CHAPTER 10
THE NATIONAL DRUG CONTROL STRATEGY

Drug dependence is a chronic, relapsing disorder that exacts an enormous cost on individuals, families, businesses, communities, and nations. Addicted individuals frequently engage in self-destructive and criminal behavior. Treatment can help them end dependence on addictive drugs. Treatment programs also reduce the consequences of addiction on the rest of society. Providing treatment for America's chronic drug users is both compassionate public policy and a sound investment.

—National Drug Control Strategy, 2001, Office of National Drug Control Policy

THE COST OF DRUG ABUSE

The Office of National Drug Control Policy (ONDCP), a part of the White House, issued a report in 2004 on the economic costs of drug abuse, The Economic Costs of Drug Abuse in the United States: 1992-2002 (http://www.whitehousedrugpolicy.gov/publications/economic_costs/economic_costs.pdf). The report included such costs as those to the health care system; the cost of crime associated with drug abuse; and such economic impacts as job loss and decreased productivity. The estimated direct and indirect societal cost for 2002 was $180.9 billion, according to the agency; corresponding costs for 1992 were $102.2 billion and for 1998 were $143.4 billion. Costs increased in the 1992-2002 period at a rate of 5.3% a year. The nation's Gross Domestic Product (GDP) for the entire economy, in comparison, increased in this same period at a rate of 5.1% a year. (See Table 10.1 and Table 10.2.)

The raw number—$180.9 billion—is huge and difficult to grasp without comparisons. The cost is very significant. In 2002, for instance, doctors' offices had total revenues of $236 billion and all dentists earned $69 billion (Service Annual Survey: 2002, U.S. Census Bureau). Total expenditures of all colleges and universities in 2001-2002 were $317 billion (Digest of Educational Statistics, U.S. National Center for Education Statistics, annual).

Most of the $180.9 billion cited by ONDCP is accounted for by estimates of lost productivity ($128.6 billion or 71%). Elements of this figure are premature death, time lost through illness and incarceration, time spent in criminal careers, and other unproductive time expended by victims of crime and of individuals during hospitalization. Direct health care costs accounted for $15.8 billion in 2002 and other expenses for $36.4 billion. The two largest components of the "other" category were state corrections expenditures (34% of the category) and police protection (28% of the category).

ORIGINS OF THE NATIONAL STRATEGY

The Anti-Drug Abuse Act of 1988 (PL 100-690) established the creation of a drug-free America as a U.S. policy goal. As part of this initiative, Congress established the Office of National Drug Control Policy in order "to set priorities and objectives for national drug control, promulgate The National Drug Control Strategy on an annual basis, and oversee the strategy's implementation." To stress the importance of the issue, the director of the ONDCP has been given a cabinet-level position. The person holding the position, John P. Walters as of mid-2003, is usually dubbed the nation's "drug czar" by the media.

The first National Drug Control Strategy (NDCS) was submitted by President George H. W. Bush in 1989. It had been prepared under the reign of the nation's first drug czar, William J. Bennett. Its chief emphasis was on the "principle of user accountability—in law enforcement efforts focused on individual users; in decisions regarding sentencing and parole; in school, college, and university policies regarding the use of drugs by students and employees; in the workplace; and in treatment" (White House Fact Sheet on the National Drug Control Strategy, The White House, September 5, 1989, http://bushlibrary.tamu.edu/research/papers/1989/89090503.html). The strategy called for active

efforts directed at countries where cocaine originated, improved targeting of interdiction, increasing the capacity of treatment providers, and accelerated efforts aimed at prevention and at the education of youth. In its details, the drug strategy laid emphasis on law enforcement activities and the expansion of the criminal justice system.

Since that time, the basic building blocks of the national strategy have remained the same, but the specific emphases taken by different administrations, or the same one in different years, have changed, at times leaning more toward enforcement, at other times more toward fighting drug racketeers, and at yet others more toward treatment and prevention. The Clinton administration, in its 2000 strategy, emphasized 1) empowering young people to reject drugs; 2) treatment for drug offenders within the criminal justice system; 3) increasing treatment resources for those who need them; 4) interdicting the flow of drugs across the nation's borders; and 5) aid to other democracies to help them fight traffickers (The President's Message to Congress on the 2000 National Drug Control Strategy, Washington, DC: U.S. State Department, April 12, 2000, http://www.ncjrs.org/ondcppubs/publications/policy/ndcs00/message.html).

In the 2004 National Drug Control Policy (http://www.whitehousedrugpolicy.gov/publications/policy/ndcs04/2004ndcs.pdf), the ONDCP under George W. Bush established three priorities:

• Stopping Use Before It Starts: Education and Community Action
• Healing America's Drug Users: Getting Treatment Resources Where They Are Needed [and]
• Disrupting the Market: Attacking the Economic Base of the Drug Trade

Table 10.3 presents the administration's stated benchmarks for measuring the success of its strategy.

The Clinton administration adopted the view that the "war on drugs" was the wrong model because wars could be expected to end and the effort to control drugs could not. Drugs, therefore, should be seen as a disease, like cancer, requiring long-term strategies (NDCS 2001). The George W. Bush administration adopted the view that drug use was akin to cholera and should be fought on public health principles (NDCS 2003). Whatever the model, all strategies to date have had the same components: prevention and treatment (together constituting demand reduction) and law enforcement, interdiction, and international efforts (together constituting supply disruption). The emphasis given to each of these components has been reflected in federal budgets.

THE FEDERAL DRUG BUDGET

Redoing the Accounts

Table 10.4 presents an overview of drug control spending in the federal budget. In its 2002 National Drug Control Strategy, the ONDCP published budget requests for Fiscal Year (FY) 2003 of $19.2 billion. A year later the FY 2003 budget had shrunk to $11.4 billion. This change was not the consequence of a severe cut in the drug budget but, rather, the consequence of a one-time reorganization of the budget categories that define drug control spending. The missing $8 billion was still in the overall FY 2003 federal budget, but the sum had been taken out of the "drug control" category as newly defined by the office.

In every category of expenditure, changes had taken place because of the reorganization, but the largest change came in the category of domestic law enforcement, where the change between the new and the old way of reckoning the budget had resulted in a decrease of $6.5 billion, accounting for 82% of the downward shift in the total budget. Nearly 70% of domestic law enforcement expenditure was moved out of the new, more narrowly defined "drug control" category. The prevention budget lost 21%, treatment 13.9%, interdiction 14.4%, and international operations 4.3% of funds. At the same time, ONDCP also restated previous years' budgets using the new definitions back to FY 1995.

The principal reason for this budgetary reorganization was to show clearly what funds were being (and had been) expended on the actual control of the drug phenomenon, rather than including in the federal definition funds expended in dealing with the consequences of drug use and trafficking. Thus, for instance, funds that had been allocated to the prosecution and incarceration of drug offenders were removed from the "control" categories. Expenditures on consequences, according to

ONDCP's discussion of this subject in NDCS 2003, would henceforth still be reported in the agency's report (cited above) on The Economic Costs of Drug Abuse in the United States but would be excluded from the drug control budget definition.

Using the old method, in the 1995-2003 period (fiscal years), $146.5 billion had been expended on drug control; using the new method, $83.7 billion had been expended—suggesting that 42.9% of historical expenditures at the federal level had gone for managing the consequences of drug abuse rather than for trying to control the phenomenon. During the entire period, most of the funding excluded from the new definition was associated with domestic law enforcement activities. Domestic law enforcement has not been eliminated under the new accounting method, but it is no longer the dominant category it has been. Under the new budgetary definition, treatment programs, including associated research, are the leading category of expenditure.

Budget Components

The national drug control budget (using the new accounting method) is shown as Table 7.3 in Chapter 7. Data are from FY 1996 to the budget request for FY 2005. The federal fiscal year extends from October 1 through September 30, so that FY 2005 dollars include funding for the last quarter of calendar year 2004 and the first three quarters of 2005. The budget has grown from $6.3 billion in FY 1996 to well over $12 billion in FY 2005, an annual percentage increase of 5.8%.

The budget is divided into two broad components aimed at reducing the demand for drugs and disrupting their supply. The budgets span five years of the Clinton administration and five years (including one projected based on the 2005 request) of the George W. Bush administration. One administration was Democrat, the other Republican, yet the allocation of funding to the demand and the supply sides have been similar. Both the highest and lowest percentage of funds allocated to the demand side took place in the Clinton administration, the highest in FY 1998 when 50.1% of the budget went to treatment and prevention, the lowest in FY 2000, when only 43.2% of funds went to stem demand. FY 2000, conversely, also saw the highest allocation of funds to disrupting the supply of drugs, 56.7% of the budget. The Bush administration's request for FY2005 divided funding 45% for demand reduction and 55% for disrupting supplies. In every year since FY 1998, funds for law enforcement, interdiction, and international programs have been higher than funds allocated to treatment, prevention, and the research to support these efforts.

CURBING DEMAND.

Funding aimed at stopping drug use has been divided (unequally) between drug abuse treatment and programs of prevention. Treatment has received 24.5% of the total budget during the FY 1996-2005 period, prevention 14.4%. In the requested budget for FY 2005, treatment made up 24.4% and prevention 12.4%, both increases over the previous few years, but still below historic averages over the previous decade.

When the research funding to support these two activities is added, treatment got 29.2% of total budget over the period and 29.4% in the 2005 budget request (28.1% enacted in 2004); prevention, with research, averaged 17.6% over the ten-year period and received 15.6% in the 2005 budget request (16.4% enacted by Congress in FY 2004). (See Table 7.1 in Chapter 7.)

On average, over the ten-year period shown, treatment (with research) received 62.5 and prevention (with research) 37.1% of the demand reduction component of the budget. Treatment funds go into actual treatment of individuals, typically through grant programs to states. Prevention budgets support many educational activities, including television ads.

DISRUPTING SUPPLY.

During the entire ten-year period shown in Table 7.3 in Chapter 7, supply disruption consumed 53.2% of the total federal drug control budget—slightly less the percentage that it was allocated in the FY 2005 budget request. Within this component, domestic law enforcement was the largest piece (46.6% over the ten-year period). Interdiction came next (36.9%) and international programs were last (16.5%).

Most domestic law enforcement funds are spent by the U.S. Department of Justice (DOJ) (or on its behalf) and underwrite the operations of the Drug Enforcement Administration, the chief domestic drug control agency. Interdiction funds are managed by the U.S. Department of Homeland Security (DHS), which now oversees all border control functions and the U.S. Coast Guard. International funds are divided roughly equally between the U.S. State Department and the U.S. Department of Defense. The Department of State's Bureau of International Narcotics and Law Enforcement Affairs is the lead agency managing international programs. The Department of Defense is involved in supporting anti-insurgency programs in the Andean region and elsewhere.

As shown in Table 7.3 in Chapter 7, the most budgetary fluctuation over time has been associated with international programs. Funds ranged from 3.9% of total budget (FY 1996) to 15.9% (FY 2000); in 2001 funding dropped again to 6.3%. Significant portions of this budget are expended on supporting international eradication efforts which, in turn, depend on the cooperation of other countries and on the U.S. drug certification program, which may temporarily deny funding to certain regimes.

Seen as part of the total drug control budget, domestic law enforcement has represented 27.4% of the budget on average in the FY 1996-2005 period, interdiction 17.9%, and international programs 7.9%. In the FY 2005 budget request, the corresponding allocations are 25.3% for law enforcement, 20.6% for interdiction, and 9.1% for international activities.

HIGHLIGHTS OF THE CURRENT STRATEGY

The 2004 National Drug Control Policy, which features the FY 2005 budget request, takes as its main theme performance-based management of the drug problem in America. One element of this is the already-described reorganization of the budget categories so that actual control activities are featured, rather than expenditures forced on the nation by the fact that people use and trade in drugs. The managerial emphasis is further underlined by streamlining and rationalizing authority for programs within the federal departments. The newly created DHS thus takes control of all interdiction activities and funding for the Organized Crime Drug Enforcement Task Forces (OCDETF) Program, which is an interagency effort and is consolidated in the DOJ.

Within the prevention functionality, the strategy includes an investment of $25 million in programs for drug testing of young people. Another highlight is a $145 million national youth antidrug media campaign. It also features funding for one hundred new local community antidrug coalitions working to prevent substance abuse among young people.

A closer look at two of the strategy's initiatives follows.

Drug Testing of Kids

NDCS 2004 calls for and funds expansion of a program introduced the previous year for testing high school students for drugs. Grants are available to schools that implement appropriate programs. Students who test positive will also have access to treatment under the provisions of the program.

The initiative was based on findings cited in the strategy that drug use in some Oregon schools, where athletes were tested, was 25% less than in schools that did not test. Similar but lower declines were also noted in a New Jersey regional high school after a two-year testing program. The national program was launched in part because the legality of testing students was clarified by a Supreme Court decision in 2002.

The legal situation is broadly defined by the Fourth Amendment of the Constitution, which protects "the right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures." In 1989, in Skinner v. Railway Labor Executives' Association, the Supreme Court held that state-compelled collection and testing of urine constituted a "search." It would thus appear that mandatory drug testing of youths was unconstitutional without a showing of probable cause for a "search"—such as unruly and strange behavior.

In 1995, however, the Court ruled in an Oregon case that drug testing of high school athletes was constitutional, even if individuals were not suspected of drug use. The Court held that special needs governed the school environment and that determining "probable cause" for each individual in the school environment was unnecessary (Vernonia School District v. Wayne Acton, 515 U.S. 646, 1995).

Vernonia involved only school athletes and was not seen as unambiguously permitting "suspicion-free" drug testing in the context of other schools activities. In 2002, however, in the case of Board of Education of Independent School District No. 92 of Pottawatomie County et al. v. Earls et al. (536 U.S., 2002), the Supreme Court extended its judgment to all activities. The case involved drug testing for all extracurricular activities before students could take part in them, testing at random during their participation, and also testing when suspicions arose. This Oklahoma case provides broad authority for school districts and thus represents the "go ahead" for the strategy first adopted in NDCS 2003.

Vouchers for Treatment

According to data from the Substance Abuse and Mental Health Services Administrations (SAMHSA), cited in NDCS 2004, there were an estimated 7.7 million individuals in need of drug abuse treatment in 2002—yet more than three quarters of such individuals did not feel that they were in need of treatment. (See Figure 10.1.) These findings underlie the initiative, announced in 2003, to expend $1.6 billion on drug abuse treatment over the next three years. In the FY 2004 budget, the government allocated $600 million as a down payment toward this

goal, the money to be dispensed to individuals in the form of vouchers that can be exchanged for actual treatment services. The FY 2005 budget request increased funding for this voucher program, known as the Access to Recovery (ATR) initiative, by another $100 million. Table 10.5 outlines the key elements of the program.

Vouchers are made available to health professionals in hospital emergency rooms, in clinics, and in private practice; vouchers are also available from justice system officials and others able to determine an individual's need for treatment. The concept is to use such professionals, in contact with those who require treatment but do not perceive the need themselves, to suggest that treatment is in order while also enabling the professional to give the individual the means of obtaining treatment at whatever facility the individual may choose to use. The program is aimed principally at people who do not have provisions in their health policies (if they have such policies) that pay for drug abuse treatment.

Unique features of this approach to drug abuse treatment include provisions that individuals can "cash in" the vouchers at all kinds of drug treatment facilities, including those operated by religious organizations, and that the redemption value of the vouchers, from the treatment provider's point of vantage, will be on a sliding scale that rewards treatment effectiveness. The incentive for the person counseled to seek treatment is that the treatment is paid for; the incentive for the provider is to help the treatment-seeker to succeed so that a higher reward is paid out. The strategy calls this a "consumer-driven path to treatment."

Vouchers will cover the full range of services—from working with youths who need help detaching from the drug culture, to outpatient services, and finally to intensive residential treatment. Which level of service is required will be determined by the health professionals involved.