Dealing
With Drug Use??
(See: Drugs
in American Society, 5th, 6th, 7th, and 8th editions, Erich Goode, McGraw-Hill,
1999/2005/2008/2012. Chapter 15)
Education
and Intervention
(or
should that be "No thanks, I can make up my own mind?")
WWW Links:
Is
this your child's future?
Prevention:
Primary
- For the very
young
- Those who have
not tried or experimented
- School based
(captive population)
- Emphasis- Abstinence
- Broad goals:
Social conceptions of drugs, Impact of drugs, Self-esteem, Alternatives.
- Effect- often
stimulates curiosity
- Central problem:
Measuring Effectiveness
Secondary
- For those with
some experience or exposure
- High school
and college populations
- Not a treatment,
but extended and focused education
- Prevent further
use and/or involvement, promote rational use.
- Sophisticated
- Emphasizes responsibility
Tertiary
- Treatment programs
- Relapse prevention
- Residential
care
- Includes penal
approaches
Primary
Prevention
Widespread today,
practically universal
Early approaches:
Cognitive
- Information
on drugs and their effects
- Emphasized negative
attitudes
- Scare tactics
- Knowledge=>
Attitudes=> Behavior
- By early 1970's-
re-evaluate. Increased knowledge==> Positive attitudes! Various programs
worked fairly well at expanding knowledge of drugs and their effects, but
impact on "attitudes" was problematic: Use increased.
- 1973: SAODAP
ordered a stop to programs of the "cognitive sort. New emphasis: Decision
making skills, rational choice. By 1976 use was still up, but increasing at
a decreasing rate.
Late 1970's: Affective
Education/Values Clarification. Focus:
- Emotions and
attitudes
- "Getting
in Touch" with oneself
- Values clarification
- Independence
- Elevating self-concept.
Dealing with being included and/or excluded.
- Decision making
skills
- Alternatives
to drugs
- Basic philosophy:
"If you feel good, why do drugs to feel good?"
- No real direct
focus on drugs per se, but on moral choices/problem solving. Example at the
high school level: Alien Invasion- All drugs destroyed, which should we bring
back?
- Coping skills:
explore and express feelings.
- Personal and
social skills: increase competence; communication, success, etc. Role models
and peer counseling/tutoring programs
1980's and on-
Social Inoculation
- Focus shifts
away from student and towards the "negative aspects" of the environment
- "Just say
NO!"
- A 1984 review
of existing programs (of various sorts) indicated that few, adequate evaluation
studies existed and for the most part the indication was that there was little
success
- Concern: Environment
and Temptation. Drug use as endemic.
- Children must
understand the pressures, learn to avoid situations, learn how to say NO,
make a public commitment, and have experience/relationships with those who
do not use.
- Zero Tolerance:
1987 William Bennett, "What Works; Schools Without Drugs"-- Ignores
education, stresses: Searches, Suspension, Expulsion. By example: Official
policy must indicate complete opposition, Smoking banned (Kirkwood High and
video), Laws upheld, shift away from the "values stuff". Funding
only for schools that demonstrate programs that teach drug use is wrong and
harmful.
Types:
- Student assistance,
group focus, peer counseling
- Smoking prevention:
Refusal, normative education, role models, public commitment
- "
Safety First: A Reality-Based Approach to Teens, Drugs, and Drug Education,"
(.pdf file) Martha Rosenbaum (TLC)
- Safety
First: Parent, Teens, and Drugs, Martha Rosenbaum (Drug Policy Alliance).
- Safety
First Web Site
- STAR, SMART,
ALERT: curriculum based (7th grade)
- DARE:
(LA Police), First introduced in 1983. Designed for 5th-6th grade. Uniformed police, interactive- variety of components,
stressing refusal and public commitment. DARE gained rapid popularity. By
1988: 500 programs, 1.5 million students. Today, practically universal. Drug
Free School bill of 1991: 10% of funding to support DARE. Problems: No demonstration
of effect. Recent criticism: Looks good, and sounds good, but having little
impact on substance use.
DARE Focus
Good points:
- Popular--builds
community (parents, schools, and police).
- Does not tie
up school resources (taught by police officers).
- Promotes good
relationships with police.
Problems:
- Questionable
effect
- Target audience
(preaching to the choir)?
- Focus on Abstinence
(legal drugs receive little focus)
- Any use is
defined as abuse
- Gateway theory
- Knowing risks
automatically produces deterrence
- Fallacy of
misplaced concreteness: drugs versus social context
- Defines children
as not being responsible decision makers (Just say NO).
Studies
- An
Analysis of DARE
- Dare
Re-Evaluated
- The
Economic Costs of D.A.R.E.. Edward M. Shepard III, November 2001
- Assessing
the Effects if School-Based Drug Education, by Dennis P. Rosenbaum,
Ph.D. Professor and Head and Gordon S. Hanson, Ph.D. Research Associate
Department of Criminal Justice and Center for Research in Law and Justice
University of Illinois at Chicago, April 6, 1998
- Project
D.A.R.E.: No Effects at 10 Year Follow-up,(.pdf) Donald R. Lynam, et
al, 1999. (local
copy)(short)
- Commonsense
for Drug Policy: DARE
Admits Failure
- GAO report
on: Youth Illicit Drug
Use Prevention: DARE Long-Term Evaluations and Federal Efforts to Identify
Effective Programs
- Articles
About the D.A.R.E Program from DrugSense
- How
Effective is DARE (PBS)
- "Lesson
from the Battle Over D.A.R.E.: The Complicated Relationship between Research
and Practice," Greg Berman and Aubrey Fox, Center
for Court Innovation, Bureau of Justice Assistance, U.S. Department
of Justice, 2009
- Exposure to Substance Use Prevention Messages and Programs among Youths Aged 12 to 17: 2002-2009--NSDUH
The New millennium:
Harm Reduction?
- Safety
First Web Site
- Teenagers
can make responsible decisions if given honest information.
- Accept reality
of experimentation: Focus on safe outcomes,
- Drugs are
Drugs--legal and otherwise. Good and Bad are normative issues, not
inherent properties of substances.
- Abstinence
may not be realistic goal for all.
- Controlled
use is the norm and a practical goal.
- Promote stake
in life and responsible lifestyles: Build individuals not defenses
- Promoting
rational thought and objective analysis will be of benefit to the entire
educational process.
Studies:
- "
Safety First: A Reality-Based Approach to Teens, Drugs, and Drug Education,"
(.pdf
file)Marsha Rosenbaum (TLC)
- Safety
First: Parent, Teens, and Drugs, Marsha Rosenbaum (Drug Policy Alliance).
- Assessing
the Effects if School-Based Drug Education, by Dennis P. Rosenbaum,
Ph.D. Professor and Head and Gordon S. Hanson, Ph.D. Research Associate
Department of Criminal Justice and Center for Research in Law and Justice
University of Illinois at Chicago, April 6, 1998.
- Scare
tatics don't work
Secondary
Prevention
- Little systematic
attention
- Big question:
GOALS??? Abstinence or ??? Moderate/rational USE??
- Most user of
licit and illicit drugs do so in a controlled and moderate fashion: What works
for them????
- Can we teach
heavy users? Can we develop cultural norms that orient users away from dangerous
use (IV and smoking)?
- Serious problem
here with public attitudes
- Federal Government
: Moving away from such approaches
Tertiary
Prevention (Treatment)
Treatment Theories
Medical/Disease:
Lost control, incapable of responsibility- medical intervention
- Detoxification
(not a "real" treatment in and of itself).
- Antagonists:
Alcohol (Antiabuse- Disulfiram), Narcotics: Nalorphine, Cyclazocine, Naloxone
- Maintenance
programs and/or total abstinence.
- These approaches
are designed to get drugs out of peoples system and, through negative reinforcement,
keep them out. Seldom used individually.
Learning/Free
will: Value issue, choices, decision making: Education
Moral
Model: Immoral choice- Punish. Prison.
Drug Courts
- Begin in 1980s
(Dade County, Florida, 1st in 1989). CJS overwhelmed
- 2002: 1,200
across country.
- Paradigm shift:
treatment versus punishment
- Non-standardized,
various criteria for eligibility
- One-on-one,
judge and defendant. Not adversarial
- Compared with
cohorts of non graduates of treatment, graduates of the drug court program
do better
- number of
arrests per 100 participants: 22 for court program grads, 77 for matched
sample of probationers, 156 for nongraduates.
- In study
based on random assignment to drug court treatment or standard treatment
(jail/probation): recidivism for drug court cohort one-third that of the
others.
- Drug Courts
cost per defendant: $1800-$4400 versus $20-$30,000 for incarceration. (Goode,
page 400-402)
- Drug
Courts in Seattle, 2008
- Drug
Courts in St. Louis (local)
- Maybe Drug Courts aren't as effective as other "harm reduction" and treatment options.
Treatment
Types:
- Maintenance
(medical model) (MM)
- Therapeutic
Community (TC)
- Out-Patient
Drug Free (OPDF)
- Social/Self-help
(AA)
Studies on
Treatment
- Most users don't
require treatment
- Many (if not
most) who discontinue use, stop on their own!!!
- "Natural
Recovery" appears to be the norm (see also: Mocenni, C., Montefrancesco, G., and Tiezzi, S. 2010. "A Model of Natural Recovery from Addiction. The Dipartimento di Economia Politica (Department of Economics). University of Siena: Italy."
- Those enrolled
in treatment facilities: "Failures," hardest core. (See: "Through
a Blue Lens," a 1999 film on the streets in Vancouver, BC by Veronivca
Alice Mannix).
- Programs have
high failure rate: 75-90%
- Natural recovery:
High rates- (Viet Nam Vets)
- Different kinds
of people, Different Situations!
- DARP,
TOPS (NTORS
in UK) 1969-1980s (MM, TC, and OPDF)
- Length of
enrollment and Methadone Maintenance
- All good
at reducing use (volume, frequency, complexity)
- All good
at reducing crime
- Employment
still problematic
- Little impact
on alcohol use
- Treatment
works
- DATOS
(NIDA summary
from 1997)
- Principles
of Drug Abuse Treatment for Criminal Justice Populations -
A Research-Based Guide
- Online
or face-to-face treatment? (citation)
General Considerations
- Number of enrollees
with narcotics as primary drug has been declining
- Poly drug use
treatment is increasing (except for methadone maintenance)
- Yet even heroin
users are typically poly drug users
- Alcohol use
is very high (20-50% enrolled are heavy drinkers), Use tends to increase during
treatment (except for TC)
- Ratio of males
to females- 3 or 4:1 (BUT, number of females increasing)
- Traditionally
most enrollees were first timers, today most are "previous failures"
(3/4 of MM)
- Only 50% are
high school graduates, most "outside" of the labor force (~20% had
40 week/year of employment prior to enrollment)
- Referrals: Most
self, family and friends. 1/3 of OPDF and TC==> CJS (only 3% of MM)
- MM clients older:
average age=> 37, for other programs=> 20's.
- MM and TC: Large
ratio of African-Americans- 37 and 40%, Hispanics increasing. OPDF: 80% White
Criteria
for Evaluation
- Decline
in use of drugs
- Decline
in use of alcohol
- Decline
in criminal behavior
- Increase
in employment
- Yet,
What is success?????
- Used specifically
for opiate abuse
- Metabolic imbalance
(Adaptive)
- Oral dosing,
utilizing high doses to block the effect of street opiates.
- New version,
oriented towards change: low dose level, gradually wean off. (Change, Abstinence-oriented)
- 4 out of 10
clients enrolled in treatment programs are in MM (75-100,00)
- Cost: ~$3500-5500
per year (based on $2-3,000 per year in 1989)
- Typical regime:
everyday contact, weekend dosing, (LAAM 2-3 day duration), drug testing individual
and group counseling.
Criticism
- Diversion of
methadone out to the street
- Abuse of methadone
(low 1/20th of the DAWN showing for aspirin)
- Railroading:
Suck in the young and keep under supervision (only 3% from CJS, average age
37, typical client- long time addict, tired of the hassle)
- Enslave African-Americans:
Enslaved to heroin, voluntary (self-referral is the norm), only 37% of clients
are Black.
- Use of one drug
to treat abuse of another???
Effectiveness
- Original treatment:
Dole and Nyswander- Problematic evaluation, question as to what defines success;
Very high "split" rate; Very selective: older and motivated addicts
(Aging out phenomenon)
- Recent
- Retention
(Critical element: the longer one stays in any program, the better the
outcome): ~50% stay one year (another study suggests 38 weeks). Longest
of any modality!!!
- History
of previous failures: Maybe not so problematic. Multiple attempts may
be necessary.
- Hundreds
of thousands have been treated!
- National
study of 4000: 2/3 used regularly prior to enrollment: after 3 months-
10%; 5 years later- 20%. Total volume of heroin used reduced to 1/3- 1/4
of prior
- Cocaine
use also down, as well as other drugs use.
- For each
major drug of abuse: Complete abstinence after one year: 40-50%; 70-80%
of those still using- reduced.
- Significant,
dramatic decline!!!!!!
- Criminal
activity fell to 1/3 or of pre-treatment levels
- Little change
in employment (1/4)
- Alcohol
consumption: dropped slightly during, rises slightly following, then steady
decline. (1/4 heavy prior; 1/5 heavy after)
- Methadone
Factsheet (ONDCP) (see also, CDC)
- Overall:
Not bad. Cost effective. Helps about 40%
Heroin
Maintenance (a re-emerging alternative)
- Synanon
(permanent community)
- Others: Temporary-
Phoenix House, Daytop Village, Odyssey
- Require total
Abstinence (Except: Coffee and Nicotine)
- Drug use is
seen as deviance. Problem resides in the person. Whole person is "treated."
Drug use is only a symptom or manifestation of a deeper problem. Drug use
must be stopped in order to address the "real" problem.
- Emphasis: Resocialization.
- Staff: Characteristically-
Recovering Addicts (somewhat atypical of treatment programs)
- Methods: Confrontational;
Group and Individual therapy, Work and "upward mobility through organizational
hierarchy: Strict rules, brutal honesty, Reinforcement.
- Duration: Traditional-
15 months or more (Synanon: lifetime commitment). New "modified"-
less than a year.
- Cost: $10-12,000
per year (based on $6-7,000 per year in 1989). Perhaps most expensive of the
different types.
- Services about
10% of the population (20,000)
- 1/3 of referrals
from CJS, 40% African-American
Effectiveness
- Traditional:
"Split" rate fairly high. 6-27% complete; Average stay: 21 weeks
(little over half of MM); Only 13% stay for over a year. Newer "modified"
programs: too early to evaluate.
- "Success"-
similar to MM.
- During treatment:
Essentially NO drug (except caffeine and nicotine)
use or criminal activity.
- After: 1/3-1/2
reduction in heroin use
- Other drug
use down, and less poly drug use.
- Criminality:
High prior (2 times the rate for MM), after treatment: 2/3's report reduction.
Seems that CJS referrals do better!
- Employment:
Pre- 15% with full-time work; after 36%
- Little impact
on alcohol use
Out
Patient Drug Free
- Counseling services:
Individual and Group
- Not purely "out-patient"
or "drug-free"
- Many use
short-term residential detox
- Not "maintenance,"
but oftentimes prescription drugs are used to mediate withdrawal, treat
other disorders, and of course there's nicotine (and for out-patients,
alcohol).
- Clients reside
in "normal" community (again, some varieties may have short-term
residential detox).
- Lot's of variety
and LITTLE evaluative research
- Change oriented:
Resocialize and Drug-free. Adaptive: Get control of life.
- Clients: Young
(in comparison to other modalities), White, 1/3 Female, 1/3 CJS referrals
- Least likely
to have history of heroin use.
- Duration: Varies-
~15 weeks
- Cost: $4,000-6,000
(based on $2,000 average for 15 weeks in 1989).
Effectiveness
- Little impact
on heroin use
- Some impact
on cocaine: Pre- 30% used regularly; after-10%
- Other drug use:
Pre- 50%; after- 10% (seems relatively effective here)
- IV administration
down by 1/3
- Criminality
down by 1/3
- Employment:
Pre: 25%; after 50% (Perhaps the best showing of all modalities, yet population
characteristics are significant in success here)
- Little impact
on alcohol use
Self-Help
Groups
AA Philosophy
- Alcoholism (drug
abuse) is a disease
- Alcoholic is
one who has lost control
- No cure; but
Recovery
- Alcohol use
for others- OK. Alcoholic is different
- No use for members
(relapses are expected- part of the recovery process)
- 12 steps: Higher
power
- Public confession
- Regular attendance
- Mutual support:
Sponsor/Buddy
Effectiveness
- Does attract
more conventional and motivated clientele
- 50% relapse
- Those that stay:
70% sober after 1 year, 90% after 2 years. Long-term carry over
- "Split"
rate is high, but success/cost: Amazing
Back to Policy
Issues
Overall
Considerations on Treatment
- : Modified definition of "success"- HELP
People- 4-5 out of 10.
- "Split"
rate are high, but may not be indicative of failure.
- Control and
evaluation difficult: Natural recovery, motivation, definition of success
- Clients typically:
hard core, multiple problems, crime, unemployment, psychiatric needs
- Costs: There's
a payback here- $3-4 for every $1 spent (Productivity, reduced crime, long-term
medical costs, etc.) Especially for AA
- Variety is NECESSARY
- "Treatment
Facts"
YET:
Drug
Testing: Jar Wars!
- International
Journal of Drug Testing
- An Alternative:
An Evaluation of
Fitness-for-Duty Testing. Presented at the 1995 APA conference by Debra
R. Comer (25pp)
- The
Non-Testers List Drug
Test Information Page (page not found ;-(but here is a list of those that do)
- Hair
Testing, Image, (see also:
erowid
and wikipedia)
- Legal
Concerns
- Drug
Policy Alliance- OnLine Library: Drug Testing
- Marsha Rosenbaum,
"No Silver
Bullet," AlterNet Drug Reporter, 1/28/04.
- Erowid's
Drug Testing Basics
- Making
the Whizzinator Illegal?
- In the news: States Adding Drug Test as Hurdle for Welfare (NY Times, October 11, 2011)(local copy)
- In the news: At One College, a Fight Over Required Drug Tests (NY Times, October 11, 2011)(local copy)
- False positives
and False Negatives
- Type of
test: Urine- cheap varieties (even dip sticks) $15-30. High error rates.
State of the art: Gas Chromography/Mass Spectrometry (machine cost $15,000),
test $100 or more: Fairly reliable. Hair
test: still being evaluated by scientific community- popular within
the private sector
- Issue: Previous
use or intoxication (presence of metabolites)
- Problems:
Other substance interaction and security.
- Overall
(for urine tests) 2% false positives, 30% false negatives.
- Hair Testing:
level of dectection? Dark hair versus light hair? African-American versus
Caucasians, impact of bleaching, etc., and environmental contamination.
- Use versus
Abuse: What are we testing for?
- Usefulness:
Lower number of positives correlated with deterrence or overall lower use
levels?
- Firms with
drug testing: Lower productivity (issue of trust, degrading experience,
deters qualified employees).
- Drug users
are not necessarily less reliable, nor unsafe.
- Cost effectiveness:
Federal program--spent $11.7 Million (29,000 tests). 153 positives
(.5%). This equals $77,000 per positive.
Drug Testing
becomes "common" in the early 1980's
- Interesting
splits: Pro/Con
- Political
and Ideological: Conservatives vs. Liberals
- Management
vs. Workers
- Public vs.
Private industry
- Type of
job in question
- Appears many
are more opposed to use of drugs rather than testing.
- Most Americans
are not strong civil libertarians: Can see benefits that may stem from violating
rights under certain circumstances, or just don't care.
- Widespread
testing in Private sector: pre-employment, random testing
- Over 52%
of major firms require.
- Testing
Positive=> major drawback to employment (Marijuana #1 disqualifier=>
47%, ETOH=> 2%
- Many workers
support
- Military:
Began testing in 1980: 27% reported use, by 1988 only 3% (17,000 discharges).
- Officers
vs. enlisted: Discharge vs. Treatment
- Illicit
drugs vs. ETOH
- 3 stage
program
- Testing of
Civilian sector of government: Difficulties.
- Reagan:
YES- "Drug Free Workplace"
- Courts:
random testing of government employees is unconstitutional: Issue of probable
cause and/or reasonable suspicion.
- Type of
job is relevant: Issue of "clear and present danger" to public
The
Law
URL:
http://www.umsl.edu/~keelr/180/prevent.html
Owner: Robert O. Keel rok@umsl.edu
References and
Credits for this Page of Notes
Last Updated:
Tuesday, January 15, 2013 12:03 PM