Second of a four-part series.
PART 1: Cleaning Up: Federal money is expanding drug treatment in Baltimore--and causing providers headaches. 06/22/2010
PART 3: "We Are Not In the Housing Business": Baltimore's recovering addicts need a clean, affordable, safe place to live. Somebody's making money on it--but don't ask who, or how
PART 4: Waiting for the Plan: As more money flows into drug treatment centers and the number of addicts rises, Baltimore can't determine which programs actually work 11/10/2010
"There are a lot of changes happening right now that could have a big impact on behavioral health," Sebelius told anacof mental health professionals at Sheppard Pratt Health System. "Parity, health insurance reform, the growing popularity of integrated care models, an increased focus on prevention, huge gains in our understanding of the science behind mental illness and substance abuse."
"Parity" means that mental health care can no longer be discouraged by health insurers, who for years have argued for their right to charge more to cover treatment of mental disorders than for physical ailments. Since July 1, interim regulations require insurers to make a "good faith compliance effort" to follow the law--the Mental Health Parity and Addiction Equity Act--forbidding the practice.
"If 10 or 20 million Americans were walking around with open wounds, we'd call it a national crisis," Sebelius continued, according to a transcript of her speech. "But because mental illnesses and addictions can be harder to see, we don't feel the same urgency. And yet, the costs of mental illness are right there in front of us. Thirty-two thousand Americans commit suicide each year. People with mental illness make up half of the 700,000 homeless people in America. People with substance abuse disorders account make up four out of five prisoners. The National Academies estimate that mental illness in Americans under 25 alone costs our country almost $250 billion a year."
In Sebelius' model, which is pervasive in drug treatment circles, ending up in prison is just one unfortunate symptom of substance abuse disorder. It is part of a new paradigm called the Recovery Oriented System of Care (ROSC), which seeks to integrate drug and mental health treatment into the larger medical care system, reduce the social stigma associated with these disorders, and "normalize" addiction treatment. In the ROSC model, drug addiction is really no different from other chronic ailments such as diabetes or heart disease.
But this model glosses over differences in the way various medical conditions manifest themselves, and in the way treatment outcomes are measured. People with diabetes and heart disease seldom break into homes to steal electronics or push over grandma to snatch her purse. People with substance abuse disorder routinely do these things, even while receiving treatment for their disease.
And by the industry's current measures, treatment is considered successful if the patient commits fewer crimes than usual during the "treatment episode."
As drug addiction has become "substance abuse disorder" and understood by medical professionals to be a chronic condition, the drug treatment industry has moved its goal posts. The old system was based on short-term treatment leading to abstinence; the new system is usually predicated on open-ended treatment leading to reduced days of drug use, with the main goal being more drug treatment. This is the model set to be fully and indiscriminately funded by Medicaid and private insurance as part of the Sebelius-led final push to "medicalize" drug treatment.
As the history of drug treatment shows, the medical model was present at the beginning. What has long been missing is the scientific rigor and clear-eyed analysis of the kinds of long-term outcomes studies that, in other branches of medicine, bring improved care. As the Baltimore Substance Abuse System (bSAS) celebrates its 20 anniversary and burnishes its reputation as a national model for addiction treatment, the treatment industry's evolution is worth reviewing.
The seminal heroin eradication program was conducted in Washington, D.C. from 1970 through 1973, and, even at the conceptual stage, proposed a medical/public health model. The designer of that program, Dr. Robert DuPont, was young and confident. He envisioned a three-year program that would treat every heroin addict in Washington, D.C.--5,000 of them, by his estimate.
"Heroin addiction is like an epidemic of Plague--the infected person passes his infection to those around him," DuPont wrote in his proposal, dated Feb. 4, 1970. "To stop this epidemic, swift massive action must be taken to treat all infected persons. Unless all infected persons are reached, the epidemic may rage without abatement despite modest treatment success with some infected persons."
DuPont's paper came on the heels of a shocking study he led that discovered that 44 percent of D.C. jail inmates tested positive for drugs. Most of them were heroin addicts.
Defining the district's problem as "a continually rising crime wave" caused by heroin addicts stealing to support their habits, DuPont proposed the creation of a non-profit government "Addiction Control Agency" with a budget of $6 million by 1971 (about $32 million in 2009 dollars). Asserting that, with methadone maintenance therapy, "the problem of heroin addiction is solvable," DuPont set "the goal of the elimination of heroin addiction in the Metropolitan Washington area within three years."
DuPont's proposal touted the political advantage to President Richard Nixon of establishing a Task Force on Heroin Addiction, and included estimates of both the addict population and their crimes' financial damage. "Making some relatively conservative assumptions, [the] data reveal that the direct dollar cost of heroin addiction in the District of Columbia in stolen money and goods is approximately $240,000,000 a year," DuPont wrote.
In sum, DuPont's 1970 drug treatment model contained every major element of modern drug treatment systems, plus it had the advantage of urgency and novelty. DuPont became the director of the D.C. Narcotics Treatment Administration in 1970 and endeavored to measure treatment intakes, drug use by those in treatment, crime, and employment rates.
Three years later, while carefully crediting police efforts to stem the drug trade and the various drug treatment approaches he had instituted, DuPont declared victory in the journal Science--with a few caveats. One was the rise of illicit methadone use, including "a marked increase in methadone overdose deaths." He also urged vigilance. "It is imperative that both treatment and law enforcement efforts be maintained if heroin abuse is to be kept at the lowest feasible level," DuPont wrote. "The passage of time alone will tell whether the problem is truly solved."
Still, DuPont took credit for halving the district's crime rate by late 1972. His program became especially influential with federal policy makers, Dr. Jerome Jaffe recalls, chiefly because "they could show a large drop in crime."
Jaffe, now a psychiatry professor at the University of Maryland and a bSAS board member, is something of an elder statesman in Baltimore drug treatment circles. He advised Nixon on drug treatment strategies as chief of the Special Action Office for Drug Abuse Prevention and was credited with helping to devise the federal government's drug treatment bureaucracy in the early 1970s. Though his own office was funded for only a few years, Jaffe helped design and erect a permanent bureaucratic drug treatment structure before the political winds shifted and law enforcement would again dominate drug policy.
Even 40 years ago, drug treatment was not new. When Nixon tapped him in 1970, Jaffe was a pioneer in methadone research and practice, having established a successful program in Chicago in the late 1960s. Also up and running were Synanon (an alternative-treatment community that emphasized harsh self-examination and "lifetime rehabilitation" that meant one could never be cured, only treated), and therapeutic communities such as Phoenix House (a New York group home founded in 1967 that emphasized self discipline and social structure). A federal "civil commitment" law had passed in 1966, enabling the family members of drug addicts to force their loved ones into a government-paid six-month, in-patient program followed by outpatient monitoring.
But the programs were fragmented and federal policymakers did not know which ones brought consistent results. In the early '70s, federal drug policy "was spread across 15 agencies," Jaffe says, and Nixon asked for ideas from people both inside and outside his administration.
"Our group recommended several things to extend because they work," Jaffe says. "One was therapeutic communities, one was methadone."
The civil commitment system phased out because it was shown to be less effective than other methods, Jaffe says. Nixon encouraged this kind of scientific study to improve drug treatment approaches by establishing the National Institute on Drug Abuse (NIDA), tapping DuPont to head it in 1973. "[Nixon] did say let's have an overall way to measure outcomes," Jaffe says. "The concept that we need to do it has endured."
The optimistic spirit of the '70s faded in the 1980s as outcome measures morphed into marketing hype amid a new drug crisis. The new epidemic of crack left drug policy experts gasping. Wide-spread addiction and frightening crime rates returned to Washington, D.C., with 60 percent of arrested Washingtonians testing positive for cocaine in December 1987, up from 15 percent in March 1984.
"At the moment the conventional wisdom is [that] nothing works," University of Maryland and RAND Corporation researcher Peter Reuter told a Los Angeles Times reporter in 1989. "It's a view that comes out of despair."
Reuter published several papers in the late '80s that questioned the efficacy of both drug interdiction efforts and the prevailing drug treatment regimes that had grown up based on the 1970s models. Treatment programs had become big business by the mid-'80s. But for most people, the programs didn't work.
"The largest nationwide study of drug treatment outcomes (the Treatment Outcomes Prospective Study, or TOPS) showed that the majority of those treated for heroin or heavy cocaine use were again using drugs on at least a weekly basis within a year of their discharge," Reuter wrote in one of his RAND studies. "Recovery from drug dependency is a long process," he wrote, citing statistics from the Maryland Department of Health and Mental Hygiene showing that only 20 percent of those treated for heroin addiction in Montgomery and Prince George's Counties were drug-free when discharged.
Simplistic promises to eradicate drug abuse gave way to cost-benefit analyses touting the savings to society from fewer days of drug use, and fewer crimes committed by addicts while in treatment. This change, mostly unnoticed outside the drug treatment industry, led to sunnier interpretations of the data. The TOPS results are today cited to claim that "Treatment was found to be effective in reducing daily opiate use and other illicit drug use during and after treatment," as the study's NIDA-funded authors claim.
DuPont, now president of the Institute for Behavior and Health in Rockville, says that shift was toxic. "That's what's called harm reduction," he says. "It has become a dominant view in the treatment field, a view that I think is totally wrong. What it does is justify failure."
The crisis of the 1980s led to a renewed interest in novel and even radical solutions. By 1988 Baltimore Mayor Kurt Schmoke was calling for a debate on drug legalization, saying the concept should be discussed openly and seriously.
"I propose that we make a dramatic change," Schmoke told a gathering of correctional officers in Baltimore in 1989, "that we have the war on drugs considered primarily a public health rather than a criminal justice war, that the war on drugs should be led not by police and prosecutors, but by the Surgeon General."
Although Schmoke's ideas are still considered ahead of their time, the language of medicalization was already en vogue. "We're trying to get them to deal with addicts as patients," then Baltimore Health Commissioner Maxie Collier told The Washington Post, explaining the Schmoke administration's efforts to coordinate drug treatment programs with the city's private medical community. "Addiction has to be viewed as a primary care problem . . . like hypertension or diabetes."
With that goal in mind, Schmoke obtained a federal grant in 1990 to establish the Baltimore Substance Abuse System within the city's Health Department. The model was not unlike Jaffe's old White House Special Action Office for Drug Abuse Prevention, which was phased out by 1975. "BSAS was supposed to put itself out of business in five years," bSAS Chief Financial Officer Arnold Ross says.
Like the 1970s treatment pioneers, Schmoke was unafraid of new ideas--some based on the harm reduction model. He instituted the nation's first government-run needle exchange program and, in 1994, a drug court to channel non-violent offenders into drug treatment programs instead of prison. The city also set up an acupuncture clinic inside the city jail--it served almost 40 percent of drug court convicts by the mid-1990s, despite being an uncertified (and untested) treatment approach.
The city was in such desperate straits that it was willing to try almost anything--whether or not anyone could show that it actually worked. (Schmoke was not available for an interview for this article.)
Needle exchange was successful in combating AIDS among intravenous drug users, according to former Health Commissioner Peter Beilenson. But the drug courts' outcomes were marginal. Fully "49.5 percent of drug court participants self-reported being arrested in the year prior to their follow-up interview," a three-year follow-up study found, "versus 57.8 percent of controls." The study's authors noted that the difference between 49.5 percent and 57.8 percent was "not statistically significant," yet concluded that the drug court was successful.
With almost every new approach deemed "successful," treatment advocates argued that the principal obstacle to widespread recovery was lack of funds for more treatment centers.
In 1995, Beilenson recast bSAS as a quasi-governmental non-profit corporation in order to access private grant funding more easily. But gaining access to the city's treatment centers was increasingly difficult, as Beilenson discovered in 1996 when, dressed in a mud-stained shirt and a ratty ball cap, he wandered into several treatment centers to see how an addict seeking help might be treated.
"He was turned down at a number of centers," Schmoke toldThe Sun at the time. "That points out the need for more drug treatment centers."
Beilenson says the effort to increase drug treatment in the city was ongoing from before he took over as Health Commissioner in 1992, "but we didn't get our money where our mouth was until 1999 or so--when [Gov. Parris] Glendenning came in. Mayor [Martin] O'Malley and I really pushed for that--we got about $20 million."
Drug treatment funding in Baltimore increased about three-fold thereafter, from about $17.7 million in 1996 to nearly $53 million in 2005--nearly double (in inflation-adjusted dollars) what DuPont was given in 1971 Washington, D.C. Yet, after decades of drug treatment, Baltimore had about 10 times the number of addicts than D.C. had in the early 1970s.
In 2000, Beilenson implemented DrugStat. "Every four weeks each of the different modalities had to come before this drug stat meeting--so adolescents, residential, methadone, adult out-patient--we held them accountable for outcomes," Beilenson says. One of the main measures was "how long the [patient] stays, because it's well proven that 90-day-plus [in drug treatment] is correlated with better outcomes."
DrugStat also took note of urine test results, employment, housing status, and other measures that were first used in the late 1960s. Beilenson says the stat meetings led to improvements in treatment methods, citing one center that had remarkably good job placement numbers. "They said that instead of job placement programs, we found some potential employers who could take people," Beilenson recalls. "So we changed the contract so that they [all] had to make that effort . . . we were able to identify best practices and spread that around."
Baltimore treatment programs' 90-day retention rates slowly improved, with nearly 90 percent methadone maintenance patients and nearly 50 percent of outpatients staying at least three months by 2005.
While bureaucratic systems were adapting modern management techniques, drug treatment researchers were slowly developing better methods with which to treat patients. One of them was Maxine Stitzer, a professor in the Department of Psychiatry and Behavioral Science at the Johns Hopkins University School of Medicine, who for the past 30 years has focused on incentives.
"People respond to the consequences of their own behavior," Stitzer says. "The problem is that the rewards of foregoing drug use are out there in the future. So today, it's hard. It's painful. It's difficult. So we're trying to bring those distant rewards and make them more immediate."
The prizes for presenting clean urine samples (or just showing up) can range from modest things such as toiletries to elaborate such as like electronic devices or even cash. Perhaps unsurprisingly, "the [remission-prevention] benefit of the prizes increases with the value of the prize."
During the 1980s and '90s, as researchers conducted these small-scale experiments, the drug treatment industry lumbered along with few practitioners learning about the new, scientifically tested techniques. In 1998, the Institute of Medicine published a study called "Bridging the Gap Between Practice and Research," calling for better coordination between clinical researchers and treatment providers.
"They said, this is nuts," Stitzer recalls. "We have all this research, then we have this entrenched network of people using [12-step recovery] techniques." (Not, she hastens to add, that there is anything wrong with 12-step techniques, but the field was not learning from the research done by people like her.)
In 1999, the National Institute on Drug Abuse established the Clinical Trials Network as a clearing house for new research on drug-treatment effectiveness. Now, part of Stitzer's job involves attending conferences where researchers and practitioners meet and evangelizing for the techniques that are proven to work. "There is way more interest in the use of incentives than I ever thought possible," she says.
While incentives to stay in treatment have borne good results, DuPont has advocated a punishment-based approach that may work even better.
DuPont designed a drug court program called Hawaii's Opportunity Probation with Enforcement (HOPE) that combines more intensive monitoring with swift--yet light--punishment for relapse. The idea is to make the sanction for drug use or missing a probation meeting immediate, and progressively harsher for more noncompliance. Jaffe endorses this as well. "You should have graduated sanctions," Jaffe says. "The first time for using [drugs] you maybe go to jail for four days. Next time, maybe it's eight days. And so-on."
In most probation and parole programs, offenders face the possibility of years in prison for a single relapse. But those consequences typically come months after the relapse. Drug courts--including Baltimore's--have for years experimented with graduated penalties, with mixed results.
Relying on an outside study, DuPont claims drug use reductions of more than 90 percent in his HOPE program, and crime reduction of 50 percent. Only five percent of the HOPE group saw their probation revoked, versus 37 percent for the non-HOPE probationers. In a longer article about a different study, this one involving drug-abusing doctors covered by the comprehensive Physicians Health Services (PHS) plan, DuPont and his co-authors show how the combination of extensive random drug testing; swift, progressive sanctions for drug use; and long-term monitoring and treatment combine to produce lasting abstinence in four out of five treated individuals.
PHS programs "are not involved in the financial aspects of addiction treatment," DuPont wrote. This eliminates potential conflicts of interest for the treatment providers.
"If the key ingredients of [such programs]--particularly ongoing monitoring for this chronic illness linked to meaningful consequences--were universally available," the study contends, "we might find that relapse was far from inevitable, and that active addiction careers could be significantly shortened and stable recovery careers extended."
So after 40 years, evidence-based practices are finally becoming something of a priority in drug treatment. But improvement of the drug treatment industry is fitful. "There is increasing pressure to adopt evidence-based practices," Stitzer says. "Well, the problem is, which evidence-based practices? The funders are just allowing anything from a big menu of possibilities."
Even as research into new and better treatment techniques gets disseminated, the long-term outcomes studies that early drug treatment advocates (and even President Nixon) envisioned are still rare. One problem is that each state has a different way of measuring drug treatment outcomes--and sometimes counties do as well.
A potential solution is the National Outcome Measures, an effort by the National Association of State Alcohol and Drug Abuse Directors (NASADAD) to implement a uniform measurement and data gathering system.
Originally scheduled for completion in 2007, the project remains unfinished.
"It's sorely lacking, 'cause so much has happened since then," NASADAD Executive Director Robert Morrison says, citing the passage of health care reform, the implementation of expanding Medicaid as a principle payer for drug treatment, and several state health reform efforts that required close attention from NASADAD's staff. The work done on the project so far constitutes "an important first step," he says, "[but] you put your finger on an important issue, which is now what? Are you using the [data] to improve service delivery?"
Morrison's characterization of National Outcome Measures suggests that improving service to addicts is not the first priority. "What we wanted to do was learn, how can we continue to tell our story," he says. "Policy makers were asking--what are the outcomes we are getting from the dollars we are allocating to you?"
In other words, National Outcome Measures is pitched to justify drug treatment expenditures to sometimes skeptical lawmakers.
Morrison says that 70 to 80 percent of the $21 billion spent on drug treatment is "public money," but that figure is dwarfed by the costs of addiction, which his staff economist estimates at $243 billion for alcohol and $181 billion for illicit drugs. Thus the benefit of treatment--even the imperfect methods now employed--far outweighs the costs, he says. And so the treatment providers' goal is to keep people with substance abuse disorders in treatment for as long as possible.
"The whole view of treatment is changing to a recovery-oriented model," says Bill Rusinko, a long-time research statistician with the Maryland Department of Health and Mental Hygiene. "The addict is seen like someone with high blood pressure or diabetes. They're basically going to be treated forever in some way or another, and never reach the point where we can say, 'You're cured and can stop seeing a doctor.'"
This idea is still controversial, even among bSAS board members. "People say that addiction is a chronic disease, so when people relapse it's not the fault of the treatment providers, and that [the providers] should not be held responsible for the behavior of people when they leave treatment," says Robert Embry, head of the non-profit Abell Foundation and a bSAS board member. "There are some who disagree, and I enthusiastically put myself in the category of people who disagree with that.
"In providing public money for drug treatment, we ought to know, within certain modalities, and within certain sub-groups of addicts, that we're having more beneficial effect on people when they get out of treatment than with other modalities," Embry says, "because we don't have unlimited money."
Yet, even as the industry welcomes the prospect of substantially increased funding--thanks to the 2008 Mental Health Parity and Addiction Equity Act, the most recent national health reform bill and the expansion of the state-run Primary Adult Care (PAC) program to cover more drug treatment services ("Cleaning Up," Feature, June 23)--the prospect of better long-term outcomes data seems to be fading.
"I think you can make improvements if there were money to follow people long-term . . . on a monthly or quarterly basis, just call them and reconnect them to the system," says Dr. Robert Schwartz, a bSAS board member and medical director at the non-profit Friends Research Institute. But "if you don't have money to pay for basic treatment, that seems like a luxury."
Schwartz suggests that concerns about drug treatment efficacy are misplaced--and maybe even reflect the stigma that still clings to addiction itself. "In some ways drug treatment outcomes monitoring is better than for most [other chronic medical] conditions," he says. Medications for opiate addiction are very effective, Schwartz says, citing methadone and buprenorphine, the latest medicinal heroin treatment, as are therapeutic communities.
Like a more modest version of Robert DuPont in 1971, Schwartz sees the problem in terms of volume and scale. "The idea with drug treatment is to have a public health outcome for a city, or a state, or for a nation," Schwartz says. "To have a public health outcome you have to--if you know you have an effective treatment--get as many people as possible into treatment."