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For decades, the U.S.'s chosen strategy for combating drug addiction and abuse has been more focused on stopping the flow of illegal drugs and punishing the user than on drug abuse prevention, education, or addiction treatment. Drug policy has not historically been based on scientific evidence about the causes of addiction but rather on preconceived ideas about drug addicts.

Although public health experts have increasingly been advocating the need for more treatment and prevention dollars, the U.S. has yet to reassess its allocation of dollars. Today, only one third of the billion of dollars the federal government spends fighting drug abuse is targeted at prevention and treatment, or so-called "demand reduction"; two thirds continues to be devoted to law enforcement and interdiction of drugs, or "supply reduction."
 

Government spending on treatment has multiplied by a factor of 60 since 1969, from $40 million to $2.4 billion. That sounds high -- until one realizes that spending on law enforcement has burgeoned by a factor of 190, from $40 million to nearly $7.7 billion during the same period. As William McColl, director of government relations for the National Association of Alcoholism and Drug Abuse Counselors in Washington, D.C., sums it up, "Society has chosen to deal with [illicit] substance abuse through the prism of criminal justice."
 

Prison tents

The Maricopa County Jail in Arizona is so overcrowded that many inmates are housed in tents in the desert.

Dr. Herbert Kleber, who worked as Deputy Director of Demand Reduction in the Office of National Drug Control Policy under President George Bush, believes the government should devote many more resources to addiction treatment. "We need a better balance," he says. The funding shortfall that exists today is a "bipartisan failure," he says, partly because views on addiction and treatment outcomes continue to be major hurdles in the way of a more enlightened policy. The stigma associated with addiction continues, he says, and there is also a mistrust of the data about treatment success. Drug treatment outcomes vary widely, but Kleber, who is now executive vice president and medical director of the National Center on Addiction and Substance Abuse (CASA) at New York's Columbia University, says the failures are publicized more often than the successes. "Everyone has a [treatment] failure that they know about and successes tend to be relatively anonymous. Very few people go around saying, 'I'm a recovered cocaine addict,' so it's not surprising that people who have the power to get the money for treatment say, 'We don't believe it works.'"

One result is that individuals who need drug treatment often can't get it, because there aren't enough programs to serve them. "I would say we have half the number of [treatment] slots we need," says Kleber. He estimates that there are nearly 3 million hard-core addicts who need treatment, yet the U.S. can provide only 1.3 million treatment slots. A 1998 report published by Join Together, a national resource center for communities fighting substance abuse, noted that last year more than half a million people needing substance abuse treatment in Illinois were turned away. In San Francisco, the report adds, as many as 1,500 drug and alcohol addicts are shut out of treatment daily.
 

Addictions to legal substances such as alcohol and nicotine cause more damage to public health than illegal drugs, but we deal with them very differently. In general, it has become accepted that alcoholism and nicotine addiction are treatable health problems. In contrast, we have tended to view illicit drug addiction as a criminal issue, not a public health matter. As a result, instead of treating illegal drug addicts, we imprison them.
 

Chart: 75% of those in need of alcohol and drug treatment do not receive treatment

Alfred Blumstein, a criminologist at Carnegie Mellon University in Pittsburgh, estimates that drug offenses have accounted for more than a third of the major growth, since the 1970s, in the number of Americans in prison and jail. Since 1980, the incarceration rate for drug arrests has increased a whopping 1,000 percent. In fact, some two-thirds of all federal inmates today are drug offenders. About a quarter of the new inmates entering prison in New York State are "drug-only" offenders, with no record of other types of crimes. According to a 1998 report from Columbia University's CASA, one in every 141 adults in America is behind bars for alcohol- and drug-related crimes, at a cost to taxpayers of $30 billion in 1996.

Many of these imprisoned drug offenders are addicts, and their crimes are frequently related to their addiction (for instance, burglaries commited to get money to buy drugs). But they rarely receive treatment, which is available for less than 10 percent of those who need it.

The gap between treatment and funding is most evident in state and federal prisons. State officials estimate that 70 to 85 percent of inmates need some level of substance abuse treatment, but in 1996, only 13 percent were in any treatment. In 1996, about 840,000 state and federal inmates needed treatment, but only about 150,000 actually received it. From 1995 to 1996, according to a 1998 CASA report, the number of inmates who needed it rose by nearly 40,000, while the number who received it actually decreased by 18,360.

Critics of our current policy focus argue that if we do not provide treatment for addicts, prison is only a revolving door for people who commit crimes for drugs, on drugs, or both. They say that the large number of arrests spurred by the U.S.'s drug policy has done little to stop people from selling drugs but rather has yielded a glut of drug users and dealers behind bars who are not provided the rehabilitation and coping skills they need to turn their lives around. "Prison is not treatment," notes a 1996 report from Join Together. "The majority of offenders who go to prison will sooner or later be released back into the community, still addicted, still dealing," the report says, adding that the criminal justice system needs to address the disease, not the symptoms, of addiction.
 

A 1997 RAND Corporation report found that treatment is much more effective in reducing cocaine use and related crime than either mandatory minimum prison sentences or conventional law enforcement. The study found that for every $1 million spent, treatment would cut cocaine use by more than 100 kilograms compared to a reduction of 13 kilograms from mandatory minimum sentences and 27 kilograms from conventional law enforcement. "The current criminal justice-driven approach is not reducing, let alone controlling, drug abuse in America," adds Dr. Lonnie Bristow, a member of the Physician Leadership on National Drug Policy, an ad-hoc group trying to push for drug policy reform that would shift more resources toward prevention and treatment.
 

Lonnie Bristow, M.D.

Lonnie Bristow, M.D.

"Failure to use the criminal justice system to get nonviolent drug- and alcohol-abusing offenders into treatment and training is irrational public policy," says CASA President and former Health, Education and Welfare Secretary Joseph Califano. Releasing drug-addicted inmates without treatment "is tantamount to visiting criminals on society," not to mention helping maintain the market for illegal drugs and supporting drug dealers, Califano says.

Experts also note that incarceration compares poorly to treatment in terms of cost to taxpayers. Putting an addicted offender in a therapeutic community, a form of intensive, inpatient treatment, for a year costs only about half of what it does to jail him or her for a year. The Join Together report notes that one judge estimates that unnecessary imprisonment for minor drug offenders is costing taxpayers nearly $359 million a year -- money that would be better spent fighting high-level and violent crime. "In terms of cost effectiveness, you can get much more for the tax dollars that are being spent if we concentrate on treating this as a chronic illness," Bristow says.

 -- Janet Firshein
 

Chart: Courtesy of the Robert Wood Johnson Foundation
Chart Source: Institute for Health Policy, Brandeis University. Substance Abuse: The Nation's Number One Health Problem. October 1993. P. 60.

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