Background

Background on AODD and Recovery In DC

DC has the worst drug and alcohol problem in the country – three times worse than the HIV/AIDS epidemic. One in every eight residents over the age of 12 not only uses illicit drugs and/or alcohol, but has problems in daily living because of it.[2] It affects all sectors of society and all parts of the city. Those afflicted, and those affected by them, are not “those people”, but our brothers, sisters, sons, daughters, mothers, fathers, co-workers, and neighbors.

Alcohol and Other Drug Disorders (AODD) underlie many other social problems, contributing to them or blocking their solution. The burden that this places on DC government programs is the highest in the country ($1,316 per capita in 2005). This represents 18.3 percent of the total budget, or $765 million. This does not include the burden for prosecution of crimes or corrections, which are paid for by the Federal government, or for Alcoholic Beverage Control, which is paid for by fines and fees[3].

It also does not include lost productivity (and alcohol and drug users take more sick days and have more on-the-job accidents than non-users), family disintegration, health effects, poor school performance, and crime (over half of those arrested in DC in 2008 tested positive for illegal drugs; no test was made for alcohol)[4].

Yet the DC government spends only less than one percent of its budget on prevention and treatment, which is less than three percent of the total burden, or about $45.00 per capita, less than it takes in for alcohol and tobacco taxes[5] (which themselves are below the national average. In part because of low spending, DC has the worst treatment gap – the difference between those who need treatment and those who get it – in the country.[6]

Alcoholism has long been recognized as a chronic disease by the American Medical Association. But it, and drug abuse, is viewed as a moral failing or weakness of character. Even if it is recognized as a disease, too often it is treated only in the acute stage, with resulting relapse. Still, treatment is more effective than for many other chronic diseases such as asthma, diabetes, and high blood pressure.

The moral stigma attached to AODD spills over onto people in recovery, prompting an almost-pathological commitment to anonymity, far beyond the intent of the founders of the 12-Step movement to which many belong. So AODD problems get plenty of attention, but successful, sustained recovery gets very little. This contributes to a feeling of hopelessness, frustration, and denial, ultimately making AODD DC's Forgotten Epidemic. Too many people have lost hope, and would prefer to pretend the problem does not exist. With no public pressure, government has been content to sweep the problem under the rug and move on to more pressing issues.

Yet there are reasons for hope. Thousands of DC residents are living lives of sustained recovery, treating their disease every day and helping others to get clean and sober. There is a small, but growing, The Recovery Advocacy movement that is bringing recovery out of the shadows and celebrating victory in the War on Drugs, especially during September, National Recovery Month.

The citizens of DC support recovery, if they are given an opportunity. In the 2002 election, a ballot Initiative to mandate treatment instead of jail for non-violent drug offenders got 86,162 votes, more than Mayor Anthony Williams with 79,841 votes. The Initiative was later overturned on procedural grounds (it was found to be a de facto appropriation of funds, a function reserved to the Council), but not before support for recovery was clearly demonstrated.

And there is new hope for the recovery they want in the new and growing understanding of how experience, biochemistry, brain structure, and behavior interact. Alcohol and drugs hijack the biochemical signals that guide behavior, and help tell right from wrong. This means that it is not enough to remove those signals or to “Just Say No”. New behavior, guided by new and more authentic signals, must be introduced and reinforced to make recovery satisfying and long-lasting. Much of this research validates the folkways of the 12-Step Movement that found that recovery works best in a community that provides those new signals and multiple reinforcements for them.

This new research and new practical approaches based on it promise to narrow the treatment gap and to increase recovery rates. For instance, Screening and Brief Intervention with Referral to Treatment (SBIRT), similar to that now commonly practiced for smoking, high blood pressure, and other chronic diseases, can catch AODD early, while it is easier (and cheaper) to treat.

AODD and its treatment have many of the characteristics of a “public good” (like education, environmental quality, and national defense) that is not effectively or efficiently provided by markets. So many people who had no part in the decision to use or not use drugs are affected by AODD, that its prevention and treatment will always be a matter of public concern, and government intervention.

The Obama Administration has recently declared an end to the War on Drugs[7] , while increasing its commitment to prevention, treatment, and sustained recovery. This is expected to be expressed in increased financial and technical support for recovery, as opposed to just opposing drug use.

There are new sources of funding for treatment and recovery support. AODD (and Mental Health) treatment must be offered in parity with other disorders in private insurance plans that offer any such treatment, a victory won before Health Reform. The current Health Reform legislation extends coverage for AODD to many more people. Some changes in DC's current programs may be necessary to take advantage of these, and Medicare/Medicaid coverage, opportunities.

Combining mental health with AODD treatment to create Departments of Behavior Health has proved effective in many states, despite the fears of advocates for both that their problem would get lost in the mix.

DC's Addiction Prevention and Recovery Administration has long been the ugly stepchild of health care and has shown “mission shrink”, going from an original, if challenging, mission to offer and support programs (including Detox for acute cases) that reduced the number of people with problems to one of regulating (some would say over-regulating) treatment providers and counting success in the number of referrals to others that it makes. Even so, APRA's target for referrals that result in as little as six months' recovery is only 50 percent[8]. This makes reducing the number of people who need treatment a difficult, and expensive, goal – one that APRA no longer seeks to attain.

New programs to sustain recovery, such as Federal Access To Recovery grants, Recovery Community Centers, “warm calling”, and reduced stigma (such as Ban the Box), can make recovery last longer without relapse. This lowers the cost per person/month of recovery and returns more people to full participation in society, rather than sending them back to treatment. This is why the DC Recovery Community Alliance community has moved beyond advocating for more treatment to advocating for sustained recovery.  

[8] FY2010 Performance Plan, DC Department of Health.