Dealing
With Drug Use??
(See: Drugs in American Society, 5th, 6th, 7th editions, Erich Goode,
McGraw-Hill, 1999/2005/2008. Chapter 14)
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), 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
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
Treatment Types:
- Maintenance (medical
model) (MM)
- Therapeutic Community
(TC)
- Out-Patient Drug
Free (OPDF)
- Social/Self-help
(AA)
Studies on Treatment
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)
- 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
- Most modeled after Alcoholics
Anonymous: 12 Step Programs
- Different from other
types: Voluntary, Independent, Reject outside funding and oversight.
- AA: Founded in 1935-
Bill W. And Bob S. (Ohio) 2 years after Prohibition ended.
- Today: over 1,500,000
members world wide
- Originally: Clients-
white, middle class and employed. Today: tremendous variety, specialty groups.
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!
- 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:
Saturday, August 22, 2009 10:33 AM