While the criminal justice system is quietly and slowly shifting
from punishment to treatment for illegal drug use, sweeping changes must take
place in public policies and in the health care system to resolve the
inadequacies in substance abuse treatment in the United States. This was the
conclusion of a group of leaders from science, medicine, law enforcement,
politics, and public health at a conference in Washington, D.C., in
Nora Volkow, M.D., is director of the National Institute on Drug
The conference was sponsored by the National Center on Addiction and
Substance Abuse (CASA) at Columbia University and supported with funding from
the Substance Abuse and Mental Health Services Administration (SAMHSA), Josiah
Macy Jr. Foundation, American Legacy Foundation, and Henry J. Kaiser Family
Substance abuse in the United States costs society half a trillion dollars
a year, according to Nora Volkow, M.D., director of the National Institute on
Drug Abuse. She presented cutting-edge research on how addiction grips the
biochemical wirings of a person's brain and why simply stopping substance use
does not permanently cure addiction. Brain-imaging studies have shown that
substance-induced damage lasts long after a person stops taking drugs, and the
cravings can be immediately rekindled under stress, she explained. Ongoing
treatment maintained throughout recovery is critical to prevent relapse.
For example, Kevin Hauschulz, an individual in recovery who serves as a
telephone recovery support coordinator in a community program, described his
experience and emphasized that continued support and treatment in recovery,
especially his volunteer work with other youth, was a critical component of
Terry Cline, Ph.D., administrator of the Substance Abuse and Mental
Health Services Administration and NIDA director Nora Volkow, M.D., say there
is an urgent need to implement effective public policies to treat substance
Credit: Ellen Dallager
Throughout the country, access to treatment for substance abuse, however,
is limited. "On any given day, 1.2 million adolescents 12 to 17 years
old were smoking, 631,000 were drinking alcohol, and 50,000 were abusing
inhalants," said SAMHSA Administrator Terry Cline, Ph.D., citing data
from a 2006 survey conducted by the agency and CASA.
The same survey found that a quarter of all community hospitalizations were
related to substance abuse. In 2006, 23.6 million individuals needed treatment
for substance abuse, but only 2.5 million received specialty care.
"The problem is that substance abuse treatment and prevention have
not been integrated into the main-stream health care system," Cline
said. "I look forward to the day when substance abuse and mental illness
are treated with the same urgency as any other illness."
Other experts echoed the pervasive shortage of specialized substance abuse
treatment. "The medical community has not taken the responsibility for
prevention and treatment of substance addiction," Volkow said.
Louis Sullivan, M.D., founding dean and first president of Morehouse School
of Medicine in Atlanta and a former secretary of Health and Human Services,
agreed that many physicians are biased against patients with substance abuse
problems and "still view substance abuse as something they should not
get involved in."
Other barriers to adequate substance abuse treatment include lack of
reimbursement and limited training for medical students and residents in this
field. Even many psychiatrists lack sufficient training to treat addiction,
Volkow said. "Medical students don't know what to do with these
patients. They feel uncomfortable and ashamed."
Ralph Lopez, M.D., a professor of pediatrics at Weill Cornell Medical
College, discussed the challenges in screening young patients for substance
use in primary practice.
Family physicians and pediatricians feel uncomfortable questioning
adolescents about drug use in front of their parents, he noted, but screening
is important because "the adolescent brain is vastly different
from" that of adults, and often lifelong addictions begin at this stage.
The key is to build rapport with young patients. "you'll be amazed what
kids will tell you once they realize they can trust you," he said.
Leonard Schaeffer, former chair and president of WellPoint Inc., a major
insurance company, believes that the lack of coverage for substance abuse
treatment should not be blamed entirely on the private insurance industry.
"Most Americans, including physicians, do not view substance abuse as
a medical problem," he said, noting that when employers and the insured
do not demand coverage, there is little incentive for the insurance company to
offer it. He cited a paucity of research data to convince private insurers
that providing reimbursement is cost-effective for them. In addition, there is
no social or political pressure for better coverage because neither
policymakers nor the public generally consider substance abuse a medical
In contrast, the business case for treating substance abuse is making
headway with state and local governments, especially in the justice
The attitude toward drug offenses has been quietly shifting from punishment
and incarceration to treatment, a group of experts noted. For example,"
Florida is investing $38 million on in-prison treatment because of the
prohibitive cost of building more prisons," said then-secretary of the
Florida Department of Corrections, James McDonough, who recently left that
post. It was difficult to persuade the state legislature that treating
offenders with substance abuse was medically necessary, but the economic and
social benefits were enough to convince them to make this investment.
Other panelists agreed that substance abuse treatment clearly reduces
recidivism, neighborhood crimes, and the cost of building more prisons.
Drug abuse is involved in more than 50 percent of violent crimes and
presents a heavy burden for the criminal justice system, according to research
cited by Volkow. She noted that substance abuse treatment inside prisons has
been shown to be vastly more effective than no treatment in preventing
relapses and recidivism after offenders are released.
Drug courts are gaining popularity in more and more states, said Karen
Freeman-Wilson, former presiding judge of the municipal court in Gary, Ind.,
former attorney general of Indiana, and former chief executive officer of the
National Association of Drug Court Professionals. ▪