FACING FACTS

Drug Strategies

Facing Facts

Prevention and Treatment

The paucity of information in this section of the report reflects the prevailing situation in the District: far too little in the way of prevention and treatment to address the scope of the problem.

Numerous studies have demonstrated the cost-effectiveness of prevention and treatment, including a 1994 RAND report which concluded that drug treatment was seven times more cost-effective than law enforcement in reducing cocaine use.(110) Nonetheless, publicly funded treatment is scarce in the District, as are current data on the treatment needs of D.C. residents.

Even without stronger data, long waiting lists for existing treatment programs clearly indicate that current efforts are not meeting the city's needs.

Prevention

Key Findings

The District's prevention activities are limited, and their effectiveness remains unknown.

Key questions must be addressed regarding prevention education in the city schools.

The overwhelming majority of District residents place a high priority on drug prevention, but few consider existing programs adequate.

In addition to the cigarette excise tax hike, which is a proven deterrent to smoking, the District is implementing several innovative prevention approaches. However, little is known about the effectiveness of publicly funded prevention efforts in the District, due to lack of evaluation.

Since 1991 city residents have donated more than $550,000 to local organizations involved in drug prevention through a contribution box on the D.C. income tax form. Indeed, a 1997 survey conducted for the Control Board found that 78 percent of District residents gave drug prevention a high priority. However, only 10 percent rated existing programs as excellent or good.(111)

Community coalitions are critically important to Washington's drug abuse prevention activities. Two examples of such coalitions are Fighting Back and the National Capital Prevention Network.

Fighting Back, operated by the Marshall Heights Community Development Organization and funded by the Robert Wood Johnson Foundation, aims to reduce the sale and use of drugs through community revitalization projects, such as refurbishing rundown buildings, cleaning up parking lots and creating new jobs. The National Capital Prevention Network, a coalition of seven programs and agencies, provides a comprehensive approach to prevention through alternative activities, community mobilization projects, technical assistance and culturally specific programs for youth.

The D.C. Addiction Prevention and Recovery Administration (APRA) has primary responsibility for alcohol, tobacco and other drug prevention activities through its Office of Prevention and Youth Services (OPYS). OPYS uses information dissemination, prevention education, alternatives for at-risk youth, problem identification and referral, community-based programs and environmental approaches.

OPYS has Prevention Centers in Wards 1, 2 and 8 that are operated in partnership with the Department of Housing and Community Development. Early education and intervention programs for adults, youth and families administered by OPYS reach an estimated 200,000 residents annually, including about 100,000 youth.(112) During 1998 OPYS spent $1.9 million alcohol and other drug prevention in the District.(113)

Three in four parents with children in D.C. public schools say that expanding after-school and summer recreation programs for youth would be very effective in reducing drug problems in the city.(114) Peter D. Hart Research Associates, 1998

Each year, the D.C. Public Schools offer drug prevention programs, which are funded primarily through federal Safe and Drug-Free Schools and Communities (SDFSC) funds ($2 million in 1998).(115) Placing a heavy emphasis on implementing a Peaceable Schools Model in every school, the city devotes 75 percent of these funds to violence prevention and 25 percent to drug prevention programs, spending an annual total of $19.23 per pupil. Some public schools currently uses the Students Taught Awareness and Resistance (STAR) drug prevention program, which research has shown to be effective in reducing alcohol, tobacco and marijuana use.(116) But the research on Drug Abuse Resistance Education (D.A.R.E.), the program implemented in most of the city's public schools, shows no sustained effects on drug use.

Treatment

Key Findings

Drug treatment is not easy to find in the District.

The city's treatment budget has dropped 28 percent since 1993, and contracting problems have further reduced treatment capacity.

The District's methadone maintenance services have been particularly hard hit, and more people are waiting for methadone than for any other form of treatment.

For drug abusers who do complete treatment, results are impressive. If replicated widely, effective treatment services will lead to significant cost savings.

Changes in Medicaid and Managed Care. Medicaid restructuring, currently underway in Washington, D.C., will affect delivery of all health services, including alcohol and other drug treatment. The first step (implemented in October 1998) increased the number of residents eligible for Medicaid by raising the income cutoff to twice the federal poverty rate for families with children ($32,900 for a family of four). By October 1999 the District is planning to expand coverage to childless couples and individuals.

Newly eligible Medicaid recipients will be enrolled in managed care, which will include a standard drug abuse treatment benefit. Recipients requiring additional treatment services that are not covered will receive them through a Medicaid fee-for-service structure. D.C. officials hope that over the long term, all drug abuse treatment will move to a managed care system.

The District currently spends $24 million annually for outpatient drug abuse treatment and related services for uninsured and underinsured residents. With the proposed insurance expansions, funding for these services will more than double within two years.

A private sector approach to addressing the shortage of treatment slots was initiated in September 1998 by the Marshall Heights Community Development Organization. Funded by the Robert Wood Johnson Foundation's Fighting Back program, Marshall Heights has contracted with Providence Hospital to provide 100 treatment slots. The program, designed to serve residents of Ward 7, also accepts clients from other sections of the District. It is a comprehensive treatment program with an aftercare component and free child care. Marshall Heights and Providence Hospital expect that the program will become self-sufficient, 12 to 18 months after becoming operational, by utilizing funds from Medicaid and the criminal justice system.

Rather than fund city agencies (which can run out of funds before services are delivered), officials involved in the Medicaid restructuring hope to shape a new system in which treatment dollars follow clients. The Marshall Heights-Providence Hospital initiative is a good example of this type of funding mechanism. The majority of treatment funding will be paid through Medicaid, although APRA will retain funds to continue special outreach and prevention initiatives and to fill any remaining services needs. APRA would shift its focus to certifying providers, monitoring the quality of care and possibly serving as a gatekeeper for services to chronic patients.

Difficulty Estimating Treatment Needs. In 1989 APRA (at that time called the Alcohol and Drug Abuse Services Administration) completed a drug abuse treatment needs assessment for Washington. Based on 1986 data, the study estimated that between 94,500 and 125,500 city residents were drug abusers (15 to 20 percent of the population), including 60,000 people abusing multiple drugs.(117) Since then, these figures have formed the basis for agency estimates of treatment needs, with annual adjustments made to account for population changes.(118)

These annual projections have been flawed, and without reliable data, accurately estimating Washington's treatment needs has been impossible. APRA's current estimate of 65,000 people in the District who need treatment may underestimate the need by tens of thousands of people. [FOOTNOTE:The 1989 treatment figures were based not on surveys but on extrapolations from national data. It is unclear whether the original study estimated "treatment need" or "risk of abuse" as these terms are used synonymously in the report. Only alcohol abusers have been counted in the adjusted annual projections. Thus, the figure of 65,000 drug abusers (which is widely cited) clearly underestimates current treatment needs. If 15 to 20 percent of current city residents need alcohol and other drug treatment (as they apparently did in the 1989 estimates), then 78,000 to 104,000 people need treatment now -- 13,000 to 39,000 more than APRA's current estimate.

Since 1994 a treatment needs assessment funded by the Center for Substance Abuse Treatment has been planned for the District but has not yet been carried out. In December 1998 APRA concluded a report on Social Indicators of Substance Abuse in Washington, D.C. The report analyzes demographic and socioeconomic indicators associated with drug abuse in the city, but it does not estimate the prevalence of drug abuse or the city's treatment needs.]

A 1998 treatment needs assessment for Latino residents in the District found that although 4,700 were problem drinkers and chronic illicit drug users in 1997, only 644 received treatment (14 percent). The study also found that treatment needs in the Latino community would be better met by expanding bilingual and bicultural programs in Latino neighborhoods.(119) No comparable study has been done for the general population.

Treatment Services. In Washington, D.C. alcohol abusers account for 16 percent of treatment admissions, compared to 54 percent nationwide.(120) Conversely, addicts on methadone maintenance comprise 23 percent of admissions in the city, compared to 6 percent nationally. According to the National Association of State Alcohol and Drug Abuse Directors, there were 14,546 drug abuse treatment admissions in the city in 1995 (1,870 for alcohol, 3,321 for methadone maintenance, and 9,355 for other drug treatment).(121)

Like other social service agencies, APRA's budget has been hard hit by the city's financial problems. In FY 1998, $20.9 million was spent on publicly funded treatment in the District, compared to $29 million in FY 1993.(122) APRA currently has only 2,220 treatment slots -- a 50 percent drop from 1994 -- with more than 1,100 people on waiting lists. The number of methadone maintenance slots dropped from 1,780 to 860, residential treatment beds from 357 to 98, aftercare slots from 600 to 50.(123)

Additional treatment slots could be available; however, expired contracts with some service providers were not renewed, leaving the city with insufficient capacity to meet the high demand for publicly funded treatment. Contracting problems and budget cuts are blamed for the city's failure to provide much-needed youth treatment, therapeutic community beds and additional detoxification.(124)

The Office of National Drug Control Policy has called for an expansion of methadone maintenance programs nationwide in response to the recent increases in heroin use.(125) In an average month, 90 percent of the people on APRA's waiting list are in line for methadone maintenance.(126) APRA's FY 1999 budget includes funding for a new 360-slot methadone maintenance program that will serve some clients currently on the waiting list.

APRA also provides services to probationers and parolees required to participate in treatment, further limiting access for the general public. Criminal offenders can easily fill the city's treatment slots on their own, but they must also wait. At the end of 1998, some 600 of the 1,100 people on treatment waiting lists were criminal offenders.(127)

Only one in 10 residents consider treatment to be readily available in Washington, compared to one in four nationwide.(128) Peter D. Hart Research Associates, 1995 and 1998

There are currently no residential treatment beds in the city for youth, nor are alcohol and prescription drug abuse among the elderly addressed. The homeless need opportunities for assessment and treatment in shelters and mobile units. Existing services also fail to meet the treatment needs of the dually diagnosed, Latinos and pregnant and parenting women.

The city's Latino population suffers from the lack of bilingual treatment programs, and inadequate outreach efforts and support networks within the community.(129) In an effort to address these problems, in 1998 APRA awarded $609,000 to the Council of Latino Agencies to develop services targeting the Latino community.

Sixty percent of the District's drug abusers also have psychiatric disorders, and more than half of patients in treatment for mental disorders in the city need drug treatment.(130) These patients frequently have numerous problems, such as homelessness, unemployment and poor social functioning. The challenges of dual diagnosis are complicated by the fact that mental health and drug treatment are administered by different agencies with separate funding, professional orientations and areas of expertise. In 1999, the D.C. Commission on Mental Health Services (CMHS) launched a pilot program to integrate treatment services for clients with co-occurring addiction and mental health disorders. The program will cross-train about half of the city's mental health providers on how to provide simultaneous, standardized addiction and mental health treatment to the dually diagnosed. CMHS also operates a small inpatient program which serves about 250 dually diagnosed clients annually. Four Community Mental Health Centers in the city also provide day treatment programs, but they do not track the number of dually diagnosed clients served. APRA's FY 1999 budget includes a new day treatment program for 150 dually diagnosed clients, but this program will reach only a fraction of those in need.

To address youth drug abuse and underage drinking, two in three Washington residents favor devoting more funds to education, prevention and treatment, compared to one in five who support more funds for law enforcement.(131) Peter D. Hart Research Associates, 1998

Treatment Results in the District. In 1997 the Center for Substance Abuse Research at the University of Maryland conducted the District of Columbia Treatment Initiative. Completing both residential and aftercare components of treatment was the critical factor in predicting outcomes.(132) At the six-month follow-up, clients completing both components were far less likely than those who completed only the residential phase to be rearrested (9 percent vs. 31 percent) and to test positive for cocaine (18 percent vs. 53 percent).

Since two-thirds of APRA clients have arrest records and three-quarters have no legal source of income, the potential benefits of successful treatment are enormous.(133) If these outcomes can be replicated throughout the city's treatment system, significant savings in criminal justice and social welfare costs will be realized.

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