Target Population

Substance abuse affects vast numbers of people through a litany of social ills-from the destruction of individual lives; to the devastation of families through child abuse, neglect, and domestic violence; to the ravaging of neighborhoods through open-air drug markets and violent street crime. In 2003, the estimated number of Americans 12 or older needing treatment for dependency on alcohol and/or drugs was 22.2 million, nearly 10 percent of the nation's population. ^[1]   Because so many incarcerated people have a history of substance abuse (80 percent, according to the Bureau of Justice Statistics), this need is the rule, rather than the exception, for individuals under correctional supervision. ^[2]   Ensuring that these individuals have access to substance abuse treatment upon their return to the community, and that the treatment available is effective and comprehensive, is critical to supporting safe and successful re-entry.

As the evidence showing that drug treatment is an effective recidivism reduction strategy has mounted, the federal government and many states have taken steps to improve both the quantity and quality of treatment services. An estimated 3.3 million Americans received some form of substance abuse treatment in the 12 months prior to being interviewed in 2003. ^[3]  

Key Problems

Although many individuals receive some form of substance abuse treatment, there are many who have not received needed services. If the nation is to realize the full potential of treatment, there must be significant new efforts to improve both its availability and the effectiveness of the services and the systems that deliver them. Three large gaps-denial, treatment, and intensity gaps-characterize the current system, and policy makers must find ways to bridge them.

The denial gap comprises alcohol or drug dependent users who do not feel the need for treatment or fail to seek it out. The 2003 National Survey of Drug Use and Health found that of the roughly 20 million people who needed treatment but did not receive it, only about one million (5.1 percent) reported that they felt they needed treatment. ^[4]  

The treatment gap refers to those who acknowledge the need for treatment, but never receive it. Indeed, of the one million who indicated that they needed treatment, the vast majority (73 percent) said they made no effort to find treatment, while the remaining 27 percent reported seeking treatment but not getting it. ^[5]   Survey respondents' most common reasons for not obtaining treatment were the respondents' personal decisions that they were not ready to stop using, cost or insurance barriers, social stigma, and the sense they could kick their habits on their own. ^[6]  

The difference between the treatment that someone received and the full course of treatment they should have received is the intensity gap. Due to the abundance of outpatient services, for instance, many people with substance abuse disorders are counted as having received treatment but may have received once-per-week counseling for three months, when a clinically appropriate course of treatment would have been three months in a residential placement, followed by three months in intensive outpatient services, then another six months in regular outpatient counseling.

System Organization and Funding

Several federal and state agencies, as well as private insurers, are responsible for filling the denial, treatment, and intensity gaps. Understanding who provides substance abuse treatment services and who regulates those providers must precede any effort to improve coordination and promote access to effective treatment.

At the federal level, The Substance Abuse and Mental Health Services Administration (SAMHSA), a branch of the US Department of Health and Human Services, administers $1.8 billion in federal funding and promotes federal policy on substance abuse treatment through its Center for Substance Abuse Treatment (CSAT). Most of the funds are awarded to the states in formula-driven block grants through the Substance Abuse Prevention and Treatment (SAPT) Block Grant program. Eighty percent of SAPT funds are for treatment; 20 percent must be spent on substance abuse prevention efforts. ^[7]  

The US Department of Justice provides treatment funding for initiatives involving criminal offenders through specific initiatives, such as the Drug Court program for non-violent offenders under supervision in the community. ^[8]   Additional Justice funding for treatment comes through discretionary grants, both from federal agencies and from state criminal justice coordinating agencies that administer the federal Byrne formula grants, which provide support for certain local programs designed to improve functioning of the criminal justice system and enhance drug control efforts.

The Center for Medicare and Medicaid Services and the Veterans Administration each play an important role in making substance abuse treatment available, but they tend to be involved primarily through their state and local organizations.

The White House Office of National Drug Control Policy (ONDCP) sets policies, priorities, and objectives for the nation's drug control program. The ONDCP seeks to reduce illicit drug use, manufacturing, and trafficking as well as drug-related crime, violence, and health consequences.

In many states, substance abuse prevention and treatment are coordinated by an Alcohol and Other Drug (AOD) agency. The AOD agency is often part of a state's department of health and/or human services. In a few states, the state AOD agency is a cabinet-level position, which allows the AOD director to work directly with the Governor.

AOD agencies in each state administer the federal SAPT Block Grant in addition to other substance abuse treatment dollars to support a wide variety of treatment programs. Some states directly employ clinicians and provide treatment to those with AOD abuse disorders, while most states contract out some or all treatment provision to private organizations. The state AOD Director is responsible for determining the array of services available in a particular state-that is, the mix of residential, outpatient, medication-assisted, correctional, and other treatment modalities that receive funding. AOD agencies often are responsible for drug education and prevention efforts in addition to treatment.

State AOD agencies also develop and enforce treatment standards for the substance abuse providers in their states. Each state has a unique set of provider standards based on research and practical experience unique to that state's organizational structure and treatment needs. Standards generally cover issues such as program governance, fiscal management, data reporting, client rights and responsibilities, and other administrative matters. Today, any organization or agency seeking to provide AOD treatment services is expected to be able to demonstrate its ability to meet the standards adopted.

State substance abuse administrators must work closely with other state agencies that serve significantly overlapping populations, including agencies dealing with mental health, public health, and various public safety issues (such as law enforcement, courts, and corrections) for reasons of funding as well as service coordination. (See Policy Statement 5, Promoting Systems Integration and Coordination, and Policy Statement 4, Funding a Re-Entry Initiative, for further discussion of such collaboration between systems.) Benefits programs administered through the states can also serve as an important source of treatment funding for eligible drug dependent users. Under some circumstances, for instance, states can use federal welfare dollars (under the Temporary Assistance to Needy Families program) or Medicaid or Medicare to fund substance abuse treatment. ^[9]   (See Policy Statement 24, Identification and Benefits, and Policy Statement 34, Children and Family Systems, for more on federal benefits programs.)

Local entities, such as county governments, may also serve as a source of funding for substance abuse treatment, in parallel or in coordination with the state and federal agencies described above. In addition, non-governmental organizations or local government agencies are the direct providers of most substance abuse treatment, with the exception of treatment administered directly by state institutional providers, such as those based in corrections facilities or hospitals. In some cases providers are "quasi-public" and operate with a degree of autonomy outside of the typical city, county, or state organizing structure.

Treatment providers fall into two main categories, those that are drug-free providers and those that provide medication-assisted treatment, such as methadone to help users combat heroin addiction. Drug-free providers are licensed, certified, or accredited by state AOD agencies. Drug-involved providers are regulated by federal authorities in addition to the state AOD agency. ^[10]  

Both types of providers often participate in professional membership associations, which may develop their own standards and principles and represent the collective interests of the providers to policymakers. The most widely accepted national health care accrediting bodies are the Joint Commission on Accreditation of Healthcare Organization (JCAHO), the Commission on Accreditation of Healthcare Facilities (CARF), and the Council on Accreditation (COA) and, in the correctional field, the National Commission on Correctional Health Care (NCCHC).

The following recommendations outline the key actions that must be taken in order to maximize the ability of substance abuse treatment agencies and providers to fulfill their missions. These steps also are critical to the fulfillment of the overall national drug policy goals set by the White House: a 10 percent reduction in current use of illegal drugs in two years, and a 25 percent reduction in five years. ^[11]