's power to reduce substance abuse, reduce medical costs, and reduce crime more than any other single approach.

That means creating more treatment programs where they are needed, and more funds for the good ones to expand," she added.

Relative to the PLNDP study, Lonnie Bristow, M.D., the Vice Chair of PLNDP and Past President of the AMA, said, "doctors have not been sufficiently involved in diagnosing and treating substance abuse, with a major reason being the stigma attached to substance abuse.

"The research we are releasing today shows, conclusively, that drug addiction is very treatable and that it reaches across all strata of society with affluent, educated Caucasians being the most likely drug users, and the most likely to be addicted," Dr. Bristow said.

"Stigmatizing drug abusers is counter productive both for those who need treatment, and for society. Stigma discourages drug abusers from seeking help, discourages doctors from providing it, and discourages health policy people from finding the best ways to deliver treatment," Dr. Bristow added.

The report released today on drug addiction and treatment is an integrated effort by leading researchers to provide a scientific foundation on which to build the best drug policies. The report includes the following five components:

Myths and Facts about Drug Use and Addiction
The major, false stereotype is that all drug addicts are social misfits and outcasts even though drug use is common through all segments of society. In reality the "typical" American family is greatly impacted by addiction, and those family members can have their lives turned around by entering treatment. Unfortunately, stigma is a barrier to those who would otherwise seek treatment, to doctors who would otherwise do more in treating addiction, and to legislators and public health officials who would otherwise do more to make treatment available.
Principal Researcher, Jeffrey Merrill, University of Pennsylvania.

Prevalence and Costs of Addiction Relative to Other Chronic Diseases
The economic impact of addictions, including lost productivity, medical and other costs is greater than any other chronic medical conditions. However drug treatment greatly reduces all these costs. Improvements in employment status and in work productivity, in addition to medical savings, far outweigh the costs of drug treatment. Drug Addiction is a chronic health problem like heart disease, diabetes, smoking, alcoholism, and stroke. As with these other health problems, behaviors such as diet, exercise and taking medications appropriately, affect the natural progression and treatment outcomes of drug addiction.
Principal Researcher, Henrick Harwood, The Lewin Group

Is Drug Dependence a Treatable Medical Illness?
Drug dependence meets the criteria for a treatable, chronic medical condition and is as consistently diagnoseable as other illnesses. As important, addiction treatment has outcomes comparable to their chronic conditions.
The heritability, or estimate of genetic contribution for addictions is comparable to that of hypertension, diabetes, and asthma.
Comparisons of medication and behaviorial compliance reveals that addicted patients have compliance rates comparable to patients receiving treatment for diabetes, asthma and hypertension. In fact the likelihood of requiring additional treatment within a 12 month period is generally higher for diabetes, hypertension and asthma than for drug addiction.
Principal Researchers:
Thomas McLellan, Ph.D., University of Pennsylvania
Charles O'Brien, M.D., Ph.D., University of Pennsylvania
Norman Hoffmann, Ph.D., Brown University
Herbert Kleber, M.D., Colombia University


Cost-Effectiveness of Drug Treatment

Among a list of more than 500 health and life saving measures, addiction treatment consistently ranks among the top 10%. Compared to other chronic conditions, additional professional services to enhance maintenance of recovery are among the most cost-effective forms of treatment
In addition to considerable savings in short and long term medical treatments, major savings to the individual and society also come from significant drops in interpersonal conflicts, various types of accidents, crime and assaults.
Principal Researcher, Donald Shepard, Ph.D., Brandeis University

Returns on Drug Addiction Treatment Investments

Alcohol and drug addiction make a major contribution to the incidence and severity of a wide range of medical conditions, such as certain forms of cancer, pancreatitis, endocarditis, injury and AIDS.
Although addicted persons are among the highest users of medical care, only 5% to 10% of these costs are due to addiction treatment. The rest is attributed to medical problems that are most often the result of, or triggered by the addiction. However addiction treatment produces marked reductions in medical care utilization and costs.
While reduced health care costs are impressive, even larger savings can be made in other areas. The most dramatic return is the effectiveness of drug addiction treatment in reducing the occurrence and costs relating to crime.
Principal Researcher, James W. Langenbucher, Ph.D., Rutgers University.

List of Lead Researchers

A. Thomas McLellan, PhD is a Professor of Psychiatry at the University of Pennsylvania and the Senior Scientist at the PENN/VA Center for Studies of Addiction. Dr. McLellan and colleagues have developed the Addiction Severity Index (ASI) and the Treatment Services Review (TSR) an d have used these evaluation instruments in over 150 studies of psychosocial therapy, pharmacotherapy, and combined interventions in the treatment of substance abuse disorders. He is interested in the measurement of treatment outcome and effectiveness and in the matching of particular types of treatment to specific types of patients.

Henrick J. Harwood is Vice President with the Lewin Group and has studied the economics and policy of alcohol and drug abuse since 1976. Previously he served in the Office of National Drug Control Policy/Executive Office of the President. He has been on staff at the Institute of Medicine/National Academy of Sciences and at the Research Triangle Institute, where he directed Economic Costs of Alcohol and Drug Abuse and Mental Illness--1980. Mr. Harwood is currently performing a new study of the costs of drug abuse for NIDA and NIAAA. He coedited the IOM report "Treating Drug Problems" and directed the economic analysis on the CALDATA study.

James W. Langenbucher, PhD is a Clinical Psychologist and Associate Professor at the Center of Alcohol Studies, Rutgers University. He is a federally funded researcher with interests in psychiatric diagnosis and the application of health economics to public policy for mental health services. Dr. Langenbucher is senior author of Socioeconomic Evaluations of Treatment, the most comprehensive review of the health economics of addictions treatment available, which was published in 1993 by the White House Printing Office and distributed broadly to lawmakers and policy analysts here and abroad.

Jeffrey C. Merrill is the Director for Economic and Policy Research of the Treatment Research Institute at the University Pennsylvania School of Medicine. He is currently involved in a number of research projects looking at issues pertaining to substance abuse and criminal justice, welfare reform, and managed care. Much of his work examines both the costs of substance abuse and the potential cost offsets that may result from prevention and treatment programs. Mr. Merrill serves as an advisor to a number of federal agencies and is the author of numerous articles as well as a book on health care reform.

Donald S. Shepard, PhD is Research Professor at the Institute for Health Policy at the Heller School, Brandeis University. A health economist, his research focuses on cost-effectiveness analysis and financing of substance abuse treatment and other services. Dr. Shepard is currently principal investigator of a multi-site NIDA study on cost-effectiveness of drug treatment and a NIAAA evaluation of the impact of managed care programs for substance abuse for Medicaid recipients in Massachusetts and Michigan. He also leads the cost and cost-effectiveness analyses in a major national study of substance abuse treatment (the Alcohol and Drug Services Study) and in an analysis of substance abuse treatment in Connecticut prisons.

List of Organizations Represented
Selected Slides