The Drug Abuse Treatment Gap: Recent Estimates
Woodward, Albert, Epstein, Joan, Gfroerer, Joseph, Melnick, Daniel, Thoreson, Richard, Willson, Douglas, Health Care Financing Review
The NHSDA is conducted annually among the general U.S. civilian non-institutionalized population 12 years of age or over and is designed to produce drug and alcohol use incidence and prevalence estimates. NHSDA prevalence estimates show that the total number of illicit drug users has been unchanged since 1992, following more than a decade of decline since the peak year for illicit drug use, 1979 (Substance Abuse and Mental Health Services Administration, 1995c). The decline appears to reverse a longer term trend of increased prevalence and to reflect a decline in incidence that slightly preceded peak prevalence (Gfroerer and Brodsky, 1992; Johnson et al., 1996). With current estimation procedures, in 1994, 13 million persons in this country (6 percent of those 12 years of age or over) used illicit drugs; 10 million persons (four-fifths of current illicit drug users) used marijuana, making it the most commonly used illicit drug; and 1.4 million Americans (0.7 percent of the population) used cocaine (Substance Abuse and Mental Health Services Administration, 1995c).
Improved planning for public expenditures related to drug abuse treatment requires reliable estimates of the number of people needing and receiving treatment for drug abuse. Previous estimates have been developed for the Office of National Drug Control Policy (ONDCP). In this article, more recent data and improved estimating procedures are used to develop better estimates.
Estimating treatment need for the Nation is made difficult by the dynamic aspects of drug and alcohol consumption and its consequences. Estimating need for the Nation is a different problem from diagnosing the need for treatment in an individual based on history-taking, physical examination, and information on medical records. The NHSDA does not include physical examinations or take a detailed history, and it would be impractical to do so. In addition, even if it were possible to have a clinical diagnosis for all respondents surveyed, there may be a significant number of people not receiving treatment, such as incarcerated and homeless individuals, and these would not be included in the need estimate.
In recent years, several methods have been developed to estimate treatment need using the NHSDA, and each has its limitations (Wright, Gfroerer, and Epstein, 1997; Epstein and Gfroerer, 1995). In 1989 the National Institute on Drug Abuse (NIDA) developed an illicit drug index that defined heavy drug users who need treatment as persons who had used illicit drugs at least 200 times in the past year. A shortcoming of this illicit drug index is that it did not consider the personal, health, and social problems associated with use.
To overcome this limitation, NIDA developed another method based on reported problems and symptoms of abuse or dependence on illicit drugs. This method used clinical criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (1987). In 1990 the Institute of Medicine developed a method for estimating treatment need using a combination of frequency of use and problems and symptoms associated with use (Gerstein and Harwood, 1990). This method is based on combining data from three separate variables: frequency of drug use, symptoms of dependence, and problems or consequences of use. Need for treatment of homeless and incarcerated groups was estimated separately. Each of the last two methods has strengths that the other does not: The DSM approach potentially missed some people in need of treatment because of its clinical bias, whereas the Institute of Medicine approach may not be sufficiently precise because it lacks a clinical perspective.
In this article, we use NHSDA data but apply more comprehensive selection criteria to identify need. Clinical criteria for dependence and new criteria for abuse are applied. The new abuse criteria are defined to include specific drug abuse behaviors, e. …