Smart Steps, Treating Baltimore's Drug Problem

The Case for Treatment

Baltimore’s commitment to treatment is supported by three decades of scientific research and clinical practice demonstrating treatment’s effectiveness. The most recent national, multi-site evaluation of clients in publicly-funded treatment found substantial reductions in drug use, arrests, alcohol- and drug-related medical care, and homelessness.[180] These reductions saved more than $6,000 per client. In-prison treatment followed by aftercare in the community is also effective in creating significant, long-term reductions in drug use and recidivism.[181] This is critical for Baltimore and for Maryland, where 80 percent of prisoners have alcohol and drug problems.[182]

Drug Addiction Is a Chronic Disorder
Alcohol and drug addictions are similar to other chronic medical conditions, such as diabetes, hypertension and asthma, in that successful treatment often requires life-long behavioral change.[183] Prolonged drug use produces changes in brain function that drive a compulsive craving for the drug, despite adverse consequences.[184] Relapse occurs with all chronic illnesses, and drug addiction is no different. Once the intensive supervision of treatment ends, a patient’s failure to adhere to behavioral changes and prescribed medication, if any, can lead to relapse. As with other chronic disorders, major contributors to relapse are low socioeconomic status, co-occurring psychiatric conditions, and lack of family or other social supports.[185] The fact that 50 to 60 percent of hypertension patients relapse[186] within a year because they fail to adhere to their medication and dietary regimens does not mean that hypertension treatment does not work. On the contrary, the abatement of hypertension’s symptoms during periods of treatment compliance, and their recurrence due to lack of compliance, are evidence that the prescribed treatment works.[187]

Reduced Drug Use Is the Measure of Success
The reductions in drug use and corresponding social damage accomplished through treatment confer real benefits, especially when compared to the alternative—non-treatment and unchecked drug abuse. The most recent national, multi-site evaluation—the National Treatment Improvement Evaluation Study (NTIES),[188] —examined results for 4,411 patients in treatment between 1993 and 1995 (including patients in Baltimore)[189] and found that the proportion of patients using any drug dropped by 41 percent in the year after treatment. Significant reductions also occurred in the proportion of patients selling drugs (down 78 percent), arrested on any charge (down 64 percent), requiring medical care due to alcohol or other drug use (down 54 percent), and being homeless (down 42 percent).[190]

Treatment Is Cost-Effective
The benefits of treatment far exceed the cost. A landmark 1994 study, The California Drug and Alcohol Treatment Assessment (CALDATA), found that every dollar invested in treatment saved taxpayers $7 in future costs. CALDATA researchers concluded that “each day of treatment paid for itself ... on the day it was received, primarily through an avoidance of crime.”[191] In the NTIES treatment evaluation, treating low-income clients created a net savings of $6,236 per client—due to reduced spending on health care, welfare and crime-related costs—with a three to one ratio of benefits to costs.[192] Based on these findings, NTIES researchers estimate that public treatment services supported by CSAT funds in 1994 generated a net benefit to society of $1.7 billion.[193]

Private companies offering drug treatment services to their employees reap the benefits of reduced medical claims, absenteeism, corporate liability, and disability costs.[194]

In the private sector, Northrup Corporation saw productivity increase 43 percent among the first 100 employees to enter an alcohol treatment program; after three years, savings per rehabilitated employee approached $20,000.[195] Blue Cross/Blue Shield has found that families’ health care costs dropped by 87 percent after treatment—from $100 per month in the two years prior to treatment to $13 per month five years after treatment.[196] Business leaders in the Baltimore area understand that treatment’s benefits improve the business climate of the entire region by reducing crime, lowering health care costs and improving worker productivity.[197]

Extensive research offers abundant evidence that providing treatment is less costly than not providing treatment. Calculations based on National Institute of Drug Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA) estimates of the nationwide costs of alcohol and drug abuse suggest that investing in treatment makes very good economic sense in Baltimore. Conservatively estimated, each person addicted to drugs and not in treatment costs Baltimore $30,000 a year.[198] By comparison, the average treatment cost per methadone maintenance patient in Baltimore is $3,500 a year, a funding level that permits only bare-bones services (methadone maintenance slots comprise more than half of all publicly-funded treatment slots in Baltimore).[199] Even if the average treatment cost per patient in Baltimore were as high as $10,000 a year, the savings would outweigh the costs by a three to one margin.

Treatment is also cost-effective compared to other drug control strategies that compete for public funds. The RAND Corporation has found that treatment for heavy cocaine users is 23 times more effective than source-country programs, 11 times more effective than interdiction,[200] and three times more effective than mandatory minimum sentencing in reducing cocaine consumption.[201]

Treatment Works Whether Voluntary or Coerced
People typically enter treatment when the adverse consequences of drug use compel them to seek help.[202] For many, this may be some personal calamity (job loss, marriage breakup, legal difficulties) if they fail to rein in their drug use. Those arrested for criminal activity may be compelled to enter treatment by court order, or offered the chance to participate in treatment rather than face full criminal prosecution and the threat of incarceration.

Treatment can work whether a patient enters freely or under coercion from the criminal justice system.[203] Most of the research on treatment outcomes has dealt with patients who entered treatment voluntarily, but several studies have demonstrated the effectiveness of coerced treatment as well.[204] Indeed, involvement in the criminal justice system presents a prime opportunity to engage drug users in treatment. A 1998 study based on a large nationwide sample of heroin users found little history of involvement with treatment, but a high level of contact with the criminal justice system. While more than 70 percent of the sample of 38,561 heroin users had never been in methadone maintenance, 75 percent had been incarcerated within the previous five years, and 40 percent were either on probation or parole or had pending criminal charges at the time of the research interview. Among the nearly 30,000 heroin users who had been incarcerated within the previous five years, only 15 percent reported having received treatment while incarcerated.[205]

Treatment interventions within the criminal justice system can work at several stages. Offenders who complete drug court programs—intensive court-supervised treatment in lieu of criminal prosecution or incarceration—are one-third as likely to be arrested for new drug offenses or felonies, and only one-fourth as likely to violate probation or parole.[206] A 1998 study of 440 drug court participants in Multnomah County, Oregon found a two-year savings to the county of $10.2 million.[207] Research in the Delaware correctional system underscores the importance of aftercare in the community for sustaining the benefits of prison treatment.[208]

Given the expense of incarceration ($25,000 per inmate per year)[209] and the high proportion of Maryland prisoners with alcohol and drug problems (80 percent),[210] prison-based treatment followed by aftercare in the community is a critical means of reducing crime and spending on criminal justice. The 8,160 Baltimore offenders with drug problems in state prison as of September 2000 will cost Maryland over $200 million a year to keep behind bars, more than one-fourth of the state’s entire annual corrections budget.[211] Failure to provide adequate treatment, including aftercare in the community, increases the likelihood that many of these people will return to prison. According to the National Institute of Justice, between 65 and 70 percent of all untreated parolees with histories of cocaine or heroin use will return to drug use within just three months of release.[212] By achieving even modest reductions in the rate at which former prisoners return to drugs, treatment can help prevent crime and avoid millions of dollars in spending on public safety and criminal justice.

In FY 2000, Baltimore spent $263 million on police protection and the courts ($415 per resident), compared to $30 million on treatment ($47 per resident).[213]

Investing in drug treatment cannot substitute for competent policing and a functional court system, but drug treatment can reduce the burden borne by public safety and criminal justice institutions. Given the extent to which crime in Baltimore is associated with drug use and drug trafficking, the research suggests that increasing access to treatment—both in prison and in the community—will help the police and the courts to do their jobs more effectively.

The Gap Between Research-Based Evidence and Public Perceptions of Treatment
By its nature, addiction cannot be fixed the way a broken leg can be set and healed. Once a broken leg is mended, we do not expect that the leg will break again. But because addiction is a chronic disorder, the ultimate goal of long-term abstinence often requires repeated treatment episodes. Much of the public’s ambivalence toward treatment reflects unrealistic expectations for what treatment should achieve—expectations frequently dashed by the reality of addiction.

The gap between research and practice is illustrated clearly within the medical community itself. Physicians are often unschooled in modern addiction medicine and hold a low opinion of treatment’s effectiveness.[214] They often treat the acute medical conditions resulting from drug abuse without recognizing the underlying problem.[215] According to a May 2000 survey by the National Center on Addiction and Substance Abuse (CASA) at Columbia University, most primary care physicians believe that treatment is “very effective” for chronic disorders such as hypertension (86 percent) and diabetes (69 percent), but very few consider treatment “very effective” for alcohol dependence (4 percent) and illicit drug dependence (2 percent).[216] These findings underscore why treatment’s growing support in Baltimore is so noteworthy.

[180]. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA). The National Treatment Improvement Evaluation Study (NTIES) Preliminary Report: The Persistent Effects of Substance Abuse Treatment – One Year Later. 1996.

[181]. S. Martin et al. “Three-year outcomes of therapeutic community treatment for drug-involved offenders in Delaware: From prison to work release to aftercare.” The Prison Journal, 79(3):294-320, September 1999. Participants in Delaware’s prison-based therapeutic community (TC) program are significantly more likely to be drug-free (22 percent vs. 6 percent) and arrest-free (41 percent vs. 30 percent) than other prisoners three years after release. However, participants in prison-based treatment who also participate in a work release program followed by community-based aftercare show even stronger results: 35 percent remain drug-free three years after release, and 69 percent remain arrest-free.

[182]. Maryland Department of Public Safety and Correctional Services (DPSCS). Based on intake assessment of prisoners, DPSCS officials estimate that 80 percent of Maryland prisoners have substantial substance abuse problems. Accordingly, Drug Strategies estimates that at least 80 percent of the 10,200 prisoners sentenced in Baltimore had substantial substance abuse problems upon entering prison.

[185]. A. McLellan et al. “Drug dependence, a chronic mental illness: Implications for treatment, insurance, and outcomes evaluation.” Journal of the American Medical Association, 284(13):1689-1695, October 4, 2000.

C. O’Brien & A. McLellan. “Myths about the treatment of addiction.” The Lancet, 347(8996):237-240, January 27, 1996.

[186]. C. O’Brien and A. McLellan. “Myths about the treatment of addiction.” The Lancet, 347(8996):237-240, January 27, 1996. Between 50 and 60 percent of hypertension patients relapse due to failure to comply with their medication and dietary regimen, where “relapse” is defined as re-treatment within 12 months by a physician at an emergency room or a hospital.

[187]. A. McLellan et al. “Drug dependence, a chronic mental illness: Implications for treatment, insurance, and outcomes evaluation.” Journal of the American Medical Association, 284(13):1689-1695, October 4, 2000.

C. O’Brien & A. McLellan. “Myths about the treatment of addiction.” The Lancet, 347(8996):237-240, January 27, 1996.

[188]. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA). The National Treatment Improvement Evaluation Study (NTIES) Preliminary Report: The Persistent Effects of Substance Abuse Treatment – One Year Later. 1996.

[189]. NTIES included patients in treatment in Baltimore, where certain programs were funded through the federal Center for Substance Abuse Treatment’s (CSAT) Target Cities programs and therefore counted among the 78 service delivery units (SDUs) from which NTIES patients were drawn.

[190]. U.S. Department of Health and Mental Services, Substance Abuse and Mental Health Services Administration (SAMHSA). The National Treatment Improvement Evaluation Study (NTIES) Preliminary Report: The Persistent Effects of Substance Abuse Treatment – One Year Later. 1996.

[198]. See Note 149 and Note 13 for a discussion of Drug Strategies’ calculations that in 1999 alcohol and drug abuse cost Maryland $8.5 billion and cost Baltimore $2.5 billion. In 1995, the Center for Substance Abuse Research (CESAR) provided Maryland’s Alcohol and Drug Abuse Administration (ADAA) with a memorandum outlining a method for estimating the cost to Maryland of not providing treatment for someone in need on treatment. Replicating CESAR’s method for Baltimore using more current figures yields a cost to Baltimore of $30,800 for each person who needs treatment but is not receiving treatment.

1. Estimated cost of alcohol and drug abuse to Baltimore = $2.50 billion
2. Cost to Baltimore minus treatment spending = $2.45 billion
3. Cost to Baltimore minus cost due to alcohol and drug use by people not considered in
     need of treatment = $2.45 billion - (.33)(2.45) = $1.64 billion
4. Number of Baltimore resident in need of treatment = 60,375 (1998, ADAA)
5. Number Baltimore residents treated = 20,445 (1999, ADAA)
6. If the 66.1 percent of those in need of treatment but not participating in treatment
     (39,930 people) account for 75 percent of costs, then:
     $1.64 billion x 0.75 = $1.23 billion, and $1.23 billion divided by 39,930 = $30,803.91,
     or about $30,800 per untreated individual in need of alcohol or drug treatment.

[199]. L. Koenig et al. The Costs and Benefits of Substance Abuse Treatment: Findings from the National Treatment Improvement Evaluation Study (NTIES). Fairfax, VA: National Evaluation Data Services, August 1999. Koenig et al. estimated the 1994 cost of one year of methadone maintenance treatment for participants in NTIES at about $3,575. Updating for inflation (using the medical care Consumer Price Index) would bring the cost of a year of methadone maintenance treatment to about $4,250, or 21 percent higher than the $3,500 per methadone maintenance slot that BSAS is able to allocate.

[200]. C. Rydell & S. Everingham. Controlling Cocaine: Supply Versus Demand Programs. Santa Monica, CA: RAND Drug Policy Research Center, 1994. In dollar terms, RAND estimated that a 1 percent decrease in annual cocaine consumption can be achieved by spending an additional $34 million on treatment for heavy users, compared to achieving the same result by spending $783 million on source-country drug control programs or $366 million on interdiction.

[202]. Physician Leadership on National Drug Policy (PLNDP). Physician Leadership on National Drug Policy: Position Paper on Drug Policy. Providence, RI: PLNDP, 2000. “Chemical dependency,” according to PLNDP, “is an illness characterized by denial, and few people volunteer for treatment. Some form of coercion is usually involved (from an employer, family member, or the criminal justice system).”

[203]. National Institute on Drug Abuse (NIDA). Principles of Drug Addiction Treatment: A Research-Based Guide. October 1999. Principle number 10: “Treatment does not need to be voluntary to be effective. Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting or criminal justice system can increase significantly both treatment entry and retention rates and the success of drug treatment interventions.”

[208]. S. Martin et al. “Three-year outcomes of therapeutic community treatment for drug-involved offenders in Delaware: From prison to work release to aftercare.” The Prison Journal, 79(3):294-320, September 1999. Participants in Delaware’s prison-based therapeutic community (TC) program are significantly more likely to be drug-free (22 percent vs. 6 percent) and arrest-free (41 percent vs. 30 percent) than other prisoners three years after release. However, participants in prison-based treatment who also participate in a work release program followed by community-based aftercare show even stronger results: 35 percent remain drug-free three years after release, and 69 percent remain arrest-free.

[209]. Bureau of Justice Statistics (BJS). State Prison Expenditures, 1996. August 1999. In FY 1996, Maryland’s operating (92 percent) and capital (8 percent) expenditures per prisoner was $24,068. Adjusted for inflation through 1999 (Consumer Price Index-All Urban Consumers, Pennsylvania-New Jersey-Delaware-Maryland), per prisoner expenditures rose by 5.59 percent to $25,413.

[211]. P. Ditton & D. Wilson. Bureau of Justice Statistics Special Report: Truth in Sentencing in State Prisons. January 1999. Based on the national average (for all offenses) of two and half years prison time, Maryland will be paying $500 million to keep the current group of drug-involved Baltimore offenders in prison.

[213]. Baltimore Department of Finance. In FY 2000, Baltimore spent $262.555 million on police protection and the courts (police, $231.298 million; state’s attorney’s office, $16.859 million; circuit court, $10.264 million; mayor’s office on criminal justice, 4.134 million). Based on Baltimore’s 1999 population of 632,681, the city spent $414.99 per capita on police protection and the courts.

Baltimore Substance Abuse Systems, Inc. (BSAS). In FY 2000, Baltimore spent $29.849 million on alcohol and drug treatment (not including Medicaid and Medicare). Based on Baltimore’s 1999 population of 632,681, the city spent $47.18 per capita on alcohol and drug treatment. Therefore, for every dollar the city spent on police protection and the courts, it spent only 11¢ on treatment.

[214]. Office of National Drug Control Policy (ONDCP). National Drug Control Strategy, 2000 Annual Report. February 2000. According to ONDCP, “Many health-care professionals lack the training to identify the symptoms of substance abuse. Most medical students, for example, receive little education in this area.”