2010: U.S. drug and alcohol policy, looking back and moving forward.
Since the early twentieth century, both moral perspectives and
changing perceptions of the disease model of alcoholism and addiction
have significantly influenced the formulation of U.S. domestic policy on
drugs and alcohol. Some fluctuations have occurred in federal drug
policy but overall a prohibitive, punitive approach has been emphasised.
Racial and socioeconomic disparities have been exacerbated by the
inequities of drug laws. Over the past 50 years, limited progress has
been made in challenging and changing these unproductive policies. A
great deal of progress has been made in research and treatment, and in
the understanding of the process of recovery. For the upcoming
generation to move policy in the direction shown to be effective by
experienced addiction professionals will entail a wide spectrum of
interdependent actions in substance abuse research, education,
prevention and treatment, and continued cooperation between many
Keywords--addiction, alcoholism, federal policy, illegal drugs, recovery
(Laws, regulations and rules)
Narcotic laws (Interpretation and construction)
Narcotic laws (Social aspects)
Substance abuse (Care and treatment)
Substance abuse (Laws, regulations and rules)
Substance abuse (Forecasts and trends)
Lee, Philip R.
Lee, Dorothy R.
|Publication:||Name: Journal of Psychoactive Drugs Publisher: Haight-Ashbury Publications Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Haight-Ashbury Publications ISSN: 0279-1072|
|Issue:||Date: June, 2010 Source Volume: 42 Source Issue: 2|
|Topic:||Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime; 010 Forecasts, trends, outlooks; 290 Public affairs Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation; Market trend/market analysis|
|Product:||Product Code: 8000143 Alcohol & Drug Abuse Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers SIC Code: 8093 Specialty outpatient clinics, not elsewhere classified|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
This review of U.S. federal domestic drug and alcohol policy begins
with a brief look at the mid-nineteenth and early twentieth century
background. While including some aspects of mental health policy, we
have excluded policy on tobacco and cigarettes, although smoking is a
major health hazard associated with disease and all types of substance
abuse. The Food and Drug Administration (FDA) did not regulate
cigarettes until 2009. Also beyond the scope of this article are the
details of federal policy on medicinal cannabis, prescription opioid
analgesics, methamphetamine and other stimulants, anabolic steroid
drugs, and a host of other substances liable to abuse, including LSD,
PCP, club drugs such as Ecstasy (MDMA), "designer heroin,"
inhalants, mushrooms, ketamine, and Salvia divinorum. (For further
information on such issues see Inaba 2007; Lowinson et al. 2005; Lester,
Andreozzi & Appiah 2004; Doblin 2001; Brooks 1997).
EARLY STAGES OF CRIMINALIZATION AND PROSCRIPTION OF TREATMENT
David Musto (1987) points to regulation, the initial phase of drug policy formation: "Licensing of pharmacists and physicians, which was the central government's responsibility in European nations, was, in the United States, a power reserved to each individual state. In the era of Andrew Jackson, any form of licensing that appeared to give a monopoly to the educated was attacked as a contradiction of American democratic ideals." Licensing authority was not within the domain of either the American Medical Association (AMA) or American Pharmaceutical Association (AphA), both founded in the mid-nineteenth century: 'There was no national group for the health professions to which government could turn for regulation, even if the American constitutional system had permitted such an arrangement." President Abraham Lincoln established the Department of Agriculture's Bureau of Chemistry in 1862, the predecessor of the Food and Drug Administration (FDA) which was established as a regulatory agency in 1927. In the U.S. there was significant resistance from a variety of special interest groups to the establishment of federal standards of purity, regulation and labelling of food and drugs, and it wasn't until 1906 that Congress passed the first Pure Food and Drug Act (Independent Institute 2009; Scheindlin 2008). This was in marked contrast to Great Britain, where members of the Royal Pharmaceutical Society were active in the formulation of a Pharmacy Act, passed in 1868, governing both professional standards of training and controls on the sales of drugs (RPSGB 2010).
A particular concept of virtue, which necessitates the prohibition of morally unacceptable behavior, was characteristic of the Progressive social reform that emerged in America in the late nineteenth to early twentieth century (Silver 1992). While drinking was frowned on for women, opiate- and cocaine-based formulas were medical mainstays and readily available, and early studies revealed that White middle class women comprised the majority of opiate and cocaine addicts (Kandall 1996). The temperance movement gained political currency following the Civil War (1861-1865). The nation's first federal narcotics laws and the mandate for prohibition of the manufacture and supply of alcoholic beverages were formulated concurrently, early in the twentieth century.
Moral objections voiced by Christian missionaries prompted President Theodore Roosevelt (1901-1909) to veto reinstitution of the opium monopoly in the newly acquired territory of the Philippines in 1903, ending a government-regulated supply of opium to the local Chinese population. This decision indicated the direction federal future policymakers would take on the question of nonmedical use of opiates (Musto 1987). During the terms of Presidents Woodrow Wilson (1913-1921), Warren Harding (19211923) and Calvin Coolidge (1923-1929) federal legislation was enacted regulating the import, export, manufacture, sale, and prescribing and medical use of narcotic substances, and establishing penalties for drug violations. Both opium and coca derivatives were assigned to the category of narcotics (Musto 1987).
Federal regulation of drug use was perceived as contrary to the limited role of the federal government as framed in the Constitution. To avoid such objections, the Harrison Narcotic Drug Act of 1914 used a revenue approach to regulate physicians and pharmacists and restrict narcotics transactions. William White (1998) emphasizes, 'The criminalization of addiction did not come as the result of sustained public debate and legislation that clearly expressed this intent. It was a result of the administrative fiat of one federal agency. What was even more remarkable was that this agency--the Department of the Treasury--formulated its position based on its view of what the medical treatment of addiction should and should not consist of, and did so without direct consultation with the mainstream medical community." U.S. society was racially segregated and the advocates of comprehensive federal narcotics control, and punitive policies, deliberately inflamed prejudices against minorities, convincing legislators and the public to share their beliefs and goals (Drug Policy Alliance 2010; Courtwright 1992; Gerstein & Harwood 1990).
The Harrison Act prohibited physicians from prescribing narcotics for addiction maintenance; when the law was challenged in 1919, the U.S. Supreme Court unanimously upheld the Act's constitutionality in two landmark cases: United States vs Doremus and Webb vs United States (Courtwright 1992; Bonnie & Whitbread 1970). Federal drug control and prohibition were soon further defined by the Narcotic Drug Import and Export Act of 1922, and the Heroin Act of 1924.
Data gathered on known users in the U.S. between 1915 and 1920 enabled Terry and Pellens (in 1928) to estimate of the number of opiate addicts to be between 140,554 and 269,000 (Ball, Englander & Chambers 1970). After 1925 all community public health drug maintenance clinics were shut, shifting, as "Dr. Marie Nyswander later noted . . . medical responsibility for America's addicts from physicians to criminal syndicates" (White 1998). During the 1920s addicts and their physicians were vilified and increasingly treated as criminals: ". . . a very tough policy toward physicians was maintained. Between 1914 and 1938, 25,000 doctors were arrested for supplying opiates, and 5,000 of them actually went to jail. Those doctors who maintained that addiction was more complicated than what the official view held, and who advocated maintenance, were purged from the field" (DeLong 1970: 184). The AMA adopted resolutions opposing ambulatory care of opiate addiction and collaborated with enforcement of the Harrison Act, stigmatizing physicians who had been arrested by publishing their names in the Journal of the American Medical Association (White 1998; Gerstein & Harwood 1990).
A number of states were already "dry" when Prohibition was imposed nationwide, through the Eighteenth Amendment to the Constitution and the National Prohibition Act of 1919 (the Volstead Act) and the Bureau of Internal Revenue's Prohibition Unit that was established to enforce it. Organized crime branched out from liquor bootlegging and used its vast resources to foster the illicit drug trade, reaping the rewards of enormous power and profits. In the words of George Silver (1992) "The legislation to prohibit alcohol use created a huge criminal enterprise, and was eventually abandoned. The legislation to control or eliminate narcotic drug use in the United States has been in place far longer, and despite periodic fluctuations in use, has been equally unsuccessful."
RIGID ANTIN ARCOT IC S POLICY, AND INITIAL FEDERAL INVESTMENT IN RESEARCH AND TREATMENT FOR DRUG ADDICTION AND MENTAL HEALTH
Under President Herbert Hoover (1929-1933), the National Institute of Health (NIH) was established within the Public Health Service in 1930. That same year, the Federal Bureau of Narcotics (FBN) was created within the Treasury Department. David Courtwright (1992) characterizes the FBN's first director, Harry Anslinger (former Assistant Commissioner for Prohibition) as "the personification of the antinarcotic regime" and quotes two of the aphorisms he voiced in regard to the punitive drug policy he championed throughout the course of 30 years and five administrations: "Wherever you find severe penalties, addiction disappears" and "The best cure for addiction? Never let it happen." At this time, laws varied from state to state concerning control of importation, sale, possession, production and consumption of narcotics. In the interests of aligning state and federal drug legislation, the Uniform Narcotic Drug Act was adopted for ratification by individual states in 1932 (Galliher, Keys & Elsner 1998; King 1974; Anslinger & Tompkins 1932).
From the outset of his career with the FBN, Harry Anslinger actively--but unsuccessfully--had sought to include marijuana together with narcotic drugs already under federal control. State laws preceded federal legislation on marijuana. Hostility towards Mexican immigrant agricultural workers motivated prohibition in some states, and belief that marijuana was a stepping stone to addictive drugs in others; in Utah legislators passed one of the first state laws criminalizing its use in 1915, after strictly temperate Mormon Elders declared marijuana intoxication to be against their religion. By 1937, 27 states had criminal laws on their books. During brief U.S. House of Representatives hearings, testimony by the legal representative of the AMA that there was no evidence of marijuana being a dangerous drug was ignored. The Marijuana Tax Act of 1937 was passed without debate in the Senate (Bonnie & Whitbread 1970).
Violent crime surged during Prohibition, the enforcement of alcohol and drug laws became more vigorous, and the U.S. prison population increased rapidly (Kopel 1994; Thornton 1991). Confronted with the problem of federal prisons filling with addicts, legislators passed the Porter Narcotic Farm Act in 1929, establishing the Public Health Service (PHS) Narcotics Division in the Office of the Surgeon General, and calling for the PHS to create and oversee specialized hospitals for addiction treatment. The first PHS "narcotic farm" was opened in 1935, in Lexington, Kentucky and the second in Fort Worth Texas, in 1938. These institutions, treating both federal prisoners and voluntary patients, were maintained for over three decades.
President Franklin D. Roosevelt (1933-1945) provided leadership during the troubled Depression era, and initiated significant federal responsibility and investment in public health and welfare. In 1933, Congress passed the Twenty-first Amendment to the Constitution, repealing Prohibition on a national level and delegating the authority to regulate alcoholic beverages to the individual states. Although the federal government relinquished its control over alcohol, it did not become involved in the study or treatment of alcoholism. As William White (1998) thoroughly documents, concern about alcoholism as a public health problem continued to be widespread following Repeal and, in the absence of federal initiatives, the private sector was active. Alcoholics Anonymous (AA), founded in 1935, has withstood the test of time and spread around the world. Many studies of the "alcoholism question" were undertaken during the following decades and diverse and conflicting opinions abounded. Treatment was often based on psychoanalytic theories and it wasn't until 1956 and 1967 that the American Medical Association (AMA) would pass resolutions acknowledging the disease model of alcoholism.
New maternal and child health services, grants to the states for public health programs and increased funding for the PHS were included in the key New Deal legislation, the Social Security Act of 1935. During President Roosevelt's second term, the National Cancer Act of 1937 increased support for biomedical research and training. In 1938 the Food, Drug, and Cosmetic Act began the process of giving the FDA more responsibilities and powers and instituting the process of New Drug Applications, requiring--for the first time--that drug safety be demonstrated before marketing (Independent Institute 2009).
Under President Truman (1945-1953) health services and medical research continued to receive federal support and significant appropriations began to be made for health care infrastructure. Following the National Mental Health Act of 1946, the National Institute of Mental Health (NIMH) was established in 1949. The Lexington facility's Research Division, renamed the Addiction Research Center (ARC) was brought under the jurisdiction of National Institute of Mental Health's (NIMH) intramural programs. The ARC is renowned for spearheading a wide range of investigation of psychoactive drugs, addiction, and related neurochemistry. Many groundbreaking discoveries were made over the years, and numerous clinicians and scientists who trained there went on to specialize in substance abuse research (UMSARC 2008; NIDA 1995; Inciardi & Martin 1993; Besteman 1992). In the Truman era, voluntary health advocacy organizations began to play a major role in targeting disease issues and lobbying for Congressional support of research. In 1950, the President signed the Omnibus Medical Research Act and the National Institutes of Health assumed the major federal role in the funding of biomedical research.
Drug abuse was on the rise, yet the federal government didn't address broader issues of prevention and treatment, beyond the PHS narcotics farms and associated research. The most popular prescription drugs being abused in America right after World War II were amphetamines (widely prescribed for military personnel in combat) and barbiturates. Confronting and solving problems of racial inequality was not yet a national priority and returning African-American WWII veterans, seeking to obtain the benefits of the 1944 G.I. Bill, were confronted by obstacles of poverty, racism and the discriminatory and inequitable administration of the program (Onkst 1998). Racial disparity increased, 'white flight' from the cities began, and heroin addiction, on the rise among urban youth after "WWII, was becoming part and parcel of ghetto life for impoverished African Americans and Latinos. Congress, urged by Narcotics Commissioner Anslinger towards stricter enforcement, responded by passing the Boggs Act of 1951, establishing mandatory minimum sentencing for drug offences (Rettig & Yarmolinsky 1995; Courtwright 1992; King 1974). David Courtwright (1992) notes the tragic irony: although Anslinger himself had observed addiction coexists with ". . . the lowest economic and social standards . . . There is no drug addiction if the child comes from a good family, with the church, the home, and the school all integrated" he did not "advance to the conclusion implied by his analysis: doing something about black addiction meant doing something about black economic and social conditions." In the early 1950s the Civil Rights movement gained ground and the U.S. Supreme Court ruled in favor of school desegregation, but President Dwight Eisenhower (1953-1961) was reluctant to provide leadership on the issue.
In response to the Mental Health Study Act of 1955, The Joint Commission on Mental Illness, a private nonprofit organization, was formed. The scope of federal commitment to public health was reflected in the Health Amendments Act of 1956, which supported training for public health specialists and nurses, extended grants for construction of hospitals and nursing homes, and broadened PHS research grant authority in mental health (Woolley & Peters 1956). At this time patients in long term mental health care and persons suffering from alcoholism and substance abuse disorders occupied half the nation's hospital beds and the costs were " . . . sometimes the largest single item in a state budget" (AJPH 1956). New solutions were being sought, and Congress appropriated a total of $12 million to NIMH for a new program on psychopharmacology (NIH 1998). Martin M. Katz (2010) recalls that the efficacy of drugs for the treatment of schizophrenia was one area where investigation was being focused and more than $2 million was allocated for extramural psychopharmacology research, new research grants to US investigators, and funding for the Psychopharmacology Service Center. The NIMH program for research on substance abuse originated in this new facility, and young psychiatrists trained by Director Jonathan Cole would "expand this field until it became an Institute in itself (Katz 2009).
Detoxification was beginning to be seen as a "revolving door" (Courtwright 1992) and, as Jerome Jaffe has observed (UMSARC 2007) "Keeping people six months or a year at Lexington did not prevent a high level of relapse." At the ARC, projects included the formulation of nonaddictive analgesics, and the formative stages of research on methadone and narcotics maintenance. Concerning illicit drugs, the FBN held firm on its course, and even a joint report by the American Bar Association and the AMA did not persuade policy makers and legislators to reconsider the criminal prohibition of addictive drugs. The Narcotics Control Act of 1956 mandated harsher punishments and increased mandatory minimum sentences for drug violations (Galliher, Keys & Elsner 1998; White 1998).
Anticommunism, part of the legacy of the Eisenhower era, was perpetuated in the policies backed by President John F. Kennedy (1961-1963) in support of the Cold War (to the detriment of domestic social policy). Drug traffic from Southeast Asia escalated along with the growing US military involvement in Vietnam, and more potent heroin than ever before began to be available in the US.
Community-based care for mental illness received increased federal support and the foundation was laid for taking the same approach to substance abuse treatment. The 1961 report of the Joint Commission on Mental Illness, Action for Mental Health, outlined a plan for integration of the institutionalized mentally ill into the general population. The establishment of Community Mental Health Centers was a key element and President Kennedy urged Congress to take action on this issue as part of his vision of "The New Frontier." Reversing the 100-year-old policy, based on President Pierce's 1854 veto of federal aid for state mental health services (Woolley & Peters 1854), the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 was applauded as a major development in domestic policy. In practice, limitations of the Federal budget and further woes of the nation's "stagflation" financial crisis of the 1970s (stagnation of economic growth combined with inflation) prevented the program from ever being fully funded. The confluence of advances in psychopharmacology and changing state level budget priorities led to the discharge of a large number of patients into communities where the anticipated federally funded services were not available (Sharfstein 2000; Thomas 1998). This in turn led to homelessness for many and drug abuse for some, possibly in an attempt to self-medicate (NMHIC 2003).
President Lyndon Johnson (1963-1969) headed a capable administration, and policy-makers interacted directly and effectively with the legislative branch. Responsive to the climate of change, the Eighty-ninth Congress enacted a wide variety of groundbreaking legislation, much of which had been proposed during preceding administrations but never adequately supported by lawmakers. The Civil Rights Act of 1964; the Economic Opportunity Act of 1964; the Voting Rights Act of 1965; the Elementary, Secondary, and Higher Education Acts, and Medicare and Medicaid were key instruments for social change.
Many Americans participating in the broad social, cultural and political transformations underway in the 1960s sought to reverse social inequity and correct injustices. At the same time, this openness to changing concepts in society extended to attitudes towards drugs. Concerning drugs and alcohol, Courtwright (1992) observed: "The baby boomers were, so to speak, polypharmaceutically perverse. They cheerfully experimented with a range of illicit drugs while they drank alcohol and puffed cigarettes with their conventional elders". Prescription drugs were being overprescribed, misused and abused, and so-called "recreational" drugs were becoming increasingly popular. Overseas, in Vietnam, alcohol, prescription drugs, hallucinogens and marijuana were all being used in the Armed Forces and many servicemen acquired the habit of smoking local heroin (Brush 2002).
In drug policy, the way forward was difficult to find in the face of swiftly multiplying challenges posed by rising drug and alcohol abuse. The Drug Abuse Control Amendments of 1965 legislated control over the nonmedical use of depressants, stimulants, and hallucinogens, established FDA oversight for research on hallucinogens, and created the Bureau of Drug Abuse Control within the FDA to enforce the law (Doblin 2001). Testifying in 1966 before the Senate Judiciary Committee, Attorney General Nicholas Katzenbach took a stand in favor of a therapeutic, rather than punitive, response to drug addiction. New York Senators Jacob Javits and Robert Kennedy had been proposing bills for civil commitment since 1961, and they were instrumental in the passage of the Narcotics Addict Rehabilitation Act of 1966, authorizing a system of treatment and rehabilitation for nonviolent federal prisoners modelled on prototype state civil commitment programs. The Act also funded grants to private organizations as well as individual states for the development of rehabilitation and treatment services for heroin addicts. Public Health Service treatment centers were planned for major U.S. cities, but the unexpected surge in demand for treatment and limitations of the healthcare workforce made the implementation of community-based outpatient services more feasible (Besteman 1992; King 1972; DeLong 1970).
ADDICTION MEDICINE INITIATIVES, AND A WIDER FEDERAL FOCUS
The 1960s saw groundbreaking activity at the state and local level: addiction medicine pioneers took the initiative and rapid advances were made in evidence-based treatment. In 1964, in New York City, Vincent Dole, Marie Nyswander and Mary Jeanne Kreek undertook a small study of the medical technique of narcotic blockade, using methadone, to treat chronic heroin addiction. Better than expected outcomes motivated them to expand their investigations, and the results of subsequent trials contributed to further understanding of heroin addiction as a metabolic disease and alerted the field to the potential for use of methadone on a wider scale (Dole & Nyswander 1967; Dole, Nyswander & Kreek 1966).
Dr. Jerome Jaffe was the director of the Drug Abuse Division of the State of Illinois Department of Mental Health in 1967, and under its auspices undertook further study of methadone maintenance. Results of this multimodality program in a community setting revealed how short-term treatment with moderate doses of methadone could facilitate recovery, and pointed to areas for future research. A significant and unexpected general observation made by the researchers was that " . . . the availability of methadone maintenance does not inevitably destroy the motivation of patients to achieve abstinence" (Jaffe, Zaks & Washington 1969).
In San Francisco during the late 1960s, innovative solutions for the problems of substance abuse (including detoxification protocols still in wide use today) were a hallmark of the nation's first Free Clinic, the Haight Ashbury Free Clinic. The San Francisco Medical Society and the California Medical Society, physicians from UCSF Medical School, and promoter Bill Graham and concerned musicians, all helped to support the Free Clinic's services. A 1971 federal grant enabled the Clinic to substantially expand its multimodality Drug Detoxification, Rehabilitation and Aftercare program (Smith 2009a, b).
At the federal level the priorities and responsibilities of the Department of Health, Education and Welfare (DHEW) were many and various. NIMH was transferred from NIH, and became a major unit of the new Health Services and Mental Health Administration (HSMHA), established within DHEW in 1965. Over time, the magnitude and severity of the problem of alcoholism was becoming more visible and, in his 1966 Special Message on Domestic Health and Education, President Johnson urged inclusion of "this disease in comprehensive health programs." He directed the Secretary of DHEW to appoint an Advisory Committee on Alcoholism, and called for the establishment of a PHS research center and for the development of a science-based public education program (Johnson 1966). In 1967, the AMA passed a resolution that "alcoholism is a disease that merits the serious concern of all members of the health professions" (White, Kurtz & Acker 2001). In response to President Johnson's 1967 Health and Education Message to Congress, the DHEW created a unique federal agency within the HSMHA, the National Center for Health Services Research Development. This was a general-purpose health services research agency and addiction services research was not on the Center's agenda. Despite the relevance of health services research to overall health policy formulation it was not prioritized during subsequent administrations (IOM 1979).
A wide range of strategies for combating drug and alcohol abuse were outlined in President Johnson's 1968 Special Message "To Ensure Public Safety" including: increased research, education, manpower training and rehabilitation efforts; more agents for enforcement of narcotics and dangerous drug laws; and a full scale review of the laws by the National Commission on Reform of Federal Criminal Laws; and consolidation of Treasury Department and DHEW drug agencies within the Department of Justice (this led to the establishment of the Bureau of Narcotics and Dangerous Drugs). Johnson even proposed legislation making illegal manufacture, sale and distribution of LSD and other dangerous drugs a felony, and possession a misdemeanor. Expressing full support of DHEW alcoholism programs, the President recommended increasing FY 1969 appropriations to $13.4 million, and he proposed the Alcoholic Rehabilitation Act of 1968, to "provide Federal leadership and assistance to states and localities in developing non-jail alternatives for the handling of alcoholics" (Woolley & Peters 1968). Congress took heed and the resulting Alcoholic and Narcotic Addict Rehabilitation Act of 1968 put federal support in place for training in prevention and treatment of alcoholism, and for construction of state treatment facilities. This was another vote of confidence for the funding process initiated in 1966. Alcoholism was soon recognized as "the nation's fourth most serious health problem" and early 1969 saw the bipartisan sponsorship in Congress of a generously funded Alcoholism Care and Control Act of 1969 (IIHS 1969). Due to the administration's anticipated 1970 budget constraints, the bill did not progress to hearings (AJN 1969).
During the Johnson era there was an increase in grants in aid programs directly funding local level and nongovernment organizations. Impediments at the state level were bypassed, enabling federal influence and investment in the life of the nation in a variety of ways (neighborhood health centers are one example). Many Americans came to regard an array of public services responsive to community needs as essential. Subsequent administrations, eager to redirect public resources, gradually cut back this type of funding, and creativity and persistence at the state and local level for finding and implementing alternative solutions has been imperative. The high level of investment of public wealth in the military industrial complex and the prison-industrial complex contributes to a skewed federal drug policy, detrimental to a comprehensive public health approach to substance abuse (Cringely 2004; Davis 1998). "In short, the emphasis on reducing the supplies of drugs has left the reduction of the demand for drugs with insufficient resources" (Clark, Sorensen & Morin 1993).
NEW AGENCIES, NEW INITIATIVES AND EXPANDING BUSINESS ON ALL FRONTS
During Richard Nixon's term (1968-1974) contrasting elements abounded: at the same time as prevention strategies and new data instruments were introduced and innovative substance abuse treatment, rehabilitation, and research were being supported, the antithesis--the President's "War on Drugs"--was also being implemented and enforcement agencies proliferated. Characteristic of the Nixon era, a White Paper on health policy objectives for the coming decade issued by DHEW (1971) states:
There was often bipartisan cooperation and the President found ways to work with the Democratic majority in Congress on issues of common concern. Development of alcohol and drug treatment policy was advanced in a spirit of compromise. Advocates of treatment rather than criminalization of drug addiction made headway with policy makers.
The Comprehensive Drug Abuse Prevention and Control Act of 1970 included a general repeal of mandatory minimum sentences for drug violations, as well as authorization of treatment and rehabilitation services. Drug policy perspectives were broadened to include a range of drug abuse problems besides addiction and the Act called for the establishment of a National Commission on Marijuana and Drug Abuse. The grip of enforcement was tightened by the key legislation consolidating federal regulatory and enforcement authority, the Act's Title II, known as the Controlled Substance Act, which mandated classification of drugs by utility, safety, and potential for abuse and dependence (DEA 2003).
The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970, an important policy milestone, repositioned alcoholism outside the sphere of mental illness, and out of the control of the mental health bureaucracy. The Act established a separate federal agency, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and provided for grant programs in support of treatment. Levels of funding for research and for prevention of abuse and dependence were increased in this legislation. The Office of Economic Opportunity and the NIAAA began to fund alcohol treatment programs for Native Americans in the late 1960s and early 1970s, and Indian Health Service Office of Alcoholism Programs began in 1976 (NIDA 2006; Coyhis & White 2002; Baumhol & Jaffe 1995; May 1995).
In 1970, Dr. Jerome Jaffe was asked to assemble an ad hoc committee of experts and report to the President on addiction treatment. Among the findings of the (never released) report were that federal drug abuse policy lacked planning and cohesion, and a plethora of agencies were involved in funding treatment, prevention and research, without a mechanism for inter-agency communication. The report emphasized the immediate need for framing strategy and coordinating policy; the importance of data instruments and surveys in policy formulation and evaluation; and the need for increased funding for research on drug abuse (UMSARC 2007). In 1971, President Nixon appointed Ray Shafer as Chairman of the National Commission on Marijuana and Drug Abuse, and the first surveys of the drug use of the noninstitutionalized civilian population over 12 years of age were undertaken under the auspices of the Shafer Commission in 1971 and 1972, with a survey sample of 3,000 (SAMHSA 2006).
News stories publicized heroin use among U.S. servicemen in Vietnam, and Congressmen Robert Steele (R-CT) and Morgan Murphy (D-IL) presented a report on the problem in May 1971 (PBS 2000a). President Nixon responded in a Message to Congress on June 17, proposing further emphasis on demand reduction and requesting additional FY1972 budget appropriations: $105 million for treatment and $10 million for education and training (Woolley & Peters 1971). The same day, he also signed an Executive Order creating the Special Action Office of Drug Abuse Prevention (SAODAP) within the Executive Office of the President, facilitating interagency coordination, and further consolidating authority in the White House (National Archives 1971). As its director, the President appointed Dr. Jerome Jaffe, whose experience enabled him to promote addiction treatment and direct federal attention to a wide range of drug abuse research. The SAODAP absorbed a multi-agency coordinating committee on drug abuse health education that DHEW Secretary Elliot L. Richardson had established in 1970 and, in 1972 initiated the Drug Abuse Warning Network (DAWN, now administered by SAMHSA) to collect data from a nationwide sample of 24-hour emergency departments in nonfederal, acute-care, general, hospitals (SAMHSA 2010).
The nation's increasing numbers of addicted Vietnam veterans motivated the new White House philosophy: "no addict should have to commit a crime because he can't get treatment", and the expansion of heroin addiction treatment services (Smith 2009a). The leadership of NIMH voiced uncertainty about methadone maintenance programs and Director William Martin expressed reservations about their standards of evaluation (Martin 1970). The creation of the SAODAP enabled an alternative funding stream; focus was on outpatient treatment rather than hospitalisation, and the number of programs was tripled within 18 months. The number of patients receiving treatment at methadone clinics nationwide doubled from 1970 to 1971 (to 20,000) and by the end of 1972 totalled over 60,000. The Veterans Administration also began heroin detoxification and rehabilitation programs in the early 1970s, treating more than 8,500 veterans per year by 1975. During the Nixon Administration, for the first time, more federal funds were allocated for drug abuse prevention and treatment than for law enforcement (White, Kurtz & Acker 2001; White 1998; Besteman 1992).
The National Institute on Drug Abuse (NIDA) was created under the auspices of NIMH, when Congress unanimously passed the Drug Abuse Office and Treatment Act of 1972, in response to the urgent need for planning and delivery of services (Woolley & Peters 1972). In view of the necessity for coordination among the many separate agencies involved in drug policy, the Act initiated requirements for centralized national data on patients entering federally-funded drug abuse treatment. The Client Oriented Data Acquisition Process (CODAP) was developed in 1973 to collect this information (SAMHSA/OAS 2006).
Congress continued to support the 1972 law with periodic amendments extending education and treatment programs, including the Drug Abuse Treatment and Control Amendments of 1974 and 1978 and the Alcohol and Drug Abuse Education Amendments of 1978. Tangible federal leadership and assistance to the states with prevention programs and interventions had a positive effect and contributed to the decrease in drug abuse observed during the 1970s (Butros, Bowers & Quinlan 1998).
The Schafer Commission's findings recommended decriminalisation of marijuana use, stating: "The actual and potential harm of the use of the drug is not great enough to justify intrusion by the criminal law into private behavior, a step which our society takes with the greatest reluctance" but Nixon was not deflected from the pursuit of his agenda (Kuipers 2007; National Commission on Marijuana and Drug Abuse 1973). There was ample support for the acceleration of the War on Drugs, and it was a thriving business. On the supply reduction side, federal expenditures for enforcement had increased from approximately $4 million in 1962 to the level of $60 million in 1972 (Musto 2005).
President Nixon issued an Executive Order in 1972 creating of the Office of Drug Abuse Law Enforcement, an 18-month experimental project involving a dozen different departments & agencies, to enhance cooperation of federal and local forces in the war on drug in the streets (DEA 2003). The Office of National Narcotics Intelligence was also established, and the following year both agencies were merged into the new Drug Enforcement Agency (DEA) in the Justice Department. In his 1973 Message to Congress on the establishment of the DEA Nixon declared the Administration's "all-out global war on the drug menace" and also asked Congress for prompt action on his proposal for the reinstatement of mandatory minimum sentencing (Woolley & Peters 1973).
In 1973, the PHS ordered the reorganization of federal drug and alcohol agencies. The Comprehensive Alcohol Abuse and Alcoholism Prevention Amendments of 1974 established the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA). The role of this agency was the supervision and coordination of NIAAA, NIMH and NIDA activities. The programs and functions of SAODAP and the NIMH Division of Narcotic Addiction and Drug Abuse were moved to NIDA. The Addiction Research Center at Lexington became NIDA's intramural research program, and was eventually relocated from Lexington to Baltimore, Maryland, after a law against experimentation on federal prisoners was passed in 1979 (UMSARC 2008; NIDA 2006; Kolberg 1995).
The imperative for joint responsibility of law enforcement and public health officials for methadone, as well as concerns about methadone diversion, prompted formulation of the Narcotic Addict Treatment Act of 1974. The Act established further federal regulations for methadone treatment, including definitions of detoxification and maintenance, and the requirement of annual registration of practitioners dispensing methadone (Rettig & Yarmolinsky 1995). NIDA invested in two important data instruments in 1974. The initial 1974 National Household Survey on Drug Abuse was modelled on the earlier Schafer Commission surveys. Managed since 1992 by SAMHSA Office of Applied Studies, the (renamed) National Survey on Drug Use and Health is the primary source of information on U.S. drug use and currently obtains data from over 50,000 individuals (SAMHSA 2006). Systematic collection and evaluation of data on drug, alcohol and tobacco use of U.S. students was funded for the first time at the urging of Director Dr. Robert Dupont. The Monitoring the Future Survey (MTF) has been conducted by the University of Michigan Institute for Social Research for over three decades, and is ongoing (Goodman 2008).
The Career Teachers Training Program in Alcohol and Drug Abuse, a multidisciplinary health professions faculty development program sponsored by NIAAA and NIDA, was started in 1972 and carried on for a decade. In 1976, members of the Career Teachers Training Program formed the Association for Medical Education and Research in Substance Abuse (AMERSA); its mission is health professional faculty development in substance abuse (Samet et al. 2006). Joining in the response to the need for physician education in substance abuse, the Veterans Administration Office of Academic Affiliations established the VA Substance Abuse Treatment Fellowship Program in 1980 (VA 2009).
While President Gerald Ford (1974-1977) was in office, there was little or no change in drug policy. Ford placed less emphasis than Nixon on the power of the White House, and, after signing amendments consolidating drug policy oversight, did not seek appropriations to fund the establishment of a White House Office of Drug Control Policy. The State Department, CIA, Treasury, Coast Guard and other federal agencies continued to work separately (Musto 2005; PBS 2000b). The President established the Domestic Council Drug Abuse Task Force in 1975, to assess the extent of drug abuse in America. The Task Force examined the effectiveness of the Controlled Substance Act, and reported to the President in a White Paper, recommending ". . . priority in federal efforts in both supply and demand reduction be directed to those drugs which inherently pose greater risk to the individuals and to society." A high priority was given to heroin, amphetamines and mixed barbiturates and a lower priority to marijuana (DEA 2003; PBS 2000a). It did not prove expedient for the President to act on the recommendations of the Task Force: in hopes of gaining support for his re-election, Ford proposed a revival of mandatory minimum sentencing for drug trafficking in the Narcotics Sentencing and Seizure Act of 1976, but was not supported by Congress (Musto 2005).
The visibility of mental health problems increased during more than a decade of dehospitalization. The numbers of homeless persons rose and many people with mental health disorders--and with co-occurring substance abuse problems--became enmeshed in the penal system. President Carter (1977-1981) appointed the President's Commission on Mental Health in 1977 and, in 1980, based on the Commission's recommendations for continuing federal support and increased funding for Community Mental Health Centers, Congress passed the Mental Health Systems Act (Thomas 1998).
Initially, while the national climate was favorable, President Carter favored decriminalization of marijuana possession. The 1978 Monitoring the Future survey showed high marijuana use among youth (37.1% of high-school seniors) and, after being approached by concerned parents, Dr. Robert DuPont reconsidered the issue and withdrew his support for legalization (Musto 2005).
In 1979, Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention proposed a "renewed national commitment to efforts designed to prevent disease and to promote health" (DHEW 1979). Putting the Surgeon General's words into practice, the Healthy People Initiative advances a paradigm of health that includes the social and behavioral dimensions of improving population health status. Coordinated by the Office of Disease Prevention and Health Promotion in the Department of Health and Human Services (successor agency to DHEW), the program enlists collaboration from public and private partners in each focus area. Health promotion and disease prevention goals for the nation are set a decade at a time, with measurable objectives in each area, and then the progress toward those goals is tracked. Reducing alcohol and drug misuse was one of the original subgoals and the Surgeon General noted that dealing with the problem "depends, in many ways, more on our skills in mobilizing individuals and groups working together in the schools and communities, than on the efforts of the health care system" (DHEW 1979).
SHIFTING RESPONSIBILITIES, NEW STRATEGIES AND IMPROVED COLLABORATION
"Government is the problem" was a slogan that featured prominently in the election campaign of Ronald Reagan (1981-1989) and was interpreted selectively during his Administration. Concurrently, major antitaxation initiatives were supported and oversight of drug policy was concentrated in the White House. Allocations for federal domestic social programs were reduced--at the same time that spending was increased for law enforcement, the penal system and further military involvement in the War on Drugs.
President Reagan's signature of the Omnibus Budget Reconciliation Act of 1981 repealed the Mental Health Systems Act of 1980 signed by President Carter. As Thomas (1998) notes "In accordance with the New Federalism and the demands of capital, mental health policy was now in the hands of individual states." Under the new Alcohol, Drug Abuse and Mental Health Services Block Grant, the percentage of federal funding was reduced and the burden of financing shifted to state and local agencies. Services were cut back and development of partnerships and alternative funding strategies became a vital necessity (Minnesota Psychiatric Society 2004). At this time, collection of national CODAP data was discontinued and individual states established their own data collection systems (SAMHSA 2008). In 1982 Congress amended the Posse Comitatus Act of 1876 (which had banned military involvement in law enforcement) to permit state and local law enforcement agencies to use the military for training, intelligence and investigation, and use military equipment in drug enforcement operations (Harrison, Backenheimer & Inciardi 1995).
The private sector (including philanthropic foundations, professional organizations, nongovernment organizations and community groups) plays an important role in substance abuse treatment and rehabilitation services and areas related to drug policy including advocacy and policy consulting, medical education, and research (CSAT 2005; NTAC 2000; White 1998; Adams & West 1988). The following are just two among the many noteworthy examples. Perceiving the need for the advancement of specialized substance abuse treatment for women, former First Lady Betty Ford was instrumental in founding the Betty Ford Center in 1982. She became an activist in the field, and the Center a leader in private nonprofit treatment for alcohol and drug abuse. Two decades of experience led to the establishment in 2006 of the Betty Ford Institute, with a mission of "collaborative programs of research, prevention, education and policy development" (BFI 2008a). Mothers Against Drunk Driving lobbied successfully in support of The Uniform Drinking Age Act of 1984, overcoming the initial objection raised by opponents that this federal legislation (outlawing purchase and public possession of alcoholic beverages, not drinking per se, for persons under 21) infringes on states' rights. The Department of Education-funded Higher Education Center for Alcohol and Other Drug Abuse and Violence Prevention puts the law in perspective: "A comprehensive approach to preventing student alcohol abuse brings about change at the institutional and community levels, in addition to the public policy level where the drinking age is set. This approach is grounded in the principle that people's attitudes, decisions, and behavior--and in this case, those that relate to alcohol use--are shaped by the physical, social, economic, and legal environment. The many aspects of this environment can be shaped by prevention advocates, campus officials, government officials, and others. This model, termed environmental management, is supported by scientific research for its effectiveness in bringing about lasting and positive change on a college campus" (Education Development Center Inc. 2009).
The Office of Substance Abuse Prevention (OSAP) was created under the Anti Drug Abuse Act of 1986, and the new alcohol and drug abuse treatment and rehabilitation (ADTR) block grants and other drug demand reduction and education programs were funded. Congress authorized expenditures of $6 billion over three years for a variety of programs. Mandatory minimum sentences for drug violations were reinstated, with the stated aim of targeting high-level drug traffickers. On the twentieth anniversary of the Anti-Drug Abuse Act, the American Civil Liberties Union issued a report (Vagins & McCurdy 2006) on its enormous costs and the profoundly negative consequences incurred by its implementation (Drug War Chronicle 2009; Walton 2007; Davis 1998). The Anti-Drug Abuse and Control Act of 1988 increased appropriations again, and mental health services and alcohol and drug abuse services were split into separate block grants. Congress encouraged the development of community partnerships and school-based prevention programs (Kumpfer 2008). The Act's subtitle, the National Narcotics Leadership Act of 1988, established the White House Office of National Drug Control Policy (ONDCP) as part of the Executive Office of the President.
After the passage of the Comprehensive Alcohol Abuse, Drug Abuse, and Mental Health Amendments of 1988, new federal data collection provisions were included in the revised Substance Abuse Prevention and Treatment Block Grant. The Treatment Episode Data Set (TEDS) was established to take up where the discontinued CODAP had left off eight years before (SAMHSA 2008). In 1989, due to concerns of legislators and the ADAMHA about adequate state data collection on mental health and substance abuse, an inspection was requested. The Assessment by the Office of Inspector General concluded that: "Data collected by the states, although extensive is not comparable and currently cannot be aggregated into reliable national statistics" (OIG 1989). The Epidemiologic Catchment Area (ECA) Survey, administered from1980 to 1984, had provided indications of the prevalence of co-occurring mental health and substance abuse disorders. Building on this study, NIMH funded the National Comorbidity Survey from 1991-1992. This longitudinal study was the first epidemiologic survey of substance use and mental disorders to use a national probability sampling (CSAT 2007).
Meeting the Challenges of Federal Restructuring of Services and Research
During the 1980s the level of federal funding for prevention and treatment peaked at a share of roughly a third of the total drug budget. The Administration of George H. W. Bush (1989-1993) devoted a smaller proportion of the rapidly swelling federal drug budget to demand reduction. Although prevention and research appropriations were increased the funding levels remained comparatively low (ONDCP 1999). Federal criminal justice expenditures rose rapidly and there was an increase of 50% in military spending on the War on Drugs. In December 1989, the United States invaded Panama and General Noriega surrendered to the DEA; he was later tried and convicted on eight counts of drug trafficking (PBS 2000a). In FY 1990 40% of the drug control budget was specified for law enforcement, 20% for the construction of correctional facilities and less than 12% for improvement of drug abuse treatment (Schnoll & Karan 1990). Estimated 1990 antidrug expenditures illustrate the growing burden on the states: Expenditures for law enforcement at the federal level were $7 billion and $17 billion at the state/local level. The allocations for prevention and treatment were $4 billion and $3 billion respectively (Murphy 1994). Using San Francisco as an example, Clark, Sorensen and Morin (1993) describe how momentum was built up and progress achieved in substance abuse prevention treatment and research in the wake of federal funding constraints and diminished resources. Providers and administrators at the state and local level intensified their efforts to gather resources, implement a widening range of interventions and services for addiction disorders, engage the community, and participate in advocacy at all levels. The AIDs epidemic increased the stakes and brought local and federal policy makers together to formulate a national strategy (Kritz et al. 2008; Benjamin & Lee 1989).
The ADAMHA Reorganization Act of 1992 (sponsored by Senator Edward Kennedy) created a new organizational structure to address both services and research, the Substance Abuse Mental Health Services Administration (SAMHSA). The Act established SAMHSA's Centers for Mental Health Services (CMHS), Substance Abuse Prevention (CSAP) and Substance Abuse Treatment (CSAT). The Act integrated the NIAAA, NIDA and NIMH, ADAMHA's three research institutes, into the National Institutes of Health, and mandated interaction between the institutes and SAMSHA Service Centers. All the research on addiction and alcohol was transferred to NIH, and provisions were included for separate authorization for the NIDA Medication Development Program, and for the establishment of National Drug Abuse Research Centers (Clark, Sorensen & Morin 1993). Fetal alcohol syndrome (FAS) was recognized as a serious problem and the Act also called for an Institute of Medicine study of FAS and related birth defects (Stratton, Howe & Battaglia 1996).
Upon signing the 1992 law, President Bush's remarks emphasized its significance: "Bringing research on mental illness and addictive disorders into the mainstream of biomedical and behavioral research at NIH will foster a greater exchange of information. It will also encourage the sharing of expertise in neuroscience and behavioral research within the biomedical research community" (Bush 1992). NIDA's Acting Scientific Director George Uhl later observed, in 1995, "When we [NIDA] were within ADAMHA . . .there were competing voices. There was a focus on scientific rigor, but also a focus on the provision of service--something that was split off when the Substance Abuse and Mental Health Administration was created . . . Moving just the research components of the institute into NIH has really focused the energy on research" (Kolberg 1995). The Addiction Research Center was included in the move to NIH, and NIDA Director Alan Leshner noted, "Although by NIH standards it is small, by world standards on drug-abuse research, it is a central focal point" (Kolberg 1995).
Progress was made during the Clinton Administration (1993-2001) on federal policy on addiction medicine and programs for substance abuse research and treatment. The Behavioral Therapies Development Program, begun in 1994, significantly broadened the scope of NIDA-supported behavioral research beyond clinical studies of established treatments for drug abuse. Development of treatment for co-occurring mental and substance abuse disorders was one of the programs goals (NIH 1998). The gap between practice and research was the subject of an Institute of Medicine report (Lamb, Greenlick & McCarty 1998) and, well advised, NIDA developed two nationwide programs in response. The CSAT Practice Improvement Collaboratives support partnerships between local and regional treatment programs and researchers. The NIDA Clinical Trials Network studies the effectiveness of treatment interventions in a variety of settings and supports the transfer of tested interventions into clinical practice (Jessup et al. 2008).
By the late 1990's senior health officials, scientific researchers and AIDS activists had identified needle-exchange as a priority component of harm reduction, but it was a politically volatile issue. When the President unexpectedly blocked the DHHS go-ahead for allowing federal funding for clean needle programs in 1998, the Soros Foundation responded quickly, announcing plans for $1 million in matching grants for needle exchange programs throughout the US (Harris & Goldstein 1998).
When the 2000 Drug Addiction Treatment Act (DATA) was enacted, it had been illegal for more than 80 years for physicians to prescribe opioid medications for the nonregulated, outpatient treatment of opioid dependence. This change in the law, which permits Schedule III, IV or V narcotic medications that are FDA-approved for treatment of narcotic-use disorders to be used for medically-supervised detoxification or maintenance, facilitates patients' access to treatment by addiction medicine specialists and makes office-based care possible. Subsequent FDA approval of buprenorphine, which can be used to treat prescription opioid analgesic abuse as well as heroin addiction, was heralded by SAMSHA (2002) as "a milestone in the 12-year medication development program of the National Institute on Drug Abuse." SAMHSA is collaborating with professional medical organizations to support required physician training and increase acceptance of office-based treatment (Clark 2003).
There was no fundamental change in drug control policy during the Clinton Administration. In 1995 the U.S. Sentencing Commission, which administers federal sentencing guidelines, released a report noting the racial disparities in cocaine vs. crack sentencing. The commission proposed reducing the discrepancy, but for the first time in history, Congress overrode their recommendation (PBS 2000a; Walton 2007). The ONDCP Drug Data Summary of April 1999 shows that expenditures for the criminal justice system and aspects of supply reduction continued to outstrip investment in prevention, treatment and research. The annual federal drug budget for criminal justice tripled from $2.76 billion in 1989 to $8.45 billion in 1999 (ONDCP 1999).
Prolonged Effort & Dedication in Addiction Medicine Pays Off
During the George W. Bush Administration (20012009) Congress continued to authorize disproportionate federal spending for the supply reduction aspects of drug policy, and for the unchecked growth of the criminal justice system, just as it had done for many years. The parameters of the funding situation are not news to those in the field of addiction medicine. Decades of accumulated experience and intensive collaboration have contributed to progress on the policy front. Three areas of exemplary achievement are: the advancement of medical education on substance abuse; improved dissemination of research to treatment providers; and increased focus on recovery-oriented treatment.
SAMHSA and NIH are lead agencies for the Healthy People 2010 substance abuse focus area. Interrelated public health challenges have encouraged further multidisciplinary and intersectoral participation in addressing substance abuse. SAMHSA/CSAT provides support for the collaboration, begun in 1999, between AMERSA and the Health Resources and Services Administration's Bureau of Health Professions. The development of a Strategic Plan for Interdisciplinary Faculty Development was an important objective and the AMERSA Strategic Plan, published in 2002, was a product of this synergy. It addressed the urgent need for the formulation of public policy focused on investment in health workforce education and training, and provided expert recommendations to the Secretary of DHHS, the Surgeon General, to federal agencies, and public and private sector organizations (Haack & Adger 2002).
In his 2003 State of the Union Address, George W. Bush announced a new federal substance abuse treatment initiative, Access to Recovery. First implemented by SAMSHA in 2004, the program is ongoing, funding three-year grants in aid. The objectives are to expand patient choice, improve access to clinical treatment and recovery support services, and increase substance abuse treatment capacity. Expressing its support, the National Association of Alcoholism & Drug Abuse Counselors emphasised, "... the only way effective implementation can be achieved is through faith based providers and professionals adhering to the same set of licensure and certification requirement that secular counselors have had in place for decades, those rooted in evidence based practices" (NAADAC 2010).
NIDA and SAMHSA have joined forces in the Blending Initiative, introduced in 2003 to promote the effective and timely dissemination of research results identified by NIDA, and reduce the gap between research and practice. Staff from SAMHSA/CSAT's Addiction Technology Transfer Center (ATTC) Network and researchers and community treatment providers from NIDA's Clinical Trials Network (CTN) share their expertise to enable these evidence-based practices to be used advantageously by the addiction treatment workforce (NATTC 2010; NIDA 2009).
Leaders of AMERSA's Medical Education Task Force were instrumental in organizing and leading the first ONDCP National Leadership Conference on Medical Education in Substance Abuse in 2004 (AMERSA 2004). This conference continues to be held annually and the ONDCP generates reports and working papers from the proceedings. In 2006, Conference Chair Bertha K. Madras, ONDCP's Deputy Director for Demand Reduction, stated in concluding remarks:
We will need to work together, and separately, to encourage implementation through multiple Federal agencies, such as the FDA and DEA, through State agencies and local communities, the pharmaceutical companies, health insurers, State medical boards, and the numerous other groups with a stake in these issues (ONDCP 2007).
Recognizing the importance of quality education in substance abuse being integrated into the traditional medical school curriculum, concerned medical students formed a multidisciplinary group, Health Professional Students for Substance Abuse Training. The AMERSA leadership welcomed this step and anticipated an alliance being forged with their organization that bodes well for the future (Samet et al. 2006).
Charles Bishop and Michael Flaherty provide valuable insight in the preface to Recovery, Linking Addiction Treatment and Communities of Recovery, a report produced by CSAT in cooperation with the Northeastern Addiction Technology Transfer Center:
The integration of treatment with the recovery movement depends on recognition and acceptance of some powerful, openminded, and positive principles: cultural competency, the role of client-chosen spirituality, the many roads to recovery, and the lasting commitment and valuation that our society needs to make for those who need our acceptance and assistance (White & Kurtz 2006).
The Betty Ford Institute has sponsored Consensus Conferences on defining recovery; extending treatment benefits; and the integration of primary care and Addiction Medicine and science. The Journal of Substance Abuse Treatment (2007) published a Special Section with the findings of the 2006 BFI Inaugural Consensus Conference, "What is Recovery: A Working Definition from the Betty Ford Institute", and SAMHSA followed up with a regional input process and presentations at the 2008 annual meetings of both the National Association of State Alcohol and Drug Abuse Directors and the National Association of Alcoholism & Drug Abuse Counselors. As part of the Partners for Recovery program, the CSAT has adopted the "Recovery-oriented Systems of Care" program model (BFI 2008b; SAMHSA 2009). "A recovery-oriented systems approach supports person-centered and self-directed approaches to care that build on the strengths and resilience of individuals, families, and communities to take responsibility for their sustained health, wellness, and recovery from alcohol and drug problems" (Whitter 2008).
Researchers from the University of California, San Francisco examine the challenges faced by treatment providers in moving from science to practice, in a report on the adoption of drug abuse interventions in the context of the NIDA Clinical Trials Network (Jessup et al. 2008). The authors suggest adoption of fresh approaches to the investigation of "why knowledge diffusion stalls," and concur with Glascow and colleagues (2003), who call for examining the "complexity of the world."
The passage of the Wellstone and Domenici Mental Health Parity and Addiction Equity Act of 2008 was a significant step toward overcoming the obstacles of cost and reimbursement issues that deter people from getting treatment for mental health and substance abuse disorders. Following in the footsteps of state parity laws, this federal legislation brings insurance provisions for these conditions (when offered, in plans serving over 50 people) into line with the benefits of medical and surgical coverage (see Roy & Miller 2010 in this issue for more information on this topic).
Carpe Diem--Seize the Day
A variety of strategies are needed for coping with the nation's complex problem of substance abuse and drug addiction, just one among the many challenges facing President Barack Obama (2009- ) and his administration. The newly appointed ONDCP Director Gil Kerlikowski expressed his support for expanding demand reduction initiatives (UNODCP 2009) but the FY2010 drug budget, with nearly a two-to-one ratio in favor of supply reduction, is cast in the mold of previous administrations (Curley 2009). To move forward, there needs to be a clear vision of the problem. The appointment of Dr. Thomas McLellan as Deputy Director of ONDCP gives reason for optimism that the momentum gathered by addiction medicine will be maintained, and that future federal policy will include, in his words, "a long-overdue national look at our prison policies; collaborative strategies among the prevention, treatment, criminal justice, healthcare and education fields, and continued modernization of specialty treatment and prevention centers" (Alcohol/Drug Council of North Carolina 2009; Inaba 2004).
White and McLellan (2008) propose a recovery management model in which client-directed recovery plans would assume importance, and treatment focus would be shifted away from emergency room models and more emphasis placed on long-term, low-intensity, recovery maintenance services. Both quality of care and patients' access to care must be improved, and an approach adopted that goes far beyond the common acute care model based mainly on the biomedical paradigm.
"Core Consensus Principles for Reform" are outlined in the May 2009 SAMHSA Consensus Statement: Ensuring U.S. Health Reform Includes Prevention and Treatment of Mental and Substance Abuse Disorders--A Framework for Discussion (Hutchings & King 2009). In brief, as summarized by the American Society of Addiction Medicine's online ASAM News (2009): Universal health insurance and full parity are essential to achieving improved health and long-term fiscal sustainability. A safety net for persons seriously disabled by mental health and substance abuse disorders is also a priority. There must be national planning for health and wellness; investment in specialized work force training, and coordination and integration of a full range of services. Utilization of health information technology and national standards for clinical and quality outcomes are also recommended.
An information exchange report produced by SAMHSA in November 2009 details the continued success of Access to Recovery and indicates its broader social and economic benefits. Recovery Support Services are used by a large majority of patients after initial treatment and 95.8% report no involvement with the criminal justice system at six months post-intake. Although annual funding has been gradually reduced from $100 million to $ 95.5 million, the number of states and tribal organizations participating has risen from 14 to 24 and the number of patients from 100,000 to about 127,000 (SAMHSA/ATR II 2009). Two other ongoing recovery-oriented federal programs are transforming systems, fostering partnerships, and showing encouraging results: Recovery-Oriented Systems of Care (ROSC) and the Recovery Community Services Program (RCSP) fund projects that bring together a wide range of services that help people in recovery build and maintain a substance-free lifestyle. Typical recovery support services include housing, medical and dental care, mental health treatment, employment training and placement, family counseling, peer support/mutual aid support networks, childcare and transportation (ONDCP 2010).
Leadership for the future of the Healthy People program comes from the Secretary's Advisory Committee on Health Promotion and Disease Objectives for 2020. Chairman Jonathan Fielding called for health leaders to take an "ecological approach to health promotion" focusing on the trajectory of a person's life course and what can be done at each stage of life to point that trajectory toward good health (Krisberg 2008). Given the Obama Administration's January 2010 announcement that it is implementing a recovery systems of care policy (ONDCP 2010), it is fitting to end here by noting the significance of the interdisciplinary domain of human ecology, pioneered by Urie Bronfenbrenner, and the "bioecological" model of human development within in a life course framework (Bronfenbrenner 2005, 1979). This perspective was missing from Harry Anslinger's limited education and worldview, and from the punitive policies he championed that have been stubbornly adhered to long after they have been shown to be ineffective and harmful. Setting a intelligent and compassionate new course for our nation's drug policy will help ensure a less chaotic world and contribute to the viability of future generations.
The collaboration essential to research, education, and delivery of prevention and treatment for substance abuse has been established on many levels, and changes in federal drug policies are overdue. Bipartisan political cooperation is essential to reformulate priorities and direct appropriations toward integration of health services and delivery of a wide range of substance abuse prevention and treatment modalities. The shift in the overall framework of public health policy will enhance effective health promotion and increase our capability to address problems that arise from behavior-environment interaction. This is expressed in substance abuse strategy as a Recovery-Oriented Systems of Care model, and the effective translation of the bioecological model of human development into the recovery systems of care provides leverage for the pragmatic advancement of nonpunitive drug policy. For more than incremental changes to be made, a solid commitment must be made, and public funds invested in public well being (in the broadest sense, and with the maximum imagination, good will and good sense that accumulated experience affords) rather than dumped down the drain to further enrich those who profit from the War on Drugs and the unchecked expansion of the penal system.
The authors would like to express our appreciation to Eunice Chee, William White, Alan Trachtenberg, James Sorensen, Martin M. Katz, Steven Heilig, David E. Smith, Leigh Davidson, Jeffrey Samet, Steven Kritz, Jane Silver, Laura Schmidt, and Juliana Fung.
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