|Drug Abuse and Public Policy Failures|
(Comments to the California Substance Abuse Research Consortium)
I. Treatment Efficacy
Just as American medicine in general is undergoing a "Managed Care Revolution", the field of substance abuse treatment is experiencing an "Outcome Evaluation Revolution". The acronym of this era is SMART, which stands for Specific Measurable Achievable Realistic Time-specified objectives. In other words, the taxpayers demand to see what impact their money is having upon substance abuse.
As I contended at our last SARC meeting (in February 1996 at Rand in Santa Monica) it is incumbent upon us continually to test the null hypothesis. For us, there is a seminal Null Hypothesis: "X program has no significant effect in bringing substance abusers into long-term abstinence."
In the wake of the February meeting, I carried out a test of the null hypothesis on a sample of clients at the Haight-Ashbury Free Clinic's outpatient detoxification facility. I first reviewed all of the calendar 1995 discharges from the program, a total of nearly 1,000. From these, I found 99 who were discharged with the notation, "Treatment complete". These were the cream of the crop; all others had less positive ratings at discharge. From the 99, I selected 50 at random for intensive follow-up. We pursued them first by telephone, and then by first-class letters. Of the 50, only 18 were located; of those 18, 11 (or 61%) reported that they had indeed remained "clean and sober" since leaving treatment.
Those results are discouraging, in that so many of this presumably elite group of 50 could not be located for followup despite persistent efforts. The obvious reason is that they had moved; but to have done so in such a short time, and with no usable forwarding address, hints at potential instability and/or relapse in their lives. The worst-case assumption- that all of those who weren't located for followup had relapsed- yields an estimate of 78% relapse a year or so after being discharged as "treatment complete". The best-case assumption- that the substance-use status of those not found for followup is the same as for those who were found- gives an estimate of 39% relapse. Of course, if all of the clients in treatment had been examined, rather than just the elite minority of "treatment complete" clients, these relapse percentages might have been much closer to 100%.
My study is a hint that the Null Hypothesis might indeed be true. Certainly, there is much in the literature on substance abuse that inclines toward that Null Hypothesis, for example the finding that "many of the successful quitters had made numerous attempts to change before finally succeeding" (DiClemente and Prochaska, 1982) and "almost all successes were achieved without professional aid" (Schachter, 1982). But if it is true that substance abuse treatment has a negligible effect in bringing about long-term abstinence, why is the literature so rife with reports of successful treatment outcomes? The obvious reason is that these reports are written by those with a vested interest and without a diligent commitment to careful and skeptical long-term followup.
The advent of the Internet offers another way to test the Null Hypothesis. I recommend putting out over the Internet the queries, "Are you a person who used to abuse drugs and/or alcohol, but are now abstinent for 3 or more years?" and "If so, what was the principal cause for your becoming abstinent?" Here, the Null Hypothesis is that "treatment programs" would be cited relatively rarely in answer to the second query. In sampling via the Internet, we avoid the bias of drawing our sample from treatment program clientele; however, a new bias arises in that Internet users are likely to be of higher socioeconomic status than nonusers.
Another interesting aspect of the relationship of data to public policy is in HIV prevention. In San Francisco, the fact that HIV infection among IDUs has not increased since 1986 can be cited as evidence for the efficacy of our prevention strategy. (The apparent HIV+ rate apparently decreased between 1986 and 1995, from c. 12% to c. 10%, because HIV+ IDUs died off faster than HIV- IDUs became infected.) However, there is a new danger from the recent rapid increase in prevalence of injected methamphetamine use. I have two hypotheses in this regard:
(1) "Speed" epidemics come and go swiftly; the peak of prevalence in San Francisco will occur this year, or in 1997 at the latest.
(2) Harm Reduction, although effective among heroin IDUs, is of no significant value for methamphetamine IDUs.
These hypotheses explain why I regard San Francisco's "Speed Working Group" committee as "too little, too late". We have met monthly since January and slowly, painfully worked out some proposals for prevention outreach, most of them along the lines of Harm Reduction. In my view, we should have acted with great alacrity during the period of highest incidence that's now almost over; and we should have concentrated on stopping new use and on getting current users into recovery. The best tools for this are "hit pieces" aimed at destroying speed's favorable image (for example, "Tweakers Suck!" bumper stickers) and abstinence-oriented peer support groups.
The statements of both parties' candidates for office in this political season are, in regard to effective public policy, counterproductive. I seek a word which blends the meanings of "nausea" and "rage" to express my feeling on those statements. I would urge future candidates to bear in mind three simple truths about America's relationship to substance use:
(1) Nature has provided a wide range of intoxicants, much augmented by Science. The history of their usage is replete with adverse reactions but also replete with happy outcomes. That fact is ample cause for "Just Say Yes!"
(2) Users comprise an "everlasting secret fraternity" who will nurture and support one another against the fiercest storms of public condemnation.
(3) Entrepreneurs will always flourish in all segments of our society, and will not fail to respond to the realities of supply and demand for desirable substances.
It is possible that our current leaders' enthusiasm for "zero tolerance" is compatible with these truths. I suggest, however, that the policy alternative of "legalize, tax, regulate, and discourage" is far more compatible.
DiClemente CC and Prochaska JO (1982). Self-change and therapy changes of smoking behavior: A comparison of processes of change in cessation and maintenance. Addictive Behaviors, 7, 133-142.
Schlachter S (1982) Recidivism and self-cure of smoking and obesity. American Psychologist, 37, 436-444.(printer friendly version)