WIXLIB

September 30, 1971.NTA officialsadmit, however, thatthey cannot attestto the reliabilityof the estimate betechnique decause it is based, in part, on an estimatingveloped in New York City which may have no applicabilityorvalidityin the District,and, in part, on several othertechniques which rely on a number of unproven assumptionsand relationships.The task of determiningwith any degree of reliabilitythe number of narcoticaddicts in the District,or in anyother area, is made extremelydifficultbecause there is nocommonly accepted definitionfor the term "narcoticaddict,"no reliableor complete reportingsystem, and no means ofidentifyinga person as a narcoticaddict unless he is arThe methods usedrested or enrollsin a treatmentprogram.by NTA to estimate the number of narcoticaddictsin thecity and certainother indicatorswhich provide some insightinto the size of the District'saddictionproblem are discussed in appendix III.An estimate of the annual cost of heroin addictioninthe Districtis provided by a November 1970 report entitled"The Economics of Drug Addictionand Control in Washington,D.C. ," prepared by the District'sDepartment of Correctionsthrough its Office of Planning and Research.The reportestimatedthat the annual cost of heroin addictionin theThis representsan estiDistrictmight exceed 200 million.mated outlay of (1) 175 millionfor the illegalacquisitionof heroin by addicts,(2) 8 millionfor police and courtcosts, (3) 9 millionfor jailand parole expenses, and (4) 13 millionin earnings lost to those addicted to heroin.The 175 millionestimate was based on the assumptionthat there were 15,000 addicts in the Districtand that thecost of an average heroin habit in the Districtat that timewas about 40 a day. The daily cost of an average heroinhabit was based on informationobtained by NT.A from residentsof the District'sjail during a study conducted in Augustand September 1969.The report states that addicts finance their habitsthrough a combinationof means which include (1) "pushing'for sellingdrugs, (2) prostitution,(3) obtainingfunds fromfamily or relatives,(4) working in legitimate,though7

low-wage,addiction,occupations,especiallyin the early stagesand (5) burglary,larceny,and robbery.ofThe Department'sreport states that, to estimate theamount of propertyand money that heroin addicts must stealto support their habits,several assumptions must be madeas to how addicts obtain heroin and as to the sources offunds availableto heroin addicts.These assumptions,according to the report,are based on discussionswith program officialsand not on the empiricalresearch which isessentialfor reaching valid conclusions.It was assumed in the report that 20 percent of allheroin consumed by the addict populationis obtained bypushing.The report points out that this does not mean that20 percent of all addicts are pushers but that 20 percentof the heroin used by addicts is obtained for servicesrendered in the distributionsystem.forThe report has assumed, concerningheroin purchases,that:the fundsrequiredrobbery,1. 60 percent are obtainedand larceny.throughburglary,2. 15 percentare obtainedthroughlegitimate3. 15 percentare obtainedthroughprostitution.4. 10 percent are obtainedtivity,such as forgery,games.sources.through other illegalacauto theft,and confidenceIt was assumed also that, of the amount20 percent would be stolen money and 80stolen propertythat could be convertedproximatelyone third of the property'sgained by theft,percent would beto money for apvalue.On the basis of these assumptions,the November 1970report showed that, to obtain the 175 millionneeded annually by 15,000 addicts to support their habits,the addictswould steal cash and property valued at 273 millionandwould obtain 22 millionthrough other illegalactivities,such as forgery,auto theft,and confidencegames; 33 million through legal activity;and 33 millionthrough prostitution.8

CHAPTER 2NARCOTICS TREATMENTADMINISTRATION--NTA was establishedwithinthe Department of Human Resources, Districtof Columbia, in February 1970 to lead andcoordinatea comprehensive community effortto cope withthe problem of heroin addictionin the District.The Administratorof NTA informed us that, during NTA's 1st yearprimary emphasis was placed on enrollingasof operation,many patientsas possible and that a varietyof treatmentmodalitieswas offeredat all treatmentcenters.DuringNTA's 2d year of operation,the rate at which new patientswere added slowed down and NTA began to expand its servicesfrom a medicallyorientedmode of operationto a more comprehensive approach designed to meet patients'totalneedseducation and job placement,etc.).As( i.e., treatment,part of this broadening process, NTA adopted the concept ofspecializedcenters which offered one primary modalityoftreatment.NTA's stated objectivesare to provide comprehensiveand effectivetreatmentfor all addictsin the District,tocarry out research to increase the understandingof heroinaddiction,and to advance a major educationaland preventiveprogram aimed at reducing the recruitmentof new heroinaddicts.Our review consideredonly the treatmentprogramsof NTA, not its research and education programs.As requested by the Chairman of the Subcommittee,obtained the followinginformationon NTA's treatmentrehabilitationprograms.--Program goals.--Treatmentmodalities.--Patientsin treatmentand servicesavailable.--Source of funding.--Treatmentcost of various modalities.--Criteriaused to select patientsfor treatment.--Program assessment efforts.--Program results.weand

PROGRAMGOALSNTA has fourprimarygoalsforall--Productiveand self-fulfillinga job or nof illegalpatients.socialfunctioningindrug use.of criminalactivity.in treatment.TREATMENTMODALITIESNTA operates 12 treatmentcenters throughoutthe city,includinginpatientand outpatientcenters and a surveillance unit for persons who must demonstrate that they canremain drug free as a conditionof their probationor parole.In addition,NTA has contractswith community-based privateagencies to provide services for heroin addicts at fourother centers.Two of the 16 centers provide both inpatientand outpatientservices,two provide only inpatientservices, and the other 12 are outpatientcenters.Most ofthe centers offer one predominantmodalityof treatmentinkeeping with NTA's present operatingconcept of specializedclinics,NTA's program design makes extensive use of methadonetreatment,Methadone is an addictivesyntheticnarcoticwhich shares many pharmacologicpropertieswith morphine,heroin,and other opiate drugs.Methadone, when used totreat chronic heroin addiction,has several unique properA single dose, taken orally,suppresses withdrawalties.symptoms in a heroin-dependentperson for 24 to 36 hours.If given in large enough doses, it also blocks the euphoriceffectsof heroin.Additionally,methadone-addictedperdo not continuallyneed insons, unlike heroin addicts,creasinglylarger quantitiesto prevent withdrawaleffects,once their daily doses are in the range of 40 to 80 milligrams of methadone a day.Generalcategoriesof treatment,are:10as definedby NTA,

--Abstinence--forpatientsbut needing the supportmonitoring.attemptinga drug-freeof counselingand urinelife--Methadone detoxification--forpatientsdesiringtowithdraw from physicaladdictionwith minimal disDecreasing dosages of methadone are givencomfort.on an inpatientor outpatientbasis.Methadonedetoxificationperiods are scheduled to range from2 weeks to 6 months but may be extended beyond6 months, depending on patientneeds.--Methadone maintenance--foreligiblecandidatesusually at least 18 years old with a minimal 2-yearhistoryof heroin addictionwho voluntarilyconsentDaily stabilizationdoses of methadoneto treatment.which satisfythe craving for heroin and block itseffectsare given over a prolonged period of time.--Methadone hold--forimmediate treatment,with metha&ne, of walk-inpatientsprior to determinationwithin no more than 2 weeks of the most appropriatetreatmentregimen after complete examination,diagnosis, and redfor druguse evaluationorneedingto demonstratethat theycan remain drug free for a specifiedperiod of time,i.e.,awaitingcourt action or validationof a motorvehiclelicense.NTA's methadone maintenance clinicsare designatedasinductionor stabilizationclinics.There is only one induction clinic.This clinicserves new methadone maintenance patientswho requirefrom 4 to 6 weeks to becomestabilizedon blockingdoses of methadone.The inductionclinicoperates 7 days a week because new patientsmusttake their methadone at the clinicand do not have takehome privileges.Once stabilized,the patientis transferred to a stabilizationclinicwhere there is less contact with the clinicand the patientis allowed weekendtake-home privilegesfor methadone,Stabilizationclinicsoperate on a 5-day week. As treatmentprogresses and the11

patientbecomes more advanced in the program, secures asteady job, uses no illegalfitsintodrugs, and generallysociety as a functionalcitizen,he may take home as muchas a 3-day supply of methadone.12

PATIENTS IN TREATMENTAND SERVICES AVAILABLEAny residentof the Districtof Columbia who is foundto be a narcoticaddict is admitted by NTA for treatment.In addition,we were advised by NTA that there is no waitBrieflyduring the spring and suming listfor treatment.mer of 1970, intake proceedings had to be stopped becausefacilitieswere full,As soon as this situationwas remedied, people were again admitted to treatmenton a firstcome-first-servedbasis.Within the first2 years of its operation,the numberof patientsenrolledin NTA treatmentprograms grew considerably.In February 1970 NTA had 153 patientsin treatment.The followingtable shows the treatmentmodalityforall 3,506 reportablepatientsat NTA or contractorcentersas of February 4, 1972.wandContractorAs of FebruaryPatientCount4. 1972ModalitySsti-Mainte-DetoxifinanceNTA us:iceSurveillanceUnitDrug AddictionMedicalServiceClinicDrue AddictionMedicalService--inpatientEmerge HouseDetoxificatron-AbstinenceClinicFar East AddictionTreatmentSerx.iceG StreetClinicModel ilitatlonCorksNarcoticAddictClinicYouth theastNeighborhoodyouthBonabond 31and79TotalTotalPercentageofNTA and A200-106centers3,506z2,256treatmentgo %g65%-Services availablesuch factorsas staffing,itationsof the facility,1at centers differ,depending onpatientcase load, physicallimand the needs of the patients.139

All centers offer individualcounseling and utilizeurinetestingto determine illegaldrug use.Observed urine specimens are usuallytaken two times a week.Most centers also offer some supportiveservicessuchas job placement,education and trainingassistance,healthservices,financialaid, and assistancehousing assistance,in obtainingfurnitureand clothing.The extent to whichsuch services are provided depends on the availabilityofstaff,We noted that some centers have individualstaffmembers who specializein job placement or education andtraining,but most often all of these functionsmust be performed by the counselingstaff in additionto their regularduties.In addition,centers are requiredto perform anoutreach functionto seek out patientswho have dropped outof the program and to persuade them to return to treatment.The extent to which the outreach functionis performed depends on staff availability.Services availablecenters are more fullyat each of the NTA and contractordiscussed in appendix II.14

SOURCEOF FUNDINGSince its organizationin Februaryceived the followingfinancialsupport.Districtof Columbia appropriation:Directlyto NTAIndirectlythrough the Department of CorrectionsTotalappropriatedFederal grants:Office of Economic OpportunityDepartment of Housing andUrban DevelopmentNationalInstituteof MentalHealthIaw Enforcement AssistanceAdministrationTotalgrantsGrand total1970, NTA has re-Total1970 4,914,200 354,0001,386,500240.400 6.300.700 594 , 400Fiscal Year1971 2,690,200417,300 3.107,5001972 1,870,000728,800 ,334,700TREATMENTCOST OF VARIOUS HODALITIESWe were unable to obtain actual per patientcost datafor the various treatmentmodalitiesbecause NTA does notaccumulate costs on a treatment-centerbasis.We asked NTAofficialsto provide us with estimatedper patientcostsfor the various methods of treatment.Since many of thetreatmentcenters operated by NTA offer a combinationoftreatmentmethods and services,it was necessary for NTA todevelop models for typicaltreatmentcenters.NTA chose todevelop models for a methadone maintenance center,adetoxification-abstinencecenter,and a halfway house.The methadone maintenance and detoxification-abstinencemodels provided for average staffingpatterns,averagesalary and benefitpayments, and estimatesof such otheroperatingexpenses as travel,equipment,rent, supplies,methadone, and urinalysis.The models also consideredtheestimatedcost of administrativeoverhead for Department of!%man Resources personnel.15

The model for the halfway house consistedof a typicaloperatingbudget for the residentialcenter 'at 456 C Street,Northwest,which is a halfway house for patientsreferredby the criminaljusticesystem.Estimates were included inthe budget for NTA centralizedtreatmentsupport and forDepartment of Human Resources overhead.NTA estimatedfollows:Treatment methodOutpatient methadonemaintenanceOutpatient detoxificationabstinenceResidentialltalfway houseaverageTotalannualDirectper patientAnnual per patientNTATreatment administrativesupportdirectioncosts,ascostsDept. ofHuman Resourcesoverhead 1,001 655 150 110 862,0326,2251,3084,096300938220688208503It should be noted that the operatingcosts of thehalfway house may be higher than the operatingcosts of halfway houses in other programs around the country because thepatientsbeing treated in the NTA model are parolees fromcriminalinstitutionsover whom NTA has been assigned cusMore staff is requiredto maintain custody over thesetody.people than is requiredat halfway houses where patientsareadmitted voluntarilyand are free to leave at any time.The Administratorof NTA suggested that it would bemeaningfulto compare the cost of treatingaddicts with theoncost to society of not treatingthem. As indicatedpage 8, the Department of Correctionsestimated thatannually15,000 addicts steal cash and property valued at 273 million and obtain another 22 millionthrough such other illegalactivitiesas forgery,auto thefts,and confidenceThisamountstoanapproximate 20,000annual lossgames.to society caused by each addict'scriminalactivitjes.A comparison of the estimated'lossto the cost of treating an addict,assuming that the cost estimatesare validand the addict'scriminalactivitiesare reduced duringwould suggest that the cost of treatmentis er,worthwhile.16

because we did not verifythe validityof the estimatedcost of treatmentor the estimatedcost to societyfrom untreated heroin addictionand because we did not obtain complete informationon the extent of addicts'criminalactivitiesbefore and after entry into treatment.17

CRITERIA USED TO SELECTPATIENTS FOR TREATMENTAny residentof the Districtof Columbia is eligibleAllapplicantsfor treatmentby NTA,for treatmentby WA.whether voluntaryor court-recommended,are examined andprocessed at one centralintake facility.Basically,thiscentralfacilityconsistsof a medical section and aThe nded through a grant from the Law Enforcement AssistanceAdministrationof the Department of Justice.The medical sectionis responsiblefor performingaphysicalexamination,which includes blood studies,urinalysis, X-rays,and electrocardiograms,and for obtainingamedical historyof each applicant.The counseling-intakesection,in additionto confirming an applicant'sage, identification,and referralsource,is responsiblefor counselingand assistingeach applicant.Counselors ensure that each person becomes familiarwith theprogram and understandsthe servicesavailablefrom NTA,includingthe role of methadone in the controlof drug abuse.Each new applicantis extensivelyinterviewedby acounselor who obtains and records informationon employment,educational,military,criminal,and social histories.Anextensivedrug-abuse history,includinga medical opinionas to the extentof drug abuse, is also completed for eachapplicant.A decisionas to the appropriatetreatmentmodalityis made jointlyby the counselor and the patient.Physiciansare availablefor consultationin this process.Afterthe treatmentmodalityis agreed on (methadone maintenance, methadone detoxification,or abstinence),the patientis sent to the appropriateNTA treatmentcenter.Asummarizationof importantsocial and medical needs of thepatientis sent to the treatmentcenter by the intake unit.At the treatmentcenter

Detoxification-Abstinence Clinic Far East Addiction Treatment Service G Street Clinic Model Cities Addiction Treatment Pro- . methadone maintenance, or detoxification. Currently, according to the Administrator, NTA is becoming increasingly . Chicago, Los Angeles, and San Francisco--and that individual reports be prepared for each. GAO was .