Chapter II: Intervening and Healing America’s Drug Users
Drug Use and Addiction
Although drug use is down among youth, overall levels of use are still high: 19.7 million Americans have used at least one illicit substance in the past month. Drug use is a threat to the health and well-being of the individual users, their families, and society as a whole. In 2002, more than 26,000 people died as a direct consequence of drug use, a figure that does not include those killed as an indirect consequence of drug-using behavior. Substance abuse and addiction are the costliest and most prevalent of brain maladies, surpassing Alzheimer’s, depression, spinal cord injury, and other developmental disorders, according to a recent analysis in the Archives of General Psychiatry.
Drugs can affect people at all stages of life. Prenatal exposure to certain drugs is linked to low birth weight and premature deliveries and has been associated with developmental disorders. The adolescent brain may be particularly vulnerable because it is still maturing. Drug exposure may increase susceptibility to substance abuse and addiction, and may lead to poor academic achievement, psychiatric disorders, infections, accidents, risky sexual activity, violence and crime. The work performance of substance users can be characterized by absenteeism, illness, injuries, low productivity, high job turnover, and other problems.
Research on marijuana is illustrative: marijuana use during adolescence increases later risk for abuse of heroin or cocaine and dependency on other drugs. These conclusions have been echoed in research done on the effects of marijuana on laboratory animals, which are, of course, not subject to peer pressure. Animals that were exposed to the active ingredient in marijuana during adolescence consumed higher amounts of heroin and displayed greater heroin-seeking behavior after the animals matured into adults. These findings suggest that marijuana may produce a biological effect on the brain during adolescence that can persist into adulthood.
Indeed, youth who abstain from marijuana at an early age are twice as likely to graduate from college and are much less likely to steal or sell drugs than youth who experiment with marijuana. Early use of cannabis in vulnerable young people can also be a risk factor for developing psychiatric diseases such as schizophrenia later in life.
Heavy marijuana use into adulthood has an expanding set of risks. As with other addictive drugs, marijuana addiction results in withdrawal symptoms such as tremors, sweating, nausea, irritability, reduced appetite and sleep disturbances. High-potency marijuana can result in severe, prolonged withdrawal. It can also have other adverse health consequences, including exercise-induced heart pain, and reduced lung function and irritation. Heavy marijuana use during pregnancy can lead to impaired fetal growth and development. These are all compelling reasons to prevent marijuana use by young people. The harsh behavioral, health, and social consequences of other addictive drugs, such as methamphetamine, cocaine, and heroin are equally well documented.
Despite the high costs of substance abuse, it is one of the most preventable threats to the Nation’s health. So why do people initiate drug use? Drug use can be a learned behavior transmitted by nondependent users. Because the visible consequences of drug abuse may be delayed, or not apparent to others, drug abuse may seem to be harmless or of minimal risk, just as diseases can be spread during the incubation period, before signs of the disease are apparent. Others may begin using drugs during this “honeymoon period” when the drug user does not display the harmful effects of abuse. In this way the so-called “casual drug user” is key to the spread of drug use to others.
No one starts using drugs with the intention of becoming addicted, but research shows that even a single exposure to some substances can trigger biological changes in the brain. After repeated use many people will become addicted. Once the person is addicted, the brain shows many changes in tandem with altered behavior, judgment, and physical health. The addicted user can then be driven to compulsively take the drug regardless of adverse consequences.
New research shows that drugs have powerful and disturbing effects on the human brain. Drugs resemble, but are not identical to, the chemicals produced by the brain to send messages normally. The “imposter messages” sent by cocaine, methamphetamine, MDMA (Ecstasy), and marijuana’s tetrahydrocannabinol (THC), for example, differ from the messages produced by the brain’s own chemicals—dopamine, serotonin, norepinephrine, and anandamide.
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However, because drugs are “imposters” and do not precisely duplicate brain chemicals, the brain cannot control drug messages in the same way it controls its own. The result: euphoria, delusions, hallucinations, anger, and a host of other unusual sensations and behaviors that characterize drug-induced effects. Drug abuse causes the brain to adapt to these “imposter signals.” Withdrawal symptoms are sure signs of adaptation in the brain. A person undergoing withdrawal becomes irritable, anxious, and sleep-deprived. He or she can experience a host of other unpleasant feelings and even suffer horrible physical illness. During abstinence, drug craving and relapse are indications that, even if the drug has cleared the brain, its influence persists.
In addition, drugs can rewire the brain, a process somewhat akin to forming long-term memories. In the adolescent brain, which is not fully developed, drugs may restructure it in a way that makes the progression to addiction faster and more likely, even later in life. Some drugs, such as methamphetamine, can produce visible toxic effects on the brain, produce dramatic behavioral changes, and significantly compromise brain function. However, after months to years of abstinence from methamphetamine, some changes are clearly reversible. Treatment can succeed in dismantling the destructive behavioral manifestations of the altered brain. Counseling, motivational therapies, medications, and social and spiritual support can promote recovery—indeed, a renaissance in the life of the addicted.
Targeting the Full Spectrum of Drug Users: Screening and Interventions
These findings underscore the importance of a public health approach to the drug problem and the need to identify and intervene with the full spectrum of drug users—from the so-called “casual” user to the addicted. A significant opportunity exists to target those who have a substance abuse problem but do not yet recognize it. Survey data on this paint a bleak picture: nearly 95 percent of people with a diagnosable substance abuse problem do not feel they need help.
Unidentified users are therefore an important segment of the population to target in order to achieve the President’s goal of reducing overall drug use in America. This is particularly compelling for adult users, whose rates have remained steady over time and who are difficult to reach in prevention and education efforts. The medical community has developed an important tool to tackle this problem. The Federal government partnered with health care professionals to expand use of this tool to identify the full spectrum of users and provide brief, cost-effective interventions to help them cease use. The modality, called Screening, Brief Intervention, Referral and Treatment (SBIRT), has been deployed to hospitals, health clinics, and school-based clinics across the country as a demonstration project.
Under SBIRT, medical professionals conduct brief screening in a general health care setting such as a hospital, a health clinic, or a university-based clinic. Screening, which may be administered in oral, written, or computer formats, is based on a standardized questionnaire that yields a score. The score indicates whether the person has a substance abuse problem and, if so, the extent of the problem—whether it is underage drinking, problem use, or full-scale addiction. Under SBIRT, once a problem is detected, a medical professional immediately performs a brief intervention, lasting less than 30 minutes. Brief interventions assist patients in recognizing the impact of unhealthy drinking or drug use and commit them to a plan of action to cease use. Studies show that this brief intervention can reduce substance abuse significantly. These interventions are very cost effective as they reduce readmission into emergency departments and rehospitalizations. They also reduce DUIs and have the potential to address the problems before they become more severe. In many cases the brief intervention is sufficient for the nonaddicted user. Those with scores that fall into the range of dependence are referred to intensive treatment. SBIRT has the potential to make a significant impact on the lives of substance abusers, their families, and our Nation’s health and well-being. Substance abuse is associated with a wide range of problems, such as accidents, injuries, violence, increased errors, DUIs, and worsening of medical diseases such as diabetes. By significantly reducing substance use and abuse, SBIRT programs can reduce the associated adverse consequences and their costs to society. ONDCP and the Department of Health and Human Services (HHS) are working with medical professionals to expand SBIRT programs across the country. As part of this effort, ONDCP hosted two medical education conferences to provide information to medical educators, medical associations and boards to implement SBIRT programs in medical settings. ONDCP is also collaborating with the Accreditation Council for Continuing Medical Education to disseminate screening and brief intervention on a national scale to physicians as a continuing medical education course. In addition, the Centers for Medicare and Medicaid Services recently established billing codes for screening and intervention programs in hospitals. It is now up to State Medicaid boards to decide whether their states will pay for these services. These codes have the potential to bring this important public health measure to communities around the country. Expanding Treatment Options For those referred to treatment because they have become addicted, the Administration is working to expand options for treatment. The Access to Recovery Program (ATR) program at HHS is a key source of innovation in the field of addiction recovery. The program provides clients with a voucher for treatment services as well as recovery support services. The program expands treatment options to include faith and community-based providers so that clients can choose a treatment regime in which they feel they will do best.
Many people who experience addiction face barriers to treatment, from finding child care while they are in a recovery program to accessing transportation services to take part in job training. For the first time, recovery support services such as child care, transportation vouchers, and mentoring services are provided as part of the ATR voucher program. The program is now in 14 States and one tribal organization and is working to serve more than 125,000 people who seek treatment in the grantee States. The program requires that States provide outcome data so patient progress can be measured and best practices learned for future generations.
In the past, data on key outcomes such as employment, family and social connections, and abstinence from substance abuse were not tracked. In many cases, the outcome measures have been expanded to not only the ATR program, but to all recovery programs in the grantee States. In this way, ATR is revolutionizing the way recovery is provided in the country, focusing not just on spaces available for treatment, but the clients themselves and their progress toward independent and drug-free lives. Drug Courts For drug users who have become involved in the criminal justice system, drug courts provide an important strategy to help drug offenders achieve a drug-and crime-free life. Drug courts provide a comprehensive and effective response to drug-related criminal offenses. Using the coercive power of the courts coupled with the support of family, friends, counselors, and treatment providers, drug courts bring a unique mix of sanctions and incentives to help people achieve abstinence from drug use. Strong evidence indicates that drug courts achieve their objectives. A recent survey of more than 120 evaluations of drug court programs showed that they outperformed virtually all other strategies that have been attempted for drug offenders within the 1 to 2 years that courts typically monitor offenders. Offenders who graduated from drug courts had significant reductions in rearrest rates and in charges for serious crimes. Data show that within the first year of release, 43.5 percent of drug offenders are rearrested, whereas only 16.4 percent of drug court graduates are rearrested.
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