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post-treatment outcomes were significantly better for those in methadone maintenance, therapeutic community, or drug-free outpatient treatment than for those in detoxification-only.
NIDA research has shown that outreach programs to people not in treatment can reduce intravenous use of drugs, reduce the number of people who share needles, reduce unsafe sexual practices, and increase the number of people seeking treatment.
Methadone maintenance can reduce intravenous drug use thereby reducing a high-risk behavior and the spread of HIV infection. Scientists at the ARC recently completed a survey of six programs in New York, Philadelphia, and Baltimore. They found marked variation in the effectiveness of the various programs; however, overall, 71 percent of patients who remained in treatment for two or more years stopped intravenous drug use.
The Methadone Level Study found that methadone abuse treatment without counseling has a poor efficacy, but adding family therapy makes methadone therapy highly effective.
Buprenorphine appears to have significant advantages over methadone in terms of its ability to block the effects of other opiates, in the ease with which patients may be withdrawn, and the ability to safely put this medication in long-acting formulation. Over the 17 weeks of the maintenance phase of the study, 8mg of buprenorphine was both clinically and statistically better than methadone 20mg, while methadone 60mg and buprenorphine were not significantly different.
Naltrexone, a medication developed by NIDA in cooperation with the private sector, blocks the effects of heroin. Patient compliance with Naltrexone has not been very successful. NIDA has developed a depot preparation; a single administration of this dosage form will provide "protection" against heroin for up to thirty days.
Euphoria is thought to be a major contributing factor leading to the initiation and maintenance of drug abuse. Investigators at the ARC used positron emission tomography (PET) to determine which brain areas are affected by morphine and cocaine. Morphine and cocaine, at doses that produced euphoria, reduced glucose utilization, an index of brain function. The findings indicate that a reduction in cortical activity may be part of the mechanism by which abused drugs produce euphoria.
Scientists at the ARC recently identified the brain sites responsible for the seizure producing and lethal effects of cocaine. The primary action of cocaine in producing seizures appears to be that it increases the effects of serotonin, a naturally occurring brain neurotransmitter. The actions of cocaine which result in death are more complex and involve multiple brain sites. Researchers have identified drugs which, by blocking activity at these same sites, effectively prevent these toxic effects of cocaine.
The site of action of cocaine in the brain, has recently been identified and specified. It will now be possible to clone this protein, specifically determine the sequence of its cocaine
binding site and compare the structure of the binding site to other substances that bind to the dopamine transporter protein and block uptake of dopamine. Such information could lead to a more rapid development of a drug that can interfere with cocaine.
Using PET scanning, the chronic effects of cocaine administration have been identified in animals. The D-1 dopamine receptor site, where cocaine acts, is "down-regulated" by chronic cocaine administration. A D-1 blocker could reverse this effect and bring the dopamine system back towards normal. This could possibly alleviate craving for cocaine. Over a dozen medications that are thought to reverse some of the effects of cocaine are being pursued in clinical trials.
Desipramine was shown to be effective in reducing cocaine abuse in two studies, amantadine reduced cocaine abuse in methadone maintained cocaine abusers, and buprenorphine reduced both cocaine and opiate use compared to methadone.
Random assignment of cocaine dependent patients to intensive outpatient programs or inpatient treatment has shown an outcome equally effective for both treatments. At followup, two-thirds of treated patients are cocaine-free. Outpatient treatment is less expensive than inpatient psychiatric care and this research should result in significant reduction of treatment costs.
The experimental evaluation of aversion therapy treatment for cocaine abuse is producing promising preliminary findings. Some subjects are showing clear signs of developing conditioned aversions to placebo cocaine products, and these conditioned aversions appear to be exerting some therapeutic real-life benefits following discharge.
A link between cocaine self-administration and internal opiate mechanisms has been suggested. Researchers gave buprenorphine, to a group of cocaine trained monkeys, and the monkeys stopped self-administering cocaine. These results are being followed up with both human and animal studies.
After many years of research a receptor for THC, the active ingredient in marijuana, has been isolated and cloned. This has important implications for treatment: knowing the structure of the receptor is the first step in designing a THC antagonist to block the effects of marijuana.
Recent studies show that when male rats were exposed to morphine and then bred with drug-naive females, both male and female offspring had abnormal levels of various hormones in adolescence. This is a troubling finding and suggests, at a minimum, that programs addressing the needs of female drug abusers, whether pregnant or not, must consider the drug use patterns of sex partners in terms of any potential pregnancy outcome.
Recent studies show that when male rats were exposed to morphine and then bred with drug-naive females, both male and female offspring had abnormal levels of various hormones in adolescence. This finding suggests that programs addressing the needs of female drug abusers, whether pregnant or not, must consider the
drug use patterns of sex partners in terms of any potential pregnancy outcome.
A four-year follow-up from the Midwestern Prevention Program indicates that a comprehensive, multiple component prevention strategy incorporating the individual, family, peers, schools, communities, and the workplace is reducing the use of marijuana and cocaine among adolescents.
Family interventions for high risk youth have shown significant success rates. Effective strategies including but are not limited to educating and training parents to address drug abuse issues with children beginning as early as the elementary school level, teaching parenting skills, and structuring family processes to foster healthy development and family interactions.
One of the most consistent factors correlated with the initiation of drug use is the influence of peers. Prevention intervention specialists have used this finding to develop programs that utilize the positive aspects of peer relationships to reduce the initiation of drug use.
High sensation/novelty seeking behavior has consistently been linked to drug use onset and progression. Current research is focused upon design and testing of prevention interventions targeted to high sensation seeking youth. Further research is examining the heritability of personality traits and alcohol and other drug abuse associated with drug use risk.
The demonstration programs of the Office for Treatment Improvement (OTI) were authorized beginning in FY 1990, and awards have been made and new programs are already operational. We have had an external assessment of the impact of our Waiting List Reduction Grant Program; and, while the report of this assessment is not in final form, it does seem fair to conclude that it is possible by expanding capacity to substantially reduce or eliminate the delays in entry that discourage many addicts from seeking treatment. It also seems to be true that when addicts find such delay they do not seek treatment elsewhere and, quite typically, when contacted weeks later about entering treatment, a substantial proportion of the majority have lost the motivation to accept treatment.
The bulk of OTI's other demonstration and service projects (e.g.; Target Cities, Critical Populations) will also be subjected to depth study, and this is currently being launched. Although we expect to get some information within the first two years, it will be at least three years before any in depth assessment of these programs can be made.
REDUCTION OF DRUG DEMAND
Question. In your professional judgement, should we be spending more on the "demand" side of the drug war? Is the current 1/3 demand reduction, 2/3 supply reduction strategy appropriate?
Answer. In the early 1970s, when the Federal Government first initiated its "balanced approach" with attention to both demand side and supply side reduction, the proportion spent on demand reduction
exceeded that spent on supply side efforts. Since the late 1970s supply side resource growth has substantially exceeded the growth of demand side. Coupled with growth in demand for treatment services and inflation, many programs are now less well equipped to respond to treatment needs than they were 15 years ago. If demand side treatment resources were increased, it would be possible to rebuild the capacity to deliver more comprehensive services. Such services appear to be significantly more effective than minimal services in returning drug abusers to productive lives, free of drug abuse.
Question. Did the 1990 National Household Survey on Drug Abuse show significant declines in drug use among all sectors of society?
Answer. The 1990 National Household Survey on Drug Abuse provides estimates of drug use prevalence for the civilian and noninstitutionalized population of the U.S. The sample size is large enough to permit estimates for many demographic groups; that is, by age, sex, race, region of the country, etc. However, the sample does not include some segments of the population that may contain a substantial proportion of drug users, such as the homeless, persons living in military installations and other group quarters, and institutions such as hospitals and jails.
The survey does cover the population age 12 and older living in households in the contiguous U.s. The results are based on personal interviews combined with self-administered answer sheets from 9,259 respondents, randomly selected from the household population. This is the largest sample ever used in this survey and includes an oversampling of Blacks, Hispanics, young people, and the Washington, D.C. metropolitan area enabling us to make reliable estimates about the levels of drug use among these populations.
Current prevalence rates for use of any illicit drug among persons 12 years of age and older continued to decrease from 23 million drug users (12.1%) in 1985, to 14.5 million users (7.3%) in 1988 to 13 million users (6.4%) in 1990.
The number of current cocaine users decreased significantly from 2.9 million (1.5%) in 1988 to 1.6 million (0.8%) in 1990, continuing a previous decline. This represents a 72 percent decrease in the number of current cocaine users since 1985, when there were an estimated 5.8 million (2.9%) current cocaine users.
Three major age groups are covered in this survey: youth age 12 to 17; young adults age 18 to 25; and older adults age 26 and over. Among youth (12 to 17 years old), 15.9 percent used an illicit drug in the past year and 8.1 percent used an illicit drug at least once in the past month. Comparable rates for young adults (18-25 years old) are 28.7 percent and 14.9 percent, respectively; and for adults 26 years old and over the rates are 10.0 percent and 4.67 percent respectively.
Rates for current use (past month) for males and females are 7.97 percent and 5.1 percent, respectively. In addition to males, other demographic subgroups with rates in excess of the overall rate are those for blacks (8.6%), large metro areas (7.3%), those living in the West region (7.3%), and the unemployed population (14.0%).
Over 4.8 million or 8 percent of the 60.1 million women 15-44 years of age have used an illicit drug in the past month. slightly over one-half million or 0.9 percent used cocaine and 3.9 million (6.5%) used marijuana in the past month. Among 18-34 year old full-time employed Americans, 24.4 percent used an illicit drug in the past year, and 10.5 percent used an illicit drug in the past month of these full-time workers, 9.2 percent used marijuana, and 2.1 percent used cocaine in the past month.
In summary, for sex, race/ethnicity, and geographic region, comparisons of data from 1985 to 1990 show that drug use declined for all population groups measured. While most of these declines are statistically significant, in a very few cases they are not, and should in some cases be interpreted with caution.
Question. If not, what steps do you plan to take to bring a reduction in drug use among these populations?
Answer. The criminal justice populations and vulnerable youth populations, which have dropped out of both the educational system and the labor pool, are the sectors that have shown reductions in drug use that are far less encouraging than the reductions seen for the general population. OTI has identified these populations as a priority and plans to target progressively more resources to their substance abuse treatment services over the next several years.
USE OF ADMS BLOCK GRANT
Question. What does the Federal Government know about how States are using the $3.2 billion Congress has appropriated for the Alcohol, Drug Abuse, and Mental Health Block Grant over the past three years?
Answer. Each year the States file an annual report; however, regulations governing the block grant (45 CRF Part 96) limit our ability to: 1) structure the report and set common definitions on terms; and 2) to describe prevention and treatment activities funded under the program.
To summarize program activities, it would be necessary to conduct a content analysis of the individual State reports. This is not currently possible, due to differing definitions used by the States in reporting. ADAMHA is attempting to work with the grantees to standardized reporting and definitions through the voluntary State Plan process begun this year. The Administration is proposing to make these plans mandatory in FY 1992.
STATE SYSTEMS DEVELOPMENT PROGRAM
Question. What is your intention regarding the full implementation of the State Systems Development Program?
The Office for Treatment Improvement will begin implementation of the State Systems Development Program this year. The program will encompass:
Voluntary State Plan - 35 States have pledged to participate