TREATING DRUG PROBLEMS

VOLUME 2

Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment

Committee for the Substance Abuse Coverage Study

Division of Health Care Services

INSTITUTE OF MEDICINE

Dean R. Gerstein and Henrick J. Harwood, editors

NATIONAL ACADEMY PRESS
Washington, D.C.
1992



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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment TREATING DRUG PROBLEMS VOLUME 2 Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Committee for the Substance Abuse Coverage Study Division of Health Care Services INSTITUTE OF MEDICINE Dean R. Gerstein and Henrick J. Harwood, editors NATIONAL ACADEMY PRESS Washington, D.C. 1992

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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment National Academy Press 2101 Constitution Avenue Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their competencies and with regard for the appropriate balance. The report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an advisor to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This study was supported by the National Institute on Drug Abuse, U.S. Department of Health and Human Services, under Contract No. 283-88-0009 (SA). Library of Congress Cataloging-in-Publication Data Treating drug problems. This study was supported by the National Institute on Drug Abuse, U.S. Department of Health and Human Services, under Contract No. 283-99-0009 (SA)/9D/—T.p. verso. Includes bibliographical references. 1. Drug abuse—Treatment—United States—Finance. 2. Drug abuse—Treatment— Government policy—United States. 3. Drug abuse—Treatment—United States. [DNLM: 1. Insurance, Health—United States. 2. Financing, Government—United States. 3. Substance abuse—therapy. WM 270-T784] I. Gerstein, Dean R. II. Harwood, Henrick J. III. Institute of Medicine (U.S.). Committee for the Substance Abuse Coverage Study. IV. National Institute on Drug Abuse. RC564.T734 1990 360.29'0973 90-6633 ISBN 0-309-94285-2 (v. 1)  ISBN 0-309-94396-4 (v. 2) Copyright © 1992 by the National Academy of Sciences No part of this book may be reproduced by any mechanical, photographic, or electronic procedure, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or otherwise copied for public or private use, without written permission from the publisher, except for the purpose of official use by the United States government. Printed in the United States of America

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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment COMMITTEE FOR THE SUBSTANCE ABUSE COVERAGE STUDY LAWRENCE S. LEWIN,* Chair, Lewin/ICF Health Group, Washington, D.C. RAUL CAETANO, Alcohol Research Group, Institute of Epidemiology and Behavioral Medicine, Medical Research Institute of San Francisco at Pacific Presbyterian Medical Center, Berkeley, California DAVID T. COURTWRIGHT, Department of History, University of North Florida, Jacksonville, Florida DAVID A. DEITCH, Daytop Village, Inc., New York, New York, and Pacific Institute for Clinical Training, Education, and Evaluation, Berkeley, California DOUGLAS A. FRASER, Department of Labor Studies, Wayne State University, Detroit, Michigan JAMES G. HAUGHTON,* Martin Luther King, Jr./Charles R. Drew Medical Center, Los Angeles, California ROBERT L. HUBBARD, Center for Social Research and Policy Analysis, Research Triangle Institute, Research Triangle Park, North Carolina JAMES D. ISBISTER, Pharmavene, Inc., Gaithersburg, Maryland HERBERT D. KLEBER,** Substance Abuse Treatment Unit and Department of Psychiatry, Yale University School of Medicine, and APT Foundation, Inc., New Haven, Connecticut JUDITH R. LAVE,* Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania DAVID J. MACTAS, Marathon, Inc., Providence, Rhode Island DONALD J. McCONNELL, Connecticut Alcohol and Drug Abuse Commission, Hartford, Connecticut JOHN H. MOXLEY III,* Health Care Division, Korn/Ferry International, Los Angeles, California PETER S. O'DONNELL, The KEREN Group, Princeton, New Jersey MARK V. PAULY,* Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania HAROLD A. RICHMAN, Chapin Hall Center for Children and School of Social Service Administration, University of Chicago, Chicago, Illinois *    Member, Institute of Medicine **   Herbert D. Kleber resigned August 17, 1989, and Henrick J. Harwood resigned December 4, 1989, to accept positions in the Office of National Drug Control Policy, Executive Office of the President, Washington, D.C

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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment MAXINE L. STITZER, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, and Francis Scott Key Medical Center, Baltimore, Maryland DEAN R. GERSTEIN, Study Director HENRICK J. HARWOOD,** Associate Study Director LINDA B. KEARNEY, Administrative Secretary ELAINE McGARRAUGH, Research Associate LEAH MAZADE, IOM Editor KARL D. YORDY, Director, Division of Health Care Services

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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Preface The committee members and staff appointed in 1988 to conduct the Institute of Medicine's Substance Abuse Coverage Study were given a three-part task: investigate the extent of private and public funding of treatment for drug abuse and dependence; evaluate the adequacy of funding to meet the need for rehabilitation of these disorders; and make recommendations on how to meet the needs identified by the study. The first volume of Treating Drug Problems is the committee's report on the evolution, effectiveness, and financing of public and private drug treatment systems. The chapters in Volume 1 discuss the history of ideas governing drug policy, the nature and extent of the need for treatment, the goals and effectiveness of treatment, the need for research on treatment methods and services, the costs and organization of the two-tiered national treatment system, the scope and organizing principles of public and private coverage, and recommendations tailored to each kind of coverage. A key part of the collection and development of the information needed for this report was the commissioning of seven papers to inform the committee about selected aspects of the problem for which concise, accessible sources were lacking. All seven of these papers are included in this volume. Four of them untangle the complicated interactions that exist between drug treatment and other components of drug policy at the several levels of government organization. The first paper, by David Courtwright, a member of the committee and a notable contributor to the historical literature on drug controls and social patterns, synthesizes the historical record and context of policy changes in the United States over the last century. Karst Besteman, who held major administrative responsibilities for implementing the drug treatment policies of the federal government during the 1970s, provides a closer examination of the content and rationale of successive shifts in the focus, scale, and mechanisms of federal support for treatment from 1960 to the present. Gregory Falkin, Harry Wexler, and Douglas Lipton analyze the results of drug treatment programs in state prisons. Their review aims to isolate

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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment specific factors that seem to be necessary if more prison programs are to avoid the widespread conclusion that "nothing works" in criminal rehabilitation. Looking at a different level of the criminal justice system, Mary Dana Phillips studies the ways in which county judicial agencies and penal institutions deploy treatment ideas and personnel in the management of drug cases. The other three papers consider drug treatment outside of its direct relations to government. Paul Roman and Terry Blum examine employer policies toward illicit drugs, particularly as these policies have evolved since about 1970, giving a unique overview of the era of employee assistance and drug screening programs. Richard Steinberg considers drug treatment as an economic service from the point of view of potential buyers, sellers, and regulators. The final paper, by Ronald Siegel, returns to the historical plane on which Courtwright's paper begins the volume. Siegel considers the changing technology of cocaine as a cultural and market commodity and the associated implications for the nature of the cocaine problem. The authors of these commissioned papers made major contributions to the committee's thinking, and they responded graciously to its many requests for more, less, different, or clarifying information. The committee does not necessarily concur with every conclusion drawn by these authors. Nevertheless, it learned a great deal from them and is pleased to publish their papers in conjunction with its report. The committee gained insight and information from hundreds of other individuals in addition to those who authored commissioned papers. A number of these contributors held formal roles in relation to the study, as noted in the preface to the first volume of the report. Many other contributions are made apparent in the report's citation of published references. Still, there are large numbers of people who assisted the committee not through formal or published channels but by sharing their experience in direct discussions or other communications with committee members and staff. It seems fitting to conclude this volume with a section that acknowledges these sources. Finally, a large thanks is owed to IOM editor Leah Mazade, administrative secretary Linda Kearney, and research associate Elaine McGarraugh. They have dedicated many hours to preparing this volume for publication, and without that dedication it would not have been published. I would be remiss not to express as well the committee's gratitude to the staff of the National Academy Press, especially Sally Stanfield, managing editor, for diligently shepherding this volume and its predecessor through the final stages that bring the finished book into the reader's hand. Dean R. Gerstein, Study Director

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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Contents     A Century of American Narcotic Policy David T. Courtwright   1     Federal Leadership in Building the National Drug Treatment System Karst J. Besteman   63     Drug Treatment in State Prisons Gregory P. Falkin, Harry K Wexler, And Douglas S. Lipton   89     Courts, Jails, and Drug Treatment in a California County Mary Dana Phillips   133     Drugs, the Workplace, and Employee-Oriented Programming Paul M. Roman And Terry C. Blum   197     The Market for Drug Treatment Richard Steinberg   245     Repeating Cycles of Cocaine Use and Abuse Ronald K Siegel   289     Acknowledgments   317

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