ASAM Seeks to Improve Treatment Access

In April, the American Society of Addiction Medicine (ASAM) marked its 50th anniversary at the 35th Annual Medical-Scientific Conference in Washington, D.C. A congratulatory letter from President George W. Bush was read at the opening of the conference. "Addiction destroys the lives of countless Americans, shatters families and threatens the safety of our neighborhoods," Bush wrote. "Since 1954, your organization has been committed to educating our country's medical community about this issue and improving treatment for individuals suffering from addiction."

Lawrence Brown Jr., M.D., ASAM president, described support of preventive programs, addiction research and efforts to lobby for science-based public policy. Although Brown conceded that political and economic factors often hold sway in policy formulation and implementation, he encouraged ASAM to maintain a scientific base for political activism.

"It is incumbent upon us to appreciate and know the science," Brown said, "and at the same time, to be able to translate that into a manner that our public and our public servants can appreciate."

Several speakers offered perspectives on public policy toward addicts and addictions. Andrea Barthwell, M.D., past ASAM president and current deputy director for demand reduction in the White House Office of National Drug Control Policy (ONDCP), described how the ONDCP advises President Bush in policy formulation and responding to emergent issues.

Barthwell indicated there had been some concern that the Bush Administration would structure the ONDCP around interdiction. Instead, the office was charged with three priorities: "Stopping use before it starts, healing America's drug users and disrupting the market."

The ONDCP was not charged, Barthwell emphasized, to address a "treatment gap" in the United States by increasing availability of addiction treatment programs. While acknowledging that there are waiting lists for admission to licensed narcotic addiction treatment clinics, she argued, "the big problem in this country is waiting for people who have this problem to recognize that they have a problem and get into treatment."

Barthwell quoted John Walters, the ONDCP director, on the many drug users who don't consider themselves drug abusers in need of treatment: "4.6 million of the 6 million people who need treatment don't know it. Health care professionals are a critical tool in reducing the tragic 'denial gap.'"

While the Bush Administration has increased the level of funding for addiction treatment, Barthwell noted, it has not come with a mandate to increase treatment capacity, but to increase the numbers of addicts who achieve recovery. One initiative being undertaken with the Substance Abuse and Mental Health Services Administration (SAMHSA) should increase access to screening, brief interventions and referral to treatment.

She encouraged listeners to support this initiative. "We need people such as yourselves, who are more knowledgeable, to link more thoroughly to the drug treatment system, to help them improve the quality of what's going on across the country."

She also specifically asked for help in educating about the dangers of prescription drug abuse. "It will be a much better outcome if the medical community gets engaged to self-regulate, self-educate and take some responsibility for educating the public, rather than allowing the government to do that for you."

In another session, other speakers argued that the substantial treatment gap should be addressed by policies that affect public funding for treatment as well as private health insurers. Donald Kurth, M.D., chairperson of the ASAM Advocacy Committee and associate professor and chief of addictions medicine at Linda University in California, lamented the inadequacy of current public policies and of access to treatment.

"Our addiction treatment public policy is going backward," Kurth asserted. "Between 1990 and 2000, insurance benefits for addiction treatment decreased by 75%. Is this because the disease is going away? Is this because we've cured it?

"We know that we can treat this disease," Kurth added, "and yet, we can't seem to provide these benefits for the people who have the disease."

Paul Samuels, director of the Legal Action Center in New York, concurred. "There is a huge treatment gap. There are hundreds of thousands of people ... who want treatment for alcohol and drug problems and can't get it."

This gap between the number who suffer with addictive illness and those who receive treatment is unique, according to Samuels. "Can you imagine the hue and cry around the country if there were a quarter of a million people who had heart disease and could not get care?"

These addicts don't just disappear, Samuels stated, but present in the criminal justice system, emergency departments and homeless shelters. "The dysfunctions that are created and the human toll in death and misery are really inexcusable," he said.

He suggested that public policy has not adequately supported treatment systems because too few people know anyone in recovery. Furthermore, the face of the illness remains the addicted who are dysfunctional, disrupt society, commit crimes and appear unable to achieve recovery. He indicated his optimism, however, about current opportunities to affect public policy. These are occurring in part, Samuels said, because of the growing constituency of successfully recovering addicts and their families.

Samuels encouraged attendees to participate in the advocacy process, noting the effect that individual voices and correspondence can make. "Every elected official with whom I have ever come into contact ... keeps track of the letters they get," Samuels said.

He described a grass-roots advocacy campaign that successfully opposed an amendment in the welfare reform bill before the U.S. Congress in 1997. The amendment would have barred anyone convicted of a drug offense from ever receiving any federal benefits, ranging from Medicare to student loans. The campaign succeeded in limiting the amendment to felony drug convictions and involving only the welfare and food-stamp benefits designated in the original bill.

Samuels stated, "We were able to water it down ... and we got a provision that said that states can change the law ... and now over 30 states have modified the law to either eliminate the ban or to let people who go into treatment, or otherwise succeed, collect benefits."

Therapeutic Jurisprudence

One recent development is the emergence of drug courts in the criminal justice system, which can incorporate treatment components into sentencing. "Therapeutic jurisprudence," Peggy Hora, J.D., a superior court judge from Hayward, Calif., explained, "proposes the exploration of ways in which, consistent with principles of justice, the knowledge, therapies and insights of mental health and related disciplines can help shape the law."

This new facet of criminal justice, according to Hora, requires the court to evolve from an isolated institution for meting out consequences into an interdisciplinary, problem-solving community institution. In this context, judges are increasingly concerned with wielding their sentencing powers to produce better outcomes.

This direction in the courts was codified in 2000 when the Conference of Chief Justices, representing each state, passed a unanimous resolution supporting problem-solving courts. "They are in the process of developing best practices for problem-solving courts," Hora explained, "and they recognize that collaboration and interdisciplinary training [are] appropriate for the successful outcomes of these courts."

She read a similar resolution recently passed by the Conference of State Court Administrators:

The human and political success of therapeutic jurisprudence programs is too great to ignore. ... Courts must be responsive to changing times and changing expectations, but not at the cost of their fundamental roles and responsibilities.

While therapeutic jurisprudence can be implemented only when it coincides with equal protection and due process, Hora noted, addicts receiving sentences without a treatment component are likely to commit repeat offenses. Although this link to recidivism may be apparent to health care professionals, incorporating addiction treatment into sentencing was considered radical thinking among most judges as little as three to four years ago. Progress in this area may not have risen as much from compassion, Hora suggested, as recognition of the futility of standard sentencing and increasing appreciation of data on the effectiveness of treatment.

"Patterns of systematic failures are contrary to the purpose of the courts, undermine the rule of law, and diminish public trust and confidence in the courts," she observed. This pattern can be countered by an effective problem-solving court that, she added, "moves deliberately in response to emergent issues [and] is a stabilizing force in society."

Science-Based Treatments

Public agencies can facilitate the dissemination, adoption and implementation of evidenced-based addiction treatments by health care providers, according to Jack Stein, Ph.D., chief of the services research branch of the National Institute on Drug Abuse (NIDA).

"We clearly know that advances in science are giving us a broad range of promising options for treating addictions," he said. "The problem has been that many of these approaches are not really adopted or implemented widely."

Stein referred to studies that indicate that few recommended treatments for alcohol dependence are used; few prevention programs have been embraced by schools, despite evidence of their effectiveness for student populations; and few treatment program administrators report employing newer treatment interventions.

"What we're dealing with ... is a real bottleneck--if not actually a true barrier--moving from both the [laboratory] bench to the bedside, and then into the community."

He added that it is not sufficient to develop science-based interventions for addictions if multiple issues affecting their application are not also addressed. Among these he included organizational and financial issues, and the provider's knowledge, skills and training. He attributed the slow adoption of office-based buprenorphine (Subutex) treatment of narcotic addiction, for example, to such factors as physician reluctance to treat this population, reimbursement issues and lack of avenues for referring patients for concurrent psychosocial treatment.

One means for federal agencies to approach these issues is with greater interagency collaboration. In the "Science to Services Initiative" collaboration of the National Institutes of Health and SAMHSA, Stein explained, each agency examined its activities in the three areas of research, dissemination and monitoring and considered opportunities to complement or reduce overlap.

Stein recounted NIDA efforts to provide technical assistance for SAMHSA program officials and grantees; consult to SAMHSA regarding selection of effective interventions for implementation; and link grant programs for blended funding. The latter could, for example, place a newly proposed outcome measure process into an ongoing, funded services program. One blended-funding stream described encourages integration of addiction services into primary care.

Technology-transfer centers developed by the Center for Substance Abuse Treatment (CSAT) of SAMHSA have also been funded and supported by NIDA. "[They're] a great training resource available all over the country," Stein commented. "We feel very strongly about tapping into that to ensure that NIDA-based findings are incorporated into that training system."

A NIDA collaboration with criminal justice has produced a series of grants for Criminal Justice/Drug Abuse Treatment Studies (CJDATS). "This is the major multisite study that was started in 2002, with the goal being to develop models for integrated approaches to the treatment of substance-abusing offenders," Stein explained.

Mady Chalk, Ph.D., the director of the division of services improvement at CSAT, indicated that her agency was also focused on funding and delivery of services, while noting her office's particular interest in improving treatment practices in the field.

"What we're trying to do is to create a way to accelerate the application of effective treatment interventions across agencies and among stakeholders," Chalk said.

In addition to the technology transfer centers, which train clinical personnel and help organizations adopt best practices, CSAT is co-funding with the Robert Wood Johnson Foundation an initiative to improve access to, and retention in, treatment. While the level of this funding of approximately 40 to 50 grantees is relatively low, Chalk reported that it is yielding highly innovative approaches.

Chalk described other CSAT efforts, including technical-assistance publications and consensus-developed treatment improvement protocols in areas such as brief intervention and motivational enhancement therapy. Chalk's agency is also developing a registry of effective treatment programs that have produced evidence of their success and the applicability of their methods to different treatment settings. Chalk is hopeful that within three to five years there might be block grant funding that imbeds such best practice program procedures.

She acknowledged, however, "We need to get moving on developing guidelines that support implementation of new or improved practices. We don't have very many. Our consensus documents are fine, but they are not as useful, and as usable, as they might be."