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the Northeast Regional Methadone Treatment Coalition in New York, which represents about 270 methadone treatment programs stated: “Many of these programs are functioning very close to the wire. What they are going to be compelled to do is decrease other program services and not be able to hire staff. ..." 145 Gerald DeAngelis, president of Health Care Delivery Services which operates two publicly funded clinics in the Los Angeles area that treat about 500 methadone patients said:
This is going to have an incredible impact. We're going to
.. (17 percent less]. The whole thing seems to be going
against the national interest in the area of drug abuse. 146 4. Target populations
Inner cities As discussed, a two-tiered drug war has been waged where middle and upper class drug users have access to appropriate prevention programs and obtain treatment that is partially or wholly subsidized by third-party medical insurance programs, whereas lower class and ethnic minority drug users have less access to appropriate prevention programming, less access to treatment programs due to the lack of program slots at public facilities, and lack the insurance to become eligible for other available treatment modalities.
According to Frederick K. Goodwin, administrator of the Alcohol, Drug Abuse and Mental Health Administration:
When people say treatment works, it's true, but it's a limited statement . . . It works for the middle and upper class that have a lot to lose. But for the major group of drug abusers, for the crack epidemic, in the inner cities, we don't have nearly enough knowledge about what works and how to stop the craving for the drug. The area where the biggest problem is is the area where we know the
An important reason why this situation has developed is that very few treatment programs are scientifically evaluated, and few clients receive follow-up care or are observed once they are out of treatment.
Since treatment serves a disease of relapse, it is not uncommon for an individual to go through treatment several times. The rate of recidivism is high even at costly private rehabilitation centers where a standard one-month stay can result in two-thirds of the cocaine abusers dropping out or returning to drug use within one year. However, at publicly funded programs in the inner cities, the outcomes are much worse. According to Marian Droba, director of the University of Pennsylvania's Addiction Research Center
145 Ibid. 146 Ibid.
147 Michael Isikoff, “Traditional Drug Programs Face Up to Chronic Recidivism," the Washington Post, August 20, 1990, p. 4.
About 120 drug abusers enter the emergency room with drug-related episodes every month at the Veterans Hospital in Philadelphia's outpatient drug treatment clinic. Only 60 will show up and usually no more than 20 will
make it through the first month.148 For inner city individuals that enter residential or therapeutic community settings the recidivism rates can be just as high, since most people who leave the protective environment of the treatment facility face the greatest challenges to their ability to stay off drugs when they return to the same surroundings that placed them atrisk of abusing drugs in the first place. 149
The Treatment Outcome Prospective Study (TOPS) conducted at the Research Triangle Institute which examined publicly funded treatment facilities throughout the 1980s suggested that roughly half of the people who go through treatment are drug-free or have significantly reduced their use of drugs three to five years afterwards. According to the TOPS study, the factors that contributed to the success of treatment include: good management of treatment facility, the ability of addicts to maintain strong friendships and family ties, the ability of the addict to maintain employment and the responsibility of managing house payments.150 These people have a greater incentive to control their illegal drug use, and the most to lose if they relapse.
In comparison, Bowser articulated the plight of inner city drug abusers when he identified their views of the future as hopeless and full of despair. These are the individuals who will most likely suffer relapses. Bowser's research indicates that the AIDS epidemic in African American and Hispanic communities is in fact closely interconnected with the behavior associated with drug abuse.
Intravenous drug users and crack cocaine users are two groups running very high risks of being infected with the AIDS virus. In turn, they can infect their non-drug using sexual partners, spouses, and unborn children. Intravenous drug users run a very specific AIDS risk by sharing contaminated hypodermic needles and crack users risk becoming infected with the AIDS virus by drugs-for-sex exchanges . . . In order to do AIDS research and to develop prevention strategies, we have to learn a great deal about drug abuse in community settings-specifically, who uses and why, who gets addicted, if and how the user subcommunity is informally organized, how one gets access to them, and what are the attitudes and behaviors of addict
ed drug users. Similarly, Worth points out that inner city drug dependent women can reduce their risk of AIDS through drug treatment programs once the relationship between drug dependency and the social, medical, psychological and economic behavior of the female IV drug user is defined, through gender-sensitive interventions. Worth
found that the lack of economic, social, cultural, sexual, and technological options combine to lead vulnerable women to concentrate on addressing the more immediate risks of their lives: poverty,homelessness, and the frequent disruption of socio-economic support systems.
The implications of these findings have far-reaching effects, as the socioeconomic context of these women's lives, as well as imbalances in power in the relationships between the women and their male partners are replicated
in many communities where AIDS is already present. 152 According to Dr. James Sall, Director of the Bureau of Substance Abuse in Detroit, treatment in inner city Detroit means:
We detoxify the addict, give him some counseling, and then it is a matter of saying, “Go out and sin no more." But they are still homeless, jobless, and they have a bulk of other problems with the legal system. We do not have
the resources. Sall, who also has a private practice, indicated that he is more able to keep people off crack cocaine pharmacologically, but is unable to assist the inner city poor addict because of the lack of funding. Father Pfleger testified that treatment for poor people and those not insured in most major cities is an unattainable goal since many substance abusers have to wait from 8 to 16 months. He called for the immediate expansion of facilities to accommodate inner city addicts and for ways to create jobs in poverty-stricken areas where the major employers are drug dealers. 154
In Philadelphia, only three out of every four individuals who request treatment can receive it.
I can tell you from a first-hand point of view the problem is real, the people (80-85 percent of addicts] out there can't afford to pay their way, they don't have money. They are the same people that have caused our crime rate to increase in our cities because they can't afford to have treatment programs, they go out and steal and rob and burglarize in order to receive money to buy drugs, to keep the habit going while we are waiting to accept them in a treat
ment program. 155 Mayor Goode indicated that the research available on the problems of inner city addicts is spotty and that this is a major reason for the problems in cities across the country:
What is clear to me and to other mayors around the country is that we do not yet have the real answer on what treatment plans work, and until we have those real
152 Dooley Worth, "Sexual Decision-Making and AIDS: Why Condom Promotion Among Vulnerable Women Is Likely To Fail," "Studies in Family Planning," Volume 20, No. 6, November/ December 1989, p. 1.
153 Testimony of Dr. James Sall before the Subcommittee on Legislation and National Security and the Subcommittee on Government Information, Justice and Agriculture, December 14, 1989, p. 313.
154 Testimony from Father Michael Pfleger before the Subcommittee on Legislation and National Security, July 28, 1990, pp. 37-38.
answers, then we are all going to be out there groping,
caught up in this war, and a casualty of the war. 156 Goode said that communities have begun to erect monuments in their neighborhoods in honor of the victims of the war on drugs.
Los Angeles drug treatment facilities have improved significantly during the past two years, providing an effective drug treatment network consisting of residential drug free, outpatient drug free, residential and outpatient, and outpatient/early intervention programs. Yet despite these improvements, Los Angeles exemplifies the plight of many major cities.
Despite its fundamental value to drug treatment and social services in general, this network is suffering from overload and lack of attention by funding sources. Agencies within this network have not had an increase in basic funding in over six years and although costs for personnel facilities, insurance and all other operating expenses have skyrocketed, these providers have continued
to keep their doors open. 157 According to Thelma Brown, representative of the Watts Health Foundation, while there has been improvement in the treatment system in Los Angeles, the lack of aftercare programs is severe.
One of the highest causes of recidivism occurs when a client leaves treatment. He or she is likely to be forced to return to the very same environment that contributed to the addiction in the first place. What awaits this individual is lack of employment-and, the old cycle of hopelessness and helplessness. What does he or she do but seek out that which is known best-drugs. This escape through drugs is sometimes used to dull the pain of frustration, or perhaps, as a way of survival. There should, and there must be, more treatment than what is currently available. Treatment must be extended beyond the programs. It must include structured, comprehensive, and meaningful aftercare that results in an improved quality of life. Given the severity of the problem, simple "band-aid” attempts at
treatment will lead only to a dead end. 158 Brown summed up the general sentiments of many providers in the inner city by stating:
In America, we need a mechanism to break the vicious cycle of generation after generation being caught up in abusing drugs. The ones most affected are the poor and the uneducated. For the majority, prevention and educa
156 Ibid., p. 21.
157 Statement of Pat Herrera Duran, before the Subcommittee on Legislation and National Security, July 2, 1990, p. 4.
168 Thelma Brown, op. cit., pp. 4-5.
tion is behind them, but there is still hope for their chil
dren-our children. 159 States are increasingly recognizing the complex nature of the drug crisis in the inner cities. The State of Wisconsin recently was awarded an $8.9 million federal grant to fund a three-year drug abuse treatment experiment in Milwaukee's inner city. While funds are sorely needed for treatment services in Milwaukee, there will be a difference in how it is spent. The new program will address other factors in the abuser's life likely to trigger a relapse, including unemployment, homelessness and poor health. This program actually addresses the root causes of inner city addiction.
While all states are experiencing difficulties in providing services to drug and alcohol dependent individuals, the lack of services for addicts seeking treatment disproportionately affects inner city poor abusers and those in communities of color.
Women, pregnant women and their babies Research has established that the problems of chemically dependent women are more related to the fact that they are women, than the fact that they are chemically dependent. Research also shows that there are more similarities between chemically dependent women and drug free women; than between chemically dependent men and women.160 Subsequently, treatment programs which ignore gender differences are less effective than those which address such differences. 161
As substance abuse among women of child-bearing age has increased dramatically, so has the number of pregnant women who have alcohol and drug problems. It is estimated that eleven percent (recent figures are as high as 15 percent) of pregnant women used alcohol and other drugs during their pregnancy, causing negative physical and psychological consequences for both the mother and child. 162 NIDA estimated in 1989 that over 5 million women of child-bearing age currently use an illicit drug, including almost one million who use cocaine and 3.8 million who use marijuana. In New York City alone, the number of birth certificates indicating maternal substance use has tripled from 730 in 1981 to 2,586 in 1987.163 In 1988, it has been estimated that at least 375,000 babies were born addicted; and each year, some 40,000 babies are born at increased risk because of their mothers' drinking during pregnan
According to Dooley Worth:
Drug dependent women . . . vary by age, race, ethnicity, class and economic status . Women who are dependent on drugs have, in fact, more similarities with non
160 Beschner, Reed and Mondanaro eds., "Implementing Strategies for Drug Dependent Women: An Introduction," Treatment Services for Drug Dependent, NIDA, 1981, vol. I, p. 1.
161 Dahlgern and Willander, "Are Special Treatment Facilities for Female Alcoholics Needed?”, Alcoholism Clinical and Experimental Research, vol. 13, No. 4, July-August 1989.
162 Brenda V. Smith, “Improving Treatment for Women: Work to Create or Improve Treatment for Women," ADRBD Awareness Week, January 1990, p. 25.
163 Statement of Wendy Chavkin, Chemical Dependency Institute, Beth Israel Medical Center before the Subcommittee on Health and the Environment, October 30, 1989, p. 1.
164 NASADAD, “The American Family and Alcohol and Other Drug Abuse," Background Paper, March 1990.