Treatment of Alcohol and Other Substance Use Disorders - National

156 Pages·2004·5.48 MB·English

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Treatment of Alcohol and
Other Substance Use Disorders
What Legislators Need to Know
By
Allison C. Colker
Contributing Authors
Sheri Steisel
Tim Whitney
William T. Pound, Executive Director
7700 East First Place
Denver, Colorado 80230
[phone]
444 North Capitol Street, N.W., Suite 515
Washington, D.C. 20001
[phone]
January 2004
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Treatment of Alcohol and Other Substance Use Disorders
The National Conference of State Legislatures is the bipartisan organization that serves the legislators and staffs of the states,
commonwealths and territories.
NCSL provides research, technical assistance and opportunities for policymakers to exchange ideas on the most pressing state
issues and is an effective and respected advocate for the interests of the states in the American federal system.
NCSL has three objectives:
• To improve the quality and effectiveness of state legislatures.
(cid:127) To promote policy innovation and communication among state legislatures.
(cid:127) To ensure state legislatures a strong, cohesive voice in the federal system.
The Conference operates from offices in Denver, Colorado, and Washington, D.C.
Printed on recycled paper
©2004 by the National Conference of State Legislatures. All rights reserved.
ISBN 1-58024-331-2
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C
ONTENTS
List of Figures and Tables..................................................................................................................iv
Acknowledgments.............................................................................................................................v
About the Authors............................................................................................................................vi
NCSL’s Advisory Committee on the Treatment and Prevention of Alcohol and
Other Substance Use Disorders....................................................................................................viii
Executive Summary..........................................................................................................................ix
Users’ Guide....................................................................................................................................xii
1. What Are Alcohol and Other Substance Use Disorders?...............................................................1
Defining Alcohol and Other Substance Use Disorders..........................................................1
Chronic, Relapsing Disease..................................................................................................3
2. What Are the Effects of Alcohol and Other Substance Use Disorders?..........................................9
National Survey on Drug Use and Health............................................................................9
Standard Methodology for Rate of Alcohol and Other Substance Use Disorders
by Substance, by State....................................................................................................10
Healthy People 2010.........................................................................................................13
State-by-State Treatment Gap Table...................................................................................16
Profile of a Typical Person with Alcohol and Other Substance Use Disorders.......................18
Profiles of People with Alcohol and Other Substance Use Disorders Demonstrate
that all Populations are Addicts .......................................................................................18
Use-by-age Charts.............................................................................................................20
Adolescents.......................................................................................................................21
3. Why Should State Legislators be Concerned about Alcohol and Other
Substance Use Disorders?.......................................................................................................23
Economic Costs ................................................................................................................23
Health Consequences........................................................................................................27
Social Consequences..........................................................................................................32
Solutions...........................................................................................................................36
4. What Strategies Are Available for the Treatment of Alcohol and Other
Substance Use Disorders?.......................................................................................................37
The Science Behind the Treatment ....................................................................................37
Continuum of Treatment...................................................................................................40
Treatment for Specific Populations.....................................................................................49
Culturally Competent Treatment.......................................................................................53
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Treatment of Alcohol and Other Substance Use Disorders
Treatment in the Criminal Justice System...........................................................................56
Treatment of Co-occurring Mental Illness and Alcohol and Other
Substance Use Disorders.................................................................................................61
Barriers to Recovery...........................................................................................................62
Licensing of Providers........................................................................................................62
Regulating Treatment........................................................................................................62
Confidentiality..................................................................................................................62
5. What Funding Is Available for States to Provide Services to People Affected by
Alcohol and Other Substance Use Disorders?..........................................................................65
Overview of State and Federal Funding.............................................................................65
The State Role in Financing ..............................................................................................66
Federal Role in Funding Treatment....................................................................................68
Appendices
A. Legislators’ Checklist..........................................................................................................81
B. National Resources............................................................................................................83
C. “Hot Topic” Drugs............................................................................................................87
D. PET Scans of Long-term Brain Changes in Abstinence and Brains on Drugs.......................89
E. State and Jurisdictional Resources.......................................................................................91
F. Center for Substance Abuse Treatment (CSAT) Treatment Improvement Protocols..............99
G. Quadrant System........................................................................................................... 101
H. Overview of State Laws Requiring Coverage of Alcohol and Other
Substance Use Disorder Treatment............................................................................... 105
I. Alcohol Tax, by State...................................................................................................... 117
Notes .......................................................................................................................................... 123
List of Figures and Tables
Figure
1. Activation Patterns to Spatial Working Memory Task for Adolescents ....................................7
2. Brain Activation in Young Women.......................................................................................7
3. Use of Alcohol and/or Illicit Drugs, United States, 1994–98..............................................14
4. Data Measures ..................................................................................................................14
5. Co-occurring Disorders by Severity................................................................................. 101
6. Service Coordination by Severity .................................................................................... 102
7. Primary Locus of Care by Severity................................................................................... 103
Table
1. Rate of Alcohol and Other Substance Use by Substance, by State.......................................11
2. Rate of Substance Abuse and Dependence by Substance, by State......................................12
3. Estimated Numbers and Percentages of Persons Aged 12 or Older Needing
But Not Receiving Treatment for an Illicit Drug Problem in the Past Year,
by State: 2000 ...............................................................................................................17
4. Rate of Alcohol and Other Substance Use by Substance, by Age.........................................20
5. Rate of Substance Abuse and Dependence by Substance, by Age .......................................21
6. National Averages of Federal Block Grant Allocations and State Appropriations
for Mental Health and Substance Abuse .........................................................................66
7. Per Capita State Spending on Alcohol and Other Substance Use Prevention,
Treatment and Research..................................................................................................66
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A
CKNOWLEDGMENTS
The following National Conference of State Legislatures (NCSL) staff dedicated many hours
to make this publication possible: Lee Dixon reviewed the summary; Helen Narvasa for-
matted the tables; Laura Miller planned the marketing, publishing and distribution; and
Leann Stelzer edited the summary.
This publication is made possible through a contract with the Center for Substance Abuse
Treatment, SAMHSA, and a grant from the Robert Wood Johnson Foundation. Special
thanks to Dr. Herman Diesenhaus, Dr. Al Getz, Dr. Rita Vandivort and Dr. Constance
Pechura for reviewing the summary and providing guidance.
NCSL’s Advisory Committee on the Treatment and Prevention of Alcohol and Other Sub-
stance Use Disorders oversaw the development of this guidebook from start to finish. Heart-
felt thanks go to Rep. Martha Alexander (N.C.), John Coppola, Janice Ford Griffin, Melody
Heaps, Sen. Jim Jensen (Neb.), Kenneth Stark, and First Lady Hope Taft (Ohio).
Every effort was made to ensure the accuracy of this report. Please notify Allison Colker at
NCSL about mistakes or missing information. If you have any questions or requests for
further information, call her at [phone].
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A A
BOUT THE UTHORS
Allison C. Colker, J.D., Esq. is a policy specialist for the National Conference of State
Legislatures (NCSL). Mrs. Colker monitors, tracks and reports on behavioral health legis-
lation and associated issues in the 50 states. Her topic areas include substance abuse
treatment and prevention, parity and insurance benefits for substance abuse, and treat-
ment in lieu of incarceration. This information is published for members—state legislators
and their staff and major national substance abuse associations—in the form of articles,
issue briefs and biweekly Snapshots. In addition, Mrs. Colker frequently provides techni-
cal assistance to state legislators and their staff, including state legislative committees that
are directed to assess substance abuse policy issues. She also staffs NCSL’s Advisory Com-
mittee on the Treatment and Prevention of Alcohol and Other Substance Use Disorders;
members include two state legislators, a state substance abuse agency director, a state first
lady, an advocate, a lobbyist, a provider association director, and a treatment provider.
Prior to joining NCSL in July 2001, Mrs. Colker worked at the Center for Health Services
Research and Policy of the George Washington University School of Public Health. While
there, she worked on a research project funded by the Substance Abuse and Mental Health
Services Administration (SAMHSA) that was a contract review of child welfare and Medic-
aid managed care contracts from the 50 states. Mrs. Colker is a member of the Bar of the
State of Maryland. She earned her Juris Doctorate at the George Washington University
Law School, where she focused her course of study on health law and policy. She also holds
a bachelor’s degree in biology from McDaniel College (formerly Western Maryland Col-
lege).
Sheri Steisel is the senior director of the Human Services Committee of NCSL and has
been on the NCSL staff since 1988. Ms. Steisel plays a key role in the development of
policy and lobbying strategy on state-federal human services issues. Her work with the
Human Services Committee concentrates on four major categories: income security and
social services, food and nutrition, welfare reform and immigration. Currently, Ms. Steisel
serves on the National Public Policy Committee for United Way of America. She received
her master’s of public policy with concentrations in human services policy and press, poli-
tics and public opinion from the John F. Kennedy School of Government at Harvard Uni-
versity; her undergraduate degree is from Wellesley College.
Tim Whitney, J.D., is special counsel for policy for Illinois TASC (Treatment Alternatives
for Safe Communities), a statewide social service agency specializing in linking criminal
justice and other public systems with community-based clinical and other resources needed
to support consumers of those systems. Mr. Whitney specializes in the development of
policies and initiatives related to substance abuse, crime and related issues. He also serves as
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About the Authors
legislative liaison, preparing, analyzing and making recommendations on pending legisla-
tion, while participating in local, state and federal advocacy in the areas of crime and
substance abuse. In addition to these activities, Mr. Whitney has served as a consultant for
a number of state and federal policy matters. These include participation in the criminal
justice component of the Center for Substance Abuse Treatment’s National Treatment Plan,
the health and public safety transition committee for Illinois governor-elect Rod Blagojevich;
and the advisory committee organized to develop a dedicated, evidence-based treatment
and reentry prison in Illinois. Mr. Whitney earned his Juris Doctor from DePaul University
and his bachelor of science in communication and public relations from Cornell University.
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Treatment of Alcohol and Other Substance Use Disorders
NCSL’ A C
S DVISORY OMMITTEE ON THE
T P A
REATMENT AND REVENTION OF LCOHOL
O S U D
AND THER UBSTANCE SE ISORDERS
Representative Martha Alexander Senator Jim Jensen
North Carolina Nebraska
John Coppola, Executive Director Kenneth Stark, Director
Alcoholism and Substance Abuse Providers Division of Alcohol and Substance Abuse
of New York State Washington State Department of Social
Albany, New York and Health Services
Olympia, Washington
Janice Ford Griffin, Deputy Executive
Director First Lady Hope Taft
Join Together Ohio
Boston, Massachusetts
Sue Thau, Public Policy Consultant
Melody Heaps, President Community Anti-Drug Coalitions
Treatment Alternatives for Safe of America
Communities-Illinois Alexandria, Virginia
Chicago, Illinois
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E S
XECUTIVE UMMARY
The term alcohol and other substance use disorders encompasses many disorders, includ-
ing alcohol abuse, alcoholism, drug abuse and drug addiction. Although key differences
exist between abuse and addiction, the effect on the states, the nature of treatment, and
funding streams are collective; therefore, they are discussed collectively in this book. Ad-
diction is a chronic relapsing disease that causes brain changes in the user. The initial
choice to use alcohol or other drugs may be voluntary, but if a person becomes addicted, he
or she is then suffering from a biological disease, one of the symptoms of which is a neces-
sity to continue using.
The federal government measures the extent of alcohol and other drug use in many ways.
The most comprehensive measure is the annual National Survey on Drug Use and Health.
There are also measurements of use by state, by age, and by other demographic character-
istics. Unfortunately, the need for treatment far exceeds the capacity to provide treatment
in this country. The adolescent population is particularly affected by alcohol and other
drug use.
States suffer many economic costs associated with untreated alcohol and other substance
use disorders. Employers also suffer economic consequences. States and the public suffer
many health consequences associated with alcohol and substance use disorders, including
fetal alcohol syndrome and drug-affected babies, infectious diseases, mental health, medi-
cal conditions, death, and trauma. They also suffer many social consequences, including
crime, TANF/welfare, accidents, auto crashes, suicide, homelessness, domestic violence,
and child abuse and neglect. Some promising economic solutions for states can lead to cost
avoidance or cost-offset, particularly in the criminal justice area.
To effectively treat alcohol and other substance use disorders, it is important to have avail-
able a comprehensive continuum of treatment and a full spectrum of services. The four
steps of addressing alcohol and other substance use disorders are:
(cid:127) Identification of the problem,
(cid:127) Assessment of its severity,
(cid:127) Treatment, and
(cid:127) Ongoing recovery management.
Treatment can involve medications (such as methadone), can be coerced by the criminal
justice system, and should involve a variety of intensities and modalities. Detoxification is
not treatment, but it is often a medically necessary first step to stabilize a patient and
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prepare him or her for treatment. Treatment should occur in the least restrictive setting
appropriate, and a patient should be continually reassessed and moved through the con-
tinuum from most to least restrictive settings. The range of treatment intensities includes
inpatient/residential, therapeutic communities, intensive outpatient, and outpatient.
Ongoing recovery management includes relapse prevention, such as self-help groups; edu-
cation, job and family support; and, sometimes, special living arrangements, such as sober
living environments. Treatment for some specific populations must be tailored to meet the
unique needs of each population, such as adolescents, women and older adults. It is im-
portant to provide culturally competent treatment for minorities, such as Native Ameri-
cans, Asian and Pacific Islander Americans, Hispanic/Latino populations, African Ameri-
cans, and rural populations. Treatment in the criminal justice system is a major issue for
states because the majority of offenders have alcohol and other substance use disorders.
Another significant issue is treatment of co-occurring mental illness and alcohol and other
substance use disorders because this population is large and the co-occurring disorders
complicate treatment.
Both state and federal governments fund alcohol and other substance use prevention and
treatment services. States make general fund appropriations for treatment in addition to
appropriating federal funds. Most states require some level of private insurance coverage
for treatment. Parity and mandated benefits are economically advantageous for states be-
cause they create a cost shift from the public sector to the private sector. A significant
source of state funds for treatment comes from alcohol taxes on liquor, wine and beer. The
federal government funds alcohol and other substance use prevention and treatment through
various federal agencies.
(cid:127) The Substance Abuse and Mental Health Services Administration oversees the Sub-
stance Abuse Prevention and Treatment Block Grant and various discretionary grant
programs, which are appropriated to the single state agencies.
(cid:127) The Centers for Medicare and Medicaid Services oversee Medicaid, Temporary Assis-
tance to Needy Families, the State Children’s Health Insurance Program, and Medi-
care, all of which can cover alcohol and other substance use treatment.
(cid:127) The Administration for Children and Families oversee Title IVB and Title IVE funds,
which can be used for a behavioral health demonstration program.
(cid:127) The Department of Education oversees the Safe and Drug-Free Schools and Commu-
nities State Grants Program, which addresses alcohol and other substance use preven-
tion and education.
(cid:127) The Department of Justice oversees the Residential Substance Abuse Treatment for
State Prisoners Program, the Drug-Free Communities Program, the Byrne Formula
Grant Program, the Drug Court Discretionary Grant Program, and the Reentry: Seri-
ous and Violent Offender Reentry Initiative, all of which address crime related to
alcohol and other substance use disorders.
(cid:127) The Department of Veterans Affairs oversees the Veterans Health Administration, which
provides alcohol and other substance use treatment for veterans.
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