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r r contents Nirssap• from the Chairman ..............................................2 Acidirtiun in Amt•rie•a: The Aehilles Ilee•1 of Ile•alth Care Reform ...........................6 13uilclinrc an ()rganizaticen ................................................l4 (::1S A 5taff ..................................................................18 CAtia Board uf 1)ire•c•tur. ................................................:.~tl Advisory Buard/Fundinr 5uurrt•r .................Insiele• 13ack Cover TIMN 324782

i. A 5 T Y E A R i G A V c up the practice of law in Washington, D.C., and New York to de- vote all my time to being founding chairman and president of CASA-the Center on Addiction and Substance Abuse at Columbia University. CASA is a unique think/action tank that brings together under one roof all the professional disciplines (health policy, medicine and nursing. communications. economics, sociology and anthropology, law and law enforcement, business, religion and education) needed to study and combat all forms of substance abuse-illegal drugs. pills. alcohol ancl tobacco-as they affect all aspects of society. 40 Last year Dr. Herbert Klc•- ber. the top official for demand reduction in the Bush Administration's White House Office of Na- tional Drug Control Polic•v. decided not to return to Yale Unive-rsitv's Medical School and the 1.00(1-person drug treatment demonstration program he had started there. but rather to join (:ASA. William Grinkrr. founder of The Manpower Demonstration Research Corporation anci past commissioner of New York City's 1)epartme•nt of Human Re- sources. ancl ,Jc•ffrey Merrill. former dirc•ctor of Georgetown Univer- sitv's Center for Health Policy Studies and vice president of The Robert Wood ,Johnson Foundation. also came to hrlp start CASA. 1M31y? During the past year. a broad cross section of' distinruisht•d :'lrnerican leaders. all too busy to take on one more task. found time in their crowded schedules to constitute CASA's board of directors: Jim Burke. Betty Ford. Doug Fraser, Barbara .Jordan. Don Keough. LaSalle Leffall. Manuel Pacheco. Linda ,Johnson Rice, ,John Rosen- wald, Michael Sovern and Frank Wells. 1MW" !n 1992. The Robert Wuod ,Johnson Foundation ~ave CASA the lar~;rst rrant for core sup- port it had given any single institution. The Carnegie Corporation. Commonwealth Fund. and the Dana. Ford and Rockefeller founda- substan%-Ze abuse and addiction is America's public enemy numbe- onf-. not simQr the nation's to, health and crime problem, but like a massive oil soi:•; off a beautifui , coast. a spreadint menace that fouis jusi abow. every aspect oi~ American IifE. TIMN 324784 :{

tions also made substantial contributions to help get CASA started. The Annie E. Casey. Ford and Rocke- feller foundations. The Henry J. Kaiser Family Foun- dation. The Pew Charitable Trusts, and the U. S. De- partments of Justice and Health and Human Services funded specific CASA programs. Why? A number of corporations-among them Chrysler. Coca-Cola, Disney. iYY1YEX. Primerica and Warnaco-- committed $5U,(H)A a year for five years. Many other.- among them. Automatic Data Processing. Chase Man- hattan Bank. Chemical Bank. Kmart Corporation. Mobil. Safewav. Sonv and John and Pat Rosenwald- made substantial multi-year commitments to help start CASA. Champion International provided a top execu- tive on loan for three years. Others. listed on the inside back cover. contributed f;enerouslv. Why? Because all these institutions and individual, share this conviction: substance abuse and addiction is Amrr- ica's Public Enemy Number One. not simply the nation's top health and crime problem. but like a massive oil spill off a beautiful coast, a spreading menace that fi0tils just about every aspect of American life. They believe that this nation needs an institution d(•- voted to cond)ating all forms of substance abuse and ad- diction throughout our society. So they joined forces and contributed their tale•nts. energies and resources to fiound CASA. The concept of CASA and its mission spring frum the chilling reality that unless this nation addresses sub- stance abuse and addiction. it will not be able to curb crime and vandalism. reform the health care and judi- cial systems, cut back the welfare rolls, reduce home- lessness. maintain subsidized housing in inner cities. renew our international competitiveness by increasing worker productivity and improving product yuality . and revitalize family life and urban neighborhoods. The financial costs of substance abuse approach a stag gering $400 billion annually. The human miserv is incalculable. During this past year. CASA has developed its affili- atfon with Columbia University. Why Columbia? Dr. Kleber and I had discussions with a number of univer- sities and selected Columbia for several reasons. Its president. Michael Sovern. and its vice president for r Health Sciences. Dr. Herbert Pardes, were enthusias- tic about an affiliation with CASA. Dr. Pardes. a psy- chiatrist interested in the relationship between mental health and substance abuse and for five years director of the National Institute of Mental Health in Washinr ton, shared our conviction that it was time to deal with all substance abuse and addiction under one roof. Columbia offered extraordinary intellectual re - sources-a unique array of graduate schools in :Vledi- cine. Nursing. Public Health, Business. Journalism. Architecture. Law and Social Work. Moreover. Co- lumbia University Teachers Collere. Barnard College•. Union Theological Seminary. Jewish Theological Sem- inary and the John Jay College of Criminal Justicr are nearby. The heads of each of these institutions agreed to sit on an advisory board to help CASA set its priori- ties. crossing traditional disciplinary boundaries in an effort to prevent and combat substance abuse. CASA is independent of Columbia. but affiliated with it. This flexible arranae•m<•nt permits (:ASA to take~ a far more pro-active role than would bt• traditional for a universitv. to assemble intellectual resources not only from all branches of the university. but from the entire 'nation, always free to pick the best individual or team for the task. and to raise its own resources. At the beginning of 1992. CASA was staffed bv four teeuph`Susan Iirown, who left her position a+ aeltninis- trator of a major law office to become CASA*s Sre•re•- tarv/Tre•asttre•r. and mvse•lf, on a pru-buno bask. tn~ ~L iranci a~ c®sfs of substance abuseapproach S400 billion. The human misery is incalculable. The concept of CASA and its mission spring from the reality that the nation must address the impact of all substance abuse on .lu Ann MrC:aul<•.. and Sue Kaplan. a health lawcrr and policy analyst who joined as my special assistant. Wr oper- ated out of Dewey Ballantine and were funded throuTh planning grants. with no core or pro~ je•e•t fundinr. As we Iwgin 1993. C:1tiA's first full year. we are a di- verse staff uf 36- ali aspects of society. t•e•onomists. health TIMN 324785

services and policy researchers, a psychiatrist, a psy- chologist, an anthropologist, individuals experienced in government at every level, lawyers, policy analysts, an expert in employee assistance programs and one in law enforcement, an accountant, a computer special- ist, a librarian, a communications professional and a Commonwealth Fund/Harkness Fellow. We have opened our offices on the west side of mid- town Manhattan, within easy reach of Columbia Uni- versity. We have an annual budget of $5 million, in- cluding pass-through grants we are administering. CASA's mission is ambitious. We seek to shine a spot- light where there has been too much darkness, to draw our nation's best and brightest to this field and to attract far more resources for all individuals and institutions who work to prevent, combat, research and treat substance abuse and addiction. There is much work to do and more resources are needed to do it. We appreciate the support we've had from institutions and the unsolicited personal contributions, but we have a long way to go. I could fill this report with the individuals who were key to launching CASA. But I must single out Jim Burke, who for years had urged me to try to build an institution like CASA; Steve Schroeder and The Robert Wood Johnson Foundation Board, who not only are furnishing-the key venture capital but whose questions and suggestions are invaluable in shaping CASA; David Hamburg. who has given me so much wise advice over the years; Margaret Mahoney. whose enthusiastic sup- port has been key: the encouragement and ideas -of Frank Thomas and Susan Berresford; the instant re- sponse of Peter Goldmark when I asked for planning funds; the sound counsel of David Mahoney, Hale Champion, John Gardner and Drew Altman; the pa- tience of my former partners at Dewey Ballantine; Sandy Weill's immediate support; John and Pat Rosenwald's insistence on being CASA's first personal contributors; the pro-bono assistance of Jack Hilton and KPMG Peat Marwick; and Ivan Chermayeff, who designed our logo, styled to suggest a house because we put all the skills to deal with all substance abuse throughout society under one roof. CASA is still an infant. We must learn to walk before we can run. We're off to a good start. but we need lots of helping hands, intellectual stimulation, practical ideas and financial nourishment if we are to succeed. CASA's board of directors has set these four goals for the institution: o To deterntine which preverBon and treatment programs woeic, for whom, under what circumstances, and to find ways to make such programs available to targer numbers of substance abusers and potential usenm o To move the issue of substance abuse into the main- stream of America's medical, educational, social, eco- nomic and political discourse, and accord work in the field a sense of urgency and the same respect as we accord work in other professions; to help attract more talented people to the fieid of substance abuse and addiction; and to help assure tfut sufficient public and private resources are available to understand, prevent and combat substance abuse and addiction. . To :dorm the Anmwiean people oF the social and economic costs of substance abuse and addiction and the fuil range of impact it is having on their ives, and to identify and inforrn them of the opporhnities to reduce those costs. o To encourage professioeais in business, education, the clergy, labor and health care to accept responsibility to prevent and combat substance abuse and, where neces- sary, help develop the tools to enable them to fuif•iq their resPon:ibility• In pursuit of these goals, the board approved specific strategies and projects, recognizing these may change as opportunities arise, knowledge increases and funding sources shift priorities. These projects are described on pages 1S through 17 of this report. TIMN 324786 5

T H E A M E R I C A N P E 0 P L E have high hopes that we will at last be able to provide quality health care to everyone at reasonable cost. But instead of a sparkling new system, health care in America will be marked by more rigid controls, more intrusive bureaucracies, higher taxes anti arbitrary rationinb unless the Administration and Congress recognize that substance abuse and addiction is Public Health Enemy Number One. The grim reality. shrouded for so long in our individual and national self-denial, is that successful health care reform requires an all-fronts attack on all substance abuse-legal and illegal drugs, alcohol and nicotine. An army of reformers is marching on Washington, pressing Uncle Sam to provide quality health care to all Americans. inc•luding the 37, million people without insurance. at a cost that won't keelt shoving up the deficit and pushinr down take-home pay and corpo- rate profits. These experts aim their fire at doctors, hospitals, pharmaceutical companies. nursint; homes and medical equipment manufac•turers. as they cit•visr complex hureau- craticc weapons svstems to monitor every patient. lirovider, procedure and prescription. But thevr campaign. by whatever chosen namr- managed carr. managed ceempe•tition. mandated c•arc. a single-paver sv:cte•m-risks getting bua,rcd down in the trc•nches bv special interests and red tape. as the true e•nemy-substanc•c abuse and addictiun-c•untinuf•s to spread its destruction and drive up health care custs. In the battle against runaway cu.ts. health policy cx- perts aim to: ~ Close down excess hospital beds, to save 3G billion to A8 billion a vear. ~ Reform medical malpractice. which costs some 820 billion to $30 billion in legal fees and defensive tests and procedures that doctors and hospitals order up to shield themselves from litigation. ~ Establish quality standards to stop unnecessary pro- cedures, such as inappropriate coronary bypasses (to save $44 billion). excess angiograms (to save $ 1.•t billion). and unnecessary caesarean sections (to save S1 hillion ). 0 Eliminate unnecessary administrativc costs. That mi-ht save anvwhere from Ko billion to nothina. de- pending on the cost of the bureaucracy required to manam- the new svstem. P Encourage more efficiency by some combination of competition and re•r~ulation (savings speculative). 0 1'av doctors, hospitals. pharmaceutical companies and nursing homes less. These moves to contain costs arc an important and welcome part of a more efficient delivery system. Some, like reducing rewards to providers. carry risk to maintaining the world's most advanced pharma- ceutical industrv and attracting the best minds into medicine and medical research. And these targets are modest compared to the S140 billion in costs that sub- stance abuse and addiction offers America.%s health care reformers. By the end of 1993. health care spending in America will be rollicking along at a one-trillion-dollar-a-vear pact•. By then. substance abuse and addiction will ac- count for one of every seven dollars spent on our tril- lion-dollar health industry colossus. If our nation is to provide quality care to all at a rea- sonable eost, substance abuse and addiction should be TIMN 324788

a major target of our efforts-and each of us should en- list to join in the attack. We are a nation of 260 million people, as diverse as our politics, professions. races. ages. religions, incomes, neighborhoods and tastes. Yet, tragically, every one of us-in inner cities and rural towns, on assembly lines and in executive suites, in Ivy League colleges and blackboard-jungle city schools-has been touched by substance abuse and addiction: ~ More than 50 million of us are hooked on cigarettes and at least another 10 million are hooked on smoke- less tobacco. ~ 18-and-a-half-miliion are addicted to alcohol or abuse it. ~ Some 12 million abuse legal orugs. sucn as tranauilizers. amphetamines and weeaing nilis. - Two million use cocaine weekiy. including at ieast hals z million addicted to crack. . Up to one million are hooked on heroir.. . Half a million regularly use hailucinogens such as LSD and PCP. 1~ Some 1 million, half of whom are teenaQers. use blaci.- market steroids. Abuse and addiction taxes every segment of our health care system. Half the nation's hospital beds hold victims of violence, auto and home accidents. cancer. heart dis- ease. AIDS, TB, and liver, kidney and respiratory ill- nesses. all caused or exacerbated bv the abuse of to- baccu, alcohol and drugs. Substance abuse complicates the treatment of most illnesses. prolongs hospital stays- increases morbidity and sharply raises costs. Most of us know that cigarettes are responsible for the premature death of 435.000 people in the United States a year. But we do not focus as often on the costs smoking imposes on our society. Smoking increases the risk of stroke, other cardiovascular ailments and can- cer. Cigarettes cause 18 percent of all coronary heart disease and 30 percent of all cancer that ends in death. These are the top two crippling diseases in the United States. Some 87 percent of all lung cancer can be traced to cigarettes. Since 1986. lung cancer has surpassed breast cancer as the leading terminal cancer among women. The Environmental Protection Agency recently designated second-hand smoke as a known human car- cinogen, along with only 10 other compounds. The -- price we pay in added health care costs for smokers to say nothing of time lost from work, premature death, and the costs of passive smoking-amounts to about $50 billion a year. ACCIDENTS Substance abuse is a leading cause of accidents and trauma. Although drunk driving declined over the past decade, about 350.000 people are killed or injured every year in alcohol-related traffic accidents. The toll from other drug use could push that number to 500,000. Forty percent of all Americans will be involved in alcohol-related car accidents that require medical care. The health care costs of alcohol- and drug-re- lated crashes exceed 850 billion. In 1910, ; 5 percent of trauma victims tested positive for drug use. Alcohol and/or drur abuse has been im- plicated in up to 80 percent of wife-abuse cases and three-quarters of all rapes and child molestations. Al- cohol and/or drugs are implicated in T 5 percent of all suicides and homicides. There is no way to measure the human tragedy: the cost of related illness and therapy for spouses. children and parents left behind runs into hundreds of millions of dollars. ILLNESS Alcohol is the leading cause of chronic liver disease- in- cluding cirrhosis. Alcohol abuse can lead to many seri- ous ~;astrointestinal problems including e.opha,real cancer and pancreatitis. nutritional and metabolic dis- orders, cardiovascular and neurological problems. Heavy drinking combined with smoking dramatically increases the risk of many cancers. Each alone more than doubles the risk of oral cancer. Combined. they jack up the risk more than 15 times. Drug abuse can lead to AIDS. endocarditis. cellulitis and hepatitis. Other diseases. including tuberculosis, can result from a weakening of the immune svstem and the debilitating life-style of many addicts. Dru€ abuFe can cause and exacerbate mental illness, vascular problems and malnutrition. :America's elaborate and expensive emergency rooms are largely tribute paid to alcohol and drug abuse. In 1990, there were more than 370.000 drug-related emer- gency-room episodes. In the first three months of 199'3 TIMN 324789 8 f a r r i= h t: d r u g- a x p o s. d i n f a n t s ~

merre• than at).1NNt IN•e/ple•-a t•evarel ntunlN t-e nte rv ei a hu,llital e•me•rge•m•v ruunt with adve•rw• re•ae•tiuns tu e•e)- e•ainr. During the•,ame• Ire•ritNl. the•t•t• was a I.~-I~e•rre•nt in- c•re ast• in e•me•rge•ne•v-reM)m visits attributed tu heroin use. CNlLDRE~ AN!-- SA5ia= '1'ul/aeru. ale•ohul anel eirurs u,e•d during pt•e•rnant•y Ilu.e• asavare• threat tu the health I/f newborn llal/te•... 5nll/k- int hN wwne•n elw•inr pre•gnanr, re•tat•ds fe•tal rt•/lwth. eluublimg the risk e/f eh•live•rin-, a luw-birth-we•i,att Irah.. It ine•re•ase•s the• risk of fetal and infant ele•ath hN _'.i tu :)0 Ire re e nt. Expusurr elf ne•whe/rn~ te/ e•irare•tte• .me/ke• in ute•ro ur .re•unel-hane! .melke• af'te•r bit•tlt ine•t•e•ase•. tho risk e/f.udele•n infant eie•ath svnelrume•. Fe•tal ale•ohul ~.nelro!pe• is the• tltirvl tnelst fre•efue•nt e•uuw• e)f bit•th eh•fi•rtti a.sue•iaU•e1 with mental re•tarela- tiun. 'I'hr e•osts a.,uriate•el with fe•tal alCohul .-,ndrome• are• estimated at ~I.6 billion a year. tionte• 37,53.000 babie•s born e•ae•h year in the• l nited titate•s are exposed to illie•it drugs in the womb. These nrw•burnti fat•e• hirhe•r risk uf stre/ke• at hit•th. I/hy.ie•al ele•furmitv and mental dc•fie•irne•N. The extra e•u.t uf' hu.- Ilital rat•e• in IeNN1 due tu <•zllewtu•r t)f' hahi<•s to e•ele•aine• tlnt•Itl}; })rf•gnane•% was s5u.t nlilliun. Re•Ilorts uf e•hyhl abu.e• or nrglre•t have ine•t•e•a.e•el •.3_>tl Ilevre•nt over th<• I/a:+t ele•e•ade•. Mure• than half n['all cunfirmevl ahn•e• re•- I/e/rt, anei 75 In•re•e•nt of re•I/urt. uf e•hild ele•aths inve/l%v e1rn" abu,e• by the• Ilat•e•nt.'. I'he prie•t• t•hildr+•n I)aN for e•xpusnrr to the•ir Ilar- e•nt.' .e•e•und-hanel t•irare•tte• smoke nta% be le•vn elra- [0 TIMN 324791

matic but it is far more widespread. These children are more likely to have respiratory and ear infections, the most common pediatric diagnoses. The Environ- mental Protection Agency has concluded that expo- sure to parents' smoke causes up to 300.000 cases an- nually of lower respiratory tract infections such as bronchitis and pneumonia in infants and young chil- dren. Second-hand smoke causes asthmatic problems in children. increasing both the number of new cases and the number and severity of episodes in children who already have asthma. It's not surprising that for- mer Surgeon (;eneral Everett Koop calls exposing chil- dren to second-hand smoke "child abuse." AMERICQ'S CERBERUS tiubstancc abuse has joined with AII)S and tuberculosis to hecome• an American version of Cerberus-a .i- cious. three-headed do-~uardlnr the rates of the hells we have created in inner cities and runninr loose into e•ve•rv part of our nation. Substance abuse is the fastest growing cause of new cases of IIIV infection. Intravenous drug usc is impli- cated in a third of all :UDti cases found in teenagers and adults. Less widely re•col,mized. but no less ominous, is the potential spread of li1Y infection through promi.- cuous ami unlrrotected sex by kids who are drunk or high. Thrv are far more likely to have sexual rela- tion•-and to have them without condoms. ln a random survev of 16- to 19-vear-olds. 49 percent claimeel thev were more likely to have sexual intercourse if thev and their partners had been drinkinr: a thir(i were more likely to have intercourse if they had used drttgs. In both situations they were less likely to use• cun- doms. thus increasing the risk of unwanted pregnancy and of transmitting AIDS and other sexual diseases. More than T0 percent of all female AIDS cases are linked directly or indirectly to intravenous drug use. The annual cost of treating a person infected with HIV is 510.(N>U: for a person with full-blown <tIDS, the cost jumps to nearly 540.0(H). Alcoholics and intravenous drug users are the• most likely to develop drug-resistant strains of tuberculosis. More than half the homeless-some say 80-90 pcr- cent-suffer from alcohol or other drug abuse. I Ionic- less shelte•rs. with their overcrowded conditions. poor ventilation and high population of drug addicts are often breeding grounds for tuberculosis and AIDS. It takes $250.000 to treat an individual with drug-resis- tant tuberculosis. And that does not include infra- structure costs, such as isolation rooms and negative- pressure facilities. AN EPIDEMIC Substance abuse and addiction has been epidemic in America for almost 25 years. In 1965, when President Lyndon Johnson proposed the first federal drug reha- bilitation act. he asked for $15 million to start this pro- gram to treat addicts in prison. W'e never thought the cost of such drug rehabilitation in America would exceed 650 million. Today, up to E3t) percent of inmates in state• antl local prisons are there for drug- or alcohol-related crimes. In 1993. the federal government will spend S2 bil- lion on drug rehabilitation anti related therapv. Though only 5 perce•nt of the world's population. Americans consume (>t) percent of the world's cocaine. At least 20 million of our citizens cannot make it through the day without a tranquilizer. Millions more cannot sleep without a pill. More of the nation's colle•re students-the most talented of our young men and women-are drinking to get drunk. setting the stare for alcohol addiction in later life. Teenage girls anei voung women get hooked on cigarettes, cutting their lives short and exposing themselves to frightful de•ath ~~ by the e~3~ health 1rAM spending in America will reach S'_ trillion a year. By then, substance abuse and addiction will account for one oi every seven doliars spent on the country's health-care-industr4 colossus. TIMN 324792 by emphysema and lung cancer. Even when thev know the dan,ers. they continue smoking for fear of gaining weight if they quit. The breadth and depth of this substance abuse epidemic says something deeply trou- bling about our society. the way we live and work. our values, the despair of povertv in the richest nation on earth. and the aimless boredom of many af- fluent Americans. Our failure to recornizc tI

substanc•e• abuse and addiction for what it is-the most devastating health epidemic that thrrate•ns our lre•u- ple-is a telling testament to otu• capacitN. for individ- ual and national self-denial. 1'he• issue was hare•l.• dise•usse•d in our recent lirrsi- drntial campaign. «hv'.' lie•cause. despite lerurre•.s in the• past few years. the Republican incumbent e•uulcl nut support his claims that he had won the• war on elrums with the• rava-e•s of addie•tion tiu visible on evc•m e•itv street anti all across America. and the e•halle•nge•r. though the• sun of an alcuhulir pare•nt anti broth<•r of a clrur addivt. eliel not have• anv In'ugt'am to ele•aI with the prerble•m e•onvine•inrtl.. Ne•rle•e•t of the scourge threatens to doom any at- U•mlrt Ur re•furm the he•alth e•are•.vste•m. I le alth e•are- t•e•- fortn is at be•st a dire•v anti unpredic•tablr enterprise. but it surely rannut be• achieved in the absence of a unite•d anti wste•mwide• effort mounted against sub- stance abuse on all front.-rrsrare•h, prevention anti treatment-that calls upun each of us to assume a role. To have a volid e•hane•e• tu succeed. any re•furm e•f'fort must addrerss the• larp•st and most pe•rva.ive• cause of illness and injury in :1nu•rira. Firs:, the reform effort must increast oe• support for research into substance aLus•. and addiction to a: Ieast 5: billion c, ve.=. "['he• tiatiernal Institute•s of Ile•alth slee•nd ~:_' billion a year tn ,uppurt rane•e•r research. and SI billiun u ve•ar each tu aupleen•t re•se'arCh Utl Pal'ellclva.e•ular disease anti TIMN 324793