Many people who want substance abuse treatment can't get it. The White House wants to fix this. Can they do it, and will it help?
On Wednesday, April 24, the White House Office of National Drug Control Policy (ONDCP) released its 2013 National Drug Control Strategy. They say their position has evolved. "We cannot arrest or incarcerate our way out of the drug problem," they write. No longer do they see the nation's drug problem as primarily a criminal justice matter. They see it as a public health issue. And because they see it as a public health issue, their new report- - which they call a 21st century approach -- spends a lot of ink on access and treatment.
Here the ONDCP gives us the broad strokes on why it cares about expanding access to treatment - and why we should, too:
Research shows that addiction is a disease from which people can recover. In fact, success rates for treating addictive disorders are roughly on par with recovery rates for other chronic diseases such as diabetes, asthma, and hypertension.
Recognizing this, the Obama Administration has taken unprecedented action to expand access to treatment for millions of Americans. Through the Affordable Care Act, insurance companies will be required to cover treatment for addiction just as they would cover any other chronic disease.
We estimate that with the Affordable Care Act, 62.5 million people will receive expanded substance abuse benefits by 2020, with 32.1 million gaining those benefits for the first time. To support this expansion, the President's FY 2014 Budget includes an increase of $1.4 billion for treatment over the FY 2012 amount, the largest such request for treatment funding in decades.
Here's where we stand. Only one in ten people who need substance abuse treatment get it. In 2011, this meant that nearly 22 million people needed treatment, but only 2.3 million received it. Of the remaining 19 million, many did not think they needed help. But those who wanted help, and made an effort to get it, and still could not, shared common barriers. Nearly half ran into an insurance wall. Thirty-seven percent did not have health insurance and could not afford to pay for it. Another 10 percent had health insurance, but it did not cover treatment. The Affordable Care Act promises to fix this.
Here's another way the ONDCP wants to help. In their lengthy report, they cite -- and praise -- the Substance Abuse and Mental Health Services Administration's (SAMHSA) Access to Recovery Program. This program provides "grants to states and tribes to provide vouchers to people who are seeking or are in recovery, enabling them to choose the treatment and recovery support services they need." These services aren't clinical. They help provide job networks and stable housing. In Missouri, for example, their program has a focus on "social connectedness." And they also provide faith-based recovery support.
It looks like the Access to Recovery program works. SAMSHA reports that 82.1 percent had no substance abuse within a month of services and 96 percent had reduced or no involvement with the criminal justice system.
We've seen similar positive results elsewhere. In 2009, researchers from the University of Washington and Washington's Department of Social and Health Services published a study on the impact of Access to Recovery programs in their state. The team started by identifying program clients and creating a comparison group. To achieve similarity of the groups, they matched by five variables (substance abuse treatment history, arrest history, employment history, Medicaid utilization, and health status).
They also found benefits for the Access to Recovery Program. In their study, clients stayed in treatment for 42.5 days longer and stayed employed at a rate 1.6 times greater than those who did not participate in the program. But they also found that timing is important. Here, the target seemed to be 31 to 180 days after a client started substance abuse treatment.
Timing matters. In 2011, Christy Scott and colleagues published a paper on substance abuse treatment, abstinence, and mortality. They found treatment beneficial -- as long as you got it early.
This is an impressive study. They recruited their sample of 1326 people between 1996 and 1998 and followed them for 9 years. During this period, 131 participants died -- or 11 percent, nearly three-times the rate of their community.
Here's what they found. If a person participates in a substance abuse treatment program early, then they'll likely see a benefit. But if the person participates later in life, or spends a longer period of his or her life in treatment facilities, then this benefit seems to vanish. The researchers argue that this means addiction follows a chronic disease model.
Much of the drug war is justified by moral claims. But when people lose 22.5 years of their life because they receive punishment when they should receive treatment, there's nothing moral there. If we give people only punishment, and not treatment, and send them back into their old communities with fewer resources and greater disadvantage, we shouldn't ask what is wrong with them. We should ask what is wrong with us.
This blog originally appeared on April 26, 2013 at PLOS Blogs Public Health Perspectives.