What if I told you that your state could invest in a program that produced seven dollars of benefits for every dollar invested? What if I told you that this program improved quality of life, health, and economic wellbeing for disadvantaged people? Now, what if I told you that the program was substance abuse treatment?
The 7:1 figure I cited above comes from a 2006 economic evaluation of the California Treatment Outcomes Program, which compared the nine months pre- and post-drug treatment for a diverse cohort receiving treatment at 43 treatment providers. The benefits included reduced use of emergency rooms, fewer crimes committed, and higher earnings. This estimate is within the range of other older comprehensive cost-benefit analyses of substance abuse treatment, with estimates varying across treatment setting (outpatient, detoxification, or residential) and population receiving treatment.
None of the cost benefit analyses on substance abuse treatment is perfect. The selection problem is hard to convincingly address outside of a randomized controlled trial. Because people often seek substance abuse treatment when they are ready to make a life change, some of the observed increase in employment and reduction in crime may stem from individual motivation and not treatment. The methodologies for estimating costs of treatment and the size of the benefits can be picked apart. If anything, these methods often are conservative: it is hard to capture all the ways in which substance abuse treatment changes people’s health and work behavior with a few months of data.
Why Not Expand Treatment?
There is ample evidence that few of the people that need treatment – not just recreational drug users, but people that exhibit clinical symptoms of dependence and abuse – are currently getting treated. The National Survey of Drug Use and Health estimates that 3.1 million people currently need treatment on this criteria, but only 0.6 million (19%) of these individuals received treatment last year (Table 5.46B). Why so few?
When substance users in this survey are asked, only 7% say that they either sought treatment, or wanted to stop using. This is not entirely surprising given the nature of drug addiction – withdrawing from substances is difficult and unpleasant, the long-term effects of use are often not apparent to the drug user. It is thus not surprising that more than a third of all individuals in drug treatment entered treatment because of the criminal justice system. Most criminal justice referred individuals are in rehabilitation as an alternative to serving time in jail or prison. One might assume that such individuals would not do well in treatment, but in fact the evidence suggests that criminal justice referrals are, if anything, slightly more likely to complete treatment and enter recovery.
We Could Do Better
So many people don’t want to go to rehab, but rehab could be made a much better place. For every effective intervention out there, there are many rehabilitation providers that fall severely short. Substance abuse treatment often fails because it does not address the underlying psychosocial risk factors that cause individuals to use, does not link individuals to effective outside resources (like housing or vocational training), or does not make use of the latest therapeutic innovations (like motivational interviewing, cognitive behavioral therapy, and pharmacological treatments). If rehab were improved – and coupled with better outreach – more individuals might be convinced to enter treatment, and those that do enter treatment could succeed. There are some hopeful models. For example, the state of Washington now only reimburses for evidence-based substance abuse treatment. A recent evaluation shows that this shift saved the state money and improved outcomes.
Of course, not all of this can be accomplished without some upfront public investment. Public opinion data from before the recession shows that the public is ambivalent about addiction treatment. Tighter budgets mean that legislators and citizens are even more cautious about spending money on drug addicts. Part of the challenge is one of communication: rather than emphasizing that drug treatment is a compassionate alternative to letting people waste away on the streets or in prison (which it is), the public needs to be educated about how drug treatment can improve public safety and create more taxpayers, better parents, and more productive workers.