Market Barriers to the Development of Pharmacotherapies for the Treatment of Cocaine Abuse and Addiction: Final Report. Need for Drug Treatment in the U.S.

09/12/1997

Figure 4: Summary of Estimates of Need for Drug Abuse Treatment in U.S

Several studies conducted since 1990 have estimated the need for drug abuse treatment in the U.S. These estimates provide points of reference for the overall magnitude of potential markets for drug abuse medications. 

The primary findings of these studies are summarized: 

  • The overall magnitude of the population in need of drug abuse treatment (for cocaine, heroin, amphetamines, marijuana, etc.) is approximately 3.5 to 4.5 million persons. There is another population of similar magnitude with a lower or marginal potential to benefit from treatment. (See estimates for Level 1 and Level 2 need by Woodward et al., in press).
  • The number of opiate addicts (primarily heroin users) is at least 500,000 persons (Rhodes et al. 1993; Rhodes et al. 1995; Hamill and Cooley 1990). This estimate is similar to estimates of this population dating from the early 1970s (see Appendix D).
  • The magnitude of the population in need of cocaine treatment is at least 2 million persons, based on several similar estimates (see Appendix D, Rhodes et al. 1993; Rhodes et al. 1995; Everingham and Rydell 1994; SAMHSA Office of Applied Studies 1997; U.S. Senate Judiciary Committee 1990).

Prevailing national estimates for the need for treatment of substance abuse, in general, and cocaine abuse, in particular, are based on results of the National Household Survey on Drug Abuse (NHSDA), sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA; Office of Applied Studies, 1996) and are summarized in Figure 4 (above). Due to insufficient coverage of selected populations, e.g., criminal justice populations, NHSDA data likely provide low estimates of treatment need (Gerstein and Harwood, 1990). In order to generate more realistic estimates of need for treatment, most analyses augment the estimates from the NHSDA with data from other sources. Such estimates are used as well to gauge how well the national treatment system is able to deliver care to the population in need, and to estimate the need for additional funding for substance abuse treatment (Figure 5 below).


Figure 5: Overall Need for Drug Abuse Treatment
Source
Estimate
NHSDA POPULATION ESTIMATES (OAS 1996)  
Any illicit drug use in past month (1995)
12,800,000
   
SAMHSA (Woodward et al., in press)  
Total
7,100,000
Level 1 Need (1994)
3,500,000
Level 2 Need (1994)
3,600,000
   
IOM METHODOLOGY (Gerstein & Harwood, 1990)  
(Harwood et al., 1993) Total Estimate of Treatment Need (1991)
4,887,000
Total Estimate of Treatment Need (1987-1988)
5,455,000
   
Household Population: Clear need (1987-1988)
1,500,000
Household Population: Probable need (1987-1988)
3,100,000
Homeless(sheltered, street, and transient)
170,000
Correctional Custody
320,000
Probation and parole
730,000
Pregnancies (live births)
105,000
Less overlaps
(470,000)
   
EPIDEMIOLOGIC CATCHMENT AREA (Regier et al., 1993)1  
Any Drug Disorder (1980 data, applied to 1990 pop.)
5,742,000
   
NATIONAL COMORBIDITY SURVEY (Kessler et al., 1995)  
Prior 12-month drug-dependence plus abuse (1992)
4,663,000
   
1 Based on 1980 data with a 16.5% adjustment to account for the population increase from 1980 to 1990. This is an underestimate of cocaine abuse, as cocaine use increased dramatically in the late 1980s.

In the U.S., a specialized treatment system delivers the vast majority of substance abuse treatment services, including treatment for cocaine and opiate addiction (Harwood et al., 1994; Rice et al., 1990; Harwood et al., 1984). The great bulk of substance abuse treatment services are delivered by institutional providers; only small shares of services are delivered by physicians in private practice (including general practitioners and psychiatrists), private practice mental health specialists, and general hospitals.

Based on findings of the 1993 National Drug, Alcohol Treatment Unit Survey (or NDATUS, Office of Applied Studies, 1995), the treatment system includes 11,500 institutional providers, including specialized freestanding clinics, mental health clinics, and specialized hospitals and hospitals with specialized units. Among these 11,500 institutional providers, the overall one-day census, i.e., people currently enrolled in substance abuse treatment, was 944,000 patients (Figure 6). NDATUS estimates that 38,000 of these persons are in the criminal justice population. Setting aside this likely unreliable estimate, there are approximately 900,000 patients currently enrolled in substance abuse treatment.


Figure 6: National Substance Abuse Specialty Treatment System, 1993
Number of Providers, and Daily Treatment Enrollment
Institutional Setting
Providers
24-hour Care
Outpatient
Total
   
(Clients in 000s)
TOTAL
11,496
121.1
823.1
944.2
Free-Standing Non-residential
5,038
1.7
502.0
503.7
Community Mental Health Center
1,413
4.2
136.4
140.7
General Hospital (incl. VA)
1,267
14.0
81.8
95.8
Residential Facilities
499
47.0
23.1
70.4
Specialized Hospitals
955
8.7
14.0
22.7
Halfway House/Recovery Home
1,530
18.9
5.4
24.3
Correctional Facilities
313
18.4
20.0
38.4
Other Types
481
7.9
40.3
48.2
Source: NDATUS, Office of Applied Studies, SAMHSA, 1995.

The total number of people that receive substance abuse treatment services at least once during a year is not directly available from NDATUS because, although all institutional providers provided data for current enrollees, some did not provide data for the total number of patients served during the year. Among the institutional providers that did report on this, 2.8 million patients were served at least once during 1993. Among this same set of institutional providers the overall one-day census was 720,000. This yields a turnover in daily census of about 3.9. However, that is an overestimate of turnover, because some patients enroll with more than one institutional provider during any given year. Based on findings from The California Drug and Alcohol Treatment Assessment (CALDATA; Gerstein et al., 1994), Denmead et al. (1995) estimated the true turnover rate to be about 3.6. Applying this turnover rate to the daily census of 900,000 from NDATUS yields 3.2 million people that were treated for substance abuse at least once during 1993.