Tackling Drug Addiction

The Tackling Drug Addiction initiative aims to increase the access of uninsured drug-dependent citizens to comprehensive services that respond to their individual needs. To achieve this objective, the Program is helping Baltimore City to develop a sustainable, high-quality treatment system that uses research-based clinical practices and that benefits from interagency coordination. The initiative also seeks to demonstrate to policymakers and the general public that sound treatment practices and policies will save lives, reduce crime, rebuild families and communities, and use public funds wisely.

The success of this approach may have national significance as the public seeks alternatives to the nation's ineffective "war on drugs." Current U.S. drug policy emphasizes crop eradication, interdiction and domestic law enforcement over treatment and prevention, although research indicates that treatment is between seven and twenty-three times more cost-effective than its policy alternatives. Despite increased interdiction, drugs have become stronger, cheaper and more easily available; and more Americans are in prison for drug related convictions than ever .Further, civil rights are eroded by drug laws permitting asset forfeiture without due process and by sentencing inequities. For example, the possession of crack cocaine, used more frequently by the poor, exacts harsher sentences than possession of powdered cocaine.

Connection to Open Society Values
The Tackling Drug Addiction initiative is founded on the belief that expanding access to treatment will help marginalized people both recover from addiction and develop the skills, resources and zeal to participate more fully in community life. With this increased civic engagement, Baltimore City will be able to build healthy families and communities and to benefit from the views, knowledge and experience of all of its residents, thereby setting the stage for a more just and open society. Expanding access to drug addiction treatment is therefore an important objective of OSI�Baltimore. Given the complexity and demands of building a comprehensive and accessible system, the Program collaborates regularly with OSI�Baltimore's work- force and criminal justice initiatives and partners with other funders and public agencies.

Nature of Drug Addiction
Drug addiction is one of the most common diseases in the United States. It is estimated that over nine million Americans need drug treatment, making addiction more prevalent than coronary heart disease and stroke and as prevalent as cancer. Addiction exacts an enormous burden on the nation, costing an estimated $69 billion in lost productivity, $12 billion in health care costs and $10 billion in spending on child welfare systems. There are more than 9,000 drug-induced deaths each year; and 25% of the nation's AIDS cases result from injection drug use. Further, drug related arrests have significantly contributed to the doubling of the nation's incarceration rate since 1985.

Drug use in the United States is widespread. The National Household Study conservatively estimated that 14 million citizens over the age of 12 were current drug users in 1997. The initial choice to use drugs is voluntary; as addiction develops, however, continued drug use becomes largely involuntary. Indeed, addictive drugs induce persistent changes in the brain that partially explain both the compulsive nature of drug use and the risk of relapse.

Genetic, individual and environmental factors play a role in the development of many illnesses, including addiction. As addiction runs in families, scientists are currently working to discover its precise genetic mechanism. Individual factors, such as the presence of depression or other psychiatric illness, may increase a person's vulnerability to addiction. Social factors, including environmental stress and drug availability, also play a role. Finally, addictive drugs produce powerful physical and emotional changes that contribute to compulsive drug taking.

Types of Treatment
There are many paths to recovery from addiction. Some drug dependent people stop using on their own, through religious activities or self-help groups. Others require treatment in one of the four general modalities described below. All of these types of treatment are necessary components of an effective system, as no one program is best for everyone. Treatment can include behavioral approaches, medications or, in many cases, both. For a more detailed description of treatment options, see Principles of Drug Addiction Treatment, which is available from the National Institute on Drug Abuse.

Outpatient Drug-Free Programs provide individual, group and family counseling. Patients served are typically dependent on cocaine and/or alcohol. Programs employ a wide variety of counseling styles. Historically called "drug-free", many are now appropriately using medication combined with behavioral therapies to maximize therapeutic response. These medication-based therapies include psychiatric treatment and outpatient detoxification.

Opioid Agonist Programs treat people dependent on heroin. They provide counseling and either methadone or Levo-Alpha Acetyl Methadol (LAAM), two medications which block the withdrawal, craving and euphoric effects of heroin. Carefully regulated by federal and state agencies, methadone and LAAM are initially administered under direct observation. A specialty area within outpatient treatment, this modality is beginning to integrate psychiatric and medical care and to broaden the range and intensity of behavioral therapies provided.

Inpatient Rehabilitation Programs are designed for people dependent on alcohol or drugs. They may last several days to weeks and often use counseling techniques based on self-help programs. Medical and psychiatric screening may be available. Discharged patients are usually referred to outpatient programs and self-help groups.

Therapeutic Communities are long term residential treatments for people who are unable to discontinue drug use through other treatments. Lasting six months or longer, they offer a highly structured program which uses behavior modification and assigns increasingly responsible tasks to resocialize residents.

Effectiveness of Treatment
Drug addiction treatment is as effective as treatment for other chronic disorders. For example, the one-year relapse rates for addiction, asthma and hypertension are quite similar at 60%, 70% and 55%, respectively. For the past 30 years, federally sponsored research has repeatedly confirmed that treatment results in positive outcomes and is cost effective. For example, a recent study demonstrated a reduction in alcohol and drug use (52% and 69%, respectively) one year after treatment. A 1994 study showed a 64% reduction in arrests one year after treatment. Further, drug treatment prevents the spread of HIV. Patients enrolled in methadone maintenance were five times less likely to contract HIV than drug injecting people not in treatment. For more information on the effectiveness of treatment, see Why Invest in Drug Treatment? What the Research on Treatment Effectiveness Tells Us (available from OSI�Baltimore).

National Treatment Gap
People with insurance are usually able to access treatment services through the private sector. In contrast, uninsured drug dependent individuals have limited access to the most basic treatment. Nationally, inadequate funding has led to a longstanding shortage of publicly funded treatment. The U.S. Department of Health and Human Services has estimated that there are over three million Americans in need of drug treatment who are not receiving services. As a result, the personal and societal consequences of addiction continue unabated. Given the demonstrated effectiveness of treatment, it is essential to reduce this gap by increasing access to care.

Poverty and Addiction
Drug addiction is a formidable illness to overcome for people with adequate insurance, a good job and intact social supports. For marginalized and impoverished drug dependent people, the challenge is often even greater. These individuals must cope with drug addiction and inadequate access to treatment, insufficient education, few job skills and a lack of housing. They may be living in a neighborhood characterized by violence, a high incidence of drug use and open-air drug markets. These social problems exacerbate drug addiction and, ultimately, make recovery more difficult to achieve and sustain.

A good treatment response for many chronic illnesses depends on a patient's ability to take medication as directed and to change behaviors, such as diet or exercise patterns. People with low socio-economic status have more difficulty adhering to both medication and behavioral regimens. Thus, marginalized individuals require a more comprehensive treatment approach which addresses both the addiction and the poverty-related problems that affect treatment outcome. Patients must receive comprehensive services to improve their lives and develop their potential as employees and as family and community members.

Addiction in Baltimore
Maryland's Alcohol and Drug Abuse Administration estimates that 60,000 of Baltimore's 650,000 residents are drug dependent. Addiction has a devastating impact on the city. Drug dependent people commit a large number of property crimes to purchase drugs. Approximately 70% of Baltimore's over 80,000 annual arrestees have positive drug tests. Alcohol and drug abuse are thought to fuel a significant proportion of the over 8,000 annual child abuse and/or neglect investigations in the city. Baltimore continues to be among the top cities in heroin and cocaine use found through hospital emergency room patient data surveillance. Finally, intravenous drug injection is the major cause of HIV transmission in the city.

Baltimore City's Response
The Baltimore Substance Abuse Systems (BSAS) is the agency charged with reducing the harm associated with drug addiction. In 1990, the Baltimore City Health Department created this quasi-governmental, non-profit organization to administer a Target Cities grant-a federal program aimed at enhancing treatment systems in selected jurisdictions. In 1995, the City Health Department shifted its drug abuse treatment and prevention duties to BSAS to take full advantage of the flexibility offered by a non-profit organization.

Baltimore is one of only two U.S. cities attempting to insure that drug addicted individuals gain access to treatment within 48 hours of request. Building the system's capacity has required increased funding from the city, state and federal governments as well as from local and national foundations. Since 1997, BSAS's budget and treatment slots have more than doubled. The expansion has supported improved core services, such as more frequent urine testing, counseling and expanded access to medication, as well as enhanced services (vocational training, psychiatric care and family therapy).

Researchers from three local universities evaluated the system's expansion and enhancement efforts and found that heroin use declined by 69% at 12 months after treatment entry and cocaine use declined by 48%. Furthermore, treatment participants engaged in criminal activities 64% less at 12 months after treatment entry. HIV-risk behaviors also were shown to decline significantly. The study found a 59% reduction in drug injection among patients enrolled in methadone treatment. Finally, the benefits of treatment on demand were demonstrated by determining that for every 1,000 patients enrolled in treatment $3,214,200 were saved through reduction in illegal activities.

One of the hallmarks of an effective systems approach to addiction is good communication between agencies that interact with the same patients. In Baltimore, the criminal justice and public treatment systems have engaged in a productive dialogue, resulting in increased services for drug dependent people in the criminal justice system and agreement that the treatment system must expand. More drug treatment services are needed for patients referred from both the criminal justice system and the community. As treatment is effective-regardless of the source of referral-it is encouraging that the public safety and public health departments are working in concert to expand and enhance services to meet the needs of all drug dependent individuals.

The National Institute on Drug Abuse (NIDA) initiated the Clinical Trials Network in 1999 to improve treatment dramatically by moving promising science-based drug addiction treatments into community settings. Johns Hopkins University School of Medicine was among the first centers in the country to receive this prestigious grant. The application was successful because of Hopkins's rich history of conducting drug abuse research, the presence of a strong network of treatment providers in Baltimore and the ongoing treatment outcome evaluation conducted for BSAS. NIDA's groundbreaking program has great potential for transferring research findings to the field. And, as one of the first sites, Baltimore has begun to take full advantage of the initiative.

In spite of these local, state and national efforts to improve the Baltimore City system, core treatment services require more strengthening and expansion. Further, services such as housing linkage, job training and placement, childcare and medical treatment are often not integrated with drug addiction treatment. To expand and enhance treatment in the city so that all people, including those who are uninsured, have access to comprehensive treatment, OSI�Baltimore has established a grantmaking program to address the priorities outlined below. OSI�Baltimore works closely with public and private funders to achieve these priorities, all of which aim to reduce the harm addiction inflicts on Baltimore City communities.

The Tackling Drug Addiction initiative also conducts educational forums in which national experts discuss successful approaches and programs with local policymakers, funders, researchers, clinicians and recovering people. These forums seek to enhance local leaders' knowledge about the latest thinking in the field, to provide a catalyst for reforming policy and for restructuring practice in the field.