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cost, and the longer lasting effects of the drug on the individual than cocaine can provide.
Other drug use Hallucinogens, which first gained prominence during the 1960s, include such drugs as LSD, mescaline, peyote and MDMA or “Ecstasy." Lifetime prevalence of these substances is highest among 26-45-year-olds (17.7 percent of the population) and current use is highest among 18-25-year olds (1.9 percent of the population).
It is conservatively estimated that 9 percent of youth have experimented with inhalants, 96 and current use is increasing among Hispanic youth in the Southwest. 97 The prevalence of inhalant abuse may, in fact, be greater in rural areas than elsewhere.98 2. Treatment facilities
Survey overview According to the most recent information published from drug abuse treatment units responding to the National Drug and Alco holism Treatment Unit Survey (NDATUS), 263,510 drug abuse clients were in treatment on October 30, 1987. NDATUS is a national survey which is designed to measure the location, scope and characteristics of drug abuse and alcoholism treatment and prevention facilities, services and activities. While NDATUS has its limitations, it is the only survey that includes private as well as publicly funded programs.99 NDATUS reported that New York and California accounted for 42.2 percent of the Nation's clients, while South Dakota had the least at .05 percent. An estimated 67 percent of drug abuse clients were male; 56 percent were between the ages of 25 and 44; and youth under the age of 18 accounted for 15 percent of the clients. African Americans represented about one-fourth and Hispanics about one-sixth, of the 240,598 drug abuse clients for whom race or ethnicity was known. 100
It is conservatively estimated that 42 percent of drug abuse clients were intravenous drug users; and data from the State Alcohol and Drug Abuse Profile (SADAP) show that the primary drugs of abuse among treatment clients are heroin, cocaine and marijuana. Estimates of admissions to treatment for cocaine abuse more than tripled from 1985 to 1988, from 39,696 to 134,734 clients in statesupported treatment programs.
Considered according to treatment facility ownership, the lowest utilization was observed among private, for-profit programs while the highest was for state or local government-owned programs. 102 Most programs provided individual and group counseling and therару.
95 Statement of Charles R. Schuster, Director, National Institute on Drug Abuse before the Committee on Labor and Human Resources, October 25, 1989, p. 3.
97 Ortiz, op. cit.
99 Alcohol, Drug Abuse, and Mental Health Administration. “National Drug and Alcoholism Treatment Unit Survey, 1987 Final Report.” 1989, pp. 1-4. 100 Ibid., pp. 1-6. 101 Schuster, op. cit., p. 6. 102 NDATUS, op. cit., p. 29.
Utilization rates measure the percentage of people who use a method of treatment relative to the potential total capacity. Capacity of treatment is defined as
the maximum number of individuals who could be enrolled
client visits to the unit. 103 Utilization rate for individual modalities by definition do not total 100 percent since maximum caseload depends upon a number of factors as noted above. If any one of these factors are absent, then a treatment slot cannot be made available and individuals seeking treatment would remain on a waiting list. Therefore the overall rate of utilization was 79.1 percent of the 5,015 treatment units which provided information on budgeted capacity accommodating the 260,151 clients in treatment in October 1987.
Utilization rates varied according to the type of treatment setting, e.g. 55.9 percent in the detoxification setting; 64.3 percent in halfway houses; and, 89.3 percent for methadone maintenance. Drug free treatment, the modality reported by the greatest number of units, had a utilization rate of 76.8 percent and accounted for 64.6 percent of drug abuse clients in units that reported budgeted capacity. The 3,638 units treating clients in an outpatient environment reported a total utilization rate of 80.9 percent and represented the majority of the units and clients. The total utilization rate was 57.2 percent for hospital inpatient environments and 76.8 percent for residential settings. 104 The highest proportion of funds was spent in the outpatient environment. African Americans and Hispanics represented the greatest proportion of clients in residential environments; the percentage of white clients was highest in hospital settings. 105
Treatment modalities As previously indicated, there is no heterogenous group of addicts or singular pattern of addictive behavior, and thus the type of treatment that might be successful for one individual may not be appropriate for another. According to Dr. Dooley Worth, the approaches to treatment assume a heterogeneity in addicts which has resulted in inadequate treatment responses. 106 According to ONDCP, “Unfortunately, the type of treatment a patient currently
103 NDATUS, op. cit., p. 73.
108 Statement of Dr. Dooley Worth before the Subcommittee on Legislation and National Se curity, April 17, 1990, p. 1.
receives is frequently determined by the first door on which he happens to knock." 107
The programs that are known to be most successful are those which are long-term, comprehensive, and address not only the addiction, but also address the reasons for the individual's involvement with substance abuse and the options available to the abuser. Successful programs incorporate survival coping skills and supportive networks to develop new lifestyles. The Treatment Outcome Prospective Treatment Study (TOPS) is the primary national study providing information on program effectiveness. TOPS concludes that: the longer an individual received treatment, the less substance abuse of all types of drugs the individual experienced; drug abusers tended to reduce their criminal involvement if they received treatment; and, substance abuse treatment within the criminal justice system was not less effective even though it may be coerced. 108
The following methods of treatment are most commonly found in the United States.
Detoxification According to Dr. Charles Schuster, detoxification was originally devised in 1880, and is usually considered a preliminary step in the treatment process
designed to render the patient drug free with a minimal
ment of the drug abuse problem. 109 ONDCP indicates that:
Although it is not uncommon in our treatment system today for an addict's experience in treatment to begin and end at this stage, experts agree that detox does little good unless it constitutes a transition to, or preparation for, a
long-term drug treatment program.110 Studies since the 1920s show relapse rates of 80-95 percent. According to NDATUS' October 1987 final report, the utilization rate for detoxification among the 1,129 treatment units was 55.9 per
Residential Treatment and Therapeutic Communities Clients in Residential Treatment and Therapeutic Communities live in highly structured settings aimed at creating permanent changes in attitude and value, as well as a commitment to a drugfree life. 112 One of the first such programs whose basic tenets later served as a model for therapeutic communities across the country was Synanon. Founded in 1958 in California, Synanon was run
107 Office of National Drug Control Policy. “Understanding Drug Treatment,” June 1990, p. 13. 108 Hubbard et al., op. cit. 109 Schuster, op. cit., p. 13. 110 ONDCP, op. cit., June 1990, p. 14.
NDATUS, op. cit., p. 35. 112 Schuster, op. cit., pp. 13-14.
largely by former addicts and some professionals who imposed personal and community responsibility by means of a rigid hierarchy among staff and patients. Clients in these types of facilities could remain in treatment for periods of two months to two years. 113
The traditional longer term programs such as Phoenix House and Daytop Village emerged from programs originally aimed at younger, criminally involved drug abusers. The longer a client remains in treatment, the more successful the outcome. However, the long term residential treatment program's weakness is that the retention rate is low due in part to the confrontational nature and general intensity of the program. Dropouts are highest within the first fourteen days of treatment. 114 Shorter term programs such as Hazelden and the Betty Ford Center are geared to more mature clients who have fewer economic and psychological problems and little if any criminal involvement. These types of residential programs are far costlier on a daily basis than longer term programs, and their utility for treating the severely dependent or economically depressed, or long term substance abuser is questionable.
According to NIDA, patients staying beyond 90 days in residential treatment or therapeutic communities continue to experience decreased drug use and criminal activity one year after treatment; staying one year improves employment opportunity. Originally only 7 to 15 percent remained to complete one year; however, recent surveys indicate that 24 to 35 percent complete one year in these facilities. 115 The utilization rate for therapeutic and residential settings is 76.8 percent. 116 Whites comprised 55.7 percent of inpatient care use, African Americans 29.2 percent, and Hispanics 13.0 percent. Males generally comprised 73.7 percent of the inpatient care facilities.
Inpatient hospital programs The better known inpatient hospital program is the “twelvestep" or Minnesota Model approach developed in the 1950s at Willmar State Hospital in Minnesota to treat alcoholism. Today this model is used to treat illicit drug addiction and the core of the counseling and program activities is derived from the self-help therapy of the Alcoholics Anonymous twelve-step recovery program, although conducted within a hospital or clinical setting for three to four weeks. While little research has been conducted on the effectiveness of this strategy, it is estimated that the thousands of individuals who were able to afford such care have been helped. Other inpatient hospital facilities where patients receive, on average, four to twelve weeks of psychiatric treatment, are available for private care and are not publicly funded because of the astronomical costs. 118 The utilization rate for basic inpatient hospital facilities is 57.2 percent. 119
113 ONDCP, op. cit., June 1990, pp. 14-15.
Self-help groups Self-help programs are usually run by recovering addicts. While there is no single point in time when these types of programs were first begun, they existed in Washington, D.C. in the 1840s, and many grew out of “free clinics” established during the “War on Poverty” days. The approaches used by groups such as Alcoholics Anonymous and Narcotics Anonymous can assist the moderately drug-disabled or those who have successfully completed some kind of treatment program and are simply in need of peer support. Re cently, attempts have been made to bridge the gap between "pure" self-help approaches and more structured treatment regimens, where a professional acts as a facilitator in a series of skills training sessions used to give clients coping skills to avoid drug and alcohol use. 120 Again, because of the flexible nature of self-help groups, research on the effectiveness is spotty and the success of such approaches has not been aggregated, though thousands of people are known to utilize both Alcoholics and Narcotics Anonymous. These self-help programs are widely implemented in prisons since federally funded treatment programs are not generally available for prisoners.
Drug-free outpatient treatment Drug-free outpatient modalities consist of diverse approaches to treatment and are the most widely used, accounting for about 40 percent of the drug abusers in treatment, many of whom are nonopiate drug abusers. Programs vary widely from casual drop-in centers to highly structured programs providing counseling and psychotherapy.121 Some programs offer education and vocational training, and most programs encourage clients to become involved in self-help groups both for the insight and the communal support they offer. 122 While drug-free outpatient treatment has been found effective in reducing opiate and non-opiate drug use, increasing employment and decreasing criminal involvement, there is a problem retaining hard-core drug abusers in the programs. One study indicated that only 20 percent of heroin addicts remained in drug-free outpatient programs for the recommended duration of treatment, 123 but new therapeutic techniques for preventing relapse make this modality more promising. Drug-free facilities have a utilization rate of 76.8 percent 124 because the flexible nature and more affordable cost of the programs are attractive.
Methadone Maintenance Methadone, a legally controlled drug developed in 1964 by Vincent Dole and Marie Nyswander at Rockefeller University, can substitute for heroin and prevent opiate withdrawal symptoms.
Administered orally on a daily basis, methadone allows many heroin addicts to function normally without constant craving for heroin. Methadone Maintenance, in and
120 Schuster, op. cit., p. 13.