Treatment: Effective (But Unpopular) Weapon Against Drugs

Paying for treatment of hard-core drug users is a bone in the throat of middle class taxpayers--and small wonder. Drug abusers are not an appealing group, and the programs themselves largely fail to wean their clients off drugs for good. Nonetheless, say RAND researchers, treatment programs are a sound investment of public funds because they effectively cut consumption--and consumption is what drives the drug trade.

One doesn't hear much these days about the war on drugs or the cocaine epidemic of the 1980s that provoked it. A major reason the bellicose rhetoric has subsided and drug-related crime stories have migrated to the inside pages of the nation's newspapers is that the number of people using cocaine has dropped sharply--from more than 12 million in the early to mid-1980s to 5 million in 1992. Are we to conclude that the threat, if not over, is at least contained and that society has emerged the winner?

Unfortunately, the answer is no. Despite the large decline in the number of users and the expenditure of tens of billions of dollars on law enforcement, the total amount of cocaine consumed in the United States has been stuck at its mid-1980s peak for almost a decade.

A pathbreaking study by RAND researchers C. Peter Rydell and Susan S. Everingham explains this seeming paradox: The number of heavy users is growing, making up in consumption for the overall decline in the number of users. Further, the analysis shows, the current policy emphasis on stemming the supply of cocaine is far less effective in reducing consumption--and more expensive--than treatment programs aimed at controlling demand.

Seven Times More Effective

Treatment is seven times more cost-effective in reducing cocaine consumption than the best supply-control program and could cut consumption by a third if it were extended to all heavy users, according to the study. Such a strategy could also substantially reduce the number of users and the costs they inflict on society through crime and lost productivity.

The study shows past trends and predicts future trends in cocaine consumption. It demonstrates how the shares of consumption attributable to light and heavy users have been changing and what these patterns seem to imply for cocaine-control policy. Finally, and most strikingly, it provides the first systematic method of comparing the cost-effectiveness of cocaine-control programs.

The researchers estimate there are now about two million heavy cocaine users--and they consume substantially more cocaine per capita than do light users. Heavy (once a week or more) users account for over two-thirds of today's cocaine demand, up from less than one-half in 1980. Clearly, consumption will remain high unless these heavy users reduce their consumption or quit altogether.

Evaluating control programs requires comparing their effects as well as their costs. But supply-control programs and demand-control programs produce different kinds of results. The researchers compare them by identifying a common measure--the annual program cost required to reduce U.S. consumption of cocaine by a given amount: The lower that cost, the more cost-effective the program.

Treatment for heavy users is more cost-effective in reducing cocaine consumption than domestic enforcement, the most efficient of the three supply-control programs studied. For example, cocaine consumption can be reduced over 15 years by an average of 1 percent per year by spending an additional $34 million per year for treatment. To achieve the same effect, we would have to spend annually an additional $250 million for law enforcement efforts against drug dealers and their agents, or $370 million for interdicting the drug at our borders, or $780 million to help foreign governments cut supplies at the source.

Supply control becomes more cost-effective as drugs move away from the source through the pipeline toward the consumer. Thus, interdiction at the border is less than one-half as costly as source-country control, domestic enforcement only two-thirds as costly as interdiction at the border. But treatment is the winner by a wide margin because it is less costly relative to its effects.

"These results suggest that if one were going to spend an additional dollar on drug control, it should be spent on treatment, not on a supply-control program," the authors declare. Or if the choice is to make cocaine-control policies more cost-effective within current spending levels, "cut back on supply control and expand treatment of heavy users." They emphasize, however, that treatment is not in itself a solution and that deep cuts in enforcement funding would be counterproductive.

An Unpopular Approach

Despite the advantages of demand-control programs, Congress has been loath to fund them. They are unpopular with middle-class taxpayers, too, who see drug treatment as wasting money on a group of people who can't be trusted and who have no desire to be helped.

"There is understandable skepticism about spending taxpayer dollars on these programs when only a small fraction of drug users who get treatment manage to quit for good," acknowledges Jonathan Caulkins, codirector of RAND's drug policy research center, within which the study was conducted. "But that is looking at the problem from the wrong end of the telescope. The programs work and should be funded--not because they are the cure for drug addiction, but because they effectively cut consumption and consumption is what drives the drug trade."

The United States at all levels, public and private, currently spends an estimated $13 billion on these four types of cocaine-control programs, only $1 billion of which goes for treatment. The study explores several alternative spending mixes that promise to improve on current policy.

One option--boosting the cocaine treatment budget to $4 billion by reallocating 25 percent of supply-control spending--would provide enough dollars to treat all heavy users once each year (versus the 30 percent treated today). The effects, according to the analysis, would include a one-third reduction in annual cocaine consumption, a significant drop in the number of users and, as a result, a decrease in the cocaine-related costs of crime and lost productivity, which have been estimated by others as $10 billion annually.

Expanding treatment so much, even with adequate funding, would be difficult because some heavy users may refuse treatment or prove difficult to find. Enforcement is important in this regard because it is one means of inducing users to accept treatment. Expanding treatment beyond $4 billion annually, however, is probably infeasible because of diminishing returns.

Demand Control Cuts Use Directly

Supply-control programs discourage drug consumption indirectly by raising the street price. Drug seizures, asset seizures, arrests and imprisonment increase the costs of producing and distributing the drug, and these costs are passed along to retail buyers.

Treatment cuts consumption directly, rather than through the price mechanism, and in two stages--during and after treatment. The study uses conservative estimates, derived from the literature, of the effects of treatment: Previous studies have shown that 80 percent of people in treatment stay off drugs while there, a consumption-reducing effect that is often overlooked; in addition, an estimated 13 percent of heavy users stop or reduce heavy use, some permanently and others at least for awhile, as a result of treatment.

"Cocaine treatment also has an advantage over supply-control programs in terms of consumption of other drugs," Rydell comments. "Raising the price of cocaine may increase consumption of other drugs by inducing cocaine users to switch. Treatment might reduce such consumption since many cocaine users use other drugs as well."

The study's conclusions are based on many assumptions, the authors point out, in particular the responsiveness of consumption to price increases and of heavy users to treatment. Even over a very wide range of reasonable assumptions, however, the cost advantages of treatment over supply control and of one supply-control program over another are so great that their ranking is not in doubt.

The study was funded by the Office of National Drug Control Policy, the U.S. Army, The Ford Foundation and RAND.

Controlling Cocaine: Supply Versus Demand Programs, C. Peter Rydell, Susan S. Everingham, RAND/MR-331-ONDCP/A/DPRC, 1994, 120 pp., $15.00.

Modeling the Demand for Cocaine, Susan S. Everingham, C. Peter Rydell, RAND/MR-332-ONDCP/A/DPRC, 1994, 60 pp., $15.00.

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