The persistence of America’s drug problems, despite years of costly efforts, is persuading more and more people that new approaches are needed.  One of the most promising approaches places fresh emphasis on treatment for individuals addicted to alcohol and drugs—and less reliance on the criminal justice system to provide solutions.

For many years, Drug Strategies has been conducting science-based, independent assessments of initiatives trying to reduce substance abuse.  We have objectively examined dozens of policies and programs at the federal, state and local levels and produced comprehensive studies of drug abuse trends and policies in three cities and seven states.  In Baltimore—a city with one of the most serious drug problems in the United States—we have found the most comprehensive and committed effort yet to provide ready access to high-quality treatment for all who need it, regardless of ability to pay.

Baltimore has already made great strides toward this goal, but still has a considerable distance to go.  Currently, the city can serve only a third of the estimated 60,000 residents who need treatment, and year after year of scarce resources has weakened many of the services that do exist.  Ancillary “wrap-around” services (such as psychiatric care, childcare, job training and housing assistance) are seldom available, even though they enhance treatment success.

The challenge is daunting, but given the political support already mounted and the intellectual capital being invested, Drug Strategies believes that success in Baltimore is achievable—but only if the commitment to treatment demonstrated in recent years can be sustained.

Resources and Accountability
In recent years, Baltimore has markedly increased its investment in treatment and developed a sophisticated management information system capable of informing the city’s funding decisions with data on treatment needs and program performance.

Treatment cannot achieve its potential in Baltimore without a significant, sustained increase in resources allocated to treatment programs that deliver the greatest benefits.

Building on Baltimore’s recent progress will require a substantially greater commitment of resources by both the city and state governments.  Close collaboration among city and state officials can provide the stability necessary to consolidate the gains already made and chart a long-term course to close the remaining gaps in the city’s publicly-funded treatment system.  An important vehicle for deepening city-state collaboration already exists:  A range of key city and state officials are ex-officio members of the Baltimore Substance Abuse Systems (BSAS) Board of Directors, including Baltimore’s health commissioner and Maryland’s lieutenant governor.

Increasing Treatment Funding
Treatment is now a fixture on Baltimore’s political landscape, with wide and diverse citizen support.  This support should be clearly reflected in the city’s budget.  Additional treatment funding from the Maryland state government will be more forthcoming if Baltimore is recognized to be making utmost use of its own resources.  Increased support from the state is essential.  In its December 1999 interim report, Maryland’s Task Force to Study Increasing the Availability of Substance Abuse Programs (created by the General Assembly) found that insufficient treatment capacity throughout Maryland was primarily due to “insufficient funding for treatment by the State.”[288]  Planning and implementing substantial, predictable funding increases should be central to the city-state treatment collaboration.

The Task Force has been charged with proposing ways to increase treatment availability throughout the state.  Annapolis has already dedicated a portion of Maryland’s tobacco settlement revenue to treatment, and should now tap the state’s alcohol excise tax revenue for the same purpose.  Maryland’s alcohol excise tax rates are among the lowest in the nation; raising them would help discourage underage drinking and help the state government strengthen its funding support for treatment.  Maryland’s politically potent alcohol and hospitality industries can be expected to oppose any move to raise the state’s excise taxes, so—as a first step—state lawmakers should earmark for treatment the $24 million in annual revenue generated by the beer, wine and liquor taxes at their current levels.  Most importantly, new treatment resources should come directly from Maryland’s general fund revenue, projected at $9.3 billion for fiscal year 2001.  Research provides abundant evidence that investing in treatment makes good fiscal sense, because spending on treatment can be more than offset by reductions in government expenditures on health care and criminal justice.

Performance Evaluation and Accountability
Research and information systems are critical tools for targeting treatment funds most effectively, and Baltimore’s management information system can help guide these critical decisions.  Baltimore’s Centralized Intake and Referral Management Information System (CIRMIS) and other data systems maintained by BSAS have already played a key role in significant city- and state-sponsored research projects.  Preliminary findings from the Mayor’s Initiative evaluation show steep drops among Baltimore treatment patients in drug use, illegal activity, and spending on drugs.

Baltimore has also invited ongoing external review of the city’s treatment system by a prestigious group of treatment experts from around the country.  In soliciting the suggestions of the Scientific Advisory Committee, BSAS is constantly measuring its own operations against high standards.  In December 1999, the Committee submitted its first set of recommendations on how to improve BSAS treatment services and performance evaluation; BSAS has moved to incorporate the proposals in its operational plan for fiscal years 2000-2002.

Another significant asset for Baltimore is the involvement of Scientific Advisory Committee members and BSAS treatment programs in the Clinical Trials Network (CTN), a project run by the National Institute on Drug Abuse (NIDA) in which researchers and practitioners team up to test promising new treatment techniques in the demands of real-life settings.  Involvement of some of Baltimore’s leading researchers and treatment programs in the CTN will help Baltimore to adopt the most promising approaches to meet the city’s pressing needs.

Pursuing Baltimore’s Treatment Priorities
Baltimore is already pursing the priorities described below, and should continue to do so, as part of an ambitious, all-fronts treatment strategy.  Implementing this strategy will require the city and the state to substantially increase funding for treatment services and for evaluation research.

Ø                Fortify the current treatment system.  Although expanding capacity to enable “treatment on request” has become Baltimore’s rallying cry, the city’s leaders know that the quality of existing services must be enriched at the same time.  Shoring up the current system will reinforce the foundation upon which the other priorities must be built.

Ø                  Expand the capacity of the treatment system.  Treatment cannot work if those who need it cannot gain access in the first place.  Baltimore’s health commissioner estimates that achieving treatment on request will require serving about 40,000 people per year—double the current number.

Ø                  Enhance treatment through comprehensive wrap-around services.  Patients receiving wrap-around services are more likely to remain in treatment, stay abstinent longer and improve personal functioning.  Moreover, these improved outcomes outweigh the costs of providing wrap-around services.  The BSAS Scientific Advisory Committee has recommended that Baltimore tighten the links between drug treatment and other services.  BSAS has launched pilot programs to test the feasibility of system-wide implementation of medical, mental health, vocational, housing and child care services for patients in BSAS programs.

Ø                  Strengthen outreach to drug users with little or no history of participation in treatment. Baltimore will have only limited success if, despite improved services and expanded capacity, the treatment system fails to attract drug users who have had little experience with treatment.  The Baltimore Needle Exchange Program (BNEP) is an effective bridge to treatment.  New BNEP registrants have a high level of interest in entering treatment and, although BNEP referrals have more severe problems, they do as well in treatment as other patients.  Other innovative outreach initiatives, such as Recovery in the Community and AID First, strengthen community support for addicts to enter and remain in treatment.  Baltimore’s plans to enhance treatment with comprehensive wrap-around services may also increase treatment’s attraction for drug users who previously felt that treatment did not address their own primary concerns.

Ø                  Educate the public about the benefits of an aggressive treatment strategy. Baltimore is forging a consensus about the importance of treatment in addressing the city’s drug problems, but sustained support for investing in treatment cannot be taken for granted.  The BSAS Scientific Advisory Committee recommended that BSAS engage in public education about treatment, and BSAS has hired an Advocacy and Public Information Coordinator to design and implement a public education strategy.  This campaign should involve the mayor and other top city officials, and build on local research findings.  The public education campaign should help Baltimore avoid falling into the trap of overselling of treatment.  If expectations are raised unrealistically high, then treatment’s achievements will be greeted with disappointment rather than with continued support.  For example, treatment can significantly reduce crime, but not eradicate it.  And while a more effective treatment system is bound to save money and improve Baltimore’s quality of life, the payoff will not appear overnight.

For decades, treatment has been underfunded, as policymakers at all levels have emphasized enforcement and incarceration rather than treatment and rehabilitation.  Backed by research and bolstered by public support, Baltimore’s efforts place it at the forefront of a growing movement to elevate treatment to a prominent role in the effort to reduce drug addiction and its associated problems.

Every American has a stake in the outcome in Baltimore.  If the city’s efforts succeed, they can serve as models for the rest of the country, helping to reduce crime and the size of the U.S. prison population, contributing to urban revitalization, and enhancing the quality of life for all citizens.

ENDNOTES:

[288].           Maryland Task Force to Study Increasing the Availability of Substance Abuse Programs. Interim Report by the Committee on Availability and the Committee on Effectiveness.  December 1999.