Dealing With Drug Use?? (See: Drugs in American Society, 5th, 6th, 7th, 8th, and 9th editions, Erich Goode, McGraw-Hill, 1999/2005/2008/2012/2014. Chapter 15)
Education and Intervention
(or should that be "No thanks, I can make up my own mind?")
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
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).
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
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)
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).
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)
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)
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.
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
