Sunday, September 14, 2003

Ice storm: Epidemic of the Islands


No easy solution
for ‘ice’ problem

Lawmakers face tough
choices in battling drugs

At a community anti-ice meeting in Waianae this summer, state Sen. Colleen Hanabusa asked the audience to raise their hands if they thought ice was a disease.

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Hands shot up from a little more than half of the several hundred people in attendance.

"How many of you think ice is a crime?" she asked.

About the same number of hands rose. Some raised their hands for each question.

How lawmakers approach the ice problem depends on whether they see it as a disease or as a crime, she said. If it's a disease, they'll take one approach. If it's a crime, they'll attack it from another angle.

"It's a tough question," said Lt. Gov. James Aiona, who is hosting an drug summit starting tomorrow at the Sheraton Waikiki Hotel. "Therein lies the complexity. It is both, really. It's a crime, and the results of it can be a disease."

As Aiona and the Legislature struggle to find solutions to Hawaii's ice problem, the question of where to put scarce resources -- into more treatment, into law enforcement and prisons, or into prevention -- keeps coming up.

"All of this talk is really going to ultimately boil down to where you are going to put your money," said city Prosecutor Peter Carlisle.

Some of the solutions being discussed include drug testing of students, requiring insurance companies to pay more for drug treatment, increasing prison time for ice dealers and repeat felons, and expanding drug treatment programs in prison.

Most of the proposals come with a price tag for taxpayers.

Part of the problem is that the state doesn't know exactly how much taxpayer money is being spent on the battle against ice and other drug addictions.

"We have some idea, but I don't have an accurate number for you," Aiona said earlier this month.

Aiona said the state departments of Health, Human Services, Public Safety and the Judiciary all have separate budgets for drug treatment and prevention.

In the past, the departments haven't really talked to each other or coordinated resources, he said.

They're talking now, he added, but a good analysis of how the state's money is being spent and if it can be spent more efficiently will take months to put together.

"We know we need more (treatment) programs out there," Aiona said. "But what kind of programs exactly do we need, and then, how much of it do we need?"

For Carlisle, the answer to the ice problem is to make it easier to prosecute and put away ice dealers and addicts who commit crimes.

"If it's a crime, they should go to prison. We can treat them there," Carlisle said. "But hold on to your pocketbook, because it is expensive."

Costs of prison

Prison, even without drug treatment, costs more than simply treating an addict, said Kat Brady, the coordinator of the Community Alliance on Prisons. Brady said the Department of Public Safety has estimated it costs $33,000 a year to house an inmate in Hawaii.

"We can't afford that. We're getting people in on long sentences, many of whom should be in treatment," she said. "We can't just throw people away like that."

For the same $33,000, Brady said the state could pay for drug treatment for three people.

Lt. Gov. James Aiona fields questions from members of the audience during a "talk story" session earlier this month at the Mililani High School cafeteria about Hawaii's drug problem. One of the main issues lawmakers face in dealing with "ice" is how to efficiently use the state's scarce resources.

Larry Williams, executive director for addiction treatment services at the Salvation Army, said prison is a good place to start treatment, but it has to be followed up once a prisoner is released and re-exposed to old friends and temptations.

"When a person's in prison, they don't have the chance to practice the skills they're learning," he said.

That follow-up care and case management is not always available, he said.

Carlisle would also like to see the Legislature repeal Act 161, which sends nonviolent, first-time offenders to treatment instead of prison.

The prosecutor said the law has taken away mandatory minimum sentences for drug dealers.

But state Public Defender Jack Tonaki said addicted people shouldn't all be characterized as criminals.

"Look at them as human beings that need help," Tonaki said.

Aiona also said Act 161 should be repealed, but for different reasons.

"It's at the tail end; it's not at the front end," Aiona said. He said unlike Drug Court, which diverts defendants into treatment when they enter the court system, Act 161 mandates treatment after conviction.

Treatment shortage

Treatment providers say prison can be strong motivation for getting people into drug treatment.

"The threat of prison almost has to be there for an ice addict before an ice addict will stop using," said Doug Althauser, the coordinator of the chemical dependency program at Kaiser Permanente. "It's only when you threaten their freedom that a lot of these folks will wake up."

But with a shortage of residential treatment beds, Alvin Adric, who is going through outpatient treatment at a center in Waianae, wonders if patients trying to avoid jail are taking bed space from people who are really ready to change their lives.

"You going to be wasting the treatment on someone who's not ready to start yet," Adric said. "If you do one crime, you gotta pay. You cannot think that you can get away with it."

It can take anywhere from several days to several weeks to get into a residential treatment program.

The state reimbursement for residential treatment for ice and other drug addictions is about $165 a day. But treatment providers say it costs them about $175 a day, and the difference must be made up from other funds, Williams said.

The reimbursement for day treatment is $120 a day. Outpatient therapy is reimbursed at $35 an hour.

There is a limit of 30 days for residential treatment and 24 days of outpatient treatment a year. Patients are also limited to two treatment episodes in a lifetime.

Insurance issues

Treatment providers say addiction is like any other chronic disease and should be treated as such by insurance companies.

"You're not limited on treatment if you are asthmatic," Williams pointed out.

The Hawaii Medical Service Association, the state's largest health insurer, says it opposes parity because it will add to the cost of health insurance, a cost that will be passed onto consumers and taxpayers in the case of QUEST, the program that provides health insurance to people who can't afford it.

"At this point, we have not seen many people maxing out their benefits," said Cliff Cisco, senior vice president for communications at HMSA.

Kaiser evaluates 1,400 people annually for substance abuse, Althauser said. About 800 or 900 are treated, he said. Kaiser is able to cover almost all of them, he said.

"Parity isn't going to change the way we treat patients," he said.

Williams said the success rate for treatment is higher if more intensive treatment can be given, and he believes the amount of treatment services available will also increase.

But because of low reimbursement rates, parity may not necessarily mean that the number of residential treatment beds will increase.

If patients spend more time in residential treatment, there may be fewer slots open to new patients.

Althauser said the question for lawmakers is: If you can treat 50 patients successfully for the same amount of money that you can treat two people successfully, how should you allocate your funds?

"The moral dilemma is, maybe if you gave some intensive work, you may be able to turn the two people around," he said. "However, with the scant resources, especially in our state, I don't know if we have the time or the money to do both."

James Manaku speaks about the dangers of "ice" during a community rally against ice and drug abuse at Waianae District Park.

Still, he asked, "is it fair to not treat all 52 of the patients?"

Claire Woods, executive director of the Salvation Army's Family Treatment Center, said she's afraid that cutting back on treatment will lead people to ask, "Who deserves treatment more?"

"I think we have an obligation that if someone wants treatment, they should get it," she said.

Different approaches

Alice Dickow, the principal investigator on a methamphetamine treatment study here, said her study suggests a longer outpatient treatment with sober-living homes may be more cost-effective than residential treatment.

"Research indicates the longer somebody stays in treatment, the better they do," Dickow said.

Even if they are not completely abstinent, people in treatment will use less and get into less trouble, she said.

Six months after completing treatment, the addicts in her study used ice an average of five days a month, compared with 14 days a month before treatment, Dickow said.

"Abstinence has always been the gold standard of treatment," Dickow said. But her research suggests considering whether ice users are better off -- using less, able to function at work and not getting into trouble -- rather than whether they are drug-free.

Dickow also said it's important not to demonize ice users.

"If you look at the big picture, most of the people with substance abuse problems are not offenders," Williams said.

Woods said there needs to be a variety of treatment options, including expanding follow-up care for those coming out of residential treatment and for those coming out of prison.

She envisions housing where people can sober up, therapeutic communities in public housing projects and more outreach to addicts who are not yet ready to admit they have a problem.

"The majority of the population can respond to treatment," Woods said. "It's certainly not a lost generation."

Star-Bulletin reporter Mary Vorsino contributed to this report.

Starting tomorrow:

Coverage of the state's three-day drug summit.


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