Expand drug abuse treatment so that all who apply for treatment can be accepted into treatment programs. Continually work to improve the quality and effectiveness of drug abuse treatment.
Repeatedly, medical and treatment experts have come before the National Commission on AIDS and stressed the absolute necessity of treatment on demand. It has been over three years since the Presidential Commission on HIV made their recommendations for developing "a plan for increasing the capacity of the drug treatment system so that the goal of treatment-on-demand can be met. " Yet we still lack the commitment we need from the federal government to achieve this goal. While treatment expansion is a stated goal of the federal drug control policy, no real gains have been made on any level. As Dr. Robert Newman told the Commission, "...there seems to be nothing...to indicate that any government agency either at the federal or at any of the 50 state levels is indeed pursuing the objective of expansion on a massive scale to make treatment for addicts who want it readily available."(19) We must also work to ensure that the quality of treatment is constantly improving. Immediately available, effective, high-quality treatment slots are the final goal. The Commission recognizes that improved quality of treatment and treatment on demand are expensive; but so is the unchecked spread of HIV infection. As the following statement illustrates, we are putting the available, much needed resources elsewhere:
Exactly a year ago the White House issued a strategy on drug abuse control in which it made reference to a request for $1.5 billion for one fiscal year to expand by 24,000 the number of prison beds in the federal system in addition to even more massive expansion of prisons at the state and local level.
Contrast those very specific and massive goals with what was said in that strategy report with regard to treatment. It was proposed that $100 million, be added for treatment expansion to allow 11,000 additional treatment slots to be created and to put that into perspective, the Institute of Medicine within the last six months referred to an estimate of 66,000 people in our country currently being identified as on waiting lists for various types of treatment programs." (20)
The numbers are likely even higher. NIDA has made estimates based on provisional data which indicate that as many as 107,000 persons are currently on waiting lists for drug treatment.(21) And, as early as 1988, "more than half of New York City's estimated 200,000 HIV drug users were infected with HIV. At any given time, about 33,000 publicly funded drug treatment slots were available to assist these people. " As of September 1990, there were a little over 38,000 publicly funded treatment slots.(22)
The reality of these numbers was made clear to the Commission through the following eloquent testimony of a woman who lives every day with the epidemics of HIV and substance use:
I still work the streets to support a $150 a day habit of heroin and crack. I am forced to have sex with approximately ten men per day to support my habit, which is putting me at risk of further HIV infection, sexually transmitted diseases, and rape or death. What I want to tell you is that if I ha[d]] been accepted into a drug treatment program three years ago, I would not be sitting here in front of you today telling you that I am HIV infected.(23)
Federal response to treatment on demand
Federal officials have questioned the wisdom of treatment on demand on three major grounds: first, there are already enough open slots in treatment programs, but poor coordination results in waiting lists; second, the efficacy of treatment methods is still unknown; and third, treatment on demand may create a "revolving door" effect with substance users moving in and out of treatment programs without ever taking treatment seriously.(24)
The government has argued that with a computerized system and increased coordination we could fill all the available slots, thus rendering new slots redundant. Further coordination between treatment centers and a computerized program to help expand access are excellent ideas, but coordination can only do so much. Treatment programs need to be easily accessible to people in need – being shunted to another part of the city to an open treatment slot may make treatment impossible for many substance users. Open slots in certain treatment programs may also reflect programs which are not thought to work by the substance users themselves. Whether the perception is justified or not, research should be done on what draws substance users to a particular program or type of treatment, and what drives them away.
While the Commission recognizes this need to coordinate treatment programs to make the system of providing care as efficient as possible, it also recognizes that many of the "open slots" may, in fact, exist only on paper. Budget cuts on both the state and federal levels have limited the operating capacity of many treatment programs, while leaving the original operating capabilities "on the books." Therefore, a treatment center listed as having 100 slots may in fact have only enough staff and equipment to serve 70 individuals – leaving a "phantom" 30 spots "unfilled."
Questions about the efficacy of treatment have been raised by many medical problems. The Commission recognizes the frustration faced by those who try to treat substance use, and believes that further research into treatments for specific "new" and "multiple" substance use behaviors must be developed; at the same time we must continue to treat individuals with the methods which we have on hand. As the Commission's vice chairman Dr. David Rogers said in response to this argument, "We don't use the excuse of, 'We don't know quite how to treat you ' to people with congestive heart failure . . . [or] . . . cancer." (25)
Finally, the Commission does not agree that treatment on demand will create a lax attitude among those who seek treatment, as officials of ONDCP have argued. Instead, the Commission recognizes the medical nature of substance use problems and the need to provide treatment for those problems. As Dr. Rogers said, "I know of no other fatal disease in which we say, 'Go away; we'll treat you later.' [Or, in which we] use the excuses of, '... [Y]ou may not behave; you may not stay in treatment. '"(26) The Commission recognizes the role of relapse in the process of drug treatment and believes strongly that treatment on demand can offer the substance user the hope of further treatment rather than the despair of waiting with further risk of death and disease.
In order for treatment to be truly available we also need to remove those barriers placed in the path of the substance user which can make it virtually impossible to gain access to care and treatment. As one witness told the Commission:
The drug treatment system to many substance abusers is unworkable and unmanageable. Addicts must apply for treatment, and keep in mind that most are homeless and with no support services. They must have at least two pieces of identification, a permanent mailing address, be Medicaid eligible, give and pay for a urine test, have an initial first fee for screening for the screening day, go through a series of interviews and processes, and after all this they may be admitted and medicated. This is too much for an addicted person to face.(27)
Given these requirements, it is no wonder that there may be some open slots in drug treatment centers. Treatment programs, secondary to law enforcement efforts, housed in dilapidated centers, and poorly staffed, now have been charged with not only treating substance use, but also solving the problem of HIV. It is little wonder that the problem continues to grow.