The epidemiology of illicit drug abuse in the United States has shown little change in both lifetime and current rates since the mid-1980s. Overall, the National Household Survey on Drug Use and Health (NHSDUH1) indicates that between 1985 and 1998, an estimated 35 percent of persons aged 12 and older had ever tried an illicit drug; while, for the same time period, rates of past month use dropped 50 percent between 1985 and 1992 and remained steady at about 6 percent. This pattern is similar for lifetime and past-month rates of marijuana use and drugs other than marijuana (Substance Abuse and Mental Health Services Administration, 1999; 2002). These data suggest that while initiation of illicit drugs has remained relatively unchanged overtime, a significant proportion of these initiates have discontinued use. Yet, there remains a large number of users of illicit drugs who continue use and are in need of treatment.

Combating drug abuse in the United States requires interdiction as well as prevention and treatment services at the local level. While most in the field would agree with this observation, funding and support for these strategies is both fragmented and unbalanced. This article discusses the need for comprehensive and integrated effective services at the community level, describes some of the major barriers that impede the structuring of an integrated system of services, and makes suggestions for overcoming these impediments. The development of comprehensive, integrated services accomplishes three major objectives. First, planning for such a delivery system brings providers together, sometimes for the first time, to openly own the problem of drug abuse within a community. This “ownership” by representatives of mainstream service providers such as the health services sector could serve to remove the stigma attached to being a drug user. Second, integrated service systems should help those who need a wide range of services to get these services. Lastly, if structured efficiently, such a system of services could prevent duplication or overlap and associated costs of services (McCarty & Argeriou, 2003; Parthasarathy, Mertens, Moore & Weisner, 2003). Until all relevant concerned providers address the problem of drug abuse within and across communities in a comprehensive way, drug abuse will remain a growing issue and we will not be able to reduce the associated costs to children, families, and society.

The changing epidemiology of drug abuse
Since the early 1970s, through national household and school surveys, the United States has been monitoring the incidence and prevalence of illicit drug use. These major national surveys indicate that the country has experienced peak years of use in the late 1970s followed by downward trends among adolescents for about one decade and then short-term increases through the 1990s. Most of this use has been of marijuana (see Figure 1 on page 14) but more recently there has been an upsurge in the initiation of other drugs such as ecstasy (MDMA), LSD, PCP, and the misuse of prescription drugs (see Figure 2 on page 14). While initiation remains high, for most adolescents the continuation of use ceases as they enter early adulthood. However, the noncontinuation rates vary by drug type, with highest rates for inhalants (65 percent) and lowest for marijuana (25 percent) — the third lowest after alcohol (8 percent) and tobacco (17 percent) (Johnston et al., 2002).

This means that a substantial number of persons who initiate illicit drug use continue their use. An estimated 16.6 million people aged 12 and older were categorized in the 2001 NHSDUH as abusers of alcohol and/or drugs requiring treatment (2.4 million on both alcohol and drugs; 3.2 million on illicit drugs only; and, 11.0 million on alcohol only). About half of these people were considered dependent. Only about 17 percent of those who abused or were dependent actually availed themselves of treatment.

Service delivery
Probably the most important message of the major national surveys is that the incidence or onset of illicit drug use and the prevalence of drug abuse are related. It is this epidemiology that determines how public health professionals should plan preventive and treatment services and what services are to be delivered to whom. With an infectious disease such as Severe Acute Respiratory Syndrome (SARS), efforts are made to isolate and treat the infected at the same time that preventive strategies are put in place. The delay in designing and implementing an effective preventive plan more quickly in the case of SARS was caused by the time it took investigators to determine the cause of the illness and how it was spread. What was striking was how rapidly, once the cause was known, stringent prevention and treatment programs were put in place by those governments of countries most affected, e.g., Hong Kong, Canada, and China.

Are there parallel issues between SARS and the abuse of illicit drugs? Unlike SARS and other infectious diseases, drug abuse is a chronic, relapsing brain disease that warrants sustained treatment or even serial treatments with behavioral and social supports and is highly stigmatized. Although much more research is needed to determine the causes of substance use, we DO have sufficient information upon which effective prevention strategies can be and have been developed (see page 17 for one example of such a strategy). More information on the proximate etiology, i.e., understanding the neurobiological mechanism that triggers abuse and dependence, remains unknown. Yet, even without this understanding, effective pharmacotherapeutic and behavioral treatments are available for many of the abused drugs (Rawson & Obert, 2002). To change the epidemiology of drug abuse means to reduce initiation of use and eliminate abuse warranting comprehensive and integrated services that include prevention and treatment as well as interdiction.

Challenges to integrated services
The development of a comprehensive and integrated service delivery system must overcome many challenges before it can come to fruition. Funding, training, and availability of human resources pits both prevention advocates against treatment advocates and supply reduction professionals against those focused on demand reduction. Where services are traditionally delivered tends to impede integration of these services. For instance, prevention generally focuses on policies or environmental strategies or school-based programs, while treatment services are delivered in specialty facilities outside and often away from mainstream health care structures (Wheeler & Nahra, 2000; Friedmann, Lemon, Stein & D’Aunno, 2003). Overlap service areas, such as early intervention with adolescents at highest risk to abuse and dependence, tend to fall “between the cracks.” Ideology and belief systems regarding the outcomes of prevention and treatment services conflict and separate these services systems as well as supply reduction enforcement from demand reduction service providers. Furthermore, the extent to which demonstrated effective prevention or treatment strategies have been put in place at the community level is quite limited (Hallfors & Godette, 2002; Ennett et al., 2003; D’Aunno & Vaughn, 1992; D’Aunno & Pollack, 2002).

Proposing solutions
Can these barriers to comprehensive integrated services be overcome? Clearly this goal is more likely to occur at the community level than nationally, for several reasons. First, if drug abuse is viewed as a community problem, there is a greater likelihood that focused efforts will be made to bring representatives of the service providers together to plan a community-based approach. Funding can come from specialized agencies and can be merged within a community board, partnership, or coalition and dispensed for comprehensive services. Needs assessments and strategic planning that addresses preventive, early intervention, and treatment can be conducted in ways that build on existing services and relationships. Several approaches are suggested for these efforts (National Institute on Drug Abuse, 1998; Hawkins & Catalano, 1992). The use of a focus group approach (see page 58) to review existing data from archival systems such as census data, educational data on absenteeism and drop out rates, drug-related arrests, drug-related hospital admissions and emergency episodes, treatment program admissions, as well as survey data on drug use in households or among students, helps to provide information on the nature and extent of the drug abuse problem within the community, identify gaps in services, and forge new collaborations and referral patterns. Involvement of local service providers including clinicians, judges, and school administrators in planning and evaluation efforts would bring together key community leaders who ordinarily are not involved in such efforts. Keeping an eye to areas for service integration, such as providing parenting and family interventions in treatment settings that include programs for the children of clients, can combine a broad range of services and potentially, have a positive impact on both the adults and children (Catalano et al., 1999).

Mainstreaming drug abuse services is also very important, requiring both national and local efforts. Dispelling myths about the onset of drug use and abuse and the effectiveness of drug abuse prevention and treatment should have priority with high-level federal agencies such as the Office for National Drug Control Policy (ONDCP), the Department of Health and Human Services (DHHS), and the Department of Education. A joint public relations program or media campaign that included the agency heads as well as the White House and openly spoke about drug abuse as a serious health issue for the nation, particularly our nation’s youth, and that educated the U.S. public about effective prevention and treatment strategies could support a federal program for cross-agency funding of integrated services.

The ONDCP was created to coordinate both supply and demand drug abuse programs across federal agencies and to link these with the states and local communities. In addition, the DHHS includes a number of separate organizations with a focus on drug use such as the two Centers for Substance Abuse Prevention and Treatment (CSAP and CSAT, under the Substance Abuse and Mental Health Services Administration, SAMHSA) and the National Institute on Drug Abuse (NIDA). The Centers provide block grant funds for treatment and prevention services while NIDA supports grant programs on innovative prevention and treatment programming and on services research that examines the delivery of these programs at the community level. The Department of Education not only provides funding for school-based prevention programs but also has information on the negative impact the use of drugs has on academic performance. Collaboration among these agencies for planning and the joint funding of integrated services would relay a strong message to the public and to state funding agencies and would support service delivery at the local level (see the related comments of CSAP Director Beverly Watts Davis on page 17). In addition, several agencies under the DHHS, representing mainstream health services such as the Health Resources and Services Administration, the SAMSHA Center for Mental Health Services and the National Institute for Mental Health should also become involved in these collaborations to support associated comprehensive medical and mental health services.

Furthermore, recognition of the nature of drug abuse as a chronic health problem that can be treated by health care professionals nationally and locally would begin to alter the stigma attached to being a victim of drug abuse (Wheeler & Nahra, 2000). The National Center for Addiction and Substance Abuse at Columbia Univer-sity (CASA) conducted a survey in 2000 of primary care doctors to determine how they deal with substance abusing patients. The survey indicated that 94 percent of physicians failed to diagnose substance abuse when presented with a description of early symptoms of alcohol abuse in an adult patient and 41 percent of pediatricians failed to diagnose illegal drug abuse in a description of a drug-using adolescent. Both groups failed to suggest substance abuse as one of five possible diagnoses. Furthermore, the survey indicated that only about 20 percent of physicians believed they were “very prepared” to diagnose alcoholism, 17 percent illegal drug use, and 30 percent prescription drug misuse. However, when asked about hypertension, diabetes and even depression, 83 percent, 82 percent, and 44 percent, respectively, of these same physicians believed they were “very prepared” to make a diagnosis. Discrepancies in perceptions of treatment effectiveness were also present with between 42 percent (for depression) and 86 percent (for hypertension) of physicians reporting that treatment was very effective while for smoking, 8 percent believed treatment was “very effective,” 4 percent for alcoholism, and 2 percent for illegal drug abuse.

Reasons given for physicians’ lack of confidence in both their ability to diagnose or effectively treat substance abuse were: lack of adequate training; their own skepticism about treatment effectiveness; and their perceptions about patient resistance to discussing these health issues. The CASA report recommends that physicians receive increased training on substance abuse in medical schools, residency programs, and continuing education; that coverage for substance abuse treatment services be expanded by Medicare, Medicaid, private insurers, and managed care; and, that primary care physicians be held liable for negligent failure to diagnose substance abuse/addiction and refer substance abusing patients for treatment services (National Center on Addiction and Substance Abuse, 2003). The education of health care workers in general will be important at the national as well as the local level. Involvement of community clinicians in local planning efforts could change existing attitudes about drug abuse.

In addition, efforts through the media, as well as through funding and programming support, need to alter tolerance for use or perception of risk associated with the use of drugs as these perceptions are related to drug use. For instance, data from the 2001 NHSDUH showed that 42 percent of all respondents perceived that the use of marijuana once a month was harmful. These perceptions differed by age group with those aged 18 to 25 (that have the highest rates of illicit drug use) having the lowest rates (see Figure 3). It is interesting to note that these rates have not changed much for the oldest age group, whereas it is the youngest group, aged 12 to 17, that has seen the greatest changes from more than 50 percent in 1990, when drug use rates for this group were low, to about 30 percent in 1997, when drug use increased.

Call to action
The intent of this paper is more to provoke than to solve. The epidemiology of drug abuse in the United States strongly suggests the need for an integrated and comprehensive service delivery system that cuts across existing funding, attitudinal, training/educational, and structural barriers. It is suggested that the creation of these delivery systems is more likely at the community level. However, national support for an infrastructure to support such delivery systems in terms of easing the use of funds for such services, for mainstreaming, and for altering misconceptions about drug abuse and removing the stigma of being a drug abuser needs to happen at the same time that local communities unite to solve this devastating problem.

The approaches to solving the drug abuse problem have been hindered by
ideological rather than evidence-based strategies, by marginalizing service providers because of the associated stigma of the problem, and by fragmentation of funding. Furthermore, although the epidemiology of the problem suggests integrated prevention and treatment services, both the structures and funding for these services create competition rather than collaboration. Without a comprehensive and integrated service delivery system, the problem of drug abuse will continue to overwhelm affected individuals, families, and communities.

Zili Sloboda, ScD, is a Senior Research Associate at the Institute for Health and Social Policy, at the University of Akron in Ohio. Trained as a medical sociologist and epidemiologist, she has focused on the issue of drug abuse both domestically and internationally.

Footnote
1Formerly called the National Household Survey on Drug Abuse

References
Catalano, R.G., Gainey, R.R., Fleming, C.B., Haggerty, K.P., & Johnson, N.O. (1999). An experimental intervention with families of substance abusers: One-year follow-up of the focus on families project. Addiction, 94(2): 241-254.
D’Aunno, T., & Pollack, H.A. (2002). Changes in methadone treatment practices: results from a national panel study, 1998-2000. Journal of the American Medical Association, 288(7): 850-856.
D’Aunno, T., & Vaughn, T.E. (1992). Variations in methadone treatment practices: Results from a national study. Journal of the American Medical Association, 267(2): 253-258.
Ennett, S.T., Ringwalt, C.L., Thorne J., Rohrbach L.A., Vincus A., Simons-Rudolph A., & Jones S. (2003). A comparison of current practice in school-based substance use prevention programs with meta-analysis findings. Prevention Science, 4(1): 1-14.
Friedmann, P.D., Lemon, S.C., Stein, M.D. & D’Aunno, T.A. (2003). Accessibility of addiction treatment: results from a national survey of outpatient substance abuse treatment organizations. Health Services Research, 38(3): 887-903.
Hallfors, D., & Godette, D. (2002). Will the ‘principles of effectiveness’ improve prevention practice? Early findings from a diffusion study. Health Education Research, 17(4): 461-70.
Hawkins, J.D., & Catalano, R.F. (1992) Communities that care. San Francisco, CA: Jossey-Bass, Inc.
Johnston, L.D., O’Malley, P.M., & Bachman, J.G. (2002). Monitoring the Future national survey results on drug use, 1975-2001. Volume 1: Secondary school students (NIH Publication No. 02-5106). Bethesda, MD: National Institute on Drug Abuse.
McCarty, D., & Argeriou, M. (2003). The Iowa Managed Substance Abuse Care Plan: access, utilization, and expenditures for Medicaid recipients. Journal of Behavioral Health Services Research, 30(1): 18-25.
National Center on Addiction and Substance Abuse. (2003). Missed opportunity: National survey of primary care physicians and patients. Retrieved July 31, 2003, from http://www.casacolumbia.org/publications1456/
publications_show.htm?doc_id=29109
National Institute on Drug Abuse. (1998). Assessing Drug Abuse Within and Across Communities: Community Epidemiology Surveillance Networks on Drug Abuse. NIH Publication No.98-3614: USDHHS, National Institutes of Health, Rockville MD.
Parthasarathy, S., Mertens, J., Moore, C. & Weisner, C. (2003). Utilization and cost impact of integrating substance abuse treatment and primary care. Medical Care, 41(3): 357-376.
Rawson, R.A., & Obert, J.L. (2002). The substance abuse treatment system in the U.S. What is it? What does it do? Myths and misconceptions. Occupational Medicine, 17(1): 27-39, iii-iv.
Substance Abuse and Mental Health Services Administration. (1999). Summary of Findings from the 1998 National Household Survey on Drug Abuse (Office of Applied Studies, NHSDA Series H-10, DHHS Publication No. SMA99-3328). Rockville, MD.
Substance Abuse and Mental Health Services Administration. (2002). Results from the 2001 National Household Survey on Drug Abuse: Volume I. Summary of National Findings (Office of Applied Studies, NHSDA Series H-17, DHHS Publication No. SMA99-3758). Rockville, MD.
Wheeler, J.R., & Nahra, T.A. (2000). Private and public ownership in outpatient substance abuse treatment: Do we have a two-tiered system? Administration and Policy for Mental Health, 27(4): 197-209.

Beverly Watts Davis on Local Drug Abuse Services and the Counselor’s Role

Editor’s note: In an exclusive interview, Counselor asked CSAP Director Beverly Watts Davis to name a model community-based integrated drug abuse services program already in place that incorporates the unique services of frontline counselors.

Did you know that a proven high school-based, counselor-oriented program is correcting the misconception that substance abuse prevention is “mostly for young children”? In the eyes of CSAP Director Beverly Watts Davis, the program represents “a true integration” of school and community.

Project SUCCESS (Schools Using Coordinated Community Efforts to
Strengthen Students) prevents and reduces substance use among high-risk,
multiproblem high school adolescents. Since 1995, the program has been tested with 14- to 18-year-old adolescents who attended an alternative school that separated them from the general school population. Participants typically have been from low- to middle-income families, and 30 percent had parents who abused substances. These adolescents have been placed in an alternative school setting for a variety of reasons including: poor academic performance, emotional problems, school discipline problems, truancy, negative attitude toward school, and criminal activity.

The program, which has been implemented in more than 20 schools in the United States, places trained helping professionals in schools to provide a full range of substance use prevention and early intervention services. The program connects the school to the community’s continuum of care, when needed, referring both students and families to human services organizations, including substance abuse treatment agencies.

How Project SUCCESS works
First, a partnership is established between a prevention agency, which will administer the program, and an alternative school. Project SUCCESS Counselors (PSCs) — individuals with a graduate degree in social work, counseling, or psychology who are experienced in providing substance abuse prevention counseling to adolescents — are recruited to work in the school. In addition to directing activities such as peer mentoring, tutoring, and monitoring student attendance, PSCs provide a full range of substance abuse prevention and early intervention services. Project components include a Prevention Education Series, Individual Assessment, Individual and Group Counseling, Parent Programs, and Referral.

Though the program is school-based, the Parent Programs are key because: “If a parent is dealing with a child that is acting out, we understand that the entire family is going to be experiencing stress,” Ms. Watts Davis says. “As the stressors increase for the family, what that also results in is much more stress being placed on younger brothers and sisters, who also then begin to act out.”

Regarding Referral, PSCs refer students and parents who require treatment, more intensive counseling, or other services to appropriate agencies or practitioners in the community. It is at this juncture that counselors are making the integrated program possible.

“Because you are dealing with counselors,” says Ms. Watts Davis, “they are able to make, number one, an appropriate treatment referral, but number two, [are] able to have built a relationship with those treatment providers.... They’ll know how hard it is to get adolescent treatment. And the few slots that are usually in town, in our communities, are treasures.”

In addition, training of school staff members (including teachers, administrators, janitors, and administrative professionals) helps create both “additional community eyes that begin to really work with identifying children who are in need of assistance and ... an environment in which these kinds of interventions can work better,” says Ms. Watts Davis.

Frequent collaboration among the school staff, the project director, the project supervisor, and the PSC results in a program that helps adolescents with emotional, learning, and behavioral problems expressed in behaviors such as fighting, skipping class, and talking back to their teachers. Students learn resistance and social competency skills for communication, decision-making, stress and anger management, problem solving, and resisting peer pressure.

Project SUCCESS has proven results. Adolescents participating in Project SUCCESS showed a significant 37 percent overall decrease in substance use as compared to adolescents in the comparison group who did not participate in the project. Of the adolescents using substances, 23 percent of those in the program quit using, whereas only 5 percent in the comparison condition quit. For those adolescents who did not quit using substances, there was still a significant reduction in mean substance use, ranging between 17 percent to 26.6 percent among program participants. Project SUCCESS has proven effective with African American, Asian American, White, and Hispanic/Latino youth of both genders (SAMHSA, 2002).[1]

Will lessons of SUCCESS lead to funding circles of care?
Project SUCCESS demonstrates that dedicated communities can overcome barriers to integrated drug abuse services.

“The unfortunate thing, I think, is that because of the way the federal government funds things, you do create these artificial barriers that keep things separate,” says Ms. Watts Davis.

“What’s very important and very key is that we have what we call seamless services, seamless meaning that the continuum of care goes from one end to the other and back and forth.

“Someone should not feel that they’re now doing prevention — err, stop! Now they’re doing intervention — err, stop! Now they’re doing treatment. It doesn’t work like that, because people don’t work like that.”

Substance abuse is a chronic, relapsing disease, and we have to be able to have services that flow from one end to the other, she adds. “And I am so looking forward to the day that treatment and mental health and prevention will all come together, and we will actually fund continuums of care — circles of care — such that we are providing true comprehensive wrap-around services.

“Otherwise, what ends up happening is ... it’s left up to the community to connect the dots,” Ms. Watts Davis says. “I think [funding circles of care] is what’s going to contribute to long-term effective prevention, treatment, and recovery.”

— By Stephanie Berger, MAMC, Editor, Counselor: The Magazine for Addiction Professionals

Footnote
1For more information on Project SUCCESS and implementing it in your community, visit http://modelprograms.samhsa.gov, or contact Ellen R. Morehouse, ACSW, CASAC, CPP, of Student Assistance Services Corp. at 914-332-1300 or This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
SAMHSA. (2002, October 10). Project SUCCESS. Retrieved August 15, 2003, from http://modelprograms.samhsa.gov/template_cf.cfm?page=model&pkProgramID=17&section=description

This article is published in Counselor,The Magazine for Addiction Professionals, December 2003, v.4, n.6, pp. 12-17.

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