Joseph Califano, Jr. describes his new book, High Society: How Substance Abuse Ravages America and What to Do About It, as a "call to arms". Califano, Chairman and President of the National Center on Addiction and Substance Abuse (CASA) at Columbia University, presents in devastating detail the many ways in which substance abuse infects all aspects of American society. Many of the statistics he weaves into his argument are familiar. In their entirety, however, they paint the portrait of a nation drenched in alcohol and substance abuse.

• Americans comprise only four percent of the world's population but consume two-thirds of the world's illegal durgs.
• Nearly a quarter of the nation's college students meet the clinical criteria for alcohol and drug abuse and addiction.
• Every American child will be offered illegal drugs before graduating from high school, most on several occasions.

The list goes on:

• 61 million Americans are hooked on cigarettes;
• 16 to 20 million are addicted to alcohol or abuse it regularly;
• More than 15 million abuse prescription opioids, depressants and stimulants each year;
• 15 million smoke marijuana;
• 2.4 million use cocaine; more than 60,000 use crack;
• More than half a million are hooked on heroin;
• More than 500,000 are methamphetamine users;
• One million use Ecstasy and hallucinogens like LSD and PCP;
• Almost two million of our children have used steroids;
• 4.5 million teens have used controlled prescription drugs like OxyContin, Vicodin, Ritalin and Adderall to get high.

Califano finds plenty of blame for us all to share - parents, politicians, educators, health professionals, not to mention the alcohol, tobacco and pharmaceutical industries.

He also takes substance abuse treatment providers to task for what he sees as their own significant failings.

"The substance abuse treatment community likes to attribute high dropout and relapse rates not to treatment deficiencies, but to the failure of individual addicts," he says. "In fact, problems within existing treatment systems - inadequate certification standards, frequent turnover of staff, erratic program procedures, lack of program performance accountability, absence of professional training - contribute to the discouraging cycle of recovery and relapse."

He argues that the treatment community has generally failed to conduct rigorous evaluations of client outcomes and program performance. "In the early 1990s, at CASA we sought to evaluate treatment programs in a scientifically sound way," he says. "Programs we contacted resisted such a review."

Califano questions the claims made by many treatment providers. "Worse than the failure to subject all treatment protocols to scientifically based outcomes research is how programs calculate success rates," he says. "For example, some therapeutic community programs which normally require patients to stay in residence for eighteen months to two years claim a 30% success rate. They reach that percentage by counting only those patients who complete the entire course of treatment. However commonly of those who enter therapeutic communities, 80% drop out within the first few months. Only 10% complete the lengthy program. Of that 10% (normally according to their own statements), a third are drug-free a year later, a third are using at lower levels, and a third are back to their pretreatment usage patterns."
Consequently, he maintains that "treatment success claims by programs themselves are widely discredited in the research community and by insurers and state and federal legislators."

"We are never going to get full parity insurance coverage for treatment of substance abuse the way every other disease is treated until insurance companies have the sense that the community is thoroughly professionalized," Califano told NYNP in a separate interview. "That is why professionalizing the providers is so key.

"Treatment programs are so varied. They range all over the lot. There are states in this country where you or I could hang out a shingle as addiction counselors if we have a high school diploma and a two week training course." Individuals and families facing a substance abuse problem are hard pressed to identify high quality programs with proven track records of performance. "If your child had a heart condition, you could find out within an hour what the treatment options were and how successful they are," he says.

Despite these shortcomings, the rationale for further investment in treatment programs is obvious. "Even under present circumstances, where treatment is spotty, the value of treatment compared to the costs of failure to treat is clear," he says. "A study at the UCLA compared the costs of treatment for twenty-five clients in various programs with the resulting reduced costs (less medical treatment, fewer mental health serices, and less criminal activity and welfare) and increased earnings. The study found a seven-dollar benefit for each dollar spent on treatment. The finding is similar to those of other studies. ….imagine how much greater the savings can be with more consistently effective treatment programs."

Califano calls assessing and rewarding programs based on their measurable outcomes. "Immediate short term actions can be taken to improve public programs," he says. "Delaware pays bonuses to outpatient treatment programs that retain at least 85% of their clients for the full course of care. Programs failing to reach that goal receive only 90% of the prior year's reimbursement rate. Adopted in 2003, this plan has tripled patient retention rates, an important factor, since retention intreatment is related to success."

While High Society is aimed at a broad general audience, it is also sending a clear message to the prevention and treatment community itself. Get professional!

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