Yes we should spend more money on substance abuse treatment–with some caveats

Austin Frakt asks a simple question, with a pretty simple answer–with a few needed caveats.

Austin Frakt asks a simple question: “Do we spend too little on substance use treatment?”

The simple answer is “Of course. Absolutely.” Many, many studies indicate that such services improve health and well-being and reduce crime. One of my own co-written papers contributes to this literature, finding that the reduction in one crime–armed robbery–more than offset the cost of intensive treatment in criminally active populations.

A more complicated answer would include some caveats, though….

First, a lot of substance abuse treatment is very poor. We need to spend more money, but we also need to hold providers to higher quality standards. Our work on methadone maintenance dosing and HIV prevention provides obvious examples. An admirable, often-overlooked aspect of health reform is to provide patients with better options to manage substance use disorders, and to integrate such care within the broader world of medical care.

Second, most people with problematic substance use probably don’t need and will certainly never receive specialized addiction treatment services. We need to do a much better job (a) identifying and referring people to treatment, and (b) dealing with problematic substance use that doesn’t reach the level that would satisfy formal screening criteria for treatment intervention. Efforts such as SBIRT (Screening, brief intervention, and referral to treatment) are therefore especially important.

Third, we need to recognize that substance abuse treatment will always have frustrating shortcomings, and cannot address many of the most poignant harms associated with intoxicating substances. If we expect too much from treatment or claim too much for what treatment can accomplish, we may be disappointed.

In part, this reality underscores the importance of non-treatment policies such as alcohol taxes and a variety of harm reduction interventions. In part, this reflects the even simpler reality that the misuse of intoxicating substances brings many harms which we cannot fully address.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect,, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

7 thoughts on “Yes we should spend more money on substance abuse treatment–with some caveats”

  1. Do we always include treatment expenses for prisons and jails in our totals on how much the taxpayer spends on treatment? Do we include the human services extended to others impacted by the user’s actions?

    Wouldn’t we have to legalize and tax all drugs in order to garner enough revenue for paying for socially required treatment? Granted alcohol is the greatest culprit in crime and abuse. That being said, perhaps the other recreational drugs should not be given such disproportionate attention.

  2. A good start would be to recognize that not all non-medical use of psychoactive substances is a problem, and to stop coercing people unto “treatment” programs.

    I can’t see the article (or even the abstract) for the item on methadone maintenance. Maybe you are in a position to enlighten me about something. I have always been under the impression that in the US, methadone programs are invariably aimed at getting people to be abstinent (and sooner rather than later). Are there programs in the US where patients (or clients, or whatever they’re called) can expect to receive maintenance doses indefinitely?

    It has always seemed to me that it is a no-brainer that people who are chronic opioid users, who want switch to methadone at dosages sufficient to avoid withdrawal syndrome, and who don’t want to be coerced into being abstinent, ought to be accommodated in that with a minimum of bureaucratic interference. But my impression is that methadone programs are few and waiting lists long. How does that square with your experience?

  3. The best thing that could happen to those who really want to help people with drug problems is to kick the habit of being joined at the hip with law enforcement and criminal justice. Far too often, the reason low quality treatment manages to survive is because of a co-dependent relationship to the local authorities.

    Of course getting to square one with such a concept in this country is the problem. Too many politicians swigging votes down by beating the drum of beating up on those who refuse to follow (some of) society’s (often counterproductive) legal fiction to mean that is going to change for the broad spectrum of substance abuse.

    If we get lucky, de facto marijuana legalization in whatever form it takes might set the pace for other problems, which deserve far more attention and care than society has been willing to render up — other than warehousing folks in a prison for non-violent substance use offenses, speaking of counterproductive policies.

    And don’t kid yourself. The majority of people in prison for supposedly “dealing” are there because they were holding more than some entirely arbitrary weight that happened to tickle some politician’s fancy before we all realized how expensive and ineffective paying for such pointless legal violence would be.

  4. Harold is correct to broaden the lens beyond treatment of addiction and look at lower-level interventions for less severely troubled people (e.g., SBIRT). The randomized trials for SBIRT are very strong for alcohol, modest for prescription drug abuse and marijuana, and not clear yet for the other substances.

    As Mark Kleiman has pointed out many times, spending on health care in the U.S. is many, many times that on law enforcement, so substance use treatment should not have to go begging outside of the health care system for dollars. The money is there, what is lacking is the desire and the appreciation that treatment is a good investment from a health perspective.

    p.s. to Aardvark Cheeselog: There are many methadone patients in the U.S. on medication indefinitely. I had responsibility at one point for overseeing a large number of clinics and the option of lifetime maintenance was encoded in clinical practice guidelines and seen as essential.

  5. It’s hard to sell people on government spending towards social problems when there is a lot of money out there being spent poorly. This tends to get held up as evidence that *no government spending works*, or at least that the benefits aren’t worth the cost. But there are many things out there being tried, and many of them with success. Instead of debating *whether* money should be spent at all, we need to be debating *how* the money gets spent, with the knowledge that there are answers and that we have a responsibility to find them.

  6. Regarding the statement: “We need to spend more money, but we also need to hold providers to higher quality standards.”

    Yes, but it is not just holding providers to higher quality standards. It is also about providing the right modality, time, and accountability of treatment and recovery support. Otherwise, we deliver poor outcomes and (justifiably) get hammered by policy makers as a result.

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