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Full text of "National Conference on Drug Abuse Research & Practice, an alliance for the 21st century : July 14-17, 1993, Washington, D.C. Renaissance Hotel, Washington, D.C. : Conference Highlights ; sponsored by National Institute on Drug Abuse"

NATIONAL INSTITUTE ON DRUG ABUSE 

2nd NATIONAL CONFERENCE ^_^ AN ALLIANCE 
ON DRUG ABUSE |B^ FOR THE 
RESEARCH & PRACTICE ^^^ 21st CENTURY 

July 14-17, 1993 • Washington, D.C. Renaissance Hotel • Washington D.C. 



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CONFERENCE HIGHLIGHTS 



NATIONAL INSTITUTES OF HEALTH 



NIDA Second National Conference on 

Drug Abuse Research & Practice: 

An Alliance for the 21st Century 

July 14-17, 1993 

Washington, D.C. Renaissance Hotel 

Washington, D.C. 



Conference Highlights 



Sponsored by: 

Natio n al . In s titute , on JDfl*&-Ak* » 
national institutes of health 



fJ!H U«R W 

BUHOiNG 10 
RETHESOA. MO 20892 



U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

National Institutes of Health 

Community and Professional Education Branch 

5600 Fishers Lane 

Rockville, Maryland 20857 






! / . ^ 



This publication was prepared for the Community and Professional 
Education Branch, Office of Policy and External Affairs, National 
Institute on Drug Abuse, by CSR, Incorporated, under Contract 
No. 271-92-2216. 



Disclaimer 

The opinions expressed in this volume are those of the authors and do not 
necessarily reflect the opinions or official policy of the National Institute on Drug 
Abuse or any other part of the U.S. Department of Health and Human Services. 

The U.S. Government does not endorse or favor any specific commercial product or 
company. Trade, proprietary, or company names appearing in this publication are 
used only because they are considered essential in the context of the material 
reported herein. 

Public Domain Notice 

All material appearing in this volume is in the public domain and may be 
reproduced or copied without permission. Citation of the source is appreciated. 



NIH Publication No. 94-3729 
Printed 1994 



Acknowledgments 



Special thanks to the External Planning Committee whose 
expertise, creativity, and tireless effort have substantially 
contributed to the outstanding program at this Second 
National Conference on Drug Abuse Research & Practice: An 
Alliance for the 21st Century. 



William Butynski, Ph.D. 

Diane Canova, Esquire 

Rene Cardenas, Ed.D. 

Ernest Chavez, Ph.D. 

Glen Fischer 

James Graham, J.D., L.L.M. 

Janice Griffin 

Anne Hill, MA. 



Linda Kaplan, M.A., C.A.E. 

M. Marlyne Kilbey, Ph.D. 

Jean Lau-Chin, Ed.D. 

David Mactas, MA. 

Mark Parrino, M.P.A. 

James Sorenson, Ph.D. 

Mel Tremper, Ph.D. 

Flavia Walton, Ph.D. 



Thanks also to the following groups: 

NIDA Drug Use and AIDS Community Education Network 

NIDA Hispanic Research and Technology Transfer Group 

Participants at NLDA's Conference on Overcoming 
Barriers to Drug Abuse Treatment 



III 



Contents 

Summaries of Plenary Sessions , 1 

Wednesday. July 14, 1993 

Welcoming Remarks l 

Richard A. Millstein 

Acting Director, NIDA 
Conference Host 

NIDA's New Role at NIH 1 

Ruth L. Kirschstein, M.D. 
Acting Director, NIH 

Twenty Years of Drug Abuse Research: Former NIDA Directors Look at What 

Has Been Learned 1 

William Pollin, M.D. 
Charles R. Schuster, Ph.D. 

Drug Abuse Research and Practice: Applying Today's Knowledge in Tomorrow's Programs 3 

Richard A. Millstein 

Thursday. July 15. 1993 

Drug Abuse and the Public Health 4 

Richard A. Millstein 

Remarks 4 

Peter Edelman, J.D. 

Counselor to the Secretary of Health and Human Services 

Keynote Address 4 

Lee P. Brown, Ph.D. 

Director, Office of National Drug Control Policy 

Drug Abuse Prevention and Treatment: Building the Infrastructure 5 

Elaine M. Johnson, Ph.D. 

Acting Administrator, SAMHSA 

Research and Practice: Point/Counterpoint 5 

Thomas Backer, Ph.D. 

Moderator of the Panel Discussion 

Friday, July 16. 1993 

A Videotaped Message From Donna Shalala, Ph.D., Secretary of Health and Human Services 7 

Remarks 7 

Richard A. Millstein 

Speaking Out for People in Recovery 7 

Maia Szalavitz 

Journalist, Recovering Addict 
Stan Novick 

National Alliance of Methadone Advocates 
Gerald Ribeiro 

Treatment on Demand 



NIDA Conference Highlights 



Saturday, July 17. 1993 

Looking Toward the 21st Century 9 

David Musto, M.D. 

Yale University 
Mary Jeanne Kreek, M.D. 

Rockefeller University 
Peter Renter, Ph.D. 

The RAND Corporation 
Richard A. Millstein 

Pacesetter Awards 13 

Summaries of Research Awareness Seminars 15 

Research Updates 

RS01 . Understanding Drug Addiction and the Brain 15 

RS02. Recent Trends in Drug Abuse Research 17 

RS03. Update on Drugs— Heroin and Synthetic Opioids 20 

RS04. Update on Drugs— Marijuana, Hallucinogens, and Inhalants 23 

RS05. Update on Drugs— Cocaine and Stimulants 25 

RS06. Update on Drugs— Tobacco 29 

RS07. Applications of Relapse Prevention to Addicted Populations: Problems, Prospects, and 

Promises 33 

RS08. Update on Drugs— Prescription Drugs 38 

RS09. Update on Drugs— Anabolic Steroids 41 

RS10. Drugs in the Workplace — Research Issues 42 

RSI 1 . Outcomes of Children of Substance Abusers 47 

RS12. Genetics and Drug Abuse 52 

Treatment 

RSI 3. Matching Patients and Treatments 57 

RS14. Dual Diagnosis and Drug Abuse Treatment 59 

RS15. Relapse and Relapse Prevention: The Why and How of It 64 

RSI 6. Drug Abuse-Associated Medical Problems and Their Impact on Daily Life 67 

RSI 7. Medications in Drug Abuse Treatment 72 

RSI 8. The Effectiveness of Methadone Maintenance Treatment: Special Consideration 

for Pregnancy and the Prevention of HIV Infection 75 

RS19. Behavioral Treatments for Drug Dependence 78 

RS20. Residential Treatment, Day Treatment, and Therapeutic Communities 82 

RS21 . Adolescent Diagnostic Assessment 84 

RS22. Family-Based Treatment for Adolescents 88 

RS23. Specialized Treatment for Pregnant and Parenting Teenagers 91 

RS24. Women's Assessment Procedures 93 

RS25. Women's Treatment Approaches: A Clinical Perspective 97 

RS26. Treatment for Pregnant and Postpartum Women and Their Infants 101 

RS27. Aftercare and Relapse Prevention 105 

RS28. Effective Case Management Methods With Drug Addicts: 

Research-Based Approaches 108 

RS29. Improving Drug Abuse Treatment: Findings From NIDA's Research 

Demonstration Projects 112 

RS30. Drug Abuse Treatment Outcome Study (DATOS) Research 116 

RS31 . Treatment Alternatives for Criminal Justice Clients 120 

RS32. Valid and Reliable Drug-Testing Techniques 123 

RS33. The D.C. Initiative: A Federal/State Research Project 125 



VI 



Contents 

Prevention and Epidemiology 

RS34. Prevention Research Evaluation 129 

RS35. Multicultural Aspects of Prevention Research Programs 132 

RS36. Risk and Protective Factors in Adolescent Drug Use and Abuse 134 

RS37. The Drugs and Violence Connection: Underlying Psychosocial Factors 137 

RS38. Physical and Sexual Abuse 142 

RS39. Communitywide Drug Abuse Prevention Approaches 145 

RS40. Family and School Prevention Programs for High-Risk Youth 151 

HIV/AIDS 

RS41 . Substance Abuse and HIV/ AIDS 153 

RS42. HIV/AIDS and Women 156 

RS43. Effectiveness of Teaching Safe Sex Practices With Drug Abusers 161 

RS44. HIV/AIDS Outreach Intervention Research 164 

RS45. Substance Abuse, HIV/AIDS, and Tuberculosis 168 

Summaries of Issues Forums 175 

Special Populations 

IF01 . Addressing Special Population Needs: Gays and Lesbians 175 

IF02. Addressing Special Population Needs: African-Americans 179 

IF03. Addressing Special Population Needs: Asians and Asian/Pacific Islanders 181 

IF04. Addressing Special Population Needs: Hispanics 185 

IF05. Addressing Special Population Needs: Native Americans 189 

IF06. Substance Abuse and DisABiLfTY Issues 189 

Treatment 

IF07. Current Perspectives on Models of Case Management 191 

IF08. Methadone Treatment Issues 194 

IF09. Cigarette Smoking Policies in Treatment Programs 197 

IF 10. Selecting Pharmacologic Treatments for Use in Drug Abuse Treatment Programs 199 

IF! 1 . Acupuncture and Other Alternative Treatments 201 

IF1 2. Recovery With and Without Treatment 203 

IF13. Patient Placement and Treatment Outcome 207 

IF14. Juvenile Justice 209 

IF 15. Evaluation Results To Improve Program Functioning 213 

IF16. Treatment and Prevention in Rural Settings 215 

IF1 7. Providing Ancillary Services in Drug Abuse Treatment 217 

IF18. Use of the Problem Oriented Screening Instrument for Teenagers (POSIT) in Case 

Management and Clinical Practice 221 

Research 

IF19. Questions and Answers on Drug Addiction and the Brain 223 

IF20. Drug Abuse Research Along the U.S./Mexico Border 226 

IF21 . NIDA Meets With Practitioners About Future Research Needs 229 

IF22. Child Abuse and Neglect 234 

Policy/ Administration 

IF23. The Changing Drug Abuse Treatment System: Service and Research Implications 237 

IF24. Questions and Answers on Drug Abuse and Legal Issues 241 

IF25. Legislative Issues in Drug Abuse 243 

IF26. Public-Sector Funding Resources 245 

IF27. Private-Sector Funding Resources 249 



vii 



NIDA Conference Highlights 



IF28. Using Information From This Conference in Day-to-Day Practice 252 

IF29. Technology Transfer to the Drug Abuse Community 256 

Substance Abuse and HIV/ AIDS 

IF30. Substance Abuse, HIV/ AIDS, and Tuberculosis: Implications 

for Treatment Programs 259 

IF31 . Needle Exchange and Street Outreach 261 

IF32. Strategies for More Successful Technology Transfer: 

State and Federal Collaboration 266 

IF33. Crack and HIV: Sex for Drugs— What This Means About the Spread of AIDS 268 

Prevention 

IF34. Message Development for Community Education 271 

IF35. Prevention and Primary Care 272 

IF36. Use of the Media in Prevention and Treatment Awareness 275 

Summaries of Workshops 277 

WS01 . Recovery Training and Self-Help: A Relapse Prevention Model 277 

WS02. Cue Extinction 277 

WS03. Contingency Management in Methadone Treatment Programs 277 

WS04. Contingency Management in Drug-Free Programs 277 

WS05. Evaluating Drug Abuse Treatment Programs 277 

WS06. Assessment of Adult Drug Abuse Clients Using the Addiction Severity Index (ASI) 277 

WS07. Family Approaches to Treatment 278 

WS08. Communitywide Drug Abuse Prevention Approaches 278 

WS09. A School-Based Prevention Program for High-Risk Youth 278 

WS10. AIDS Prevention: Reaching Women at Risk 278 

WS1 1 . HIV/AIDS Prevention for African-Americans 278 

WS12. HIV/AIDS Prevention for Hispanic Women 278 

WS13. HIV/AIDS High-Risk Adolescent Prevention 278 

WS14. Assessing the Extent of Drug Use and Abuse in the Community 279 

WS15. Siting Drug Abuse Treatment Facilities Successfully : 279 

WS16. Building Local Support for Drug Abuse Treatment 279 

WS17. Improving Effectiveness of Treatment for Chemically Dependent Women Through 

Specialized Training 279 

Film Festival Summaries 281 

Posters 283 

Luncheon Table Topics 285 

Exhibitors and Computer Demonstrations 287 

Directory of Speakers 289 



VIII 



Summaries of Plenary Sessions 



WEDNESDAY, JULY 14, 1993 

Welcoming Remarks 

Conference Host: Richard A. Mlllstein 

Acting Director. NIDA 

NEDA's First National Conference on Drug Abuse 
Research and Practice was held in January 1991. The 
United States has continued to see a decline in drug use 
among the general population. However, at the same 
time, there is increasing variability in drug use among 
subpopulatdons according to age, gender, and race. The 
medical consequences of drug abuse have increased 
significantly; for example, incidences of HIV/AIDS and 
tuberculosis (TB) have increased. The NIDA Second 
National Conference on Drug Abuse Research and 
Practice brought together drug abuse researchers and 
prevention and treatment practitioners to share recent 
promising research findings and to explore ways to 
apply these findings in day-to-day practice. 

NIDA reached a major turning point when it joined NIH 
in fall 1992. This union has given NIDA a strengthened 
mandate for research and has heightened the legitimacy 
of NIDA research. It also has established drug abuse as 
a medical and health problem requiring biomedical and 
behavioral treatment, just like other major diseases. 

NIDA's New Role at NIH 

Speaker: Ruth L. Kirschstein. M.D. 
Acting Director. NIH 

More than 9 months ago, NIH enthusiastically welcomed 
the inclusion into NIH of NIDA, along with NIMH and 
NIAAA. NIH is pleased to have the Institute's specific 
focus be on the integration of behavioral and biomedical 
research. This merger is significant in its reflection of 
the biological roots of addiction and the behavioral and 
biological approaches to preventing and treating addic- 
tion. This conference was extremely important in 
demonstrating the significance of this multiple approach 
to drug abuse research, prevention, and treatment and 
in sharing information on the complex social and 
medical problems overwhelming individuals and commu- 
nities. For instance, research can help elucidate the 
relationship between drug abuse and violence, child 
abuse, relapse, HIV/AIDS, TB, and other problems. 

The marriage of NIDA with NIH should promote greater 
collaboration among all the Institutes. For instance, 
NIDA currently is engaged in an ongoing collaborative 
effort with the National Institute of Allergy and Infec- 
tious Diseases on drug use and abuse, as well as 
HFV-related issues, which has facilitated the further 
collaboration necessary to address the issue of TB among 
drug abusers. NIDA also is working with the National 
Institute of Child Health and Human Development on 



studies concerning the neurodevelopmental outcomes of 
drug-exposed versus nondrug-exposed children. Fur- 
thermore, in collaboration with the National Cancer 
Institute; the National Heart, Lung, and Blood Institute; 
and the National Institute of Neurological Disorders and 
Stroke, NIDA is studying the effects of one of the most 
broadly used drugs in the United States (particularly 
among women) — nicotine. NIDA also is playing a major 
role in piloting a large-scale, multidepartmental "human 
brain project," in which nine NIH components, two 
additional Federal agencies, and the National Science 
Foundation are working together to develop computer- 
ized maps of the brain in both normal and diseased 
states. This research will enable neuroscientdsts to 
understand better the biology of drug abuse. Another 
example of NIDA's collaborative role within NIH is its 
cooperation with NIMH in examining drug-related 
violence. 

Advocates of NIDA's merger with NIH believed that 
incorporating drug abuse as a researchable disease 
within NIH would destigmatdze the disorder, so that 
individuals suffering from addiction would be treated as 
patients, not social outcasts. Treatment for addiction 
must become not only widely available but must be 
applied with care and love. The Clinton Administration 
is taking a step in that direction with the Health Care 
Reform Task Force's serious consideration of incorporat- 
ing basic benefits for drug and alcohol abuse and mental 
health services. 

Twenty Years of Drug Abuse Research: 
Former NIDA Directors Look at What 
Has Been Learned 

Speaker: William Pollln. M.D. 

Today we are encountering a cultural sickness, partly 
evidenced by a tendency to ignore institutional success. 
For instance, we are aware all too often of NIH's prob- 
lems but not its strengths. When NIDA was estab- 
lished — in the mold of NIH's emphasis on scientific 
excellence — it supported a strong program of basic 
science research. 

During my tenure as head of NIDA, beginning in 1978, 
several major successes occurred. The first major 
success was the opiate receptor endorphin studies. 
Researchers on this project made threshold discoveries 
that marked a change from focusing on plant alkaloids 
to brain chemistry, opening up rational explanations for 
why certain substances are powerfully addictive. 
Second, NEDA moved the intramural program from 
Lexington, Kentucky, to the Baltimore, Maryland, 
campus. Third, NIDA played a major role in influencing 
Congress to accept tobacco as part of the Institute's 
mandate to reduce the incidence of substance use in the 



NIDA Conference Highlights 



U.S. population; however, this was only a partial suc- 
cess, since smoking remains popular among youth. 

NIDA grew out of a culture led by psychiatry and 
consequently encountered internal conflicts over the 
need to include, as the core of its institutional identity, 
the slogan "Just Say No" (to drugs), developed as part of 
the Reagan and Bush Administrations' abstinence 
approach. NIDA needed to achieve Institute-wide 
acceptance of a policy that essentially viewed the 
national drug policy as the "Churchillian" definition of 
democracy — a terrible policy, but one that was better 
than all others. Although much time and effort went 
into obtaining a working internal consensus on that 
view, these efforts helped make other achievements 
possible. 

At least two major failures also occurred during this 
time. NIDA had hoped to develop new pharmacological 
agents and to determine the essence of what works in 
therapeutic communities, apply it more broadly, and 
then develop new treatment concepts. Unfortunately, 
the input of more researchers into these new research 
areas did not yield any breakthrough improvements in 
clinical treatment. Second, it was hoped that these 
therapeutic goals would lead to success in the way that 
in the 1840s Semelweis discovered how to prevent 
childhood fever before having any concept of the central 
mechanism involved in fever; Semelweis' answer was 
neither accepted nor implemented. Similarly, NIDA had 
difficulty communicating the nature of addiction. 

Addiction concerns the loss of control of behavioral 
choices (more so than with tolerance and withdrawal). 
It is necessary to understand the neurophysiology and 
neuroanatomy of behaviors, such as a choice, will, and 
commitment to behavioral change, before a rational 
understanding and approach to the treatment of addic- 
tive behaviors can be achieved. However, only in the 
past year has neuroscience truly begun to understand 
the neurophysiology of complex functions such as 
memory. At the time, this failure revealed a missed 
institutional opportunity to integrate into one institute 
of addictive disorders all the scattered programs in PHS 
that deal with loss of control. It is hoped that such an 
integration still may occur with enhanced policy and 
funding. 

Finally, there was a "success that wasn't." Drug use 
incidence increased rapidly in the 1970s, peaked in 1978, 
and then decreased. This downward trend indicated 
that NIDA's work was having a positive effect on drug 
abuse prevention and treatment efforts. It also was 
found that this trend corresponded directly with the 
proportional decrease of adolescents to the total popula- 
tion; NIDA alone could not claim credit for the down- 
ward turn of drug abuse. In the past year, for the first 
time in three decades, the number of adolescents again 
is increasing, and drug abuse is increasing among 
teenagers. NIDA must watch this trend carefully to 



avoid being surprised by another sharp increase in drug 
abuse as staff, dollars, and priorities are being reduced. 

Speaker: Charles R. Schuster, Ph.D. 

During my tenure as NIDA Director, NIDA's budget 
grew from $85 million to more than $400 million. 
Phenomenal growth took place at NEDA during that 
time period, largely due to the need to respond to the 
dual epidemic of cocaine abuse and HIV/AIDS. The 
increase in funding facilitated an increase in the number 
of grants from approximately 500 to 1,300, as well as an 
increase in the scope of the grants. This broad, multi- 
disciplinary scope is essential to understanding the 
complex issues associated with drug addiction and AIDS. 
The field needs molecular biologists, neurochemists, 
pharmacologists, clinicians, behavioral scientists, and 
researchers in other disciplines to collaborate on the 
myriad of problems associated with drug abuse. 

The increase in NIDA funding also was due to the 
recognition that injection drug use was largely respon- 
sible for the spread of HIV infection. One-third of the 
current AIDS cases in the United States are associated 
with drug abuse due to needle-sharing and the propen- 
sity of drug users to engage in high-risk sexual behavior. 
It became apparent that NIDA's mission of understand- 
ing the causes and consequences of drug abuse was vital 
to curtailing the spread of HIV. This recognition in part 
led Congress to add $10 million to the 1988 Anti-Drug 
Abuse Act for developing new medications for drug 
dependence; this spawned the formation of the Medica- 
tions Development Division. Progress is occurring in 
this area. For instance, the drug LAAM obtained FDA 
approval recently for the treatment of opiate dependence 
and will be available soon. Also, researchers have 
developed a depot form of naltrexone, a narcotic antag- 
onist that appears to be an effective drug abuse treat- 
ment. Medications are not the answer to drug abuse, 
but they may be a valuable component of comprehensive 
drug abuse treatment and rehabilitation. 

Treatment on demand is an unfulfilled promise, and 
many drug abusers never seek treatment. This lack of 
treatment makes the spread of HTV infection more 
likely. In 1987 NIDA started the National AIDS Dem- 
onstration Research Program to educate and treat 
injecting drug users and their sexual partners. The 
program, which has funded 41 AIDS community out- 
reach programs in 63 sites across the United States, has 
two primary goals: (1) to better understand the behavior 
of people who are not receiving treatment and (2) to 
develop, implement, and evaluate targeted interventions 
for those people. 

During my tenure as director, NIDA held its First 
National Conference on Drug Abuse Research Practice. 
Both researchers and practitioners profited a good deal 
from that conference, and it is hoped that this confer- 



Summaries of Plenary Sessions 



ence will have served as a continuation of the essential 
dialogue between researchers and practitioners. 

Drug Abuse Research and Practice: 
Applying Today's Knowledge in 
Tomorrow's Programs 

Speaker: Richard A. Mlllsteln 

NIDA research consistently has shown that, like many 
other diseases, drug addiction is preventable, measur- 
able, and treatable. Long-term funding in the addiction 
sciences can improve the quality of life for millions of 
people, decrease health care costs, and help fight com- 
municable diseases such as AIDS and TB. At the close 
of 1992, the number of adults and adolescents diagnosed 
with AIDS — as reported to the Centers for Disease 
Control and Prevention — totaled nearly 250,000; one- 
third of these cases were linked to drug abuse. Drug 
abuse also affects society through related crime and 
violence, decreased productivity of the Nation's work- 
force, and developmental deficits among newborn 
children of drug abusers. 

Much work remains in this field. Because the stigma of 
drug addiction remains — along with the misperception 
that addiction stems from a lack of willpower rather 
than biology and behavior — drug abusers encounter 
limited access to treatment. Drug addiction is a disease 
requiring a strengthened scientific base. Toward this 
end, NIDA's missions include the following: (1) improv- 
ing the scientific understanding of drug abuse preven- 
tion and control, (2) decreasing the demand for illicit 
drugs, (3) transferring research-based findings to 
practice, and (4) working with the practitioner commu- 
nity. 

The merger of NIDA with NIH is significant for NIDA, 
the field, and the individuals that NIDA serves because 
this merger associates studies on the disease of drug 
addiction with other biomedical and behavioral research 
efforts. Congress has affirmed that drug abuse is a 
disease that deserves the same personal compassion, 
scientific rigor, and funding as other diseases. NIDA 
supports 88 percent of drug abuse research in the 
United States, the highest of any of the health Insti- 
tutes; very little funding comes from the private sector. 
Therefore, the American public must be educated about 
the value of drug abuse research. NIDA's joining with 
NIH has facilitated expanded collaboration among NIDA 
and other NIH Institutes. The reorganization has 
revealed the vital links between research and practice 
and the necessity for collaboration among NIDA, NIH, 
and SAMHSA. SAMHSA's mission is to ensure that the 
most recent research is used effectively to prevent and 
treat substance abuse; NIDA therefore will continue to 
work closely with SAMHSA. 

NIDA now must support the strengthened scientific 
foundation of a treatment and prevention program. 



Since its formation in 1974, NIDA's unique breadth, 
scope, and diversity of research have demonstrated the 
comprehensive approach necessary to address drug 
addiction. NIDA's support of rigorous scientific research 
in many disciplines has contributed to an understanding 
of drug abuse. However, due to current fiscal con- 
straints, NIDA must refocus its priorities. In the past 2 
years, NIDA has been formulating 5-year research plans 
in the following six key scientific areas: (1) nonpharma- 
cological treatments, (2) HIV infection and AIDS, 
(3) maternal and fetal effects of drug abuse, (4) medica- 
tions development, (5) epidemiology and prevention 
research, and (6) neuroscience. NIDA also is giving 
special attention to minority health care and women's 
health. These plans have generated proposals for 
enhancements and redirection in all of NIDA's research 



In addition, NIDA will be emphasizing three major 
initiatives in 1994. First, NIDA will focus on behavioral 
therapies — the most frequent treatment for drug abuse. 
The assessment of behavioral therapies is still in its 
early stages, and NIDA will apply a rigorous evaluation 
process to psychosocial and behavioral therapies. This 
will involve small-scale studies along with large-scale, 
multisite clinical trials. Based on this research, NIDA 
then will develop educational materials for practitioners 
through its technology transfer program. NIDA will 
work to successfully combine medications and the most 
effective behavioral therapies into comprehensive 
treatment programs. The second major initiative is 
continuing NIDA's medications development program, 
with emphasis on winning FDA approval of effective 
medications for drug treatment. Only three medications 
have been approved for drug abuse indications: 
(1) methadone, (2) naltrexone, and (3) LAAM. It is 
hoped that two other drugs — buprenorphine and cloni- 
dine — will win approval within the next 2 years. With 
recent research developments, NIDA hopes to develop 
antagonist medications for cocaine as well. NDDA's third 
major initiative builds on basic biological research that 
has demonstrated that drug addiction is a disease of the 
brain and behavior. In Fiscal Year 1994, NIDA will 
expand a neuroscience program in the area of human 
studies with a clinical neuroscience initiative. Research- 
ers will measure neuroanatomical, chemical, and physio- 
logical outcomes associated with drug use. This type of 
research is critical to improving treatment and preven- 
tion. 

In support of new legislative initiatives, NIDA's research 
agenda will incorporate a strong emphasis on health 
services research, which is critical to justifying the 
inclusion of drug abuse treatment within a national 
health care system. NIDA's treatment and services 
research programs will build on past research, which 
has demonstrated that treatment can be effective. 

NIDA is both a research agency committed to the 
advancement of scientific knowledge and a part of PHS 



NIDA Conference Highlights 



committed to improving the health of all Americans. 
Therefore, NIDA is dedicated to both research and the 
application of that research through its technology 
transfer program and through mutual sharing between 
researchers and practitioners. Working more closely 
with practitioners is, and will remain, one of NIDA's 
highest priorities. 



THURSDAY, JULY 15, 1993 

Drug Abuse and the Public Health 

Conference Host: Richard A. Mlllsteln 

Remarks 

Speaker: Peter Edelman. J.D. 

Counselor to the Secretary of Health 
and Human Services 

With the new Federal Administration and the recent 
reorganization of ADAMHAinto SAMHSA, professionals 
in the field of substance abuse face many changes and 
have new opportunities for enhancing research and work 
in the field. Although many people are skeptical of this 
reorganization, it is important for everyone to work 
collaboratively to ensure its success. 

Workers in the substance abuse field face a number of 
important challenges. First, they face the challenge of 
building a genuine service system for treatment and 
prevention. Despite the significant number of individual 
programs in operation across the country, not enough 
exist and there is little sense that the programs and 
research work together. Additionally, workers in the 
substance abuse field face the challenge of putting the 
accumulated knowledge of the drug abuse field to better 
use; partnerships must be developed within government 
and especially in communities. Special populations, 
such as the homeless or those who are HIV positive, 
must receive special attention, as must their families. 
It is imperative to incorporate proven research findings 
into prevention and treatment programs. Workers in 
the substance abuse field also must face the challenge of 
closing an especially glaring gap in the provision of drug 
treatment for prison inmates. Furthermore, depart- 
ments of the Federal Government must work together to 
close this gap and save money while assisting these 
individuals. 

Health care reform is a major area of national debate. 
It can be anticipated that the reform will include greater 
access to a broad array of services for individuals with 
persistent substance abuse disorders; encouragement for 
alternatives to hospitalization, such as home-based 
treatment; incentives to allow for the delivery of services 
in the least restrictive environment that is appropriate 
to an individual's needs; and encouragement for early 
intervention through incentives to initiate substance 



abuse treatment. In addition to the health care reform 
changes, new grants and programs are necessary to 
create a service infrastructure and provide supplemen- 
tary funding for services, especially in the criminal 
justice system. Furthermore, much attention must be 
focused on changing American health behavior, which 
could have a vast impact in preventing disease and 
facilitating savings of up to $90 billion each year in 
health care costs. Substance abuse workers must convey 
the importance of prevention, which often is too easily 
dismissed. The Clinton Administration is committed to 
investing in prevention to facilitate better studies, 
provide more resources, and develop more culturally 
appropriate messages. 

Prevention must be a priority but cannot be viewed in 
isolation. Prevention efforts must be additive and 
cumulative. People must learn to take responsibility for 
themselves, change their behaviors, and rejuvenate their 
value systems. Public policy by itself is not enough. 
Communities must be rebuilt because healthy individu- 
als grow up in healthy communities. Everyone must 
work together on this task. Social ills can be erased 
only by rebuilding the foundations of opportunity. 

Keynote Address 

Speaker: Lee Brown. Ph.D. 

Director. Office of National Drug Control Policy 

NEDA is the world's premier drug abuse research 
agency; its programs embrace many areas of study and 
research essential for policy planning. Research on drug 
use in the United States has provided considerable 
information on who uses what drugs and with what 
consequences. Recent news has been both good and bad: 
The National Household Survey on Drug Abuse indi- 
cates that the number of occasional drug users is falling, 
especially among young people; that frequent use of 
cocaine and alcohol has remained constant for the past 
7 years; and that there appears to be a resurgence of 
heroin use. 

The principal problem lies with the heaviest users of 
drugs and the subsequent diminishment of their physi- 
cal and psychological health. Other problems persist. 
Many schools in high-intensity drug environments 
cannot effectively perform their missions, and many 
American businesses are experiencing an increased 
number of accidents and reduced productivity due to 
drug use. Inner cities are experiencing criminal and 
social violence, and the criminal justice system is 
overwhelmed by the drug problem. For taxpayers, the 
burden is immense. That is why more attention must be 
focused on reducing the number of heavy drug users. 

The Office of National Drug Control Policy's drug control 
strategy incorporates many important elements. Reduc- 
ing the overall demand for drugs is the paramount 
national goal, and reducing the level of drug use and the 
number of hardcore users also are critical. The criminal 



Summaries of Plenary Sessions 



justice system alone cannot combat the drug problem; 
prevention programs are needed, particularly for young 
people in inner cities, to avoid new high levels of drug 
use. Communities must be empowered to prevent drug 
use, and more and better treatment must be made 
accessible, particularly as part of alternative sentencing 
for nonviolent criminal offenders. Community policing 
also must be an important part of an effective drug 
strategy by discouraging criminal behavior and taking 
back neighborhoods from drug dealers. 

Drug use should not be legalized. The recent declines in 
drug use are largely attributable to the legal prohibition 
against use. Legal prohibition supports antidrug 
education, whereas the legalization of drugs is a formula 
for self-destruction. The National Drug Control Strategy 
stresses the importance of research and evaluation to 
help determine the best means to prevent and treat drug 
use. Drug strategies should be based not on ideologies 
but on empirically based data. Researchers must 
translate the results of their work into successful 
practice. Additionally, to adequately understand the 
extent of the drug problem, a new survey is needed to 
identify those drug users, usually heavy drug users, who 
are homeless and live in transient housing. The 
Nation's research objectives should include (1) improved 
understanding of the nature and causes of hardcore drug 
use, (2) the evaluation of all strategies to control drug 
use, (3) more effective knowledge transfer, (4) ways to 
make the criminal justice system more responsive to the 
needs for drug treatment and prevention, and (5) ways 
to ensure the availability of effective behavioral treat- 
ments to service providers. Such research and evalua- 
tion must play increasingly significant roles in the 
Nation's drug control strategy. 

The United States cannot measure its commitment to 
fighting drugs by how much money it spends. An 
effective strategy requires a significant amount of 
resources, but in an era of tight Federal budgets, 
positive results must be shown. Thus, better indicators 
of program effectiveness are essential. 

Drug Abuse Prevention and Treatment: 
Building the Infrastructure 

Speaker: Elaine M. Johnson, Ph.D. 

Acting Administrator. SAMHSA 

NIDA's research enterprise aims at reducing drug 
problems through research. Likewise, SAMHSA 
addresses the same goal with prevention and treatment 
services. SAMHSA must use the knowledge gained from 
research and its own programs to implement effective 
systems of care. To that end, the agency is developing 
a more responsive infrastructure to integrate findings 
from drug abuse research into action. It is hoped that 
with the reorganization of ADAMHA into SAMHSA will 
come a clearer focus of Federal substance abuse 
resources. While SAMHSA emphasizes service delivery, 



it has a mandate to support and integrate research 
results into its initiatives. Therefore, forging and 
maintaining linkages between SAMHSA and research 
institutes are priorities. 

SAMHSA's highest priority, however, is meeting the 
needs of individuals with or at risk of developing addic- 
tive disorders, along with the needs of their families and 
communities. Through service programs, demonstra- 
tions, and training activities, SAMHSA identifies 
problems and generates service-related hypotheses and 
questions that research can address. Substance abuse 
prevention and treatment require an appreciation of the 
complexity of community dynamics, and research 
findings must be applicable to the problems experienced 
by substance-abusing populations. SAMHSA provides 
the research community with program evaluations that 
are usable, understandable, and credible. Also, 
SAMHSA has developed a strategic plan with a frame- 
work for action over the next several years by facilitat- 
ing a more effective use and coordination of Federal 
resources to address drug and alcohol problems. 

SAMHSA's mission targets four primary elements: 

(1) access, (2) quality, (3) empowerment, and (4) knowl- 
edge utilization. First, SAMHSA intends to maximize 
prevention, treatment, outreach, and rehabilitation by 
establishing productive linkages with health care 
organizations and other social systems and by develop- 
ing culturally competent services for all Americans. 
Second, it is vital to have services that are of the highest 
quality, based on the most current knowledge, and 
properly matched to the people being served. Third, the 
empowerment of individuals who need services gives 
meaning to increased access and improved quality, and 
through education, consumers of services are better able 
to participate actively in prevention and treatment. 
Finally, the fostering of knowledge through program- 
matic evaluation is the foundation of SAMHSA's strate- 
gic approach and enables the determination of what 
works and what does not work. In these four areas, 
SAMHSA is placing special emphasis on three currently 
underserved populations: (1) children and adolescents, 

(2) individuals with or at risk for HIV and AIDS, and (3) 
women. 

The establishment of SAMHSA marks the beginning of 
the construction of a solid and resilient nationwide 
infrastructure to assist people suffering from addiction 
and mental disorders. SAMHSA is dedicated to the 
needs of research, practice, and the American people. 

Research and Practice: 
Point/Counterpoint 

Moderator: Thomas Backer, Ph.D. 

While many innovations developed by researchers are 
being used by practitioners, others have not moved from 
the research laboratory into the community. This gap 
between knowledge and its use may exist for three 



NIDA Conference Highlights 



possible reasons: (1) the gap may reflect a shortage in 
resources; (2) it may reflect a shortage in motivation; or 
(3) it may result from yet another gap between research- 
ers and practitioners, who often do not speak the same 
language and have different objectives and perspectives. 
The most powerful force for closing the gap between 
knowledge and its use is through human interaction 
among researchers, practitioners, clients, community 
leaders, and many other individuals. 

Speaker: George De Leon. Ph.D. 

A new paradigm for technology transfer in treatment 
research settings centers on "cross-fertilization" and goes 
beyond dissemination. Not only must research results 
be disseminated to practitioners and other individuals, 
but research must involve all of these people from the 
beginning in defining problems, developing evaluation 
designs, and conducting other related activities. 

Speaker: Patricia Evans, M.D. 

Resources generally are not sufficient for institutionaliz- 
ing research findings. Practitioners operate under many 
constraints, and funding simply is not available for them 
to implement exciting research results, which could be 
extremely valuable to their clients. 

Speaker: Herbert Kleber, M.D. 

The problems faced by researchers and practitioners in 
substance abuse are not unique. The main problem, 
however, usually lies with the researchers. It is true 
that clinicians sometimes are unwilling to suspend their 
ideologies, such as those regarding methadone doses, or 
their beliefs, such as those regarding the use of medica- 
tions, even when no data base demonstrates that they 
work. But researchers may not be doing their job 
adequately — for example, studies frequently exclude 
many of the types of patients treated in the real world. 

Speaker: Linda Lewis 

In bringing together research and practice, five sugges- 
tions may be worthwhile: (1) teach the practitioner 
community about research; (2) aggressively move drug 
abuse research out of the laboratory and into the field; 

(3) increase efforts directed at treatment, behavioral 
research, and applied health services research; 

(4) rethink technology transfer; and (5) when research 
indicates a method that works, use it. 

Speaker: David Mactas. M.A. 

Three to five years of funding for a research project are 
fleeting, and research application is too rare and insig- 
nificant. When the two meanings of R.I.P. — "research in 
progress" and "rest in peace" — fuse, practitioners become 
discouraged, because nothing happens after their brief 
collaboration with researchers. Researchers and practi- 



tioners must become more unified in their collaboration 
and communication. 

Speaker: Rafaela Robles, Ed.D. 

Researchers often focus their work in response to 
prestige, power, and money, as the academic community 
expects. However, researchers lack linkages with 
service providers. Researchers must ask themselves to 
whom they respond — to the research community or to 
the people they serve. 

Speaker: Susan Rusche 

The barriers largely are self-made, often relating to the 
complexity of research technology and a lack of respect 
for each other's work. Throughout the past two decades, 
citizens have taken more responsibility for dealing with, 
for example, parents and community partnerships, but 
such activities seldom are measured. Typically, if 
something is not measured, it is considered not to work, 
and if the Government does not fund a project, nothing 
happens at all. Workers in the drug abuse field must 
overcome these axioms. 

Speaker: Flavia Walton. Ph.D. 

The most significant barrier to unifying research and 
practice is the lack of communication between them. 
Pour basic aspects of this barrier in the drug abuse field 
include the following: (1) research is perceived as 
unrelated to the reality of the practitioner, (2) research 
is exclusive and misses valuable data, (3) there is a need 
for better dialogue between researchers and practi- 
tioners, and (4) there is a need for mechanisms to 
translate practice into research — a transition from 
demonstrations into the research arena. 

Questions, Answers, and Comments 

How can researchers work more intimately with and in 
communities, as practitioners desire? First, researchers 
can be housed in community-based settings and pro- 
grams. Program-based research should be a new mode 
of research, bringing clients, program administrators, 
and researchers together. In Puerto Rico, Dr. Robles is 
conducting NIDA research in a treatment community. 
She has found it easier to communicate her work to the 
people in treatment centers. Careful research is not 
always necessary, however, to recognize when something 
works or does not work. The research trick is how to 
reveal moderate differences that are important to 
treatment. Researchers therefore might want to focus 
more on larger trials with more of the "real" people 
whom practitioners are trying to reach so that results 
will be more relevant. Furthermore, NIDA has the 
obligation to train new researchers who come from the 
community, and these people may become more involved 
in peer review. In addition, NIDA and others may want 
to explore how to reinforce the integration and structure 



Summaries of Plenary Sessions 



of research within program operation, so that research 
becomes not an elective but a necessity in program 
operation. Research must become part of the structure 
of treatment. Research requires a long time to produce 
valid results, and when working at a community treat- 
ment level, it would be helpful to market the short-term 
benefits that programs receive when they have access to 
research in their treatment settings. Practitioners must 
be able to use research findings more quickly, even if the 
findings are in their preliminary stages. 

How do the special problems of women and their infants 
and children relate to the discussion of collaboration 
between researchers and practitioners? When the crack- 
cocaine epidemic began to affect women and infants, it 
moved from a substance abuse issue into the health 
field. When working with a pregnant, addicted woman, 
a practitioner deals with her from a treatment and 
prevention perspective — two arenas that must be 
bridged effectively. All workers in the drug abuse field 
must engage in more effective interdisciplinary dialogue 
and need to maximize dwindling resources. 

What arguments can be used to increase funding in 
important areas and bridge the gap between researchers 
and practitioners? First, NIDA demonstration grants 
showed that certain methods worked, but then those 
methods were not translated into other places. There 
must be a nexus among research, treatment, and 
prevention so methods that have been shown to work 
will be translated into dollars on the treatment and 
prevention side. Second, at the local level, the capability 
to develop needed grants must be enhanced. Sometimes 
conflict between research and practice can be useful, and 
the issue may be not so much how to ameliorate this 
conflict as how to sublimate it. 

It is critical not only to develop new knowledge but to 
better apply the knowledge that already has been 
discovered, such as the difference in the retention rates 
between the best and worst programs. Funding agencies 
must be willing to hold programs to certain standards in 
order to receive funding. The research community also 
should give more prestige to the intervention research 
projects in the community. 

Two structural changes must be considered. First, can 
funding agencies build into treatment grants designated 
funding for the translation and dissemination of infor- 
mation directly at the program site level where the 
research was carried out? Second, how can programs be 
moved into continuance beyond the grant period? 
Workers in the drug abuse field have done a poor job 
communicating their needs to Congress. It is ludicrous 
that research and demonstration funding, but not 
replication funding, are available. 



FRIDAY, JULY 16, 1993 

A Videotaped Message from 
Donna Shalala, Ph.D., Secretary 
of Health and Human Services 

Drug abuse is not just a problem for drug addicts — it 
affects everyone through its direct link to other social 
problems such as crime and violence. Studies show that 
the overall use of illicit drugs has been declining, largely 
due to the increased emphasis on prevention. However, 
several disturbing trends remain. For instance, a recent 
NIDA study showed that, while rates of drug use among 
high school seniors were decreasing, rates of drug use 
among eighth graders were increasing. It is necessary, 
therefore, to renew efforts in research, prevention, and 
treatment through a comprehensive approach and a 
major national commitment to reduce the demand for 
illicit drugs. For many people, drug abuse is both a 
symptom of and a response to hopelessness and alien- 
ation. Too many racial and ethnic minorities are 
clustered at the bottom of the economic and social 
ladder, and too many youth do not believe that educa- 
tion will bring them jobs and respect. Continued 
research efforts are needed in conjunction with local 
action and leadership to combat drug abuse. NIDA and 
other Government officials need to hear from practi- 
tioners and others about what is occurring in commu- 
nities across the country and how these communities 
may best be served. 

Remarks 

Speaker: Richard A. Millstein 

An exciting recent development in the drug abuse 
treatment field is the advocacy movement of former drug 
addicts who are representing their vital interests in 
obtaining treatment and other health care services. The 
advocacy movement has led to the following: (1) the 
creation of new role models who have been successful in 
treatment, (2) the destigmatization of drug addiction, 
and (3) the development of increased prevention and 
treatment services for drug addiction and related 
medical problems. More role models are needed in the 
drug abuse arena. In addition, the partnership that is 
being forged between researchers and practitioners must 
include the voices of patients themselves. 

Speaking Out for People in Recovery 

Speaker: Mala Szalavltz 

Many myths exist about drug addiction; therefore, it is 
crucial that recovering addicts become more open about 
their addiction in order to debunk these myths. For 
example, one myth involves the public's image of a drug 
addict as a poor, undisciplined, vicious criminal of color. 
In fact, the majority of drug addicts are Caucasian, and 



NIDA Conference Highlights 



although the use of illicit drugs is by definition criminal 
behavior, the most violent crimes are related to the most 
troubled childhoods, not simply to drug use. It is 
important to fight the racist image of drug addicts and 
to educate people that addiction is not about weakness 
or lack of willpower — addiction is a disease. 

Another myth is that drug treatment does not work. A 
recent New York Times article perpetuated this myth 
through a tone of skepticism about drug abuse treat- 
ment. The article implied that punishment is the most 
popular method of fighting drug abuse. However, this 
viewpoint ignores the extensive literature favoring 
treatment for drug addicts and the political realities that 
have dictated how drug abuse has been addressed. This 
article would not be accepted as valid if more individuals 
who have been successful in drug treatment would tell 
their stories. 

Still another myth is that addicts like to share needles — 
a myth that has hindered the development of needle- 
exchange programs which provide clean needles to 
addicts to prevent the spread of AIDS. (These programs 
will not make addicts use drugs more often). The myth 
that addicts like to share needles has been enhanced, 
sometimes unwittingly, by antidrug media campaigns 
that portray drug abusers as terrible, "scummy" people. 
For example, a media campaign sponsored by the 
Partnership for a Drug- Free America deglamorized drug 
use but also demonized drug users. The results is that 
people simply think they should punish drug addicts, not 
help them. Such attitudes make drug addicts reluctant 
to be open about their problems. To prevent addiction, 
drug addicts must become part of the process. This 
could be accomplished partly if the organizations that 
produce such antidrug media campaigns would create 
and receive input from an addict advisory board. 
Recovering addicts also must show, in large part 
through greater participation in political debate, that 
treatment is more effective and humane as well as less 
expensive than punishment. Addicts must teach that 
addiction is a disease, not a moral issue. As consumers 
of drug abuse treatment, addicts must let their voices be 
heard. 

Recovering people also need to speak out more often to 
show how addicts view drugs and drug policy differently 
from nonaddicts. For instance, drug addicts — as opposed 
to casual users — will give up anything for drugs. In this 
context, most efforts to fight drug abuse are ineffectual. 
For example, punishing drug abusers by sending them 
to prison, where drugs are readily available, generally 
leads to increased drug use. If society does not deal 
with addicts' hunger for drugs, how can it expect addicts 
to quit crime? Punishment is not a deterrent to this 
disease. Drug addicts also become afraid of treatment 
when they encounter treatment programs that strip 
them of their personal dignity. Many programs admit 
anyone who will pay for treatment, even if addicts would 
receive better treatment from an alternative program. 



Thus, effective and honest referral systems are needed 
across the country. Therefore, recovering addicts must 
become more involved in treatment development, 
administration, and counseling. The addict's voice also 
must be heard in the current debate on national health 
care reform and certainly among researchers, who 
should form addict advisory boards. Addiction must be 
treated like other diseases, and addicts must be treated 
with respect. Furthermore, addicts need a say in 
research; too few addicts now work in research. 

Some political grassroots efforts already are under way 
through organizations such as Treatment on Demand 
and the Society of Americans for Recovery. Even so, 
more recovering addicts need to speak out and become 
involved at all levels of the drug abuse issue. 

Speaker: Stan Novick 

Methadone maintenance (MM), which was developed in 
the 1960s, is one of the most effective tools we have in 
treating drug abuse. However, even now in 1993 we are 
still debating the benefits of MM and spreading the 
myth that methadone just causes another addiction. 
This myth about methadone treatment must be 
debunked. Anyone who perpetuates this myth does not 
know what the life of a heroin addict is like. Heroin is 
about death, and methadone is about life. At this 
conference, researchers and practitioners have sat on 
opposite sides and battled over this issue, yet they have 
not discussed the casualties of the schism in the debate. 
These casualties are the tens of thousands of people in 
treatment who are stigmatized and ostracized from 
society and who are afraid to speak out. We need an 
atmosphere of change in our society so that we will 
applaud those who receive treatment for drug addiction. 

The mission of the National Alliance of Methadone 
Advocates is to educate the public and to provide a voice 
for the voiceless — drug addicts. The catchword of the 
1990s is "empowerment," but we need a social atmos- 
phere conducive to empowerment. Patients have the 
right to demand treatment with dignity and sensitivity; 
treatment for and to patients must change to treatment 
with patients. 

Perhaps here we can begin a real Renaissance. A 
famous rabbi once said, "If not now, then when?" 
Similarly, if not with you, then with whom? 

Speaker: Gerald Ribeiro 

It is imperative that the issue of drug abuse and addic- 
tion be personalized with the stories of drug addicts 
themselves. The story of T.T. personalizes what it 
means to be an addict. T.T. is a 34-year-old addict 
living in New Bedford, Massachusetts. She entered 
recovery 5 years ago. One month into her recovery, her 
sister was murdered by a serial killer. In October 1992 
another sister died from AIDS. Seventy-five days later, 
her mother died of a heart attack. 



Summaries of Plenary Sessions 



T.T. has been on methadone for 4 years. Methadone has 
kept her alive, but she has needed more than treatment. 
For example, she needed employment. Three months 
ago, she entered a nurse training program, but on 
completion she could not find a job and fell back into 
addiction. One month ago T.T. attempted to enter a 
treatment program, but her HMO (health maintenance 
organization) was averse to this decision since she 
already was receiving high doses of methadone. The 
HMO finally gave her 7 days in a treatment program. 
This brief treatment did not meet her needs, and she 
soon was using drugs again. An attempt 1 week later to 
admit T.T. into another treatment program again met 
with resistance from the HMO, which allowed her 4 
days of treatment. However, this time the program 
would not admit her because she had abscesses related 
to HIV. T.T. finally entered a 2-day treatment program, 
but now she is back on the streets again. 

It should not be this difficult to receive treatment for 
drug addiction. There simply is not enough understand- 
ing of the roots of drug addiction, nor is there enough 
commitment to care for drug addicts, who are seen as 
expendable. We must recognize that drug addiction is 
a disease. We need to become, like participants in this 
conference, "Soldiers of the Struggle" against addiction 
and AIDS. We are not talking about statistics; we are 
talking about human beings who can give back to their 
communities if they are given the chance. 

Treatment on Demand requires basic human rights for 
drug addicts. An old African proverb states, "It is not 
only important to get the tiger out of the house, but also 
to find out how he got into the house, to keep the lion 
from coming in next." We need to get drugs, AIDS, and 
crime out of our communities, but we also must under- 
stand the conditions under which these problems have 
flourished. We must educate our communities. Finally, 
do not mourn — organize. 



SATURDAY, JULY 17, 1993 

Looking Toward the 21st Century 

Conference Host: Richard A. Millstein 

Speaker: David Musto. M.D. 

The slowness of historical change is important to 
consider when evaluating future drug policy and drug 
abuse trends. The clash between popular expectations 
for drug policy and the actual pace of social change 
suggests at least one speculation concerning the next 5 
to 10 years. First, as background, it is important to 
remember that the 1960s and 1970s saw a growing 
toleration of drug use; a drug problem only was consid- 
ered as such when someone took too much of a drug. 
For the last decade, a growing intolerance of any drug 
use has occurred, with a subsequent decline in use. 



Despite this promising trend, many people are frus- 
trated with its slow pace and hence are expressing 
greater alarm at the drug problem. A similar trend 
occurred in the 1930s when, after a previous wave of 
drug use subsided, anger at drugs and drug users did 
not so much stimulate research or treatment programs 
as encourage a negative depiction of drugs in the media 
and help raise the penalties for drug use. A similar 
scenario likely will continue in the next 5 to 10 years. 
Another concern is that harsher drug abuse laws are 
causing overcrowding of the criminal justice system, an 
occurrence that also occurred in the 1920s when an 
increased number of persons were imprisoned under 
Federal antidrug laws. Thus, the condition of today's 
criminal justice system is not surprising. 

Based on such an examination of the history of drug and 
alcohol abuse, it is probable that antidrug education 
intentionally may be reduced from its current plateau 
not just because of the decline in drug use but because 
of the fear that even mentioning drugs may lead to 
experimentation. Such a change in perceptions of 
antidrug education occurred earlier in the century. 
Therefore, an examination of the history of drug abuse 
indicates a possible cyclical schema. Movements since 
the 1980s to reduce drug use and the risk of drug use 
are not unprecedented and, in fact, constitute the third 
temperance movement in American history. These 
temperance movements historically have lasted about 30 
or more years and have achieved considerable power 
leading to dramatic actions as well as backlashes, such 
as the widespread disregard of the alcohol problem for 
many years after the repeal of Prohibition. It thus is 
reasonable to assume that the pattern of risk reduction 
will continue in the next few decades. The previous two 
temperance movements in the United States resulted in 
the prohibition of alcohol, and people should be aware 
that today's attitude is very similar to that during the 
beginning of the temperance movement early this 
century. 

It appears likely that alcohol will be the target drug in 
the next decade. During eras of temperance, people 
change their view of alcohol from one of a substance 
with a safe limit of use to one of a poison with no safe 
limit of use. Usually a very positive view of alcohol is 
prevalent between eras of temperance movements, but 
once people turn against alcohol, they begin to ridicule 
this positive attitude. 

One negative aspect of the decline of drug use is the 
accompanying scapegoatdng of minorities for the drug 
problem. Whether Americans will resist this trend 
depends largely on the media, who portray the drama of 
drug dealing and addiction. In summary, reduction of 
the demand for drugs may be accompanied by excessive 
penalties, scapegoatdng minorities, and overcrowded 
criminal justice systems, and then may end with policies 
that actually create conditions favorable to another wave 
of drug use. A challenge to future drug and alcohol 



NIDA Conference Highlights 



policy is whether attitude swings can end by the estab- 
lishment of an enduring, viable policy. An obstacle to 
this possibility, however, is the extreme oscillation in 
perceptions of drugs. The backlash to drug use that has 
occurred historically and is occurring presently has in 
previous years led to a triple policy to maintain a low 
level of drug use: silence when possible, exaggeration 
when necessary, and steadily escalating punishment. 
But such a nearsighted policy erases the slowly and 
painfully acquired public wisdom about drugs and 
alcohol; ignorance and distortion are conveyed to later 
generations. Thus the next decade likely will see a 
battle against drugs conducted more through words, 
images, and penalties than through treatment and 
research, and thus Americans are in danger of repeating 
past errors such as scapegoating minorities and casting 
the issue into exaggerated positions. Such a scenario is 
likely, but not inevitable. It is vital to learn from the 
mistakes of the past and the consequences of anger and 
fear. 

Speaker: Mary Jeanne Kreek. M.D. 

In combating the alcohol and drug abuse problem, it is 
vitally important for neurobiologists, clinical scientists, 
and clinicians to listen and learn from patients, prospec- 
tive patients, and others in the field of drug and alcohol 
abuse treatment and research as well as in other allied 
fields, such as the social sciences. It is critical to share 
questions and knowledge with each other. 

While the number of individuals dependent upon cocaine 
has decreased recently, still one-half to 2 million people 
are addicted to cocaine, and one-half to 1 million are 
addicted to heroin. Between 5 and 12 million people are 
addicted to alcohol. Researchers have been able to 
uncover much information about the AIDS epidemic, 
including when it hit New York City (around 1978). 
Early indicators from New York and other major cities 
suggest that risk reduction education may be having 
positive effects. Researchers also have shown, although 
through very preliminarily studies, that markers for the 
hepatitis B virus are not as common as previously. 
Prom 1985 to 1993 there has been a slow but steady 
reduction in the number of individuals infected with 
hepatitis B, indicating a reduction in the use of unsterile 
needles. Still, pharmacotherapies as well as social and 
behavioral therapies are needed urgently in addressing 
addiction. Much important research work is being 
conducted on the development of pharmacotherapies at 
both the clinical and bench levels. Any pharmaco- 
therapy for the treatment of addiction must prevent 
withdrawal systems, reduce drug craving (which causes 
former addicts to relapse), and normalize any physiologi- 
cal functions disrupted by drug use. Such a treatment 
thus should target a specific site of action — a receptor or 
physiologic system. In treating heroin dependency, for 
example, several agents have been developed, such as 
methadone, LAAM, and buprenorphine. 



Currently over 115,000 Americans are being treated 
effectively with methadone maintenance treatment. 
However, others are not treated so effectively because 
programs with inadequate funding cannot provide the 
services essential to maximize the effectiveness of 
pharmacotherapy. Methadone has three important 
actions: It prevents withdrawal symptoms and drug 
craving, blocks the effects of other imposed short-acting 
opiates, and allows normalization of physiological 
function. It acts by stabilizing the endogenous opioid 
peptide and receptor system. Effective methadone 
maintenance programs have prevented infection with 
the HIV virus by preventing continued use of unsterile 
needles. The challenge for the next decade and century 
is to use methadone or other pharmacotherapies with 
good sense and humanity. A variety of programs are 
needed, such as emergency clinics, full-service metha- 
done programs, special programs for special groups, and 
medical maintenance programs for rehabilitated 
patients. And properly trained and competent staff are 
needed to provide such services. 

Increasing evidence indicates that genetic factors may 
play a role in the neurobiological basis for addiction. No 
data support a specific genetic basis yet, but family 
cluster studies suggest its likelihood. Many labs cur- 
rently are addressing this issue at a very fundamental 
molecular biological level. Also, drugs of abuse may 
alter physiology in a way that causes permanent 
changes and may contribute to drug craving and relapse. 
Furthermore, variable host response factors appear to be 
important in the development of addiction. At the 
Rockefeller University, researchers are investigating the 
role of the endogenous opioid (or endorphin) system at 
a molecular level in the addictions of heroin, cocaine, 
and alcohol. There are three classes of endogenous 
opioids — (1) the endorphins, (2) the enkephalins, and 
(3) the dynorphins — with one gene guiding the develop- 
ment of each. Three receptor classes — (1) mu, (2) delta, 
and (3) kappa — have been studied. Within the last year, 
two groups have cloned the delta receptor, and others 
subsequently have cloned the mu kappa receptor genes. 
There appear to be at least three receptor types for the 
three classes of opioid peptides. Further study should 
reveal more information on their roles in fundamental 
processes, such as hormone control, gastrointestinal 
function, memory, and possibly addiction. Earlier 
findings revealed that in the endorphin system the most 
important stress hormone — ACTH — is released from the 
same gene, as is the most important long-acting opioid, 
beta-endorphin. These two hormones are being studied 
for their responses when opiates are placed in the body. 
Heroin, for example, has been found to suppress this 
stress response, but methadone (and possibly LAAM) 
allows normalization of stress response and the normal 
release of the hormones. During chronic treatment with 
a long-acting opioid, such as methadone or LAAM, 
researchers have found normalization of very important 
stress and reproductive responses, as well as of the 



10 



Summaries of Plenary Sessions 



immune function, due to the opioid's action on the opioid 
receptor. Opioids are one type of peptide chemical 
messengers between nerve cells; dopamine is another 
type of nonpeptide chemical messenger. Cocaine acts by 
blocking the re-uptake into the nerve cell of released 
dopamine, causing the excessive activity of dopamine. 
However, the dopamine has been found still to fade 
away, so the excess activity may in fact be from the 
endogenous opioids caused by the dopamine release. 

Finally, recent studies with rats have shown that both 
the mu and kappa receptor systems are increased in the 
brain after cocaine use. These systems are located in 
areas of the brain involved in cocaine's effect on the 
reward system. Therefore, changes effected by cocaine 
on the endorphin system may alter the reward of cocaine 
or the drug hunger and craving for cocaine by the 
addicted. The challenge in the next two decades is to 
define how this opioid system — these endorphins with 
their newly cloned receptors — may modulate or help 
control human stress responses and other behaviors and 
how they may be involved in addiction. 

Speaker: Peter Reuter, Ph.D. 

The following two primary drug policy debates have 
occurred in the United States in the last few years: 
(1) the legalization debate and (2) the supply-side and 
demand-side debate. The former has been essentially 
irrelevant to policy formulation and only looks at 
extremes; however, the latter is more common and 
narrow and has focused primarily on the balance of the 
Federal budget but has not taken into consideration the 
full consequences of strict enforcement. A third, three- 
sided debate is important and taking place between 
(1) the hawks, or those who believe in aggressive 
enforcement; (2) the doves, or those who believe that 
enforcement and prohibition actually are the problem; 
and (3) the owls, or those who believe that, within 
current prohibitions, the possible negative consequences 
from being overly aggressive must be attended to. 

Over the last decade, the hawks have prevailed in this 
debate. The Nation has committed itself to an enforce- 
ment dominated policy, with roughly two-thirds of the 
Federal drug budget going toward enforcement activities 
and only one-third toward treatment and prevention. 
Furthermore, the national drug control budget (includ- 
ing State and local government expenditures) is domi- 
nated even more by enforcement activities. For 
instance, until recently, Michigan law required a manda- 
tory life sentence without parole for possession with 
intention to distribute more than 650 grams of cocaine. 
A series of such tough laws has been enacted, and 
legislatures are reluctant to ease those laws and risk the 
perception of being soft on the drug problem. These 
changes in the law have been implemented by the 
criminal justice system (i.e., long sentences have 
increased dramatically), with the subsequent increased 
cost to the Federal Government. The public generally 



believes that such an approach has been successful; so 
it is a real challenge to confront this perception in order 
to change the emphasis on enforcement in policy. 

The focus on punishment has been codified in the goals 
of the National Drug Control Strategy. Congress 
required that the ONDCP develop measurable objectives 
for 2-year and 10-year periods. The ONDCFs goals 
have focused on prevalence (i.e., the number of people 
who use drugs, but not necessarily the frequency of use). 
However, this focus on prevalence leads Federal atten- 
tion away from treatment and biases against prevention, 
since prevention affects prevalence only after a long 
delay. These goals do not focus on the damage caused 
by drug use, such as HIV infection, crime, and the 
number of babies born exposed to cocaine. There is a 
real contradiction between prevalence-focused goals and 
harm-focused goals. The Government should concen- 
trate its efforts more on harm reduction than on preva- 
lence reduction. 

Americans have hardened their attitudes toward drug 
use partly because the connection between drug use and 
crime is increasing. The public sees the drug problem as 
a crime problem, and it does not appear likely that the 
treatment and prevention communities will compete well 
against the criminal justice system in the struggle for 
budget resources. The recent budget defeat, in which 
Congress eliminated some funds for prevention and 
treatment and claimed that Head Start was a higher 
priority, revealed that the real struggle for budget 
dollars is not with enforcement agencies but with other 
health and educational agencies. This fight can be won 
by emphasizing the extent to which drug abuse contrib- 
utes to health care costs in the United States. 

Speaker: Richard A. Millstein 

NIDA staff are committed to listening to researchers, 
practitioners in the field, and patients. For instance, 
NIDA staff are planning to meet with staff from CSAP 
to share knowledge and to discuss the dissemination of 
researchers' findings and how best to present those 
findings to practitioners and others. Besides the tech- 
nology transfer conference, NIDA is attempting to 
continue the dialogue between researchers and practi- 
tioners through the development of multicomponent 
packages for use by drug treatment practitioners and 
associations. The packages are available from the 
National Clearinghouse for Alcohol and Drug Informa- 
tion (NCADI). NIDA distributes technology transfer 
packages on such topics as relapse prevention, clinical 
assessment of adults using the Addiction Severity Index, 
and program outcome evaluation. A fourth package is 
being prepared on family dynamics related to addiction 
and recovery. 

For more than 1 year, NIDA also has been distributing 
four 20-minute videotapes and accompanying user 
guides for drug abuse treatment program staff on 



11 



NIDA Conference Highlights 



treatment approaches and information from NIDA- able from NCADI (1-800-729-6686). Four additional 

sponsored research. The tapes cover relapse prevention, videos are being produced currently on drug abuse and 

treatment issues for women, adolescent treatment the brain, dual diagnosis, methadone, and prevention, 
approaches, and assessment. The videos also are avail- 



12 



Pacesetter Awards 



The Pacesetter Awards acknowledge the contributions 
and accomplishments of individuals and organizations in 
the areas of drug abuse research, prevention, and 
treatment. Since its origination in 1976, the Pacesetter 
Award has been presented to 35 individuals. 

The most recent recipients reflect the diversity and 
breadth of achievement that can contribute to reducing 
the demand for illicit drugs. The National Institute on 
Drug Abuse is honored to be able to recognize the talent 
and dedication of the following individuals: 

• George De Leon, PhJ)., National Development and 
Research Institutes, Inc., director, Center for Thera- 
peutic Community Research, was recognized for 
outstanding leadership in pioneering research on 
the therapeutic community approach to drug abuse 
treatment. The majority of Dr. De Leon's profes- 
sional work has been devoted to developing the 
research basis for the therapeutic community 
approach to drug abuse treatment. Through his 
pioneering research efforts at Phoenix House in 
New York City, Dr. De Leon has produced an 
impressive series of studies which have illuminated 
the characteristics of clients entering community 
treatment. 

• F. Ivy Carroll, Ph.D., Director for Organic and 
Medicinal Chemistry at the Research Triangle 
Institute in North Carolina, was recognized for 
exceptional achievement and productivity in cocaine 
chemistry, the synthesis of cocaine analogs with 
potential as medications, and the elucidation of 
structure activity relationships of cocaine receptors 
in the brain. Dr. Carroll has produced a vast 
number of cocaine analogs and has provided the 
drug abuse research field with a large number of 
novel tools to explore psychostimulant mechanisms. 
He has also assisted in patenting the licensing 
many of the compounds that are useful agents for 
imaging cocaine receptors in humans. 

• Charles P. O'Brien, M.D., Ph.D., Professor and 
Vice-Chairman of Psychiatry, University of Pennsyl- 
vania and Chief of Psychiatry, Veterans' Adminis- 



tration Medical Center, was recognized for out- 
standing contributions to the field of drug abuse 
treatment and treatment research. Dr. O'Brien 
founded a treatment program that integrated 
treatment, research, and training. His group has 
conducted pioneering studies of conditioning in 
patients dependent on opioids or cocaine, controlled 
studies of psychotherapy and pharmacotherapy, and 
studies of patient-treatment matching. 

HudaAkil, PhJ)., the Gardner C. Quaxton Profes- 
sor of Neuroscience, Department of Psychiatry, 
Research Institute, Mental Health Institute, Uni- 
versity of Michigan, was recognized for outstanding 
leadership and continuing contribution to the 
understanding of the biological and molecular bases 
of drug addiction. Dr. AkH's research represented 
the first physiological evidence for the existence of 
endogenous opioids in the central nervous system. 
Her work, with emphasis on the biology of endoge- 
nous opioid systems, has contributed greatly to our 
current understanding of the underlying mecha- 
nisms of drug abuse. 

Daniel X. Freedman, M.D., the Judson A. Braun 
Professor of Psychiatry and Pharmacology at the 
University of California, Los Angeles, School of 
Medicine, was honored in memorium for outstand- 
ing contributions as Chairman of the Board of 
Scientific Counselors to the research programs of 
NIDA's Addiction Research Center and the drug 
abuse and mental health research fields. Dr. Freed- 
man passed away June 2, 1993. He was a pioneer 
in psychopharmacology, and in the 1950's he demon- 
strated the link between hallucinogens and seroto- 
nin. He was the first to identify elevated serotonin 
levels in the blood of autistic patients, thus estab- 
lishing a biological basis for the condition. He also 
was among one of the first researchers to describe 
how stress affects the brain and how the brain plays 
a role in allergy symptoms. Dr. Freedman was also 
editor of the American Medical Association's 
Archives of General Psychiatry. 



13 



Summaries of Research Awareness Seminars 



RESEARCH UPDATES 

RS01. Understanding Drug Addiction 
and the Brain 

Moderator: Christine Hartel. Ph.D. 
Speakers: David Friedman, Ph.D. 

Michael Kuhar. Ph.D. 

Frank Voccl. Ph.D. 
July 15. 1:15 p.m.-2:45 p.m. 

For the first 30 minutes of this session, 
participants viewed the videotape "Drugs and 
the Brain," produced by the NIDA's Com- 
munity and Professional Education Branch. 
For further information on this and other 
films, please refer to the section Film Festi- 
val Summaries. 

Speaker: David Friedman, Ph.D. 

Drug addiction is a brain disorder resulting 
from chronic use of drugs. Individuals ex- 
periment with drugs for many reasons, but 
after their first exposure, a number of bio- 
logical learning processes take place. To 
help addicted individuals, it is crucial to 
understand exactly what is happening in 
their brains. 

Studies have shown that animals can be 
trained to take virtually every drug that 
humans abuse; this fact strongly indicates a 
biological basis for drug use. It is difficult to 
determine exactly why individuals use drugs, 
but research on animals provides a simplified 
approach to addressing this issue. This 
research has shown that something common 
to both humans and other animals leads to 
drug abuse and addiction. However, this 
viewpoint was not held a short time ago 
when people believed that drug addicts had 
a problem with morality and willpower. 
Gradually the medical community began to 
accept that addiction, along with mental 
illness, is a disorder of the brain. 

The brain is the organ of behavior. Drugs 
change how people behave because they 
change the way the brain works. Different 
parts of the brain control different functions; 
for example, the brain stem governs func- 
tions that are important for survival, such as 
the heart beat. Higher cognitive functions 
are handled by the cerebral cortex. Localiza- 
tion of function is found within the cortex, 
with many different parts controlling separ- 
ate functions. Emotions are controlled by the 



brain's limbic system, part of which consists 
of a group of neurons that constitute the 
brain reward system, and when this area is 
activated, one feels pleasure. Thus, it is very 
important to one's survival as it prompts one 
to want the things he/she needs, such as 
food. Because one feels good when one gets 
what he/she needs, a condition that 
B.F. Skinner labeled a natural reinforcer, 
one works hard to acquire those things. 
Studies in the 1950s showed that electrical 
stimulation of certain parts of the brain can 
induce similar feelings of pleasure, causing 
the subjects to work hard to gain that pleas- 
urable feeling again and again. People 
repeat behaviors that are reinforced, and 
drugs, which are very powerful reinforcers, 
work directly on the brain reward system. 
In a process of unconscious learning, drugs 
reinforce the very act of taking drugs. 

Other kinds of learning involved in drug 
addiction are cognitive learning and classical 
conditioning. By pairing certain neutral 
environmental stimuli with drug-taking, 
much is learned about drugs. For instance, 
a recovering cocaine addict may feel a crav- 
ing for the drug upon the sight of sugar. 
Most neuroscientists agree that learning 
constitutes some kind of change in the brain. 
Another change that takes place in the brain 
during drug use is tolerance, which happens 
as the body becomes accustomed to having 
that substance in its system. Another re- 
sponse is physical dependence — the body 
goes into withdrawal when the drug is with- 
held. With all these responses occurring in 
the brain, one major tool in treating drug 
addiction is merely talking to the addicts. 
This process of talking encourages them to 
use their cognitive abilities to change their 
behavior and fight the effect of drugs at the 
noncognitdve level. 

Speaker: Michael Kuhar, Ph.D. 
One reason that highly effective treatments 
for drug addiction are lacking is that it is not 
known what is malfunctioning in the brain. 
Most of the information about drug addiction 
comes from animal studies, and the medica- 
tions developed as a result of these studies 
have not worked on humans as well as ex- 
pected. Perhaps studies need to concentrate 
more on what happens in human brains 
differently than in animal brains. Using a 
positron emission tomography (PET) scanner 
to develop an image of the brain, scientists 



15 



NIDA Conference Highlights 



can learn about drugs' effects on certain 
regions of the human brain. In looking at a 
PET scan image of activity in slices of the 
human brain, the distribution or effect of 
drugs in this structure can be seen in vary- 
ing concentrations. For instance, scientists 
can see a drug similar to cocaine con- 
centrated in one region of the brain slice 
which contains a large number of cocaine 
receptors — the molecular sites to which 
drugs must, bind to produce their effects. In 
looking at the same image over time, one can 
see that the cocaine has dissipated after 20 
minutes, which corresponds to the time that 
cocaine users say they feel the drug's psycho- 
logical effects. However, these receptors are 
not in the limbic system, and it is likely that 
they do not cause the rush of euphoria. 
Therefore, many researchers now are trying 
to find cocaine receptors in the limbic 
system. 

It can be surmised from these images that 
certain receptor sites are decreased in ad- 
dicts. Consequently, one drug treatment 
strategy is to administer an excess of dopa- 
mine stimulants. When one region of the 
brain works hard, the glucose metabolism 
increases at that region. Thus, an image 
taken when the subject was administered 
radio-labelled glucose indicates that cocaine 
can activate parts of the brain far away from 
its receptors and trigger a pleasure response. 
In addition to seeing the receptor sites and 
effects of drugs through the PET scan, re- 
searchers also can discover the parts of the 
brain associated with drug cravings. Since 
the brain is the organ of human behavior, 
the strategy is to use these technologies to 
discover which behaviors are associated with 
drug addiction and how to counteract them. 

Speaker: Frank Vocci, Ph.D. 

In reviewing the history of drug abuse re- 
search, one can see how research leads to 
discoveries which lead to new treatments. 
This process started in the United States in 
1929 when the National Research Council 
(NRC) was asked to develop a strategy for 
addressing heroin addiction. The NRC 
decided that further sociological studies were 
not likely to solve the problem and that 
research should focus on the biological basis 
of addiction. NRC researchers wanted to 
develop nonaddictdve substitutes for mor- 
phine that would produce similar effects 
without addiction. 



Next the U.S. Public Health Service (PHS) 
was charged with implementing the biologi- 
cal and chemical aspects of this strategy. 
PHS started labs at the University of Vir- 
ginia and in Lexington, Kentucky, where Dr. 
Clifton Himmelsbach operated a "narcotic 
farm" to measure the physical dependence of 
narcotics addicts. He developed the Him- 
melsbach Scale, which equates narcotics 
addiction to abstinence signs yet does not 
account for psychic distress or drug-seeking 
behavior. Dr. Himmelsbach did not trust 
addicts in interviews and therefore wanted to 
study their addiction phenomenologically by 
grading their withdrawal effects after a 
period of being on morphine. 

Other researchers with the Addiction Re- 
search Center contended that studies should 
focus not only on physical dependence but 
also on the subjective effects of drug use. 
Frank Frasier was one of the first research- 
ers to declare that physical dependence is 
insufficient for explaining addiction to opi- 
ates, because in the absence of withdrawal, 
addicts still crave the drugs. To quantify 
this assertion, Frasier measured the subjec- 
tive, or reinforcing, effects of opiates by 
talking to addicts about how the drugs made 
them feel. Then, in 1965, Chuck Gorodetsky 
and Bill Martin found in a study with nalor- 
phine (a drug similar to morphine) that 
addicts showed a withdrawal syndrome, but 
they did not request drugs. There appeared 
to be a dissociation between withdrawal and 
drug-seeking behavior, which coincides with 
today's knowledge of how the three com- 
ponents of the narcotics syndrome do not 
necessarily covary. For instance, stadol is 
another drug that produces less drug-seeking 
behavior than either morphine or heroin. 

The concept of addiction in the 1990s is 
based less on the psychopharmacological 
properties of drugs and more on behavior. In 
other words, addiction is viewed not as phy- 
sical dependence or reinforcing effects, be- 
cause an individual can abuse drugs without 
being dependent. The key issue then con- 
cerns the patterns of use and the reasons 
people continue to use drugs despite the 
. consequences. Skinner said that behavior is 
controlled by its consequences, but this is not 
true with addiction. Addiction appears to be 
a loss of control — despite the negative conse- 
quences of drug addiction, some other factor 
controls an addict's behavior and keeps 
him/her from changing it. Drug addicts 
recognize that at some point they stop want- 
ing to use drugs and begin needing to use 



16 



Summaries of Research Awareness Seminars 



RS02. 



them. Thus, the focus has shifted from the 
psychopharmacology of drugs to an examina- 
tion of their effects on addicts' behaviors, a 
change reflected in the DSM-III-R (Diagnos- 
tic and Statistical Manual, revised third 
edition). The concept of physical and psycho- 
logical dependence is outmoded, and now the 
focus is mainly on dependence. Addiction is 
a neurobiological disorder, not just a psycho- 
logical or physical problem. 

In one study, rats in a group were trained to 
self-administer cocaine by hitting a bar. 
Rats in another group were given the drug 
whenever the rats in the first group self- 
administered it, and at that time, rats in a 
third group received saline. The results 
demonstrated cocaine's effects on glucose 
utilization in brain structures. Furthermore, 
the study showed that there is a difference 
between the amount of glucose utilized and 
the brain structures in which it is being 
utilized, depending on whether the user self- 
administers or is given the cocaine. This 
effect likely is related to motor behavior and 
learning. 

In other research, by isolating and studying 
the primary amino acid structure of the 
dopamine transporter, researchers can learn 
about its neurobiology and how cocaine and 
dopamine bind to it. In this way, re- 
searchers hope to find a drug that will block 
cocaine but allow dopamine to bind to it. 
Consequently, findings such as these can be 
used in molecular biology, along with find- 
ings in behavioral pharmacology and radio- 
isotope work, to design drugs to counteract 
addiction. 

Recent Trends in Drug Abuse 
Research 

Moderator: Ann Blanken 
Speakers: Joseph Gfroerer 

Lloyd Johnston. Ph.D. 

Andrea Kopsteln, M.P.H. 
July 15, 10:30 a.m.- 12:00 p.m. 

Speaker: Joseph Gfroerer 

The 1992 National Household Survey on 
Drug Abuse (NHSDA), conducted with a 
sample of 28,832 participants ages 12 and 
older, had a response rate of 95 percent for 
household screening and 83 percent for 
interviews of people selected in the house- 
hold. No significant changes occurred in the 
prevalence rate of drug use between 1991 
and 1992, and the survey results generally 
continued trends that had been observed in 



recent years, such as the steady decrease 
since 1988 in the levels of alcohol consump- 
tion and cigarette use. Heavy alcohol use 
(five or more drinks on five or more occasions 
in the past month) has remained steady. 
According to NHSDA results in past years, 
the use of any illicit drugs peaked (in terms 
of the number of users) in 1979 at 24 million 
users and has been decreasing ever since to 
a current level of 11 million users. Cocaine 
use peaked in 1985 with 5 million users. 
Incidence rates from the early 1970s indi- 
cated that the number of new users of mari- 
juana equaled the number of new births — 
about 3 million per year. The 1992 survey 
showed that about one-half of individuals 
ages 23 to 49 had tried marijuana at some 
time in their fives, with a slight pattern of 
increase with education status. Although 
little difference is evidenced in lifetime 
cocaine use based on education status, per- 
sons who have graduated from high school 
only are three times as likely as college 
graduates to be engaged in current use. 
Additionally, the survey found that 18- to 
25-year-olds reported the highest rate of 
drug use in the past month, although there 
have been decreases since the late 1970s. 
Although there have been decreases since 
1979 in drug use in the past month among 
individuals in the age groups of 12 to 17, 18 
to 25, and 26 to 34, the rate of use among 
those in the 35-and-older age group has 
remained fairly constant. The 35-and-older 
age group demonstrates the lowest rate by 
percentage; however, because the group 
consists of such a large population, the per- 
centage indicates a large number of users. 
Furthermore, the NHSDA has shown that 
cocaine use has decreased among occasional 
users, while the number of heavy users has 
remained fairly constant. 

The following results were found in a 1991 
analysis of heavy cocaine users (an estimated 
population of 625,000): 43 percent were high 
school dropouts, 39 percent had no health 
insurance, 35 percent had been arrested 
within the past year, 32 percent were un- 
employed, 30 percent had received drug 
treatment, 21 percent had received psychi- 
atric treatment at some time within their 
lifetime, 16 percent had received treatment 
for alcohol abuse within the past year, and 8 
percent had received treatment in an emer- 
gency room for drug abuse. 



17 



NIDA Conference Highlights 



Speaker: Uoyd Johnston, Ph.D. 

The findings discussed below are based on 
the Monitoring the Future Survey, which 
NIDA has funded since 1975. Researchers 
with this project recently completed its 19th 
national survey of high school seniors and its 
13th national survey of American college 
students. Younger age groups (i.e., 8th- and 
lOth-grade students) recently were added to 
the study. Earlier in the year, the project 
released findings from recent surveys of five 
main population groups: 8th, 10th, and 12th 
graders; college students; and young adults 
who are high school graduates. 

Currently the Monitoring the Future Survey 
gathers data from about 50,000 8th-, 10th- 
and 12th-grade students in over 500 schools 
nationwide. Results of these surveys from 
1986 to 1992 have indicated a steady decline 
in overall drug use among young adults, high 
school seniors, and college students. Mari- 
juana use, however, appeared to level off in 
1992 but now has risen among young adults 
and college students, while LSD use also has 
increased among all five populations in 
recent years. The availability of LSD 
appears to be increasing, while the perceived 
danger of LSD (especially among younger 
students) and social disapproval of LSD use 
are declining. Studies have shown that 
cocaine was the drug of the 1980s and that 
levels of cocaine use decreased in the latter 
half of the decade and into the early 1990s. 
Now use of inhalants (other than nitrites) is 
on the rise, mainly among the younger popu- 
lations, and this is a trend that must be 
addressed. The alcohol consumption rate 
continues to be very high and constant 
among college students, while high school 
seniors have shown a decrease in the level of 
heavy drinking. Alternatively, alcohol con- 
sumption rates among eighth-graders appear 
to have risen in the past decade. 

Although cigarette smoking rates dropped by 
about one-third since the late 1970s, the 
initiation rate of cigarette smoking among 
American young people has been stable for 
the past 8 years, a statistic of vital concern 
with dramatic implications for health, di- 
sease, and health care costs. Until greater 
measures are taken toward fighting the 
tobacco use problem, no substantial improve- 
ments will be seen. 

During the peak years of drug use, 1979 to 
1981, almost two-thirds of high school 
seniors had tried an illicit drug at least once, 
and by the time this population reached their 



late twenties, about 80 percent had tried an 
illicit drug. The use of any illicit drug other 
than marijuana peaked 1 year later and has 
decreased since then. The cocaine epidemic 
has shown more regional variation than any 
other illicit drug epidemic, with high lifetime 
prevalence rates particularly in the West and 
Northeast. Furthermore, study results 
indicate that drug use is an all-class prob- 
lem; not much difference occurs as a function 
of socioeconomic status. Likewise, decreases 
in drug use have occurred across all econo- 
mic classes. However, as the cocaine epi- 
demic was evolving, upper classes tended to 
use cocaine more frequently than lower 
classes until the mid-1980s, when 
crack-cocaine availability caused cocaine use 
among the lower classes to catch up with the 
higher classes. The declines in drug use 
cannot be attributed to declines in avail- 
ability or supply reduction, because drug 
availability actually has remained constant 
or has risen in some cases. But the per- 
ceived dangers of drug use and peer group 
disapproval of drug use have been found to 
be the most predominant deterrent tools in 
reducing demand for and use of drugs. 

Speaker: Andrea Kopstein, M.P.H. 
The Drug Abuse Warning Network (DAWN), 
an ongoing data collection system operated 
by NEDA, monitors two types of adverse 
consequences associated with drug use. In 
1988 NIDA instituted a new sampling proce- 
dure for DAWN to produce national esti- 
mates of drug-related emergencies. The first 
component of DAWN consists of information 
on the number of people seeking hospital 
emergency room services for their drug abuse 
problems. The second component consists of 
data on episode reports of drug-related 
deaths that occur at the approximately 130 
participating medical examiner facilities 
throughout the United States. However, the 
second component is not nationally repre- 
sentative; information presented in this 
session thus focuses on the hospital emer- 
gency room portion of the data set. Episodes 
reportable to DAWN involve the nonmedical 
use of legal drugs and any use of illegal 
drugs. Hospitals that are eligible for DAWN 
are non-Federal, short-stay general hospitals 
with at least one 24-hour emergency room 
department. Trained reporters collect data 
at participating hospitals, including demo- 
graphic information about the patient and 
information on the circumstances pertaining 
to the emergency room visit, such as 



Summaries of Research Awareness Seminars 



motive(s) for taking the drug, reason for the 
visit, and type(s) of drugs used. 

The latest DAWN data released from 
SAMHSA cover the third quarter of 1992. 
Although the Monitoring the Future Survey 
and the NHSDA have shown decreases in 
drug abuse, results of the DAWN study from 
1988 until the third quarter of 1992 have 
shown increases in drug use. In the first 
three quarters of 1992, there was a 7-percent 
increase in the number of drug-related emer- 
gency room visits, compared to the first three 
quarters of 1991. The greatest increase 
occurred among the older age group, which 
comprises the largest part of the population. 
Population-based rates are used to help 
eliminate overrepresentation of specific 
population groups. 

The following statistics indicate recent trends 
in drug-related emergency room visits: the 
population-based rate of drug-related emer- 
gency room visits for the 12- to 17-year-old 
age group peaked in 1989 at 277 per 100,000 
and dropped to 240 per 100,000 in 1991; the 
rate of drug-related emergency room visits 
for 18- to 25-year-olds peaked in 1988 at 325 
per 100,000, dropped in 1990, and began to 
rise again in 1991; the rate of drug-related 
emergency room visits for the 26- to 
34-year-old age group reflects the same 
results as the 18- to 25-year-old age group's 
trend; and the 35-and-older age group exhi- 
bited the greatest increase in the rate of 
drug-related emergency room visits, with an 
increase from 99 per 100,000 in 1988 to 115 
per 100,000 in 1991. 

Of the over 685,000 drug mentions in DAWN 
for 1991, 15 percent were cocaine related and 
5 percent were heroin related. Over time, 
these two drugs have been a major portion of 
drug-related emergencies. Cocaine-related 
emergency room visits hit a low in late 1990 
but then sharply increased, with a peak in 
the third quarter of 1992. Comparing the 
first three quarters of 1991 with those of 
1992, cocaine-related visits increased 16 
percent and were greater for males than 
females. Furthermore, between 1988 and 
1992 there was a large increase in the num- 
ber of cocaine-related problems among per- 
sons over 26 years of age. The 1990 rates 
were the lowest for all age groups. Also 
notable is the fact that heroin-related emer- 
gency room visits increased significantly 
between 1991 and 1992, particularly among 
men between 26 and 34 years of age, but also 
among men over 35 years of age. Not many 



12- to 17-year-olds report to emergency 
rooms with heroin-related problems, and the 
18- to 25-year-old group has shown a steady 
rate between 1988 and 1992. 

In general, central-city emergency rooms are 
more likely than other types of emergency 
rooms to treat drug-related emergencies. For 
instance, a drug-related emergency room 
visit is five times more likely to occur in San 
Francisco compared with the national aver- 
age. However, of 14 metropolitan areas in 
the DAWN study, only San Francisco showed 
a decrease in drug-related emergencies from 
1991 to 1992. Suicide attempts form a large 
proportion of the drug-related visits to these 
emergency rooms. 

Therefore, after hitting a low point in 1990, 
the number of drug-related emergencies now 
are rising and are reaching peaks. There are 
many possible reasons for these increases, 
including the increased purity of available 
drugs and the increased medical consequen- 
ces among people who continue drug-taking 
behavior (i.e., aging chronic drug users). The 
increasing frequency of drug-related emer- 
gencies, despite apparent declines in drug 
use, points out the importance of using 
multiple data sets when monitoring drug 
trends. 

Questions, Answers, and Comments 

How are the self-reported data from this 
study validated? The data are validated in 
many ways, such as through determination 
of face validity, examination of the logistical 
consistency of the data, determination of 
construct validity, and the use of questions 
about the respondents' friends — not just 
themselves. Results from such questions are 
similar to the self-reported data, thus sup- 
porting its validity. However, it is likely that 
results from the survey would be higher with 
completely truthful responses. 

Why has tobacco use not declined along with 
other drug use? The advertising and promo- 
tion of tobacco is a very powerful influence in 
creating a great demand for tobacco. Poli- 
tical leaders have not had the courage to 
address this problem. 

How does perceived personal risk compare 
with concerns about the legal risk of drug 
use? The two factors that studies indicate 
are of greatest concern to marijuana users 
are the risks for physical and psychological 
harm; fear of arrest is not very high. 



19 



NIDA Conference Highlights 



RS03. 



Are there any differences among males and 
females in the patterns of drug use, par- 
ticularly for smoking? Sex differences do 
exist. For instance, males are more likely 
than females to use illicit drugs. But the 
trends appear to have been similar for both 
sexes. Males were heavier tobacco smokers 
until the late 1970s, when females became 
heavier smokers. Since then, both sexes 
have decreased use of tobacco by one-third, 
and the rates now are about the same among 
high school seniors. In college, however, 
females are more likely to smoke. 

Are any data available on prevalence rates of 
drug abuse among pregnant women? The 
only national data base for such data is from 
the National Maternal and Infant Health 
Survey, which is administered by the 
National Center for Health Statistics, part of 
the Centers for Disease Control and Preven- 
tion. This survey used self-reports, and the 
numbers were very low. A recent longi- 
tudinal followup to this survey examined the 
mental development of children whose 
mothers used drugs. It is expected that 
beginning next year, the NHSDA will add a 
question asking women if they are pregnant. 
Several local studies have been conducted, 
and NIDA's Division of Epidemiology and 
Prevention Research currently is conducting 
a Pregnancy and Health Study, interviewing 
women in hospitals within 24 hours after 
delivery. 

Update on Drugs— Heroin 
and Synthetic Opioids 

Moderator: James Dlngell. Ph.D. 
Speakers: John French. M.A. 

Mary Jeanne Kreek. M.D. 

Frank Voccl. Ph.D. 
July 17. 1 1:15 a.m.-12:45 p.m. 

Speaker: James Dingell, Ph.D. 

Since opioids are the drugs of choice among 
chronic, intravenous (IV) drug abusers, they 
will continue to be a major concern to our 
society and an important factor in the propa- 
gation of HIV through needle-sharing. This 
seminar provided a review of the epidemi- 
ology of opioid abuse together with an over- 
view of the findings from recent research and 
their present and potential impact on treat- 
ment and medications development. The 
imagination and productivity of organic 
chemists have brought forth a remarkable 
variety of semisynthetic congeners of mor- 
phine, as well as totally synthetic compounds 



with morphinelike actions. Moreover, recent 
research has demonstrated the presence in 
mammalian tissues of not only several pep- 
tides with opioid activity but also endogenous 
morphine and codeine. The search for new 
opioid analgesics has yielded a large number 
of compounds of diverse chemical structures 
with a spectrum of pharmacological 
activities — from agonists with many times 
the potency of morphine through mixed 
agonist-antagonists to pure antagonists 
which totally prevent the actions of opioids. 
The availability of these compounds, together 
with the discovery and characterization of 
the receptors with which they interact, has 
both increased therapeutic options and sug- 
gested new strategies for the treatment of 
opioid addiction. 

Speaker: John French, M.A. 

Heroin and various other opioid addictions 
always have been and probably always will 
be regional problems. The Mexican importa- 
tion of heroin dominates the opioid trade 
throughout the West, Southwest, and a large 
part of the Midwest; the Northeast's primary 
importers of heroin are parts of southwest 
and southeast Asia. In 1980 a new form of 
heroin, known as "P dope," was introduced 
on the streets of Newark, New Jersey. As a 
result, the number of addicts who reported 
never injecting heroin, but only snorting it, 
rose significantly by 1985 and has continued 
to increase since then. This finding has both 
positive and negative aspects. The main 
negative aspect is that snorting heroin often 
leads to injection of heroin. The positive 
aspects of snorting heroin are that (1) the 
morbidity rates are much lower for heroin 
snorting than they are for heroin injection 
and (2) the risk of contracting the AIDS 
virus is much lower than that among IV 
drug users. Why are more people snorting 
heroin now as compared to in the past? One 
reason is the fear of contracting AIDS, and 
the other reason is that the purity of heroin 
on the streets today is much higher than it 
has been in the past. 

The media have a tendency through their 
reporting to create epidemics, such as the 
"ice" epidemic which was highly publicized in 
the United States several years ago but 
which was largely nonexistent. Recently, the 
media have been reporting extensively about 
heroin smoking, which actually occurs only 
rarely. Heroin smoking is popular in Europe 
and Asia but is not yet popular in the United 
States. However, because smoking heroin 



:-n 



Summaries of Research Awareness Seminars 



provides a better high than snorting heroin 
does, it could become more prevalent in this 
country. Also, high purity heroin is available 
for smoking, and the risk of AIDS from 
injecting heroin may lead more people to 
smoke heroin instead. However, people's 
ignorance about how to convert heroin into a 
form fit for smoking and how actually to 
smoke it, along with the lack of an available 
heroin base, may prevent heroin smoking 
from becoming more prevalent in the United 
States. Heroin users easily could overcome 
these obstacles, however, by learning how to 
convert heroin into its base for smoking or by 
shipping in the base from other countries. It 
also is possible that the increasing number of 
Asians entering the United States could 
bring about increased knowledge of and 
access to heroin smoking, particularly in the 
Northeast. 

Fentanyl, an opioid, began receiving more 
attention as a widely available and danger- 
ous drug in 1990 when 20 people in the 
Northeast died in 1 weekend after using the 
drug without proper knowledge of how to cut 
it. The drug had been sold in too pure a 
form to distributors. Between 1990 and late 
1992, 126 people died of fentanyl overdose 
between Boston and Baltimore. The Drug 
Enforcement Agency arrested the manufac- 
turers of the drug, based in Wichita, Kansas, 
in early 1993. The chemists had used 
organized crime networks to distribute the 
drug in the Northeast. The low cost of 
manufacture, coupled with user interest, 
create the possibility of future popularity for 
this drug. Even though dozens of addicts 
died from using it, others are attracted to it 
because of its potency. 

v Speaker: Mary Jeanne Kreek. M.D. 

Updated and improved methods of pre- 
vention and treatment for various addictions, 
with a special emphasis on the use of synthe- 
tic opioids and their antagonists, should be a 
primary area of focus from the standpoint of 
the pharmacotherapy field. Also, an in- 
creased amount of information about the 
causes of vulnerability toward drug abuse 
and addiction would be helpful for future 
treatment practices. 

The following important treatment 
agents — which either are being used cur- 
rently, are being researched, or are still in 
the theoretical stage — were discussed: 
(1) the widely used racemic mixture of meth- 
adone; (2) the active 1-enantiomer meth- 
adone; (3) L-Alpha-Acetyl-Methadol (LAAM); 



(4) the two metabolites of LAAM — norLAAM 
and dinorLAAM; (5) the endogenous opioid 
dynorphin-related peptide; and (6) the speci- 
fic opioid antagonists — naloxone, naltrexone, 
and nalmefene. 

Morphine is a natural derivative from the 
poppy seed and also may be synthesized in 
humans and other mammals. Heroin is a 
manmade, di-acetylated derivative. These 
two drugs are very similar, but heroin has a 
quicker rate of onset. When methadone 
maintenance was first investigated in 1964 
as a treatment agent, V.P. Dole, M. Nys- 
wander, and M.J. Kreek, as researchers, had 
two criteria for a treatment agent. The first 
was to develop an effective oral treatment 
agent because an oral agent would gradually 
steer intravenous, drug-using individuals 
away from the lure or mystique of using 
needles and from the dangers of using un- 
sterile needles. The second objective was to 
use an opioid which is long acting in humans 
for proposed long-term pharmacological 
treatment to allow stabilization and hope- 
fully normalization of physiological function 
with a medication given only one time per 
day. 

In 1964 methadone specifically was chosen 
for research on the treatment of addiction. 
Methadone was found to satisfy both objec- 
tives: (1) it is orally effective and (2) it has 
a long-acting (over 24 hours) pharmacological 
profile in humans. Subsequent studies 
showed that, if the initial dose of methadone 
was properly chosen not to exceed the degree 
of tolerance developed by the patient, then 
no euphoria or narcotic effects were ob- 
served, and the dose then could be increased 
gradually to a full-treatment dose — a dose 
that would "blockade" any euphoric or other 
narcoticlike effects of any illicitly super- 
imposed short-acting narcotic such as heroin. 
During early studies of methadone main- 
tenance, methadone proved to be a very 
stable treatment, producing neither "high" 
(i.e., euphoric) periods nor narcotic with- 
drawal periods. Because patients do not 
receive any euphoric effects from use of illicit 
heroin while on methadone maintenance, 
they typically choose to stop using heroin 
and become normalized through methadone 
maintenance. Methadone also has been 
shown to be medically safe to use, with 
prospective studies conducted for 3 years and 
with followup studies for over 10 years. 

Methadone is most effective when used in 
combination with counseling and other social 



21 



NIDA Conference Highlights 



and medical services for the long-term treat- 
ment of opiate dependency. One common 
misconception among a large number of the 
methadone maintenance facilities is that 
lower dosages are better; this is not true. 
For the majority of individuals in methadone 
maintenance treatment, there is a need for a 
dose that will effectively prevent withdrawal 
symptoms, block drug craving, and also block 
any effects of illicit use of short-acting nar- 
cotics through the development of tolerance 
and cross -tolerance. A recent study by Dr. 
John Ball revealed that persons treated with 
60 to 100 mg. of methadone had less than a 
6-percent incidence of testing positive for 
heroin use, whereas those treated with 
smaller doses of methadone showed a higher 
incidence of relapse. However, it is true that 
some patients may do very well on low doses 
of treatment. Therefore, individualization, 
not legislation, of dose is necessary. 

In summary, methadone has been shown to 
prevent withdrawal symptoms and drug 
hunger and to block the euphoric effects of 
short-acting narcotics, all of which result in 
significant reduction or cessation of illicit 
narcotic use. Also, methadone, as used in 
stable doses in maintenance treatment, has 
been shown to allow the normalization of 
physiology disrupted by chronic use of 
short-acting narcotics like heroin. The 
mechanisms of action are by the provision of 
steady state levels of exogenous opioid at 
specific opioid receptor sites. Methadone 
treatment in steady dose allows normaliza- 
tion of many critical physiologic systems dis- 
rupted by heroin use, such as the stress 
responsive hormonal axis and the reproduc- 
tive biological hormonal axis — disruption 
which may contribute to the drug-seeking 
behavior itself. Of critical importance to the 
AIDS epidemic is that, during methadone 
maintenance treatment, normalization occurs 
of some of the most important indices of 
immune function (e.g., the restoration to 
normal activity of natural killer cell func- 
tion), in addition to reduction or cessation of 
illicit drug use and thus exposure to un- 
sterile needles. 

Another agonist that has been under study 
for some time is LAAM, a cousin of meth- 
adone. LAAM will undoubtedly become 
another important agent in the treatment of 
addiction; NIDA is very supportive of addi- 
tional studies of its use. LAAM has a long 
duration and may be effectively administered 
orally. It was approved by the FDA in July 
1993. In early studies of LAAM, it was 



found that retention in LAAM treatment was 
slightly less than in methadone maintenance 
treatment, but new techniques for induction 
of LAAM should allow for greater retention. 
As with methadone, stabilization of patients 
is the most critical issue in the use of LAAM. 
LAAM is not a substitute for methadone; 
however, it can serve as an alternative choice 
for treatment since it also is a long-acting 
opioid effective for the treatment of opiate 
dependency. Also like methadone, LAAM's 
effectiveness depends in part on the quality 
of other services administered along with the 
drug and on how well staff are trained in its 
usage. 

/ Speaker: Frank Vocci. Ph.D. 
To begin, a few brief comments on drug 
abuse in the United States are noteworthy. 
First, there is a widespread misperception in 
the United States that heroin use is no 
longer a significant problem and that the use 
of crack -cocaine has taken its place. Many 
heroin addicts inject the drug intravenously, 
putting themselves at risk for HIV infection 
if they share needles. In fact, one out of 
three AIDS patients in the country is an IV 
drug user or the sexual partner of an IV 
drug user. Second, the fentanyl compounds 
are a very potent series of opiates. One 
derivative is 25,000 times as potent as mor- 
phine. Synthetic chemists can make ex- 
tremely potent synthetic opioids that likely 
will keep addiction around for a long time. 
Attention must be paid to addiction to opi- 
ates in general, not just to heroin. Heroin 
has only been around for about 100 years, 
whereas use of other opiates has occurred for 
thousands of years. 

There historically has been difficulty in 
transferring technologies from researchers to 
practitioners. About 3 years ago, the FDA 
would not approve LAAM, despite controlled 
clinical studies with 6,000 patients, because 
it was unknown how practitioners would use 
the drug. The FDA wanted to ensure that 
the knowledge gained from the clinical trials 
would be transferred effectively to practi- 
tioners, who may see many uses for the drug. 
The FDA suggested that practitioners be 
given the drug with instructions to use it on 
whomever they thought could benefit from it. 
Consequently, a team of investigators gave 
the drug to methadone maintenance program 
directors with instructions on the use of 
LAAM. This study required only that the 
patients given LAAM not be at immediate 
risk of death (i.e., were expected to live for at 



22 



Summaries of Research Awareness Seminars 



RS04. 



least the following 12 weeks) and that the 
patients not have court dates during that 
time, which would interrupt the admini- 
stration of the drug to them. This LAAM 
study revealed, as expected, a lack of any 
kind of organ toxicity due to the drug. Es- 
sentially, this study validated the results of 
the earlier controlled clinical trials. The 
FDA was pleased with these results and soon 
approved the drug. 

The more drugs available for treatment of 
narcotic addiction, the better practitioners 
will be able to tailor therapies to patients. 
One drug that should be mentioned as a 
possible future treatment is buprenorphine, 
a partial agonist and synthetic opioid. An 
agonist produces a biological response in a 
physiological system. A partial agonist, on 
the other hand, also produces a biological 
response but needs greater receptor occu- 
pancy to produce the same level of biological 
response. Buprenorphine is an analgesic and 
may be administered in doses of 0.15 to 0.6 
mg. Many studies currently are being con- 
ducted on buprenorphine, such as on its dose 
responsiveness, with the hope of bringing the 
drug to treatment by as early as 1995. Due 
to concerns about the drug, however, re- 
searchers are investigating a formulation 
that includes an antagonist. One potential 
candidate, naloxone, is being tried in combi- 
nation with buprenorphine in NIDA studies. 

In addition, naltrexone is available for treat- 
ment of addiction, but addicts do not like it 
and therefore do not comply with treatment 
using the drug. It has a rapid onset, which 
may lead to dysphoric effects. A depot for- 
mulation currently is being evaluated as a 
possible treatment for addiction. This for- 
mulation may be effective without producing 
unwanted side effects. 

Update on Drugs— Marijuana, 
Hallucinogens, and Inhalants 

Moderator: Ann Blanken 
Speakers: Christine Hartel. Ph.D. 

Arturo Hernandez 

Geraline Lin. Ph.D. 
July 15, 4:45 p.m.-6:15 p.m. 

Speaker: Ann Blanken 

Based on continuing surveys, it has been 
determined that approximately 33 percent of 
all high school students have tried marijuana 
at least one time during their lives. Another 
alarming finding is that use of the hallu- 
cinogenic drug LSD is again on the rise. In 



addition, inhalant use has shown a gradual 
trend toward a younger population of users. 

Speaker: Geraline Lin. Ph.D. 
Hallucinogens can be defined loosely as 
drugs that alter one's mental state within a 
very short period of time. LSD — the main 
hallucinogenic drug — gained a lot of publicity 
during the psychedelic revolution of the 
1960s and seems to be making a notable 
return. In 1970, LSD was classified as a 
Schedule 1 substance, which means that 
using this drug for medical reasons was 
outlawed due to the determination that high 
levels of its use and/or abuse were unsafe. 
In conjunction with this ruling, human 
testing also was banned, with the result that 
little is known about the long-term medical 
effects of LSD use or treatments for LSD 
abuse. There are, however, many known 
pharmacological effects associated with LSD 
use, including the following: perceptual 
hallucinations, blurring of the senses, 
heightened awareness of audio reception and 
other sensory input, the sense of being part 
observer of and part participant in one's own 
thoughts and actions, clear mental capabi- 
lities, dilated pupils, increases in hormonal 
activity, and sense of time distortion. 

A number of side effects have been experi- 
enced among LSD users. The most 
well-known, acute side effect is what is 
referred to as a "bad trip." Simply, this is 
experiencing a certain level of fear and 
anxiety while under the influence of the 
drug. Three known chronic side effects have 
been reported by LSD users. The first, a 
"flashback," is an LSD-type encounter experi- 
enced by a person who is not actually using 
the drug at the time of the flashback's occur- 
rence. The second is an LSD-induced mental 
psychosis. Lastly, long-term use of this drug 
has been found to gradually impair vision. 

Researchers must be able to conduct tho- 
rough investigations of LSD in order to 
understand completely its physiological 
effects. Human testing now is needed to 
validate any findings that come about 
through animal testing. Until all the 
mysteries surrounding LSD are discovered, 
including its underlying mechanisms, scien- 
tists will never find effective treatment for 
the abuse of this drug. Also, it is possible 
that a therapeutic use for LSD may be 
discovered. 



23 



NIDA Conference Highlights 



Speaker: Arturo Hernandez 

Very little research has taken place in the 
area of inhalant use and abuse. Therefore, 
very little is known about the level of dam- 
age caused by prolonged inhalant use. Limi- 
ted studies have found that the following are 
the most commonly used inhalants: adhe- 
sives, aerosols (e.g., a popular inhalant is 
spray paint), anesthetics, cleaning agents, 
solvents or gases, and food products (e.g., 
whipped cream nitrogen dioxide). 

Inhalant use is most prevalent among 
younger populations. Two studies — the 
National High School Senior Study and the 
National Household Survey on Drug Abuse — 
found that inhalant use has been increasing 
since it was first covered in the survey in 
1975. A 1988 Texas study analyzed lifetime 
prevalence rates for inhalant use. The find- 
ings were disturbing, revealing that 75 
percent of all secondary school students 
admitted using an inhalant at least once in 
their lives. A 1990 followup study showed an 
increase of 5 percent, bringing the rate of use 
among high school students to an alarming 
80 percent. In 1992, the rate dropped back 
to 75 percent. Inhalant use has been found 
to have an equal ratio of use among males 
and females, with children living in 
single-parent homes having a higher rate of 
use than children living in two-parent envi- 
ronments. The following traits have been 
exhibited by some or all young chronic inhal- 
ant users: difficulties in school; slow cogni- 
tive processes; extensive rates of school 
absenteeism; high rates of suspension and 
expulsion; higher rates of dropping out of 
school compared to noninhalant users; more 
criminal problems; tendency toward poly drug 
use; greater likelihood of coming from low 
socioeconomic environments; greater likeli- 
hood of coming from families that have 
problems with drugs and/or the law; and 
more emotional, personality, and conduct 
disorders. 

What needs to be done in regard to this prob- 
lem? Since it has been noted that inhalant 
abusers do not tend to be very receptive to 
inpatient programs, an increased number of 
outreach programs should be provided. 
Traditional methods of finding inhalant users 
will not work with this population. For 
instance, it must be explored how the crimi- 
nal justice system can assist with outreach to 
inhalant users. In addition, more advanced 
and comprehensive methods of screening and 
assessing incoming patients should be devel- 
oped in order to provide more accurate 



client-to-treatment matching. Cultural 
sensitivity is a big consideration when staf- 
fing various treatment facilities. Further- 
more, concerning treatment, extended 
detoxification must be made available prior 
to other therapeutic interventions. Treat- 
ment workers should explore nontraditional, 
creative ways of working with inhalant 
users, and treatment planning should 
include multi disci plinary case management. 
In addition to treatment, a greater emphasis 
must be placed on prevention of inhalant 
abuse. For instance, in Texas, the Texas 
Prevention Partnership has earmarked all of 
its prevention efforts toward this problem, 
and an education and media campaign has 
helped steer youth away from inhalant 
abuse. 

Speaker: Christine Hartel. Ph.D. 

Marijuana use reached its peak among high 
school seniors in the late 1970s and has been 
declining ever since. However, marijuana 
use among eighth graders has experienced a 
steady rise over the last 2 years. Based on 
comparisons of levels of THC (the major 
psychoactive ingredient in marijuana) in 
seized batches of marijuana and in the mari- 
juana grown on NIDA's own marijuana farm, 
it has been found that potency levels have 
risen over the years. Marijuana found in the 
late 1970s and early 1980s generally had 
THC levels in the 2-percent range. Recent 
seizures of marijuana have revealed 
3-percent levels of THC and, in some cases, 
levels as high as 20 and 30 percent have 
been detected. Despite the extreme levels of 
potency for these plants, no THC toxicity 
deaths have been reported. Immediate 
effects of marijuana use include the follow- 
ing: change in perception, irritated eyes, 
increased heart rate, anxiety, and acute 
psychotic reactions. 

It is hard to determine the long-term effects 
of marijuana use due to the fact that nearly 
everyone who uses this drug also uses other 
drugs. The use of alcohol in conjunction with 
marijuana poses the greatest threat in terms 
of ill health effects for the user. 

A recent Baltimore Shock Trauma Study 
tested the blood of 1,000 patients for the 
presence of alcohol, marijuana, or both. The 
study results showed that one-half (500 
patients) of the people tested had either 
alcohol, marijuana, or both in their system at 
the time of the test. Of those tested, one- 
third tested positive for alcohol, one-third 
tested positive for marijuana, and one-third 



24 



Summaries of Research Awareness Seminars 



tested positive for both. These findings give 
an idea of the extent of the problem sur- 
rounding both marijuana and alcohol use. 
The THC found in marijuana — while mainly 
used by people in search of euphoric effects — 
has a few positive uses, such as pain-killing 
attributes and treatment qualities for reliev- 
ing muscle spasms commonly associated with 
multiple sclerosis. 

Questions, Answers, and Comments 

Comment: Inhalant treatment needs to focus 
on the young user because as inhalant use 
continues, polydrug use becomes very com- 
mon. It is not that older chronic users 
cannot be treated, but that not enough infor- 
mation is available about the long-term 
effects of use. NIDA soon will be sponsoring 
a technical review on inhalants. 



RS05. Update on Drugs: 
and Stimulants 



Cocaine 



Moderator: Robert Millman. M.D. 
Speakers: Anna Rose Childress. Ph.D. 

Christine Hartel. Ph.D. 

Thomas Kosten. M.D. 
July 16. 2:30 p.m.-4:00 p.m. 

Speaker: Anna Rose Childress, Ph.D. 

The most prominent effects on patients after 
withdrawal from prolonged cocaine use are 
druglike effects reminiscent of cocaine use. 
External and internal factors reminiscent of 
cocaine use seem to trigger craving and 
arousal in the patients. Long after detoxifi- 
cation, patients often experience strong 
episodes of cocaine cravings upon returning 
to their normal environment. These episodes 
usually are marked by a quickened 
heartbeat, the taste of cocaine in the back of 
the throat, and ears ringing or head buzzing, 
as though the patient had in fact been using 
cocaine. While the druglike state patients 
call "craving" is a prominent one, it is dif- 
ficult to study because it describes more than 
one subjective state. Patients related their 
desire to use cocaine, or return to use, to 
these cravings. It is clinically important to 
understand and measure these states in 
order to develop clinical studies for the pur- 
pose of reducing these states. 

Strategies are developed according to those 
things in a patient's internal and external 
environment that have been paired, signaled, 
or associated with cocaine use over the 
course of an addiction. Patients in the study 
discussed here were tested with exposure to 



a variety of stimuli associated with cocaine 
use and usually evident in their normal 
environment. They reported craving, which 
was the most common subjective response, as 
well as a host of psychophysiological re- 
sponses. Various arousals were described, 
such as cooling of the fingertips, increased 
heart rate, and occasional respiratory 
changes. This study demonstrated a simple 
model of Pavlovian conditioning — that cer- 
tain stimuli precede things that are biologi- 
cally significant or important. In this case, 
a drug stimulus can become a signal for that 
event. 

Once certain states of cocaine craving were 
recognized, the next step involved devising 
methods of reducing these cravings. Patients 
who had just completed detoxification versus 
those who had stayed away for 30 whole 
days were given a great deal of exposure to 
possible stimuli found in their normal envi- 
ronments. For an extensive 2-week period 
after detoxification, inpatients were given 
15-hour sessions of exposure to these cues to 
help reduce physiological reactivity and 
cravings. When patients were shown cocaine 
videotapes, they experienced the same cra- 
ving response and temperature drop of the 
skin as those patients handling cocaine. The 
strategy tried in this case was passive cue 
exposure. The results show a reduction to 
subjective craving. There was a reduction in 
positive urines and better retention in the 
outpatient phase. Both groups of study 
participants experienced similar difficulties, 
however, in achieving this reduction in 
craving, thus showing the persistence of 
cocaine-craving stimuli. Also, they showed 
no reduction in craving when exposed to cues 
that had been used in the testing laboratory. 

Strategies also were developed to aid users 
during outpatient treatment in dealing with 
outside stimuli. In one strategy, a patient 
would recount the craving episode and then 
would be taught active tools to respond to 
this craving, such as a deep relaxation re- 
sponse. In a second strategy, it is suggested 
that when the patient has a craving, he/she 
should do nothing for 5 minutes, consider 
behavioral alternatives based on an already 
prepared mental list, and then do one of 
those alternatives (e.g., call a friend). Also, 
patients are told to think through a written 
list of negative consequences of cocaine use. 
Another strategy involves imagery (com- 
paring the positive alternatives versus the 
negative consequences) or mastery imagery 
(conjuring up a metaphorical image of the 






25 



NIDA Conference Highlights 



craving that they can attack). The last 
strategy is a cognitive therapy session during 
which the patient analyzes his/her thoughts 
and what he/she tries to convince 
himself/herself of in these situations. If 
these strategies prove to be effective for 
cocaine, they also may work for other sub- 
stance classes or compulsive behaviors. 
Other possible involvements are interfacing 
these cuing techniques with medications 
development work and relating cuing work to 
brain imaging. 

Speaker: Christine Hartel. Ph.D. 

Khat is a shrub that grows in Northeast 
Africa and the Southeastern part of the 
Arabian peninsula. Khat leaves have been 
used as a mind-altering substance for over 
700 years. The shrubs are harvested and 
sold in the marketplace for the purpose of 
masticating. A substance in khat called 
cathenone is extracted by the combination of 
saliva and chewing, creating a "high." 
Seventy-five to ninety percent of those people 
using the shrub, primarily men, are addicted 
to khat. It has been used for hundreds of 
years to relieve fatigue, an effect also caused 
by the coca leaf. The use of khat was ritual- 
ized in these societies and only certain 
classes were allowed to use them. In recent 
years, however, people have become aware of 
the widespread use of this substance and, in 
the late 1970s, appealed to the World Health 
Organization for help in controlling this 
substance. At that time, cathenone, the 
effective ingredient, was isolated from khat 
leaves and given to universities around the 
world to study. 

One of the first necessary studies conducted 
on a drug is to see if animals will take the 
drug (stimulants are taken avidly by ani- 
mals); cathenone was no exception in this 
case. Usually if animals will take a drug, it 
has a high likelihood for being abused by 
humans. The study showed that cathenone, 
like amphetamines or cocaine, is taken by 
animals. Drug discrimination studies with 
animals also showed that cathenone can act 
as a substitute for amphetamines or cocaine. 
Cathenone can be taken either intravenously 
or intranasally. The structures of amphe- 
tamines and cathenone and the results of 
taking either drug are extremely similar. 
Cathenone shares all the properties of am- 
phetamines and cocaine in terms of increas- 
ing alertness and activity, decreasing ap- 
petite, alleviating fatigue, and producing 
euphoria. Amphetamine was the first group 



of drugs to be shown to have neurotoxicity. 
Methamphetamines and related drugs cause 
actual nerve damage in the brain, an effect 
probably also caused by cathenone, though 
studies have not yet been conducted on this 
issue. Tolerance can develop from use of 
cathenone. Users take about one-half to 
1 per day, at a cost of $100.00 per gram. 
Amphetamines cause psychosis, hyper- 
activity, and agitation and can be treated 
clinically with antipsychotics and benzodia- 
zapines; cathenone appears to have similar 
results. 

Concern about whether khat would become a 
problem in the United States was heightened 
by media attention during the Somalia 
conflict, but use in the United States was 
considered unlikely because khat is only 
effective when fresh. Cathenone breaks 
down chemically when the leaves lose their 
freshness after 2 to 3 days. However, the 
chemical synthesis of cathenone is relatively 
simple, and quantities of cathenone now 
have shown up in DEA seizures. On the 
street, cathenone is referred to as "cat." It is 
an extremely potent and addictive drug, with 
highs lasting as long as 6 days. 

Speaker: Thomas Kosten. M.D. 

With the neurobiological adaptation that 
occurs during chronic cocaine use, a variety 
of adverse actions occur in brain receptors. 
Studies show evidence of changes in animals' 
brain receptors in certain serotoneurgic, 
dopamineurgic, and noradreneurgic areas. 
All of these areas are affected by cocaine in 
fairly direct ways. 

When a normal brain is given a ligand that 
binds to dopamine receptors, a PET scan 
shows the cordate area lit up brightly due to 
the large amount of dopamine receptors in 
this area, which is intimately involved with 
Parkinson's disease. When looking at a PET 
scan of a cocaine abuser's brain that has 
been given the same ligand, the cordate area 
is virtually nonexistent. There is about an 
80-percent decrease in dopamine receptors in 
a cocaine abuser's brain, exemplifying what 
typically results from Parkinson's disease. 
Part of the reason these symptoms are not 
noticed is because there is a tremendous 
reserve of dopamine receptors in this area. 
This test clearly shows a significant toxicity 
and decrease in dopamine receptors with 
chronic cocaine use. Clinical cases of cocaine 
users in their thirties show an increase in 
the development of dystonia (i.e., Parkin- 
sonian tremors or stiffness) after using 



2o 



Summaries of Research Awareness Seminars 



cocaine. Amphetamine users from the 1960s, 
for example, are developing symptoms of 
Parkinson's disease much earlier in life (in 
their forties) than is normal. 

In other studies, on a PET scan, cortical 
areas of the brain experiencing decreased 
activity portray the result of multiple strokes 
in an older person. Tests of younger drug 
users show major profusion deficits in their 
brains, similar to stroke patients. Neuro- 
psychological testing on these patients shows 
marked problems with concentration and 
memory. Two major deficits that also occur 
in cocaine users are cortical abnormalities 
related to higher cognitive function and 
subcortical abnormalities shown in move- 
ment disorders and other types of disorders, 
such as Parkinson's disease. 

One concern has been with cocaethylene, a 
compound formed when cocaine and alcohol 
are ingested and mixed together in the liver. 
The alcohol metabolizes cocaine into this 
compound, which is similar to cocaine itself 
except for a few key properties. For in- 
stance, cocaethylene is active (meaning it 
produces profound changes in the brain) for 
about 6 to 7 hours, versus 1 hour or so for 
cocaine. Also, cocaethylene is formed at 
about 15 percent of the levels of cocaine; 
however, if a person were to take cocaine 
every 20 to 30 minutes for several hours, the 
cocaethylene level eventually would exceed 
the cocaine level and the toxicity would go on 
for hours. High cocaethylene levels cause 
high levels of cardiovascular and central 
nervous system toxicity, which is potentially 
greater than that of cocaine alone. The 
combination of cocaine and alcohol also 
causes behavioral effects. Alcohol is a 
long-acting, sedating drug, and cocaine is a 
short-acting and activating drug. A person 
mixing the two will feel the alert effects of 
cocaine at first, but the sedating alcohol 
effects remain once the cocaine wears off. 
Consequently, cocaine and alcohol interact in 
a variety of very toxic ways, both in a neuro- 
biological interaction and a behavioral 
pharmacological interaction. 

Cocaine itself has significant effects on sero- 
tonin transport, dopamine, and norepine- 
phrine. But cocaethylene does not have as 
much effect on serotonin transporters. Sero- 
tonin has many effects that are opposite to 
those of dopamine and norepinephrine, 
particularly on the cardiovascular system. 
There appears to be somewhat of a protective 
effect from cocaine relative to norepine- 



phrine. Because cocaethylene is not affecting 
these certain neurgic systems, a person has 
unopposed adrenergic and dopaneurgic acti- 
vity, a substantially increasing heart rate, 
higher blood pressure, the chance of a stroke 
or seizures, and other complications. Thus, 
cocaethylene may be more toxic, depending 
on the way it is taken. 

A study conducted in the 1980s on desipra- 
mine and the treatment of cocaine abuse 
compared amounts of cocaine use over a 
6-week period with treatment using placebos, 
lithium, and desipramine. The use of desi- 
pramine showed a decrease in cocaine use 
that persisted throughout the 6 weeks. 
Noticeably, the psychotherapy given at the 
same time as a placebo or lithium clearly had 
a substantial effect. There was a 50-percent 
reduction in cocaine use due to ongoing 
psychotherapy. Clearly, these medications 
did not operate alone but benefited from the 
effects of psychotherapy as well. Later 
studies have not been able to replicate this 
dramatic treatment effect and have shown 
cocaine pharmacotherapy techniques being 
less successful. This may be due to the fact 
that, when the study was first done, most 
people were using intranasal cocaine. Now 
most people are using intravenous or smoked 
cocaine. Such routes of administration and 
use at earlier ages are resulting in a greater 
prevalence of substantial neurobiological 
deficits. Thus, there are fewer success 
stories now compared to 5 years ago. 

A study using Prozac, the supposed wonder 
drug that many people believe cures every- 
thing, including drug abuse, shows some 
reduction in cocaine abuse. The levels of 
cocaine abuse are measured in urine benzoy- 
lecgonines. Someone relatively abstinent 
would have a level of 300. An improved 
patient would drop from a level of 60,000 to 
30,000, still about 100 times above the 
abstinent level. Clearly, the best these 
medications are doing with cocaine abusers 
is reducing the amount of cocaine they are 
abusing, but they are not stopping their 
cocaine use, with very few people becoming 
abstinent. 

Other medications have been examined, such 
as buprenorphine, and hold promise in alter- 
natives to methadone for opiate addicts. One 
big problem with opiate addicts is that 70 
percent also use cocaine. An earlier study 
comparing methadone to buprenorphine 
shows that only 25 percent tested positive for 
cocaine use when on methadone, and only 



27 



NIDA Conference Highlights 






2.5 percent tested positive when on bupre- 
norphine. Buprenorphine helps decrease 
opiate use and cocaine use. 

Three randomized clinical trials have ana- 
lyzed buprenorphine at dosages of up to 
8 mg. daily and shown virtually no difference 
between methadone and buprenorphine. If 
the buprenorphine dosages are increased to 
16 mg. daily, the amount of cocaine use 
drops off. Buprenorphine appears to be 
dosage dependant. When using more, it 
decreases opiate use as well as cocaine use. 
In a randomized trial study comparing 2 mg. 
to 6 mg. of buprenorphine with opiate with- 
drawal symptoms of people using and not 
using cocaine, subjects on low doses of bupre- 
norphine had persistent low-level opiate 
withdrawal symptoms. When taking cocaine, 
their persistent level of opiate withdrawal 
symptoms significantly and substantially 
dropped. Cocaine reduces these withdrawal 
symptoms. More critical, at this relatively 
lower dose of buprenorphine (6 mg.), cocaine 
use at higher dosages increases withdrawal 
symptoms. With larger dosages of an opiate, 
there is no persistent, long-term, low-level 
withdrawal. With 16 mg. doses of buprenor- 
phine and dosages of up to 120 mg. or higher 
of methadone, people stop using cocaine and, 
if they do use it, the effect is now 
unpleasant. 

Finally, pharmacotherapies and psycho- 
therapies go hand in hand and are very 
helpful when used together. A study done 
looking at two types of psychotherapies, an 
interpersonal psychotherapy and relapse 
prevention psychotherapy, showed the per- 
centages of cocaine abusers who were absti- 
nent for 6 weeks and received relapse 
prevention therapy to be less than 40-percent 
abstinent. Those who received interpersonal 
therapy alone were 30-percent abstinent, and 
patients who received a placebo plus inter- 
personal therapy were 20-percent abstinent. 
Those who received desipramine and inter- 
personal therapy were 80-percent abstinent. 
Clearly, the combination of psychotherapies 
and medications is effective. 

Questions, Answers, and Comments 

Which types of populations were researched 
in the cocaine craving reduction studies? 
Two primary types of populations that have 
been served during the history of this 
research are Vietnam veterans and 
African-American males (mostly in their 
thirties). Sixty percent of the Vietnam veter- 



ans were involved with opiates, and 40 per- 
cent of the African-American males were 
more heavily involved with cocaine. In the 
past 2 years, more women and non-Vietnam 
veterans are being treated. A larger sample 
of women is needed in order to be able to 
understand their differences in more depth. 
Most subjects treated were users who 
smoked cocaine, with opiate users primarily 
excluded from this particular research. 

What types of mentally disturbed people were 
treated in those studies'? Subjects evaluated 
to be experiencing psychosis of any nature 
were those of Axis-I and Axis-II disorders. 
This research excluded psychotics or organics 
because they could not be interviewed using 
these tools. This research did not exclude 
people with personality disorders or major 
affective disorders but did exclude those with 
thought disorders or organic symptoms. 

Is the route of administration of drugs impor- 
tant as to what type of treatment to use? The 
route of administration is very important in 
terms of what type of treatment is set up and 
how quickly it needs to be set up. 

What are some of the side effects ofkhat? Be- 
cause there is a lot of tannin in the leaves, 
one side effect of too much use is severe 
gastrointestinal upset. 

Are there any other derivatives ofkhat? The 
plant has been methylated into meth- 
cathenone, which is considered better than 
cathenone. (Cathenone is on the Schedule 1 
list of illegal substances.) 

What is a blunt? A blunt is an emptied cigar 
that is refilled with cathenone, marijuana, 
stimulants, tobacco, or any combination of 
these substances. Such a route of admini- 
stration is significant because any substance 
that is smoked reaches the brain very 
quickly. 

7s khat used to stimulate aggression? It is 
believed that khat is used for aggression in 
war tactics in the geographical areas where 
it is most prevalent, but the most abused 
substance for creating aggression in our 
society is alcohol. The link between violence 
and stimulants is not as established as many 
people think it is. 

When cocaine abusers experience a decrease 
in their number of dopamine receptors, what 
happens to the receptors? They recede into 
hidden receptors: they enter a different or 
low-affinity state, or they get swallowed by 
membrane and are sitting inside of the cell. 



■?e 



Summaries of Research Awareness Seminars 















The system has been downregulated with a 
reuptake blocker blocking dopamine from 
coming back into the cell. Therefore, when 
the synapse is being flooded with dopamine, 
the postsynaptic cell responds by decreasing 
the number of receptors. This process ap- 
pears to be reversible, however. 

What is the relation between heroin and co- 
caine, and does heroin make cocaine 
unpleasant in the withdrawal phase? The 
amount of heroin used on the street is equi- 
valent to about 25 mg. of methadone, a 
relatively low dose. Alow dose of methadone 
or heroin mixed with cocaine results in a 
decrease in withdrawal symptoms and is also 
a pleasant experience, according to the data. 
However, a large dose of heroin makes the 
use of stimulants, like cocaine, unpleasant. 

Do you have any experience using 
methylphenidate to treat cocaine users? In 
some studies, people with versions of atten- 
tion deficits who also were cocaine abusers 
were treated with methylphenidates 
(Ritalin). These people used relatively small 
amounts of cocaine and showed no binge 
patterns. When they took methylphenidate, 
they did well and most quit using cocaine. 
But when a variety of cocaine users were 
tested, results indicated that the treatment 
was successful only at first — patients stopped 
using cocaine, but then they began to want 
more methylphenidate and, ultimately, more 
cocaine. 

What test might determine neurological 
deficits? There are various memory tests, 
such as story recall, random-digit tests, and 
Sternberg's memory test, to name a few. 
Using these tests, people who had stopped 
using cocaine for a period of 6 months still 
had deficits. Preliminary data from giving 
such people Diamox show it may reverse 
profusion deficits. Much more information is 
needed on this subject. 

Comment: Surveys show that cocaine use 
may be decreasing in the general society, but 
it looks like the adverse sequelae of cocaine 
use is increasing in certain areas (e.g., the 
inner city). The cocaine epidemic may have 
waned, but it is becoming more endemic. It 
is not sweeping across a normal population 
but is thriving in a sicker population and 
attacking those individuals who are at 
risk — the psychologically, physically, and 
socially disadvantaged. 

Comment: It makes clinical sense that 
cravings would vary with psychopathology; 



consequently, a highly anxious person might 
express an increased craving. Withdrawal 
also depends on psychological effects. Some 
work was done with opiate patients to see 
whether or not inducing a mood state (such 
as depression, anxiety, anger, or euphoria) 
actually triggers cravings; many patients 
reported that a mood state could be just as 
powerful as seeing a crack vial in the street. 
It was demonstrated that depression was a 
prominent cue for opiate use. 

Comment: Animal models are critical in 
determining how addiction and dependency 
work. Good animal models exist for cocaine 
and heroin but not for alcohol. This may be 
due to animals' innate fear of predators and 
the impediment that alcohol causes to their 
protection. 

RS06. Update on Drugs— Tobacco 

Moderator: Jack Henningfleld. Ph.D. 
Speakers: Sharon Hall, Ph.D. 

Marlyne Kllbey. Ph.D. 

David Sachs. M.D. 

Karen Sees. D.O. 
July 16. 8:30 a.m.-10:00 a.m. 

Speaker: Marlyne Kilbey, Ph.D. 

Although there is ample scientific evidence 
that smoking is widespread and highly addic- 
tive, the causes of smoking are not very well 
understood. The distinction between smok- 
ing and nicotine dependence rarely has been 
made, and the relationship between nicotine 
dependence and other substance abuse dis- 
orders and affective disorders has received 
little attention. Fifty million smokers have 
quit smoking, but nearly 50 million others 
continue to smoke despite overwhelming 
information about adverse health effects, 
expense, and increased inconvenience (with 
the advent of recent antismoking rules and 
regulations). 

A study done in 1989 classified young adults 
between the ages of 21 and 30 according to 
smoking status categories to examine 
whether significant differences existed 
among the groups in terms of the relation- 
ship between smoking status and other 
substance use disorders and between major 
depressive disorders and anxiety disorders. 
Three smoking status groups were formed: 
(1) nonsmokers, (2) nonnicotine-dependent 
smokers, and (3) nicotine-dependent smokers. 
Of this sample, 39.1 percent smoked daily for 
1 month or more in their lifetime, of which 
51 percent were nicotine dependent. Among 



29 



NIDA Conference Highlights 



smokers with nicotine dependence, 62 per- 
cent were mild dependents, 38 percent were 
moderate dependents, and none met the 
criteria for severe nicotine dependency. 
Rates of smoking and nicotine dependence 
were higher for Caucasians than 
African-Americans, and these rates were 
inversely correlated with levels of education. 

In rates of other substance use disorders in 
smoking history, it was found that all people 
who had smoked daily for 1 month or more 
at any time in their lifetime were at 
increased risk for other substance use depen- 
dence disorders. Nondependent smokers had 
a twofold increase in their rate of cannabis 
and cocaine dependency compared to non- 
smokers. Dependent smokers had between 
threefold and fourfold increases in the rates 
of substance dependence. The rates of anxi- 
ety disorders with major depressive disorders 
(MDDs) were higher in those with other 
substance use disorders. Nicotine depen- 
dence was associated with twofold increased 
rates of MDDs and fourfold increased rates 
of anxiety disorders with MDDs. 

Fourteen months later, a followup interview 
of 995 of the original 1,007 subjects exa- 
mined whether smokers with a history of 
MDDs had progressed to nicotine dependence 
and whether persons with a history of nico- 
tine dependence are at increased risk for 
MDDs. Of the various smoking status 
groups, 20 to 46 percent of the smokers 
progressed to the next level of abuse. Within 
a 14-month period, 38 percent of smokers 
with a positive history for major depression 
showed progressive nicotine dependence. 
Most of the subjects did not show any pro- 
gression toward MDDs; however, MDDs were 
more evident in those who smoked more. 
Overall, the history of MDDs increased the 
risk twofold for progression to nicotine de- 
pendence and more severe levels of nicotine 
dependence. 

A history of an MDD or any anxiety disorder 
also was associated with failure to quit 
smoking. Of 394 people who had smoked 
daily for 1 month or more, 61 percent tried to 
quit — 86.2 percent of these people failed. 
Only 14.3 percent of those with moderate 
nicotine dependency had been able to quit 
compared to 24 percent of those with mild 
nicotine dependency. The severity of with- 
drawal symptoms was examined to see if it 
accounted for the association between the 
history of MDDs and continued smoking. 
The initial analysis showed that people with 



MDDs experienced more severe withdrawal 
symptoms when they tried to quit. 

Nicotine-dependent smokers differ from non- 
dependent smokers in terms of personality 
characteristics and cognitive patterns. It 
was found that nicotine dependence is associ- 
ated with increased scores on neurotdcism, 
negative effects, and hopelessness. Neuro- 
tdcism and correlated psychological measures 
may constitute common predispositions to 
nicotine dependence, major depression, 
and anxiety disorders. Nicotine-dependent 
smokers had higher expectations that smok- 
ing would reduce negative effects, aid in 
appetite and weight control, and provide 
sensory satisfaction and distraction. Thus, it 
would appear that the expectations of posi- 
tive reinforcement from smoking increased in 
nicotine-dependent persons. 

Data suggest that all smokers are at risk for 
other substance abuse disorders and that 
dependent smokers are at risk for MDDs and 
anxiety disorders. This is probably because 
a common set of predispositions underlie 
both disorders, because persons dependent on 
cigarettes are less likely to be successful in 
quitting, and because dependent smokers 
with MDDs and anxiety disorders are even 
less successful in quitting smoking. 

Speaker: Sharon Hall. Ph.D. 

Histories of depression result in more severe 
withdrawal symptoms when people quit 
smoking. Two studies found that smokers 
with a history of depression were more irri- 
table, angry, and anxious and had more 
trouble quitting when they quit smoking 
than smokers who did not have this history. 
This could be because (1) nicotine actually 
prevents the recurrence of major disorder 
episodes, (2) a history of major depression 
makes withdrawal symptoms worse, or 
(3) major disorder episodes and withdrawal 
are correlated. Smokers with a history of 
depression appear to lack the social resources 
and skills needed to quit smoking. 

One treatment available attempts to 
decrease the bad mood experienced by some 
smokers with a history of depression and to 
prevent the occurrence of negative moods 
that may cause relapse. Negative thoughts 
and activities that may lead to increased 
smoking are discouraged, and healthy 
thoughts and activities are encouraged. The 
present intervention is aimed at changing 
thinking patterns and more global patterns 



30 



Summaries of Research Awareness Seminars 



of behavior that lead to bad moods and thus 
the relapse of smoking. 

Several treatment sessions focus on the 
internal environment, increase positive 
moods, analyze situations, and develop dif- 
ferent beliefs. One session focuses on people, 
moods, and increasing the kind of social 
activities that lead to good moods. One 
session focuses on demoralization in relapse 
(i.e., that things are hopeless) and the devel- 
opment of life goals. The final session 
reviews the results and introduces more 
cognitive intervention skills. A followup 
treatment involves nicotine gum, group 
support in developing individualized quitting 
strategies, commitment to abstinence, and 
health education materials. 

Outcome data at each assessment show that 
with continued abstinence for more than 
1 year, MDD history negative was slightly 
worse in those who were in a cognitive be- 
havior condition than in those who were in 
standard treatment. The MDD history 
positive subjects had reverse results. For a 
subject who did not have a history of depres- 
sion, significant factors were the following: 
(1) whether he/she had quit smoking or was 
abstinent for 1 year, (2) his/her baseline 
carbon monoxide levels, and (3) the age at 
which he/she first smoked. The important 
predictors for a person who has a history of 
MDDs are the following: (1) whether he/she 
was abstinent for 1 year, (2) the type of 
treatment condition he/she received, 
(3) whether he/she was in a cognitive be- 
havioral condition, (4) whether he/she was 
more likely to be abstinent, and (5) what 
his/her score was on the profile of mood, 
state, anger scale when he/she came into 
treatment. People who had a history of 
depression and started treatment with very 
low, negative moods were more likely to 
succeed. 

Cognitive behavioral intervention may be 
differentially effective for smokers who have 
a history of mood disorders. Different vari- 
ables may be important in determining 
quitting and relapsing in smokers with and 
without a history of mood disorders. As 
smoking shows up at increased rates in 
special populations, interventions will have 
to be developed to fit these populations. 

Speaker: David Sachs, M.D. 

Tobacco dependence is driven by two inter- 
linked forces: (1) psychological dependency 
and (2) nicotine dependency. A variety of 



external and internal factors are related to 
these driving forces that effect cortical neuro- 
transmitter function. In the internal factors, 
a sudden withdrawal of nicotine produces 
symptoms of anxiety, restlessness, or diffi- 
culty in concentrating. 

Two medications that have FDA approval for 
use in treatment of nicotine dependence are 
(1) nicotine polacrylax gum and (2) the nico- 
tine transdermal patch. There are four 
brands of nicotine patch available and two 
doses of nicotine polacrylax. Data provided 
show that the 4-mg. dose of nicotine polacry- 
lax is the medication of choice for treatment 
of high nicotine-dependent smokers. Both 
nicotine reduction medications have very 
similar absorption mechanisms in that the 
nicotine in the medication is absorbed very 
slowly across the buckle epithelium. In the 
case of nicotine polacrylax, the nicotine is 
absorbed slowly into the submucosal capil- 
lary bed. The nicotine transdermal patch is 
also a very slow nicotine delivery system in 
contrast to the tobacco cigarette, slowly 
releasing its nicotine molecule by molecule 
across the epidermis into the subdermal 
capillary bed. 

The obvious strength of the nicotine patch is 
that the patient has to apply it only once per 
day. The nicotine patch delivers only a 
preprogrammed nicotine blood level over the 
course of the 16- or 24-hour day, depending 
on the patch type. With nicotine polacrylax, 
the patient has to be using enough pieces per 
day. The average is about 1 piece per hour 
or about 16 pieces per day. The advantage of 
nicotine polacrylax is this: If a smoker or 
exsmoker goes into a high-risk situation (i.e., 
has a strong urge to smoke), he/she can 
increase the blood nicotine level by chewing 
more gum. Some smokers have an oral 
sensory need and require a combination of 
the two treatments. 

Dose-response relationships are important in 
designing treatment specifically to meet 
patient needs, and they are common in many 
other areas of pharmacotherapeutics. One 
study involving nicotine polacrylax looked at 
patients that were screened and divided into 
low-dependency and high-dependency groups. 
Throughout the 2 years of treatment and 
followup, the sustained continuous absti- 
nence was always higher in the group that 
had started with the 2-mg. dose versus a 
placebo. At the end of the 2-year period, 
there was a 30-percent sustained abstinence 
in the group that started out with 2 mg. of 



31 



NIDA Conference Highlights 



nicotine polacrylax versus 10 percent in the 
placebo group. A similar relationship occur- 
red with highly nicotine-dependent smokers. 
The sustained abstinence in the group that 
started out with the 4-mg. dose was always 
higher than that of the group that received 
the 2-mg. dose with almost a fourfold 
increase in sustained abstinence at the end 
of 2 years. The higher the nicotine depen- 
dency level, the higher the dose of replace- 
ment medication needed in treatment. 
High-dependency smokers were assigned 
randomly to one of four treatment conditions 
involving 2-mg. and 4-mg. nicotine polacrylex 
versus a placebo. Sixty-five percent of the 
group that received 4 mg. of polacrylax sus- 
tained 1 month of abstinence versus 25 
percent of the group that received a placebo 
as well as the 2-mg. dose. 

A nicotine patch study conducted used a 
randomized double-blind placebo control trial 
involving 220 healthy men and women. 
They received nicotine patches for 3 months, 
with a 6-week tapering-off period. There was 
no group counseling, no behavioral modifica- 
tion, and no psychological counseling. Sub- 
jects were given a self-help audiobook 
designed by the American Academy of Fam- 
ily Physicians and were instructed to use it 
to develop an action plan in the 2-week 
preparation period before their target quit 
date. For all smokers starting treatment, 
those receiving the active nicotine patch 
during the first 3 months of treatment 
showed statistically higher abstinence rates 
than the group receiving a placebo. In con- 
trast, when these people stopped using the 
patch, the risk of relapse rose to 30 percent. 
The tapering-off phase of 3 weeks on a 
one-third reduction patch and 3 weeks on a 
two-thirds reduction patch is not very useful. 
Researchers cannot continue to use the 
treatment paradigm that one size fits all in 
treating smokers. The growing body of 
data indicates that treatment must be 
individualized. 

Speaker: Karen Sees. D.O. 

A long-held belief in the substance abuse 
treatment community has been that it is too 
difficult to treat all addictions at the same 
time. More information has been gathered 
on the association between substance use 
and cigarette smoking in the past several 
years. Studies done in the 1980s found that 
a relapse to tobacco use did not appear to 
lead to a relapse to alcohol use but a relapse 
to alcohol use did lead to a relapse to tobacco 



use. Another study found that alcoholics 
who stopped smoking stayed sober much 
longer than alcoholics who continued to 
smoke cigarettes. In one study, nonsmoking 
substance abusers relapsed less often and 
also had longer periods of time before they 
relapsed back to whatever their main drugs 
of abuse were. Various concurrent substance 
abuse treatments were studied, and it was 
found that those patients assigned to treat- 
ment with smoking cessation had longer 
periods of sobriety from their primary drugs 
of abuse and stayed in treatment longer. It 
was hypothesized that there is something in 
smoking cessation that, in fact, may help in 
maintaining sobriety from other drugs. 
Many treatment providers advise smokers 
attempting to quit use of their primary drugs 
to continue smoking while doing so. Advice 
about smoking and health through literature 
or simple advice from someone produces only 
a minimal chance of quitting smoking; how- 
ever, if this advice is linked to cigarette 
smoMng-related health problems that the 
patient is experiencing, then the smoking 
cessation increases to 20 to 40 percent. 

Numerous factors must be considered in 
treating nicotine dependence among patients 
with a history of other psychoactive subs- 
tance use disorders or other chemical depen- 
dencies. The psychoactive effects of nicotine 
and the use of tobacco products producing an 
addiction are well known. Health concerns 
are increased greatly in people who drink 
alcohol heavily and smoke cigarettes. There 
is a 35-fold increase in oral pharyngeal 
cancer, lung cancer, and esophageal cancer 
in someone who drinks and smokes. Addi- 
tive health effects occur when using cocaine 
or heroin and smoking cigarettes. There are 
many triggers and cues in using drugs, 
especially when other smokable drugs are 
involved. Consequently, unless one quits 
using both drugs at the same time, there is 
a strong possibility of relapse. 

In the general population, 32 percent of all 
men and 27 percent of all women smoke. In 
the substance abusing-population, more 
women than men smoke. However, the 
desire to stop also may be in part a function 
of what a person's other drugs of choice are. 
Other trends found in looking at the data 
include the following: Caucasians tend to 
smoke more than other ethnic groups, 
smokers tend to be less educated, and the 
less educated a smoker is the less likely 
he/she will want to quit. 



32 



Summaries of Research Awareness Seminars 



Questions, Answers, and Comments 

Comment: Looking at the pharmacological 
effect of nicotine and thinking of it as a 
stimulant, it fits into a nice opponent process 
model. A person who has a slightly dys- 
phoric mood when he/she uses nicotine will 
find it more reinforcing, use it more, and 
become more dependent. As he/she with- 
draws, his/her mood becomes more dysphoric 
and perhaps eventually will trigger a depres- 
sive state. 

Comment: Differential diagnosis is impor- 
tant when looking at nicotine-dependent 
persons. 

Comment: In treating depressed patients, 
there needs to be knowledge about nicotine 
dependence because the ideologies and treat- 
ment aspects are intertwined. In conducting 
nicotine-dependence treatment, the treat- 
ment of the population needs to be adjusted, 
depending on its particular problems. If 
using nicotine replacement therapies, adjust- 
ing the dose is critical. 

Are different patches better than others? In 
looking at the Nicoderm data, Habitrol data, 
and Nicotrol data, the results at similar time 
points in treatment are strikingly similar. 
The Nicotrol trials did not use group coun- 
seling, whereas the Nicoderm and Habitrol 
trials used a very intensive 6- to 12-week 
weekly group counseling component for the 
behavioral side. In the Nicotrol patch trials, 
compared with the Nicoderm trials, the 
treatment results are virtually the same, 
implying that use of the nicotine patch and 
a more minimal behavioral intervention 
treatment package can achieve similar 
results. The Nicotrol patch is different in 
nicotine pharmacokinetics delivery. Even if 
the patch is left on for 24 hours, it still has 
delivered about 90 percent of its nicotine 
within the first 16 hours. Nicoderm was 
designed to have zero order kinetics, deliver- 
ing a constant level of nicotine throughout 
the day. This means that when the smoker 
is asleep, his/her blood nicotine level is 
stable, whereas with Nicotrol, the blood level 
decreases during the night. 



RS07. Applications of Relapse 
Prevention to Addicted 
Populations: Problems, 
Prospects, and Promises 

Moderator: Arthur MacNeil Horton. Jr.. Ed.D. 
Speakers: Terence Gorski. M.A.. C.A.C. 

Benjamin Lewis. Ph.D. 

Dellnda Mercer. M.S. 

Rafaela Robles. Ed.D. 
July 16, 4:30 p.m.-6:30 p.m. 

Speaker: Arthur MacNeil Horton, Jr., Ed.D. 

On average, approximately 75 percent of the 
people who receive treatment for their addic- 
tions relapse after approximately 6 months. 
The development of relapse prevention was 
geared toward lowering this percentage. The 
main areas focused on during the develop- 
ment of a relapse prevention theory were the 
behavioral, cognitive, and effective factors 
that have been known to lead to relapse in 
substance abuse. Lapses in substance abuse 
(i.e., a single episode of drug use) and re- 
lapses into substance abuse (i.e., full returns 
to substance abuse) are distinguished within 
the relapse prevention theory. 

Speaker: Terence Gorski, M.A., C.A.C. 

The Center for Applied Sciences (CENAPS) 
has been developing a relapse prevention 
model since the early 1970s. The primary 
focus of this model is recovery and relapse 
prevention. Within the model there is a 
smaller clinical model, which embodies a 
field of knowledge or theory. This clinical 
model is taught to patients and clinicians 
who wish to pass it onto patients. There is 
also a program structure, which acts as a 
delivery system for all of the information. 

People who relapse into chemical dependency 
are taught that relapse is a biopsychosocial 
condition. The reason relapse is considered 
a biopsychosocial condition is because 
patients tend to have different physical, 
psychological, and social symptoms that are 
associated with their individual dependen- 
cies. One area that clinicians need to look at 
prior to treatment is the level at which their 
patients' brains have been damaged by exces- 
sive drug and alcohol use. It has been 
determined that about 33 percent of all the 
chemically and alcohol dependent clients 
involved in CENAPS suffer from cognitive 
impairments that are serious enough to block 
the effects normally achieved through cogni- 
tive and affective therapy. Another 33 per- 
cent of these patients have been impaired to 



33 



NIDA Conference Highlights 



the point where stressful days will cause 
them to not respond well to therapy. The 
last 33 percent suffer from only mild to 
minimal impairment and have been seen to 
have a relatively high rate of success. 

Chemical- and alcohol-induced brain impair- 
ment have been seen to alter many patients' 
thinking patterns. This phenomenon, which 
often leads to irrational talking or behavior, 
is commonly referred to as addictive think- 
ing. One event that often results from a 
person's addictive thinking is that he/she 
argues that it is everyone's right to be able to 
drink or use drugs, regardless of the conse- 
quences. Addictive emotional management 
strategies also are often developed by chemi- 
cally dependent people. These are ways in 
which people simply repress the feelings that 
may otherwise bother them. This often 
continues until the pressures build up and 
become too much for a person to handle. 
This buildup of pressure often leads to re- 
lapse into drug or alcohol use, which in turn 
leads to a strong feeling of guilt. This guilt 
more often than not causes the person to 
begin repressing his/her feelings again. Once 
this repression begins, the whole cycle tends 
to repeat itself. 

Personality disorganization — which includes 
a person's deeply rooted habits of thinking, 
feeling, and acting in certain ways — often 
acts as a defense mechanism that sub- 
consciously protects the way in which a 
person feels about his/her drug and/or alco- 
hol use. Social and lifestyle problems (i.e., 
difficulties related to employment and rela- 
tionships) also commonly result from 
personality disorganization. Guided self- 
assessment techniques are crucial to a per- 
son's recovery from this problem: It does not 
make any difference if a counselor can de5ne 
a person's problem if that person does not 
also recognize the problem. 

Once a person recognizes his/her drug and/or 
alcohol problem, an evaluation needs to be 
conducted to determine the extent to which 
that person's brain, personality, and lifestyle 
have been disrupted. Once these deter- 
minations have been made, a suitable treat- 
ment strategy can be developed. CENAPS 
has produced a developmental model of 
recovery for use by treatment workers that 
includes the following six stages: 
(1) transition, in which the client is en- 
couraged to admit his/her addiction; (2) stabi- 
lization, in which the client becomes "clean 
and sober" but realizes that he/she cannot 



function without the drugs or alcohol; 

(3) early recovery, in which the treatment 
focuses on changing the client's addictive 
thoughts, feelings, and behaviors; (4) middle 
recovery, in which the treatment focuses on 
repairing the client's lifestyle through the 
identification and fixing of things that were 
"broken" by the client's drug or alcohol use; 

(5) late recovery, in which the client, through 
the help of counselors, begins to develop a 
more productive and healthy lifestyle; and 

(6) maintenance, which encompasses a period 
of growth and development in which the 
client is now ready to live a "normal" life- 
style. This recovery model enables clients to 
assess themselves with respect to deter- 
mining where they are in their individual 
recovery. 

Studies at CENAPS have found that there is 
a strong connection between clients' different 
personality and lifestyle problems with drug 
and alcohol abuse relapse. In order for 
relapse to be avoided, treatment workers 
must focus more of their attention on the 
underlying issues that actually lead to re- 
lapse instead of simply working on the super- 
ficial aspects of recovery. Warning sign 
identification is a process in which treatment 
providers work with patients in developing a 
list of relapse warning signs that the clients 
can periodically refer to when experiencing 
certain difficulties or temptations toward 
relapse. There are four different levels 
involved in the development of this list of 
warning signs: (1) the situation level, (2) the 
thinking level, (3) the feeling level, and 

(4) the action-urge level. These four levels 
basically cover the entire process that might 
lead a client toward relapse. For instance, a 
particular situation might cause a client to 
think about drugs or alcohol, which in turn 
might lead to certain feelings that ultimately 
result in the urge to carry out certain ac- 
tions. Helping a client recognize and posi- 
tively deal with the various warning signs 
that often lead to the progression of these 
levels is another important step in a client's 
recovery. With the help of cognitive rehear- 
sals, guided imagery, and role-playing, 
CENAPS works toward helping clients 
develop different strategies that they can use 
when encountering difficult or tempting 
situations. 

During relapse-early intervention training, 
clients are asked what they would do if they 
started using drugs and alcohol again and, in 
response to this, are requested to develop 
self-intervention strategies. Clients also are 



34 



Summaries of Research Awareness Seminars 



asked to determine what other people can do 
to intervene. To help in answering this 
question, the friends and family of the clients 
are asked to participate in support groups 
that work toward the development of exter- 
nal intervention strategies. These support 
groups also are designed to help lower the 
rates of low consequence relapse, commonly 
referred to as "lapses." 

Speaker: Benjamin Lewis, Ph.D. 

A 5-year controlled clinical trial study, which 
randomly assigns clients in blocks as opposed 
to on an individual basis, is being conducted 
at both the Marathon House Incorporated in 
Providence, Rhode Island, and the Spectrum 
Addiction Services in Westboro, Massa- 
chusetts. The Marathon House is a tradi- 
tional therapeutic community (TC), whereas 
the Spectrum Addiction Services has shifted 
from a TC to more of a short-term residential 
program. The issues being addressed in this 
study are treatment effectiveness, HIV pre- 
vention, retention, and drug and HIV risk 
reduction. 

The Marathon House's clients are assigned to 
either a 6- or 12-month TC program, depend- 
ing on their individual needs. The Spectrum 
Addiction Services, on the other hand, ran- 
domly assigns blocks of clients to either a 
90- or 180-day relapse prevention/health 
education program. Followup procedures are 
performed 3 months after discharge and 18 
months after admission into the programs. 
An 80-percent compliance rate toward the 
use of hair analysis testing has been seen 
among the clients involved in the followup 
procedures. A behavioral risk assessment, a 
motivational scale, and a number of other 
self-efficacy tools are looked at within the 
study. 

Relapse prevention training can greatly 
affect treatment effectiveness and recovering 
addicts' outcomes. The important question to 
keep in mind when looking at the efficacy of 
relapse prevention is as follows: For whom 
is relapse prevention appropriate, in what 
settings, and at what point in the recovery 
continuum? Care providers' knowledge of 
relapse and the relapse process tend to 
greatly effect the production of new pro- 
grams. The three main areas of knowledge 
concerning relapse can be categorized as 
(1) the parameters of relapse, (2) relapse 
rates, and (3) variables to relapse. 

There is an urgent need to develop a univer- 
sal set of definitions that can be used by 



clinicians, practitioners, and researchers to 
better address the issue of what relapse and 
recovery actually mean. All too often, the 
definition of what is meant by relapse or 
recovery is swayed by the particular treat- 
ment modality that is being applied or the 
different treatment workers that are 
employed by the various treatment pro- 
grams. The theoretical model of addiction 
that many care providers understand, along 
with their views on relapse and recovery, 
helps to determine the type of treatment 
modalities they use. A substantial amount of 
disagreement has occurred between the 
treatment and research fields as to whether 
relapse means that a client has returned to 
his/her primary drug of choice or if the use of 
a secondary drug also qualifies. A return to 
the use of a primary drug of choice on the 
part of a recovering addict has implications, 
more often than not, to cause that person to 
return to a state of drug abuse. Studies also 
have shown that the use of secondary drugs 
also can lead to a number of complications in 
terms of a person returning to drug abuse. 
In working toward remedying the problem of 
posttreatment drug use, the issue of what 
period of use (i.e., daily, a specified period, or 
any level of use) qualifies as relapse must 
first be addressed. In other words, should a 
lapse from recovery actually be viewed as a 
relapse or simply a slight fall from grace? 
Some studies on opioid and heavy alcohol use 
suggest that lapses do not, in fact, lead to 
abuse but, instead, have been known to act 
as valuable causative learning experiences. 
The relationship between subsequent and 
baseline use also needs to be defined more 
accurately. More accurate verification tools 
need to be developed by treatment practi- 
tioners for use in better determining lapse 
and relapse on the part of recovering addicts. 
Hair analysis testing has been found to be 
effective in determining what substances a 
person has used within a 90-day period. 

A number of variables must be considered 
during the implementation of an individual 
treatment model, including (1) the different 
things that have happened to a client before 
he/she entered treatment, (2) the things that 
happened once the client was in treatment, 
and (3) the things that happen to the client 
after treatment. Relapse prevention tech- 
niques can be successful in not only working 
toward lowering the rates of posttreatment 
drug use but also the amount of high-risk 
behavior that can lead to the contraction of 
HTV/AIDS. 



35 



NIDA Conference Highlights 



Issues that need to be addressed include the 
following: (1) the amount of sobriety re- 
quired for relapse prevention training, (2) the 
length of time that a client should be in 
treatment before he/she is introduced to 
relapse prevention training, and (3) the 
extent to which relapse prevention can affect 
a client's sexual tendencies with regard to 
reducing his/her risk for contracting the HIV 
virus. There has been some disagreement 
among treatment providers as to whether or 
not sexual risk behavior is an issue that 
should be addressed within the drug abuse 
treatment field. A controversial issue that 
might lead to a vast improvement in terms of 
the number of drug-related HIV cases is 
whether or not treatment programs are 
willing to begin teaching that nonintraven- 
ous drug use is preferable to intravenous 
drug use. 

Different treatment providers also have tried 
to determine the level of learning capability 
that clients need in order to participate 
effectively in relapse prevention. Speculation 
also has been raised concerning the rate at 
which clients can learn within a relapse 
prevention atmosphere when they are forced 
to be there. Learning capabilities can alter 
depending on a client's choice of drugs. 
Cocaine addicts, for instance, tend to have 
lower knowledge retention capabilities as 
compared to many other types of drug ad- 
dicts. Different staff characteristics also 
must be considered for their effects on re- 
lapse prevention techniques. There is an 
ongoing question regarding whether or not 
staff, who are trained in stressing absti- 
nence, are qualified to provide relapse pre- 
vention training. And, if in fact they are 
qualified, whether this training should be in 
the form of group or individualized training. 
Another issue that needs to be addressed is 
whether relapse prevention can and should 
be applied to people who are actively using 
drugs. Afollowup consideration to this issue 
might be whether or not some clients possess 
certain characteristics that render them unfit 
or inapplicable to the services offered in 
relapse prevention. 

Speaker: Delinda Mercer. M.S. 

Through funding provided by NIDA, the 
treatment research unit at the University of 
Pennsylvania is conducting an abstinence- 
oriented, cocaine psychotherapy study. This 
multisite clinical trial compares three 
psychosocial treatments for primary cocaine 



dependence. The majority of the population 
involved in this outpatient clinical trial study 
tend to be socioeconomically disadvantaged 
urban dwellers. Of the total trial population, 
86 percent are African-American and 14 
percent are Caucasian. In order to obtain 35 
people who were able to be randomized 
within the study, approximately 175 people 
needed to be screened. The two main re- 
quirements for clients to be eligible to be 
randomized in the study were that they 
needed to remain clean of drugs and in the 
study for approximately 4 weeks. The 
employed/nonemployed ratio of the study 
participants is about 50/50. Nearly all of 
them smoke, as opposed to snort, cocaine. 

A number of the clients in this study are 
polydrug users; however, cocaine is always 
their primary drug of choice. They also often 
tend to have no visible dual diagnosis. The 
socioeconomic state of the clients involved in 
the study differs among the four sites. Two 
of the sites work primarily with people who 
are fairly economically stable, whereas the 
other two sites work with people who are 
not. This difference in socioeconomic stabil- 
ity among the clients will help in determin- 
ing which treatments are most effective for 
treating which people. In general, however, 
the more socioeconomically disadvantaged a 
person is, the more difficult it is to treat that 
person. 

The basic definition of relapse prevention is 
"never again using drugs after abstinence 
has been reached." One problem that has 
occurred continuously in the program for 
cocaine addicts is premature dropout. About 
50 percent of the people who enter this 
program drop out prior to randomization. 
This dropout more often than not leads to 
relapse. The services offered prior to ran- 
domization are significantly more intense as 
compared to those services following ran- 
domization. These services generally refer to 
daily urinalysis testing, greater rate of addic- 
tions counseling, and various skill-building 
practices. Two individual therapy sessions 
also are attended every week. These ses- 
sions vary in presentation; they can be either 
psychoeducational, relapse prevention orient- 
ed, or 12-Step oriented. Over a 6-month 
period of addiction treatment, about 70 
percent of the initial population drops out. A 
self-report study on why people drop out of 
the program has revealed that the only two 
significant reasons for dropping out are 
(1) the client feels that he/she is doing better 
or (2) the client has relapsed. Basically all of 



36 



Summaries of Research Awareness Seminars 



the early dropouts (people who left prior to 6 
months) relapsed. This fact would point 
toward the need to keep people in treatment 
for a longer period of time. 

Relapse is thought to occur long before a 
person resumes use of his/her drug of choice. 
Due to this belief, steps are taken during the 
individual and group therapy sessions to 
advise the clients as to the relapse warning 
signs to look for and avoid. Alternative 
coping skills and other methods of dealing 
with relapse warning signs are gradually 
taught to the clients as they continue with 
the program. One coping skill that has been 
seen to be effective in helping people deal 
with temptation is the development of posi- 
tive social and family supports. Primary 
medical care, access to vocational counseling, 
welfare and medical assistance, and infor- 
mation of HIV risks are all services that are 
offered within the program. A four-stage 
model is used to deliver these skills to the 
clients. The four stages are as follows: 
(1) motivation counseling, (2) early 
recovery/early establishment of abstinence, 
(3) maintaining abstinence or relapse preven- 
tion, and (4) advanced recovery. 

There appears to be a growing need for more 
treatment services that focus primarily on 
female clients because it is this population 
that has exhibited a disproportionately high 
dropout rate. Temporary psychiatric conse- 
quences of cocaine use must begin to be 
recognized in dual diagnosis and treated 
appropriately. In general, either inpatient or 
intensive outpatient programs should be 
applied to those people who are suffering 
from severe cases of drug and alcohol addic- 
tion. The average outpatient programs have 
been seen to be not as effective in treating 
these people as compared to inpatient pro- 
grams. The most important thing that needs 
to be accomplished is the development of 
more successful strategies for keeping both 
men and women in treatment for longer 
periods of time. 

Speaker: Rafaela Robles, Ed.D. 

A 5-year prevention/intervention study was 
funded by NIDA and developed for use in a 
treatment system in San Juan, Puerto Rico. 
A total of 40 percent of the drug abusers in 
Puerto Rico who enter into a 20-day detoxifi- 
cation program leave prematurely. Only 50 
percent of the people who complete the 
20-day detoxification program actually con- 
tinue on in treatment, and 47.9 percent of 



these people who continue treatment leave 
before they reach a 6-month plateau. 
Studies have found that 70 percent of the 
current injecting drug users in Puerto Rico 
have been in treatment at least twice. The 
NIDA-funded prevention/intervention study 
prides itself on providing an atmosphere for 
recovering addicts that is free from social 
conflicts, stressors, pressures, and prejudice. 
The theoretical model of social integration 
that is the underlying basis of this study 
makes the assumption that recovering ad- 
dicts become integrated into the drug addic- 
tion network. Some of the many areas that 
need to be stressed in order to bring about a 
lowering or abstinence from drug use on the 
part of these people are the building or 
acquirement of positive and supportive 
friends, family, work conditions, and environ- 
ments. Recovering addicts must be gradually 
taught, through long and tedious methods, 
how to again be good fathers, friends, and 
upstanding community members. 

Recovering addicts who participate in these 
types of studies must be reminded that they 
may experience various forms of physical and 
psychological pain and distress. A sense of 
not belonging or being out of place among 
the people associated with the treatment 
community often is felt by recovering addicts. 
A fear of not having the skills necessary to 
function adequately in a sober community is 
another fear that many recovering addicts 
experience. Since these fears are fairly 
common, treatment programs need to focus 
a sufficient amount of their energies on 
addressing these problems. 

A detoxification period is the first stage in 
the NIDA-sponsored project. Information 
also is given to the recovering addicts con- 
cerning the possibilities of relapse and the 
warning signs leading to this. Detoxification 
periods are often not long enough to cover 
the difficult tasks of not only getting a per- 
son clean of drugs but also dealing with the 
issues surrounding relapse. Due to this fact, 
a continuum of care on the part of recovering 
addicts is imperative for the full recovery of 
these people. Not surprisingly, the per- 
centage of recovering addicts who turn back 
to drug use is much higher among those 
people who return directly to the community 
as opposed to those who have a continuum of 
care. 

The second stage of the NIDA-funded project 
is a period of social integration. Some issues 
focused on during this stage are diet, positive 



37 



NIDA Conference Highlights 



relationships, self-help groups, and methods 
aimed at helping for a smooth reintegration 
into the family and community. The recover- 
ing addicts are assigned to various control 
groups based on purely randomized methods. 

Family intervention is one of the main goals 
of the entire recovery process. The success of 
this type of intervention depends on a 
two-way chain of information in which family 
members begin to learn better ways of deal- 
ing and helping with the problems that the 
recovering addict may be experiencing. 
Family intervention also focuses on helping 
to teach the role which the recovering addict 
is to play within his/her family. Patience by 
both the family members and the recovering 
addicts is key during this period of recovery 
because the family intervention process is an 
extremely slow and trying one. 

Success in this project greatly depends on 
the integrity of the personnel, the relevance 
of the information that is collected, the work 
of the project's anthropologist, and the per- 
sonality of the staff. 

Questions, Answers, and Comments 

The word "lapse" is often frowned upon in the 
treatment community. What word is general- 
ly used in place of it? "Lapse" is not a good 
word to use when addressing patients be- 
cause it can instill a sense of confidence 
within these people which can lead them to 
have a false sense of security if and when 
they decide to use a small amount of alcohol 
or drugs. Instead of placing a particular 
word on a person's decision to have a small 
fall backward in terms of their recovering, it 
is suggested that the consequences surround- 
ing relapse be stressed more thoroughly. 
The level of danger associated to a person's 
relapse can be determined based on the 
duration of use, frequency of use, and the 
danger of consequence. Instead of referring 
to these episodes as lapses, it might be better 
to refer to them as short-term, low-conse- 
quence relapses. Whatever these episodes 
are called, they need to be addressed very 
delicately so that they do not develop into a 
full-blown relapse. 

What are some of the differences between the 
powerlessness model and the relapse preven- 
tion model? There does not seem to be a 
clear-cut distinction between the two. Al- 
though these two different models do not 
have a clear-cut distinction, they are in fact 
quite closely related. In programs that are 
relatively new, however, treatment workers 



may not be able to see the same similarities 
that more "seasoned" workers may be able to 



RS08. Update on Drugs— Prescription 
Drugs 

Moderator: Dorynne Czechowicz. M.D. 
Speakers: Shlbanl Ray-Mazumder, Sc.D. 

Sidney Schnoll. M.D.. Ph.D. 

Bonnie Balrd Wllford. M.S. 
July 15. 1:15 p.m.-2:45 p.m. 

Speaker: Shibani Ray-Mazumder, Sc.D. 
Two formerly NDDA-sponsored surveys speci- 
fically deal with the problem of prescription 
drug abuse: (1) the National Household 
Survey on Drug Abuse (NHSDA) and (2) the 
Drug Abuse Warning Network (DAWN). 
These two surveys, which were formerly 
sponsored by NIDA, were transferred to 
SAMHSA this past year. NHSDA staff 
interview people about drug use, demogra- 
phics, lifestyle, perceptions of risk, and any 
other important factors associated with drug 
abuse. The 1991 survey was the first of its 
kind to include self-reported information 
obtained within Alaskan and Hawaiian 
households, as well as households located on 
military bases. The only people not included 
in this particular survey were incarcerated 
people and homeless people not living in 
shelters. 

Before an informative discussion can be 
conducted concerning the problem of prescri- 
ption drug abuse, a working definition of 
what this problem involves needs to be 
stated. Prescription drug abuse can be 
defined simply as "using any prescribed drug 
in such a way that goes against the fol- 
lowing: (1) the amount recommended, 

(2) how often the drug should be taken, 
and/or (3) the prescribed use." In the event 
that a drug is taken by someone other than 
the person for whom the prescription was 
written also can be grounds for abuse. The 
four major categories of abused prescription 
drugs are (1) sedatives, (2) analgesics, 

(3) tranquilizers, and (4) stimulants. 

The 1991 NHSDA revealed some very in- 
teresting drug prevalence rates. Of the 
people surveyed. 37 percent reported using 
illicit drugs at some point in their lives, and 
6 percent admitted to using illicit drugs 
currently (within the past month). Of all the 
drugs used, marijuana was the most popular, 
with a 33-percent rate of lifetime use and a 
5-percent rate of current use. Prescription 



38 



Summaries of Research Awareness Seminars 



drug use came in at a distant second, with a 
12.5-percent rate of lifetime use and a 
1.6-percent rate of current use. Finally, 
cocaine measured a close third, with an 
11.5-percent rate of lifetime use and a 
0.09-percent rate of current use. Of all the 
prescription drugs reported, sedatives were 
the most popular, with a 7-percent rate of 
lifetime prescription drug abuse. The re- 
maining three abused prescription drug 
categories had lifetime use rates of 6 percent, 
5.6 percent, and 4.3 percent, respectively. 

Higher rates of lifetime prescription drug 
abuse were detected among people between 
the ages of 18 and 34. However, the highest 
levels of current prescription abuse included 
not only 18- to 34-year-olds but also included 
12- to 17-year-olds. The 18- to 25-year-olds 
have experienced a gradual decrease in 
prescription drug abuse since 1979. Unfortu- 
nately, no real changes have been seen 
among any of the other age groups in this 
area. Regarding male-to-female prevalence 
rates, males exhibited a 13.4-percent rate of 
lifetime prescription drug abuse, compared to 
an 11.7-percent rate for females. In com- 
paring prescription drug abuse between 
Caucasians and African-Americans, Cauca- 
sians displayed a 13.5-percent rate of lifetime 
prescription drug abuse, compared to a 
predominately lower use rate of 8.7 percent 
among African- Americans. Other interesting 
data worth mentioning include increased 
prescription drug abuse in the western 
States and higher rates of overall use (16.3 
percent) among people with some college 
education. Finally, there is a 24-percent rate 
of lifetime prescription drug abuse among the 
Nation's unemployed and a 4.1-percent rate 
of prescription drug abuse in the past month. 

Ongoing DAWN studies have allowed data to 
be collected from hospitals located in 21 
metropolitan areas. In the emergency room 
data for 1991, 133,217 drug abuse episodes 
were reported. Within these episodes, 
221,114 drug mentions (there can be many 
mentions in each episode) have been accu- 
mulated. Information for this survey is 
collected from patients ages 6 and older, and 
alcohol is listed only as a drug mention if it 
is used in conjunction with other drugs. 

Medical examiners' data from 1991 have 
been tabulated and include information from 
130 participating medical examiner facilities 
in 27 metropolitan areas. It was found that 
within the 6,601 reported drug abuse deaths, 
there were 15,576 drug mentions. On fur- 



ther review, it was determined that prescrip- 
tion drugs were responsible for between 60 
and 70 percent of the drug abuse-related 
deaths reported by medical examiners and 
drug-related emergency room visits. (How- 
ever, these statistics may include accidental 
overdoses and suicides.) DAWN studies have 
pointed toward tranquilizers, sedatives, and 
nonnarcotic analgesics as being the main 
drug indicators implicated in suicides. In 
fact, drugs included in these categories 
constitute between 67 and 77 percent of the 
mentions in conjunction with reported sui- 
cide cases. Implementation of some sort of 
national or statewide "prescription drug 
abuse surveillance system" is needed in order 
to determine what percentage of the drugs 
being prescribed are being misused or 
abused. 

Speaker: Bonnie Baird Wilford, M.S. 

Prescription drug abuse became a national 
problem in 1980, with the discovery of the 
widespread use of amphetamines by long-dis- 
tance truck drivers. Subsequently, the 
Carter Administration sponsored a con- 
ference on the topic and policymakers be- 
came more interested in the problem. In 
response, the American Medical Association 
brought the public and private sectors to- 
gether to address the problem of prescription 
drug abuse. Before this problem can be 
addressed at the level needed to successfully 
combat it, prescription drug abuse must be 
viewed and incorporated into the overall 
picture of drug abuse. Initially, policy- 
makers examined supply-side solutions to the 
problem, but this approach proved only 
slightly effective. 

A wide array of policies on prescription drug 
abuse and distribution exists. International 
treaties dating back to 1912 regulate the 
scheduling and distribution of prescription 
drugs. Many Federal laws, dating back to 
the Harrison Narcotics Act in the early 20th 
century, attempted to accomplish the same 
objectives as the aforementioned interna- 
tional treaties. The Omnibus Act of 1970 
placed 50 different Federal regulations on 
the prescribing and dispensing of drugs. The 
point that needs to be recognized is that 
despite the international and national regu- 
lations and laws, the problem of prescription 
drug abuse has not been solved. Each State 
has the ability to regulate its own drug 
prescription and distribution laws. The 
medicaid claims data have been found to be 



39 



NIDA Conference Highlights 



one of the most effective methods of detecting 
abuse problems from one region to another. 

Two prescription drug regulatory mechan- 
isms have gained exposure in attempting to 
prevent future increases in the Nation's 
prescription drug abuse problem. The first is 
the Triplicate Program, which requires all 
doctors prescribing any of the Schedule 
Three analgesics to fill out a State-provided 
form that outlines the particular drug needs 
of individual patients. Each doctor then acts 
as his/her own data entry person, cutting out 
a "middle man" to do data entry. This hope- 
fully will lead to the recording of more ac- 
curate information. The second approach 
involves the Diversion Investigation Units 
and consists of using specialized police en- 
forcement groups that focus primarily on the 
problems surrounding prescription drug 
abuse. This specialized police force also 
could inadvertently help with the Nation's 
overall drug problem, since criminal prescrip- 
tion drug abusers usually also abuse either 
alcohol and/or illicit drugs. 

The reasons why prescription drug abuse 
still seems to be a problem within this coun- 
try, despite programs such as the aforemen- 
tioned, include the following: (1) the public 
perception that prescription drug abuse is a 
new and growing problem based on highly 
publicized but isolated cases of prescription 
drug abuse; (2) the attitude that there is a 
"War on Drugs" instead of on just abuse, 
thereby making any use of drugs — even 
legitimate medical use — suspect and unac- 
ceptable; (3) the lack of understanding that 
exists throughout the country as to what 
addiction really is, which makes some 
people's use of prescription drugs seem more 
problematic than it actually is; (4) the public 
expectation that governmental programs can 
eliminate risk associated with prescription 
drug abuse, thereby driving the level of the 
problem to a higher degree than actually 
exists; and (5) cost concerns. 

ARCOS, a Drug Enforcement Administration 
(DEA) data base that tracks prescription 
drugs at the retail level, constitutes a rela- 
tively new development in drug control and, 
through data collection, helps determine 

(1) what amount of drugs are being used and 

(2) how many different drugs are being used. 
This process can help in determining the 
percentage of legitimate to illegal drug use. 
A system similar to a nationwide credit card 
machine procedure should be developed to 
review which drugs are being used and 



prescribed throughout the country. Some 
questions exist about whether the country's 
current policies on prescription drug use 
actually address all the issues of prevention, 
education, intervention, and law enforce- 
ment. Often programs are federally funded 
at the expense of other equally important 
programs. For the time being, money being 
used for data collection should be transferred 
into the treatment field. When implemen- 
ting programs and passing new laws and 
regulations, the concept of "social algebra" 
needs to be considered. "Social algebra" 
involves taking into account the social losses 
that would come about as a result of social 
gains — for example, the number of legitimate 
patients who would remain in pain and in 
need of medicine if morphine use is outlawed 
in an attempt to lower the number of mor- 
phine addicts. 

A universal definition of what prescription 
drug abuse involves should be agreed on 
within the entire therapeutic community. 
Once this definition is clear, determining 
which prevention and treatment methods are 
most effective for different drug-abusing 
populations will be easier. 

Speaker: Sidney Schnoll, M.D., Ph.D. 

Less than 1 percent of the average medical 
school education is devoted to substance 
abuse and addiction. Generally, many doc- 
tors' first experience with prescribing drugs 
occurs within inpatient settings under the 
guidance of either students not much older 
than themselves or interns who merely have 
a secondhand-working knowledge them- 
selves. Consequently, a large percentage of 
the Nation's doctors' expertise in prescribing 
drugs results from (1) reading drug bro- 
chures, which often do not provide the 
needed information, and (2) trial and error. 
One problem of a typical doctor is prescribing 
unneeded medicine simply to console worried 
patients. This practice — in conjunction with 
underprescribing, which dates back to the 
Harrison Narcotic Act of 1914 — creates a 
noteworthy problem within the Nation's 
medical community. There are courses on 
how to effectively learn the art of appro- 
priately prescribing therapeutically useful 
medications, including Dr. Sidney Schnoll's 
2-day program, which consists of lectures, 
computer simulation, simulated patients, and 
discussion time. The course also teaches 
physicians new methods of managing their 
patients' pain. 



40 



Summaries of Research Awareness Seminars 



RS09. 



Pain has been found to be the number-one 
complaint of patients. A recent study of 198 
emergency department patients who were 
injured and in pain revealed that 56 percent 
had no analgesia and only 14 percent of 
them received analgesia within 1 hour of 
their arrival at the hospital. Pear of using 
pain-killing medications that fall under the 
addictive narcotic grouping is fairly common 
among physicians. Studies have shown that 
less than 0.1 percent of the patients who 
receive narcotics for their pain actually 
become addicted to narcotics. Therefore, 
many patients continuing to seek medica- 
tions, or increased dosages of their medica- 
tions, may not be addicted but may have 
been given inadequate medication to begin 
with and are in need of a stronger one. 
This can be described broadly as 
"pseudoaddiction," which is appropriate 
medication-seeking behavior to relieve pain. 
Some of these patients may be drug depen- 
dent but not addicted. Some common precur- 
sors to pain that physicians need to be aware 
of include anxiety, depression, and stress at 
home. If acute pain problems are not ad- 
dressed when they first surface, they can 
easily develop into chronic problems that are 
more difficult to treat. Therefore, medical 
schools should place more emphasis on teach- 
ing the best methods for treating pain. 

Update on Drugs— Anabolic 
Steroids 

Moderator: Lynda Erlnoff. Ph.D. 
Speakers: Michael Bahrke, Ph.D. 
Charles Yesalis. Ph.D. 
July 17. 8:15 a.m.-9:45 a.m. 

Speaker: Charles Yesalis, Ph.D. 

Anabolic steroids can be defined simply as 
synthetic versions of the male sex hormone, 
testosterone. The 1991 National Household 
Survey on Drug Abuse (NHSDA), which 
conducted 32,000 interviews of people ages 
12 and up, included questions on steroid use. 
Based on these data, experts estimate that 
anywhere from several hundred thousand to 
over 1 million people in the United States 
use steroids. (Steroids, however, are not the 
only type of performance-enhancing drug 
being used in the United States.) The first 
national study that included data on steroid 
use was conducted in 1988 among high 
school seniors; about 6.5 percent reported 
using steroids at least once in their lives. 
About 40 percent of the students interviewed 
admitted five or more cycles (6- to 12-week 



periods) of steroid use within their lifetimes. 
In 1993 estimates indicated that somewhere 
between 4 and 12 percent of male high school 
seniors and between 0.5 and 2 percent of 
female high school seniors have used steroids 
sometime in their fives. While very little is 
known about the extent of use among the 
adult population, evidence points to an in- 
crease in the amount of overall steroid use 
among high school students since 1960. 

Many misconceptions exist regarding the 
effects of long-term steroid use. Some of the 
known psychiatric side effects reported to be 
associated with prolonged use include in- 
creases in irritability, hostility, anger, ag- 
gression, and psychological dependence, as 
well as depression associated with 
withdrawal. 

Analysis of 1991 NHSDA data indicated that 
steroid users have higher levels of alcohol, 
tobacco, and illicit drug use than people who 
refrain from using steroids. This survey also 
indicated that over one-half of the steroid 
users in this country are over the age of 26; 
therefore, efforts being made to deter steroid 
use should no longer be focused only on the 
young. Crime rates for steroid users have 
been noted as higher than those for non- 
steroid users: 80 percent of steroid users 
interviewed in the 1991 NHSDA admitted to 
committing a property crime within the last 
year, compared to only 27 percent of non- 
users who admitted to the same crime. In 
addition, 83 percent of steroid users reported 
an act of physical aggression within the past 
year, compared to only 38 percent of non- 
users who reported the same kind of act. 
Generally, steroids are taken for one of the 
following two reasons: (1) to look better or 
(2) to win/succeed in athletics. The belief 
that steroids are mood altering at the time 
they are administered is a very common and 
widespread misconception among the general 
public. There is an urgent need for improved 
cross-sectional and/or case studies that can 
be used as more reliable and accurate indi- 
cators of the levels of national steroid use. 

Speaker: Michael Bahrke. Ph.D. 

Currently an ethnographic study is being 
conducted on the use of steroids in the 
Chicago area. About 25 percent of the inter- 
views have been administered. This is a 
3-year, $1.8 million, NIDA-funded project 
that began early in 1992. On completion of 
this project, 400 interviews will have been 
conducted. Of the 400 interviewees, 300 will 



41 



NIDA Conference Highlights 



be steroid users and 100 will be nonusers. 
Two hundred of the users will be male, and 
100 will be female. Of the 100 nonusers, 67 
will be male and 33 will be female. 

The project interviews are broken down into 
life-history focused questions and past 
steroid use. The research goals and objec- 
tives of this project are as follows: (1) to 
determine the risk factors of long-term 
steroid use (i.e., both the physical and men- 
tal health hazards), (2) to determine patterns 
of steroid distribution and the effects that 
legislation has had on this (i.e., how adding 
steroids to the Controlled Substance Act has 
affected anabolic steroid use and 
distribution), and (3) to determine the rela- 
tionship of steroids to violence. 

Preliminary findings have revealed that most 
people who use steroids (1) tend to compete 
in some sort of contest, such as athletic 
events; (2) want to reach their absolute max- 
imum level of potential in body building, 
weight lifting, or power lifting; or (3) have a 
need to build up their bodies for occupational 
reasons, such as with male dancers or strip- 
pers. It also has been found that marijuana 
use is popular among steroid users, since this 
drug both increases appetite, which leads to 
weight gain, and acts as a relaxing agent 
after workouts. Data also indicate fairly 
high rates of physical and sexual abuse 
victimization among people who use steroids. 
In addition, childhood feelings of inadequacy 
often can lead to adult steroid use. 

Questions, Answers, and Comments 

Have their been any studies that investigated 
the cancer-causing effects and other long-term 
health risks of steroid use? Unfortunately, 
the long-term health risks of these drugs 
really cannot be specified. They are not big 
"killer" drugs, although they do pose health 
risks to users. 

If mortality is not the main problem facing 
steroid users, what are some of the harmful 
effects of these drugs ? A large number of 
steroids being used are black-market drugs; 
consequently, many may have impurities. 
The risk of contracting AIDS and other 
contagious diseases, such as hepatitis, is 
always high when needle- and or vial-sharing 
occurs among steroid users. Use of steroids 
also has been known to "stunt" growth when 
taken by adolescents (e.g., a person with the 
genetic potential to be 6 feet, 2 inches tall 
could instead end up being a very muscular 
5 feet, 5 inches tall). Widespread cases of 



scarring and acne also have been evident 
among long-term steroid users. Steroid 
abuse is associated with adverse effects on 
behavior, including increased incidences of 
violence, aggression, and psychiatric syn- 
dromes including psychotic reactions. 

RS10. Drugs in the Workplace- 
Research Issues 

Moderator: M. Beth Babecki. M.A. 
Speakers: Terry Blum, Ph.D. 

Donna Bush. Ph.D. 

Richard Lennox. Ph.D. 

Stephen Salyards. Ph.D. 

Robert Stephenson II, M.P.H. 
July 17. 8:15 a.m.-9:45 a.m. 

Speaker: Donna Bush, Ph.D. 

Following a presidential executive order 
made in 1986 (Executive Order No. 12564), 
which mandated a drug-free Federal work- 
place, mandatory guidelines for Federal 
workplace drug-testing programs were pub- 
lished in the Federal Register. The National 
Laboratory Certification Program was esta- 
blished to ensure the accuracy and reliability 
of urine drug test results of Federal and 
federally regulated employees. When a 
program requires urine testing, a specimen 
must be collected and then sent to a labora- 
tory for accurate and reliable testing. A 
medical review officer interprets all results. 
If the result is positive, as verified by the 
medical review officer, then the employee 
assistance program may be involved in fol- 
lowup actions with the donor or employee 
client. 

The National Laboratory Certification Pro- 
gram challenges laboratories performing the 
urine drug testing by proficiency-testing the 
analytical, qualitative, and quantitative 
capabilities of the labs and submitting urine 
specimens for the labs to analyze. Labs are 
inspected every 6 months by three trained 
DHHS inspectors to enable DHHS to deter- 
mine the labs' compliance with the require- 
ments of the mandatory guidelines. Urine 
drug testing by these DHHS-certdfied labora- 
tories has become the "gold standard" for 
urine drug testing. The key for this drug 
testing is accuracy and reliability. 

Drug testing begins with the collection of 
urine specimens that come with a 
chain-of-custody form which accompanies 
each specimen to the lab. All testing is 
performed under a chain of custody. Each 
specimen comes from a collection site via 



42 



Summaries of Research Awareness Seminars 



secured means to a laboratory. If the speci- 
men is forensically sound, it is stored in a 
limited-access area. When the urine is 
tested, an aliquot, or small portion, is re- 
trieved for an initial immunoassay test. If 
the result is negative, it is reported, at that 
time, to the medical review officer. If the 
test is presumably positive, a fresh aliquot is 
taken through the confirmation process and 
a result is determined. If this second result 
is positive, the specimen is secured and 
stored frozen. This positive result then is 
reported to the medical review officer. 

The initial test of a urine specimen is an 
immunoassay test required by Federal guide- 
lines; it is a biochemical test that recognizes 
the three-dimensional chemical structure of 
any drug present in the urine. This test is 
based on the concepts of immunology regard- 
ing the mammalian immune systems and is 
very applicable to rapid analysis. The test 
relies on the fact that an antibody binds to 
the chemical present from a drug, recogni- 
zing the three-dimensional structure and sig- 
naling a presumably positive result. This is 
a good screen to determine the presence or 
absence of a possible drug metabolite in the 
urine. A second specimen is then needed to 
confirm this presence. 

Urine contains anilide and other waste 
products. When testing urine for the pre- 
sence of drugs, the anilide needs to be iso- 
lated. The process of chromatography 
separates the drugs based on physico- 
chemical properties. Next, the process of 
mass spectrometry fingerprints each drug. 
This technique is part of the gold-standard 
process. Analytical considerations must be 
examined when testing any biological fluid. 
Dual chemical theory, immunoacetate, and 
gastrometography all aid in biological fluid 
analysis. There is a very sound foundation 
for testing in the workplace. As techniques 
develop in the future, these three test as- 
pects must be considered. 

Speaker: Robert Stephenson II, M.P.H. 

In the third quarter of 1992, 10 quarters' 
worth of data from a variety of labs were 
compiled. These data provide the results of 
tests from one quarter to another, comparing 
types of clients, regions, and positive results. 
"Watchlists," a computer process, was used to 
examine the changes for statistical difference 
from one period of time to another. The 
subjects included the various industries of 
agriculture, construction, transportation, 



wholesale, retail, and public administration. 
Ninety-five percent of all specimens provided 
information on what industry they were 
from, with transportation organizations 
comprising 35 percent of all testing. Cocaine 
and marijuana had the highest confirmation 
rates. The results of opiates, PCP, and 
amphetamines were skeptical; the decisions 
of these results are based only on the initial 
screening of acetates. 

For the future, the Department of Trans- 
portation has appended a management 
information system (MIS) to the mandatory 
testing system, which will provide infor- 
mation on about 8 million employees in the 
regulated industries described above. These 
data will compare data from the criminal 
justice system, provide a DHHS confirmation 
rate, and show potential conflicts. Different 
criteria and the consistency of testing will be 
developed as an alternative. Alcohol will be 
tested for in the future. Different specimens 
will include hair, saliva, and sweat. Screen- 
ing affirmation is a powerful tool, knowing 
that there are other specimen options. A 
Centers for Disease Control and Prevention 
program is being conducted to validate the 
quality of assays from this particular subset 
of Americans. 

Speaker: Richard Lennox, Ph.D. 

There are several issues to be addressed in 
the private sector (as opposed to the public 
sector) when considering various treatments 
for an employee who has been detected as a 
drug abuser. Recent health care reform 
agenda strikes at the core of the need to 
establish methods and protocols for under- 
standing the cost-effectiveness of various 
treatment types. There are many issues 
including the cost of treatment, the lack of 
standardization, and what counts as treat- 
ment for the future. The field is resistant to 
providing evidence of cost-effectiveness in 
treatment. This will possibly affect the 
provision of treatment, with services being 
reduced and the private sector limiting the 
provision of services that do not appear to be 
cost-effective. The industry needs to empha- 
size more and better treatment in a cost- 
effective way. 

Health care utilization patterns look at 
limited kinds of outcomes that are economic 
in nature, called the cost-offset paradigm. If 
the initiation of alcohol or substance abuse 
treatment reduces subsequent health care 
utilization, a real savings can offset the cost 



43 



NIDA Conference Highlights 



of treatment. This paradigm is vague in that 
it does not specify the nature of costs re- 
duced. A more serious problem for this cost- 
offset paradigm is that the costs of treatment 
are never a part of the equation. 

A study was done of a large midwestern 
manufacturing firm that is self-insured and 
has a liberal drug and alcohol policy with 
unlimited coverage for drug and alcohol 
abuse. The data have been used to assess 
the cost offsets as they relate to alcohol 
abuse. When compared to a matched control 
group of nonalcohol abusers, the alcohol 
abusers had higher costs in general for 
pretreatment. These costs decreased imme- 
diately following the initiation of treatment, 
to the point of converging with the control 
group of nonabusing subjects. This control 
group was not a nontreatment control group 
and was inadequate in terms of determining 
a causal link between treatment and 
reduction. 

Another study, identified as ICD9304, of 480 
drug abuse patients or drug dependents in 
all categories was completed. Of the total 
number of investigations from 1980 to 1987, 
265 occurred for people under the age of 20. 

Other diagnoses that determine indirect 
costs offset by effective treatment are drug 
abuse, alcohol abuse, mental illness, and 
severe medical illness. Severe medical ill- 
ness cannot be treated effectively by simple 
alcohol dependency treatment, although 
there is some spread of effect of treatment 
across alcohol abuse and somewhat for men- 
tal illness. These conditions co-occur fre- 
quently in most drug abuse populations. The 
issue remains of what to expect in terms of 
offsets for these various other disorders. 

In one analysis, patients treated in a 2-year 
period from a nonabusing control group, 
between the second and third year of pre- 
treatment, cost $175 per month for the first 
year of treatment, up to $322 per month for 
the second year of treatment, and as much as 
$544 per month for the first year of post- 
treatment. The second year posttreatment 
costs dropped significantly. In comparing 
males to females, there is no significant cost 
difference, but when comparing age groups, 
the older group's costs were higher than the 
younger group's. 

In the very near future, the value of drug 
abuse treatment across a variety of contin- 
uums will be looked at more closely. Health 
care utilization is only one of many reason- 



able outcomes. As treatment is shown to be 
effective, health care costs should be reduced 
over the long term. 

Speaker: Terry Blum, Ph.D. 

It is important to think of a drug abuse 
problem in the same way as any other kind 
of problem that employees might have. If 
this belief is part of human resource practice, 
treatment of drug problems could be more 
effective. Human resources are the most 
expensive and least managed resources. 
How drug programming might be effective in 
an organization requires an understanding of 
the larger resource management system. 
Understanding that drug prevention pro- 
grams are part of a larger human resource 
management context, there will be more 
effective drug abuse prevention in the work- 
place. Many workplaces consider drug abuse 
an illegal framework, often seeking the 
advice of lawyers. Worksites often lose the 
potential skill of well-trained human re- 
source managers because of this attitude. 

When the War on Drugs was announced in 
1986, one-half of the workforce was working 
full time and there were very few drug test- 
ing programs. Through suggestion and 
minimal regulation, there has been a proli- 
feration of drug testing throughout the pri- 
vate sector. The public policy regarding drug 
testing should state that the private sector 
has to have a wide range of prevention and 
intervention available for all employees, not 
just those in safety-sensitive positions. In 
terms of public policy, the larger societal 
effects need to be kept in mind. 

A study based on a national sample of em- 
ployed people shows that there is a consen- 
sus that alcohol and drug problems are 
medical issues that should and could be 
successfully treated. There is also some 
agreement that employers still want to treat 
these problems with punishment as well. 
While there is agreement that drug testing 
should be used to help employees, there is 
disagreement regarding the exclusion of drug 
abusers. These results show that the public 
does not differentiate between alcohol and 
drugs, but that policies and work settings 
often do, leading to the exclusion of drug 
abusers while those with alcohol problems 
are helped. The American public does not 
separate drug and alcohol abuse to the same 
extent as public and private policymakers. 

Another study of 342 worksites in Georgia 
showed that the more turnover there was in 



44 



Summaries of Research Awareness Seminars 



these work environments, the less likely 
there was to be preemployment screening, 
Employee Assistance Programs (EAPs), and 
cause for drug screening. If there was more 
unemployment at a worksite, there was more 
drug testing. In industries of core economic 
sectors, employees are more likely to have an 
EAP instead of just drug testing. The manu- 
facturing and transportation industries have 
more drug testing but fewer EAPs. 

In another study of managers and super- 
visors and the factors that influence the use 
of EAPs, it was found that it was possible to 
change the attitudes someone has toward an 
EAP so that he/she will have a propensity to 
use this program. Variables that change this 
effect are making people (1) feel the EAP is 
more accessible, (2) feel support from their 
management of these programs, and (3) trust 
the EAP. 

It is necessary to provide followup of super- 
visory training and orientation about drug 
and alcohol abuse. There must be continual 
implementation and a changed cognitive 
knowledge about these programs. 

Another study about the employee assistance 
referral process explains a variety of situa- 
tions. Different referrals are those that come 
from supervisory documented routes or 
supervisory influences. African-Americans 
are more likely and women are less likely to 
experience a bureaucratic referral based on 
job performance criteria. The racial relation- 
ship disappears when job performance issues 
are controlled. There is racial and gender 
disparity in workplace programming. Be- 
tween 4 and 5 percent of employees use an 
EAP each year, and about 1 percent use the 
program for an alcohol or drug problem. 

There are several variables related to health 
care cost containment. The more African- 
American employees there are, the less 
employees are involved in EAPs. Further, 
when there is little EAP development, there 
are fewer EAP or health promotion preven- 
tion activities. In terms of drug testing, 
human resources managers' perceptions are 
as follows: Drug abuse has a greater impact 
on the productive performance of 
African-Americans in the workplace than 
other racial/ethnic groups; the more women 
there are in the workplace, the less the drug 
abuse problem; and the lower the education 
or salaries of employees, the greater the 
impact of the EAP. 



Despite NIDA guidelines showing tests can 
be done well, only 82 percent of worksites 
with 200 or more employees are using confir- 
mation procedures. Confirmation is much 
less in smaller workplaces, rural workplaces, 
and places with a higher percentage of Afri- 
can-American employees. The overall posi- 
tive rates are greater for places with more 
African-American employees, but this could 
be the result of the lack of confirmation. 
People are terminated as a matter of policy 
for first offenses at smaller workplaces that 
have more African-American employees or 
are in manufacturing settings. The termi- 
nation rates are lower when there is an EAP. 
There needs to be comprehensive programs 
that are coordinated and well integrated in 
workplaces. There is a need for continued 
care, prevention, assistance, and treatment. 
Access to treatment is becoming more and 
more limited. One-fourth of private treat- 
ment centers have closed in one research 
project. There also may be a lack of diversity 
of treatment, such as the lack of treatment 
geared toward women from a wide range of 
cultural backgrounds. As more programs 
close and as more piecemeal programs are 
encouraged, the societal benefits of drug 
testing will decline. There is a need for a 
comprehensive program that includes assis- 
tance, makes treatment and followup ser- 
vices available, and is "human" as well as 
competitive in a global market. 

Speaker: Stephen Salyards, Ph.D. 

In 1987 the U.S. Postal Service was looking 
at the possibility of screening all applicants 
for drug use. At the time, there was little 
information to defend this proposed policy 
against legal challenges. There also was no 
national policy in place for applicant drug 
screening. The idea came about to screen 
U.S. Postal Service applicants for drugs and 
put them through the usual selection proce- 
dures of ability tests; performance tests; and 
checking of employment histories, criminal 
histories, and medical histories. The U.S. 
Postal Service would then hire them and 
keep the drug test results completely confi- 
dential, tracking these people through time. 

Employees were categorized according to 
their level of education completed, and drug 
test results were recorded. Employees com- 
pleting high school or at least 2 years of 
college had much lower rates of positive drug 
test results than employees who did not 
complete high school. Drinkers and smokers 



45 



NIDA Conference Highlights 



had much higher positive results. In 
general, younger applicants, African- 
Americans, and males all tended to have 
higher rates of positive drug tests. 

The first outcome of data showed no relation- 
ship between drug test results and voluntari- 
ly leaving the company. In comparing firing 
rates versus performance actions, there was 
a very strong relationship between getting 
fired and positive drug test results and 
absenteeism among U.S. Postal Service 
employees. The percentage of absenteeism 
was calculated as a ratio of absenteeism to 
scheduled work hours, excluding vacation 
and annual time, but including sick leave 
and unofficial leave. In terms of absenteeism 
differences, by June 1989, there would have 
been a $52 million cost savings had 
drug-positive applicants been screened out. 
By June 1991 the difference increased and 
the cost savings were more in the range of 
$105 million. Fourteen percent of the posi- 
tives were referred by themselves or by 
management staff to an EAP, versus about 6 
percent who were not referred. Overall, 
applicants who tested positive for drugs and 
were later hired were 2.7 times more likely 
to be referred to an EAP. Those testing 
positive for alcohol use were 3.5 times as 
likely to be referred to an EAP. Employees 
who tested positive for illicit drugs or poly- 
drug abuse and were later hired were 5.7 
times as likely to be referred for drug-related 
problems. Thirty-seven percent of the posi- 
tives had been disciplined one or more times 
during this 3-year test period. The biggest 
difference by type of infractions was for 
attendance. Not only did employees not 
show up, but they also had to be disciplined 
more often for their drug or alcohol prob- 
lems. Employees with positive results were 
disciplined for conduct-related infractions at 
a higher rate than those who had negative 
drug test results. 

Another study looked at the number of medi- 
cal claims, the dollar amount of the claims, 
and whether the claims were related to a 
drug-related diagnosis. In a median test 
splitting the group in halves according to the 
frequency of claims, those with positive drug 
tests were 1.7 times more likely to have a 
high number of claims. Among those testing 
positive for drugs, the average claim was 
$487 per year, versus $260 per year for those 
with negative drug test results. Those test- 
ing positive for drugs were about 3.4 times 
as likely to file claims for drug and alcohol 
abuse than those testing negative for drugs. 



There are a number of implications employ- 
ers should take into account when consider- 
ing applicant drug testing as a human 
resources intervention. There is an enor- 
mous cost savings in terms of reduced absen- 
teeism, turnover, and disciplinary actions. 
In terms of EAP workload, the drug test 
results are related to later problems with 
drugs and alcohol. The recommendation was 
that the U.S. Postal Service could not afford 
to not screen applicants for drug use. This 
research is only the beginning, and factors 
such as drug use that affect job performance 
are not known and have not been measured. 
Most employers assume that since their 
competitors are testing applicants for drug 
use, they should too, but whether this 
decision is rational and cost-effective is 
questionable. 

Questions, Answers, and Comments 

Looking at the quality of data and longi- 
tudinal value of the data, has the U.S. Postal 
Service been asked to provide any infor- 
mation to a health care reform group in 
providing good quality analysis in work- 
based programs? What if an applicant was 
notified of a positive drug test result — could 
this person be tracked, treated and eventually 
allowed to reapply? When looking at the 
issue of exclusion versus inclusion, are they 
sharing the same destiny? The U.S. Postal 
Service wants to know what can be gained 
from screening applicants, such as whether 
this person is going to show up for work or 
have poor job performance. The U.S. Postal 
Service wants to share its results but is 
reluctant because of legal implications and 
criticism. 

Is there anyone familiar with any studies on 
the effectiveness of the more generic preven- 
tion techniques? If there is an EAP in the 
worksite, then there will most likely be other 
prevention activities, education alternatives, 
policy changes, and nonsmoking policies. 

What is the status of using sweat for testing? 
Sweat is a continuation of the kinds of test- 
ing mediums there are with drugs. When 
applying sweat patches to the various parts 
of the scalp, there were large boluses of the 
drug being introduced into the hair through 
the scalp. The testing of sweat is not yet 
accurate or reliable. 

Comment: All workplaces do not test in the 
same way, which implies a need for national 
reform on drug-testing legislation. 



46 



Summaries of Research Awareness Seminars 



RSI 1 . Outcomes of Children 
of Substance Abusers 

Moderator: Loretta Flnnegan. M.D. 
Speakers: Dan Griffith. Ph.D. 

Stephen Kandall. M.D. 

Linda Mayes, M.D. 
July 16. 2:30 p.m.-4:00 p.m. 

Speaker: Loretta Finnegan, M.D. 

Many myths and misunderstandings exist 
concerning fetal damage from maternal drug 
use and the effects of these drugs on the 
newborn infant and the child. Subsequently, 
there has been a rush to judgment without 
adequate information. 

All psychoactive drugs move easily from the 
mother to the fetus, and the pharmacological 
effects of these drugs must be considered 
along with the many other issues that impact 
infant and child outcomes, including related 
obstetrical complications. These outcomes, 
particularly in preterm infants, are discussed 
below. The United States compares un- 
favorably with other industrialized nations 
concerning infant mortality, which is caused 
primarily by birth defects, low birth rates, 
and Sudden Infant Death Syndrome (SIDS). 
Japan has the lowest infant mortality rates. 

Infants exposed to alcohol are at risk for 
Fetal Alcohol Syndrome. However, research- 
ers continue to delineate to the potential 
effects of cocaine and heroin on infants. 
More scientific, methodological studies on 
infant outcomes are needed to replace the 
anecdotal information. Researchers must 
reach beyond the knowledge that infants who 
are exposed to drugs have some kind of 
biological vulnerability. Knowledge must be 
gained about the effects of the environment 
and its impact in later years. For instance, 
important issues that must be considered 
include (1) whether the mother is in reco- 
very, (2) the mother's past home-life condi- 
tions, and (3) the history of child abuse and 
adult abuse in the mother's life. 

Speaker: Stephen Kandall, M.D. 

Little is known about the extent and scope of 
interuterine exposure to drugs. This is 
illustrated by the attempt to estimate the 
number of drug-exposed infants in 1987 and 
1988. The estimates of this number from 
five large studies range from 12,600 to 
375,000. Unfortunately, the press usually 
sensationalizes the issue by using the high- 
est figure available. Also, most neonatal 
outcome studies are based on a select part of 



the spectrum of drug exposure, namely those 
mothers and infantB who fall into additional 
risk categories. 

What is known about fetal welfare in terms 
of opiates? Many studies show that metha- 
done maintenance reduces perinatal mor- 
bidity and mortality, which is attributed to 
fetal stability under the influence of moni- 
tored methadone dosing and the provision of 
prenatal care. Methadone also appears to 
contribute to improved fetal body growth and 
head circumference, as compared with the 
effects of heroin. In one study, daily doses of 
80 mg. of methadone restored infants' birth 
weights to those of the control group. No 
congenital malformations are known to occur 
following exposure to opiates. 

Opiate abstinence syndrome occurs in about 
two-thirds of heroin-exposed infants and 
about four-fifths of methadone-exposed in- 
fants. The syndrome has been divided into 
the following four major groups of signs and 
symptoms: (1) central nervous system signs, 
such as irritability, tremors, high-pitched 
crying, and neuromuscular coordination; 
(2) gastrointestinal signs, such as vomiting 
and diarrhea; (3) respiratory signs, such as 
rapid and deep breathing or apnea; and 
(4) autonomic system signs, such as fever, 
sweating, and tearing. If untreated, opiate 
abstinence syndrome demonstrates a signi- 
ficant morbidity for the infant. Early studies 
of heroin abstinence were associated with 
mortality rates between 34 and 93 percent. 
Today, with prompt recognition and treat- 
ment, there should be no incidences of infant 
mortality as a result of neonatal abstinence. 
Because of the pharmokinetic differences of 
heroin and methadone, the management of 
methadone abstinence is more difficult. 
Heroin abstinence usually begins within the 
first 3 days of life, whereas methadone main- 
tenance abstinence may appear later, be 
biphasic, or worsen in the second week after 
birth. Some researchers have found that 
lower methadone dosages in the third tri- 
mester may reduce the severity of abstinence 
in the infant. In one study, the severity of 
methadone abstinence was affected most by 
the rate of fall in the infant's blood level 
between days 1 and 4 after birth. In addi- 
tion, findings indicated that premature 
infants show fewer withdrawal signs than 
term infants, but the reason for this remains 
unclear. Furthermore, study findings have 
shown that seizures associated with absti- 
nence occur in about 1 percent of heroin- 
exposed infants and in about 5 percent of 



47 



NIDA Conference Highlights 



methadone-exposed infants; however, infants 
with these seizures were found to be func- 
tioning normally by the end of their first 
year. 

In treating opiate abstinence syndrome, 
replacement opiates are recommended, such 
as Paragoric, which has been shown to re- 
duce symptoms. Breast-feeding among 
women who are maintained on methadone is 
not contraindicated if they are not using 
other drugs and are HIV negative. During 
pregnancy, methadone maintenance is defi- 
nitely preferable to street-drug use. The 
relatively minor disadvantage in caring for 
the methadone-exposed infant is more than 
offset by the marked improvement in mater- 
nal health and fetal well-being. However, 
data are needed concerning the specifics of 
methadone management during pregnancy. 
Careful tapering during pregnancy is feasible 
for some women; however, most programs do 
not change drug regimens during pregnancy 
for a number of reasons. Studies support the 
administration of higher dosages of metha- 
done during the first trimester to promote 
fetal growth and then providing lower do- 
sages during the third trimester to minimize 
neonatal withdrawal; but this paradigm may 
be suitable for only some methadone-main- 
tained women. 

The typical cocaine-exposed infant is not 
similar to those portrayed by the media. 
Most studies show reduced weight and head 
circumference among cocaine-exposed in- 
fants, which is similar to the results of 
heroin exposure but occurs via a different 
mechanism. Cocaine-exposed infants do not 
show true abstinence but neurotoxicity, 
which is expressed through mild symptoms 
generally requiring no treatment. Studies 
concerning malformations are controversial. 
It also is important to note that the available 
studies have been conducted with infants 
who were at high risk for poor outcome. 
Breast-feeding is contraindicated because 
cocaine passes into breast milk and conse- 
quently may cause direct neurotoxicity. 

Recently studies have been conducted on the 
relationship between maternal drug use and 
SEDS, which is the leading cause of death 
among infants between the ages of 1 month 
and 1 year in the United States. A few 
studies, along with anecdotal information, 
indicate that maternal drug use may lead to 
SDDS. A large study was just completed on 
SEDS which, after correcting for high-risk 
variables, demonstrated that maternal use of 



heroin, methadone, and cocaine are associ- 
ated with an increased rate of SDDS. 

CSATs improvement protocols should pro- 
vide helpful and valuable information on the 
issues of assessing and treating drug-exposed 
newborns. 

Speaker: Linda Mayes, M.D. 

During the past 5 years, an increasing num- 
ber of children who have been exposed pre- 
natally to cocaine and crack-cocaine have 
reached school-age. Due to the scarcity of 
published studies on the problem, however, 
firm conclusions cannot be made about the 
specific effects of prenatal cocaine exposure 
on early development. However, hypotheses 
can be refined about central areas for study 
and possible interventions for children and 
their families. 

It is important to review the various levels at 
which drugs may affect infant outcome. Until 
recently, most research has focused on the 
effects of cocaine on the developing fetal 
brain and on behavioral expression, but 
research needs to be conducted on other 
levels. Other areas that need to be examined 
are as follows: first, the effects of cocaine on 
fetal growth, which may be expressed 
through cocaine's more general effect of 
reducing placental blood flow, causing fetal 
undernutrition and hypoxia; second, cocaine's 
overall effect on maternal health, which 
increases the risk of impaired fetal outcome; 
and third, the psychological factors that lead 
an adult to substance abuse, since these 
factors may have genetic implications for the 
child, such as inheriting attention deficit 
disorder. 

Additionally, many postnatal areas of re- 
search warrant greater attention. Ongoing 
brain development may be affected adversely 
during the infant's first year of growth by 
passive exposure to drugs in the home. 
Similarly, the effect of crack-cocaine on 
norepinephrine levels and thus on metabolic 
rates poses a far greater risk for the infant's 
failure to thrive. 

Postnatal drug use affects the caregiving 
environment for infants on at least two 
levels. First, adult substance abusers are 
less capable of responding to their children's 
needs, and the lifestyles commonly associated 
with drug use, such as prostitution and 
violence, may create a chaotic and neglectful 
environment for children. Secondly, there is 
risk of genetic contribution of maternal 



48 



Summaries of Research Awareness Seminars 



neuropsychiatric disorders. For example, 
depression in the adult has a well-studied 
effect on the child's early development. None 
of these levels of prenatal or postnatal effects 
of cocaine use is more operative than ano- 
ther. Also, a prenatal genetic effect may 
increase a child's vulnerability to postnatal 
exposure to drug use and a chaotic environ- 
ment. Thus, it is important to examine 
multiple aspects of any substance-using 
family and a child's functioning and environ- 
ment, as well as to consider the cumulative 
effects of maternal drug use and the environ- 
ment in which a child is raised. 

As studies have become more specific and 
sophisticated, measures of overall com- 
petency have failed to show any differences 
between cocaine-exposed and non- 
cocaine-exposed infants. Such findings have 
required a reevaluation of earlier concerns 
about global developmental delay in 
cocaine-exposed children. Studies also have 
shown the insensitivity of measures, such as 
the Bayley, to the types of clinical problems 
displayed by many cocaine-exposed children. 
Therefore, more specific measures of early 
developmental functioning are needed, rather 
than more global measures of developmental 
competency. 

Studies have revealed the following four 
major domains in which the influences of 
drug abuse are manifested: (1) recognition 
memory, (2) visual habituation, (3) language 
development, and (4) capacity for symbolic 
play. It must be pointed out that these 
studies involve mild to moderate impair- 
ments, and at most, each study is repre- 
sented by two studies with cohorts having 
mixed drug exposure. These domains reflect 
links with the central monoaminergic sys- 
tems. Among drug-exposed children, studies 
also have explored impaired parent-child 
interactions; diminished exploratory capaci- 
ties; impaired attachment; and increased 
exposure to violence, abuse, and neglect. A 
central question for researchers is whether 
the incidence of multidetermined and socially 
imbedded problems — such as problems with 
language or symbolic play among 
drug-exposed children — is different than 
among children from dysfunctional families 
or multirisk families not affected by sub- 
stance abuse. 

In the first year of life, specific measures of 
attention and habituation are predictive of 
later cognitive outcomes. For example, in a 
recent study, a significant number of 



cocaine-exposed infants could not attend to 
novel stimuli and became irritable. At the 
same time, many of the drug-exposed infants 
showed responses similar to those of non- 
cocaine-exposed infants. Thus, the problem 
appears to lie with reactivity. When 
cocaine-exposed infants are able to attend 
and focus, differences do not occur in 
measures of attention or early information 
processing. Attention levels and reactivity to 
novelty thus warrant further study. Addi- 
tionally, impairments in these domains have 
important implications for later school 
performance. 

Many sources of individual variation exist in 
the domain of language development. 
Cocaine-abusing mothers may be less likely 
to perform tasks, such as naming of objects, 
that support language development in their 
children. Only one published study has 
specifically examined language in 
drug-exposed children, and this study sug- 
gests a delay in both receptive and expres- 
sive language. Therefore, substance abuse 
treatment programs servicing their patients' 
children should include speech and language 
courses. 

In another study, drug-exposed children were 
significantly less likely to engage in imagi- 
nary play than nondrug-exposed children, 
and their play was very disorganized and 
poorly modulated. This finding suggests that 
interventions should focus on how long and 
how often the children play, both of which 
have important implications for their perfor- 
mance in school. 

The most methodologically problematic area 
in studying the effect of in utero cocaine 
exposure concerns parent-child interaction. 
The previously mentioned domains are con- 
textualized within this one. Substance- 
abusing parents' difficulties in caring for 
their children are evidenced by the increased 
rate of child abuse and neglect in such fami- 
lies. Ample evidence substantiate the verbal 
and physical violence that many children and 
mothers suffer as witnesses and victims on 
an almost daily basis. Yet researchers have 
not addressed the influence of these events 
on parenting abilities or the children's modu- 
lation of aggression and development of 
capabilities of empathy. Two studies have 
demonstrated the increased incidence of 
impaired, distorted attachments in sub- 
stance-abusing families, which reflect dys- 
functions in parenting, as well as how 
difficult some drug-exposed children can be 



49 



NIDA Conference Highlights 



to raise. It is important to remember that 
children in substance-abusing famines often 
are raised not just by their parents but by 
siblings, other relatives, or foster care for 
indefinite time periods. Assumptions have 
been made that this type of caregiving has 
deleterious effects; however, scant data exist 
about the patterns of caregiving among 
substance-abusing families. 

Looking to the future, there are several areas 
of ongoing, much needed, and potentially 
fruitful research. First, researchers are 
examining reactivity, persistence, attention 
regulation, and the stability of such capaci- 
ties between infancy and the second and 
third years of life. Second, researchers are 
focusing on language and communication and 
their relationship to the risks and cumula- 
tive effects of drug exposure for these chil- 
dren. A third area of research involves the 
direct observation of parent-child interaction. 
Fourth, and perhaps most pressing, is the 
study of the effects of chronic exposure to 
violence on children's capacity for empathy 
and mediating aggression. 

Each of these research areas points to re- 
lated areas of intervention. First, 
language-intensive services need to be 
provided for preschool-age children. Second, 
it should be ensured that children enter 
some kind of preschool program, such as 
Head Start. Third, in addition to substance 
abuse treatment, interventions should model 
appropriate parenting skills and address 
other parenting concerns. Fourth, more 
attendance should be made to the levels of 
abuse and violence among substance-abusing 
families. Fifth, more readily available pedia- 
tric care is needed to address the lack of 
immunizations, poor nutrition, and overall 
poor health care among children of substance 
abusers. Sixth, it is likely that children may 
benefit more from group interventions than 
individual attention. Training for profes- 
sionals working with children of substance 
abusers should address all of these areas. 

These types of interventions are not new, but 
they should be integrated into substance 
abuse treatment programs that serve 
mothers and, more broadly, adults who are 
trying to parent children while they struggle 
with addiction. 

Speaker: Dan Griffith, Ph.D. 

Unfortunately, little is known about the 
long-term outcomes of drug-exposed children. 
However, many parallels exist among re- 



search findings on alcohol, marijuana, 
cocaine, and other drugs, as well as on the 
more general variables affecting high-risk 
children, such as low birth weight and 
poverty. 

Thus far, research on illicit drugs has 
focused on a very narrow segment of the 
population, which includes chronic, long-term 
substance-abusing women from poor urban 
areas who are receiving treatment. Little is 
known about fighter users, those who can 
afford private treatment, or those who are 
not receiving treatment. Therefore, one must 
be careful about making generalizations 
regarding research findings in this area. 

Many inconsistencies exist in the research on 
women substance abusers and their children, 
primarily among studies concerning light use 
of alcohol and drugs. It is likely that drugs 
create biological vulnerability in some of the 
exposed children, and their environment 
then influences the exacerbation or ameliora- 
tion of the vulnerability. For instance, Sam 
Roff s transactional model of reproductive 
casualty and the additive nature of risk is 
accurate in its assessment of high-risk 
children. 

Research on substance-abusing women and 
their children is difficult due to the signi- 
ficant differences among cocaine users, other 
drug users, and nonusers. Despite these 
contrasts, however, some studies have re- 
vealed no differences in general develop- 
mental milestones among the children of 
these groups of parents. A huge difference is 
evident, however, among the children in 
later years, apparently due to poverty, not 
drugs. It is possible that effects are not seen 
in the early years partly due to the insensi- 
tivity of the Bayley, but also because re- 
searchers focus mainly on poor women, and 
poverty may mask the subtle effects of the 
drugs. A few studies on alcohol have taken 
this methodological issue into consideration. 
One study found that children of 
middle-class women who drank moderately 
(i.e., an average of two drinks a day during 
pregnancy) generally had lower IQs than 
children of nonusers. Another similar study, 
conducted at the same time using women in 
poverty, showed no IQ differences between 
the groups. Thus, it is important that re- 
searchers carefully document such influential 
factors as poverty. One also must keep in 
mind that this test population, unlike the 
general population of drug-exposed children, 
includes motivated women volunteering for 



50 



Summaries of Research Awareness Seminars 



treatment and children receiving interven- 
tions at early ages. 

The effects of drugs in early studies may 
elude researchers because the drugs may 
cause subtle damage to the nervous system, 
which affects skills that do not develop until 
children get older. Some recent research 
supports this possibility. Global measures 
reveal few differences, but more specific 
measures, such as language, show the effects 
of drug use. Researchers must be 
careful — particularly in studying users who 
abuse many drugs — not to overinterpret 
data. It is important to consider how much 
of the substances were used, how often, 
which drugs, and other subtle conditions that 
influence research results. In some studies, 
for example, cocaine proves to be a signi- 
ficant predictor, but it is not the most impor- 
tant factor. Virtually all of the children in 
one study stayed with one stable caregiver 
since shortly after birth; about one-third 
remained with their biological and still 
drug-using mothers, another one-third re- 
ceived care from their biological but 
drug-free mothers, and the other one-third 
were placed with drug-free foster relatives. 
According to this environmental breakdown, 
biological vulnerability coupled with a 
drug-using environment increases the risk of 
problems such as language difficulties. But, 
despite biological vulnerability, a drug-free 
environment seems to decrease the incidence 
of language problems among the children. 
Thus, more research that examines these 
complex variables needs to be conducted. 

Finally, there are clinical barriers to ac- 
curate research in this field. Drug-exposed 
children have been found to be consistently 
harder to test, due for instance to easy over 
stimulation. The issue of low threshold is 
important to interventions with children. It 
should be pointed out, however, that the 
problems evident in drug-exposed children 
are similar to those of other high-risk chil- 
dren. Even if group statistics indicate that 
drugs are related to particular problems, one 
must be careful not to jump to that same 
conclusion with each individual child. 



Questions, Answers, and Comments 

What are the views of elementary or preschool 
teachers about this issue? Preschool teachers 
seem to see children with more language and 
behavioral problems, and the teachers tend 
to attribute these problems to drug exposure, 
an assumption that is a methodological 
problem. It is very risky to automatically 
equate these kinds of problems with drug 
exposure. 

Teachers across the country voice similar 
complaints about their students. However, 
most of the information that teachers receive 
about drug-exposed children comes from the 
media, which has professed that all drug-ex- 
posed children are damaged and hyperag- 
gressive. Consequently, teachers may tend 
to treat drug-exposed children differently and 
contribute to this self-fulfilled prophecy. 
This stereotype of drug-exposed children will 
remain a problem until more and better 
research is conducted in this area. Also, the 
increasing number of children with problems 
could be attributed to the increase in chil- 
dren in poverty or without homes. Although 
little systematic data are available about the 
effects that living in poverty and around 
violence have on children, one project in New 
York has revealed the enormous significance 
of children's exposure to violence. Teachers 
must be cautioned about the preliminary 
nature of these findings, which the media 
often sensationalize. Efforts are being made 
to convert terminology from "at risk" to "at 
promise." 

Could clarification be provided concerning 
the recommendation regarding tapering 
methadone dosage during the third trimester? 
Is it appropriate for only a small population 
of women? There is a conflict in the litera- 
ture concerning the dose of methadone given 
late in pregnancy and the outcomes. Al- 
though there appears to be a general associ- 
ation between the amount of methadone and 
the severity of withdrawal, it is not a predict- 
able phenomenon. 

In the era of HIV/AIDS, one has to look at 
methadone in a different fashion, since the 
benefits far outweigh the risks of methadone 
treatment during pregnancy. Although 
around 60 to 70 percent of the infants in 
these studies show withdrawal, the effects of 
withdrawal do not appear to be significant. 
In fact, the children seem to be doing well. 
If methadone treatment is accompanied with 
comprehensive prenatal care, the result 



51 



NIDA Conference Highlights 



tends to be healthy children, along with 
healthy recovering mothers. 

The science indicates that fetal growth, birth 
weight, and head circumference can be opti- 
mized with higher doses in the first tri- 
mester. It also indicates that a lesser 
amount of abstinence can be achieved 
through a lower dose during the third tri- 
mester. These findings support the tapering 
of the dosage throughout pregnancy. Of 
course the mother should not resume to 
using street drugs during the methadone 
treatment. Hence, this type of tapering 
treatment seems applicable mainly to 
well-motivated women who will abide by the 
regimen. 

Perhaps Dr. Kandall was mistaken in refer- 
ring to the first trimester, since fetal growth 
occurs mainly in the last two trimesters. His 
studies show that it appears advantageous to 
the fetus for the mother to remain on metha- 
done for a long time during pregnancy. 
Dr. Mary Jeanne Kreek also has shown that 
it may be helpful to increase the dose of 
methadone during the third trimester. 
Consequently, it is difficult to know what is 
the best treatment. 

All of those caveats are well taken and 
should be conveyed to practitioners, but 
treatment through tapering dosages should 
be one therapeutic option for well-motivated 
women who want to be taken off the medica- 
tion. To clarify this point, in 1976 the only 
relationship found was with the first tri- 
mester dosage. This finding coincides with 
research showing that the impact of heroin 
and methadone resides with cell number, 
which is determined in the first trimester. 

While methadone is a cornerstone of drug 
treatment, one should not deny women who 
want the option of getting off of it. Tapering 
women off methadone during pregnancy is 
not an overall recommendation, but it should 
be a feasible option. 

How does the placement of children in many 
forms of foster care impact on the evaluation 
of their outcome in relation to their prenatal 
exposure 1 ? Clinical data show that multiple 
experiences of loss do not benefit the chil- 
dren. However, little research actually docu- 
ments the effects of multiple placements on 
children. Multiple placements likely exacer- 
bate problems for high-risk children who 
already have a low threshold for frequent 
transitions. 



The media's contention that drug-exposed 
children are difficult to care for has limited 
the number of foster parents willing to pro- 
vide that care. Also, there appear to be few 
programs to train caregivers of drug-exposed 
children. Some studies have been conducted 
on the injurious effects of multiple place- 
ments on children. 

Comment: To summarize, the research 
available on the outcomes of substance abuse 
on children is not conclusive, but ongoing 
projects funded by NIDA and other agencies 
are looking at these issues with appropriate 
methodologies. In addition, the Perinatal 20 
research demonstration projects are provid- 
ing followup on children to examine the 
impact of comprehensive care with specific 
interventions for the children. Lastly, 
several Government agencies — including 
NEDA; the Administration on Children, 
Youth and Families; CSAT; and the National 
Institute on Child Health and Human Devel- 
opment — are working together to examine all 
the variables during pregnancy and up to 
about age 6. We may not have all the 
answers, but hopefully treatment profes- 
sionals will appreciate the importance of 
incorporating a treatment component for the 
children, as well as the mothers. These 
children are our future generation, and if we 
help them, hopefully they will not have to 
address these same problems. 

RSI 2. Genetics and Drug Abuse 

Moderator: Roy Pickens. Ph.D. 
Speakers: Michele LaBuda. Ph.D. 

Kathleen Merlkangas. Ph.D. 

George Uhl. Ph.D. 
July 16, 8:30 a.m.-lu:00 a.m. 

Speaker: Michele LaBuda, Ph.D. 

The following results come from studies 
aimed at discovering whether drug abuse 
clusters within families and, if so, whether 
this commonality is due to genetic factors. If 
genetic factors do influence the risk for drug 
abuse, it would be expected that family 
members of drug abusers would demonstrate 
an increased risk and be affected more often 
by drug abuse. Two recent large-scale 
studies looked at families of individuals 
abusing opioids, cocaine, and sedatives. 
These studies have not yet been published, 
but some results are available. Although few 
studies of this sort have been conducted, 
similar research has occurred with alcohol 
abusers and their families. 



52 



Summaries of Research Awareness Seminars 



The two studies involved drug abusers and 
their immediate family members. In the 
first study, cited by Marin, the rate of drug 
abuse among relatives of drug abusers 
ranged from 4 to 13 percent. A control group 
was not established. However, in comparison 
to general population estimates of drug 
abuse, it appears that an increased risk for 
illicit drug abuse does exist within such 
families. In the family study published by 
Bruce Rounsaville, Kathleen Merikangas, 
and their colleagues, results indicated a six- 
fold increase in the rate of drug abuse among 
primary family members of opioid abusers as 
compared to families in a control group. 
While these studies point to a clustering of 
cases of drug abuse within families, they do 
not provide clues as to whether the com- 
monality is due to genetic or environmental 
factors or both. For instance, the large 
increase of drug abuse risk in the second 
study could be due to methodological factors, 
such as the populations targeted or the type 
of diagnostic study used. 

Traditionally in the study of behavioral 
disorders, researchers have used two 
methods to determine genetic and/or environ- 
mental influences on behavior: twin and 
adoption studies. In the substance abuse 
field, only three significant twin studies and 
one adoption study have been conducted. 
Two of the three twin studies are, as indi- 
cated earlier, so recent that their results 
have not been published yet. In twin 
studies, researchers contrast identical twins 
(with the same genetic makeup) and frater- 
nal twins (who share about one-half of the 
same genes). If a greater resemblance is 
found among identical twins, the resem- 
blance can be attributed to greater genetic 
similarities. It is hoped that converging 
evidence will be found across methods to give 
researchers confidence in making a conclu- 
sion about the role of genetic factors in drug 
abuse. 

Roy Pickens' twin study of alcohol abuse, 
conducted in Minnesota, also provided data 
on drug abuse. In cases where the first twin 
was a drug abuser (of sedatives, stimulants, 
analgesics, hallucinogens, or cannabis), 
researchers looked for a specific concordance 
rate for use of the same drug in the other 
twin. In each instance, identical twins re- 
sembled each other more closely than did 
fraternal twins. The other two twin studies 
had similar results. Goldberg et al. found 
significant differences between identical and 
fraternal twins, indicating that genetic fac- 



tors were involved. Grove et al. looked at 
identical twins who were separated at birth 
and thus shared genes but not the same 
environmental factors. In assessing the 
twins for drug abuse 30 or 40 years after 
separation, the researchers found a con- 
cordance rate of about 40 percent (i.e., if the 
first twin abused drugs, then 40 percent of 
the time the second twin did as well). These 
data imply that the risk for drug abuse 
among individuals sharing genes is 40 per- 
cent higher than among the general popula- 
tion; thus, genetic factors appear important 
in the onset of drug abuse. Another small 
twin study on prescription drug usage also 
found some twin resemblance regarding use. 

The only relevant adoption study, conducted 
by Cataray et al. in Iowa, provides some 
information on the rates of substance abuse 
among the biological and adoptive relatives 
of drug abusers. An increased risk of drug 
abuse is expected (1) among biological rela- 
tives if genetic factors are important and 
(2) among adoptive family members if envi- 
ronmental factors are important. Although 
drug abuse was not specifically assessed in 
biological and adoptive parents, data on risk 
of alcoholism indicated that a genetic trans- 
mission of vulnerability to substance abuse 
can occur. 

These same research methods also provide 
information about nongenetic familial or 
environmental factors involved in substance 
abuse. First, in the twin studies, identical 
twin concordance is much less than unity, so 
it seems obvious that many other factors 
besides genetics are involved in drug abuse. 
Second, twins who grew up together are 
more alike than those who were separated at 
birth, a result that is consistent with the 
belief that common environmental factors 
contribute to drug abuse within families. 
Sibling/adoptive studies also provide evidence 
that intrafamilial environmental factors are 
related to substance abuse. Two sibling 
studies of opioid addicts and cocaine addicts 
looked at influences besides the presence of 
an affected sibling, such as peer influence 
and experimentation with drugs. Also, the 
adoption study found evidence concerning 
the influencing effect on substance abuse of 
disruption within the adoptive family envi- 
ronment, such as death or divorce. 

The Addiction Research Center is planning a 
study on identical twins who are discordant 
for drug use or for drug of choice. This is an 
example of how the methodology of a family 



53 



NIDA Conference Highlights 



genetic study can look at both genetics and 
environment. Similarly, there are other 
methods beyond family, twin, and adoption 
studies for examining the genetic basis of 
behaviors such as drug abuse. For instance, 
segregation analysis looks at patterns of 
transmission within a family and tries to 
assess the likelihood of alternative modes of 
genetic transmission (i.e., whether a single 
gene has a large effect or whether many 
genes create an additive effect). This method 
has not yet been applied to families of drug 
abusers, but at least two such studies have 
been conducted with alcoholics. Second, 
linkage analysis and association studies are 
ways to pinpoint areas on chromosomes that 
may be related to individuals' vulnerability 
to substance abuse. 

Lastly, genetic factors operate at many 
levels; there are many ways to see dif- 
ferences between individuals with regard to 
drug abuse. The differences may be caused 
by genetic factors, environmental factors, or 
both. Likely focuses of studies on this issue 
include exposure to drugs, initial use, the 
transition from initial to regular use or 
addiction, and the effects on metabolism. It 
is very important to consider exactly what a 
study design will show. Genetics influences 
certain types of personalities that might pre- 
dispose some individuals to use drugs. This 
finding may demonstrate a genetic basis for 
drug abuse but does not necessarily imply 
that one gene directly causes drug abuse. 

Although fewer family genetic research 
studies have been conducted on drug abuse 
than on alcoholism, converging evidence from 
twin and adoption studies suggests that a 
genetic basis for illicit drug abuse does exist. 
Researchers must keep in mind designs that 
focus on the impact of genetic influence at 
different levels and that measure people's 
genetic relatedness and environmental fac- 
tors, such as family conflict. 

Speaker: George Uhl, Ph.D. 
There are possible predispositions to using 
addictive substances. Researchers are trying 
to determine which paradigms might be used 
in upcoming decades to identify individual 
genes that could contribute to genetic vul- 
nerability to drug abuse. In one paradigm, 
looking at chromosome number 21 for the 
kinds of disorders that' fit segregation analy- 
sis in family patterns exhibiting Mendelian 
inheritance, one can determine the location 
of the gene for familial ALS (amyotrophic 



lateral sclerosis). Individuals inheriting one 
particular allele on the chromosome will get 
this neurodegenerative disorder. The trans- 
mission of substance abuse does not fit this 
kind of classic paradigm. Most disorders 
that affect people, in fact, are contributed to 
by many different genes, rather than a single 
one, as well as by environmental factors. 
Such a model better fits the possible factors 
involved in substance abuse. A chromosome 
piece has different genetic markers that 
reveal the function of a particular spot on 
the chromosome. Because chromosomes 
break and recombine infrequently in a parti- 
cular family, several DNA markers are 
transmitted in families along with, of course, 
their function. When a number of genes may 
contribute to a behavior or vulnerability, 
research becomes more difficult. It is impor- 
tant to find different approaches to use the 
increasing density of genetic markers at 
chromosome loci. These kinds of studies will 
become an increasing part of substance 
abuse literature. 

In finding the location for familial ALS on 
the chromosome, researchers used a linkage 
study of how one of the markers cosegre- 
gated with the disease phenotype. Thus, in 
an individual family, these markers were 
moving from father to son with the disease 
phenotype. These classical approaches be- 
come more difficult as more genes and envi- 
ronmental factors are involved. Modeling 
studies by Eliot Gershon suggest the need to 
find a linkage in cases of increasing hetero- 
geneity, number of genes involved in the 
disorder, and environmental influence — all of 
which are larger for linkage studies than for 
allelic association studies. Instead of looking 
at affected pedigrees only, allelic association 
studies compare the frequencies of a specific 
gene in related individuals who have the 
disorder with frequencies in the control 
populations. Association studies are better 
able to detect heterogeneity or the influence 
of more than one gene. For instance, an 
association approach was used to examine 
the dopamine D2 receptor's involvement in 
substance abuse, not just among families 
with multigenerations but also among popu- 
lations of drug abusers compared with popu- 
lations of individuals who do not abuse 
addictive substances. 

These studies are challenging because of the 
complicated patterns of inheritance. From a 
geneticist's point of view, the environmental 
impact of drug abuse is manifested as a 



54 



Summaries of Research Awareness Seminars 



reduction in penetrance. Even individuals 
with all the predisposing genes do not neces- 
sarily abuse drugs or become addicted. 
However, the ability to identify vulner- 
abilities, if not causalities, facilitates the 
development of interventions to stop drug 
problems from occurring. It is likely that 
substance abuse is caused by multiple in- 
dependent genes that interact with environ- 
mental influences. Each gene identified is 
unlikely to have strong predictive powers 
itself for substance abuse. It is unlikely that 
the certainty that exists in other genetic 
studies can exist on the individual level. But 
on a population basis, and as more genes are 
identified, panels of vulnerability-inducing 
genes can be identified and targeted and help 
guide interventions in groups of individuals. 

In presenting an example of this approach, it 
must be cautioned that the data are contro- 
versial but likely to represent the kind of 
paradigm increasingly used in the field. 
These studies are made possible because of 
the development of polymorphic markers — in 
this case on each side of the dopamine D2 
receptor gene. The markers provided, in an 
association study context, the ability to ask 
whether specific genotypes at this locus were 
identified with substance-abusing popula- 
tions in greater frequency than in control 
populations. It is not surprising that in 
looking for genes with small effect and with 
much environmental noise, not all studies 
would agree. An examination of 300 to 400 
polysubstance abusers showed fairly consis- 
tently across studies that there is a higher 
frequency of specific gene markers at the 
dopamine D2 receptor locus in substance 
abusers than in control individuals. These 
results have statistical significance. Further- 
more, when combining the number of dif- 
ferent studies looking at alcoholism and 
substance abuse or just those examining 
substance abusers, highly statistically signi- 
ficant differences occur between abusers and 
control groups. There is a significant, al- 
though not very large or predictive, enhanced 
vulnerability. 

Results from these studies are tempered by 
technical considerations about how markers 
are linked to a possible disease-causing 
allele. The data are still controversial. The 
modest effect size and large amount of envi- 
ronmental noise raise skepticism. But the 
bulk of data indicates that this gene may 
contribute modestly to substance abuse 
vulnerability. It is likely that a number of 
different genes with modest effects are pro- 



ducing an additive effect. This does not 
mean clinicians can predict an individual's 
substance abuse vulnerability based on this 
gene, nor can reliable tests for insurance 
risks be conducted. As increasing numbers 
of genes that contribute to vulnerabilities are 
identified, researchers can better understand 
the genetic influence of vulnerability to drug 
abuse. Predictability in group vulnerabilities 
may become possible and facilitate the tar- 
geting of behavioral and pharmacological 
interventions at particular populations with- 
out necessarily stigmatizing individuals. 

Speaker: Kathleen Merikangas, Ph.D. 

In trying to determine the genetic factors 
that clearly appear to exist in the transmis- 
sion of alcoholism, it is helpful to look at 
patterns of transmission in families. A 
sample pedigree helps illustrate common 
patterns. As an example, as part of a family 
study, an alcoholic individual was identified 
and his relatives, including spouse, former 
spouse, children, parents, siblings, and in- 
laws, were identified and systematically 
examined. Interviews with relatives were 
conducted independently to avoid the bias 
that might turn up with the knowledge that 
alcoholism appeared in the family. Inter- 
views also were conducted with families in 
which alcoholism was not a problem. In this 
example, as with many other cases, the 
alcoholic's spouse had depression. The ma- 
jority of female spouses of alcoholics were 
found to have depression or anxiety dis- 
orders. Also, since a history of divorce typi- 
cally exists among alcoholics, the researcher 
interviewed the alcoholic's former spouse and 
children. (Often former spouses will not talk 
to researchers.) It turned out that the for- 
mer spouse's father had a history of alco- 
holism, another common occurrence. Women 
married to alcoholics may have a history of 
alcoholism in their own families. The 
researcher also found that the current 
spouse's mother had an anxiety disorder, 
while her father showed no major conditions. 
The alcoholic's mother suffered from manic 
depression, and his sister was alcoholic. The 
man's oldest son had abused drugs, and his 
oldest daughter had bipolar depression. In 
examining these circumstances, it is unclear 
whether the son's drug abuse was a mani- 
festation of the same underlying factors as 
those affecting his father. The generation 
growing up in the 1960s was much more 
exposed to drugs, whereas the father's gene- 
ration was more exposed to alcohol. Thus, 



55 



NIDA Conference Highlights 



there was not an equivalent level of exposure 
to drugs in the family, and genetic transmis- 
sion became hard to judge. Researchers are 
better able to test alcohol transmission, 
which has common exposure across the 
generations. 

These kinds of disorders are very common in 
the general population. For instance, one 
out of every six males has a history of alcohol 
abuse, about 20 percent of the population has 
met the criteria for one or more anxiety 
disorders in their lifetimes, and about 12 
percent of the general population has suf- 
fered from depression. Thus, it is difficult to 
determine whether the existence of such 
disorders in one family is to be expected 
based on general population prevalence or 
whether the disorders are due to underlying 
factors in the family. Researchers must 
check patterns in the community of comor- 
bidity within individuals and families before 
drawing conclusions about what disorders 
may run in families. Other studies have 
focused on the specificity of choice of drugs, 
particularly cocaine, opioids, alcohol, and 
marijuana. Index cases with these con- 
ditions have been selected and the children 
in these cases are being examined for any 
specificity in their choice of drugs to help 
determine what is transmitted in families. 

In these kinds of families, which are not 
atypical, researchers disagree about who 
should be counted as an affected individual 
in genetic analysis (e.g., alcoholics and manic 
depressives). The pedigree could involve 
transmission of manic depression, which 
then may lead to alcohol use rather than 
alcohol use primarily. Researchers must 
solve these kinds of problems even before 
studying the patterns of transmission. 

Tables from the Epidemiologic Catchment 
Area (ECA) study show the comorbidity of 
alcoholism and other psychiatric disorders in 
the ECA and the comorbidity of drug abuse 
and other psychiatric disorders. In a survey 
of 30,000 individuals in the general popu- 
lation at five major sites (from a book by Dr. 
Lee Robins and Darryl Regier), individuals 
who met criteria for alcoholism were exa- 
mined for other disorders. The prevalence 
ratio was about 20 percent of alcoholics with 
a secondary condition compared to nonalco- 
holics who had the condition. Thus, alco- 
holism is strongly associated with an anti- 
social personality. Mania, a key feature of 
bipolar depression, showed a high association 
with alcoholism among the general popu- 



lation. Drug abuse and dependence also are 
highly associated. Around 80 to 90 percent 
of cocaine abusers also meet the criteria for 
alcoholism. Alcohol brings down the high 
induced by cocaine, a state similar to mania. 
In addition, there is a strong association with 
schizophrenia. Finally, the study also found 
an increased association between alcoholism 
and panic disorders, but not major depres- 
sion, counter to expectations. The same 
kinds of patterns of associated disorders 
emerge with drug abuse. 

In family studies, researchers select families 
with substance abuse and, by investigating 
them, determine which disorders run in the 
families and in what combinations. Re- 
searchers must use these data to untangle 
the mechanisms for associations as well as to 
look at the disorders that children express 
even before exposure to alcohol or drugs to 
conclude whether a self-medication model 
exists. If it is shown that these are pre- 
morbid conditions — that children use alcohol 
to minimize the symptoms — then interven- 
tion to prevent drug and alcohol abuse 
should occur. 

It has been found that anxiety disorders and 
affective disorders in adulthood are associ- 
ated with both alcoholism and drug abuse. 
Specific to drug abuse, however, are child- 
hood anxiety disorders, except for social 
phobia. These disorders are increased in the 
offspring of people who abuse drugs. Con- 
duct disorder and attention deficit disorder 
also are increased in the children of sub- 
stance abusers. In addition to these specific 
associations, children of substance abusers 
have more severe expressions of these dis- 
orders. Researchers now are following these 
children to find out which children prefer 
alcohol and which prefer drugs. Then, inter- 
ventions can be planned to address the 
problem and to look at patterns to examine 
how genes are involved in transmission. 

Questions, Answers, and Comments 

Comment: It was noted that DSM-III {.Diag- 
nostic and Statistical Manual, third edition) 
or DSM-III-R (Diagnostic and Statistical 
Manual, revised third edition) criteria are 
used for the most part in family, twin, and 
adoption studies to diagnose drug abuse 
and/or dependence. One participant sug- 
gested the inclusion of alcohol in examining 
substance abuse in the family of the drug 
user since children might choose alcohol just 
to be different from their parents. It was 



56 



Summaries of Research Awareness Seminars 



noted that the relationship of research on 
alcohol with research on other drug abuse is 
still an open issue. Most researchers want to 
separate the behaviors at this point. Both 
types of substances are reinforcing; thus, it 
might not be reasonable to distinguish be- 
tween them. But for now it is preferable to 
look just at other drug use and not alcohol 
use in families. 

Comment: Even though many reward-rein- 
forcement circuit similarities exist between 
alcohol and drugs, the genetic bases of al- 
coholism and drug abuse may differ. Several 
bits of data support this contention, includ- 
ing the family studies of Shirley Hill et al. 
and Marin. Although there may be some 
common genetic basis, they do not appear to 
be identical. 

Comment: Alcohol dependence can be found 
intergenerationally among families of alco- 
holics. There is a distinct difference between 
dependence on and abuse of alcohol. There 
is an equal amount of alcohol abuse among 
children of alcoholics and children of non- 
alcoholics. However, children of alcoholics 
demonstrate an increased rate of dependence 
on alcohol. The dependence or craving seems 
to be transmitted. 

TREATMENT 

RSI 3. Matching Patients and 
Treatments 

Moderator: A. Thomas McLellan. Ph.D. 
Speakers: Barbara Havassy. Ph.D. 
Robert Hubbard, Ph.D. 
Respondent: Linda Lewis. M.A. 
July 15. 10:30 a.m.-12:00 p.m. 

Speaker: A. Thomas McLellan. Ph.D. 

The most difficult aspect of outcome research 
is probably matching patients to the ap- 
propriate treatments. In order to make an 
appropriate treatment match possible, there 
is (1) a need for more than one kind of treat- 
ment program in order to make comparisons 
between one treatment method to another 
and (2) a need for multidimensional patients 
that are noticeably different in their overall 
treatment outcomes. Although various 
programs offer patients different services, 
they should be relatively equal in their level 
of effectiveness. Treatment effectiveness 
often can be measured by the relationship 
between the initial patient characteristics 
sighted during the patient-to-treatment 



matching period and the point to which these 
characteristics have been addressed within 
the final treatment outcomes. The four basic 
methods of matching are (1) inpatient to 
outpatient (setting differentials); (2) match- 
ing of patients to different programs within 
a setting; (3) component matching within a 
program and within a setting; and (4) match- 
ing of patients to different therapists within 
a component, program, and setting. 

The Addiction Severity Index (ASI) is a 
method of determining the problems patients 
are experiencing and to what degree they are 
suffering from these problems. The problems 
most often noted are medical, employment, 
alcohol, drug, legal, family, and psychiatric. 
Due to this wide array of problems, treat- 
ment programs must focus not only on drugs 
and alcohol but also on the other problems 
that surface during the initial patient evalu- 
ation. 

Speaker: Barbara Havassy. Ph.D. 

A matching study, encompassing six private 
treatment programs in the San Francisco, 
California area, reviewed the outcomes of 
numerous cocaine dependents that had 
attended either inpatient or outpatient pro- 
grams. The first 3 weeks of all the programs 
were similar in that they were devoted to 
baseline assessment of the incoming patients' 
needs. The various treatments consisted of 
basic 12-Step systems. Medical detoxifi- 
cation units also were provided for those 
patients in need, whether inpatient or out- 
patient. The maximum stay of any patient 
enrolled in an inpatient treatment program 
was 28 days. However, people enrolled in 
outpatient programs were in treatment from 
between 6 to 26 weeks. In both kinds of 
treatment, drug use was detected through 
urinalysis. Of the 1,262 people studied, 550 
were assigned and actually entered treat- 
ment; of these 550, 450 completed their 
baseline assessments. The qualifications 
necessary for completing the baseline assess- 
ments to enter the programs were the fol- 
lowing: (1) the patient could not have been 
in any other kind of treatment 90 days prior 
to entering this program and (2) the patient 
had to possess two or more symptoms associ- 
ated with the DSM-III-R (Diagnostic and 
Statistical Manual, revised third edition) 
criteria for cocaine dependence. Ninety -three 
percent of the participants met these two 
requirements. Another interesting statistic, 
which was not a program requirement, was 
that 63 percent of the participants were 



57 



NIDA Conference Highlights 



employed full or part time. This information 
was obtained from a Cocaine Screening 
Questionnaire, a program-developed 
interview. 

On qualifying for treatment, each patient 
participated in a Treatment Assignment 
Measure (TAM), a measuring toolAnterview 
for determining the severity of an individ- 
ual's cocaine use. Based on the results of 
these interviews, patients then were assigned 
to an appropriate treatment program. To 
determine each individual's severity of 
cocaine use, the TAM interviews focused and 
scored on the following primary areas of 
interest: employment status, legal status, 
family relationships, recovery environment, 
alcohol and other drug use history, and 
psychological status. The people that scored 
in the low range of the TAM interview (i.e., 
less severe problems) were assigned to out- 
patient programs. The people that scored in 
the middle range of the TAM interview were 
assigned to either outpatient or shorter term 
inpatient programs. The people that scored 
in the high range of the TAM interview (i.e., 
more severe problems) were assigned to 
inpatient programs. The interview results 
revealed that 342 people were able to be 
matched to a program and 108 were not. 
The reasons for not matching these 108 
people were either financial, employment, or 
insurance problems. Of the 342 people that 
were matched, 68 percent were assigned to 
inpatient programs, and 32 percent were 
assigned to outpatient programs. Only 91 
percent of the inpatient assignments were 
accepted; consequently, only 57 percent were 
matched to treatment programs successfully. 
The outpatient assignments gained a 42- 
percent acceptance rate, bringing their final 
match rate to 43 percent. The overall accept- 
ance rates for inpatient assignments were 
higher than the outpatient assignments. 
This is due largely to the fact that many 
participants come to treatment with a pre- 
conceived notion about what type of treat- 
ment would best suit them. Despite the 
differential in the number of inpatient/out- 
patient assignments, there are a number of 
hybrid cases. These hybrid cases simply 
refer to patients that begin their treatments 
in either inpatient or outpatient care and 
consequently switch to the other before they 
are through. For an unknown reason, higher 
abstinence rates (25 percent) are detected 
among the outpatient participants. 



Speaker: Robert Hubbard, Ph.D. 
An epidemiological study of 120 programs 
nationwide currently is under way. Thus 
far, 92,000 clients from methadone main- 
tenance, long-term residential, and short- 
term chemical dependency programs have 
been studied. The study consists of an initial 
3-hour assessment interview, followed by 
four 90-minute interviews conducted at 1-, 
3-, 6-, and 12- month intervals. These inter- 
views are designed to determine the level of 
services being received by clients. 

Within a large portion of this country's 
community-based programs, matching 
patients to treatment is based simply on the 
availability of services. After assessing client 
needs, programs should alter their individual 
constructs in order to address these needs 
instead of having clients change their ap- 
proaches to entering programs. Accessibility 
is also a noteworthy problem. Treatment 
programs should be able to easily access 
their clients' past treatment histories, includ- 
ing what services they have received and/or 
programs in which they have participated. 
Once treatment workers have obtained all 
the needed information, they should make a 
decision about what type of treatment they 
deem appropriate for each individual client. 
After this decision has been made, treatment 
workers should stick to it wholeheartedly. 
Personal preferences, insurance factors, and 
the criminal justice system too often dictate 
the clients' treatment settings. 

Careful screening and assessment practices 
must be broadened, and a universal language 
must be implemented to permit accessibility 
when trying to locate a client's treatment 
history records. Treatment programs need to 
learn how to better match their services not 
only at the initial assessment of a client but 
also throughout the individual's many "re- 
covery phases." One way of working toward 
this goal is by training the clinical staff 
better so they are able to easily identify all 
the problems facing different clients. The 
four basic models that clinical staff can use 
when matching services to clients include the 
following: community services, recruitment 
services, counseling services, and special 
services. The ratings given to most pro- 
grams after 3 months of attempting to pro- 
vide the above-mentioned services are fairly 
low for both methadone maintenance and 
short-term inpatient programs and only a 
little bit higher for the long-term residential 



58 



Summaries of Research Awareness Seminars 



programs. Due to this fact, it would seem 
that there is much room for improvement. 

Questions, Answers, and Comments 

Comment: Unfortunately, treatment has 
come to mean basically just counseling, while 
the other known aspects of treatment are 
seen simply as extras. The factors that 
usually lead to the matching of clients to 
treatment programs have been the clients' 
level of dysfunction and the severity of the 
clients' problems. The following question 
must be addressed: What length of stay is 
appropriate for what level of drug problem 
severity? 

Were the modalities associated with length of 
stay considered during the various mentioned 
programs' attempts to improve their patient- 
to-treatment matching skills? Generally, at 
the beginning of a patient's stay, the length 
at which he/she may continue on is not taken 
into account because this factor depends on 
so many other different issues. As time goes 
on and the various needs of patients surface, 
individual lengths of stay can be determined 
accordingly. Length of stay is actually a 
secondary factor to address when the ser- 
vices offered during an individual's stay are 
not sufficient in dealing with the areas of 
need. 

What can a small, community-based treat- 
ment program do in the area of implementing 
patient-to-treatment matching practices if 
indepth research studies are not within the 
budget? The three most simple and least 
costly methods of attaining this goal include 
the following: asking patients upon entering 
programs what their particular problems are; 
performing followup meetings with a sample 
of the patients to see if the patients feel they 
are receiving the necessary services to 
address their individual problems; and con- 
ducting outcome evaluations of patient-to- 
program success. 

7s it the development of new modalities, new 
inpatient / outpatient methods of care con- 
tinuum, or new services within any of these 
areas that stimulates the greatest level of care 
improvement within any given treatment 
program? The services within the modalities 
and the degree to which these services can 
and will be continued are what produce the 
most positive results. 

Do racial or cultural differences have any 
effect on program outcomes in terms of indi- 
vidual patient success rates? The predictors 



to outcome generally have been the same for 
all of the programs for African-American, 
Caucasian, and Hispanic patients. However, 
some groups of people obviously need some 
special attention in order to be successful 
within their given programs (e.g., pregnant 
women, people who cannot speak English, 
etc.). 

Are there any factors, motivational or other, 
that lead to longer lengths of stay on the part 
of the patients ? It is hard to determine any 
particular factors — with the exception of a 
court order — that lead patients into staying 
in treatment longer. 

RSI 4. Dual Diagnosis and Drug Abuse 
Treatment 

Moderator: Bruce Rounsavllle, M.D. 
Speakers: David McDuff. M.D. 

Richard Ries. M.D. 
Respondent: Charles Thiessen. M.A. 
July 16, 10:15 a.m.-l 1:45 a.m. 

Speaker: Bruce Rounsaville, M.D. 

Using data on cocaine and opiate abusers in 
New Haven, as well as treatment-seeking 
alcoholics in Hartford, one can dispel con- 
cerns that some people have about treating 
depression and anxiety disorders among drug 
abusers. Such concerns are common among 
substance abuse professionals when they are 
encouraged to try to treat depression or to 
consider pharmacological solutions for 
psychological problems. Medications are not 
solutions to psychological problems. How- 
ever, the dual diagnosis/multiple disorder 
approach, which is consistent with the offi- 
cial diagnostic nomenclature of the World 
Health Organization and DSM-IV (.Diag- 
nostic and Statistical Manual, fourth edi- 
tion), is useful in its consideration of sub- 
stance abuse problems, depression, schizo- 
phrenia, and other disorders. This approach 
views these disorders as separate conditions 
that may interact with one another as well 
as with other health problems, such as pneu- 
monia. The recognition of these separate but 
possibly interacting disorders is worthwhile 
and not necessarily contradictory. It is 
important that clinicians treat all of these 
issues together rather than, for instance, 
concentrating solely on substance abuse 
issues while ignoring a depression disorder 
that remains symptomatic and problematic. 

Dozens of studies using modern diagnostic 
methods have indicated that dual diagnosis 



59 



NIDA Conference Highlights 



is more the rule than the exception. Studies 
of groups of drug abusers in treatment found 
high rates of many disorders, particularly 
anxiety, depression, antisocial personality, 
and polysubstance abuse. likewise, studies 
with mental patients show that substantial 
numbers, ranging from 20 to 60 percent, 
have current substance abuse disorders, 
including abuse of cocaine and marijuana. 
Community surveys show that if a person 
has any one disorder, such as substance 
abuse, he/she is more likely to have another 
disorder, such as an anxiety problem. Clini- 
cians are trained as specialists, but data 
show that they must work as generalists. 
They cannot treat one disorder and assume 
that the others will simply go away with 
time. 

When using DSM-III-R {Diagnostic and 
Statistical Manual, revised third edition) or 
other strict criteria to assess lifetime dis- 
orders among treatment-seeking opioid 
addicts, cocaine abusers, and alcoholics, one 
of the primary problems found is depression. 
About 1 in every 18 to 20 individuals in the 
general population will have had an episode 
of major depression at some time in their 
lives, with 2 to 3 percent having current 
depression. However, more than one-half of 
opioid addicts, 30 percent of cocaine abusers, 
and 38 percent of alcoholics will have had a 
major depression episode. About 10 to 20 
percent of alcohol and drug abusers experi- 
ence depression. Other disorders are more 
frequently found among drug abusers than 
the general population. While about 2.1 
percent of the general population meets the 
criteria for antisocial personality (which is 
popularly perceived as associated with drug 
abusers), using restrictive criteria, 26 per- 
cent of opioid addicts, 15 to 20 percent of 
cocaine abusers, and 41 percent of alcoholics 
suffer from the disorder. In considering 
comorbid alcoholism, about 33 percent of 
opioid addicts and 60 percent of cocaine 
abusers meet the lifetime criteria for alcohol 
as well as opioid addiction or cocaine abuse. 
Conversely, 43 percent of alcoholics in detoxi- 
fication or treatment meet the criteria for 
abusing other substances. Thus, it is 
imperative that clinicians be prepared for 
patients' multitude of problems. 

Anxiety disorders also are common among 
alcohol and drug abusers, including simple 
phobias or schizophrenia. There typically is 
no significant difference in the frequency of 
schizophrenia or bipolar disorders between 
treatment-seeking drug abusers and the 



general population. People with full-blown 
manic depressive illnesses typically are not 
seen in a nondual diagnosis or nonspecialty 
treatment facility, since they will seek a 
more specialized program for treatment of 
their condition. Studies have found that 
these disorders are significant. For instance, 
the presence of depression and anxiety confer 
a poorer prognosis. Interviews with signifi- 
cant other informants indicate that the 
observed psychiatric problems are symptom- 
atic of true disorders rather than just 
overreported attention-seeking behavior. 
Symptom patterns indicate that the depres- 
sion among drug abusers and nondrug 
abusers is similar. Furthermore, the identifi- 
cation of depression can have prognostic 
significance, even though the depression 
associated with drug abusers tends to wax 
and wane and thus may not appear as 
classically severe. Also, the diagnosis of 
depression tends to run in the families of 
depressed drug abusers. 

In considering treatments for comorbid 
anxiety and depression, systematic clinical 
trials have provided evidence that formal 
psychotherapy seems more effective with 
depressed cocaine and opioid abusers than 
with abusers who are not depressed. Non- 
depressed patients can receive regular coun- 
seling, whereas depressed patients seem to 
need more intense psychotherapy. The most 
common and effective pharmacological treat- 
ment for depression is antidepressants. 
Evidence shows that depression among 
heroin users can be treated effectively with 
antidepressants. However, little evidence is 
available on antidepressants' effects with 
cocaine abusers. Early studies on alcoholism 
showed that antidepressants did not seem to 
treat depression effectively. But in those 
studies, depression was not well defined and 
thus may have been alcohol induced. It later 
was found that alcohol interferes with the 
metabolism of tricyclic antidepressants, so 
patients probably were receiving too low a 
dose of the antidepressant s). There is some 
evidence that anxious alcoholics respond well 
to buspirone, a nonaddictive antianxiety 
agent. 

There are many challenges in diagnosing 
comorbid disorders in drug users. For 
instance, most treatable disorders can be 
mimicked by drug withdrawal states during 
intoxication and from chronic use of drugs. 
There are several approaches to determining 
which disorders will go away with or without 
specific treatment (in the process of detoxifi- 



60 



Summaries of Research Awareness Seminars 



cation) and which disorders require targeted 
treatment. First, clinicians may be con- 
servative and not address a possible psychi- 
atric condition until it has been present a 
lengthy time (i.e., 6 weeks) during which the 
patient is drug free. However, clinicians 
should wait only about 2 weeks to avoid the 
risk of missing clinically relevant syndromes. 
Further, inpatient stays are becoming 
shorter at programs, so even if the strategy 
involves waiting 14 days before making a 
diagnosis and providing treatment, the 
patient may have left the program already. 
Outpatient treatment then is difficult 
because few patients can remain drug free 
for 6 weeks. Thus, it appears more effective 
to use a shorter time window for deciding to 
treat comorbidity. 

Second, clinicians could consider diagnosing 
comorbid disorders if the condition appears 
to have been present in the patient prior to 
drug abuse. However, it is difficult to deter- 
mine whether the psychiatric condition 
existed first, since drug abuse likely started 
many years ago; many patients, in fact, 
hardly have any history of being drug free. 
Regardless of which condition occurred first, 
the comorbidity causes poorer prognosis and 
increased risk of relapse. Third, the symp- 
toms can be treated regardless of their rela- 
tion to substance abuse, but this approach 
rarely is used. Finally, clinicians can decide 
to address symptoms only if they occurred 
during periods of increased use or during 
periods of discontinuation of use. 

Some arguments can be made against treat- 
ing comorbid disorders. For instance, the 
reliability of diagnosing depression in drug 
abusers is slightly worse than diagnosing 
depression in nondrug abusers. However, 
there is only 10- to 15-percent less reliability, 
not a substantial difference. Some people 
also argue that diagnosed depression is 
substance induced. But many substance- 
induced depressions can be protractive. Also, 
with new pharmacotherapies, there is rela- 
tively low risk of overdosing and developing 
adverse drug interactions. 

It is important to consider the time range 
within which depression should be diagnosed 
among people abusing various drugs. Indi- 
viduals using alcohol and sedatives, which 
are very neurotoxic drugs, should be 
"detoxed" before clinicians consider the users' 
depression too seriously. Patients using 
heroin, which is not a depressant drug, 
should not have to be drug free before a 



diagnosis of depression can be made. With 
abusers of cocaine and stimulants, the use of 
antidepressants even early in treatment can 
be worthwhile. 

To summarize, rates of such disorders as 
depression, anxiety, and antisocial per- 
sonality are very high among treatment- 
seeking, drug-abusing populations. Clini- 
cians cannot act simply as specialists and 
ignore these disorders. Methods are avail- 
able for reliably diagnosing and treating the 
disorders, and patients usually respond to 
regular treatment. 

Speaker: David McDuff. M.D. 

The substance abuse system has been able to 
expand the capability of its inpatient and 
outpatient programs simply by adding 4 to 
12 hours per week of psychiatric consultation 
with staff at all levels in treatment. In 1990 
a group of addiction psychiatrists at the 
University of Maryland collected data sys- 
tematically for 1 year from consultation work 
with three programs: (1) a publicly funded 
program with 60 beds in inner-city 
Baltimore, (2) a private program in the 
suburbs, and (3) a Veterans' Administration 
(VA) program. At the time, each offered 
28-day rehabilitation. About 20 percent of 
admitted patients in the first two programs 
were seen by an addiction psychiatric con- 
sultant. The comparable VA numbers were 
lower because a psychiatrist already was on 
staff. Most patients were young men. 
Results indicated that about 20 to 25 percent 
of patients in inpatient or rehabilitation 
settings can benefit from active clinical 
consultation with an addictions psychiatrist, 
including followups. Furthermore, about 10 
to 20 percent are likely to benefit from out- 
patient consultation. The most common 
diagnoses made were for mood and anxiety 
disorders. Data from the VA program were 
not consistent, because consultants saw only 
the most difficult cases. 

During this time a NIDA-funded study that 
used structured clinical interviews (the 
Structured Clinical Interview for DSM-III-R 
and the Addiction Severity Index [ASI]) was 
introduced into the public program, so infor- 
mation was being derived from both clini- 
cians and researchers with essentially the 
same findings. By this time, the public 
program was admitting psychotic patients 
from some of the State psychiatric facilities, 
thus creating useful information on the typi- 
cal composite scores for public, private, 



61 



NIDA Conference Highlights 



inpatient, and outpatient treatment 
programs. 

In determining how to make the psychiatric 
diagnoses most relevant to patients' recovery 
work, several developmental models of 
recovery seem helpful. In particular, 
Terence Gorski's model of recovery has prov- 
en operationally to work well, and both 
treatment providers and patients liked the 
approach. (Stephanie Brown's model also is 
noteworthy.) The Gorski recovery process is 
broken down into stages with accompanying 
tasks which must be mastered at each stage. 
During the pretreatment stage, the patient 
either does not want to stop or cannot stop 
using drugs. It is important to identify the 
person's current stage of recovery, diagnose 
any psychiatric problems with respect to the 
stage of recovery, and then integrate recom- 
mendations into the recovery program. In 
stabilization, the task is for the individual to 
stop using drugs. Some patients cannot stop 
their drug use. If an individual can remain 
abstinent for 60 days or more outside a 
treatment program, then he/she should be 
considered able to stop using drugs. Staying 
abstinent is a different issue that requires 
that the individual develop a level of comfort 
with abstinence. This perspective, con- 
sidering the stage of recovery, seems to make 
the task easier for patients. 

In considering how psychiatric diagnoses 
contribute to clinical issues that block 
recovery, the concept of denial is used 
broadly, not simply as an unconscious 
psychological defense mechanism. Denial, as 
defined in a recent Journal of the American 
Medical Association article, consists of any 
thought patterns, behavioral sets, or inter- 
pretation of emotional states that are 
designed to reduce the person's awareness of 
his/her accountability for a problem. Denial 
is the most common barrier to recovery 
progress. The person will not or cannot stop 
his/her drug use. Often a barrier to stopping 
is clinical model mismatch. In the Journal of 
Substance Abuse Treatment, Brower and 
colleagues discussed various clinical models 
used in addiction treatment. Often staff use 
one model, while patients have a different 
point of view regarding the methods to be 
used. Consultants often must negotiate 
these differences to counter the mismatch 
that may have occurred. For instance, dur- 
ing the first 24 hours of consulting, the 
consultant usually addresses behavioral 
problems that impede recovery. 



Marlatt and others have identified a number 
of common relapse triggers, which occur most 
often in the stage during which individuals 
are trying to become comfortable with re- 
maining abstinent. The psychiatric diagnosis 
is extremely significant in this respect, 
because depression or anxiety disorders 
impede the feelings of comfort that are neces- 
sary to stay abstinent. Common relapse 
triggers include continued use of other mood- 
altering drugs, interpersonal conflict, and 
social pressures. Conditioned craving can 
trigger relapse; when an individual returns 
to a social setting in which conditioned cues 
are very prevalent, relapse can occur. 

The proposed approach is to send addiction- 
trained psychiatrists into substance abuse 
treatment programs to try translating 
psychiatric practice into relevant recom- 
mendations within a recovery plan. This 
approach has received a positive reaction 
thus far from clinicians. As a derivative, an 
approach has been developed that includes 
brief psychotherapy during a rehabilitation 
program. 

Speaker: Richard Ries, M.D. 
There are various kinds of approaches to 
dual diagnosis when treating more severe 
and combined psychiatric and addiction 
disorders. In looking at chemical dependency 
and psychiatric spectrums ranging from low 
to high severity, one can develop a quadrant 
depicting interactions so that the world of 
dual diagnosis patients is divided into four 
squares. Such categorization can be impor- 
tant in planning treatment. For instance, 
high-severity psychiatric disorders are found 
mostly in the mental health treatment spec- 
trum, whereas high-severity addiction dis- 
orders mostly are found in the chemical 
dependency treatment area. Most people 
probably fall in the range of high chemical 
dependency treatment needs and low to 
moderate psychiatric disorders, such as 
depression or personality disorders. 

This presentation also concerns a program 
developed to treat people with psychiatric 
problems of high severity, such as schizo- 
phrenia, bipolar disorder, or recurrent 
depression with either low or high chemical 
dependency disorders. The Harborview 
program for the mentally ill, chemically 
affected (MICA) focuses on individuals with 
a definite mental illness and either low or 



62 



Summaries of Research Awareness Seminars 



high addiction severities. The program 
treats about 330 chronically mentally ill 
outpatients; employs 3 psychiatrists and 15 
case managers; and involves medical treat- 
ment, treatment of intoxication or with- 
drawal, psychological therapy, and social 
programs. The program has a higher density 
of African-Americans and Native Americans 
and a lower density of Asian-Americans and 
Latinos than exist in the Seattle population 
overall. Almost all program participants 
have been hospitalized, and most are diag- 
nosed as schizophrenic or bipolar. The pro- 
gram involves phases of treatment somewhat 
similar to those of the Gorski recovery model. 
About 50 percent of patients are in the "pro- 
phase" and their mental illness and drug or 
alcohol use is still out of control. They are 
barely engaged in treatment, but case mana- 
gers attempt to control damage, stabilize the 
persons, and motivate them for recovery. 
Interventions at this time include case 
management as well as managing patients' 
money to keep them from spending it on 
drugs. In Phase 1, the program offers group 
therapy and one-on-one psychotherapy. This 
stage involves a structured, integrated men- 
tal health and addiction treatment group 
focusing on denial and acceptance of illness 
and trying to engage patients in the treat- 
ment process. Most people in this phase 
have to 3 months of sobriety and are 
engaged in some kind of psychiatric treat- 
ment. Many of them still are using drugs or 
alcohol. Only 7 percent of the patients are in 
Phase 2, having established sobriety and 
begun working actively on recovering. The 
program serves people who range from low to 
high severity, with a significant number on 
the higher end, as would be expected in such 
a program. If a chemical dependency unit 
suddenly is ordered by the State to become a 
dual disorder unit, which will happen 
increasingly in the future, it may be difficult 
to adjust to treating people with severe 
psychiatric disorders. Programs must be 
built, staffed, and funded to treat the 
patients they admit. About one-half of the 
Harborview MICA patients virtually are 
unable to take care of their daily needs and 
need help paying their rent, obtaining food, 
and performing other activities. 

Another significant issue in addiction and 
mental health treatment is compliance with 
treatment. Many people who work in 
straight addiction treatment agencies say 
that only 50 percent of individuals who 
arrive for their first appointment return for 



their second appointment. Long-term 
patients often must be "chased down" to 
comply with their treatment. To what 
degree do the patients have the autonomy to 
return for treatment on their own? Do staff 
enable patients' dysfunctions by doing too 
much for them, or is such action necessary to 
ensure that the individuals receive proper 
treatment? It seems important to assist 
some individuals in such an enabling manner 
at least for some period of time. About 40 
percent of the program's patients are 
compliant only about 40 percent of the time. 
In starting to treat patients with moderate or 
severe dual disorders, case management and 
compliance become more and more impor- 
tant. Otherwise, some patients simply will 
keep getting sick, continue going to the 
emergency room and hospital, and never 
stabilize. 

There are compliant patients in the program 
as well. Surprisingly, although a large 
number of patients are using drugs everyday 
or every other day, about 100 of the mentally 
ill patients have been abstinent for more 
than 6 weeks, and about 40 have maintained 
sobriety for about 1 year. This information 
is case manager generated, with the use of 
one form to assess the patient's degree of 
substance use, degree of psychiatric symp- 
toms, degree of compliance with treatment, 
and degree of dysfunction. Every 3 months 
the case managers take one afternoon to rate 
their entire caseloads. The ratings then are 
used to determine where patients fit in the 
various phases and what treatment needs 
exist. 

Questions, Answers, and Comments 

An emerging concern in dual disorder pro- 
grams is whether clients are being harmed by 
treatment. Common errors include mistaking 
transient symptoms for primary psychiatric 
or substance abuse disorders and blaming 
clients for noncompliance and discharging 
them prematurely. What factors are most 
important for providers to be aware of to 
avoid such mistakes and reduce the risk for 
harm? Also, what questions should con- 
sumers and referents ask when shopping for 
dual disorder services ? One qualifying factor 
for admission for severe mental health treat- 
ment, and thus for the Harborview program, 
is frequent admissions to hospitals. How- 
ever, frequent admissions to hospitals do not 
necessarily indicate the presence of a pri- 
mary mental disorder. Many people are 
admitted to the program who abuse drugs or 



63 



NIDA Conference Highlights 



alcohol and have antisocial personality dis- 
orders; such persons usually have been 
diagnosed with something like atypical 
bipolar disorder. The program probably 
rediagnoses about 5 percent of its patients 
out of treatment around 3 months after 
admittance. It is difficult to "undiagnose" 
someone. Dealings need to be improved with 
the antisocial primary drug abuse patients 
who need more confrontation. One harm 
may be the enabling of ongoing antisocial 
behaviors among persons who should not be 
in psychiatric-based dual disorder treatment 
but instead should be managed more in a 
typical chemical dependency treatment 
environment. 

Also, when providing consultation to resi- 
dents of a homeless shelter, it became obvi- 
ous that one cannot be as aggressive or 
confrontive with a mentally ill substance 
abuser as with a primary substance abuser. 
Harm can be done by being too aggressive in 
demands for abstinence in too short a time 
period. Furthermore, addiction-trained 
psychiatrists are very helpful additions to 
treatment programs and can reduce the risk 
of harm. 

Drug abuse treatment should be tailored to 
individuals depending on the severity of their 
psychopathology. Patients with disorders 
such as depression, in which they are tempo- 
rarily in a disabled state, can benefit from a 
specific diagnosis and treatment. There 
should be more than a one-time psychiatric 
consultation, however, to monitor their 
progress. People with schizophrenia or 
bipolar disorders, on the other hand, are 
more disabled and need a less confronta- 
tional approach. People with antisocial 
personality disorders need less of a specific 
diagnosis than an assessment of how their 
behaviors can change. 

Relevant questions for consumers concern 
staffing patterns of the unit and the orienta- 
tion of the patient population. For instance, 
for severe problems, staff should have high 
sophistication, particularly at the nursing 
staff level, in dealing with extreme behav- 
iors. Also, consumers should ask providers 
about targeted symptoms, what changes 
should occur, and what side effects and 
dangers are likely. 

Should one automatically assume that for 
someone with depression who is using 
cocaine, the major motivation for the cocaine 
use is self-medication? Although in some 
surveys it has been shown that individuals 



RSI 5. 



with depression are more likely than non- 
depressed individuals to try cocaine, this is 
not a common scenario. The effects of 
cocaine, in fact, mimic some of the symptoms 
of depression, such as paranoia. Even if 
some disorders are substance induced, it still 
may be worthwhile to treat them. 

Many people who abuse cocaine and often 
mix it with alcohol are more likely to be 
misdiagnosed with bipolar disorder. Any- 
body who uses cocaine over time experiences 
psychotic symptoms. In a recent issue of 
Psychiatric Clinics of North America, an 
article on dual disorders summarizes circum- 
stances in which patients might go to either 
serial treatment, parallel treatment, or 
integrative treatment. 

Since psychiatric diagnosis is only one among 
several problems that a substance abuser may 
bring into treatment, why are clinicians 
singling it out to the extent that they are 
creating dual diagnostic units, implying that 
psychiatric diagnosis has special status? 
There are two good reasons to single out 
psychiatric diagnosis. First, data show that 
psychiatric condition is the best predictor of 
poor prognosis. Second, many of the dis- 
orders are treatable. In comparison to giving 
people housing, psychiatric treatment is 
fairly accessible to a large number of people. 
Severity of dependence does not predict 
treatment outcome very well. Sometimes 
psychiatric treatment is relatively easy and 
is fairly cost-effective. Often addiction treat- 
ment professionals are better at treating 
most personality disorders than most psychi- 
atrists and mental health workers. 

Relapse and Relapse Prevention: 
The Why and How of It 

Moderator: Arthur MacNelll Horton, Jr., Ed.D. 
Speakers: Sharon Hall. Ph.D. 

G. Alan Marlatt. Ph.D. 

Saul Shiftman, Ph.D. 
Respondent: Valera Jackson, M.S. 
July 15, 3:00 p.m.-4:30 p.m. 

Speaker: G. Alan Marlatt. Ph.D. 
A study of the cognitive behavioral model of 
relapse and relapse prevention found that 
similar relapse curves have been demon- 
strated for different addictive behaviors. A 
classic study by William Hunt and col- 
leagues, for example, found that two-thirds of 
the sample violated an absolute abstinence 
requirement within the first 90 days after 
treatment. The similarity in the relapse 



64 



Summaries of Research Awareness Seminars 



curves suggests that there may be something 
in common about relapse that runs across 
different kinds of behaviors, such as biologi- 
cal or personality commonalities. Psychologi- 
cal and behavioral commonalities also seem 
significant, since common triggers push 
people into relapse. 

Within the field, different definitions of 
relapse are used in the context of various 
theoretical models. For instance, the "moral 
model" places responsibility on the client for 
being addicted and for making change; thus, 
relapse is viewed as immoral, weak behavior. 
The "disease model" stipulates that addiction 
is a disease, that addicted people cannot be 
held responsible for the development of the 
disorder, and that treatment is necessary to 
change addictive behavior. Most 12-Step 
programs adhere to the disease model. The 
"biopsychosocial habit model," or "compensa- 
tory model," does not blame addicted people 
but does maintain that they can take respon- 
sibility for changing their behavior, either on 
their own or through treatment. The "spirit- 
ual model" points out that relapse and the 
literature are out of touch with a higher 
power. One project, discussed below, adheres 
most strongly to the biopsychosocial habit 
model and examines the learning factors 
involved in changing drug behavior. 

This cognitive behavior model examines the 
moment of relapse or a person's first use of 
drugs after treatment and how the person 
reacts to the lapse. If the individual copes 
effectively with the situation, then it is 
hopeful that as similar situations continue to 
occur, there will be an overall decreased 
possibility of relapse. But the individual 
may react negatively and feel a decreased 
sense of self-efficacy along with very positive 
expectations of drug use. Not everyone who 
lapses continues into complete relapse, how- 
ever. Thus, it is critical that programs try to 
restrengthen clients' motivation and sense of 
efficacy. While proximal psychosocial factors 
are emphasized, it is important to note that 
many distal factors in the person's social and 
physical environment also may be critical. 

In studies conducted in Seattle, Washington, 
different high-risk situations for relapse were 
found to be common across samples of alco- 
holics, smokers, and addicts. One study, 
using retrospective interviews, looked at 
whether relapse occurred when the person 
was alone or with other people. A significant 
interpersonal factor that often is found in 
these situations is a negative emotional 



state, such as anger, depression, or loneli- 
ness. Such conditions were found to be more 
significant at the time of relapse than were 
negative physical withdrawal rates. Inter- 
personal conflict and social pressure were the 
other two main triggers identified. Certain 
questionnaires, such as the Inventory of 
Drinking Situations, developed at the Addict- 
ion Research Foundation in Toronto, provide 
an indication of a person's vulnerability and 
needs for extra strengthening to prevent 
relapse. However, problems do exist with 
using retrospective accounts about relapse, 
such as when people give erroneous reasons 
for relapse. 

Keeping in mind the stages associated with 
relapse, it is important to identify 
process-based intervention strategies (e.g., by 
identifying specific high-risk situations and 
determining the best ways to handle them, 
such as with coping strategies and infor- 
mation on long-term consequences). Some 
projects use a contingency contracting ap- 
proach or the provision of reminder cards, 
detailing what a person should do in the 
event of relapse. If possible, interventions 
should be individualized as much as possible. 

Relapse prevention has two main facets. 
First, programs can attempt the prevention 
of initial lapses through individual self- 
management training. However, current 
research does not reveal relapse prevention 
to be any more effective in maintaining 
abstinence than other programs. For 
example, a University of Washington study 
on alcoholics did not reveal more abstinence 
among alcoholics who had received relapse 
training. The alcoholics, however, showed 
less serious relapses and remained in after- 
care treatment for a longer time. It is impor- 
tant to support people even if they have 
lapsed but not completely relapsed. Some 
treatment centers have relapse groups to 
provide social support. Second, it must be 
remembered that relapse is a process. It 
should not be considered necessarily as a 
negative outcome. Even if people lapse tem- 
porarily, they still may recover fully. 

Speaker: Sharon Hall, Ph.D. 

A line of research, entitled "Relapse to 
Abused Drugs," has received funding from 
NIDA to examine variables that predict 
relapse across different drugs of addiction. 
This research includes a three-drug study 
that examined variables which predict 
relapse in alcoholics, opioid addicts, and 



65 



NIDA Conference Highlights 



cigarette smokers and a study that focused 
on the same variables in cocaine treatment 
patients. (A parallel study looking at relapse 
to needle use among stable methadone 
patients has been completed but data are not 
available.) In both studies, a battery of 
measures was used with patients still in 
treatment. Upon discharge they were tested 
weekly for up to 12 weeks. In the first 
study, they were followed until they returned 
to daily use. In the second study, cocaine 
patients were studied for as long as possible. 

Variables examined in the study included 
demographic factors, treatment history, 
withdrawal symptoms, major life events, 
daily life events, drug use, and social sup- 
port. Psychopathology also was studied 
among the cocaine abusers. Definitions were 
developed for slip and relapse. "Slip" re- 
ferred to a single use of a problem drug after 
a period of nonuse; "relapse" was defined as 
a return to daily use for 4 consecutive days. 
Three variables showed up consistently in 
findings across the drugs. First, commitment 
to abstinence was an important factor in 
determining which patients would succeed. 
In these two studies, this variable was as- 
sessed with a measure, developed by Alan 
Marlatt, that asked patients to endorse one 
of six abstinence goals. The subjects that 
endorsed a goal of total abstinence were less 
likely to slip after treatment than any of the 
others. One implication of this finding is 
that the people who do best are those who 
endorse their programs' goals, especially 
complete abstinence. Another implication is 
that the endorsement of the goal of total 
abstinence actually could correlate with some 
other variable. Clinically, at least, this 
attitude is worth encouraging among clients. 

The second variable is related to clients' 
levels of stress prior to relapse. Usually 
relapse data are collected retrospectively, 
after patients have resumed using drugs. In 
these studies, however, data were collected 
both before and after relapse. Across the 
drugs, using retrospective data, a high cor- 
relation was found between negative moods 
and relapse. Using prospective data (i.e., 
examining client moods from interviews 1 
week before relapse), only a relationship 
between abstinence and positive moods was 
found. (This connection also was found with 
the retrospective data.) It could be that the 
stressors that lead to relapse are those that 
occur just prior to the lapse, and a 
week-to-week study may not detect that 
occurrence. Also, the relationship between 



stress and relapse could be illusory (i.e., after 
people relapse, they describe the conditions 
leading to the lapse differently than they 
actually were). The lapse itself could cause 
more stress, too. Based on this information, 
it appears that researchers should begin to 
focus more on the significance of positive 
moods and dispositional optimism in addition 
to stress-linked variables. 

Third, social support (e.g., social integration, 
perceived support, and support for absti- 
nence) was found consistently across the 
drugs to relate to relapse. The most consis- 
tent finding concerned social integration. 
High social integration predicted abstinence 
across all drug categories in the three-drug 
study. Those clients with the least social 
integration were most likely to relapse. In 
the study with cocaine abusers, social sup- 
port predicted abstinence only among Cauca- 
sian individuals, so perhaps the measure's 
applicability needs to be expanded in some 
ways. 

Speaker: Saul Shiftman. Ph.D. 

Researchers at the University of Pittsburgh 
have been studying the critical situations, or 
crises, during which relapse often occurs. 
Retrospective data are not very reliable in 
assessing these situations, so other study 
designs are being developed. The University 
of Pittsburgh developed a computer for 
clients to carry with them and use to report 
episodes conducive to smoking relapse. 

The relapse process has been found to be 
very similar across various types of addic- 
tions. It is likely to occur, for example, in 
several types of key situations. First, relapse 
often happens at parties, when individuals 
are not experiencing stress but are around 
other people using substances, especially 
alcohol. The use of one drug, such as alco- 
hol, may promote cravings for another drug. 
Also, situations that arouse negative emo- 
tions are conducive to relapse. People often 
will cope with anger or depression by lapsing 
into drug use. Thus, programs should assess 
depression and history of depression in 
patients to indicate their vulnerability to 
such a condition in the future. In one study, 
more than one-half of the relapse situations 
were attributed to stress. The next leading 
variable included association with other drug 
users. Although clients in this sample used 
computers to document their relapse epi- 
sodes, the data still were retrospective to a 
certain degree. However, since the patients 



66 



Summaries of Research Awareness Seminars 



also were measuring stress on a daily basis, 
prospective data were obtained. It was found 
that individuals who relapsed to drug use, in 
this case tobacco, typically had reported a 
high level of stress the day before. 

Once individuals have been drawn into the 
temptation of drug use, they still have 
opportunities to react positively through 
various coping strategies. The strategies can 
be as simple as leaving the room when in a 
difficult situation or remembering the nega- 
tive effects of using drugs. Dramatic effects 
of coping also have been found. For instance, 
individuals who do anything to cope with a 
risky situation have 15-tdmes greater odds of 
resisting relapse than those who do nothing. 
The combination of cognitive and behavioral 
coping has an even stronger effect. Thus, it 
is important that clients develop coping 
strategies, even very simple ones. 

Questions, Answers, and Comments 

Were any differences based on gender or color 
found concerning relapse probabilities and 
the influences of stressors? No gender dif- 
ferences were found in these studies. The 
only cultural difference found concerned the 
apparent effect of social support in Dr. Hall's 
study with cocaine abusers, which may be 
due to the measure's lack of sensitivity to 
social support structures in the 
African-American community. 

Comment: The alcohol treatment literature 
does not support the idea that the longer the 
inpatient treatment phase, the lower the rate 
of relapse. It is difficult for many people to 
leave the sheltered environment of the treat- 
ment center for their communities, in which 
drug use often is very common. Thus, pro- 
grams should try to integrate aftercare 
followup into the environment in which 
lapses are occurring. 

Comment: More work needs to be done on 
measures sensitive to the Hispanic com- 
munity (i.e., concerning social support). A 
good resource on this subject is Lasao 
Perezstable at the University of California's 
Department of Internal Medicine. 

Comment: Relapse rates tend to be highest 
within the first 90 days after treatment. It 
may be helpful to consider relapse episodes 
as mistakes while the person learns new 
strategies for coping with stress. 

Comment: People who lapse even during 
treatment should not automatically be ter- 
minated from treatment. They should be 



provided additional assistance or some other 
form of support. Inpatient treatment must 
be adjusted. It isolates patients into a 
drug-free, stress-free world, so they do not 
always learn how to cope with the stresses 
they encounter in the "real world." 

Comment: Researchers should look more at 
the short-term/long-term course of the re- 
lapse process (e.g., initial motivation and 
social support). Many questions still require 
further study. 

Comment: More studies are needed on such 
issues as whether people who can continue 
controlled drinking have less physical depen- 
dence than others or whether they just have 
different goals. Many people who enter 
programs that initially encourage controlled 
drinking, rather then complete abstinence as 
a goal, eventually do become abstinent. 
Thus, it may be easier to recruit people into 
programs that have similar initial goals. 

Comment: Studies with young adults who 
are heavy drinkers have found a significant 
positive impact of exercise and relaxation 
training. Increasingly, exercise and general 
lifestyle approaches are becoming acceptable 
alternatives to drug treatment programs. 

RSI 6. Drug Abuse-Associated Medical 
Problems and Their Impact 
on Daily Life 

Moderator: William Grace. Ph.D. 
Speakers: Allen Helnemann, Ph.D. 

Jeffrey Kreutzer, Ph.D. 

David Portee. M.D. 
Respondent: Darleen Yuna. R.N.. M.Ed.. 

C.A.D.C. 
July 15, 4:45 p.m.-6:15 p.m. 

Speaker: David Portee, M.D. 

Disabilities due to stroke are among the most 
common disabilities evaluated and treated by 
physiatrists (specialists in physical medicine 
and rehabilitation). In addition, one of the 
more difficult issues that physiatrists try to 
address is pain control. Little research has 
been conducted on cocaine-related strokes 
and their rehabilitation, but it is an impor- 
tant area of study. 

"Stroke'' is defined as the sudden onset of 
neurological deficits resulting from the inter- 
ruption of the blood supply to the brain and 
the tissues served by the vessel involved. In 
the general population, two main categories 
of strokes exist: (1) ischemic, when the blood 
stops flowing to certain areas, and (2) hemor- 



67 



NIDA Conference Highlights 



rhagic, when an actual bleed occurs some- 
where within the brain tissue. Most strokes 
occur in the older population and are 
ischemic. Although hemorrhagic strokes 
initially are more lethal, after survival of the 
initial onslaught, the prognosis usually is 
more promising. Strokes in the younger 
population are uncommon: Only about 4 
percent of strokes occur in individuals under 
age 45. In one 10-year study of young people 
who suffered strokes, usually hemorrhagic, 
the most common risk factor was cigarette 
smoking, followed by recreational drug abuse 
and hypertension. 

Stroke syndromes of either the left or right 
hemispheres of the brain may involve cogni- 
tive dysfunction, bladder discontinence, 
difficulty with vision, and affective disorders. 
There are unique aspects of each hemisphere 
however. Individuals in which the stroke 
affects the right hemisphere suffer left-sided 
weakness, tend to be impulsive and dis- 
organized, and demonstrate poor judgment 
and lack of insight. Individuals with 
left-sided strokes suffer right-sided weakness 
but are able to learn from their mistakes 
and observations and are more cautious. 
Also, they are more prone to post-stroke 
depression. 

Cocaine can cause a number of neurological 
problems, such as seizures, headaches, and 
transient loss of sensation and other func- 
tions. The cause of stroke is not clear among 
cocaine abusers but does not appear to result 
from a direct insult on the blood vessel wall 
by the cocaine itself. Cocaine causes vaso- 
constriction of blood vessels; increased 
platelet aggregation; cardiac emboli (blood 
clots); and aneurysm rupture, which tends to 
be in the middle cerebral artery distribution 
and in the frontal lobe, so that strokes re- 
sulting from cocaine use frequently involve 
the left and right hemispheres more than 
other parts of the neural axis and occur 
within 6 to 72 hours of onset of the last use 
of cocaine. 

The type of stroke suffered depends on the 
type of cocaine used. For instance, 
crack-cocaine leads to hemorrhagic strokes as 
often as ischemic ones. Intranasal abusers 
tend to have hemorrhagic strokes twice as 
often as they have ischemic strokes, whereas 
intravenous users almost exclusively have 
hemorrhagic strokes. After the stroke, the 
patient usually undergoes three phases of 
abstinence while in treatment. Lasting from 
9 hours to 4 days, the first stage is charac- 



terized by agitation, depression, and high 
cocaine craving. During this time, a rehabili- 
tation unit determines whether the patient is 
a candidate for admission. The evaluators 
must understand, however, that this is a 
temporary phase and should not interfere 
with the rehabilitation process. The second 
phase lasts about 10 weeks and is character- 
ized by anxiety and high cocaine craving. 
This period generally coincides with the 
rehabilitation stay and first part of the 
outpatient program. The rehabilitation unit 
should understand that these patients may 
have more problems depending on which 
hemisphere was affected. A diagnosis should 
be made early (i.e., to treat depression) if 
evident. Medications could include tricyclic 
antidepressants. Monoamine oxidase inhibi- 
tors probably should be avoided due to their 
association with hypertension. If the stroke 
affected the right hemisphere, the patient 
likely would exhibit impulse control prob- 
lems, poor judgment, and an inability to 
learn from mistakes and, therefore, could be 
a behavioral problem in the rehabilitation 
unit. Lasting an indefinite length of time, 
the third stage is characterized by further 
depression and poor judgment. 

Cocaine abusers may suffer two major types 
of pain, nonmalignant and malignant. Non- 
malignant pain includes mechanical back 
pain, muscular pain, and similar ailments 
and can be treated with medications other 
than opioids (such as aspirin) or with physi- 
cal therapy. Any strong medications, even 
mild narcotics, should be administered with 
caution and for only brief periods of time to 
a substance abuser actively abusing drugs. 
Sufferers from malignant pain, such as that 
due to cancer, should be referred to a pain 
control program for cohesive pain manage- 
ment. Program patients include drug-free 
patients, those on methadone, and active 
abusers. The first two types of patients 
should be treated like patients with no his- 
tory of drug abuse. 

The World Health Organization has an 
analgesic approach to pain control, starting 
with a nonopioid, escalating to mild to 
moderate opioids, and then, if necessary, 
moving to moderate to strong opioids. Clini- 
cians often worry that the administration of 
a medication such as codeine to a non- 
addicted individual will cause addiction, but 
this happens only rarely. However, in the 
substance-abusing patient, there is more of a 
risk of relapse after the administration of 



oft 



Summaries of Research Awareness Seminars 



pain medication. If such a patient is moni- 
tored carefully, however, the dosage of 
opioids can be escalated as necessary with 
few side effects until the pain is controlled. 
Stress could cause relapse, as could aberrant 
drug abuse. An active abuser with malig- 
nant pain presents a problem, and it is 
critical that his/her drug abuse behavior be 
addressed. 

Speaker: Jeffrey Kreutzer, Ph.D. 

Most traumatic brain injuries occur to indi- 
viduals between the ages of 26 and 32. 
About 80 percent of these individuals are 
male, and most of the accidents are alcohol 
related. It is unclear how often cocaine and 
other drugs also are involved. A 1982 Uni- 
versity of Virginia study showed that about 
25 percent of people admitted with traumatic 
brain injuries have two times or more the 
legal limit for intoxication. One study con- 
ducted about 2 years ago demonstrated that 
66 percent of clients in vocational rehabilita- 
tion services at the Medical College of 
Virginia indicated that they were heavy 
alcohol abusers prior to their injury. 

The Level 1 Trauma Center in Richmond, 
Virginia, can serve patients from the first 3 
weeks after admission with intensive care 
treatment, a neurosurgical unit, and reha- 
bilitation. Most patients are discharged 1 to 
3 months after injury and face long-term 
problems, such as depression and unemploy- 
ment. Consequently, most drug problems 
occur after people are discharged from the 
rehabilitation program. Although many 
people with traumatic brain injury abuse 
drugs before and after the injury, it is impor- 
tant to recognize that the abuse may result 
from their sometimes severe depression, 
aggression, and intense frustration. Aggres- 
sion sometimes exists preinjury, but aggres- 
sion often is directly linked to the injury. 
Individuals with traumatic head injuries also 
face family problems, intellectual problems, 
and self-awareness problems. For instance, 
a frontal lobe injury could make someone 
unaware even of his/her substance abuse 
problem. Substance abuse is only 1 of about 
20 to 30 problems that those in the trau- 
matic brain injury field must address. 

Substance abuse workers sometimes work 
with abusers in denial. Similarly, with brain 
injury patients, it is important to convince 
them to stop drinking, since they perceive 
drinking as one of the few pleasures left to 
them. However, alcohol use could exacerbate 



their current problems and lead to additional 
ones. For instance, many clients take medi- 
cations for seizures, depression, and anxiety; 
these types of medications often cause the 
users to become very slow, and alcohol and 
drug use make them slower. Unfortunately, 
some methods used by rehabilitation workers 
to help individuals become more independent 
actually place them at greater risk for sub- 
stance abuse. For instance, a patient who is 
helped to live independently might fall back 
into alcohol abuse more easily while living 
alone than while living with someone in a 
support network. Thus, ongoing assessment 
is very important. Although some people 
criticize self-report questionnaires, they can 
be helpful, along with interviews, in moni- 
toring clients. It is important to monitor 
social, vocational, and academic behavior. 
People with substance abuse problems have 
six times the rate of absenteeism from work, 
and absenteeism is a behavior that can 
facilitate the identification of rehabilitation 
clients with substance abuse problems. 

Based on information from a data base on 
1,000 patients with brain injuries occurring 
over the last 7 years, the only factor found to 
predict people at risk for head injury is 
preinjury alcohol and drug abuse. Some 
theories contend that drinking or drug use 
tends to begin after injury, but most patients 
were abusing substances before injury. 
Clients in substance abuse educational pro- 
grams often become defensive and feel that 
warnings about alcohol and drugs are imper- 
tinent to their rehabilitation program. Such 
individuals are at great risk for substance 
abuse. People whose social events or 
families revolve around alcohol also are at 
great risk, even if they say they do not drink. 

Because many commonalities exist between 
research on substance abuse and brain injury 
and their treatment, substance abuse 
workers should work in rehabilitation pro- 
grams, and rehabilitation workers should 
work more closely with those in the sub- 
stance abuse field when discharging patients. 
For instance, rehabilitation experts should be 
able to refer at-risk clients to accessible 
substance abuse centers. Also, since many 
people with brain injuries experience 
memory problems, more written materials 
should be available to them for reference. 
Furthermore, individuals with brain injury 
may suffer from comprehension problems; 
therefore, these patients should be asked to 
paraphrase information they are given to 
ensure they understand it. Although these 



69 



NIDA Conference Highlights 



individuals need long-term followup and 
support, funding is inadequate since it is 
mostly budgeted for inpatient services. 
Followup is the weakest area in medical 
rehabilitation and perhaps in substance 
abuse rehabilitation. Finally, although 
confrontation may work with persons with 
substance abuse problems, it does not work 
with brain injury patients. 

The medical community is just starting to 
understand the relationship between brain 
injury and substance abuse problems. Sub- 
stance abuse is a common problem in rehabi- 
litation for people with medical problems. 
Now is a critical time for further research 
into this area. 

Speaker: Allen Heinemann, Ph.D. 

The prevalence of alcohol-related problems in 
persons who suffer traumatic spinal cord 
injury (SCI) and permanent physical disabili- 
ties is a compelling issue in physical medi- 
cine and rehabilitation. Alcohol abuse often 
contributes to the onset of disabilities and 
then undermines rehabilitation outcomes. 

The prevalence of intoxication at SCI onset 
has been the subject of many studies. 
O'Donnell reported a two-third rate of use at 
SCI onset, with about the same percent 
resuming drinking during rehabilitation 
hospitalization. Other studies show a range 
varying from 17 to 50 percent. It appears 
that impaired judgment due to alcohol use 
leads to increased risk-taking behavior, 
which in turn leads to injuries. The preva- 
lence of alcohol use following initial care for 
traumatic disability has been reported in 
several recent studies. One study by 
Johnson in Wisconsin found twice the rate of 
heavy drinking in people with SCI under- 
going vocational rehabilitation compared to 
the general population. Another study 
examined the prevalence of intoxication at 
SCI onset in 88 cases at admission to an SCI 
center. Forty-seven of these patients partici- 
pated in an ongoing study of drug use. 
Eighty-five percent of this sample was male, 
and the age range was 14 to 60 years. The 
majority of participants were Caucasian. 
The most frequent cause of injury was road 
and traffic crashes. Findings also indicated 
that greater than 50 mg. per deciliter of 
seromethanol was the most frequent sub- 
stance in 40 percent of the cases, followed by 
cocaine (14 percent), cannabinoids (8 per- 
cent), benzodiazepines (5 percent), and 
opiates (4 percent). In 35 percent of the 



sample, evidence of substances with abuse 
potential was detected. Sixty-two percent 
had either seromethanol greater than 50 mg. 
per deciliter or a urine analysis positive for 
illicit drugs. However, when asked directly, 
only 42 percent reported being intoxicated. 

In examining the substance abuse histories 
of 103 people with recent SCI injuries, it was 
found that, generally, lifetime exposure to 
and recent use of substances with abuse 
potential was greater among this sample 
than in a similar sample of the general popu- 
lation using the National Household Survey 
on Drug Abuse (NHSDA). The SCI sample of 
18- to 25-year-olds had significantly greater 
exposure to amphetamines, marijuana, 
cocaine, and hallucinogens. The SCI group 
of individuals over age 26 reported greater 
exposure to narcotics, analgesics, and tran- 
quilizers than did the national sample. 
Reports of recent substance use in the last 6 
months was significantly greater than the 
NHSDA sample for alcohol, amphetamines, 
marijuana, cocaine, and hallucinogens for 
18- to 25-year-olds and for tobacco, alcohol, 
amphetamines, and marijuana for the older 
group. 

Results suggest that intoxication at the onset 
of SCI is a marker for preinjury substance 
use. Thus, it is important to screen for 
substance abuse in people who incur such an 
injury. While substance use does not neces- 
sarily constitute abuse or result in injuries, 
it is important to understand the context and 
motives for use. 

Researchers also looked at substance use 
over time and at activity patterns during 
inpatient rehabilitation. Patients were asked 
to describe their activities using the Activity 
Patterns Indicator. The frequency and 
quantity of alcohol use was recorded 
separately for weekdays and weekends. A 
family history of alcoholism was reported by 
29 percent of participating patients. Persons 
who reported drinking more often and whose 
drinking resulted in problems before their 
injury were more likely to have been drink- 
ing when the injury occurred. As expected, 
family histories of drinking problems were 
related to many of the reported drinking 
problems. It also was found that persons 
who drank before the injury and reported 
more family drinking problems also reported 
more drinking problems for themselves. 
Also, those with more problems spent less 
time in productive activities, such as reha- 
bilitation therapies. This finding is disturb- 



70 



Summaries of Research Awareness Seminars 



ing, since rehabilitation activities are 
important in helping make the transition out 
of the hospital successful. 

Substance use is a concern even for young, 
able-bodied persons, with peak use occurring 
at times of critical social and vocational 
commitments and often having lifelong 
effects. For SCI persons, who already face 
many barriers, alcohol and drugs can provide 
an immediate and appealing means of grati- 
fication. To try to determine changes in 
drinking patterns before and after injury, a 
followup study was conducted of the data 
reported previously. Over the last 5 years, 
almost 150 people were assessed on 5 occa- 
sions, from immediately after injury to 30 
months after injury. Light, moderate, and 
heavy drinkers — along with abstainers — were 
included in the sample. From before injury 
to 18 months afterward, most abstainers 
remained abstinent, and only a few became 
light drinkers. About one-third of the heavy 
drinkers continued drinking heavily, whereas 
others became moderate drinkers or 
abstained from drinking. The pattern for 
light and moderate drinkers was inter- 
mediate. Thus, spinal injury does not lead to 
a cessation of alcohol or drug problems, but 
such injury causes some users to cut back. 
Following injury, few people begin to have 
drinking problems for the first time. 

In examining psychological outcomes, one 
important aspect of well-being is a sense of 
being valued by and connected to other 
people, quantified as perceived social sup- 
port. Eighteen months after injury, 
abstainers who had histories of having drink- 
ing problems reported low social support 
from friends, whereas drinkers at various 
levels perceived equivalent support from 
their families and varying support from 
friends. These results were unexpected. It 
is important to remember that perceptions of 
support are not the same as actual depth of 
social networks. 

In addition, the study examined the relation- 
ship between changes in employment status, 
substance use, depression, and disability 
acceptance in 100 individuals. Twenty-one 
percent were employed at the same status an 
average of 13 years after injury, while 16 
percent reported increased job status, 23 
percent became employed, 18 percent became 
unemployed, and 22 percent remained 
unemployed. Employed individuals were less 
likely to use drugs. People who were using 
prescription drugs (i.e., for pain) were more 



depressed and less accepting of their dis- 
ability. Although it is difficult to pinpoint 
the cause-and-effect relationship between 
substance abuse and employment, clinicians 
should explore the association, since voca- 
tional outcomes certainly could be effected by 
substance use. 

A prevention program was developed that 
attempts to integrate alcohol and drug abuse 
concerns in injury prevention efforts for 
able-bodied adolescents. National model 
programs, such as Think First and Safe 
Kids, should incorporate these issues even 
more than the programs currently do. Also, 
rehabilitation staff should be trained on 
chemical dependence issues and referral 
sources. A packet of prevention materials 
has been developed that addresses spinal 
injury and brain injury — including chal- 
lenges, risks, and resources — and includes 
articles from the literature. The packet can 
be ordered from the Rehabilitation Institute 
of Chicago (RIC) through Mary Schmidt, 
RIC's substance abuse prevention specialist. 

Questions, Answers, and Comments 

How do staff deal with the problems of 
patients with right-sided cerebral vascular 
accidents with impulsivity and oppositional 
behavior? Often neuropsychologists are 
brought in to do an evaluation and make 
recommendations, such as behavior modifi- 
cation. Each case is treated individually. 

Do patients who want drug and alcohol 
treatment have difficulty with access? The 
cost of medical problems related to cata- 
strophic illnesses contributes to difficulties in 
obtaining funding for more postacute issues. 
Many insurance companies will not pay for 
substance abuse treatment. The two great- 
est obstacles are finances and motivation. 
Although many programs are free, patients 
often do not utilize them. CSAP funds a 
center in Washington, D.C., that is an excel- 
lent resource for prevention materials and 
awareness issues (for information, call 
202/737-2700). 

Often drug abuse treatment centers do not get 
acute rehabilitation patients but are more 
likely to admit people who have been in 
automobile accidents or who have gunshot 
wounds. However, it seems like it could be 
helpful to have guideline questions for clients, 
such as whether they have ever been knocked 
unconscious. What are some of the questions 
that should be asked, and would they be 
helpful? Loss of consciousness, other major 



71 



NIDA Conference Highlights 



trauma, and fractures are obvious areas to 
ask new clients questions about. It is usual- 
ly obvious, even with a general question 
about medical background, if a person has 
suffered a stroke. A review of the literature 
on homicide and assault shows that at least 
50 percent of those involved in such acts 
were drinking. One sees patterns such as 
the husband drinking and beating the wife or 
getting into fights. A clear link exists 
between drinking and all sorts of traumatic 
injuries. When an assault has occurred, 
clinicians should look for substance abuse 
problems and determine whether head 
injuries were incurred. 

RSI 7. Medications in Drug Abuse 
Treatment 

Moderator: Charles Grudzlnskas. Ph.D. 
Speakers: Anna Rose Childress, Ph.D. 

Frank Vocci. Ph.D. 
Respondent: Michael Hayes, M.D. 
July 16, 8:30 a.m.-10:00 a.m. 

Speaker: Charles Grudzinskas, Ph.D. 

NEDA's Medications Development Division 
(MDD) focuses on the three main factors that 
trigger drug abuse-seeking behavior. The 
first is a set of modulating variables, such as 
the pharmacotherapeutic history of an indi- 
vidual as well as his/her genetic and behav- 
ioral makeup. The second focuses on the 
positive effects that will result from drug use 
(i.e., stimulation and relaxation). The third 
consists of cue effects that tempt and cause 
people to crave drugs. These three factors 
are the main components considered when 
attempts are made to produce new 
medications. 

The concept of NIDA's MDD originated with 
Congressman Silvio Conte in 1988, and the 
Division was officially created in 1990. 
MDD's four primary goals are (1) identify 
new medications, (2) evaluate new medica- 
tions, (3) develop new medications, and 
(4) achieve approval for new medications. 
The many groups involved in helping MDD 
to ensure the safety and effectiveness of new 
medications are the FDA, the academic 
community, the Drug Enforcement Admini- 
stration, SAMHSA, and the Office of 
National Drug Control Policy. In order to 
fully ensure the clinical safety and effective- 
ness of a newly developed drug, it must first 
undergo an average of 3 years of clinical 
testing, which generally costs between $20 
million and $30 million. 



The identification and development of new 
medications stem from various sources, 
including natural products, plant extracts, 
ocean extracts, and synthetic chemistry. In 
addition to the identification and develop- 
ment of these various materials, the practice 
of improving existing medications also plays 
an important role in the field of medications 
development. Following long periods of 
animal safety testing, as well as other types 
of testing, new drugs are evaluated in 
human clinical trials. During these trials, 
answers to questions concerning what the 
drug does to the body and what the body 
does with the drug are sought. This is 
known as Phase 1 of medications develop- 
ment. Phase 2 consists of tests aimed at 
determining activity and the proper dose 
levels. Phase 3 is devoted to offering world- 
wide proof of the effectiveness of the medica- 
tion, as well as the positive and negative 
consequences of its use. This final phase is 
directed toward generating sufficient data to 
gain approval from the FDA. 

Nicotine and alcohol abuse are two areas for 
which NIDA's MDD does not try to develop 
treatments. This is due in large part to the 
fact that the pharmaceutical field has been 
assuming this role through the development 
of such products as the nicotine patch, and 
NIAAA has as its mission the research of 
alcoholism and alcohol abuse. Inhalants, 
analgesics, marijuana, and other similarly 
abused drugs also are not cited for medica- 
tions treatment development. The majority 
of the focus throughout the past 2% years 
has been the production of medications that 
would be useful in helping to treat opiate, 
crack-cocaine, and amphetamine abuse 
because these drug abuses are the major 
vector of AIDS transmission among drug 
abusers. 

NIDA's MDD has implemented a cocaine 
treatment drug discovery program that is 
devoted to improving drug abuse treatment 
through the production of the following four 
types of medications: (1) medications that 
would combat or destroy the "high" caused by 
certain drugs (e.g., opiates, crack -cocaine, or 
amphetamines) as soon as they enter a user's 
body; (2) a medication that would act as a 
barrier when the aforementioned 
high-producing drugs attempt to cross the 
user's blood/brain barrier; (3) a medication 
that focuses primarily on the neuro- 
transmitters in the brain, which produce 
dopamine, the agent that causes the feeling 
of euphoria in a user; and (4) a medication 



72 



Summaries of Research Awareness Seminars 



that can get to the root of why an addict 
feels a craving for a certain drug and then 
treat or block that craving accordingly. 

It is imperative that antiaddiction medica- 
tions be used in unison with behavioral 
modification techniques. One without the 
other will not produce a maximum level of 
success. Before deciding what formula (i.e., 
behavioral modification methods and medica- 
tion dosages) to use when treating an addict, 
the addict's level of addiction must first be 
defined. Different combinations of care will 
be applied to users in either a "binge, crash, 
or withdrawal" phase of addiction. 

Betty Tai and Peter Bridge, from NJDA's 
MDD, are working on finding methods of 
accurately determining drug abuse clients' 
backgrounds in order to include those factors 
in treatment. The extent to which a person 
is using drugs is especially important in 
developing the proper treatment approach. 
Dual diagnosis is also a strong factor to 
consider. The discovery that drug abuse 
clients are suffering from more than one 
disorder is becoming more and more com- 
mon. Disorders that are among the more 
frequently diagnosed range from multiple 
drug abuses to various mental problems (e.g., 
depression and schizophrenia). 

Speaker: Anna Rose Childress, Ph.D. 

A large number of substance abuse patients 
attribute their relapse to craving triggered 
by exposure to drug-related cues. Craving 
can occur at any time, whether it is 2 weeks 
or 20 weeks following full detoxification. 
Some common triggers for craving on the 
part of recovering addicts include seeing 
paraphernalia on the street, seeing 
drug-using locations or people with whom 
they used drugs, and receiving money on a 
particular day. It is important to address 
drug-craving in treatment of a recovering 
addict because it can lead to drug-seeking, 
even in well-motivated patients. 

In Dr. Childress' work, craving and arousal 
to cocaine-related cues were recorded in a 
laboratory setting. To simulate real-world 
drug-use situations, the addicts were exposed 
to videotapes of "buying" and "selling" 
cocaine and were asked to handle actual 
paraphernalia, including a white powder 
resembling cocaine. During and following 
exposure to these cues, each addict's reactiv- 
ity was recorded. One commonly observed 
response was that the addict's fingertips 
would become cold, indicating a state of 



arousal. A drop in galvanic skin resistance 
also commonly occurred among the addicts 
who observed these videos and handled the 
paraphernalia. Finally, a rise in the heart- 
beat, which sometimes triggered a sporadic 
change in respiratory functions, often came 
about. Increased cocaine-craving was the 
most commonly observed subjective response 
to cocaine cues, confirming patients' anec- 
dotal reports. 

These studies were conducted to develop a 
set of cues that could be used by personnel 
attempting to measure the problem of 
cocaine cue reactivity. Initial treatment 
studies featuring passive repeated exposure 
to these cues demonstrated a benefit in 
treatment retention and in reduced cocaine 
use, but patients still sometimes experienced 
craving and arousal to cues that could not be 
easily simulated in the lab or clinic. 

To improve this initial approach, patients are 
now taught a number of tools or methods of 
combating the craving urges triggered by 
drug-related cues. These strategies include 
a variety of behavioral techniques, including 
a planned delay before acting on a craving, 
having an alternative behavior planned for 
this delay period, and systematic relaxation 
to counter arousal. Other techniques include 
a recording of positive/negative craving 
consequences, which instructs the recovering 
addict to list the three most negative conse- 
quences that would result if he/she were to 
relapse to cocaine use and the three most 
positive consequences of not acting on crav- 
ing. Negative imagery is used to encourage 
the recovering addicts to remember their 
worst period of addiction. These images then 
can work as a kind of scare tactic. Recover- 
ing addicts can be reminded that, if they 
resume their drug habits, they could very 
easily regress to their worst state of addic- 
tion. Comparatively, positive imagery can be 
used as an incentive to stay off drugs. 
Recovering addicts are asked to describe 
their best times and then continually are 
reminded that those times can continue if 
they remain drug free. Finally, cognitive 
therapy techniques have been designed to 
help recovering addicts analyze the varia- 
tional thoughts ("I can do just a little 
cocaine") that they have during a craving 
episode. A reactivity assessment is done not 
only at the beginning and end of an addict's 
stay, but also in the middle of his/her 
recovery. These reactivity assessments are 
helpful in the area of analyzing brain 
imagery in terms of a patient's brain neuro- 



73 



NIDA Conference Highlights 



chemistry and blood flow patterns, which 
have been known to change during periods of 
drug-craving. 

Cue reactivity techniques have been used in 
two additional ways: (1) to assess the possi- 
ble benefit of anticraving medications (e.g., 
amantadine) and to study the brain cor- 
relates of craving with the use of brain 
imaging techniques, such as PET and SPECT 
scans. The overall goal of this portion of the 
research program is to develop better treat- 
ments for drug craving by understanding its 
brain substates. 

Speaker: Frank Vocci, Ph.D. 

Within the brains of all mammals there is a 
reward system, which is actually a neuro- 
anatomical pathway. This pathway can be 
stimulated electrically to provide pleasure 
within the recipient. The various drugs of 
abuse stimulate this reward system in one 
way or another. This stimulation can be 
cited as one of the main reasons people try 
and continue to use drugs. A shift from the 
emphasizing of the effects of drug use to the 
reasons or conditions leading to drug use is 
occurring within the treatment field. Dif- 
ferent methods of combating the cravings for 
drugs are being developed by the health 
field. One such method is the previously 
mentioned practice of cue extinction, which 
attempts to teach various preventive mea- 
sures that recovering addicts can use when 
tempted by different cues to use drugs. 
Innovations have been made in the area of 
being able to identify and repeat certain 
memory tracks in the brain. The glutamate 
system, which is an excitatory amino acid 
that interacts through glutamate receptors 
(categorized primarily as an NMDA recep- 
tor), plays a very important role in the pro- 
cess of instilling memory tracks within 
recovering addicts. This process of trying to 
fight drug abuse by entering the memory 
system may be a very important step toward 
improving treatment methods. 

The above-mentioned reward system is a 
dopamine-centered system that may be at 
the core of many addicts' drug-abusing prob- 
lems. A drug discovery program at MDD is 
attempting to pinpoint the effects of cocaine 
on a user's dopamine-based reward system. 
This program is using the following behav- 
ioral tests to accomplish this goal: (1) loco- 
motor activity in rodents, (2) cocaine drug 
discrimination, and (3) cocaine self-admini- 
stration in animals. 



Clinical trial-based surveys are being used to 
measure the amount of cocaine-seeking 
behavior being exhibited within the cocaine 
abuse community. These surveys center on 
the level of craving being felt by the recover- 
ing addicts on a day-to-day basis. Urine 
samples also are taken three times per week 
in order to monitor the amounts of cocaine 
being used. It is recommended that partici- 
pants in the clinical trials be seen as often as 
possible in order to raise program retention 
rates. This is very important because high 
numbers of cocaine users tend to drop out of 
their respective programs within the first 
month. Medication development is being 
sought in this area in order to help increase 
retention. 

A program conducted by Dr. John Ball 
helped determine the methadone dosage 
levels needed to effectively treat various 
stages of intravenous drug addiction. While 
many patients are helped with doses in the 
30- to 50-mg. range, Tom Payte and Liz 
Khuri believe that doses of 80 mg. and above 
may be needed to suppress opiate use in 
some individuals. 

An epidemiologic study conducted in Sweden 
looked at a large number of treated and 
untreated heroin addicts. Methadone had a 
strong effect on the mortality rates of this 
group of people. The yearly observed death 
rate, as compared to the number of deaths 
that are expected to occur within any given 
year, was 63 percent higher for untreated 
heroin addicts. This death rate was recorded 
before the AIDS epidemic really hit Sweden. 
The death rate for the methadone-treated 
heroin addicts is sufficiently lower than that 
of the untreated ones. 

Medicinal chemists are hoping to develop 
additional agonist medications that can be 
used in place of methadone to treat opiate 
addiction. The ideal agonist medication 
would be one that performs a function simi- 
lar to that of methadone but is able to last 
longer. Studies on the use of partial agonist 
medications also are being conducted in 
order to test their efficacy in treating opiate 
abusers with low to moderate levels of de- 
pendence. One of the main benefits of using 
partial agonists is that they do not produce 
dependence to the extent that full agonists 
do. 

A number of nonopiate-based medications 
also are being developed in order to treat the 
various withdrawal symptoms experienced by 
recovering addicts. Future medication devel- 



74 



Summaries of Research Awareness Seminars 



RSI 8. 



opments are going to focus on the production 
of medications that interact with the dif- 
ferent opiate systems in order to gain a 
certain amount of therapeutic advantage. 
LAAM is one medication that will hopefully 
be used much the same way as methadone. 
LAAM not only provides the same shield 
from withdrawal symptoms that methadone 
does, but it also takes longer for its effects to 
occur. Once the effects occur, they last for a 
longer time than those of methadone. 
Another positive characteristic of LAAM is 
that its effects take a very long time to 
develop when injected, as opposed to when 
taken orally. This would suggest that LAAM 
someday may be distributed and used as 
take-home doses. 

Questions, Answers, and Comments 

Why does it take so much longer for LAAM to 
take effect when injected as compared to oral 
administration? LAAM is converted into 
more active substances by the liver. When a 
person takes the drug orally, it has to pass 
through the liver. This makes LAAM's oral 
activity occur within hours. When injected it 
takes much longer for a higher level to be 
generated in the liver. 

Comment: Methadone helps to reduce the 
number of drug-related overdoses and the 
number of violent and medical-related 
deaths. 

Comment: It does not seem likely that 
LAAM will ever replace methadone. Instead, 
it is hopeful that in the future there will be 
a number of medicinal agents that physicians 
can choose from based on the needs and 
levels of abuse experienced by their patients. 

The Effectiveness of Methadone 
Maintenance Treatment: Special 
Consideration for Pregnancy 
and the Prevention of HIV 
Infection 

Moderator: James Cooper. M.D. 

Speakers: Lawrence Brown. Jr.. M.D.. M.P.H. 

Karol Kaltenbach. Ph.D. 
Respondent: Frank Satterfleld 
July 17. 8:15 a.m.-9:45 a.m. 

Speaker: Karol Kaltenbach, Ph.D. 

Methadone maintenance has been used for 
narcotic dependent women since the early 
1970s. One benefit of using methadone 
maintenance for pregnant women is that 
high levels of opioid presence in the blood of 



both the mother and fetus can be avoided. 
Another benefit is that lowered cases of 
repeat withdrawal within the fetus are 
experienced. Loretta Pinnegan, creator of 
the Family Center, developed a model on 
comprehensive methadone maintenance 
treatment for pregnant women. This treat- 
ment model is based on the "one-stop 
shopping" theory. The Family Center com- 
prehensive methadone maintenance model, 
which also includes prenatal care, has been 
successful in lowering the number of obste- 
trical and fetal complications, in utero 
growth retardations, and prenatal morbidity 
and mortality rates. 

The overall maternal nutritional practices 
also have improved as a result of this pre- 
natal-included, methadone maintenance 
model. HIV risk also has experienced a 
reduction, due in large part to a lowered rate 
of needle use. Psychosocial rehabilitation, 
which is helpful in the preparation for child- 
birth, is more of a possibility for women 
when participating in the comprehensive 
services provided by the Family Center. 

Pregnant women who abuse drugs are con- 
sidered to be at a higher level of risk as 
compared to other women. This can be 
attributed to the complications that often 
accompany alcohol and other drug use. A 
relatively common occurrence among 
drug-using pregnant women and their 
physicians is mistaking normal pregnancy 
symptoms (e.g., fatigue, headaches, nausea, 
vomiting, cramps, etc.) for actual withdrawal 
symptoms. This type of false diagnosis often 
leads to increased drug use on the part of the 
pregnant woman because she thinks she is 
experiencing withdrawal. This increased use 
has the potential to cause great harm to both 
the mother and the unborn fetus. High 
levels of drug use during pregnancy can 
result in a wide variety of obstetrical and 
medical complications depending on the 
method of administration of the drugs (intra- 
venous or nonintravenous), the amount of 
withdrawal experienced by the mother when 
drug supplies run low, and whether problems 
are identified through the help of prenatal 
care. 

The area that sees the greatest number of 
complications due to a lack of prenatal care 
is obstetrics. Delays in treating commonly 
occurring obstetrical problems often occur 
because some women have the tendency 
either to avoid entering medical facilities 
because the women view these facilities as 



75 



NIDA Conference Highlights 



threatening or deny the actual existence of a 
problem. Infections are the most predomi- 
nant kind of medical complication associated 
with drug use during pregnancy. If an 
infection remains undiscovered throughout 
the entire gestation period of a pregnant 
woman, it can cause serious health damage 
for both the mother and her unborn fetus. 
This is just one of the many reasons for 
getting women into prenatal care programs 
early in their pregnancies. 

In many cases, methadone maintenance is 
not effective enough to be the one and only 
cure-all method for treating drug-abusing 
pregnant women. Instead, many women's 
problems are severe enough that they need 
methadone maintenance programs that are 
paired with both prenatal care and psycho- 
social counseling. With the help of these 
three methods of treatment, medical compli- 
cations gradually will be identified and 
treated earlier in women's pregnancies, thus 
lowering the infant morbidity and mortality 
rates. 

Small doses of methadone given to women 
prior to pregnancy are generally sufficient in 
treating them after they become pregnant, 
although pregnancy alters the metabolism of 
methadone. Opioid-dependent women who 
have not undergone methadone maintenance 
treatment prior to pregnancy should seek 
treatment within a hospital setting. The 
purpose of the hospital stay, which averages 
2 to 3 days, is to evaluate both the woman's 
prenatal status and level of methadone main- 
tenance needed. Initial hospital dosages of 
methadone range between 10 and 20 mg., 
depending on the severity of an individual's 
opioid addiction. A followup assessment of 
the initial dose effectiveness determines 
whether future dosages should be increased 
or decreased. A large number of women 
require a 30- to 40-mg. dose increase as their 
pregnancies advance. The average daily 
dosage for women in this program is 45 mg. 

Federal regulations emphasize that metha- 
done dose distribution needs to be held to the 
lowest effective amounts when treating 
opioid-dependent women (note that the 
Federal regulations specify using the metha- 
done dosages that are the most effective as 
opposed to simply the lowest). The lowest 
and most effective dosages tend to range 
anywhere from 35 to 80 milligrams per day. 
The following four factors should be con- 
sidered when determining the proper dose 
for the patient: (1) duration of patient's 



addiction, (2) duration of patient's methadone 
maintenance treatment, (3) patient's meta- 
bolic rates, and (4) patient's use of certain 
interactive drugs (e.g., anticonvulsive 
medications). 

Withdrawing pregnant women from metha- 
done maintenance for one reason or another 
during the first 14 weeks of gestation is 
discouraged due to the risk of induced abor- 
tion. This also is not recommended after the 
32nd week of pregnancy because fetal stress 
can result. If it is decided to withdraw a 
woman from methadone maintenance it 
should be done only with the consent and 
guidance of a trained and qualified perinatal 
physician. Entering the woman into a peri- 
natal facility where she and her unborn fetus 
can be monitored for dangerous stress levels 
also is strongly urged. 

High rates of neonatal abstinence are seen in 
infants that experience the effects of prenatal 
heroin or methadone use by their mothers. 
Between a 60- and 70-percent rate of neo- 
natal abstinence has been recorded in this 
program for infants whose mothers used 
either heroin or methadone during preg- 
nancy. Neonatal abstinence generally can be 
defined as an infant disorder that promotes 
and causes symptoms that focus on the 
central nervous system. Hyperirritability as 
well as gastrointestinal problems are also 
common among infants suffering from neo- 
natal abstinence. Although these symptoms 
can occur immediately or take many days or 
even weeks, the average length of time for 
all of the symptoms to surface is 72 hours. 
The factors determining the rate and degree 
to which the infants experience abstinence 
are the following: types of substances used 
by the mother, timing of dose before delivery, 
difficulty level in labor, amounts of anes- 
thesia and analgesic used during labor, 
maturity and nutrition of the infant, and 
whether or not any intrinsic diseases are 
detected in the infant. 

The use of an abstinence scoring system, 
such as the one developed by Loretta 
Finnegan, is recommended for the purpose of 
evaluating and assessing the onset, progres- 
sion, and diminution of abstinence symptoms 
in an objective manner. A study conducted 
from 1976 to 1977 by Austria and Madden 
suggested a correlation between the severity 
of withdrawal and the methadone dosage 
levels. However, many other researchers 
and studies do not agree with this belief. 



76 



Summaries of Research Awareness Seminars 



Programs must be comprehensive in nature 
in order to best treat the many problems 
facing the numerous opioid-addicted preg- 
nant women. Some of the issues that must 
be addressed are problems dealing with 
domestic violence, support, the acquisition of 
food, housing, AIDS prevention/counseling, 
and child care. The services provided by the 
treatment programs should place more 
emphasis on ending drug use, building up 
clients' positive options and resources that 
they can turn to in times of need, the 
improvement of relationships (both family 
and interpersonal), and curbing of the ten- 
dency toward negative social behavior. 

Speaker: Lawrence Brown, Jr., M.D., M.P.H. 

It is common for physicians to be skeptical of 
methadone maintenance and to want to 
prescribe the lowest, not the most effective, 
dosages. Physicians are concerned about the 
uncertainties associated with methadone 
maintenance when, in fact, there are similar 
and as many uncertainties in other aspects 
of medicine. The use of controlled clinical 
trials is relatively minimal in all of medicine, 
so methadone maintenance should not be 
singled out for skepticism. 

The idea behind methadone maintenance is 
that if a dose is effective in treating a 
patient, then that patient will not be tempted 
to use any other drugs (or at least no injec- 
tion drugs). In connection with this theory, 
patients hopefully also will be less likely to 
participate in the activities that might lead 
to HIV transmission (e.g., needle-sharing). 

There have been many studies conducted 
that help prove that different drugs of abuse 
have varying effects on the immune system. 
The main problem facing the clinical commu- 
nity is that the effects exhibited vary greatly 
from one patient to another. Clinical studies 
often only focus on control groups when 
collecting their data — but in the world out- 
side the clinic, there is a vast array of prob- 
lems that need to be addressed. 

A recent NIDA-sponsored technical review, 
which was held June 30 through July 1, 
focused on HIV, women, and children. One 
presenter at this conference addressed the 
various social and health factors related to 
HIV infection among women and children. 
This study looked at a number of women in 
New York who were on medicaid and the 
factors influencing their utilization of medi- 
cal services. Among other discoveries, it was 
found that women in this study who were 



treated with methadone maintenance better 
utilized medical services as compared to 
women not treated with methadone main- 
tenance. Therefore, it is possible that one of 
the benefits of methadone maintenance may 
be the greater attention given by health care 
providers to patients. 

Another study by Dr. Ball compared different 
treatment programs in three parts of the 
United States. Patient and provider charac- 
teristics were the primary areas of focus 
within this study. Followup data on patients 
that had been interviewed by the programs 
4 years earlier also were collected. Similar 
to the aforementioned study, this study 
indicated that people thoroughly involved in 
methadone maintenance are less likely to 
become involved in other types of drug use 
(especially intravenous drug use). 

Still another study in New York associated 
HIV infection with duration of drug use, 
duration of drug treatment, and the dosage 
level of methadone. It was found that people 
who receive higher doses of methadone for 
their drug problems actually tended to have 
lower rates of HIV infection. This finding 
would suggest the importance of increased 
methadone maintenance attendance and 
the need for effective methadone dose 
distribution. 

A University of Pennsylvania investigation 
revealed that baseline infection rates were 
noticeably higher for people not already in 
treatment. This is yet another reason for 
stressing the importance of recruiting more 
drug-using people into some type of metha- 
done maintenance treatment facility. This is 
especially true for intravenous drug users, 
who are among the groups at risk of con- 
tracting HIV infection. 

Questions, Answers, and Comments 

Are there any effective methods for providing 
prenatal care at actual methadone main- 
tenance programs that are not hospital 
based? Although it can be done onsite, it is 
quite costly to hire private obstetricians to 
come work at these facilities. The practice of 
combining the services provided by metha- 
done maintenance programs and hospitals is 
not only less costly but also probably just as 
effective as onsite treatment. This is partly 
dependent on the assumption that programs' 
outpatient facilities are nearby. 

Comment: Women that are using methadone 
but no other drugs are encouraged to breast 



77 



NIDA Conference Highlights 



feed their infants — unless, of course, they are 
HIV positive. Despite this encouragement, 
few women actually decide to breast feed. 

Comment: Drug-using pregnant women 
admitted into a hospital for stabilization 
should be treated within the obstetrical unit 
as opposed to the detoxification department. 

Comment: Housing is one of the most impor- 
tant factors keeping women in treatment. 

In regard to the fact that illicit cocaine use is 
a predominant problem within many metha- 
done maintenance programs, is it felt that 
methadone maintenance has any kind of 
positive effect on people who abuse cocaine? 
Yes, some studies show that the number of 
people using cocaine while in methadone 
maintenance programs actually does de- 
crease with time. The reason for this would 
seem to be that, as methadone works to curb 
a client's appetite for opiates, it also may 
work toward lowering that person's want or 
need for cocaine. A number of studies are in 
progress that are attempting to help in the 
production of drugs that might be used 
concurrently to work against both opioid and 
cocaine dependence (e.g., buprenorphine). 

What can be done on the part of treatment 
clinicians to update the country's way of 
looking at drug abuse treatment and the use 
of methadone maintenance? Individual work 
must be applied to each and every com- 
munity by the most experienced clinicians. 
This process will be a very slow one, but it 
has the potential to cause some change 
gradually. 

Is it better to strive for rigidity or flexibility 
when attempting to develop a program's 
policy on positive drug testing? The answer 
to this question relies on both the program's 
philosophy on drug use and the level of 
receptiveness exhibited by the patient toward 
treatment. 

Are there any noteworthy differences in the 
rates of success found through methadone 
replacement or methadone maintenance? 
Very different attitudes surrounding the 
effectiveness of methadone replacement and 
methadone maintenance can be seen, 
depending on what community is examined. 
Effectiveness really depends on the patient — 
what works for one person may not work for 
another. 



RSI 9. Behavioral Treatments for Drug 
Dependence 

Moderator: Lisa Simon Onken. Ph.D. 
Speakers: Kathleen Carroll, Ph.D. 

Stephen Hlgglns. Ph.D. 

G. Alan Marlatt. Ph.D. 
Respondent: Peter Hayden 
July 16.4:30 p.m.-6:00 p.m. 

Speaker: Stephen Higgins, Ph.D. 

Researchers have been studying the Com- 
munity Reinforcement Approach (CRA), an 
outpatient comprehensive behavioral therapy 
used thus far for people suffering from 
cocaine dependence and alcoholism. CRA 
provides effective treatment for both dis- 
orders, either alone or in combination. About 
one-half of individuals dependent on cocaine 
also are dependent on alcohol, and many 
more abuse alcohol. 

In the CRA system, treatment workers do 
the following: detect cocaine use and/or 
abstinence from use through periodic 
urinalysis monitoring; provide positive rein- 
forcement in multiple aspects of an indi- 
vidual's life (e.g., interpersonal, recreational, 
and vocational) to individuals who have 
abstained from cocaine use; withhold rein- 
forcement if it is found that an individual 
has used cocaine; and increase the density of 
reinforcement available to individuals from 
nondrug sources so that, when these indivi- 
duals move beyond treatment, other forms of 
support compete with the reinforcement 
effects of drugs. 

Treatment is delivered through CRA over the 
course of 24 weeks. For the first 12 weeks, 
urinalysis monitoring is conducted three 
times each week, and counseling sessions are 
held twice per week. During the final 12 
weeks of the program, urinalysis testing 
occurs two times each week, and counseling 
sessions are held once per week. After the 
6-month program is completed, clients are 
checked periodically (i.e., for drug use 
through random urinalysis testing and for 
general progress). 

Initially in CRA, it was determined that 
positive reinforcers would be given to 
strengthen individuals' abilities to remain 
abstinent until more naturalistic lifestyle 
changes occurred. Therefore, each time an 
individual has a negative urinalysis test, the 
client receives a voucher. These vouchers, 
which increase in value with every con- 
secutive negative urinalysis test, can be used 



78 



Summaries of Research Awareness Seminars 



to purchase retail items. Thus, clients have 
an incentive not to use cocaine, because if 
they test positive, the value of their vouchers 
returns to the lowest initial value. All pur- 
chases are made through clinic staff. In 
addition, the CRA program provides recipro- 
cal relationship counseling for clients' non- 
abusing spouses, romantic partners, or other 
significant persons, such as close relatives. 
Reciprocal relationship counseling involves 
education in positive communication skills 
and mutual reinforcement of positive 
changes in each person's behavior, with the 
hope that the client will receive meaningful 
rewards from the relationship instead of 
from drugs. A behavioral contract is devel- 
oped in which the significant other asks for 
cocaine abstinence from the client, and the 
client requests that the significant other do 
something positive, such as provide praise, 
as a reward for abstinence. Staff contact the 
significant other after each urinalysis test. 

Another aspect of CRA is functional analysis, 
in which staff teach clients how to identify 
and avoid factors in their environment, such 
as high-risk situations, that increase the 
likelihood that the clients will use cocaine. 
This approach also encourages clients to 
recognize and spend more time in low-risk 
situations and to obtain the "benefits" they 
derived from cocaine from other, more posi- 
tive sources. Priority also is given to further- 
ing clients' educations or helping them obtain 
jobs. Furthermore, clients are encouraged to 
engage in drug-free recreational and social 
activities without their drug-abusing friends. 
Additionally, the clinic conducts monitored 
antabuse therapy for clients who are 
alcohol-dependent or drink abusively. Some 
research studies indicate that if individuals 
who abuse both alcohol and cocaine are able 
to abstain from alcohol, reduction in cocaine 
use also is likely to occur. 

Research findings based on studies of CRA 
indicate that the approach has been effective. 
In one study involving clients randomly 
assigned either to the CRA clinic or to stan- 
dard outpatient treatment, 68 percent of the 
clients receiving the CRA behavioral treat- 
ment completed the entire program, whereas 
only 11 percent in standard outpatient treat- 
ment remained until completion. While 
about 60 percent of clients in each group 
initially tested negative for cocaine in a 
single week, that percentage increased in the 
CRA group and decreased in the standard 
group. Furthermore, the positive effect of 
the vouchers lasted even after they were 



removed as an incentive after week 12 of the 
CRA treatment. 

In another study, some clients were 
randomly assigned to receive the entire 
behavioral treatment, including the vouchers, 
while others received the treatment protocol 
without the vouchers. (After the 13th week, 
the vouchers were no longer offered; hence, 
all clients were treated the same at that 
point.) Seventy-five percent of the clients 
who received vouchers completed the CRA 
program, while only 42 percent of the clients 
not rewarded under the voucher system 
completed the program. Only 11 percent of 
the clients receiving standard outpatient 
treatment completed the program. Addi- 
tionally, about 60 percent of the clients who 
received vouchers were able to abstain from 
cocaine use for at least 8 of the 24 weeks 
during treatment, whereas only 25 percent in 
the group not receiving vouchers abstained 
from cocaine use for at least 8 weeks. 

These findings indicate that several elements 
of CRA, not just the voucher system, are 
effective in cocaine abuse treatment. CRA 
therapy both with and without vouchers is 
more effective than standard outpatient 
treatment. Thus, the use of a systematic 
incentive program involving social support, 
education about drug-free recreation, voca- 
tional support, and monitored antabuse 
therapy appears to be very helpful in initiat- 
ing drug abstinence. 

Speaker: Kathleen Carroll, Ph.D. 

Relapse prevention is a type of 
cognitive-behavioral therapy that helps 
individuals identify and cope with high-risk 
situations. Different relapse prevention 
approaches have been developed for various 
types of drug abusers and alcoholics. One 
approach to relapse prevention for cocaine 
abusers involves an individualized, 12- to 
16-week outpatient treatment program 
focused primarily on achieving abstinence 
and preventing relapse by both teaching 
productive coping strategies and determining 
how to reduce exposure to cocaine and 
cocaine cues. Early in treatment, it is very 
difficult for clients to tolerate even the sight 
of cocaine or cocaine users, but later they are 
helped to cope with these and other difficult 
situations. One way in which this is done is 
by initially reducing the patients' access to 
money (e.g., by having close relatives or 
significant others at least temporarily control 
the clients' finances until the clients are 



79 



NIDA Conference Highlights 



more stable), since many cocaine users 
associate money with drugs. The relapse 
prevention program also works on strategies 
to foster personal motivation to stop using 
cocaine (e.g., by encouraging clients to list on 
a card the benefits of abstaining from cocaine 
use). Self-monitoring of cravings and of 
high-risk situations also is very important 
among cocaine abusers. Therapists spend a 
large amount of time addressing their clients' 
cocaine cravings, from determining exactly 
how clients crave cocaine to helping them 
cope with cocaine cues. 

The therapy consists of three main sets of 
treatment strategies. The first strategy 
focuses on clients' behavioral patterns, the 
second strategy concerns identifying cogni- 
tive processes that lead clients toward 
high-risk situations and encouraging clients 
to think carefully through such things as 
preparation for emergencies, and the third 
strategy focuses on developing behavioral 
alternatives to cocaine use (e.g., pursuing 
meaningful activities and building worth- 
while relationships). Staff use a homework 
sheet for each treatment session, covering 
the session topic and practice exercises to 
help clients master the skills needed to 
abstain from cocaine use. 

One study examining this relapse prevention 
approach focused on inner-city cocaine 
addicts at a cocaine clinic that already had 
been using short-term interpersonal psycho- 
therapy (IPT). The study consisted of a 
12-week randomized clinical trial comparing 
individualized relapse prevention with IPT. 
The study found that individuals treated 
with relapse prevention tended to stay in 
treatment almost twice as long as those 
treated with IPT. People treated with 
relapse prevention consistently did better 
than those undergoing IPT, with nearly 
double the rates of abstinence. In comparing 
clients' initial levels of substance use, the 
two treatments had approximately equal 
effects at low levels of severity; however, at 
high levels of severity, individuals receiving 
IPT did not have positive outcomes, whereas 
those receiving relapse prevention services 
did well. Apparently the additional structure 
and skills obtained in relapse prevention 
services are very helpful to individuals with 
high rates of cocaine use. 

Another recently completed study examined 
treatment results of cocaine abusers treated 
with relapse prevention and those treated 
with a relatively new drug for cocaine abuse 



called desipramine. Both groups received 
psychotherapy, either through relapse pre- 
vention or, less intensively, through clinical 
management. The outcome of the study 
indicated no substantial differences in the 
treatment approaches: Clients in both treat- 
ment groups improved in terms of their 
psychological well-being and decreased 
cocaine use. However, when looking at the 
baseline severity of clients' cocaine use, 
clinical management produced more positive 
effects at low severity levels, whereas relapse 
prevention appeared to be the most beneficial 
treatment at high severity levels. Also, at 
high levels of depression, only relapse pre- 
vention was shown to help decrease cocaine 
use and improve other conditions among 
clients. A followup study of clients at 1, 3, 6, 
and 12 months after treatment showed a 
higher level of success among those clients 
treated with relapse prevention. Relapse 
prevention seems to teach people skills that 
they can apply to other parts of their lives. 

Speaker: G. Alan Marlatt, Ph.D. 

NIAAA has been engaged in research on a 
secondary approach to the prevention of 
binge drinking (i.e., five or more drinks per 
occasion) among young adults. This is a very 
important concern, since alcohol-related 
death is the leading cause of death among 
this population. The approach discussed in 
this session primarily concerns alcohol abuse 
(repeated use of alcohol in hazardous situ- 
ations for 1 or more months), rather than 
actual alcoholism, and is similar to the 
approach known in Europe as harm reduc- 
tion (in England it is referred to as harm 
minimization). The approach is designed to 
reduce the harm of ongoing drug or alcohol 
activities, based on a continuum model of 
harm presented by the Institute of Medicine 
in 1990. The Institute noted that, while 
many programs existed for alcohol depend- 
ence, the much larger number of people with 
mild to moderate alcohol problems might 
respond to brief interventions designed to 
reduce the risk of drinking. 

Former Surgeon General Antonia Novello 
proclaimed binge drinking to be a major 
health problem because of its association 
with accidents, aggression, date rape, vandal- 
ism, and other problems. Binge drinking 
usually involves drinking to the point of 
intoxication. Research suggests that many 
young adults will not continue binge drink- 
ing as they grow older, but studies are being 
conducted on the relationship between binge 



80 



Summaries of Research Awareness Seminars 



drinking and subsequent dependence. While 
research indicates that males seem to drink 
more than females, additional studies are 
investigating such factors as family history; 
genetic disposition; early adolescent behav- 
ioral disorders; and living environment, such 
as fraternity houses for students. 

Although abstinence is the goal for young 
adults, it may be unrealistic. The harm 
reduction model provides a middle-road 
alternative by suggesting that people can 
make small changes in their knowledge, 
awareness, and skills and reduce their level 
of alcohol abuse. An NIAAA 5-year study 
known as Lifestyle '94 focuses on students 
first assessed in high school who are 
expected to graduate from college in 1994. 
The entire population of the University of 
Washington's freshman class (4,250 students) 
was administered a screening questionnaire 
assessing their level of drinking in high 
school and a number of risk factors. Of the 
2,152 students who completed the question- 
naire, 450 (about one-half males and one-half 
females) were selected based on a high risk 
for alcohol problems. Fifteen percent of 
these people reported that either their 
father, mother, or both parents had drinking 
problems. Forty -five percent also reported a 
history of conduct disorder. The 450 stu- 
dents were randomly assigned to a treatment 
group or to a nontreatment control group. 
Also, 150 people were randomly chosen from 
the freshman class, regardless of level of 
risk, for a natural history control group. 

The group chosen to receive treatment 
received a stepped-care series of interven- 
tions patterned on the treatment of border- 
line hypertension. The series began with the 
most minimal treatment that might work, 
which in this study consisted of motivational 
interviewing. In a nonconfrontatdonal man- 
ner, a staff member reviewed students' 
drinking rates, risk factors, and potential 
problems. The majority of the students were 
"precontem platers" — they did not think that 
their binge drinking was problematic. There- 
fore, the staff encouraged the students to 
enter a contemplation stage, in which they 
would think more carefully about their 
drinking behaviors, followed by an action 
stage, in which the students would follow 
specific advice about altering their drinking 
patterns. Students who already had been 
determined to be alcohol dependent (about 15 
students) skipped the stepped care but were 
provided with individual counseling and 
referrals. Research staff followed the 450 



students every 6 months. The stepped-care 
options were continued for students who did 
not respond as well as the majority to the 
initial step; these students moved to other 
options, such as a self-help manual or 
participation in a group educational class. 
The control group also was assessed every 
6 months. 

Two years after the motivational interviews 
and stepped-care interventions were con- 
ducted, research results indicated that the 
control groups showed improvements consis- 
tent with normal maturation, whereas a 
quicker response rate occurred among indi- 
viduals receiving the secondary prevention 
program. Furthermore, the treatment group 
showed more significant improvements in 
alcohol-related problems than did the control 
group. The study currently is examining 
many other variables, but data are not yet 
available. 

The method employed in this study is consis- 
tent with the harm reduction approach. The 
goal or precondition of abstinence may pre- 
sent a barrier to many young people seeking 
some kind of help; consequently, the harm 
reduction approach may bring down this 
barrier by suggesting that gradual changes, 
with abstinence as the ideal but not manda- 
tory goal, are beneficial. As a continuum 
model, this approach progresses from excess 
through moderation to, ideally, abstinence. 
Any steps toward decreased risks are steps 
in the right direction. 

Questions, Answers, and Comments 

In recognizing that abstinence is not a reali- 
stic goal for a 14-year-old who has been using 
alcohol, how can the harm reduction method 
be sold, particularly in States in which 
methods like Alcoholics Anonymous are well 
regarded? Abstinence still is the best goal 
for the treatment of dependence; however, 
because alcohol is the most widely used 
substance among young people, safe use may 
be a more realistic goal. One can talk about 
both goals and recognize both as acceptable. 
The main opposition has come from parent 
groups, who think that the harm reduction 
method has encouraged underage drinking. 
Young people are going to drink; therefore, 
the challenge is to encourage them to do it 
more safely. 

In terms of prevention, has the impact of 
alcohol advertisement on young people been 
studied? In the NIAAA study, students 
discussed the manipulative methods of 



81 



NIDA Conference Highlights 



RS20. 



advertisements. Such discourse should be 
part of any prevention program. 

In addition to engaging clients' significant 
others, does the CRA program incorporate 
into its treatment other community members, 
such as church groups? The CRA program 
does not do that, but it is a good idea if done 
in a systematic way, especially in large 
urban areas. 

In examining the success rates of participants 
in the individualized relapse prevention 
treatment, was the significance of partici- 
pants' educational levels studied? Yes, but 
education was not found to predict a client's 
success or lack of success. Other studies 
have found a connection however. The most 
predictive factor of success during followup 
was whether the client had attained a 
substantial period of abstinence during 
treatment. 

Can group incentives and small fines for 
drug use be used effectively in drug treat- 
ment, with participants deciding together 
how the fund from fines should be used? In 
research with children, group contingencies 
have been shown to be effective, but no such 
work has occurred in the area of illicit drug 
abuse. It may be more helpful to use more 
positive reinforcement than imposing fines. 
Clients feel very good about success and even 
small measures of recognition of success. On 
average, the voucher system used in the 
CRA program has cost about $3 per day in 
incentives. 

Residential Treatment, Day 
Treatment, and Therapeutic 
Communities 

Moderator: George DeLeon. Ph.D. 
Speakers: Benjamin Lewis. Ph.D. 

Jerome Piatt. Ph.D. 
Respondent: Lynn Nicholson 
July 17. 1 1:15 a.m.-12:45 p.m. 

Speaker: Benjamin Lewis, Ph.D. 

For a treatment program to be successful, it 
needs to address some or all of the following: 
behavioral risk, depression, self-esteem, 
self-efficacy, client satisfaction, motivational 
scales, and instruments such as the Addic- 
tion Severity Index and the Diagnostic Inter- 
view Schedule. A recent study on the effec- 
tiveness of increased treatment duration was 
based on information obtained from 710 
participants. The participants were asked to 
undergo a 15-month program with followup 



at 3 months postdischarge, 12 months post- 
admission, and at periodic times thereafter. 
The main purpose for conducting the study 
was to examine treatment duration as well 
as the differences across programs between 
relapse prevention and therapeutic com- 
munity approaches and how they impact on 
HIV risk reduction. The study includes 
process evaluation. 

One important facet needed for success in 
both treatment strata was the rate of reten- 
tion over given periods of time. The smallest 
time period measured — after 14 days — 
yielded the highest retention rate at 82 
percent. The retention rate after 30 days 
was 80 percent. After 40 days the retention 
rate dropped to 74 percent. And after 80 
days the retention rate had fallen to a low of 
33 percent. The completion rates were equal 
for both the participants that were retained 
in treatment for 30 days and those that 
stayed for 80 days. Receptiveness to the 
particular program modalities was very high. 
An average of 94 percent of the clients were 
willing to participate in the program without 
changing anything about it. 

With regard to the followup meetings, focus 
groups were implemented to provide clients 
with an opportunity to voice their feelings 
concerning what they were and were not 
comfortable with answering. Constant jug- 
gling of the followup schedule proved that 
off-hour meeting times were the most suc- 
cessful in attracting attendees. In-jail inter- 
viewing also took place for those incarcerated 
clients. These interviews were identical to 
those performed in the treatment facilities, 
with the exception of hair analysis testing, 
which was not permitted due to scissor 
regulations in the jail. These aforementioned 
techniques have led to an increase in overall 
followup rates. There are two main reasons 
for the recent upsurge in the use of hair ana- 
lysis testing. The first is that hair analysis 
testing can be used as a method of vali dating 
self-reports. The second reason is that hair 
analysis testing makes the detection of drug 
use over a long period of time feasible. 

Speaker: Jerome Piatt, Ph.D. 
It is not widely known that cocaine addiction 
and problems stemming from its use have 
surpassed heroin addiction and its problems. 
Despite this high rate of addiction, there are 
very few treatments available that are cap- 
able of effectively dissuading addicts from 
discontinuing their use. In attempting to 



82 



Summaries of Research Awareness Seminars 



create a program that stimulated the highest 
degree of positive outcomes within groups of 
cocaine users, the following four treatment 
components were considered: (1) cognitive, 
(2) cognitive-behavioral, (3) skills training, 
and (4) pharmacological interventions. 

In the early 1950s, Dr. Zwirling and his 
associates found psychiatric day treatment to 
be more effective than both traditional 
inpatient and outpatient treatments. Almost 
every study and program using psychiatric 
day treatment has experienced success. 
These successful programs generally are 
nonmedically based, run by the government 
(State or county), incorporate a social reha- 
bilitation model, do not have overnight treat- 
ment, have an abundance of coordinated and 
comprehensive forms of treatment, and 
involve clients' significant others in 
treatment. 

Cocaine users tend to be highly disruptive, 
possess a general lack of competency and 
skills, and devote a large portion of their 
lives to searching for drugs. The main key to 
treating these disturbed individuals suc- 
cessfully is by gaining a certain degree of 
control over their lives and constructively 
filling their time. Psychiatric day treatment 
provides an environment that focuses on 
making more time available for treatment. 
It also works toward generally improving the 
clients' lives through the teaching of every- 
day positive reinforcement tools. These 
programs are not passive and are based on 
active intervention methods that address the 
various clients' needs. One imperative 
aspect to the success of any such program is 
regular client attendance. Relapse into drug 
use commonly is known to occur when a 
person has too much leisure time. Regular 
attendance at treatment programs is an easy 
way to avoid this problem. 

The main question that all studies should 
seek to answer is whether contingency 
management, employment of skilled treat- 
ment workers, and increased amounts of 
time spent in treatment actually lead to 
improved outcomes and retention rates. 

A 12-week intervention outpatient program 
is under way. The first 3 weeks of the pro- 
gram consist of three weekly V/2- to 2-hour 
meetings. The next 6 weeks follow a 
two-meeting-per-week schedule for approxi- 
mately the same amount of time. The last 3 
weeks include one meeting per week, which 
primarily focuses on gathering followup 
information. Those clients who remain in 



treatment and hold positive employment 
positions tend to have the lowest rate of 
cocaine relapse. One important goal of this 
program is to instill a number of positive 
skills — interpersonal, employment, relapse 
prevention, and mental — in the clients to 
help them reduce the environmental tempta- 
tions that often fuel their inner cravings for 
drugs. One odd finding is that depression 
has been discovered to be a beneficial charac- 
teristic in helping keep clients in treatment. 
This is assuming that the depression is both 
detected and properly dealt with. High 
anxiety, on the other hand, has been found to 
be a barrier to treatment retention. If a 
person feels pressure or discomfort, he/she 
probably will not remain in that treatment 
environment. The study also found that 
people are more likely to show up at their 
initial meeting when their appointment is as 
close as possible to their telephone contact. 
The less time people have to wait before 
coming into the treatment facility, the better 
the chance is that they will attend. 

Speaker: George De Leon, Ph.D. 
The sense of community, as opposed to the 
actual services offered, is the distinguishing 
trait when applying the "therapeutic model" 
to different populations. The use of "com- 
munity" is one of the most effective tools 
with which to change the negative behaviors 
illustrated by many drug users. Community 
can be exhibited in a number of different 
ways. For example, heightening the roles of 
the participants in the programs and show- 
ing an intense interest in membership feed- 
back can have very beneficial effects. The 
presence of role models within the suggested 
program groups (e.g., eating, working, meet- 
ing, etc.) has propagated the use of positive, 
shared values among the clients. The 
above-mentioned program groups need to be 
structurally based systems that allow for the 
use of open communication, which then can 
be used for sharing ideas and strengthening 
positive relationships. The primary goal of 
any treatment program should be to train 
clients regarding the necessary skills that 
will allow them to make a successful transi- 
tion to a drug-free, productive lifestyle. 

The following items, as well as the previously 
mentioned keys to success, should be incor- 
porated into every therapeutic community 
program/model that wishes to be thoroughly 
effective: peer encounter groups, work (used 
as a therapeutic and educational tool), 
structured days, recovery and value 



83 



NIDA Conference Highlights 



strengthening, development and learning in 
stages, awareness training, emotional 
growth, and emphasis on individualism and 
separateness outside the treatment facility. 

There are three main issues that need to be 
addressed by practitioners if further 
advances are to be made in the area of treat- 
ment. The first is to have a better under- 
standing of the differences that exist between 
clients. Secondly, better client-to-treatment 
matching is needed. Finally, more care 
needs to be placed on the practitioners' 
decisions to send clients on to the next level 
of treatment. Some clients do not advance as 
quickly as others, and therefore these people 
may need to undergo longer durations of 
treatment at lower intensity levels than their 
faster advancing counterparts. 

Questions, Answers, and Comments 

What percentage of the people that claim they 
have not been using drugs come up positive 
for drug use through hair analysis testing? 
Cocaine users, who claimed to have been 
presently using, generally were backed up by 
their hair analyses testing. 

Comment: The relapse prevention program 
generally tries to identify and teach methods 
of avoiding situations that may lead to drug 
relapse on the part of the clients. 

Why does Dr. Lewis' 710-client program have 
higher rates of retention as compared to the 
average program? That particular study only 
deals with heroin users, while most similar 
studies tend to incorporate dually diagnosed 
and polydrug-abusing clients into treatment. 
The overall followup rates for these types of 
programs range from 85 to 93 percent and 
are rising all the time. 

Do recruitment and retention rates experience 
any ill effects due to the gradual increase of 
demands placed on the clients? The longer 
clients seem to stay in treatment, the better 
they are able to meet the increasing 
demands put on them. The reason for this is 
that they gradually build the arsenal of 
weapons needed to combat or meet these 
demands. Assuming that the demands 
placed on clients are only increased in con- 
junction with teaching or providing the 
resources needed to meet those demands, 
then the recruitment and retention rates 
really are not affected. 

Comment: The three components of standard 
treatment — mental health, alcoholism, and 
drug abuse — are listed by descending order 



according to the amount of programs offered 
nationwide. Drug abuse treatment, although 
presently at the bottom of the list, slowly 
seems to be gaining attention and the needed 
State and Federal funding. 

RS21. Adolescent Diagnostic 
Assessment 

Moderator: Elizabeth Rahdert. Ph.D. 
Speakers: David Metzger. Ph.D. 

Kenneth Winters. Ph.D. 
Respondent: M. Yolanda Nolan. M.S.W. 
July 16. 1:15 p.m.-2:45 p.m. 

Speaker: Elizabeth Rahdert. Ph.D. 

In examining and purchasing screening and 
diagnostic instruments for use in practice, 
research, and program evaluation, consumers 
should look for several important character- 
istics. Screening tools determine the pres- 
ence or absence of a specific problem and 
should be easy to administer, answer, score, 
and interpret. Diagnostic instruments 
describe in detail an individual's problem; 
usually require a professional for admini- 
stration, scoring, and interpretation as well 
as an adequate amount of time to conduct; 
and demand complex responses from clients. 
A consumer's list of diagnostic and screening 
tools was reviewed along with a checklist of 
characteristics for use in examining each 
clinical tool: utility, objectivity, reliability, 
validity, objectivity, cultural sensitivity, 
cost-efficiency, and of course the fact of 
whether or not the particular instrument 
was designed specifically for use with 
adolescents. 

Speaker: David Metzger, Ph.D. 

The Problem Severity Index (PSI) was devel- 
oped for use with adolescents involved in the 
juvenile justice system. A later modified 
version, the Adolescent Problem Severity 
Index (APSI), was developed for use in non- 
criminal justice settings. The APSI is an 
indepth assessment tool that employs an 
interview format to help nonclinicians deter- 
mine the areas of functioning in which an 
adolescent is having problems and whether 
the problems are related to substance abuse. 

A growing number of tools are available to 
assess adolescents and their substance use, 
and consumers should review these tools 
very carefully before purchasing them. Some 
instruments are simple and may be com- 
pleted by pencil after careful instruction, 
while others involve personal interviews, so 



84 



Summaries of Research Awareness Seminars 



programs must consider whether staff have 
the time and capability to administer a test 
that they are considering using. Many tools 
are modeled after adult assessment tools 
(i.e., several closely approximate the Addic- 
tion Severity Index), so programs also should 
consider whether they want instruments that 
are more specifically developed for adoles- 
cents. Furthermore, it is important to 
understand the obstacles that may arise in 
administering tests to adolescents (e.g., they 
may be very reluctant to be assessed; those 
with normal, developmental limitations may 
have difficulty expressing their thoughts 
clearly; or those with abnormal developmen- 
tal problems may not respond appropriately 
to questions). Thus, adolescents often may 
need assistance clarifying their thoughts and 
responses. Finally, language and cultural 
barriers make assessment especially chal- 
lenging with adolescents, who often describe 
drugs or situations using terminology that 
varies with age or geographical location. 

About 5 years ago, researchers at the Uni- 
versity of Pennsylvania began developing the 
PSI and APSI with the aim of having a 
diagnostic tool that would feed directly into 
a treatment planning process by giving 
interviewers a clear idea of appropriate 
interventions. It was thought that adoles- 
cents should not be categorized by severity 
ratings without suggestions for interventions, 
line staff without sophisticated clinical 
work, such as probation officers and person- 
nel in noncriminal justice settings, also 
needed to be able to complete the instru- 
ment. The instrument was developed as 
interview-based to gather detailed infor- 
mation, challenge inconsistencies in 
responses, and enable the interviewer to 
assess a respondent's honesty. It initially 
was hoped that the tool would determine 
with 20 simple questions the severity of 
adolescents' substance use problems, but the 
instrument's developers gradually realized 
that a more indepth approach was needed to 
assess other issues and areas of functioning 
besides actual substance use. Furthermore, 
a structured tool was desired that could be 
applied consistently, yield objective meas- 
ures, and produce automated administrative 
and clinical reports. 

The three main components for the APSI's 
administration process include the interview 
format, a manual, and software that pro- 
duces a data base with automated reporting 
features. The test contains questions about 
the adolescent's involvement with the juve- 



nile court system and police, the stability of 
the family situation, school attendance and 
performance, work history, personal skills, 
medical history, indicators of emotional 
distress, use of specific substances, high-risk 
sexual behaviors, and history of physical and 
sexual abuse. Parents usually are not pre- 
sent during the last two sections of the 
interview. Each section on the ASPI 
generates two types of quantitative scores: 
(1) a mathematical compilation of the num- 
ber of different risk factors in that section 
and (2) an intervention severity rating, 
which is the most important information on 
a day-to-day basis. The interviewer decides, 
based on items in the sections, whether and 
how urgently any particular intervention is 
warranted. Thus, interviewers are required 
to process the information that they hear and 
make assessments of the need for further 
intervention. 

It appears that the instrument has been 
successful on several levels. Feedback has 
been positive and helpful for future revisions. 
Sixty-seven counties throughout Pennsyl- 
vania currently use the instrument. 
Responses to the instruments' questions have 
been found to correlate with other measures 
of adolescents' behavior. Some preliminary 
data are available. 

Speaker: Kenneth Winters, Ph.D. 

Assessment can be difficult and perhaps lead 
to the wrong conclusions if conducted with 
preconceived perceptions and assumptions. 
Standardized tools improve objectivity in 
assessment. Since 1985 the number of tools 
available in the adolescent drug assessment 
field has increased dramatically; however, 
having so many assessment tools available is 
confusing. Several recently completed large 
scale reviews critically evaluated available 
adolescent assessment instruments concern- 
ing factors such as ease of administration, 
cost, and content. When consumers are 
investigating an instrument, they should 
consider whether it actually predicts what 
they as clinicians want to predict and 
whether it will produce data related to clini- 
cal decisions that must be made. Also, they 
should check on the adequacy and appro- 
priateness of the norms. Furthermore, 
computerized data based on group statistics, 
while valuable, should be used with caution 
and not automatically assumed to be more 
valid than subjective, clinical intuitions and 



85 



NIDA Conference Highlights 



evidence. Standardized assessment is not 
always best for every client. 

The Minnesota Chemical Dependence Adoles- 
cent Assessment Package has developed 
three instruments: (1) the Personal Experi- 
ence Screening Questionnaire (PESQ), (2) the 
Personal Experience Inventory (PEI), and 
(3) the Adolescent Diagnostic Interview 
(ADI). They were designed to be user 
friendly and helpful for clinicians — not neces- 
sarily for researchers; however, research 
versions are available. Most of the tools 
were developed with the philosophy that no 
matter what drug a client uses, the dimen- 
sions and form of treatment are relatively 
similar (a notion subject to much debate). 

Only the PESQ is used at the screening 
level. Both the PEI and the ADI assist with 
problem identification and description, treat- 
ment planning, and case management. The 
former is a paper and pencil instrument, 
while the latter two use structured interview 
formats. The PESQ includes 40 items, cover- 
ing drug abuse problem severity, frequency 
and onset, physical and sexual abuse, and 
other areas. It attempts to measure invalid 
response tendencies, too. It costs about $1 
per test and can be scored easily and 
immediately. The ADI is based on the 
DSM-III-R (Diagnostic and Statistics 
Manual, revised third edition), and appears 
to correspond also to the DSM-P7 (Diagnostic 
and Statistics Manual, fourth edition). It 
usually takes about 1 hour to complete, and 
it assesses the criteria for substance abuse 
disorders and psychosocial functioning. The 
ADI includes screens for eight psychiatric 
disorders. The instrument costs about $6 
and must be scored by hand. 

The PEI, a very expensive and good instru- 
ment, includes a detailed computerized 
report and 33 scale scores, with both drug 
clinic- and school-normed scores. Ten scales 
relate directly to problem severity, centering 
on adolescents' behavioral and psychological 
involvement with drugs. Five scales meas- 
ure "good and bad faking" tendencies; the 
former includes defensiveness and denial of 
problems, and the latter includes exaggera- 
tion of symptoms, which occurs fairly often 
among juvenile criminal justice clients. The 
test may be administered by paper and 
pencil or by computer, and it can be scored 
either directly on the administrator's per- 
sonal computer or by sending the test to 
California via mail or FAX for scoring at a 
cost of $9 to $10 per test. The test does not 



measure factors such as quantity of illicit 
drug use, coexisting mental disorders, and 
tobacco use. The PESQ and PEI have been 
tested in diverse settings, including with 
non-Caucasian samples, but the relatively 
new ADI has not been validated as much as 
the other two. Research staff are in the 
process of comparing the publisher's norms 
with recent data and will revise norms as 
needed. 

Results from one of the PEI scales indicated 
that teenagers go through five stages as they 
become addicted, starting with social use and 
progressing to use due to psychological bene- 
fit. When youth reached this latter stage, 
the rate of diagnosis and referral to treat- 
ment increased. The final stages involve 
physiological signs of addiction and loss of 
control, at which point the base rate for 
receiving treatment referral recommendation 
was in the 90th percentile. Most adolescents 
at this stage received diagnoses of depend- 
ence. This progression is similar to the 
adult stages of alcoholism. 

Predictive validity is an important factor in 
evaluating tests. The PESQ is used to pre- 
dict adolescents' need for further assessment. 
The comparison of PESQ results with 
independent ratings of the need for further 
assessment revealed a hit rate of 87 percent. 
Hit rates typically should be in the 80th- or 
90th-percentile range. If a measure's hit 
rate does not reach the 90th percentile, 
programs should be careful not to overrely on 
the test. The ADI was found to have signifi- 
cant predictive validity in diagnosing alcohol 
abuse. And the PEI, which was designed to 
predict adolescents' need for chemical de- 
pendency treatment, made the same assess- 
ment as an individual clinician 85 percent of 
the time. The test had a hit rate of 81 per- 
cent in assessing whether clients needed 
intensive inpatient or outpatient services. 

The reliability of the PEI across ethnic 
groups is holding up well. Other validity 
tests, though, still are necessary to further 
validate norms, which were based largely on 
Caucasian samples. Revisions in language 
and content, for example, may be needed in 
order to make the instrument appropriate for 
diverse groups. 

Research staff are planning on conducting 
expanded validity and content analyses for 
ethnically diverse samples and on field-test- 
ing non-English versions. They also are 
examining the ADI in terms of DSM-rV and 



86 



Summaries of Research Awareness Seminars 



are developing parent versions and scales to 
supplement the existing PEL 

Questions, Answers, and Comments 

Despite the availability of many adolescent 
assessment instruments, several problematic 
issues need to be addressed. For instance, 
computerized inventories sometimes are not 
effective for a variety of reasons. Many chil- 
dren play with the computer and do not 
answer the questions seriously, thus the test 
responses are not valid. Also, many children 
cannot read or understand the questions, or 
they have learning differences and difficul- 
ties. Assessment tools do not appear to 
address learning problems despite the fact 
that there seems to be a strong correlation 
between such difficulties and severe substance 
abuse problems. In addition, many children 
in inner-city programs do not follow the 
stages described by Dr. Metzger (i.e., they are 
introduced to drugs after they start selling 
them, not via a social entrance). Finally, 
assessments do not seem to be very useful 
without family input, separately and with the 
adolescents, to screen out exaggerated re- 
sponses and supplement other information. 
How can these many issues be addressed 
further 1 ? Although self-report tests are easy 
to administer and score, many problems (e.g., 
children's reading levels) do remain. Some 
questions may be read aloud, but if children 
have been screened for their reading level 
and have demonstrated difficulty under- 
standing an instrument, it should not be 
used. Assessments via interviews may be 
more successful. The computer tests appear 
to have been successful overall, but the 
barriers presented by children not using 
them correctly should be investigated fur- 
ther. No approach is without its strengths 
and weaknesses. Self-administered question- 
naires have a valuable role in assessing 
adolescents, but they certainly have limita- 
tions. Data obtained from adolescents taking 
tests inappropriately should not be used. 
Consumers who have doubts about tests they 
are considering buying first should ask 
publishers to send free samples to try. 

After screening, what factors might identify 
the best time at which to administer the more 
intensive, comprehensive assessment? 
Screening is conducted prior to a diagnostic 
assessment in order to identify what needs to 
be done with a more thorough exam (i.e., 
problem areas to address). Adolescents 
should be screened as soon as possible in a 
situation in which the most information can 



be obtained. Then intake workers may rule 
out certain problem areas for possible assess- 
ment with more costly diagnostic procedures. 
Also, the quality of rapport between the 
client and intake worker is important to 
consider. Clients respond more honestly if 
they trust the person conducting the assess- 
ment. Furthermore, it should be remem- 
bered that treatment most often is based not 
on a specific diagnosis, but on an adolescent's 
immediate behaviors, which may be diag- 
nosed at a later date. 

It is important to obtain as much information 
from instrument publishers as possible to 
determine the appropriateness of their instru- 
ments for a specific clientele (e.g., based on 
age or cultural issues). Normative issues 
such as these must be considered in the 
development of an instrument. How have the 
instruments discussed in this session been 
developed in this way? Good ways of assess- 
ing the validity and reliability of the APSI 
and PSI are being explored continuously. 
One problem in this process, however, is the 
difficulty in identifying a standard against 
which to compare responses. For instance, 
composite scores were compared with the 
PESQ with high rates of agreement, but it is 
possible that clients simply lied on both 
tests. The most important evidence of a good 
measure is whether it actually predicts 
anything in an adolescent's future, such as 
participation in treatment, success in treat- 
ment, and performance in school. Such 
studies require longer term assessments than 
have been done thus far. In considering the 
use of norm-based tests, consumers should 
make sure that the test did not use all 
adolescents of all age groups as the standard 
for comparison with clients. Norm-based 
tests should be broken down at least by age 
and gender for comparative, interpretative 
purposes. Tests that are criterion-based 
might not have to be categorized in this way 
(e.g., age), but they still should be examined 
carefully for the appropriateness of their 
questions. 



87 



NIDA Conference Highlights 



RS22. Family-Based Treatment 
for Adolescents 

Moderator: Elizabeth Rahdert, Ph.D. 
Speakers: Scott Henggeler. Ph.D. 

Howard Llddle. Ed.D. 
Respondent: Mary Thomas. M.S. 
July 15. 3:00 p.m.-4:30 p.m. 

Speaker: Howard Liddle, Ed.D. 
Technology transfer and the relevance of 
research for clinical work are at the heart of 
substance abuse work. This work is located 
at the intersection of many activities, includ- 
ing research, clinical practice, clinical model 
development, and policy. In the following 
pages, six themes will be discussed that 
exemplify these concepts. 

First, integration and interaction are impor- 
tant not only in technology transfer but also 
in other areas of the substance abuse field. 
For example, individuals working in the 
treatment and prevention fields are collab- 
orating and working more closely together, 
as are those in individual and family 
therapy, drug abuse and psychotherapy, and 
developmental psychology and clinical treat- 
ment. It is increasingly evident how 
research informs practice and practice 
informs research. Furthermore, clinical 
models are beginning to integrate sensi- 
tivities to the culture, class, and gender of 
individuals needing assistance more deeply. 
Advocates of individual treatment for teen- 
agers that includes developing teenagers' 
skills are now more likely to work with 
family therapists in treating youth. Finally, 
the family-preservation or home-based treat- 
ment movement and family therapy are 
merging. Only recently have specialties like 
family therapy begun to appreciate the 
power of home-based treatment. Fositive, 
new results from these integrations take 
time but are in progress. 

Second, although the idea that families are 
important may be intuitive, it is important to 
reemphasize that treatment should focus 
both on the individual adolescent and his/her 
peer relationships and on the family's role in 
the adolescent's life. The family performs 
different socializing functions in the adoles- 
cent's life than the peer group, and under- 
standing these differences enables clinicians 
to give each the proper amount of attention. 
Much literature currently exists on this 
topic. 



Third, treatment models do exist, and treat- 
ment manuals have been developed by clini- 
cians who (1) work with adolescents and 
their families and (2) appreciate the difficul- 
ties and complexities of that work. The 
manuals address treatment methods as well 
as the intersections between treatment 
systems. Numerous studies also exist that 
address difficult populations and the multiple 
systems involved in treating such popula- 
tions, as well as studies in community set- 
tings with many types of therapists. 

Fourth, family interventions do work. How- 
ever, the term "family interventions" does 
not truly capture the kind of work that 
clinicians currently do. It is hard to label 
goals (e.g., "Do clinicians try to change the 
adolescent, the family, the school, and the 
probation system?"). A complex interplay of 
goals and interventions takes place in vary- 
ing situations. Further, knowledge is begin- 
ning to increase about the intersection of 
outcome and process research. In the past, 
researchers tended to look at final outcomes, 
whereas process research permits research- 
ers to learn more about the mechanism of 
change, the interactions between the clini- 
cian and adolescent, and what skills make a 
client want to return. 

Fifth, attitude is a critical concept in adoles- 
cent treatment. The more long term and 
chronic the problem is, the more a clinician 
is in danger of feeling hopeless and despair 
about an adolescent. For instance, a family 
may no longer consider itself a family (that 
attitude can become contagious), or an 
adolescent may feel that his/her family will 
not change and that he/she has no hope for 
the future. Thus, in interventions and 
therapy, clinicians must be able to deal with 
this feeling of helplessness and fight catching 
that feeling themselves. 

Lastly, it is important to consider the context 
in which clinicians make assessments and 
provide treatment. Assessment involves 
locating the family in the context of the 
multiple systems in which it naturally exists. 
Individuals are biopsychosocial organisms 
who act independently, yet who are con- 
nected to many other systems. With this in 
mind, clinicians must treat an adolescent as 
a whole and see him/her, as well as the 
parents, alone for part of the treatment. 
With this one-on-one treatment, it is possible 
to see the adolescents and parents in relation 
to other systems. Such a vision guides clini- 
cians everyday in considering goals in treat- 



88 



Summaries of Research Awareness Seminars 



ment, with whom they should speak, and the 
approach that should be used. 

Speaker: Scott Henggeler, Ph.D. 

The thrust of work in the past has been to 
develop a clinically effective treatment pro- 
gram for serious antisocial behavior in 
adolescents. After a decade of focusing on 
treatment programs for violent, chronic, and 
juvenile sex offenders, in the past year work 
has begun with substance-abusing delin- 
quents. The approach is called "family pre- 
servation," which uses multisystemic 
therapy. It is important to note that family 
preservation is not a treatment but is a 
model of service delivery — the treatment is 
the multisystemic therapy. 

This model, a theory of social ecology, is a 
broad systems perspective that views adoles- 
cents as embedded in a family system and 
the family system as embedded in larger 
social networks, including peer, school, 
neighborhood, and church systems. Work in 
this area is aimed at these extrafamilial 
systems as well as at the family system. 
Thus, the key assumptions of the family 
preservation theory are that adolescents are 
embedded in multiple systems that have 
direct and indirect influences on behavior 
and that behavior is reciprocal and bidirec- 
tional in nature. 

Extensive literature exists in the field of 
delinquency, with studies that model how 
multiple determinants factor into delinquent 
behavior. For instance, a researcher at the 
University of Chicago highlighted three 
influential factors that can predict antisocial 
behavior — prior delinquency, association with 
deviant peers, and family and school prob- 
lems. Emerging literature in substance 
abuse demonstrates similar parameters in 
addition to the fact that substance abuse also 
is multideterminate, and for every individ- 
ual, these determinants may differ. Clear 
treatment implications follow; in other 
words, an effective treatment must have the 
flexibility to deal with the multiple systems. 
It is imperative to have therapists who can 
address multiple causes of a problem in a 
flexible, comprehensive way, often drawing 
on the strengths of the individual systems. 

The family preservation model has been in 
use for many years. In fact, it was used 15 
years ago before it was known as a theory. 
When few adolescents were showing up for a 
treatment study on juvenile offenders, thera- 
pists were asked to search out clients, and 



then the wealth of information and positive 
results acquired from home-based work were 
realized. At about the same time, the family 
preservation model was developing in the 
social work field as a method for keeping 
abused and neglected adolescents in their 
homes. The first aspect of this model 
includes the direct delivery of services in the 
clinic, traditional mental health services, the 
home, and the community. Family preser- 
vation, or one-stop shopping, tries to address 
any barrier to effective outcomes; therefore, 
therapists must be well-trained generalists. 
A team approach is taken to providing these 
services, for example, each therapist has met 
every family being treated by the other 
therapists at least once. A very low staff-to- 
client ratio exists, and staff are available 24 
hours per day, 7 days per week. Traditional 
services provide contact every couple of 
weeks, whereas family preservation thera- 
pists contact clients as often as needed, 
sometimes up to eight times per week. 
Traditionally, treatment outcome is the 
responsibility of the client and family, but 
this perspective holds that the responsibility 
lies with the therapist, supervisor, and — 
ultimately — the researcher. However, the 
therapists cannot be held responsible without 
providing them with the training, resources, 
and support to deal with difficult situations. 
Usually, case management involves a broker- 
age of services, but in family preservation 
the goal is to provide all services (with few 
exceptions). 

With family preservation, there is a decreas- 
ing association with deviant peers, increasing 
association with prosocial peers (e.g., sports, 
church, and civic activities), an improvement 
in school performance, increasing engage- 
ment in recreational activities, and an 
improvement in family-community relations 
(e.g., increasing parent involvement in the 
schools). Therapists should be charismatic 
but not try to work magic; it is the parents 
and the adolescent who must make the 
changes. 

In the project, more than one-half of the 
clients were violent offenders with an aver- 
age age of 15. To enter the project, adoles- 
cents had to be violent or chronic offenders 
and at high risk for incarceration. The 
project's goals are to reduce the rates of 
criminal activities, reduce the costs of 
services, reduce the amount of time in out-of- 
home placement, and preserve family inte- 
grity. Family preservation was found to be 
more effective than usual services in meeting 



89 



NIDA Conference Highlights 



each goal. For example, family preservation 
clients spend an average of 73 fewer days in 
the year following treatment in out-of-home 
placement than those who have traditional 
treatment. 

A 2.4-year followup was conducted using the 
survival analysis statistical technique, which 
usually is used in medicine but adapts well 
to recidivism. At Day 1, 100 percent of the 
clients were "alive." A graph of the recidi- 
vism rate reveals that after 1 year, approxi- 
mately 73 percent of adolescents in the 
control condition were rearrested, while 
approximately 42 percent of adolescents in 
family preservation were rearrested. This 
was the first evidence of a long-term treat- 
ment effect among youth with serious anti- 
social behavior. The results of this study 
lead to the conclusion that the family preser- 
vation method, using multisystemic therapy, 
is more effective than traditional services in 
reducing criminal activity, less expensive, 
and more ethical in maintaining family 
integrity. 

In addition, 4V6-year followup data from 
another study of 200 chronic offenders ran- 
domly assigned to treatment conditions (i.e., 
multisystemic family preservation as opposed 
to individual counseling) show the positive 
effects of home-based, multisystem interven- 
tions. Dropouts from the treatment group 
showed a higher recidivism rate than those 
who remained. Based on this information, a 
study will begin in fall 1993 on the effects of 
dosage and the integration of community 
volunteers. On the other hand, recidivism 
among dropouts and nondropouts in individ- 
ual therapy does not differ; of course, individ- 
uals who had neither type of treatment had 
a very high recidivism rate. 

Family preservation treatment is very dif- 
ferent from the homebuilders' model, where 
treatment involves cognitive behavioral 
interventions plus social support. In addi- 
tion, all evaluations of this model to date 
show that effects disappear after 6 to 9 
months, and no difference occurs compared 
to traditional treatment. The family preser- 
vation model was effective because the 
known causes of delinquency were targeted, 
including family and peer relations and 
school performance. The homebuilders' 
model targets the family system, but it does 
not try to change other things like peer 
relations. Also, family preservation treat- 
ment was shown to be successful because it 
occurred in the youth's natural environment, 



which increases the probability of long-term 
outcomes. Therapists were well trained and 
supportive, and much attention was devoted 
to developing positive interagency relations, 
such as with school officials. 

With regard to peer relations, family preser- 
vation therapists do all they can to dis- 
courage youth's association with problem 
peers. Many of the youth need support and 
assistance to integrate into a new positive 
peer group) — this change is very important to 
the effectiveness of the youth's treatment. 

A study in Charleston has been going on for 
14 months that currently consists of 38 
juvenile offenders who meet the DSM-III-R 
(Diagnostic and Statistical Manual, revised 
third edition), criteria for substance abuse. 
Nineteen are in a control group, and 19 are 
receiving family preservation treatment. 
Postevaluations have been collected on 8 
adolescents, and in 3 months, there should 
be postdate, on at least 36 adolescents. Pre- 
liminary results show one rearrest and zero 
out-of-home placements among adolescents 
receiving family preservation treatment and 
six rearrests and six out-of-home placements 
among adolescents in the control group. 
Posttest data over a 4-month period on 4 
adolescents from each group show 7 self- 
reported crimes among adolescents in family- 
preservation treatment and 51 self-reported 
crimes among those in the control group. 
Further, three out of the four experimental 
youth reported abstinence versus one youth 
in the control group. Although these are 
very preliminary results, they are exciting 
and have implications for health care reform 
by showing the need for family-based and 
community-based treatment. Again, the 
project's goal is to change the adolescents' 
ecology. 

Questions, Answers, and Comments 

Should drug abuse professionals continue to 
provide inpatient treatment, and if so, how 
does multi-system therapy fit into the con- 
tinuum of care? No controlled clinical trials 
have shown that residential or inpatient 
treatment of serious psychiatric problems, 
delinquency, or substance abuse are better 
than any other treatment or no treatment at 
all. However, 75 percent of children's mental 
health dollars fund residential and inpatient 
treatment. A large amount of money is made 
on such services, and tremendous vested 
interest has developed in them despite the 
fact that some studies have demonstrated 



90 



Summaries of Research Awareness Seminars 



negative effects from them. Still, it is possi- 
ble that health care reform may move those 
dollars and reinvest them into community- 
based projects. 

Are offenders who appear to have a heredi- 
tary link to their substance abuse illness 
faring worse in comparison with youth who 
do not seem, to have such a hereditary link? 
There are not enough data to answer that 
question. Biological contributions do seem to 
be very important and should be studied 
further. It is possible that biological inter- 
ventions, such as minor tranquilizers for 
anxiety, may become important parts of 
treatment. 

How can legislators and others be convinced 
of the benefits of outpatient services over 
inpatient treatment? Legislators should 
become convinced of the benefits of out- 
patient treatment because of its cost-effec- 
tiveness — as rates of violent behavior 
increase, the current answer of simply incar- 
cerating offenders for longer periods of time 
is extraordinarily expensive. 

Comment: The family-based treatment 
movement is changing the field and clinical 
sensibility, even though it is not easy. 
Researchers and clinicians are excited about 
such findings as they try to make a dif- 
ference in adolescents' lives. The whole 
training and delivery system needs to 
change. Clinicians and others in the field 
may obtain training manuals and keep 
abreast of findings by being on pertinent 
publishers' mailing lists and corresponding 
with researchers and other workers in the 
field. 

Comment: With the growing movement 
toward family preservation treatment, many 
child and adolescent therapists already have 
moved out of mental health centers and into 
schools or family preservation projects. For 
instance, there is a major push in South 
Carolina to move services and therapists out 
of centers (which frequently have high no- 
show rates) and into the communities, where 
they can provide more direct, comprehensive 
interventions. It is hoped that medicaid 
compensation for such services will increase. 

What kinds of strategies can be used to 
encourage adolescents to change their behav- 
ior and to associate more with prosocial 
peers? First it is important to convince both 
the adolescent and parents that this social 
change is imperative in the adolescent's life. 
If the adolescent resists this assertion, then 



parents must be persuaded to discourage 
their child's association with antisocial peer 
groups by setting curfews and other restric- 
tions and by facilitating his/her involvement 
with other groups, such as sports teams. 
The therapist's relationship with the parents 
should be distinct from his/her relationship 
with the adolescent. It is important for 
therapists to speak directly to adolescents, be 
on their side, and help them recognize and 
accept behaviors they should change. 

RS23. Specialized Treatment for 
Pregnant and Parenting 
Teenagers 

Moderator: Elizabeth Rahdert. Ph.D. 
Speakers: Tiffany Field. Ph.D. 

James A. Hall. Ph.D. 
Respondent: Mildred Colon-Sandlno. A.C.B.S.W. 
July 16, 10:15 a.m.-ll:45 a.m. 

Speaker: Tiffany Field, Ph.D. 

The NIDA-supported research grant program 
at the University of Miami focuses on teen- 
age girls who have used drugs and alcohol 
during pregnancy. For the young women 
who have so far enrolled in the program, 
marijuana has been the primary drug of 
choice, with alcohol use viewed as a second- 
ary problem. For some of the young women 
deemed eligible due to their prior pregnancy 
and drug use behavior, their drug-related 
problems were deemed too severe to allow 
them enrollment into the program. Some of 
these young women were placed in jail pro- 
grams or, if they were not involved in the 
criminal justice system, were admitted into 
an inpatient program at the hospital. 

The main method of recruiting these adoles- 
cents into the program has been through the 
use of an intensive interview conducted on 
the day of delivery. The interview is com- 
posed of a number of questions that refer to 
the patient's drug use history and family 
background. A key to increasing the rate of 
recruitment into the program is to ensure 
the mother of the confidentiality that will 
be maintained throughout the interview 
process. 

Following enrollment into the program, the 
first step is to enter the teenage mother in 
school so that she can earn her GED (general 
equivalency diploma) and/or learn job skills. 
This later will enable the teenager to obtain 
and maintain a job that will gain her the 
needed income to support herself and her 
infant. A day-care facility is provided for the 



91 



NIDA Conference Highlights 



infant while the mother attends the high 
school classes. This facility offers other 
services, including massage therapy for the 
infant, physical therapy exercises for the 
mother, mother-infant interaction sessions 
during nonschool hours, and preventive 
childhood accident training. 

The program schedule is made up of a 
4-month schedule in which the mother ful- 
fills her high school requirements. This then 
is followed by a 6-month period consisting of 
biweekly sessions between the mother and 
the program staff. During the initial 
4-month period, the mother's mornings 
normally are spent attending high school 
classes or studying for GED exams. Voca- 
tional counseling classes also are available. 
In addition to the classes, 2 to 4 weeks are 
spent working in the infant nursery, where 
the mother learns how to better handle/inter- 
act with her infant. The program afternoons 
are spent in the treatment facility, where the 
mother can participate in any of the fol- 
lowing activities: socializing, cooking (which 
is a stepping stone to teaching proper diet 
and nutritional habits), drug rehabilitation 
sessions, social skills training, parenting 
classes, tutoring, aerobics, relaxation 
therapy, and occasional offsite cultural and 
recreational outings. 

A token economy is employed within the 
structure of the program to reward positive 
behaviors that occur when the mother is 
participating in any one of the various com- 
ponents of the program. Tokens that are 
earned can be used to buy things the mother 
likes. In contrast, tokens can be taken away 
if the mother exhibits negative behaviors 
during any of the program activities. An 
electronic monitoring beeper system is used 
when the mother is outside the treatment 
facility as a way to check that she is not 
experiencing any problems or difficulties. 
Random urine screens are conducted 
throughout the month to check for drug use 
and pregnancy status. One hundred tokens 
are awarded to a mother whose urine screen 
reveals no drug use, and 90 tokens are given 
when the pregnancy test is negative. 

Also offered during the program are 
job-seeking skills training that involves areas 
such as resume building and interview prac- 
tice. Results of the program indicate that 
mothers who receive job training have higher 
rates of program completion, lower rates of 
continued drug use, fewer repeat preg- 
nancies, higher rates of GED completion or 



high school graduation, and larger numbers 
of job offers as compared to those mothers 
who do not take job training. A 60-percent 
success rate has been experienced within this 
program. 

Speaker: James A. Hall. Ph.D. 

A NIDA-supported research project in San 
Diego assesses the efficacy of the Positive 
Adolescent Life Skills (PALS) Program, a 
drug treatment program designed for teenage 
pregnant and parenting girls between 14 and 
19 years old. Mexican-American and Afri- 
can-American adolescents make up the 
majority of young women enrolled in the 
program. Among these participants, "gate- 
way" drugs, such as alcohol and marijuana, 
are the drugs of choice, although a majority 
of the participants report quitting or reduc- 
ing drug use when they discovered they were 
pregnant, with higher rates of drug use 
found among the nonpregnant "parenting" 
girls. 

The PALS Program consists of a 
1-day-per-week outpatient program, with 
skills training, a Facts-of-Life class, case 
management, and medical care making up 
the main components of the program. The 
medical care component consists of two 
clinical services: (1) standard medical treat- 
ment for all program participants and 
(2) obstetrical services for the mothers-to-be. 

Problemsolving and social skills training 
make up the main activities in the PALS 
Program. Social skills training encourages 
the girls to determine their positive and 
negative role models and to learn how to "say 
no" to drug use and high-risk sexual behav- 
ior. And most importantly, these teenagers 
find out how to seek more information, 
decline assertively, provide reasons, and 
describe to themselves a better plan 
when confronted by a potentially dangerous 
situation. 

The Facts-of-Life class consists of a 16-week 
course that answers questions related to 
issues such as sexual activity and birth 
control. The main components of the case 
management program are needs assessment/ 
monitoring, treatment planning, referral to 
community services, crisis intervention, and 
advocacy. 

Although the PALS Program provides a 
certain degree of punishment for negative 
behavior, a point system was developed in 
order to reward the girls for positive partdci- 



92 



Summaries of Research Awareness Seminars 



patdon within any or all components of the 
PALS Program. Outcomes occur when the 
pregnant or parenting teenager shows indi- 
cations of possessing more positive social 
support and improved problemsolving skills; 
when she can handle criticism in an asser- 
tive, constructive manner; and when she 
avoids high-risk sexual activity and 
decreases the degree to which she depends 
on negative rather than positive social 
support. 

Questions, Answers, and Comments 

Are there any real behavioral traits to be 
aware of that would indicate a tendency 
toward future drug abuse on the part of 
pregnant teenagers who are involved in 
various treatment programs? The data 
obtained through the PALS Program suggest 
that there is not any set pattern or cure-all 
method for predicting the factors responsible 
for future drug use. 

Are any special methods or techniques used 
within these two programs (the University of 
Miami program and the PALS Program) in 
regard to addressing the many cultural 
differences of the teen participants'? There 
have been no culturally based barriers to 
treating the participants. Despite not citing 
any differences between the various ethnic 
groups, there is a difference in the way in 
which one racial group acted toward another. 
The best example of this can be seen when 
all of the participants of the PALS project 
are assembled in one room; three categories 
of people congregate: (1) African-Americans 
(on one side of the room), (2) Caucasians (in 
the middle), and (3) Hispanics (on the other 
side). 

How is the issue of childhood sexual and 
physical abuse being addressed within both 
programs? In the University of Miami pro- 
gram, the only way in which any progress is 
made toward curbing the trends of physical 
and sexual abuse of the participants is to 
report their abusers to the proper authori- 
ties. Another method which reaps some 
success in terms of lowering the abuse cases 
is to threaten the participants with termina- 
tion from the program if they continue to live 
with the people who are abusing them. 

What alternatives are there for communities 
that may want to set up a similar program 
but do not have the same number of resources 
at their disposal? The University of Miami 
program was unable to start until the pro- 
gram's innovators received funding from 



NIDA. It is therefore sometimes a question 
of which resources can be acquired from 
outside help when attempting to implement 
programs in needy communities. 

In regard to the University of Miami pro- 
gram, is there a fear that the girls, upon 
leaving the relatively safe and unrealistic 
program environment, will fall back into an 
unsafe lifestyle? This is a primary concern of 
every program worker. The best way to 
combat such an unfortunate turn of events is 
to help ensure that each and every girl's 
safety is secure before they leave the pro- 
gram. This generally is done by helping 
them settle into safe and stable living 
conditions. 

Where in the PALS Program is the issue of 
HIV/AIDS addressed? The Pacts-of-Life 
class is devoted to this subject. 

Comment: The male component needs to be 
included in more of the programs in terms of 
the educational factors that lead to such 
occurrences as teen pregnancy and the con- 
traction of HP7/AIDS. More programs 
should begin to include the partner of the 
pregnant girl so that he not only sees what 
role he needs to play in her life but also so 
that they gradually learn how to avoid the 
numerous dangers and problems facing 
them. 

RS24. Women's Assessment Procedures 

Moderator: Paul Marques, Ph.D. 
Speakers: Elizabeth Brown. M.D. 

Karol Kaltenbach. Ph.D. 
Respondent: Janice Ford Griffin 
July 15. 10:30 a.m.-12:00 p.m. 

Speaker: Elizabeth Brown, M.D. 

Studies of substance abuse treatment require 
accurate assessments of drug use history. 
There are numerous important assessment 
areas in addition to actual substance use in 
the context of the New Beginnings program, 
which operates in conjunction with a neigh- 
borhood health center in a high drug use 
area of Boston. New Beginnings provides 
medical care; substance abuse treatment 
support; and a series of services especially 
designed for women, such as parenting 
support, legal advocacy, and a child activities 
center. As a NIDA research demonstration 
project, New Beginnings uses assessment 
tools to examine outcomes of the 
interventions. 



93 



NIDA Conference Highlights 



Women coming into treatment present a 
different set of problems than do men. Most 
treatment programs originally were devel- 
oped to serve primarily men, so assessment 
procedures were directed at substance abuse 
among men. For instance, most questions on 
the widely used Addiction Severity Index 
(ASI) have addressed problems more specific 
to men, such as criminal behavior, but many 
have limited relevance to women. In order to 
be more gender specific, a new series of 
questions exclusively for women has been 
added to the ASI. 

The characteristics of the patients being 
served influence the types of assessments 
that should be conducted. Among the first 
58 pregnant women in the New Beginnings 
program, the average age was 27. In con- 
trast, the average age of men in drug treat- 
ment is in the mid- to late thirties. Preg- 
nancy usually serves as the woman's primary 
motivation for entering treatment because 
she is concerned about her baby's health. 
Staff face the challenge of convincing a 
woman that she needs treatment just as 
much as her fetus. Often women believe 
that programs are only for their babies and 
not for the women as well; thus, the highest 
dropout rate occurs at the time of birth. It is 
useful, therefore, to develop a woman's 
self-esteem so she recognizes that she 
deserves treatment as an individual. 

Seventy-eight percent of New Beginnings' 
delivery population is African-American, and 
virtually all of the women are single or 
separated. Many live with a partner but 
only in a temporary arrangement. The 
women have a mean of four prior pregnan- 
cies and two live births. The high rate of 
spontaneous abortions indicates the dan- 
gerous level of illness in the women (e.g., 
hypertension or diabetes). Thus, a medical 
assessment protocol is needed upon admis- 
sion of pregnant women in treatment pro- 
grams, covering factors such as family risk, 
medical problems prior to pregnancy, and 
risks associated with pregnancy loss. Also, 
programs should have a well-developed 
linkage with a primary care/obstetric 
provider. The women's average age at first 
pregnancy is 18; thus, their average four 
prior pregnancies occurred over a 10-year 
span. 

A woman generally is motivated to enter 
treatment by the time of her fourth preg- 
nancy because she does not have custody of 
her other children and realizes that unless 



she enters treatment, she may not be per- 
mitted to keep her newborn. This situation 
creates a dilemma for treatment staff. Most 
States have child abuse reporting laws that 
require all health care providers to report a 
suspicion of child abuse or neglect. These 
laws supersede Federal confidentiality 
statutes for drug treatment programs, so 
staff must report to child protective services 
a woman who delivers but still is using 
drugs. This requirement conflicts with staffs 
confidentiality commitment. Thus, staff 
must inform a woman of this procedure, 
assess the woman's prior and current parent- 
ing capacity, and help her learn parenting 
skills. New Beginnings expected a decrease 
in the number of children entering foster 
care, but the opposite occurred due to the 
mandate to report mothers' drug use. In its 
first 6 months, New Beginnings was known 
on the streets as "the baby snatchers." Only 
after women had been in treatment and then 
regained custody of their babies did the 
program's reputation turn around and 
recruitment become easier. 

The mean educational level of women in New 
Beginnings is 11 years of school, but their 
reading level has been determined through 
assessment to be at the sixth-grade level. 
Thus, staff have had to present information 
orally or in very simple written language. 
New Beginnings started a GED (general 
equivalency diploma) program in the treat- 
ment center, and even women with a high 
school diploma participate in the program to 
improve their reading ability. Also, it is 
important at intake to assess physical and 
sexual abuse. However, it is equally impor- 
tant not to raise sensitive issues that staff 
cannot handle immediately. For instance, it 
is irresponsible to raise such troubling issues 
among women who, through random assign- 
ment, face a delay in treatment. Thus, New 
Beginnings staff do not ask detailed ques- 
tions about prior abuse but do assess abuse 
during the pregnancy. Even at intake, with 
interviewers who are strangers, 47 percent of 
women have discussed current abuse. After 
women begin to know staff better, 85 percent 
have admitted that they currently are suf- 
fering physical and sexual abuse. For most 
women, programs cannot treat substance 
abuse problems without first addressing 
physical and sexual abuse issues. 

Finally, in a 20-year-old study from Michi- 
gan, 76 percent of women under 30 entering 
treatment came from families in which alco- 
hol was abused in the home. And, even 20 



94 



Summaries of Research Awareness Seminars 



years ago, 50 percent of women entered 
treatment with a history of drug use in the 
home, and one-third admitted being physi- 
cally or sexually abused. In current 
scenarios, alcohol use has lessened and drug 
use has remained substantial. It is impor- 
tant now to assess sexually transmitted 
diseases, including AIDS, and other 
infectious diseases — all of which are on the 
rise. 

To accurately assess substance abuse, both 
self-reports and objective measures appear to 
be useful. A study at Boston City Hospital 
on women presenting for prenatal care 
assessed substance abuse through interviews 
at intake and delivery, along with three 
periodic urine samples. Some women 
reported substance use but had negative 
urine tests, some reported substance use and 
had positive urines, and others reported no 
substance use but had positive urines. 
Assessment should involve both self-reports 
and urine samples to attain an accurate 
picture of the problem. 

Speaker: Karol Kaltenbach, Ph.D. 

A cardinal rule in assessment is to ensure 
that instruments are valid and reliable, but 
this presents a challenge in the assessment 
of substance-abusing women. One cannot 
assume that measures with good psycho- 
metric properties are adequate for assess- 
ments of this population. For instance, the 
ASI is widely used but also widely criticized 
as inappropriate for women. In general, a 
new movement appears to be occurring in 
the area of instrumentation to develop more 
appropriate measures. A further area of 
concern involves deciding who is appropriate 
to administer the instruments. In research 
demonstration projects, it is helpful — but 
sometimes difficult — for research and clinical 
staff to work together while maintaining the 
integrity of the research. For instance, it is 
difficult to determine whether clinical or 
research staff should administer questions 
concerning sensitive clinical issues. It may 
be useful for a research staff person to 
administer instruments but have a clinician 
available to attend to related emotional 
issues. 

An additional concern in assessment regards 
when instruments should be administered. 
Sometimes the timetable for assessment may 
be at odds with a woman's progress in clini- 
cal treatment. One cannot assume that a 
valid instrument always will yield valid 



information. For instance, in obtaining 
intensive abuse histories, the ASI was too 
intensive at first and thus was modified for 
early assessment. Programs must ensure 
that assessment questions do not set a 
woman back in her treatment progress. 

One of the Perinatal 20 Projects — the 
Cocaine, Pregnancy, and Progeny 
Project — has been examining the effective- 
ness of residential treatment as compared to 
outpatient treatment for cocaine-using 
women. The project aims to improve safe 
and healthy pregnancies and perinatal out- 
comes. Extensive maternal and infant 
assessments are conducted, and most items 
are administered at intake and at different 
points in the woman's pregnancy. Staff for 
this and other Perinatal 20 Projects felt 
pressured to use the ASI in order to have 
some comparable data across the projects, 
yet most projects also felt that the ASI was 
not appropriate for women and was not 
yielding very meaningful information; thus, 
the instrument was modified. A psychosocial 
history was developed to extend the scope of 
the ASI, adding quantitative and qualitative 
assessments that are specific to the needs of 
women, including medical aspects of preg- 
nancy, caregiving history, child care and 
living situations, relationship with the father 
of the child, and victimization history. These 
additions are included in the module of the 
new training tape that NIDA is developing 
on the ASI. 

The Cocaine, Pregnancy, and Progeny Project 
used this modified ASI, along with the Beck 
Depression Inventory, a stress checklist, and 
a self-reported abuse questionnaire. It is 
important to remember that stress is specific 
to the assessed population. The project also 
uses the Everyday Stressors Index developed 
by Hall in 1985 particularly for low-income 
women. Additionally, a social support inter- 
view format was developed using the 1983 
Social Network Inventory from Weinrub and 
Wolf and the Social Network Assessment to 
measure information on women's help with 
child care, satisfaction with support, and 
nature of emotional support. The Internal 
Control Index measures locus of control and 
was chosen for use with both male and 
female African-Americans of heterogeneous 
education and socioeconomic levels. 

Above all, it is important to conduct assess- 
ments with compassion and respect for 
mothers and their children and to provide an 



95 



NIDA Conference Highlights 



environment to support their recovery 
progress. 

Speaker: Paul Marques. Ph.D. 

This study, beginning in 1989, examined 
treatment outcome differences among post- 
partum, drug-abusing women in Prince 
George's County, Maryland. Despite much 
controversy at the time over the use of hair 
testing as an outcome measure, the possible 
benefits of such a method motivated the 
program during the first 6 months to try 
using hair samples from mothers and their 
infants to determine the joint presence of 
drug levels. In this study, mothers had an 
average age of 27 years, and infants 
averaged 74 days old at the time of hair 
sampling. The results were good, and hair 
collection was continued on all 160 
mother-infant pairs; mother hair samples 
were collected every 4 months for 2 years. 

The data indicated that among women who 
had been positively identified through urine 
testing for cocaine use, 99 percent tested 
positive for cocaine 3 to 6 weeks later using 
hair samples, and 93 percent of their infants 
also were found to be cocaine positive. Look- 
ing at cocaine metabolite (or the parent 
compound cocaine), however, the hit rates 
were considerably lower when again using 
the same sample of women who had tested 
positive for cocaine use a few weeks earlier. 
These results are interesting but do not 
confirm the reliability of hair testing as a 
quantitative outcome measure, which is 
necessary if it will be useful for research. 
The researchers also found by examining 
hair samples of a mother and infant exposed 
to the same blood supply that the correlation 
was 0.52. When restricting the sample to 
only hairs determined to be in good condi- 
tion, the correlation was 0.62. The condition 
of the mother's hair is an important deter- 
minant of whether it is reliable as a quanti- 
tative outcome measure. These findings 
strengthen the case for quantitative 
accuracy. A paper recently was published on 
this issue in the American Journal of Drug 
and Alcohol Abuse. 

Callahan in Seattle also recently published a 
study in the Journal of Pediatrics that 
reported a 0.72 correlation between a sample 
of mothers' and their infants' hair. This is a 
strong correlation, and with adjustments, 
approximately the same magnitude of effect 
was found in the Callahan and Marques data 
sets. Thus, hair testing does seem to be a 



useful outcome measure under certain cir- 
cumstances. One study also found a correla- 
tion of 0.4 between positive testing for 
cocaine by urinalysis and by hair analysis, 
which also is reasonably supportive of the 
reliability of hair testing. Also, using 
self-reported scales (an assessment of use in 
the past 30 days) was positively but weakly 
correlated to the amount of cocaine found 
both in urine and hair. Therefore, if it is 
accepted that hair testing for cocaine is a 
quantifiable measure, it can be used to 
assess infants' third trimester in-utero expo- 
sure to cocaine and to determine the relative 
decline of cocaine use among adult groups 
receiving treatment. For instance, one study 
of 56 women, using hair samples at 4 and 8 
months after intake, revealed a decline in 
cocaine abuse on a group basis. There is too 
much error to have confidence in any one 
sample, but as a group outcome measure, 
hair testing is very useful. 

Questions, Answers, and Comments 

To what extent does the assessment procedure 
present a barrier to gaining access to treat- 
ment? It is extremely important to consider 
whether a lengthy assessment process poses 
a barrier to treatment for women and 
whether women will be receptive to the 
process. It may be helpful, for instance, to 
be accommodating to women by providing 
lunch for them and their children during 
assessment. Also, it should be remembered 
that women are not required to participate in 
the research in order to receive treatment; 
thus, assessment does not necessarily pose a 
barrier to access services. 

Furthermore, it is very important for 
research staff to be honest with patients and 
to inform them of the reasons for and signifi- 
cance of the research. Patients often respond 
positively to this approach because they 
realize that they may be contributing to 
important developments in treatment. Addi- 
tionally, research needs should be tied into 
therapy whenever possible. For instance, in 
New Beginnings, urine testing of women was 
conducted not only to attain research data 
but to help women understand and deal with 
relapse issues. Thus, the tests were per- 
ceived not as punishment but as a service 
and, therefore, as less threatening and 
invasive. 

Attention to the history of physical and sex- 
ual abuse during a woman's current preg- 
nancy should not minimize the impact of 



96 



Summaries of Research Awareness Seminars 



early childrearing practices of the woman's 
parents. The patterns that people show as 
adults are determined in the first few years of 
their upbringing. Thus, is it important to 
gather this kind of information from 
patients? Certainly such information is 
critical; however, it should be attained only 
when treatment is subsequently available. 

What are the two most important facts that 
researchers would most like the community to 
understand? The patient's history of physi- 
cal and sexual abuse and the family's history 
of substance abuse are critical. Additionally, 
it should be remembered that relapse is part 
of recovery; treatment is a process, not a 
single intervention. People must recognize 
that treatment intervention outcomes cannot 
be measured only 1 month after the onset of 
treatment — and not all successes are mea- 
sured by abstinence. 

How do researchers control for research bias? 
If a funding source sets up criteria for fund- 
ing, these criteria must be met in order to 
receive the money. Funding sources must be 
educated to ask the right questions so that 
they request useful information. Researchers 
may ask the questions requested by the 
funders and then add on other questions 
they feel are important. People fund projects 
to gain information that is in their best 
interest to have. Researchers must be care- 
ful with the inferences made from their data. 
The knowledge base in the drug field is fairly 
tentative. 

What cost factors are associated with hair 
analysis? Few laboratories are available to 
analyze hair samples. Hair sent to a com- 
mercial lab in Santa Monica, California, was 
analyzed at a rate of $45 per sample. This 
cost at first seems high compared to urinaly- 
sis testing. However, costs even out when 
one considers the reduction in personnel 
costs for staff taking hair samples every 4 
months as opposed to urine samples every 2 
or 3 days. Also, women do not find providing 
hair samples to be as demeaning as urine 
samples, and the hair sample does seem to 
be a reasonably good quantitative measure in 
the aggregate. 



RS25. Women's Treatment Approaches: 
A Clinical Perspective 

Moderator: Loretta flnnegan. M.D. 
Speakers: Elizabeth Brown. M.D. 

Shirley Colettl 

Irma Strantz. Ph.D. 
July 17, 1 1:15 a.m.-12:45 p.m. 

Speaker: Loretta Finnegan. M.D. 

The 3 speakers for this session were princi- 
pal investigators for 3 of the 20 
NIDA-research demonstration projects con- 
ducted in 17 cities across the country during 
1989 and 1990. NIDA funded these projects 
because of the perceived need to learn more 
about treating pregnant, drug-addicted 
women. The senior adviser on women's 
issues in NIDA's Office of the Director 
advises on issues related to women, pregnant 
women, and children, as well as fosters 
interest in these and related issues. 

When women began using a significantly 
greater amount of cocaine in the late 1980s, 
concern initially centered on the drug's effect 
on the women's children before concern 
focused on the women themselves. It is 
important to recognize the complex nature of 
addiction, specifically for women. The cycle 
of addiction includes illicit and licit drug use 
along with the multiple medical and obstetri- 
cal complications related to addiction. In 
addition, one must consider other issues, 
such as comorbidity, physical and sexual 
abuse, legal and socioeconomic concerns, lack 
of employment, and number of dependents. 
A multidisciplinary clinical approach is 
needed to address the many factors of 
addiction. 

Speaker: Elizabeth Brown, M.D. 

New Beginnings, a neighborhood-based, day 
treatment program, is one of the Perinatal 20 
evaluation grants funded by NIDA Working 
in association with a neighborhood health 
center that is operated from Boston City 
Hospital, New Beginnings offers comprehen- 
sive one-stop services to pregnant women, 
including drug treatment, prenatal and 
postpartum medical care, pediatric care for 
newborns and other children, and parenting 
education. The program aims to help women 
abstain from drug use and maintain 
recovery, as well as teach women about 
pregnancy and how to enjoy life in settings 
different than the women generally are used 
to. The program employs culturally appro- 
priate staff for the targeted population. 



97 



NIDA Conference Highlights 



New Beginnings involves a study composed 
of a randomized trial between a treatment 
group, which receives New Beginnings' 
services, and a comparison group, which 
receives general substance abuse treatment 
and other services at Boston City Hospital. 
The women in the treatment group, who 
voluntarily come into New Beginnings for 
treatment, are generally between 26 and 27 
years of age, which is slightly older than the 
pregnant women admitted to Boston City 
Hospital. The women in the treatment group 
are predominantly African-American, single 
or separated, have an average of four pre- 
vious pregnancies, and have an average of 
two living children. The women have a high 
incidence of sexually transmitted diseases 
and pregnancy, as well as a large number of 
complications from medical conditions that 
have a high prevalence among African- 
Americans, such as hypertension. More than 
80 percent of the women have been abused 
physically or sexually. On average, the 
women have completed 11 years of school. 

The program provides drug-free counseling. 
The women at New Beginnings primarily use 
cocaine. Opiate-dependent women who are 
admitted may be maintained on methadone. 

Many pregnancy losses among substance- 
abusing women are preventable and are 
related to underlying, untreated medical 
conditions. However, women who receive 
prenatal care tend not to lose their babies. 
Substance-abusing women typically experi- 
ence their first pregnancy at age 18 and tend 
to seek treatment on an average of 18 years 
after their first pregnancy. Many women do 
not seek treatment earlier because they want 
to keep their children and fear that if they 
admit to using drugs, child protective ser- 
vices will take their children away. There- 
fore, many of these women keep trying to get 
pregnant with the hope that their drug use 
will remain undetected. 

Approximately 40 percent of the women in 
the treatment sample currently are being 
physically or sexually abused; consequently, 
treatment strategies also must take into 
account the women's risk of harm and how 
that risk affects their chances for relapse. 
Individuals working in treatment must learn 
about the many circumstances that influence 
a person's use of drugs. 

The hypothesis for the randomized trial 
conducted at New Beginnings was that a day 
treatment program would result in 
(1) decreased drug use, (2) increased reten- 



tion in drug treatment, (3) improved peri- 
natal outcomes, and (4) improved parenting 
skills. It was important that the outcome 
measures examine not only abstinence and 
outcome but also harm reduction. For 
instance, women may not stop using drugs, 
but they may decrease their drug use; thus, 
relapse may be considered part of the 
recovery process. Women's decreased and 
more controlled use of drugs will lead to a 
reduction in the harmful outcomes from drug 
use. Research projects should have realistic 
outcomes and not overlook positive results 
other than complete abstinence. 

In the New Beginnings study, several harm- 
reduction strategies were examined. For 
example, the study examined the outcomes of 
pregnancy, such as differences in birth 
weights and the outcomes of children evalu- 
ated by the Bayley Scales of Infant Develop- 
ment in the first 2 years of life. Children in 
both the treatment and comparison groups 
showed similar results on this measure. 

In assessing parenting skills, it is helpful to 
use new strategies that examine behavioral 
assessments. For instance, at Children's 
Hospital in Boston, a face-to-face assessment 
is conducted during the first 6 months of life, 
observing how each baby reacts to his/her 
mother's actions and facial expressions. In 
addition, the mothers' actions are examined 
and the mothers are told to act "normally" 
around their infants. Substance-using 
mothers often consider it normal to act 
aggressively toward their infants, such as 
poking them to get a reaction. When the 
infants typically react adversely to this type 
of behavior, it reinforces the mothers' percep- 
tions that their children don't love them. 
Women who are not involved in drug use, 
however, act more lovingly toward their 
infants. This kind of study provides better 
information about parenting and parent 
education than gross, global, and/or func- 
tional assessments. 

Finally, the NCAST and the Caldwell Home 
Scale have been used. The first, a feeding 
and teaching scale, investigates a mother's 
ability to teach her child tasks, while the 
second examines the quality of the home 
environment for rearing a child. The results 
of the Home Scale improve greatly after 
women have been in the program 1 year, as 
they put their newly acquired parenting 
skills to use. Furthermore, the Home Scale 
appears to be the best predictor of school 



98 



Summaries of Research Awareness Seminars 



performance and the best way to measure 
the environmental impact on learning. 

Speaker: Shirley Coletti 

Operation PAR (Parental Awareness and 
Responsibility), a multimodality addiction 
service program in St. Petersburg, Florida, 
currently is the recipient of funds from 47 
sources. It speaks sadly for the state of the 
art of drug abuse treatment that so much 
time must be spent seeking funds. It is 
important to point out that demonstration 
project funding has time limits. For exam- 
ple, these projects have 3 or 5 years to prove 
that they are effective, but often they then 
are not in a position to continue funding and 
operating on their own. Until the drug 
abuse field moves beyond this method of 
funding, the whole industry will be in a state 
of disarray. 

Community-based organizations will not go 
very far unless they become learning labora- 
tories for researchers and themselves. Since 
1973 Operation PAR has provided a tradi- 
tional therapeutic community with 125 beds 
for men and women. However, because few 
women initially entered the program, Opera- 
tion PAR developed a special therapeutic 
community for drug-abusing mothers who 
had left treatment early to be with their 
children. It was discovered that the length 
of time mothers would spend in treatment 
depended on their relationship with other 
social service workers, who often posed the 
threat of taking the women's children from 
them. More and more, women were deliver- 
ing drug-exposed children. Consequently, 
Operation PAR developed resources to meet 
the women's needs, and a proposal was 
submitted to NIDA to examine the retention 
of women in treatment when they have 
children. 

According to data from 1988, women dropped 
out of the long-term residential treatment at 
a much faster rate than men. It was difficult 
for women to find care for their children, and 
often when a mother appeared to be recover- 
ing (after a short time in treatment), the 
relative or individual who was caring for her 
children usually pressured her to resume her 
parenting duties immediately. As a result, 
PAR Village, a therapeutic community, was 
developed and consists of 14 houses where 
mothers and their children live together. 
While the children receive developmental day 
care, the mothers receive treatment and 
parenting skills training and work in PAR 



industries to learn job skills. To be eligible 
to live in PAR Village, also known as TC 
Plus, women must be cocaine dependent, age 
18 or older, and have one or two children age 
10 or under. 

As part of a research study, Operation PAR 
screened women and made random assign- 
ments either to PAR Village or to standard 
residential treatment (without their chil- 
dren). The study observed women in both 
groups after 18 months of treatment, with 
followup at 2, 6, and 12 months. The results 
upheld the hypothesis that having both the 
mother and child in the program would 
improve treatment retention. Data show 
that employment and transportation con- 
tinue to be among the greatest barriers to 
success for this population of women fol- 
lowing treatment. Operation PAR has devel- 
oped a full-range continuum of services. 
With the realization that returning to vio- 
lent, drug-ridden communities poses great 
risks to women just coining out of treatment, 
Operation PAR also obtained a 43-unit apart- 
ment building in order to offer mothers 
drug-free housing after treatment. In reno- 
vating these apartments and those for PAR 
village, Operation PAR relied on work pro- 
vided by the residents and support from local 
corporations. Consequently, the apartments 
have been cost-effective. Drug-free housing 
must become an integral part of the contin- 
uum of care for women to succeed outside 
treatment. 

Cocaine-abusing women have a high risk of 
relapse for a number of reasons. Of the 
women in Operation PAR, 79 percent have 
experienced prior treatment failure, usually 
at 28- to 30-day treatment programs; 64 
percent are high school dropouts; 76 percent 
have poor work skills; 82 percent have a 
criminal record; most have at least one child; 
92 percent have multiple sexual partners; 
and 93 percent are single parents. A 
relatively high percentage of women in PAR 
Village have custody of their children during 
treatment and by the time they leave the 
program most obtain custody. However, 
women in the standard residency program 
who do not have custody of their children 
must participate in special State-mandated 
activities, such as seeking employment after 
they leave the program, in order to win 
custody. 

The program has changed drastically from a 
traditional therapeutic community to one 
specializingin women's needs andreintegrat- 



99 



NIDA Conference Highlights 



ing their spouses or partners into treatment. 
Again, it is critically important that pro- 
grams offer to serve as a laboratory for 
researchers in the field in order to explore 
and share new ideas and approaches. 

Speaker: Irma Strantz, Ph.D. 

The Uhuru Family Research Project is a 
collaborative effort conducted in Los Angeles, 
California, between the University of 
Southern California, the Watts Health 
Foundation, the Los Angeles County 
Department of Children Services, and the 
South Central Los Angeles Regional Center 
for Developmental Disabilities. Uhuru 
means "freedom" in Swahili. The research 
centers on an intensive 6-month day treat- 
ment program for drug abusers. The 
research subjects are women who have 
(1) been reported to the county child protec- 
tive services agency after giving birth to 
drug-exposed infants and (2) either volun- 
tarily or by court order entered drug treat- 
ment to receive custody of their infants. 

The research project aims to develop and 
refine, over time, a day treatment model for 
these women; evaluate the model's effective- 
ness as compared to outpatient drug treat- 
ment; and explore the relationships among 
the client characteristics, the level of treat- 
ment, and outcomes over an 18-month treat- 
ment and followup period. The project is 
trying to determine (1) the critical com- 
ponents of the day treatment model, (2) for 
whom this treatment is most effective, and 
(3) what impact client variables have on 
predicting treatment compliance and short- 
and long-term outcomes. Upon referral, 
subjects are assigned randomly to either the 
intensive day treatment or the traditional 
outpatient programs. Basic services at each 
site include the following: social and health 
assessment, individual and group counseling, 
Narcotics Anonymous, random urine toxi- 
cology screening, case management, parent- 
ing education, and alumni activities. The 
outpatient treatment consists of 1 to 2 hours 
of services Monday through Friday, whereas 
the day treatment program provides 6 hours 
of services 7 days per week. Infants attend 
the day treatment program with their 
mothers twice a week. 

The day treatment program represents a 
multipronged, cognitive behavioral approach 
to women with drug dependency and focuses 
on women's psychosocial needs, particularly 
regarding empowerment. The clients receive 



4 hours per week of education on drug abuse, 
recovery, relapse prevention, managing 
internal and external triggers, interpersonal 
skills, AIDS awareness, family planning, 
housing, and other topics — many of which 
also are addressed in group counseling. The 
study found that mothers often do not know 
how to care for their children — a pediatric 
nurse specialist now provides 4 weeks of 
training and education to parents on infant 
development. The entire parent education 
class consists of a 12-week curriculum, focus- 
ing on the social learning process and effec- 
tive approaches to discipline. Completion of 
this training program is mandatory for 
women in the day treatment program, who 
also may participate in self-help groups, 
family counseling, self-improvement activi- 
ties, and vocational assessments. This 
approach is based on research demonstrating 
that effective treatment for cocaine abusers 
includes a structured treatment program, 
individualized treatment plans, small coun- 
selor caseloads, daily individual or group 
counseling, support for abstinence, life skills, 
empowerment training, and family involve- 
ment in the treatment process. 

Data from this project are collected in 
several ways, including client interviews, 
developmental assessments of infants, infant 
and family risk assessments, and other 
in-treatment data from records or the women 
themselves. Several well-established instru- 
ments are used, including the following: the 
Coping Strategies Inventory, which reflects 
at least seven dimensions of coping; the 
Sareson Social Support Questionnaire, which 
looks at the respondent's perception of avail- 
able social support; and the Social Provision 
Scale, which assesses six social functions 
that may be obtained from relationships with 
others. 

Data currently exist on 180 women who 
enrolled in the project. Most of the enrollees 
are African-American women, with an aver- 
age age of 30 and an average of 3.6 children. 
More than one-half of the enrollees have at 
least a high school education, but 72 percent 
were unemployed prior to pregnancy. Ninety 
percent have used cocaine regularly. During 
the initial years of the project, the client 
retention rate was lower than expected, with 
47.8 percent of day treatment clients and 
14.3 percent of outpatient clients graduating 
from the 6-month program. The most fre- 
quently reported barriers to staying in treat- 
ment were related more often to personal 



100 



Summaries of Research Awareness Seminars 



decisions than to program restraints or 
practical problems. 

Most of the women have a small ring of 
social support, primarily consisting of family 
members. Deficits in perceived family sup- 
port occurred mainly when the women were 
emotionally upset. Graduates of the program 
usually have a larger support group, par- 
tially reflecting treatment contacts such as 
counselors. Also, the women generally 
improved both their coping strategies and 
use of social support. While the intensive 
day treatment model is demanding in both 
time and effort, it is more rewarding to 
participants. 

Questions, Answers, and Comments 

Comment: Of particular concern right now is 
the rapid increase of HIV among women. 
Also, many studies show that women on 
drugs are more often abused, depressed, and 
in need of long-term treatment than are 
men. More studies are looking at these 
kinds of gender differences in drug abuse 
research. To address these issues, services 
for women must be provided in a compas- 
sionate, persistent, and comprehensive 
manner. Addiction services need multidisci- 
plinary providers working toward the same 
goal of helping the women recover. Compre- 
hensive services are needed to address the 
multitude of issues related to women and 
address these problems during the many 
stages of a woman's lifecycle. These issues 
must be examined in a scientific manner in 
order to make sound clinical decisions and 
influence public policy. 

Comment: Ongoing gynecological examina- 
tions for women are important but usually 
not offered in most drug treatment programs. 
The high rate of sexual activity with multiple 
partners among many of the women could 
lead to many health problems, such as cancer 
of the cervix. Most cocaine users also are 
cigarette smokers, and much of the birth- 
weight discrepancy among cocaine-using 
mothers actually could be attributed to 
nicotine exposure. Thus, the long-term 
adverse health habits that accompany the 
drug lifestyle must be studied and more 
longitudinal studies must be funded. 

Comment: The issue of HIV and 
crack-cocaine use with multiple partners is 
relevant to geographical location. For 
instance, in New York City, the highest risk 
factor for HIV infection in women is 
crack-cocaine use associated with multiple 



sexual partners, but in Boston, women are 
not as involved in prostitution at crack 
houses. 

Comment: In a program in New York City, 
funded by the Child Welfare Administration, 
mostly older women with several children 
have been coming in for treatment. These 
women are successful in the program, not so 
much in order to keep custody of their child- 
ren but because they are tired of the lives 
they have been leading. The younger women 
are not as prepared to give up their drugs. 
Many studies on addiction treatment have 
shown that the length of time in treatment 
correlates with successful outcomes. Prior 
treatment experience is an important com- 
ponent in the success of current treatment, 
[hus, the challenge is to provide younger 
vomen with treatment experience early in 
cheir addiction. 

Comment: Most of the high-risk units in the 
Uhuru Family Research Project are for 
women who have been reported for the first 
time for giving birth to a drug-exposed 
infant. At this point, no correlation has been 
found between the length of stay in treat- 
ment and the age of the mother. However, 
court-ordered mothers have been harder to 
engage and keep in treatment. 

RS26. Treatment for Pregnant and 
Postpartum Women and Their 
Infants 

Moderator: Loretta Flnnegan, M.D. 
Speakers: Shirley Colettl 

Karol Kaltenbach. Ph.D. 

Sidney Schnoll. M.D.. Ph.D. 
July 16. 8:30 a.m.— 10:00 a.m. 

Speaker: Loretta Finnegan, M.D. 
During 1989 and 1990, NIDA funded a total 
of 20 research demonstration projects to 
examine the nuances of care of pregnant, 
drug-dependent women. The projects exist 
in 17 cities throughout the country. In June 
1994 NIDA will hold a conference to present 
project findings. In providing care for preg- 
nant, drug-dependent women, it is important 
to combine primary care, substance abuse 
treatment, mental health services, and HIV/ 
AIDS services. Consequently, many individ- 
uals must be involved in that care, encom- 
passing, for instance, a "vital dozen": 
(1) general medical doctor, (2) psychiatrist, 
(3) obstetrician, (4) gynecologist, (5) pharm- 
acist, (6) nurse, (7) counselor, (8) social 
worker, (9) child development specialist, 



101 



NIDA Conference Highlights 



(10) child protection worker, (11) legal con- 
sultant, and (12) outreach worker. 

Speaker: Karol Kaltenbach, Ph.D. 

During the past 20 years, a treatment model 
for pregnant, substance-abusing women has 
been in development. In particular, new 
strategies are being identified for pregnant, 
cocaine-abusing women. The research 
demonstration project "Cocaine, Pregnancy 
and Progeny" evaluates the efficacy of resi- 
dential treatment compared with outpatient 
treatment for pregnant, cocaine-dependent 
women. The program offers a drug-free, 
supportive environment for cocaine-depen- 
dent, pregnant women and their children for 
up to 2 years, in addition to long-term treat- 
ment, such as vocational and educational 
training, to help integrate the women into 
the community. Data on the program will be 
analyzed and presented in 1994. 

A biopsychosocial therapeutic treatment 
strategy with group and individual therapy 
at the core is used in both the outpatient and 
residential treatment models. All other 
services are provided within this therapeutic 
context, including biological and physiological 
services, such as obstetric, pediatric, medical, 
and psychiatric care. 

Too often clinicians overlook the significance 
of each service for this target population. 
For instance, in addition to intensive thera- 
peutic treatment, women need assistance 
with life skills management, problem solving 
techniques, and parenting skills. "Survival 
management," or attendance to basic 
needs — such as housing, food, and 
clothing — are imperative upon admission to 
the program. In fact, housing has been 
shown to be one of the most critical variables 
associated with retention and success in 
treatment. Thus, this program's examination 
of the effectiveness of residential care is very 
significant. The program also maintains a 
food and clothing bank in order to meet the 
participants' basic needs, at least tem- 
porarily. In addition, staff act as social 
service liaisons for the women with both the 
judicial system and DHHS. 

To meet the residential program criteria, 
women must be pregnant upon admission 
and have one or two children under age 5. 
Since few of the women actually have cus- 
tody of their children, who may be with 
foster care or kinship foster care, the pro- 
gram tries to reunite the family. For 
instance, during the first year the program 



provides a safe environment in which the 
children may visit their mothers and the 
mothers can learn caring skills. The pro- 
gram also is working on providing 
gender-specific treatment based on sociologi- 
cal considerations, social class, racially and 
culturally sensitive issues, and frequent 
social dependency of women and its impact 
on their decisions. 

Another program goal is the optimal develop- 
ment of the women's children. In addition to 
meeting the primary needs of obstetric and 
medical care for newborns, program services 
are designed to improve relationships 
between mothers and their children. During 
the newborn period, mothers are shown how 
to adapt their behavior to their infants' cues, 
to develop care-giving strategies, and to 
participate in well-baby care and immuni- 
zation programs. A pediatric nurse advocate 
spends time at the residential program and 
conducts home visits for outpatient women. 
In both the outpatient and residential pro- 
grams, parent-child centers staffed by early 
childhood specialists provide educational 
intervention services for mothers and chil- 
dren, including child-focused and parent- 
child group interventions. A parent support 
group also is conducted by one of the thera- 
pists and an early childhood specialist. 

Speaker: Sidney Schnoll, M.D.. Ph.D. 

The program presented in this session both 
challenges and supports the existing myth- 
ology of the field. The program is primarily 
an outpatient program that also offers super- 
vised transitional housing for women, child 
care, and transportation, all of which are 
critical to successful treatment. The pro- 
gram has encountered unexpected problems 
in the provision of child care because of 
failure to account for the women's large 
number of children. Once the women enter 
treatment, they regain custody of their chil- 
dren. This has caused an overload in the 
child care center to the point where some 
women have not been admitted to the pro- 
gram because of lack of room for their chil- 
dren. Similarly, the unexpected increase in 
the number of children has overcrowded the 
program's van service. Thus, other programs 
should be made aware of these potential 
problems. 

The program's research design includes two 
identical services delivered by the same staff, 
with one group limited to 5 months of treat- 
ment and the other group self-paced for up to 



102 



Summaries of Research Awareness Seminars 



18 months. Data also are being collected on 
"treatment rejectors" (i.e., women who were 
identified with problems that qualified them 
for admission but who rejected treatment). 
For instance, it was found that within 
6 months of identifying the treatment reject- 
ors, 90 percent of them were incarcerated. 
Consequently, such women ultimately end up 
costing society a large amount of money if 
not treated. 

Most of the women in treatment have a high 
rate of sexually transmitted diseases (with 
HIV likely to follow). Ninety percent of the 
women are susceptible to psychiatric dis- 
orders, primarily cluster B, including border- 
line antisocial personality, and 25 percent of 
them are depressed at the time of admission. 
The average IQ is 85, with 25 percent of the 
women being mildly or moderately mentally 
retarded. Most of the women five in danger- 
ous, high-crime neighborhoods, virtually all 
are single at the time of admission, and 
about 5 percent have been married. Most of 
the women have not finished high school or 
been employed. 

Several forthcoming papers include data 
from retention studies conducted on the 
program. For instance, preliminary results 
show that older women tend to stay in treat- 
ment longer than younger women; almost all 
of the younger women leave the program 
within 4 months, indicating the possible need 
for different service models for this popula- 
tion. Also, data show that women who enter 
the program during their first trimester of 
pregnancy stay in treatment much longer 
than women who enter during the second or 
third trimester or postpartum. While the 
program admits women up to 6 months' 
postpartum, the women may not feel as moti- 
vated to stay in treatment at that point. 
Additionally, women living in the transi- 
tional housing stay in treatment for a much 
longer period. And, although the mythology 
in the field dictates that women must be 
willing to enter the program voluntarily, 
data indicate that women with legal prob- 
lems stay in the program longer than women 
without legal problems. Thus, appropriate 
use of legal coercion may be helpful in get- 
ting women to enter and stay in treatment. 
Another finding, with great funding implica- 
tions, is that the more treatment women 
have had, the more likely they are to stay in 
treatment. Outcomes still are unclear, but 
retention at least seems to be affected posi- 
tively, possibly due to women's increased age 
and maturation. 



Differences in retention figures initially were 
found among treatment groups. Upon 
admission to the program, women were 
randomly assigned to either the self-paced 
program, which required a minimum stay of 
8 months, or to the time-limited program, 
which had a maximum stay of 5 months. 
When it was found that women assigned to 
the self-paced program perceived themselves 
as "sicker" than the other women because 
they had been assigned a longer treatment 
time, the minimum time in the self-paced 
treatment program was changed to 5 months 
in order to be consistent with the 
time-limited treatment's minimum stay 
requirement. Subsequently, retention results 
evened out among the groups. 

Contrary to common perception, it was found 
that antisocial personality disorder is not as 
negative a factor in the treatment of women 
as it is with men. Also, the presence of Axis 
I or Axis II disorders, low IQ, or depression 
did not appear to have an effect on retention, 
contrary to expectations. Consequently, 
these data indicate that different programs 
may be needed for women, since women 
appear to respond differently than men to 
some factors and treatments. 

Speaker: Shirley Coletti 

PAR Village in St. Petersburg, Florida, was 
constructed using 14 houses that the county 
had planned to demolish for a road. County 
officials were persuaded to donate the houses 
to Operation PAR and to donate $350,000 to 
move the houses onto the program's prop- 
erty, adjacent to an existing therapeutic 
community that occasionally had treated 
pregnant women. Operation PAR already 
had been providing detoxification services, 
day treatment, outpatient care, and after- 
care. PAR Village was developed to offer a 
highly specialized residential component for 
women and their children and is now raising 
numerous children. NIDA research is cur- 
rently being conducted to examine the reten- 
tion of women in treatment when their 
children are with them as compared to the 
retention of women in treatment without 
their children. In the study design, women 
may enter the standard treatment center 
(TC) or TC Plus (PAR Village) for 18 months. 
Followup is conducted at 2, 6, and 12 
months. Most treatment centers were devel- 
oped years ago for male, criminal justice 
populations; however, it has become 
apparent that gender-specific treatment with 



103 



NIDA Conference Highlights 



other services, such as medical, vocational, 
and educational components, are needed for 
women and their children. 

At PAR Village, family case management 
staff identify, assess, and manage cases, as 
well as refer women. Each month the staff 
manage the cases of at least 100 women and 
their children (the women have an average of 
three to four children) and simultaneously 
handle 30 new assessments. Many of the 
women in the program are dually diagnosed: 
(1) they are survivors of rape, incest, or 
family violence and (2) they have low educa- 
tional and vocational skills. Also, most of the 
women live in dangerous environments with 
inadequate support systems. Although PAR 
Village offers a 148-bed residential program, 
the women still face the problem of a short- 
age of treatment beds and child care. 
Unfortunately, Medicaid pays for expensive, 
inpatient, 28-day "miracle" programs that 
often do not help women, but it does not pay 
for long-term residential programs, which 
seem to be more effective. 

Pregnant women are priority clients for PAR 
Village, partly because of State mandates 
and partly due to program policy. The faster 
that one responds to pregnant women who 
are using drugs or alcohol, the more likely 
that services will benefit both the mothers 
and their children. Outcomes are far more 
positive when women receive treatment 
within 48 hours of referral. Due to prioriti- 
zation, however, many women have to wait 
for services. Although efforts are made 
during this time to help the women through 
home visits and other contacts in safe places, 
patients eventually suffer from limited staff 
and resources. When women have to wait 
for treatment, positive outcomes are greatly 
diminished. Housing and transportation are 
perhaps the two most important aspects in 
the continuum of care for women. It is 
difficult both to locate and to bring into 
treatment some of the women who keep 
moving from home to home. Staff try to 
maintain patient contact in order to give 
women the opportunity to learn to trust and 
bond to staff and to involve them in preven- 
tion and pretreatment services. 

Although ideally treatment on demand 
should be made available, more funds are 
needed. Also, once demonstration projects 
are completed, money must be channelled 
into programs that have been shown to be 
effective. Many women are appropriate for 
Operation PAR's day treatment, which is 



highly successful in meeting many of their 
needs. The developmental day care center 
for mothers of both types of treatment is very 
supportive and educational, providing both 
GED (general equivalency diploma) and 
vocational training. 

The NIDA research conducted at PAR Vil- 
lage shows that allowing women to enter 
treatment with their children improves 
retention. The whole person, including the 
diverse aspects of the person's life, must be 
treated. It cannot be expected that all the 
women involved in the program will have 
common knowledge and skills. For instance, 
many of the women in treatment did not 
understand how to read a thermometer, and 
72 percent of them had never had a driver's 
license. Driving lessons are now offered so 
that the women can acquire the ability to 
transport themselves. 

Women must feel comfortable in treatment. 
Staff must be trained with a philosophy of 
professional caring. The more engaged 
women are in treatment, the better the 
prognosis for their success. 

Questions, Answers, and Comments 

How do you explain the process of random 
assignment to women in treatment, who 
might be upset when they are not assigned to 
the preferred treatment, such as PAR Village? 
Random assignment is a difficult task. The 
principal investigator for PAR Village is 
extremely understanding and has assisted in 
maintaining the integrity of the science. At 
first the research did not seem worth the 
trouble of randomly assigning women to one 
of the two treatments. Protocol was modified 
to allow women to bring their children in 
during inpatient treatment two to three 
times a week. After 3 years of random 
assignment for the research, the program 
now makes nonrandom assignments. De- 
spite the trouble involved in random assign- 
ment, without such a procedure neither the 
science nor the money would have been 
available to the facility. 

At another program, clinical staff tried to 
subvert random assignment efforts, so their 
activities had to be monitored. Unfortu- 
nately, some staff members had to be termi- 
nated because of their problems with the 
process. It is difficult for people to under- 
stand the rigorous needs of research. How- 
ever, without random assignment, the 
research data are meaningless. 



104 



Summaries of Research Awareness Seminars 



How has Florida's aggressive prosecution of 
pregnant, drug-abusing women impacted 
Operation PAR, and how do programs pro- 
vide culturally sensitive services for African- 
American women? Operation PAR is very 
culturally sensitive. About 80 to 85 percent 
of the women in treatment are African- 
American; therefore, the program has many 
minority staff members and provides exten- 
sive training in cultural sensitivity. Florida's 
aggressive policy was more problematic for 
the prosecutor than for Operation PAR. The 
State's attorney was cofounder of Operation 
PAR, and he was committed to both helping 
the women and upholding the law. The 
policy seems to be less aggressive now; many 
hospitals have stopped identifying and test- 
ing drug-abusing, pregnant women, and 
officials are attempting to work within a 
middle ground. In Virginia, legislators who 
had written the law about drug-abusing 
women's culpability with regard to their 
children wrote to a judge stating that they 
never intended the law to include in utero 
delivery, and the judge threw related cases 
out. Thus, individuals concerned about such 
aggressive policies may look for cooperation 
from State legislators. 

It is important to keep in mind that the 
treatment model, as well as the organization 
itself, must be culturally sensitive. 
Resources on this issue include two publica- 
tions on cultural sensitivity developed by 
CSAP (call 301-443-0365) and a compendium 
of State laws developed by Lewin-ICF, a 
N IDA contractor. CSAFs Perinatal Resource 
Center can be contacted for these 
publications. 

Are there other solutions to random assign- 
ment? Currently much debate exists on the 
necessity of random assignment. It is pro- 
bably one of the cleanest processes for scien- 
tific research. An AB washout design could 
be used, in which all patients are assigned to 
one treatment, then participate in a washout 
period with treatment as usual, and then are 
assigned to another treatment. More dif- 
ficult methods also exist. It would be best to 
talk with a biostatistics professional about 
current, effective techniques without random 
assignment. 

What kind of uncertainty is necessary to do a 
random design study? There is little efficacy 
about anything right now. Most of the field 
is built on myths that have become dogma; 
therefore, it is important to step back and 
determine whether certain kinds of treat- 



ments really are effective. However, there is 
much resistance to this process in the field. 
Nonetheless, the efficacy of random assign- 
ment needs to be examined, and random 
assignment must be used to gather infor- 
mation and help make decisions about other 
treatment models. It is a difficult process 
that should begin immediately. Otherwise, 
problems from managed care will occur. 

RS27. Aftercare and Relapse 
Prevention 

Moderator: Barry Brown. Ph.D. 
Speakers: Sherilynn Spear, Ph.D. 

Fred Zackon. M.Ed. 
Respondent: Stephen Bartz 
July 16. 2:30 p.m.— 4:00 p.m. 

Speaker: Sherilynn Spear, Ph.D. 

Numerous issues need to be considered when 
designing aftercare programs for chemically 
dependent adolescents, particularly in how to 
sustain gains made in primary treatment 
once the adolescents return to their home 
communities. Not much is known about 
posttreatment functioning of adolescents or 
of their patterns and rates of relapse fol- 
lowing treatment. A common view of after- 
care is that it focuses on helping adolescents 
make the transition from participating in 
primary treatment to functioning drug free 
in the community. Generic tasks in making 
that transition include increasing the effec- 
tiveness of adolescents' functioning in the 
community and helping them to build a 
social support network. 

A NIDA-funded study followed 117 adoles- 
cents (two-thirds were male) for 1 year after 
they completed a 30- to 35-day residential 
treatment program. Data sources included 
clinical files, random urine screens, as well 
as interviews with the adolescents and at 
least one parent four times during the year. 
The participants' average age was 15, and 80 
to 90 percent of the adolescents lived in 
households with someone who was either 
chemically dependent or a heavy drug user. 
Most of the adolescents said that they used 
drugs most frequently at home or at school. 
Within the first day of their return to school 
following treatment, many reported that they 
were offered drugs. Thus, findings indicate 
that adolescents face enormous difficulties in 
trying to remain drug free and in developing 
a strong social support network. Also, other 
problems in addition to drug use, such as 
physical and sexual abuse or psychiatric 



105 



NIDA Conference Highlights 



disorders, often persist after treatment. 
Therefore, aftercare must attend to the same 
range of problem behaviors as treatment 
programs. 

Ninety-two percent of the adolescents in the 
study used drugs at least once in the first 
year after treatment, while 62.2 percent of 
the adolescents (41 percent of the girls and 
75 percent of the boys) returned to their 
pretreatment usage levels (i.e., weekly or 
multiweekly use). Another study, conducted 
by Sandra Brown, found that 56 percent of 
the adolescents returned to their pretreat- 
ment levels of use within 6 months of exiting 
treatment. It was found that the time of 
greatest risk for relapse was during the first 
3 months after treatment. Thirty-four per- 
cent of the adolescents dependent only on 
alcohol returned to pretreatment levels of 
use, whereas 74 percent of marijuana-depen- 
dent adolescents resumed use at pretreat- 
ment levels. 

Research staff attempted to find pretreat- 
ment variables that could help in the early 
identification of adolescents at the greatest 
risk for returning to pretreatment use levels. 
Among girls, those characteristics included a 
history of delinquency, pretreatment drug 
use in three or more different situations, and 
a family history of alcohol abuse. For boys, 
the predictive characteristics included a 
history of drug-related arrests, a pretreat- 
ment level of drug use of four or more times 
a week, and the choice of cocaine as the first 
drug of use. Although these data are pre- 
liminary, they should encourage practitioners 
to recognize that they are working with a 
very heterogenous group of people, and that 
girls and boys may require different 
approaches. 

It is encouraging to note that of the 62 per- 
cent of adolescents who returned to pretreat- 
ment levels of drug use, 34 percent only used 
drugs at that level for a short time period 
and then decreased their use to periodic 
instances or abstinence. This pattern is 
similar to the adult relapse process. 
Recovery may not involve linear progress and 
may include intermittent periods of heavy 
use. 

These data lead to several implications for 
aftercare programs. First, fairly intensive 
aftercare services should be provided to 
adolescents for the first 3 months after 
treatment, and at least some aftercare 
should be available throughout the first 6 
months. Second, clinicians may want to 



reconsider their policies and interventions in 
light of findings with regard to posttreatment 
drug use. For instance, agencies that restrict 
services from individuals who keep or 
resume using drugs may want to rethink 
such a policy. Third, program staff should 
consider how these relapse patterns should 
impact program design and how both clini- 
cians and adolescents should be prepared to 
handle such patterns. Fourth, practitioners 
should recognize that drug use occurs in the 
context of many other problems and that, 
therefore, aftercare program designs must be 
as complex as treatment program designs. 
Finally, it is critical to link adolescents to 
support networks that will help them con- 
tinue the recovery process despite being in 
drug-using environments, such as their 
homes or home communities. 

Speaker: Fred Zackon, M.Ed. 
When the Recovery Training and Self-Help 
(RTSH) model was begun at the Harvard 
University School of Public Health in the 
early 1980s, it proved important to bring 
together as many well-recovered individuals 
(i.e., drug free for 2 to 3 years) as possible to 
examine critical issues in their experiences. 
Based on the experiences of these indivi- 
duals, a tentative paradigm may be con- 
structed that indicates aspects of a "fulfilled 
recovery" (i.e., the state of being free of 
addictive behavior and leading a normal 
lifestyle). There may be a risk of relapse for 
people who have achieved a fulfilled 
recovery, but they are as recovered as the 
real world allows people to think of recovery. 

The following eight major factors typically 
are found in a fulfilled recovery: 

1. Commitment. — The individual is commit- 
ted through action, not just enthusiasm or 
desperation, to leading a functional life- 
style (i.e., by taking even simple but con- 
crete steps to accomplish what he/she 
wants to do). 

2. Spiritual centeredness. — The individual 
feels a part of something greater than 
himself/herself, whether it be God, a moral 
code, a political cause, or some other 
entity. 

3. Daily routine. — The individual has learned 
to be concerned with basic daily concerns, 
such as being punctual. 

4. Mainstream socialization. — The individual 
is comfortable with the world at large, not 
just with a recovery group. He/she can 



106 



Summaries of Research Awareness Seminars 



share information about himself/herself in 
regard to other issues besides recovery. 

5. Goal-directedness. — The individual is able, 
at some point and to some extent, to let go 
of social supports (i.e., the need for con- 
stant reaffirmation from others.) He/she 
is able to move in a chosen direction 
beyond the first steps of recovery. 

6. Reenjoyment. — The individual is able to 
derive pleasure from everyday activities, 
not just from drug use. He/she has 
learned to develop skill-based sources of 
satisfaction. 

7. Deactivation. — The individual has experi- 
enced a significant reduction in craving 
drugs, triggered by internal and external 
cues. He/she can deal with crises and 
stresses without having the physical reac- 
tion of desiring drugs. 

8. Self-reintegration. — The individual feels 
that recovery is a way of life, that it is a 
blessing, not a burden. He/she can talk 
about the past without dwelling on it with 
regret. 

All of these aspects are interrelated. Listen- 
ing to recovered people and learning from 
their experiences can provide important 
information about aftercare issues and ways 
to think about relapse prevention. 

Speaker: Barry Brown, Ph.D. 

As relatively recent phenomena, relapse 
prevention and aftercare have now become 
acceptable kinds of interventions to study. 
Still, impediments exist to initiating relapse 
prevention and aftercare programs. First, 
there remains limited development of after- 
care programs. Second, the prevailing phil- 
osophy that drug use is a chronic relapsing 
disorder suggests to both clients and staff the 
inevitability of posttreatment failure and the 
futility of aftercare programming. Nonethe- 
less, a study by Dr. Dwayne Simpson has 
shown that 18 percent of individuals dis- 
charged from drug treatment never return to 
drug use or the criminal justice system 
without need of further treatment. 
Researchers have shown that other individ- 
uals recover without the benefit of treatment. 
Thus, there is no justification and there is 
considerable harm in insisting that drug use 
is a chronic relapsing disorder. 

There is an enormous need to improve com- 
munity supports for drug-free living, such as 
changing expectations of and increasing 



assistance from families, employers, and 
school personnel. Programs also should work 
to develop peer groups for drug-free social 
support. Studies have shown that adoles- 
cents are more likely to remain drug free if 
they have a peer group available that avoids 
drug use and antisocial behaviors. 

With the threat of AIDS, the need for relapse 
prevention and aftercare strategies has never 
been greater in the field of drug abuse treat- 
ment. Professionals in the field have a 
special responsibility to develop extended 
aftercare programs for individuals leaving 
drug abuse treatment and the criminal 
justice system. To help posttreatment people 
handle the stresses and pressures to which 
they are exposed outside of treatment, after- 
care programs should be set up in the com- 
munity, with such services as case 
management, crisis counseling, and com- 
munity mobilization of support, including 
church groups and athletic organizations. 
Aftercare has enormous potential in provid- 
ing assistance in a tapered fashion to former 
drug abuse clients in order to help them, as 
well as protect members of their 
communities. 

Questions, Answers, and Comments 

Are any statistics available on the percentage 
of people who complete primary treatment but 
never make it to aftercare? Data do not seem 
to be available on this matter. It also is 
unclear how much of an effort aftercare 
programs make to engage treatment drop- 
outs, but such efforts are necessary. It 
seems reasonable to believe that these indi- 
viduals have made some commitment to 
behavior change if they entered a treatment 
program in the first place, but some 
researchers have decided that the treatment 
program is not the route to that change. It 
may be useful to come up with a develop- 
mental perspective on recovery that defines 
the markers in progress toward recovery. 
Also, it could be worthwhile for programs 
gradually to expose clients to the community, 
that is, to mainstream them in a continuous 
process, not one marked by distinct 
boundaries. 

Is the RTSH manual appropriate for lower 
functioning clients? The RTSH manual is 
not just for higher functioning people, but it 
does have a strong cognitive component and 
requires complex thinking. It is mainly for 
adults, and it foresees a developmental 



107 



NIDA Conference Highlights 



recovery track into adulthood, not just one 
aiming toward adulthood. 

Why is the term "aftercare" still used and not 
just considered one of many levels of treat- 
ment? Calling this type of service "aftercare" 
is an artifact of the past. Many people think 
that so-called aftercare should be considered 
an intermediary step in the recovery process. 

Has Dr. Spear's project studied the relation- 
ship between family functioning at intake or 
at discharge and outcome? Data collection 
was completed in May, but independent 
measures of family functioning are not avail- 
able. Some indicators of family histories of 
use were recorded, such as the level of family 
participation during the treatment phase. 
This is a complex area that needs further 
investigation; however, data are available 
from studies. For instance, Macro, a 
research firm, conducted a study several 
years ago which found that positive outcomes 
were associated with greater evidence of 
family support. In fact, a greater number of 
community variables should be studied for 
their relation to outcome. 

Is there a model for training substance abuse 
counselors effectively to help their clients in 
the community? It does not appear that such 
models currently exist. Manuals should be 
written on this important issue, and strate- 
gies should be tested for their efficacy. In 
Southeast Asia, however, where community 
seems to be valued more strongly, models 
have been developed to address community 
factors. It may be helpful for programs to 
look within their own locales and see if Asian 
community groups in the United States may 
be involved in modeling community support 
and training for staff. Furthermore, a NIDA 
monograph on case management that came 
out in 1990 also may be a helpful resource. 

Why do organizations such as Alcoholics 
Anonymous and Narcotics Anonymous not 
receive more attention in the discussion of 
relapse prevention and aftercare? These 
groups certainly are very important, but it 
also is important to address what they miss 
in their services. For some people, the 
12-Step fellowships provide sufficient after- 
care; other people, however, need more 
specialized services. It is true that the 
fellowships generally do not get their due 
from professionals who often are invested in 
other forms of treatment. The 12-Step pro- 
grams should be used more frequently in 
aftercare programs — for example, programs 



should invite the 12-Step groups into their 
existing facilities for meetings. 

It is difficult to convince many people, 
especially politicians, of the importance of 
spending money on services such as aftercare. 
Besides the schooling aspects of aftercare, 
what other aspects are good selling points for 
its services? Whereas 12-Step programs take 
in all people at all levels of recovery, 
so-called aftercare programs are intended for 
people with common needs at a particular 
point in recovery. These people need and 
should receive the expertise and speciali- 
zation that aftercare programs can provide. 
The 12-Step programs cannot do everything. 
Data increasingly show that rigorous and 
systematic programs can reduce relapse, so 
these data should be shared with the public. 

RS28. Effective Case Management 
Methods With Drug Addicts: 
Research-Based Approaches 

Moderator: Arthur MacNelll Horton, Jr., Ed.D. 
Speakers: Douglas Anglln. Ph.D. 

Peter Bokos. Ph.D. 

Steven Martin, M.A. 

Harvey Siegal, Ph.D. 
Respondent: Janet Lerner, D.S.W. 
July 17, 1 1:15 a.m.-12:45 p.m. 

Speaker: Peter Bokos, Ph.D. 

Interventions, an organization based in 
Chicago, Illinois, operates 15 to 18 programs 
in the city. One program is a central intake 
unit based on a triage methodology that 
refers approximately 8,000 people annually. 
To investigate impediments to bringing 
clients into treatment, a case management 
model was examined for its effectiveness in 
delivering services. The study discussed 
here aimed to determine whether case 
management can (1) enable clients to access 
treatment more quickly, (2) improve treat- 
ment retention among clients, (3) facilitate 
clients' ability to meet counseling goals, 
(4) more effectively reduce AIDS risk behav- 
ior, and (5) enable clients to complete treat- 
ment more efficiently and effectively. The 
. study also analyzed the cost-effectiveness of 
case management. 

The literature documents five core functions 
of various case management models: 
(1) assessment, (2) planning, (3) linking, 
(4) monitoring, and (5) followup. In addition, 
case managers provide advocacy for their 
clients. Using these core functions, Interven- 
tions' staff developed a problemsolving case 



108 



Summaries of Research Awareness Seminars 



management model, in which the case mana- 
ger and the client assess the client's current 
situation, determine the client's goals, 
develop a plan of action, review resources for 
the client, link the client with these 
resources, and monitor the client's progress. 
Overall, the three primary stages of case 
management are as follows: (1) treatment 
initiation, admission, and engagement; 

(2) treatment retention and completion; and, 

(3) maintenance of recovery. 

The sample for this study was 70-percent 
male and 85-percent African-American and 
had an average age of 41. All subjects used 
intravenous drugs and had 10 or more years 
of addiction history. The most frequently 
used drugs were alcohol, marijuana, cocaine, 
and opiates. The clients averaged three 
previous treatment experiences and multiple 
problems. Counselors and case managers 
addressed several access barriers, including 
lack of space and treatment locations; clients' 
inability to pay for treatment; difficulty 
contacting clients by telephone; lack of docu- 
mentation, such as social security cards; and 
comorbidity factors. The case managers 
attempted to reduce these barriers by paying 
for initial care, transportation tokens, hous- 
ing deposits, and other necessities. Essen- 
tially the case managers tried to do whatever 
was required in order to engage clients in 
treatment. 

On average, case-managed clients took 18 
days to enter treatment, while non-case- 
managed clients (i.e., the control group) took 
87 days. The former group also remained in 
treatment six times as long as the control 
group. Furthermore, clients in the case- 
managed group were more likely to stay out 
of jail and reduced their opioid, cocaine, and 
marijuana abuse. (Preliminary data indicate 
no differences between the groups in their 
use of alcohol.) 

Speaker: Steven Martin, M.A. 

A valuable resource on case management is 
NIDA Monograph No. 127, which details case 
management strategies for use in drug 
treatment. 

The program described here, the Assertive 
Community Treatment (ACT) for High Risk 
Parolees, operates in Delaware and involves 
a case management model for criminal jus- 
tice clients, particularly those in the Dela- 
ware prison system who have histories of 
drug use or risky sexual behavior placing 
them at high risk for HIV infection. Crimi- 



nal justice clients face a number of problems 
in addition to those faced by drug users and 
are in particular need of case management 
services. The linkage of clients with treat- 
ment, as well as with resources to help them 
find employment, begin educational or voca- 
tional programs, and reestablish home ties, 
is very important. The Delaware program is 
based on assertive community treatment, or 
assertive case management, a strategy that 
emerged in the early 1970s in the mental 
health field and that encourages counselors 
to be proactive and aggressive in helping 
clients deal with problems. The similarities 
between drug users and chronically mentally 
ill individuals suggested the value of similar 
approaches in their treatment. Both groups 
require a variety of services to rehabilitate 
them. An assertive continuity of care 
appears to be an appropriate treatment 
methodology for substance abusers, particu- 
larly ones who also are coming out of the 
criminal justice system and who are not 
likely to be self-starters in treatment. 

Clients in the Delaware project, or the ACT 
for High Risk Parolees, were required to 
have a previous history of chronic drug use 
that placed them at risk for HIV infection. 
Northeast Treatment Centers, based in 
Philadelphia, Pennsylvania, provided the 
treatment and case management services for 
the clients. The design for the ACT program 
included five stages over a period of 6 
months: (1) intake evaluation and assess- 
ment; (2) intensive drug treatment, including 
group counseling and family assessment 
therapy; (3) group counseling and life skills 
training; (4) relapse prevention; and (5) case 
management services to facilitate the clients' 
transitions into normal community life. 
Parolees with histories of high-risk behaviors 
were randomly assigned on release from 
prison to either the ACT project or conven- 
tional parole. Program staff also conducted 
interviews with the sample 1 year after 
completion of the program. Approximately 
456 subjects completed the baseline inter- 
views, and 258 subjects (114 in ACT and 144 
in the comparison group) also completed the 
6-month followup interview. 

Preliminary findings from this study were 
reported in the January 1993 issue of the 
Journal of Drug Issues. Analyses of the data 
have continued since that time, controlling 
for a number of covariates, in order to deter- 
mine whether any differences occurred 
between the two groups' rates of relapse, 
recidivism, and risky sex behaviors. The 



109 



NIDA Conference Highlights 



study controlled for age, gender, ethnicity, 
past history of drug use, past treatment 
history, previous arrest record, and length of 
time in treatment. (Many individuals in the 
comparison group may have received treat- 
ment on their own, sometimes more intensive 
than treatment in the ACT program.) Con- 
trolling for these factors, the ACT parolees 
were found to be no less likely than the 
comparison group to relapse to any illegal 
drug use or to be rearrested. However, they 
were less likely to relapse to injection drug 
use or to engage in unprotected sex. 

Several problems occurred in the implemen- 
tation of the Delaware project. First, it was 
funded under a Federal research demonstra- 
tion project, with such restrictions as volun- 
tary participation, which severely impacted 
client retention. Many clients never made 
contact with the project staff, failed to 
engage fully in the program, or dropped out. 
Another difficulty concerned the random 
assignment of clients to the program. Some 
inmates who wanted to participate in the 
ACT program were assigned to regular 
parole and vice versa. Finally, the interven- 
tion turned out to be less assertive than 
originally expected. ACT counselors and 
case managers were less willing to reach out 
to clients who, in some cases, were trying to 
avoid treatment and who occasionally scared 
the counselors. 

Despite these limitations, the ACT program 
reduced injection drug use and HIV risk 
behaviors in a difficult treatment population. 
The analyses suggest that outpatient case 
management may not be ideal for primary 
treatment of new releasees with extensive 
histories of drug use, who have numerous 
problems compounding treatment issues. 
Long-term residential treatment may be 
more appropriate for this group. Assertive 
case management could be more effective as 
an aftercare approach following more inten- 
sive primary treatment. Also, case manage- 
ment, combined with legal sanctions man- 
dating treatment, would be very beneficial as 
well. 

Speaker: Harvey Siegal, Ph.D. 

The concept of case management is a very 
exciting breakthrough in drug abuse treat- 
ment. The "strengths" model of case 
management discussed in this session, 
for example, can greatly enhance drug 
treatment. 



NIDA's mandate in funding case manage- 
ment demonstration projects focused on 
increasing the number of treatment locations 
available and on strengthening the drug 
treatment process. Two fairly common pro- 
blems affect drug treatment. First, many 
people withdraw early from drug treatment. 
Second, and more significantly, many people 
do not comply with treatment and stop mak- 
ing progress. Case management presented a 
way to deal with these problems. Volumi- 
nous literature exists on case management, 
but there is not much agreement on its 
scope. Some researchers consider case 
management as a process or method for 
ensuring that clients are provided with 
whatever services they need. Case manage- 
ment is a general focused, rather than nar- 
row focused, intervention. Consequently, the 
"whole client" is addressed, rather than just 
the client's drug use. 

Quite simply, case management seems to 
work well when it actually is in operation, 
but not when it stops. Gains made during 
case management among mentally ill people 
rapidly deteriorate when case management 
ends. Individuals who receive case manage- 
ment tend to benefit in terms of services 
accessed, more productive leisure time, more 
employment, and better overall adjustment. 
Furthermore, case management has been 
shown to work best with the most problem- 
atic cases, and it seems to facilitate the 
securing of more services for the client. 
Unfortunately, however, case management is 
difficult to evaluate. 

The NIDA-funded case management model 
developed in Ohio primarily targeted Viet- 
nam veterans addicted to cocaine and crack- 
cocaine. Many of these individuals had 
histories of extensive alcohol and marijuana 
use, but it was not until they began using 
cocaine and crack-cocaine that they seemed 
to lose control of their lives and sought 
treatment, which typically they could access 
only through the Veterans' Administration 
(VA) Medical Center. The case management 
program supplemented the services that they 
were receiving at the VA Medical Center. 

This model used the "strengths perspective." 
Because the systemic application of case 
management is very new in the drug treat- 
ment field, most models have been derived 
from the mental health field. The strengths 
perspective, developed by Rapp and 
Chamberlain during the mid-1980s for indi- 
viduals being deinstitutionalized from mental 



110 



Summaries of Research Awareness Seminars 



health facilities, focuses on the positive 
aspects of the patients' lives, as well as the 
strengths and abilities they can use in their 
recovery and achievement of life goals. In 
the NIDA-funded project, this perspective 
was used in tandem with drug treatment. 
The case managers did not review their 
clients' medical records before meeting with 
their clients for the first time in order to 
facilitate unbiased meetings. Subsequently, 
the first two contacts focused on developing 
assessments of the clients' strengths. At the 
third or fourth meeting, the case managers 
helped the clients develop comprehensive 
plans focusing on achievable objectives in 
major life areas. Finally, for the 6-month 
tenure of treatment, the case managers 
helped the clients progress toward their 
goals. 

Preliminary data indicate that this case 
management approach works. The research 
design involved the random assignment of 
clients entering the VA Medical Center drug 
program — with some restrictions such as an 
existing psychotic condition or overriding 
medical problems — to one of several treat- 
ment options, which included (1) regular 
drug treatment plus case management, 
(2) regular drug treatment, or (3) regular 
drug treatment plus pretreatment induction. 
Clients were assessed at 6, 12, and 18 
months. As of July 1993 almost 400 people 
were in the study. Data suggest that case 
management appears to accomplish at least 
its intermediary objectives of meeting the 
clients' goals. In fact, clients overwhelmingly 
achieved the goals that they had developed 
in their first few meetings with their case 
managers. 

In conclusion, the strengths model of case 
management was well accepted by the VA 
drug treatment program as an alternative to 
its previously used disease-based medical 
model. Both the case managers and the drug 
treatment staff worked well together, and 
the drug treatment patients positively 
accepted their case managers and the case 
management process. The strengths model 
proved to be understandable, acceptable, and 
implementable by a wide range of profes- 
sionals who served as case managers. 

Speaker: Douglas Anglin, Ph.D. 

Despite its apparent success in many 
research demonstration projects, case 
management is not an easy process in "the 
real world." A case management design that 



currently is being used in Los Angeles, Cali- 
fornia, with high-risk narcotics addicts 
enrolled in a methadone maintenance pro- 
gram revealed that case management iB 
applicable only in a general mode. It is 
important to keep in mind several points 
when trying to maximize the potential of a 
case management approach. In any geo- 
graphical area in which a program may be 
established, there are several levels of avail- 
able services, including the area's social 
services system external to the program, the 
area's treatment system, the program's array 
of services, the case manager or counselor, 
and the recipient of these services — the 
client. Unfortunately, at the top level, the 
social services system in many areas, and 
certainly in Los Angeles, is deteriorating. 
For instance, case managers have become 
exceedingly frustrated by clients' inability to 
receive the medical care that they need and 
by the fact that shelters are overflowing and 
low-cost housing is becoming less available. 
Valuable resources for both clients and case 
managers, such as the education system, are 
becoming more difficult to access. An equity 
problem exists in many social services sys- 
tems: Case managers end up becoming 
service providers, but they have limited 
resources. Many people who do not have 
case managers advocating for them do not 
get the services they need. Therefore, while 
case management can upgrade the effec- 
tiveness of current resources, there is a 
ceiling to the potential benefits available 
until social services and treatment services 
are built up again. Thus, this is an impor- 
tant policy goal at the Federal, State, and 
county levels. 

A case manager has more control at the 
program services level if the program pro- 
vides a wide array of services. Although 
these services also are limited, program staff 
can set priorities based on different clients' 
needs. It also is important at this level to 
consider the cost-effectiveness of adminis- 
tering limited services and resources. It is 
important but difficult to impose cost-effi- 
ciency measures on case management. 

When the first 200 clients admitted to the 
Los Angeles project did not demonstrate 
better retention than the control group, the 
staff surmised that the program had over- 
whelmed patients, particularly older 
entrenched addicts, with too large an array 
of services. However, depressed and younger 
clients appeared to benefit from the attention 
of this imposed support network. Therefore, 



111 



NIDA Conference Highlights 



assessment and staging are important com- 
ponents in providing cost-effective services. 

The intersection of program services and 
counselor characteristics in an area that 
requires further investigation. It seems that 
many professionals in drug abuse treatment 
services simply are not effective in their 
positions. A good therapist must be born and 
built by life experiences; even with training, 
some people should not be counselors. How- 
ever, unions and grievances committees keep 
ineffective counselors on staff. While creden- 
tialing and licensing procedures may upgrade 
the pool of counselors who can manage coun- 
seling tasks, perhaps personality assess- 
ments could better assess counselors' 
qualifications. 

In addition, clients who receive treatment 
over and over, with no positive effects, 
should be placed "on the backburner" of 
programs and checked periodically until they 
seem more receptive to treatment. Stringent 
Federal regulations may not provide enough 
clinical judgment and, for example, may 
mandate that these clients receive consistent 
services; nonetheless, these kinds of policies 
often detract services from other individuals 
who truly may benefit from them. The drug 
treatment system faces more strict regula- 
tions than other fields, such as medicine or 
psychotherapy, making cost-effectiveness 
difficult to achieve. Debate on such policy 
issues must continue. 

Questions, Answers, and Comments 

Have any of these research projects focused 
on the extended family system? The central 
intake program in Chicago is looking at 
about 13 life domains, one of which is family 
systems. 

The Delaware project, which works with 
criminal justice clients, specifically looks at 
family circumstances. About 70 percent of 
the sample is single; therefore, the family 
primarily includes parents and siblings. 
Family therapy is offered in the treatment, 
and staff are studying the impact of family 
on treatment success. 

In the Ohio study with Vietnam veterans, 
the goals and case management plans are 
client driven. Family systems are included 
in the plan if the client desires; otherwise, 
the issue is not addressed. 

In the Los Angeles case management model, 
family information is obtained only from the 
subjects. However, if an addicted couple is 



interested, staff try to encourage them to 
participate in the program and randomly 
assign them to the experimental or control 
group. Sometimes the best action for clients 
involves separating them from a dys- 
functional family. 

What is the role of the family system in 
relapse? It depends on the individual case. 
Some families could be harmful and should 
be separated from the client, whereas other 
families are supportive and may help prevent 
relapse. Certainly it has been found that 
stressful incidences involving the family are 
associated with relapse. Sometimes pro- 
grams can try to service family members 
(e.g., their mental problems such as depres- 
sion) as a way to build support clients. 

Please elaborate on the difficulty in evalu- 
ating case management programs. NIDA 
Monograph No. 127 is a good resource on 
this problem, as is a review of the evaluation 
of case management disseminated by the 
NIAAA. A careful process evaluation, 
describing interventions, is important, along 
with implementation analysis, staff analysis, 
and outcome analysis. 

How was the strengths model of case 
management integrated into counseling? 
Case management and research staff spent 
considerable time orienting the counselors to 
the model and holding joint meetings. Some 
disagreements occurred — for example, the 
case managers viewed certain behaviors 
positively, while the counselors viewed them 
negatively. The case managers initially were 
perceived as enablers. The fact that many 
case managers were recovering addicts eased 
the relationship between the two staffs. 

RS29. Improving Drug Abuse 
Treatment: Findings from 
NIDA's Research Demonstration 
Projects 

Moderator: Frank Tims, Ph.D. 
Speakers: George De Leon. Ph.D. 

Jerome Piatt. Ph.D. 

Dwayne Simpson, Ph.D. 
Respondent: Eric Bamford, C.A.C. 
July 15, 1:15 p.m.— 2:45 p.m. 

Speaker: Dwayne Simpson, Ph.D. 

The Drug Abuse Treatment for AIDS Risk 
Reduction (DATAR) demonstration project 
involves a collaboration between outpatient 
methadone programs in Dallas, Houston, and 
Corpus Christi, Texas, providing services for 



112 



Summaries of Research Awareness Seminars 



approximately 1,000 heroin addicts. The 
DATAR project aims to gain an under- 
standing of contributions to early stages of 
recovery. It uses a modification of the DARP 
model, which examined social functioning of 
clients, modality and retention, and partici- 
pation and compliance in relation to post- 
treatment outcomes. The project examines 
the significance in the treatment process of 
the clients' social and psychological function- 
ing, the influence of friends and families, and 
the clients' rapport with staff. 

Three particular aspects of the DATAR 
project may be useful in improving other 
projects: (1) the measurement system used, 

(2) enhancements of counselor skills, and 

(3) the diverse manuals that staff have 
developed. First, the DATAR data collection 
system may be applicable to other projects. 
Most community-based programs face limita- 
tions, such as resources, staff experience, and 
available time. DATAR project staff use a 
behavior-based intake interview that 
replaces the normally used narrative forms, 
which are difficult for quantitative data 
collection. The DATAR project also uses a 
psychosocial form and scales that assess the 
clients' behavioral status, the clients' evalua- 
tion of the program, and the clients' inter- 
action with the counselors, as well as 
measures the counselors' assessments of the 
clients' progress and the clients' termination 
from the project. 

Second, DATAR's use of nodelink mapping to 
enhance the counselors' skills could be appli- 
cable to other projects. DATAR assumes that 
the counseling objectives focus on identifying 
and confronting the clients' problems and 
helping the clients change and that there are 
four conceptual stages in the counseling 
process: (1) engaging and orienting the 
clients, (2) defining and understanding the 
problems, (3) generating alternatives for 
choices, and (4) implementing behaviors. 
During this process, nodelink mapping 
enhances abstract and verbal communi- 
cation, as well as improves cognitive re- 
trieval, interpretation, and integration. 
Nodelink mapping is a visual representation 
system analogous to organizational charts 
and flowcharts and is characterized by nodes 
and links. "Nodes" are facts, feelings, 
thoughts, and actions, whereas "links" are 
directions and relationships. The nodelink 
maps have the following two primary uses: 

(1) as information maps to describe facts and 

(2) as process maps to describe feelings, 
actions, and thoughts. Studies have shown 



that the maps are effective in communicating 
(e.g., for lectures and training materials), 
enhancing learning, and enhancing the 
engagement of clients in treatment progress. 
Third, DATAR project staff have produced 
numerous helpful manuals and data collec- 
tion forms for both new and experienced 
counselors. The manuals cover such areas as 
AIDS and HIV education training, relapse 
prevention training, assertiveness skills 
training for women, support networks and 
transition skills training, cognitive enhance- 
ment, and counseling. All of these manuals 
are available. 

Speaker: Jerome Piatt, Ph.D. 

Cocaine treatment is problematic because no 
long-established interventions have been 
demonstrated and, therefore, it is difficult to 
create effective programs without empirical 
evidence on which to base them. One model 
of treatment for cocaine abusers was tested 
first on an outpatient basis and then on a 
partial hospitalization basis. This model 
brings together techniques that are impor- 
tant in addressing the problems that cocaine 
users bring to the treatment setting. 

The most difficult task for cocaine abusers is 
the establishment of abstinence; therefore, 
the day treatment project focuses primarily 
on this goal through behavioral and cognitive 
behavioral interventions. Staff try to 
identify the elements of contingencies in 
users' daily lives and to teach competitive 
behaviors, such as basic and interpersonal 
skills and how to find employment, that will 
lead to more positive life directions. Relapse 
presents a major problem, primarily because 
users do not learn strategies for coping with 
drug problems, such as how to deal with 
peers, spare time, and failure. The day 
treatment program therefore employs prob- 
lemsolving and skills training interventions 
and cognitive therapy to prevent relapse. 
These elements, along with appropriate 
pharmacological interventions, provide a 
strong model for maintaining people in treat- 
ment and improving their outcomes. 

The literature shows that the longer people 
stay in treatment, the more likely it is that 
they will succeed in treatment. For instance, 
Dr. Dwayne Simpson has demonstrated this 
connection across a wide range of programs 
and problem behaviors. However, this 
assumption did not hold for cocaine-abusing 
methadone treatment patients, for whom the 



113 



NIDA Conference Highlights 



length of time in treatment did not relate to 
better outcomes. 

Data from the day treatment project for 
cocaine users indicated that, on the grossest 
level, the number of treatment sessions that 
clients attended related positively to absti- 
nence. Research staff examined whether the 
relationship between abstinence for 4 or 
more weeks (verified through urine analysis) 
and the number of days of cocaine use was 
strong enough to predict outcome at 3 
months. The number of treatment sessions 
attended was found to relate to primary 
cocaine users' drug-free outcome status, since 
outcomes of 74 percent of the cases could be 
predicted. Because treatment tenure does 
impact cocaine use in a primary 
cocaine-abusing population, treatment staff 
should make every effort to increase client 
attendance at treatment sessions by quickly 
identifying high-risk patients and actively 
encouraging their participation. 

The study also examined the relationship 
between drug-free outcomes among metha- 
done patients and both treatment tenure and 
the possession of a positive occupational role 
(i.e., job, school, orhomemaking). Fifty-three 
percent of methadone clients who had 3pent 
a long time in treatment and who had posi- 
tive occupational roles were cocaine free 
during the past month. Individually, each 
factor was associated with less treatment use 
in the past month, and together they had 
addictive effects. 

These findings have the following two impor- 
tant implications: (1) it is critical that 
patients stay in treatment and attend 
sessions and (2) projects must increase 
efforts to provide clients with employment 
skills and opportunities for employment. A 
related area of concern was the high rate of 
people who did not show up for their first 
appointment if a long period of time had 
elapsed since contact was first made with 
them by telephone. Research conducted on 
this problem in the early 1970s concluded 
that people were more likely to attend their 
first treatment appointment if it was made 2 
weeks after telephone contact rather than 4 
weeks after contact. Thus, in the current 
study, it seemed important to assess again 
the correlation between the time of first 
contact/first appointment and actual atten- 
dance at the first appointment. Findings 
revealed that of all the variables on which 
data were collected during telephone contact, 
the only factor that predicted whether indi- 



viduals would attend their appointment was 
the number of days it occurred after the 
telephone interview. For instance, if staff 
agreed to meet with someone on the same 
day of telephone contact, there was an 
83-percent likelihood that the individual 
would attend. But if the appointment was 8 
days later, the likelihood was reduced to 20 
percent. 

Based on this information, it appears highly 
critical that project staff decrease clients' 
waiting time between the initial telephone 
contact and the first project appointment. 
Also, projects must identify high-risk 
patients early and have crisis intervention 
counselors readily available on call to meet 
clients' needs at points of highest risk. 
Additionally, staff should involve significant 
others in treatment and clarify clients' 
reasons for entering treatment. The 
management of high-risk situations is the 
most serious problem facing treatment pro- 
fessionals. High-risk situations include the 
presence of cocaine or being offered cocaine s 
the availability of money, boredom and/or 
having nothing to do, the presence of alcohol, 
and the presence of depression. As profes- 
sionals begin to apply these bits of infor- 
mation to treatment settings, they can 
improve, even incrementally, treatment 
attendance and outcome. 

Speaker: George De Leon. Ph.D. 

Passages is a day treatment model based on 
therapeutic community principles and prac- 
tices and modified for dysfunctional metha- 
done clients engaged in high-risk behavior. 
The Passages model centers on a 
recovery-stage notion (i.e., individuals move 
through stages in recovery). The model 
originally was designed to resemble a thera- 
peutic community as closely as possible by 
bringing clients together for extended periods 
and insulating them from high-risk factors. 
The best that could be done in a methadone 
setting was the establishment of a day treat- 
ment model. Although there is a history of 
residential settings for treating clients, such 
programs have not undergone extensive 
evaluation. Because methadone patients 
normally will not go to residential treatment 
settings (they mainly receive pharmacological 
treatment), Passages introduced a 
recovery-oriented model with a therapeutic 
community methodology into a methadone 
setting. Passages aims not necessarily for a 
drug-free recovery but for recovery with 
stages of change. Methadone serves as a tool 



114 



Summaries of Research Awareness Seminars 



or medicine in the recovery process. Pas- 
sages helps clients determine how to deal 
with their lives once they receive their 
medicine. 

Passages operates 5 days per week and is 
run essentially like a therapeutic community. 
Primarily, Passages uses the community to 
change clients' behaviors and attitudes with 
low-intensive, low-confrontational techniques. 
Passages has shown the efficacy of such a 
model and its replicability in a second 
setting. It remains to be seen whether it will 
run through a control trial. 

Several difficulties were encountered in 
launching the model. It was first set up in 
two hospital-based methadone clinics, but the 
operation was not yet stable at the time, and 
it was difficult to coordinate the model with 
the hospital philosophy and operations (e.g., 
the psychoecological climate in a 
hospital-related clinic). The model next was 
launched in a unit separate from, but associ- 
ated with, a free-standing methadone clinic. 
It is hoped that a version of the model next 
will be established directly in a clinic, not 
just as an addendum to one. 

Despite the model's proven efficacy, a few 
problems surfaced. First, it was difficult to 
recruit clients because Passages is a 
high-demand, enhanced treatment model 
that requires an extensive time commitment 
from clients. Low recruitment impeded 
efforts to run a random controlled trial. 
Passages now operates with open (or 
naturalistic) recruitment, in which the grow- 
ing reputation of the program creates its own 
dynamic, which serves in recruiting patients. 
The core program has attracting power. 
Subsequently, staff do not actively try to sell 
the program as much as they did previously. 
The second problem was that few methadone 
patients enter the program voluntarily; when 
they do, they do not attend sessions regu- 
larly. Clients exhibited erratic attendance 
early on, but this problem now seems to be 
abating. 

Passages clients include both new admissions 
and long-standing methadone clients, all of 
whom are engaged in high-risk behavior and 
many of whom show psychological dys- 
function and poor work histories. The pro- 
gram used open-trial data, comparing clients 
who entered Passages, regardless of how long 
they stayed, with a comparison group of 
individuals who did not enter Passages. 
Passages clients showed significantly better 
improvements than non-Passages clients, 



although the latter improved to some degree. 
Improvements occurred mainly in areas of 
injectable drug use, cocaine use, needle use, 
crime, and high-risk sexual behavior. A 
controlled trial will be conducted next. 

Questions, Answers, and Comments 

What specific steps are taken to engage the 
family members and friends of clients in the 
DATAR project? A 10-session group for 
advanced treatment clients reinforces 
recovery maintenance, improves social sup- 
port networks, increases awareness of com- 
munity self-help groups, improves com- 
munication, and improves coping and prob- 
lemsolving skills. 

Does DATAR address changes in high-risk 
sexual behavior? High-risk sexual behavior 
is assessed in treatment programs and in 
outreach efforts. Changing sexual behaviors 
is very difficult. The series of sessions is 
designed to improve women's assertiveness 
in addressing this problem. 

In some States with no differential rate for 
reimbursement, a day treatment model for 
treating cocaine addiction is not cost-effective. 
Will the model work in a less intensive set- 
ting? If outpatient treatment is the lowest 
cost intervention and inpatient treatment is 
the highest, then day treatment provides an 
appropriate middle ground. It was proven to 
be efficacious and cost-effective with other 
populations besides drug abusers. But day 
treatment has not been adapted yet even by 
the psychiatric treatment community, and 
the drug community uses it infrequently. 

Did any variables in personality profiles have 
a relationship to low engagement and reten- 
tion rates among cocaine addicts? Such an 
analysis will be conducted. It appears, how- 
ever, that no characteristics predicted 
engagement or retention rates. Behavioral 
measures have been more effective than 
personality measures in predicting addicts' 
treatment outcomes. 

What can be said to a community to sell a 
model, such as the residential program for 
methadone treatment? There is a strong 
resistance to methadone treatment. New 
clinics should be based on advanced models. 
And program organizers should be armed 
with research-based data to convince com- 
munities of the program's importance. 

Does the Passages program assess the need 
for primary health care and case manage- 
ment within its scope of activities? 



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NIDA Conference Highlights 



RS30. 



has a strong primary medical care orienta- 
tion through its associated clinic. A good, 
sophisticated methadone clinic that adopts a 
drug-free component should have a sophisti- 
cated primary medical care capability. 

What incentives were used to encourage 
continued participation in the day treatment 
program for cocaine addicts? The program 
used money as an incentive. It is difficult to 
find universally accepted reinforcers. While 
some researchers may consider money to be 
inappropriate as an incentive, it seems to be 
an effective incentive if it results in 
decreased drug use, as well as long-term 
monetary savings. The contingency manage- 
ment literature has demonstrated the effec- 
tiveness of using reinforcers. It is hoped that 
eventually behaviors, such as family-related 
issues and employment, will act as rein- 
forcers. The DATAR project has used incen- 
tives^ — such as gas coupons, T-shirts, or items 
(such as a radio) that clients may want — and 
clients can gradually earn credits toward 
acquiring those rewards. 

What are specific prescriptions for reshaping 
the attitudes of methadone patients entering 
day treatment regarding what is expected of 
them? Initially staff presented Passages as 
a general orientation to the clinic with mixed 
impact. Now that clients are in the program, 
client action plans facilitate the development 
of weekly specific goals for patients. Also, 
expectations are reinforced during group 
sessions. 

How can a program meet all the needs of its 
clients? Programs should try to ensure that 
the fullest array of services is available in 
one setting. The broader the array of ser- 
vices, the better the treatment outcomes. 

Drug Abuse Treatment Outcome 
Study (DATOS) Research 

Moderator: Bennett Fletcher, Ph.D. 
Speakers: Rose Etherldge. Ph.D. 

Patrick Flynn, Ph.D. 

Robert Hubbard. Ph.D. 

James W. Luckey. Ph.D. 
Respondent: Anne Hill. M.A. 
July 15. 3:00 p.m.-4:30 p.m. 

Speaker: Bennett Fletcher, Ph.D. 

The Drug Abuse Treatment Outcome Study 
(DATOS) is a longitudinal perspective study 
that evaluates individuals coming into treat- 
ment programs within several modalities of 
methadone maintenance, including drug-free 



outpatient, long-term residential, and short- 
term inpatient. Data are collected through 
self -report interviews with program research- 
ers and are corroborated through record 
reviews and urinalysis. Intake interviews, 
clinical interviews, and interim interviews 
are administered at 1, 3, and 6 months, 
respectively, and followup interviews are 
conducted 12 months after treatment. Cur- 
rent DATOS data include 10,000 intake 
interviews from 120 programs in 11 different 
cities. The five goals of DATOS are as fol- 
lows: (1) to describe drug abuse treatment 
populations in terms of demographic charac- 
teristics, psychological variables, sociocul- 
tural variables, and treatment histories; 
(2) to characterize treatment modalities and 
treatments within those modalities; (3) to 
define the treatment process so that relation- 
ships between client treatment variables, 
treatment process variables, and nontreat- 
ment variables in outcomes can be identified; 
(4) to analyze treatment outcomes in order to 
evaluate treatment and cost-effectiveness 
and determine the relationship between 
treatment outcomes and important program 
treatment in client factors; and (5) to analyze 
the relationship between impairment and 
outcomes during and after treatment in 
order to determine whether impairment can 
be conceptualized, to relate that to outcomes, 
and then to use that as a variable in client 
matching as a means to determine how 
impairment affects treatment. 

Speaker: Robert Hubbard. Ph.D. 

DATOS is concerned with making a large- 
scale research study scientifically sound and 
useful to the treatment community. The 
current era is one in which good solid data 
are critical to making decisions about the 
future of treatment. Results need to be 
delivered to the provider and policy com- 
munities in ways that will lead to more 
effective treatment. Scientific studies must 
be illustrated without compromising the 
scientific principles and then be translated 
into information that is immediately useful 
to the provider community. Feedback on 
these issues is needed from the provider and 
policy communities for the purpose of in- 
depth analysis and in order to determine 
ways that this information can be provided 
for maximum benefit. 

DATOS' three objectives are (1) to describe 
the abusers entering drug abuse treatment, 
(2) to describe the nature of treatment in the 
process in which change occurs, and (3) to 



116 



Summaries of Research Awareness Seminars 



look at treatment outcomes in order to deter- 
mine the comparative effectiveness of various 
treatment approaches and the contributions 
of various elements to that effectiveness. 
Indepth data were collected at various points 
in treatment, particularly at intake, by 
individuals specifically hired and trained for 
that purpose. Approximately 3 hours of 
intake data were collected for each individual 
who entered treatment. This is the most 
indepth data collection conducted from a 
sample of this magnitude. Individuals were 
followed during treatment at intervals of 1, 
3, 6, and 12 months to determine what 
changes had occurred and what services 
were received for treatment. They then were 
interviewed after treatment termination. 

DATOS is a longitudinal, prospective, clinical 
epidemiological study of treatment and client 
behavior in typical community-based pro- 
grams. Currently DATOS is focusing on 
outpatient methadone maintenance to try to 
characterize these programs by the settings 
in which they operate. Evaluations are con- 
ducted on outpatient drug-free programs, the 
particular setting, who manages the pro- 
gram, and where clients come from in an 
effort to develop a better means of charac- 
terizing the treatment variations that might 
exist. For example, there are long-term 
residential programs, shorter therapeutic 
communities, other programs that are pub- 
licly funded, and long-term residential set- 
tings. The short-term inpatient or chemical 
dependency programs were not involved in 
the earlier studies. 

Speakers: Patrick Flynn, Ph.D. 

DATOS' client assessment and intake consist 
of two interviews. The purpose of these 
interviews is to determine the nature of 
client populations entering treatment in the 
four major modalities. Earlier studies have 
indicated that the clientele entering these 
modalities are distinctly different. Observa- 
tions are based on (1) client characteristics in 
pretreatment behaviors of admission to the 
various modalities, (2) patterns of drug use 
and levels of impairment among clients, 
(3) the correlates of client behavior, (4) the 
factors that discriminate types of clients 
served by the modalities, and (5) the ways in 
which these clients compare with clients 
from earlier decades. The total intake pro- 
cess lasts about 3 hours. The instruments 
used are self-reported, highly structured 
interviews conducted face to face. Each 
interview consists of a comprehensive assess- 



ment covering multiple domains. Intake 1 
covers demographics and background; educa- 
tion and training; admission; alcohol, 
tobacco, and drug use; mental health status; 
illegal involvement; employment; income and 
expenditures; drug and alcohol dependence; 
observations; and a short mental status 
examination. Intake 2, referred to as the 
clinical assessment, includes additional 
demographics and background, health, cogni- 
tive impairment, religiosity, anxiety, depres- 
sion, sexual experiences, behavioral prob- 
lems, psychological distress, motivation and 
readiness for treatment, as well as observa- 
tions and a mini mental status exam. The 
intake contains modules from the diagnostic 
interview schedule or composite international 
diagnostic interview and are modules for 
antisocial personality, anxiety, and depres- 
sion. Also included are items and scales 
from dimensional standardized measures, 
such as SCL 90 and the California Psycho- 
logical Inventory. This allows the construc- 
tion of a diagnosis but also looks at dimen- 
sional measures and other measures of 
psychiatric impairment. 

Six different measures or criteria of cocaine 
use or dependence have been observed. 
Strong correspondence has been found 
between DSM-III-R (Diagnostic and Statisti- 
cal Manual, revised third edition) depen- 
dence criteria, the primary problem drug, the 
drug of choice, weekly drug use in the past 
year, and history of daily drug use. 

Transfer technology, such as how DATOS 
research will translate into practice and the 
types of new information or products that are 
coming out for clinical use, is emerging, such 
as the intake assessment instruments that 
were developed as an individual assessment 
profile. A computer-assisted program that 
generates a narrative report and client data 
system report also has been developed for 
this assessment. 

Speaker: Rose Etheridge. Ph.D. 
The angles of the treatment process study 
component are used to characterize the 
nature of the programs represented in 
DATOS sites within and across the four 
treatment modalities and to describe the 
treatment and services that the clients are 
receiving in these programs. DATOS also 
identifies the important cognitive and behav- 
ioral changes that occur in participants 
during the course of treatment and identifies 
the correlates of these changes and the 



117 



NIDA Conference Highlights 



correlates with retention and other post- 
treatment outcomes. Treatment process 
measures have been expanded since earlier 
studies were conducted in the late 1970s and 
early 1980s. It is important to capture the 
treatment interventions used, the type and 
amount of treatment that clients are receiv- 
ing, and the treatment changes that may be 
predictive of post-treatment outcome. 

The measurements that DATOS uses encom- 
pass three basic levels. The first level con- 
sists of capturing the treatment structures 
and characteristics of the programs in terms 
of modality, organization of treatment and 
services, philosophic approaches, staffing, 
training, caseload, treatment quality, pro- 
gram quality, and internal milieu. The 
second level involves looking at external 
features that drive the way the treatment is 
organized and delivered. These features 
include Federal, State, and local policies; 
fiscal constraints; community support; and 
other political issues. Recruitment processes 
also are evaluated. DATOS describes treat- 
ment programs arranged through community 
organizations and agencies and views charac- 
teristics and philosophies of the providers, 
approaches to treatment, training skills, and 
caseload quality. The final level views the 
treatment plan as the organization and 
structure of treatment and as a mechanism 
by which treatment is transmitted to clients. 
Treatment providers want to see what the 
treatment planning process looks like, the 
elements of the treatment plan, and the 
degree of client involvement in the treatment 
planning process. The treatment stages also 
are examined both from the programs' and 
the clients' perspectives. 

DATOS is capturing, from a structural view- 
point, the way that programs view the stages 
of treatment from detoxification to early 
treatment stabilization. Following these 
stages is a period of rehabilitation during 
which services are brought to bear, followed 
by a reentry relapse prevention continuing 
care phase. To capture the structural 
aspects of treatment, a self-administered 
questionnaire is used. Program directors, 
clinical supervisors, and program counselors 
are surveyed and questioned about basic 
treatment approaches, philosophies, charac- 
teristics of the client population served, 
perceived needs that clients present with 
policies, treatment activities and provided 
services, referral mechanisms, program 
financing and accreditation, issues that have 
affected the structure and delivery of treat- 



ment over the past several years, and any 
anticipated changes. A similar questionnaire 
developed to report how program policies 
work at the client level asks counselors about 
their backgrounds, treatment approaches and 
philosophies, and caseload size and mix. 
Another mechanism used to capture the 
structural aspects of treatment are site visits 
at the program level, which involve going to 
the programs and interviewing staff, coun- 
selors, and some clients in order to gather 
information on how treatment is delivered 
and structured, the kinds of activities pro- 
vided, the kinds of elements viewed by the 
programs as critical to treatment, the kinds 
of treatment phases delivered, the kinds of 
phases of recovery that clients are expected 
to proceed through, the kinds of measures of 
success perceived as reasonable indicators of 
treatment progression, the ways in which 
programs view positive change during the 
treatment process, and the ways in which 
activities are linked in order to create those 
positive changes. 

The most extensive measurement battery is 
conducted at the client level and researches 
what treatment was supposed to be provided 
versus what treatment the clients actually 
received. Other questions pertain to treat- 
ment access, how easy it was to get to treat- 
ment, what the treatment plan was, whether 
clients knew what the treatment was, and if 
they were involved in the treatment or if 
they agreed with the goals and types of 
services they received. They also are asked 
whether, in addition to receiving individual 
and group counseling, they received medical, 
psychological, family, legal, educational, 
vocational, or financial counseling; services 
for crisis events; or informal assistance. 
Clients are asked about the types of addi- 
tional services they received from other 
programs and whether they accessed these 
services by referral from their initial pro- 
grams or at their own initiative. Clients also 
are asked to indicate the topics discussed at 
individual and group sessions, the number of 
sessions held, the number of session links 
and days involved, the indicators of satis- 
faction with the treatment, and their need 
for particular services. The client interviews 
allow the accumulation of fairly sensitive 
measures of change over the course of 
treatment. 

DATOS uses some of the same measures 
from the intake interview and measures 
them across time during the in-treatment 
period to try to capture medical, psycho- 



118 



Summaries of Research Awareness Seminars 



logical, and other aspects of health and social 
functioning that might occur during the 
course of treatment. Information also is 
being obtained on drug and alcohol use, 
program retention, and other cognitive and 
behavioral changes. There are more experi- 
mental measures to capture some of the 
more subtle cognitive processes that may 
occur during the course of treatment. These 
measures are thought to have sound psycho- 
metric properties and seem to have a firm 
grounding in the literature. These measures 
may pinpoint analytically those types of 
client changes that may be associated with 
more long-term outcomes during the course 
of treatment and beyond. Self-concept is 
being measured along with self-efficacy or 
the clients' perceived ability to resist drug 
use in specific situations. Stage of change is 
being measured as a therapeutic alliance in 
the clients' bonds with the treatment pro- 
viders, attempting to capture program milieu 
as a measure of change and perceived change 
events. 

Preliminary findings from the client in-treat- 
ment interviews indicate that a critical point 
for retention was the 3- to 4-week period. 
Retention problems were particularly acute 
in the short-term inpatient modality. Less 
than 50 percent of the clients remained in 
treatment for more than 13 weeks. In the 
short-term inpatient modality, most clients 
stayed for 28 days or less and normally left 
at this time due to the treatment structure. 

One hypothesis that needs to be tested is 
whether the changes in insurance coverage 
and other constraints are shortening the 
time that clients remain in treatment to the 
point that interventions look very different 
than they did 2 years ago. Since psycho- 
logical services provided to clients seem quite 
low, the question arises of whether programs 
are getting less-impaired clients. One early 
analysis indicated that less than 50 percent 
of the clients actually were receiving the 
services that they reported needing. Thus, 
the next step of the program involves deter- 
mining the amount of treatment being pro- 
vided, and then following up with how this is 
related to retention during drug and alcohol 
abuse treatment. 

Speaker: Robert Hubbard, Ph.D. 

One of DATOS' unique features is its ability 
to track individuals into the community after 
treatment. The level of effort and cost of 
mounting a post-treatment followup study 



are tremendous. The only viable and 
credible way to follow individuals is through 
a large-scale scientific followup study. Two 
followup studies currently are being con- 
ducted. The first study asks DATOS clients 
to identify the levels of outcomes at 12 
months after treatment and provide a com- 
parison of the levels between pretreatment, 
in-treatment, and post-treatment and the 
factors that influence post-treatment out- 
comes. The second study is a post-treatment 
study of individuals in a variety of programs 
who were treated for cocaine abuse. DATOS 
is currently in the process of developing the 
data collection component for the adolescent 
phase of DATOS, which involves approxi- 
mately 30 adolescent programs and 6,000 
adolescents. The adolescent DATOS will 
follow the same design as the adult DATOS 
with its instrumentation geared toward 
adolescents and will include the same types 
of descriptions of the client population, such 
as following the clients through treatment 
and into the community after treatment. 
These outcome studies are most important 
for technology transfer. 

Speaker: James W. Luckey, Ph.D. 

The types of issues that treatment programs 
are interested in involve admission data 
about the clients they are serving, how the 
clients that are served match up with some 
implicit or explicit target population, the 
services that clients are receiving and how 
these services match up with the clients' 
needs, what happens to the clients during 
treatment, the lengths of patterns of reten- 
tion or how long the clients stay in treat- 
ment, and when the clients actually graduate 
from treatment. DATOS provides infor- 
mation to organizations on the clients or 
patients they are serving. Many programs 
are interested in followup data but rely on 
researchers for the information. 

Information provided to programs by DATOS 
includes relevant statistics — for example, 
almost 60 percent of the clients in treatment 
programs have less than a high school educa- 
tion, and only 20 percent of the clients are 
working, suggesting the need for educational 
and vocational services. If less than 2.5 
percent of clients received these services, this 
would indicate a gap between what clients 
need and what they are receiving. One thing 
DATOS can provide is de facto normative 
data regarding what is going on in the drug 
treatment field. This information can help 
with admission data when comparing clients 



119 



NIDA Conference Highlights 



in a particular program with the typical 
client. Another statistic compares the ser- 
vices provided with those provided by typical 
treatment programs. The same kind of 
analysis can be done with treatment process 
data by asking what services are offered, 
what percentage of clients receive these 
services, and how the program compares 
with other programs. Even though the 
statistics match up, there is a high per- 
centage of homemakers in methadone main- 
tenance and the potential need for child care 
services. DATOS is a large-scale study of 
treatment programs in which a rich array of 
data is being collected on a large number of 
clients, providing the opportunity for de facto 
normative data both on clients served and 
treatment services. 

Questions, Answers, and Comments 

How was the provider and policy community 
involved in the design of DATOS? Both the 
provider and policy community were involved 
in some of the earlier design and were 
involved heavily in the review process. Site 
visits are being made to these programs to 
understand what is going on in treatment to, 
in effect, minimize any disruptions to treat- 
ment and maximize the benefits. DATOS is 
getting involved in other studies where 
service enhancements and other types of 
research are being provided. There is a close 
interaction between the providers and 
research team in trying to generate cross- 
fertilization; they need to know what the key 
issues are in treatment, which can be found 
out from the clients in the programs. 

How can information from DATOS help to 
empower communities in assisting people to 
take responsibility for their own behavior and 
treatment needs? Programs should use the 
service information provided and compare 
themselves against what DATOS is finding 
in their study sites. These organizations 
should use this information and aggressively 
direct their services where needed. Data 
provided by DATOS give an organization a 
kind of empowerment. 



RS3 1 . Treatment Alternatives for 
Criminal Justice Clients 

Moderator: Lana Harrison, Ph.D. 
Speakers: Peter Delaney. D.S.W. 

James Inclardi. Ph.D. 

Steve Magura, Ph.D. 
Respondent: David Friedman. M.Ed., CA.P. 
July 16. 4:30 p.m.-6:00 p.m. 

Speaker: Peter Delaney, D.S.W. 

Two questions often asked of medical re- 
searchers and practitioners who are affiliated 
with the criminal justice system are 
(1) whether drug abuse treatment is effective 
and (2) how to change the public's negative 
perceptions about treatment. In general, the 
typical criminal justice system clients who 
are on drugs and enter some sort of treat- 
ment program tend to have better recovery 
results than do those clients who do not 
undergo any kind of treatment. Two 
NIDA-sponsored studies, the Drug Abuse 
Reporting Program (DARP) and the Treat- 
ment Outcomes Perspective Study, investi- 
gated treatment and its linkage to lower 
rates of illicit drug use and criminal behavior 
(e.g., theft and prostitution). The Drug 
Abuse Treatment Outcome Survey (DATOS) 
and a few smaller clinical studies, while 
working toward improving the effects that 
treatment actually has on decreasing illicit 
drug use and criminal activity, also are 
making attempts to increase clients' levels of 
social functioning and occupational status. 
Proper treatment techniques also can be 
important in reducing the AIDS risks experi- 
enced by many drug-using individuals. 

One particular area in which drug abuse 
treatment experiences problems is in the way 
that it is viewed by the public. Relapse into 
drug abuse by treated abusers, for example, 
is seen as a failure on the part of the treat- 
ment provider. In reality, relapse is a very 
common part of the treatment and recovery 
process. Therefore, more energy needs to be 
spent educating the public on the factors 
associated with treatment and recovery from 
drug addiction. A three-level approach is 
needed to change society's perspective toward 
what treatment success actually means. 
First, better education about the chronic 
nature of relapse should be provided to 
constituents. Second, the results needed to 
consider a patient outcome successful should 
be looked at by both researchers and practi- 
tioners. Third, the ways in which treatment 
is being provided should be looked at, and 
current programs should determine if they 



120 



Summaries of Research Awareness Seminars 



are adaptable to an ever-changing popula- 
tion. Treatment models that allow people to 
remain in their own communities while being 
treated for their addictions is one possible 
way that treatment may more adaptable. 

Studies have shown that longer lengths of 
stay in treatment tend to reflect higher 
success rates. Improved patient-treatment 
matching and increased retention are two 
tools that could aid in keeping patients in 
treatment longer. The quality of treatment 
may need to be improved in order to increase 
patient retention rates. The measuring of 
various group skills that patients may or 
may not possess is a good indicator as to 
whether or not particular patients will be 
able to positively interact within a group 
treatment setting. Compulsory treatment is 
basically defined as using some type of tool 
in order to get someone who would not nor- 
mally enter treatment to enter. One issue 
often raised pertains to the effectiveness of 
compulsory treatment for addicted individ- 
uals. Another factor to consider when look- 
ing at compulsory treatment is where the 
program is housed (e.g., in the criminal 
justice system, a treatment system, or an 
integrated system). Compulsory treatment 
often is seen in a criminal justice system, 
working in unison with a treatment system. 
Sanction implementation is another impor- 
tant issue that must be considered with 
regard to the policies surrounding patients 
who relapse. Studies show that the real key 
to success in compulsory treatment settings 
is the emphasis on long-term supervision. 
Defining a target group when designing a 
compulsory treatment program is also very 
important. After the target group is decided 
upon, the cost and benefits of treatment 
must be looked at. Legal protections and 
safeguards for patients are other important 
considerations. The linkage of compulsory 
treatment with other treatment systems is 
important for the avoidance of service 
repetition. 

In order to get a patient more in touch with 
himself or herself, George DeLeon and Nancy 
Jainchill performed studies to determine how 
drug abuse treatment patients perceive 
themselves in terms of being addicts, the 
circumstances behind that reality, and the 
life options that patients feel they have in 
therapeutic communities (TCs). Treatment 
practitioners also should be reminded to 
stress to clients the importance of staying at 
their program and in treatment. 



One key to patient retention is proper 
patient-to-treatment matching, which is 
affected by a number of factors. Doctors A. 
Thomas McLellan, Carl Leukefeld, and Roy 
Pickens have all stated that the therapeutic 
community does not have one foolproof 
method for determining the best treatment 
for each patient. The Individual Assessment 
Scale and a number of other scales, however, 
are able to match patients accurately to the 
various services that are offered within 
different treatment programs. The study of 
DATOS data has revealed that patients 
generally tend to receive more services in the 
medical area as opposed to social or familial 
services. 

Speaker: James Inciardi, Ph.D. 

TCs have been found to be the most appro- 
priate form of treatment for incarcerated 
people. A three-stage model has been 
developed for therapeutic treatment com- 
munities within correctional/prison facilities. 
During the primary stage, this prison-based 
TC emphasizes personal growth through 
changing deviant behavior patterns. The 
secondary stage is a transitional TC work 
release program. This kind of TC should 
have a "family" setting that is separated 
from all of the surrounding negative influen- 
ces. The normal rules and regulations pre- 
sent in a normal TC also should be strongly 
enforced in this kind of TC. The tertiary 
stage is the aftercare stage in which incar- 
cerated people have completed their individ- 
ual work release programs and are living 
again in the "free world" under the restric- 
tions of their parole officers or some other 
form of supervision. Outpatient counseling 
and group therapy are two very important 
components to include in the aftercare 
program. 

Within a maximum security prison located in 
Wilmington, Delaware, a prison-based TC 
known as the Key Program was set up for 
male inmates. This was the primary stage of 
care for those inmates who wanted help with 
their addiction problems. The secondary 
stage of the TC treatment program took the 
form of an in-prison, work-related TC known 
as the Crest Outreach Center. This work 
release TC, which is the first of its kind in 
the country, was designed to incorporate the 
secondary and tertiary stages into its pro- 
gram. A five-phase model outlines the treat- 
ment plan for a 6-month period. Phase 1 
(about 2 weeks) includes entry, assessment, 
evaluation, and orientation into the program; 



121 



NIDA Conference Highlights 



Phase 2 (about 6 to 10 weeks) focuses on 
involvement in the TC program; Phase 3 
(about 5 weeks) is a continuation of Phase 2, 
with special emphasis placed on role model- 
ing; Phase 4 focuses on preparation for 
employment through the promotion of educa- 
tional skills; and Phase 5 is reentry into the 
community. 

Upon entering the Key Program and 6 
months after a client has been in the pro- 
gram, a number of assessment procedures 
are used to determine the client's drug-using 
behaviors and HIV risk behaviors. An 
18-month folio wup assessment also is con- 
ducted. Of the 307 clients who took part in 
the Crest Outreach Center, 151 did not 
follow any kind of formal work release 
schedule. Thirty-four percent of these people 
were found to be drug free after the 6-month 
followup. Of the people who graduated from 
the Key Program but did not go on to partici- 
pate in the Crest Outreach Program, 54.5 
percent (or 24 people) were found to be drug 
free after the 6-month followup. And finally, 
83 percent of the people who graduated from 
the Crest Outreach Program were found to 
be drug free after the 6-month followup. 

Speaker: Steve Magura, Ph.D. 

Jail and prison overcrowding is largely due 
to a steady increase in drug-related crime. 
During the mid-1980s, the AIDS epidemic 
reached very high proportions among inject- 
ing drug users. In New York City, 20 per- 
cent of all men arrested are heroin addicts. 
Nearly 40 percent of male injecting heroin 
users and 50 percent of female injecting 
heroin users are HIV positive. 

Research identified the drug treatment 
facilities for the central jail at Rikers Island 
in New York City, since this correctional 
facility was the only one of its kind in the 
country that offered an in-house methadone 
maintenance program. This voluntary pro- 
gram, Project KEEP (Key Extended Entry 
Program), annually serves about 3,000 
heroin-addicted men and women. Only the 
prisoners serving misdemeanor charges or 
sentences of under 1 year can participate in 
the program. Study participants are broken 
down into two basic groups: (1) people who 
had been in methadone maintenance pro- 
grams at the time of their arrest and 
(2) people who were not in methadone main- 
tenance programs at the time of their arrest 
but desired to be in one. Findings have 
indicated that about 80 percent of the 



inmates who have been in methadone main- 
tenance programs before they were incar- 
cerated returned to methadone maintenance 
on release from jail. This percentage consti- 
tutes about one-third of Project KEEPs 
participants. Of the other two-thirds of 
KEEP participants (i.e., those who have not 
been involved in methadone maintenance 
programs before being incarcerated), about 
one-half have turned to methadone main- 
tenance on release. 

The 5-month retention rates for people who 
entered methadone maintenance programs 
on being released from prison also differed. 
Of the people who had been involved in 
methadone maintenance before being incar- 
cerated, about one-half remained in treat- 
ment. Of the people who had not been 
involved in methadone maintenance before 
incarceration, only about 20 percent 
remained in treatment. 

Many changes need to come about in the 
criminal justice drug treatment system 
before any substantial improvements in 
treatment retention will be seen. The 
human services system (i.e., criminal justice, 
social services, vocational rehabilitation, and 
drug abuse treatment) could improve its 
methods of helping addicts make smoother 
transitions from jail to community settings. 
Incentive plans for inmates that grant early 
release from prison upon completing condi- 
tional drug abuse treatment programs not 
only might be a method of decreasing the 
drug abuse problem on the streets but also 
could address the problem of prison over- 
crowding. Developing plans to create safe 
and sober housing alternatives, job training, 
and legitimate work possibilities for those 
addicts wanting to improve their lifestyles 
could be strategic in curbing the familiar 
relapse percentages more favorably. Finally, 
due to the fact that the typical addict tends 
to be a multiple drug user or abuser, inte- 
grative drug treatment programs should be 
a topic of future focus. 

Questions, Answers, and Comments 

Was counseling or case management used in 
conjunction with methadone maintenance 
when treating any of the patients involved in 
the Rikers Island project? Advanced dis- 
charge planning methods were used by 
program counselors when treating 50 men 
and 50 women involved in the project. Fol- 
lowup procedures also were attempted but 
were unsuccessful due in part to the fact that 



122 



Summaries of Research Awareness Seminars 



RS32. 



they were performed on a citywide basis, as 
opposed to being more sectionalized. Prob- 
lems arose when the counselors tried to 
locate former patients. It was found that the 
majority of the patients had disregarded 
what they had been told in jail and reverted 
back to heroin use. 

How is patient-to-treatment matching han- 
dled within a correctional facility that basic- 
ally consists of one modality and where the 
patients are homogeneous? Patient partici- 
pation in correctional-based programs is 
generally voluntary, so there is not really 
any patient-to-treatment matching that goes 
on, but there is always an abundance of 
people willing to participate. 

Can anyone remark on the problem often 
encountered regarding the obstacles that tend 
to arise between the treatment system and the 
criminal justice system when new programs 
are being created? It is a give-and-take 
situation that exists between these two 
communities. The correctional system, 
however, tends to "come around" as it gradu- 
ally realizes that the in-house TC is the 
safest and best-operated part of the entire 
prison system. 

Has any research been conducted on second- 
and third-generation drug and alcohol 
abusers (both males and females) with regard 
to the transmission of abuse from one 
generation to the next? Few studies have 
addressed this issue, but it is obvious that 
there is a substantial amount of inter- 
generational transmission of substance 
abuse. 

Valid and Reliable Drug Testing 
Techniques 

Moderator: Joseph Autry III. M.D. 

Speakers: Donna Bush, Ph.D 
Edward Cone. Ph.D 
Steven Helshman, Ph.D. 
H. Chip Walls 

Respondent: Gregory Plltt. M.S. 

July 16. 10:15-1 1:45 a.m 

Speaker: Donna Bush, Ph.D. 
On September 15, 1986, Executive Order No. 
12564 was issued, establishing a Federal 
Drug-Free Workplace Program. In July 
1987, Public Law 100-71 was passed to 
support this effort. As part of this program 
to deter the use of illegal drugs, it was 
required that urine specimens from some 
Federal and federally regulated industry 
employees be tested for illegal drugs of 



abuse. On April 11, 1988, the "Mandatory 
Guidelines for Federal Workplace Drug 
Testing Programs" was published in the 
Federal Register, defining requirements of 
the Drug-Free Workplace Program. These 
guidelines included scientific and technical 
requirements for urine drug testing. 

The National Laboratory Certification Pro- 
gram (NLCP) was subsequently established 
to assure the accuracy and reliability of 
urine drug test results. The drugs/metabo- 
lites for which urine may be tested under the 
Federal Drug-Free Workplace Program are 
as follows: marijuana metabolites, cocaine 
metabolites, opiate metabolites (morphine 
and codeine), phencyclidine, and ampheta- 
mines (methamphetamine and ampheta- 
mine). 

Accuracy and reliability are two critical 
elements of the urine drug test. In order to 
assure the accuracy and reliability of test 
results, two separate and chemically dif- 
ferent tests are used to determine the pre- 
sence of drugs in the urine, with testing 
performed under a comprehensive blanket of 
quality control and quality assurance. Per- 
formance testing and onsite inspection of 
NLCP-certified laboratories also ensure 
compliance with Federal guidelines. 

The initial test is performed on every urine 
specimen by immunoassay. When this initial 
test is negative, the result is reported as 
negative. When this initial test is presump- 
tively positive for a tested drug, a portion of 
the specimen is additionally tested by gas 
chromatography/mass spectrometry to obtain 
a "fingerprint" of the drug/metabolite present 
in the urine. All laboratory results of urine 
drug tests are reported to a Medical Review 
Officer to determine any alternative medical 
explanation for a positive result. 

Three essential components for drug testing 
any biological specimen are as follows: 
(1) accuracy and reliability of the analytical 
method(s), (2) the ability to interpret the 
drug test results, and (3) the applicability of 
the testing to the situation. 

Speaker: Edward Cone, Ph.D. 

Urine drug testing is currently the most 
objective and available method for deter- 
mining the ingestion of illegal drugs. The 
window of detecting drug use is limited when 
using urine as the tested specimen. Two 
other specimens — saliva and hair — may be 
tested for drugs, and each have different 



123 



NIDA Conference Highlights 



windows for detecting drug ingestion. The 
technologies for using these specimens to test 
for drugs is developing. Analytical studies 
concerning technical aspects of both saliva 
and hair-testing processes and the develop- 
ment of cutoff levels to assess the presence of 
drugs must be established. 

The advantages to using saliva as a speci- 
men for drug testing include the following: 
(1) saliva is easy to obtain; (2) the parent 
drug, not just metabolites, may be detected; 

(3) the presence of an active drug may indi- 
cate the potential for an ongoing drug effect 
at the time of testing; and (4) the drug con- 
centration in the saliva more closely approxi- 
mates the drug concentration in blood than 
would urine. Some of the disadvantages of 
using saliva as a drug-testing specimen are 
as follows: (1) the saliva may be con- 
taminated by oral or nasal ingestion of the 
drug; (2) acidity of the saliva and the chem- 
ical nature of the drug ingested may compli- 
cate interpretation of drug concentrations 
found in the saliva; (3) some methods of 
collecting saliva samples may alter the acid- 
ity of the saliva and, therefore, the drug 
content; and (4) the detection window for 
determining the presence of drugs is short. 
Based on research to date, the correlation of 
saliva drug concentration with plasma con- 
centrations and pharmacological drug effects, 
such as behavioral performance on the job, 
will be problematic. 

Testing hair for drugs is a developing tech- 
nique for detecting drug use. This specimen 
may be useful because it may provide a 
long-term window for drug detection. Other 
advantages to using hair as a drug-testing 
specimen include the following: (1) brief 
periods of abstinence may not alter test 
outcomes; (2) hair is easy to collect, handle, 
and store; (3) hair collection is considered 
less invasive than urine collection; and 

(4) "beating" the hair test may be more 
difficult. There are disadvantages, however, 
to hair testing: (1) it is a new science with 
few controlled clinical studies, (2) available 
data show recent drug use may not be 
detected, and (3) environmental contami- 
nation is of concern. 

In summary, different physiological speci- 
mens, when accurately and reliably tested 
for drugs, can reveal a number of different 
things pertaining to drug use. Blood, for 
instance, is ideal for the detection of drug 
use over a short period of time. On the other 
hand, testing hair for drugs, if thoroughly 



researched, may be ideal for detecting drug 
use over a long period of time. 

Speaker: H. Chip Walls 

In order to determine the incidence and 
prevalence of maternal drug abuse and its 
developmental, psychological, and physical 
effects, research is required to develop and 
improve approaches for identifying neonates 
exposed to drugs in utero. Maternal admis- 
sion of drug use may not always be obtained 
because of fear of the consequences to both 
mother and newborn. Even with maternal 
admission to drug use/abuse during preg- 
nancy, the information volunteered may be 
inaccurate. In addition, drug testing an 
infant's urine poses several problems, includ- 
ing difficulty in collection and an extremely 
short window of detecting maternal drug use 
prior to birth. 

Drug detection in meconium may be more 
sensitive as an indicator of maternal drug 
use during pregnancy. Meconium collection 
is simpler, more reliable, and noninvasive 
when compared to urine collection; however, 
the collection of meconium requires individ- 
ualized attention of attending staff. Meco- 
nium is reported to have higher drug 
concentrations than maternal or fetal urine 
and may offer a longer time window for 
detection of in utero drug exposure. This 
may be due in part to the observation that 
meconium is first detected in fetal ileum at 
about 70 to 85 days of gestation. 

Automated immunoassay techniques have 
been adapted to test meconium for the pre- 
sence of drugs of abuse. Because of the 
nature of meconium, the specimens may 
require pretreatment. Analytical techniques 
have been successfully developed to confirm 
the presence of illegal drugs in the 
meconium. 

Little is known about the placental transfer 
of drugs from mother to fetus and the phar- 
macology of drugs in the fetus. Many ques- 
tions concerning the testing of meconium for 
drugs of abuse need to be answered, includ- 
ing issues regarding (1) pharmacokinetics 
and deposition of drugs/metabolites in utero 
and in meconium, (2) drug/metabolite stabil- 
ity in meconium, (3) identification of parent 
drug versus metabolite to detect fetal expo- 
sure to a particular drug, and (4) interpreta- 
tion of drug concentrations in meconium 
from low-birthweight infants compared to 
term infants. Because of these unresolved 
issues, the interpretation of meconium data 



124 



Summaries of Research Awareness Seminars 



as an index of fetal exposure to drugs of 
abuse is difficult. Advances are being made, 
however, in this area of drug detection with 
the help of basic and applied research. 

Speaker: Steven Heishman, Ph.D. 

A number of differences exist between the 
testing of physiological specimens for the 
presence of drugs and the testing of human 
performance to detect the presence of drugs 
Drug testing of a physiological specimen 
generally focuses on searching for an analyti- 
cal endpoint, such as the chemical detection 
of a drug or its metabolite. Performance 
testing measures the effects a drug may have 
on an individual's behavior. 

One disadvantage to performance testing is 
that acute, easily detectable behavioral 
effects of a drug may last only for a few 
hours. Performance testing may be focused 
on determining an individual's ability to per- 
form certain tasks in the workplace. Dif- 
ficulties with performance testing in the 
workplace include the fact that it may actu- 
ally be difficult to isolate the cause of poor 
work performance. Poor performance in the 
workplace may be due to drug use, but it 
also may be due to fatigue or stress. Until 
better and more definitive methods of evalu- 
ating performance in the workplace are 
developed, random performance testing will 
not likely be a method routinely used to 
detect drug use in the workplace. 

Future research development of performance 
tests should include tests to detect a number 
of different drugs and drug doses to establish 
dose-response curves. Such dose-response 
curves may allow assessment of degree of 
performance impairment as a result of drug 
dose. 

In the design of research laboratory-based 
performance-testing programs, areas such as 
psychomotor skills and cognitive or thinking 
ability may be included. Measures of indi- 
vidual subjective response also may be 
included. Some questions that could be 
asked include the following: "How is the 
drug making you feel?" "How much of a 
drug effect do you feel?" "Are you experi- 
encing good or bad drug effects?" Tests that 
focus on the physiological aspects of drug use 
also should be included, such as measuring 
heart rate, blood pressure, and body 
temperature. 

One issue that arises is whether the tests 
that are being conducted in the controlled 



laboratory setting are actually representative 
of the tasks performed in the workplace. 
Three main areas of performance testing 
may be common to most workplaces: 
(1) visual attention, (2) cognitive skills, and 
(3) psychomotor (hand-eye coordination) 
skills. Much research needs to be conducted 
in order to answer the many questions sur- 
rounding the broad issue of performance 
testing in the workplace. 

RS33. The D.C. Initiative: A Federal/ 
State Research Project 

Moderator: Gary Palsgrove 
Speakers: Karst Besteman. M.S.W. 

Jeffrey Hoffman. Ph.D. 

Samuel Karson. Ph.D. 
Respondent: David Mactas, M.A. 
July 16. 4:30 p.m.— 6:00 p.m. 

Speaker: Gary Palsgrove 

The D.C. Initiative is a collaborative project 
between NIDA, CSAT, and the District of 
Columbia government. It consists of a cen- 
tral intake diagnostic unit, two outpatient 
drug abuse units, and two residential units 
housing therapeutic community treatment 
programs. 

The D.C. Initiative is funded under a 
cooperative agreement, because the public 
law that establishes the authority to issue 
grants requires grants to be used in situ- 
ations in which "no substantial involvement 
is anticipated between the federal govern- 
ment and the recipient." A cooperative 
agreement on the other hand, requires "that 
substantial involvement is anticipated 
between the Federal Government and the 
recipient during the performance of the 
contemplated activities." The cooperation 
between the three grantees in the design and 
implementation of the D.C. Initiative is a 
result of using such a funding mechanism. 

Speaker: Jeffrey Hoffman, Ph.D. 

The central intake diagnostic unit works in 
conjunction with the Research Triangle 
Institute (RTI) and coordinates the core 
battery of instruments for the study. The 
unit conducts assessments and analyzes the 
data. This project compares standard and 
enhanced services in methadone outpatient 
and therapeutic community programs. As 
resources shrink, it is important to deter- 
mine which interventions are effective. 

The project is examining the following issues: 
the differences in treatment outcomes for 



125 



NIDA Conference Highlights 



clients in standard and enhanced residential 
therapeutic treatment; the nature of comor- 
bidity among clients seeking substance abuse 
treatment; the specific client characteristics 
that predict treatment outcome, relapse, and 
HIV risk behavior; the utility of a standard- 
ized intake instrument; and the cost of and 
cost-effectiveness of the various treatment 
interventions. 

The Individual Assessment Profile (LAP) was 
developed primarily by RTI as a subset of the 
Drug Abuse Treatment Outcome Survey 
(DATOS) battery, a national drug and alco- 
hol treatment outcome survey. It was 
designed to acquire data in Washington, 
D.C., for comparison with data from around 
the country and to provide research, clinical 
intake, and management information data. 
Reliability and validity testing are being con- 
ducted on the instrument, and staff are 
comparing self-reports for drug use with 
urine and hair analysis, along with other 
validity issues. An automated version of the 
LAP was developed, enabling the interviewer 
to input data into a computer during ques- 
tioning and immediately afterward to pro- 
duce a Client Data System report, a data file, 
and a narrative summary of the client's 
self-report in various categories. Thus far, 
the LAP has proven very useful. 

At 3, 6, and 12 months after intake, and at 3 
months after treatment, clients respond to a 
smaller version of the LAP. Also used are a 
Piatt reading test, the trailmaking test for 
gross neurological problems, the Beck 
Depression Inventory, the Milan Clinical 
Multiaxal Lnventory, and the Structured 
Clinical Interview (SCLD) for DSM-LII-R 
(Diagnostic and Statistical Manual, revised 
third edition) for those in the therapeutic 
community. 

As of June 30, 1993, the standard methadone 
treatment program had 449 clients enrolled. 
Most clients in the residential therapeutic 
communities come from the correctional 
system; about 70 percent are primarily 
cocaine users, while 30 percent mainly use 
heroin. Of the cocaine users, 85 percent 
primarily use crack-cocaine. 

Prom the SCLD diagnosis, 40 percent showed 
an Axis-I disorder, 70 percent showed an 
Axis-II disorder, and 80 percent showed one 
or two disorders, indicating high comorbidity 
in this population. Of the clients with Axis-I 
disorders, 30 percent experienced depression, 
10 percent experienced anxiety, and 5 per- 
cent experienced an adjustment disorder. Of 



the clients with Axis-II disorders, 55 percent 
were antisocial, and 15 percent suffered from 
borderline disorders. Of the primary heroin 
users, 50 percent also used cocaine at least 
once a week. Of the cocaine users, 10 per- 
cent also used heroin regularly. Cocaine 
users were more likely than heroin users to 
use alcohol regularly. Only 15 percent of the 
cocaine users and 7 percent of the heroin 
users also regularly used marijuana during 
the past month. The D.C. Lnitiative is exam- 
ining whether coaddictions differentially 
predict outcome. 

People seeking treatment usually enter 
through the public system, such as central 
intake, or through the correctional system. 
The staff assign the clients into either the 
therapeutic community or methadone treat- 
ment, followed by random assignment into 
either a standard or enhanced modality. 
Heroin users entering treatment average age 
39, whereas cocaine users average age 32. 
The heroin users have been addicts for an 
average of 18 years, versus an average of 7 
years for the cocaine users. The individuals 
who have been addicted for a long time 
usually have been in treatment several times 
previously. This is a hardcore addiction 
population. The heroin users have stopped 
using heroin on an average of five times, 
whereas the cocaine users have stopped 
using cocaine on an average of three times. 
Seventy-two percent of the treatment popu- 
lation has no health insurance and, there- 
fore, depends on publicly provided treatment, 
thereby emphasizing the need for cost 
studies. 

The D.C. Lnitiative attempts to bridge the 
gap between research and practice. It is 
important to simplify instruments, methods, 
and implementations in order to have wide- 
spread applicability. 

Speaker: Samuel Karson, Ph.D. 

The residential part of the D.C. Lnitiative, 
provided at Second Genesis, has produced 
significant positive findings. The experi- 
mental facility is located on the campus of 
St. Elizabeth's Hospital, and the control 
facility is in downtown Washington, D.C. 
The experimental group receives 6 months of 
residential treatment and 6 months of after- 
care, whereas the standard group receives 10 
months of residential treatment and 2 
months of aftercare. Furthermore, there is a 
patient-to-staff ratio of 4 to 1 in the experi- 



126 



Summaries of Research Awareness Seminars 



mental facility and 7 to 1 in the control 
facility. 

This presentation focuses on retention find- 
ings as well as 6-month test results with the 
Minnesota Multiphasic Personality Inventory 
(MMPI). The project uses a battery of three 
tests: the MMPI II, the 16 Personality 
Factors (PFs), and the Bender Visual Motor 
Gestalt Test. The MMPI recently was 
revised with improved standardization and 
less sexist language. The first two tests are 
the two most often used tests in the country, 
but they have been criticized for requiring a 
minimum eighth-grade reading level. The 
Bender Visual Motor Gestalt Test, generally 
the third most frequently used clinical test in 
the United States, does not require a mini- 
mum level of reading ability. This battery of 
three tests was administered by a psycho- 
metrician at each treatment facility to small 
groups of patients during the first week of 
admission and then within 2 weeks of the 
6-month window. 

The sample consisted of all clients who were 
admitted to Second Genesis from February 
1992 through January 1993. About 72 per- 
cent of the sample were men and 28 percent 
were women. About 99 percent of the males 
were African-American, with an average age 
of 32. On average, the clients had completed 
10 years of schooling, and 40 percent had a 
high school diploma or higher. Seventy-six 
percent were involved in the criminal justice 
system. A little more than one-half had been 
convicted of drug distribution charges, and 
the rest had been convicted of possessing 
drugs, as well as other crimes. Prior to 
admission, male patients averaged six felony 
arrests, three convictions, and 19 months' 
incarceration. Only 8 percent were married, 
76 percent had never married, and 16 per- 
cent were divorced or separated. Nearly 70 
percent primarily used cocaine or 
crack-cocaine, whereas 25 percent mainly 
used heroin and other opiates. About 40 
percent reported that at least one of their 
parents abused drugs; this is a significant 
finding, since a recent study shows that 
family history of drug or alcohol abuse in an 
inner-city African-American sample often is 
associated with a history of physical and 
sexual abuse and psychological stress. 

The female clients were similar to the male 
clients in the aforementioned socioeconomic 
variables, with an average age of 32 and an 
average of 11 years of schooling. Also, they 
used comparable types of drugs at similar 



rates and had similar marital status and 
parental history of drug use. It is important 
to know these characteristics in order 
to know to whom the findings may be 
generalized. 

Clients in the experimental program, which 
has a larger staff than the control group and 
is located in an enhanced facility, had a 
slightly better retention rate after 6 months 
than the participants in the control program. 
After 6 months, the experimental program 
retained 75 percent of the residents, com- 
pared with 70 percent in the control pro- 
gram. At 10 months, 54 percent of the 
participants remained in the experimental 
program, compared with 42 percent in the 
control group. As of the time of the con- 
ference, 20 clients had completed the experi- 
mental program and 2 more were expected to 
graduate in July, producing a 39-percent 
completion rate. The completion rate of the 
control group by July was 22 percent. Staff 
are currently in the process of analyzing test 
data to determine whether the MMPI II scale 
and the 16 PF random scales successfully 
can predict early attrition from the Second 
Genesis treatment programs. 

To determine whether random assignment 
actually worked in the research design, an 
analysis of variance was conducted on the 
MMPI II test scores at the beginning of 
treatment of male clients in the two facili- 
ties. No significant differences were found 
with either the MMPI II scale or the 16 PFs. 
Thus, the comparison of progress in treat- 
ment over 6 months appears valid. 

When comparing test scores of clients in the 
experimental group at the beginning of 
treatment and 6 months later, all but two 
MMPI II variables changed — a surprising 
result, since usually such profiles are highly 
stable. Differences were found in areas such 
as clinical anxiety, depression, self-esteem, 
and feelings of alienation. It appears then 
that the experimental treatment program 
has been particularly successful in reducing 
severe psychopathology in clients. The 
typical DSM-III-R diagnosis of the male 
clients on Axis I was opioid or cocaine depen- 
dence. The Axis II diagnosis on about 50 
percent of the clients typically was antisocial 
personality disorder. Similar comparisons 
made on the MMPI II for clients in the 
control group revealed 4 significant differen- 
ces out of 13 comparisons in self-esteem, 
depression, anxiety, and alienation. Each of 
these four also was found in the experimen- 



127 



NIDA Conference Highlights 



tal facility. Thus, these results are indicative 
of treatment improvement over the first 6 
months in both groups in major facets of 
psychiatric symptomatology. 

It is also important to examine the rate of 
change found between the two programs. 
Surprisingly, significant rates of change were 
found in two key MMPI-II scales, those 
which are pathanogmonic of alcohol and drug 
abusers and antisocial personality disorders. 
During 6 months of treatment, male clients 
in the experimental facility had almost three 
times the number of significant mean 
changes in MMPI-II test scores than did 
those in the control facility, possibly account- 
ing for the somewhat better retention rates 
in the experimental facility. It should be 
noted that the accomplishments of the stan- 
dard program were factored out to determine 
what effects, if any, were attributable to the 
program in the experimental facility. 

Findings suggest that treatment at the 
experimental facility resulted in improved 
client personality changes. It remains to be 
seen whether these findings will be sup- 
ported by the 16 PFs and Bender Gestalt 
tests. 

Speaker: Karst Besteman, M.S.W. 
The two outpatient clinics, which dispense 
methadone and are run by the Institutes for 
Behavior Resources, Inc., differ in several 
ways. The patient-to-staff ratio at the stan- 
dard clinic is 40 to 1 and at the enhanced 
clinic is 20 to 1. The enhanced clinic offers 
specialty counseling services in such areas as 
vocation, wellness, AIDS prevention, com- 
munity outreach, and psychiatric assess- 
ment, whereas patients in the standard clinic 
only receive these services through referral. 
The focus of this study was on client behav- 
ior in treatment. Clients were included in 
the sample after only one contact with the 
clinic. The sample was broken down into 
four groups, based on the amount of time 
clients spent in the clinic. Data presented 
here come from the standard clinic, as no 
data are yet available from the enhanced 
clinic. 

Clinic staff dispensed initial medications 
varying from 34 mg. to 40 mg. (Detailed 
charts were reviewed for the following infor- 
mation.) Medication averages went up dra- 
matically in the first and second months and 
then dropped as patients stayed in treat- 
ment. The staff did not tell patients their 
medication levels. Those patients who imme- 



diately dropped out of the program used the 
lowest amount of medical staff time (i.e., to 
acquire medication), whereas those patients 
who stayed in treatment the longest used 
more medical time during the initial period 
of treatment. Likewise, the early dropout 
group spent the least amount of time in 
individual counseling, whereas those who 
stayed the longest participated more in 
individual counseling. In addition, the 
amount of time clients spent in group coun- 
seling varied directly according to their 
length of stay in the project. Except for the 
group of early dropouts, findings showed an 
initial rapid increase in the number of min- 
utes that clients spent in group counseling, a 
leveling off with the 2- and 5-month groups, 
and a continued expansion among those who 
stayed for 8 months. This extensive partici- 
pation in group counseling was surprising. 

Some studies have indicated that cocaine and 
crack-cocaine have been ruining outpatient 
clinics, and that methadone clinics are losing 
effectiveness because people using 
crack-cocaine and cocaine are hard to clean 
on an outpatient basis. However, except for 
the two groups that dropped out the earliest, 
patients who stayed in treatment beyond 2 
months began producing urine tests showing 
the presence only of methadone. The rate of 
dirty urines was very low for an outpatient 
clinic. On a monthly basis, 30 to 35 percent 
of all urines were clean. When dirty urines 
for opiates exceeded dirty urines for cocaine, 
it usually was due to an unusually high 
number of admissions. Additionally, findings 
showed a reduction in clients' use of needles 
and needle-sharing, thus lowering the risk 
for HIV/AIDS. 

Finally, research staff have tried to deter- 
mine whether characteristics of the four 
groups may help predict which patients will 
drop out and which will stay in treatment. 
A significant connecting characteristic has 
not been found yet. However, patients who 
stay tend to be slightly older than those 
patients who drop out, and those patients 
who stay also tend to use crack-cocaine less 
frequently than individuals in the dropout 
group. However, heroin use is highest 
among patients who remain in treatment. 

This project has tried to look at addiction in 
terms of the medical model of chronic 
diseases. Research shows that the initial 
levels of compliance among patients with 
chronic diseases are the strongest indicators 
of whether patients will comply with their 



128 



Summaries of Research Awareness Seminars 



doctors' recommendations 2 years later. 
Similarly, data from the D.C. Initiative 
indicate that patient behavior, such as show- 
ing up for testing or counseling, after 2 to 4 
weeks at the clinic is a strong indicator of 
whether the patient will remain in treat- 
ment. A simple overview of their partici- 
pation, not a research instrument, is 
sufficient to determine patients' levels of 
compliance. 

Questions, Answers, and Comments 

What is the degree to which clients them- 
selves can enhance the programs ? Is there 
any control against a client defining the level 
or frequency of care? To what extent is client 
satisfaction used in experimental and control 
conditions, and what is the correlation 
between reporting on client satisfaction and 
retention and outcome? Finally, is retention 
itself considered an outcome measure? In the 
outpatient clinics, retention is being con- 
sidered an outcome. Also, clients are asked 
to complete a form concerning their reaction 
to the treatment they receive. In the resi- 
dential program, no significant changes were 
found with the Rudolph Moos' Copes Test. 
Both staff and clients in the experimental 
facility were compared with those in the 
control facility. No significant data were 
found concerning staff perceptions and client 
satisfaction. Overall, the D.C. Initiative is 
examining retention as an outcome and is 
asking satisfaction questions in the ongoing 
interviews. Staff are planning to analyze the 
variability of services that clients access. 

How does the D.C. Initiative define a gradu- 
ate in the residential program? A graduate 
has completed all phases of the therapeutic 
community. 

7s any followup conducted on patients after 
they graduate, such as how long they remain 
drug-free? Yes, but analysis of 3-month 
followup has just begun. Not enough people 
have graduated yet for extensive followup. 

To what might the low rates of positive 
urines be attributed? The program is very 
aggressive with methadone treatment. As 
such, staff expect patients to stop using 
heroin rather quickly. 

What characteristics are looked for in staff? 
People who are committed to doing the job. 
They do not have to be certified. Many 
counselors were picked from other programs 
around the city. 



PREVENTION AND EPIDEMIOLOGY 
RS34. Prevention Research Evaluation 

Moderator: William Bukoskl. Ph.D. 
Speakers: Gilbert Botvln. Ph.D. 

Richard Clayton. Ph.D. 

Richard Spoth. Ph.D. 
July 15. 3:00 p.m.-4:30 p.m. 

Speaker: Gilbert Botvin, Ph.D. 

The majority of the country's prevention 
research has been conducted in school-based 
settings. The two most effective general 
prevention studies have taught resistance 
skills and generic personal and social skills. 
These programs can be taught separately or 
in conjunction with each other. One of the 
main goals of the resistance skills programs 
is to teach children the types of "pro-drug" 
pressures they will experience within their 
communities. The other primary goal of the 
average resistance skills program involves 
"correcting normative expectations," which 
simply means teaching children that sub- 
stance use is not necessarily something that 
everyone is doing. The generic personal and 
social skills programs place more stress on 
teaching life skills" such as problemsolving, 
decisionmaking, critical thinking, indepen- 
dent thinking, personal behavior -changing 
techniques, stress management, and 
anxiety-reduction techniques. Communica- 
tion skills training is also a big part of the 
generic personal and social skills programs. 
Some examples of communication skills 
training would be the teaching of assertive- 
ness skills, friend-building methods, and 
complimentary techniques. 

It is important when teaching in any of these 
types of programs to perform not only post- 
tests but also pretests in order to determine 
which results were obtained. Implementa- 
tion fidelity must be considered when com- 
paring control groups to the people who have 
undergone the prevention intervention. If 
the interventions are not complete, there will 
be no significant changes. The breakdown of 
prevention in many studies reflects the 
inadequacy of the prevention/intervention 
models as opposed to the prevention staff. 

A randomized trial that began in 1985 
studied the tobacco, alcohol, and marijuana 
use trends of children from 7th through 12th 
grades. The study's initial intervention 
looked at the trends of the children as 
seventh graders. Booster sessions later were 



129 



NIDA Conference Highlights 



used when the children reached eighth and 
ninth grades. Finally, a followup study was 
conducted at the end of 12th grade. The 
results of the study, upon completing the 
followup, showed a 24-percent reduction in 
the number of "pack-a-day" smokers who 
underwent prevention/intervention skills 
enhancement training. Weekly marijuana 
use also declined by 35 percent. The number 
of once-per-week marijuana users who under- 
went prevention/intervention skills enhance- 
ment training declined by 45 percent, com- 
pared to those users from a similar group of 
children, which only declined by 24 percent 
subsequent to simply viewing and reading a 
number of educational videotapes and pam- 
phlets. Daily marijuana use, on the other 
hand, declined by 61 percent for children 
who received prevention/intervention skills 
enhancement training, as compared to only 
30 percent of those children who received 
only the benefits of independent, 
school-based videotapes and pamphlets. 
Finally, measurable alcohol use, which was 
considered to be two or more drunken epi- 
sodes per month, had an overall decline of 45 
percent. 

Speaker: Richard Spoth. Ph.D. 

The success rates of different programs 
depend largely on the participants' charac- 
teristics and environment as well as the way 
in which the particular programs are 
delivered. Project Family is a relatively new 
program developed by David Hawkins and 
Richard Catalano at the University of Wash- 
ington as a longitudinal study on family 
skills building. Under Project Family, a 
family skills training program, entitled 
"Preparing for the Drug-Free Years," is 
presented to lower the likelihood of pre- 
adolescents using drugs as they get older. 
Parents are taught family management 
skills, and preadolescents are taught peer 
pressure resistance skills. The program is 
being delivered by the cooperative extension 
service in economically stressed counties in 
Iowa. Consumer research techniques are 
applied to evaluate factors influencing pro- 
gram participation in this population. 

Project Family currently is in between its 
pilot stage and a clinical trial stage. Staff 
only recently have begun to analyze project 
data. The prevention program impact model 
is driven by three sets of empirically derived 
hypotheses. The first set focuses on the 
family-related causal mechanisms related to 
the causes of adolescent drug abuse. The 



second set concerns family change mechan- 
isms designed to positively alter these causal 
processes. And the third set centers on 
processes governing family decisions to 
engage in program change activities. The 
development of these initial guiding hy- 
potheses has laid the groundwork for later 
stages of the project. 

Research at the University of Washington 
was complemented by two lines of research 
conducted at the Social and Behavior 
Research Center for Rural Health at Iowa 
State University. The first examined the 
economic stress effects on family processes 
affecting adolescent adjustment. The second 
examined the differential outcomes of pre- 
vention programs and the application of 
consumer research techniques to the evalu- 
ation of factors that influence the overall 
program participation rates. 

The Social and Behavior Research Center 
developed the research methods being imple- 
mented in this program, such as family 
observational techniques. Stage 1 is the 
developmental work. Stage 2 involved a pilot 
test of the "Preparing for the Drug-Free 
Years" program, with 209 predominately 
low-income families that had at least one 
sixth- or seventh -grade child. Stage 3 will 
involve a clinical trial. Additionally, the 
center has begun evaluating culturally sensi- 
tive adaptations of its assessments to Native 
American populations. 

Many significant findings came from three of 
the pilot stage studies on family differences 
and participation factors. These studies were 
conducted with one primary question in 
mind: How do specific program features 
differ in their appeal to parents? The five 
program characteristics perceived by parents 
to be most important were meeting time, 
facilitator background, program duration, 
program research base, and meeting location. 
A key finding of this study is the relatively 
high value that parents placed on program 
convenience factors. The reason that parents 
most often gave for not attending meetings 
was "not enough time." These findings have 
been applied to a variety of strategies for the 
improvement of program convenience, such 
as shorter travel distances to program sites 
and the provision of day care services. 

Data from the study of preferred features of 
a prevention program were used to address 
a second question: What are the subgroup- 
ings of parents that could be expected to vary 
in response to program recruitment? 



130 



Summaries of Research Awareness Seminars 



Parents showing a strong preference for drug 
abuse prevention content were willing to 
spend more program-related effort, and this 
subgroup reported a lack of preference for 
program elements that could be important in 
family focus prevention programs. This 
suggests the importance of helping parents to 
understand the role of all areas of relevant 
skills enhancement early in the program. 

A third research question was as follows: Do 
recruitment strategies differing in the level 
of time commitment requested result in 
differing participation rates? A full partici- 
pation strategy, which requested a commit- 
ment to participation in all program and pro- 
gram assessment activities, was used along 
with a time-limited strategy, which 
requested only an initial commitment to the 
in-home pretests. Significantly different 
pretest assessment rates occurred, with the 
latter strategy proving more successful. 
However, less of the pretest data obtained 
from this group would be usable in outcome 
evaluations because many of the parents did 
not complete a posttest. It also was found 
that almost 90 percent of the families that 
did attend the first session of the program 
also attended at least one other session. 

The final stage of this program prevention 
impact model development, which is not yet 
complete, consists of an NIMH total popula- 
tion survey. This survey is aimed at all 
families that have fifth-graders who are 
attending any one of 33 schools within 19 
rural Iowa communities. Information 
obtained through this survey is meant to 
help develop models describing variations in 
program participation attributable to factors 
such as perceived costs and benefits of pre- 
vention programs, prior program partici- 
pation, and risk factor variables. The people 
deemed eligible to participate will then be 
assigned to one of the following three inter- 
ventions: (1) Preparing for the Drug-Free 
Years program, (2) Multi-Component Skills 
Intervention, or (3) Minimal Contact Reading 
Materials Condition. Data from this clinical 
trial will facilitate a better understanding of 
how families differentially benefit from 
varied types of universal interventions. 

Speaker: Richard Clayton, Ph.D. 

The University of Kentucky Prevention 
Research Center is conducting a number of 
evaluations on such topics as school-based 
programs, community partnership, media 
approaches to prevention, the criminal jus- 



tice system, marijuana cultivation and distri- 
bution, female drug use/abuse, and nicotine 
replacement strategies. The primary princi- 
ple of this center focuses on the idea that 
prevention concerns the entire population 
regardless of one's age. 

A Novelty Seeking Study is under way using 
rat and mice models to obtain information 
concerning the susceptibility of humans to 
drug abuse. The main factor considered 
when studying these rodent models is their 
sensation-seeking level, which — when multi- 
plied — can be used to mimic similar reactions 
within humans. Sensation seeking is defined 
as a "general need for novel and complex 
experiences." 

Another study focused on the design of dif- 
ferent public service messages in order to 
better reach different levels of drug users. It 
has been found that high-sensation-seeking 
people tend to pay attention only to certain 
kinds of messages; therefore, high- and 
low-sensation messages have been developed. 
One way in which it was determined that 
different messages appeal to different people 
was through the help of a study that set up 
a living room environment within a labora- 
tory. This was done in order to view partici- 
pants' reactions to various messages as they 
watched television from within a comfortable 
environment, similar to that which they were 
used to at home. 

A community trial study focusing primarily 
on 18- to 25-year-olds measured both televi- 
sion viewing habits and sensation-seeking 
levels. This trial, which lasted 5 months, 
actually used public service television time to 
air different messages in order to study the 
viewers' reactions. The reach and frequency 
rates of the messages were measured closely. 
The reach rates, which simply refer to how 
far out into the community the messages 
traveled, ranged from 59 to 85 percent. In 
all, five public service announcements (PSAs) 
were aired. Of these five, the following two 
had the greatest impact: (1) "Common," a 
PSA that used heavy metal music, quick 
action cuts, and high-sensation activities to 
gain the attention of its audience; and 
(2) "Wasted," a PSA that used heavy metal 
music and literal symbols associated with 
euphemisms for drug use (e.g., for "stoned," 
a person was shown being pelted with 
stones) to gain the attention of the audience. 

A 5-year evaluation study of Project DA.R.E. 
(Drug Abuse Resistance Education) in Lex- 
ington, Kentucky, began in the 1987-88 



131 



NIDA Conference Highlights 



school year. The study conducted pretests 
for 2,000 randomly picked sixth-graders who 
attended the 23 schools assigned to the 
D.A.R.E project. Posttests later were con- 
ducted for these students when they reached 
the 10th grade. The study findings later 
were compared to those for a number of 
similar students who attended one of eight 
schools assigned to be the control group. The 
project was designed to help determine 
marijuana, alcohol, and tobacco use through- 
out the different stages of childhood. All the 
data obtained through this study pointed 
toward the fact that sensation-seeking is 
related to drug use. 

It was found that the biggest predictor of 
tobacco, alcohol, and marijuana use through- 
out all stages of childhood was peer pressure. 
In connection with this finding, the second 
largest predictor of the various kinds of use 
was determined to be the number of friends 
who either smoked, drank, or used mari- 
juana. It is imperative that sensation 
seeking be considered separately for each 
individual group in terms of tobacco, alcohol, 
and marijuana use. 

Questions, Answers, and Comments 

What tools were used when attempting to 
measure the levels of sensation seeking within 
different individuals? The Zuckerman Scale 
was the main measuring instrument used. 

Were focus groups used within the consumer 
research studies'! They were not used within 
the Family Project but were used in a previ- 
ous study that looked at the problems associ- 
ated with smoking cessation. 

Is it imperative that life training programs 
alter their makeup in order to better suit one 
cultural community over another, or is a 
universal program a sufficient method of 
prevention? In New York, where there are 
over 160 cultural groups, the school-based 
interventions are generally universal in their 
approach toward prevention. Individualized 
treatment for each and every cultural group 
probably would be more effective, but in 
environments where this is not possible, 
there is still the possibility for success 
through the use of a universal system. 

Comment: There is an overall need for an 
increase in the number of systematic inter- 
vention programs within the prevention field. 

Have there been any individual randomiza- 
tion studies conducted, and how are minority 
groups persuaded into participating in these 



studies? Most school -based studies have not 
been conducted on the individual, random- 
ized level due to a fear of contamination 
within the social environment. In terms of 
minority groups, the need for randomization 
has been seen as the key to participation 
regardless of what person or group is being 
studied. 

RS35. Multicultural Aspects of 

Prevention Research Programs 

Moderator: Arturo Cazares. M.D.. M.P.H. 
Speakers: Ford Kuramoto, Ph.D. 

George McFarland. M.S.W. 
Respondent: Judith Ward Dekle. A.C.S.W. 
July 15. 1:15 p.m.-2:45 p.m. 

Speaker: Ford Kuramoto, Ph.D. 

The Asian and Pacific Islander population 
often is viewed as the "model" minority 
group. This and the many other stereotypes 
surrounding the Asian and Pacific Islander 
population need to be avoided in order to 
design the most effective prevention and 
intervention programs. Some of the factors 
that can lead Asian and Pacific Islander 
immigrants into using alcohol, tobacco, and 
other drugs after arriving in the United 
States include the environments in which 
they settle, levels of acculturation, socioeco- 
nomic status, education levels, biological and 
genetic makeup, and whether they are orig- 
inally from rural or urban environments. 

Some recent SAMHSA information (based on 
a reanalysis of the National Household 
Survey on Drug Abuse) on a sample of the 
U.S. Asian and Pacific Islander population 
revealed a low rate of drug abuse in com- 
parison to many other cultural groups. 
However, these data were said to be not very 
"clean," indicating concerns regarding their 
accuracy. The California Attorney General's 
office has preliminary data from a recent 
study that points toward either a stable or 
declining rate of drug use among the major- 
ity of the State's high school students. Asian 
and Pacific Islander high school students, 
however, actually were found to have a 
rising rate of drug use. 

In addition to the efforts being put forth on 
behalf of the Asian and Pacific Islander 
population in the continental United States 
(in terms of alcohol and other drug preven- 
tion/intervention), the six islands in the 
Pacific where 400,000 Pacific Islanders live 
(e.g., Guam and American Samoa) also 
should receive appropriate attention. Alco- 



132 



Summaries of Research Awareness Seminars 



holism is prevalent throughout many of the 
Pacific Islands. Besides being one of the 
main health concerns facing these islands, 
alcoholism is also the primary substance 
abuse problem. Due to the very limited 
health care resources in the Pacific Islands, 
the growing problem of alcoholism is a major 
concern. 

Opium use is also a fairly common problem 
for many Asian and Pacific Islanders who 
immigrate to the United States. Often a 
high level of misunderstanding exists on the 
part of many of these people — some of whom 
have been using opium for many years in 
their native countries — with respect to the 
United States' laws forbidding opium use. 
The public health effects of prolonged drug 
use are not generally understood by these 
people. The problem of youth gangs, which 
often involves violence as well as drug use 
and distribution, is also a growing concern, 
not only in the Asian and Pacific Islander 
communities but throughout the country. 

In order to combat these growing problems, 
more research will be needed in areas such 
as the following: the successful adaptation of 
Asian and Pacific Islanders from their native 
countries into the United States, the educa- 
tion of Asian and Pacific Islander youth and 
their families, and the role of the church and 
temple on these communities. 

Speaker: George McFarland, M.S.W. 

To effectively deal with substance-abuse 
related issues, researchers and practitioners 
must stop working in isolation and must 
work toward the development of more 
cooperative professional relationships. Both 
practitioners and researchers must see 
research as a valuable strategy for improving 
the effectiveness of treatment. 

The importance of race must be a critical 
variable in the testing of prevention and 
intervention research programs if research- 
ers are to better understand both prevention 
science and the given subject population. 
The issue of race has not been adequately 
addressed. Race and cultural diversity must 
be given more consideration in the design of 
future treatment programs because, as racial 
differences and tensions are recognized and 
addressed, drug abuse treatment will become 
more relevant and effective. All kinds of 
social context issues must be examined in 
the entire context of drug abuse prevention. 
Researchers and practitioners need to begin 
to recognize diversities within all of the dif- 



ferent communities and to use this as a 
framework for understanding drug use. 

Researchers and practitioners should strive 
for more community-based intervention in 
order to obtain the most accurate results. 
The information gathered through commu- 
nity-based ethnographic studies should be 
thoroughly analyzed and applied when 
designing future programs. 

Many African-Americans are distrustful of 
research, often because the objectives and 
benefits of studies are not explained to them. 
It is imperative that researchers take the 
responsibility for ensuring that the research 
results are communicated to the people who 
participate in such studies. 

Sources of social support and self-affirmation 
are often not available to African-American 
youth. The bonding of families and schools 
can be a beneficial tool in working toward 
increased success of minorities, especially 
African-Americans. Diversity within schools 
and communities must be viewed as a 
strength, not a weakness. More positive role 
models must be found for the African-Ameri- 
can community. More youth should be direc- 
ted to look to their parents and certain peers 
when searching for someone to fill these 
roles, not to sports stars, as is frequently the 



Speaker: Arturo Cazares, M.D., M.P.H. 

The main component behind the development 
and testing of successful prevention and 
intervention research programs is an under- 
standing of prevention science and the given 
subject population. Researchers and practi- 
tioners need to begin to recognize diversities 
within all of the different subject communi- 
ties and to use these to their advantage. 
Researchers should strive for more commu- 
nity-based interventions in order to allow for 
the most accurate information when creating 
new programs. The information gathered 
through community-based ethnographic 
studies also should be analyzed accurately 
and applied when designing programs. The 
four general risk factor groups considered 
when developing effective prevention models 
are (1) individual, (2) family, (3) peer group, 
and (4) environment (e.g., school, neighbor- 
hood, and workplace). 

Other factors that may contribute to the use 
or abuse of drugs are various family interac- 
tions, family history, ambivalent attitudes 
toward drugs, and a lack of parent-to-child 



133 



NIDA Conference Highlights 



warmth and affection. The use of drugs by 
peers not only can lead to drug use but also 
can affect children's deviant behavior pat- 
terns, trigger negative social interactions, 
and cause shared pro-drug values and atti- 
tudes. Some community risk factors that 
contribute to the growing problem of drug 
use and abuse are the availability of alcohol 
and drugs, pro-drug social norms related to 
economic mobilization, social stress, and 
community disorganization. 

The scientific literature and anecdotal infor- 
mation have shown that youth who become 
involved with drugs tend to have multiple 
and often serious problems. Youth and other 
vulnerable populations require targeted, 
coordinated prevention intervention services 
that are culturally responsive and designed 
for their specific problems and needs. The 
challenge to parents and educators today is 
to get actively involved in prevention: pre- 
vention to deter experimentation and preven- 
tion to interrupt patterns of involved drug 
use. 

Questions, Answers, and Comments 

What advice could be given to prevention 
practitioners who want to apply information 
from available research to populations or 
groups with whom that research was not 
originally applied? One must be careful not 
to transfer, inappropriately, research results 
from one population to another. For 
instance, biologically, some Asian and Pacific 
Islander groups have different reactions to 
certain types of medications than do other 
populations. Furthermore, because many 
Asian and Pacific Islanders are often hesi- 
tant to disclose the problems they are experi- 
encing, research results with this population 
may be very different from results with other 
populations whose members are more willing 
to talk about themselves. The only logical 
suggestion would be to urge researchers and 
practitioners to be more aware of these 
problems. 

What does the research suggest with regard 
to children who come from bicultural families 
(e.g., Caucasian fathers and African-Ameri- 
can mothers, African-American fathers and 
Hispanic mothers, etc.)? Is there any danger 
in applying available research information to 
these children without doing any specialized 
research with them? This issue has not been 
a very substantial one, because if a child has 
one African-American parent and one Cauca- 



RS36. 



sian parent, that child is viewed as 
African-American by current-day society. 

With other ethnic groups, such as Hispanics, 
it may be more of a problem. For instance, 
the Federal Government requires that studies 
categorize Hispanics under "black" or "white." 
Also, if, for instance, a child has a black 
parent and a Hispanic parent, the child may 
look black but likely will have grown up to 
some extent in a Hispanic culture. This 
creates a complex issue. How can it be 
addressed? That is a different scenario and 
certainly is significant. For instance, there 
is great diversity even within the Hispanic 
community. While people tend to want to 
generalize with minimal information, they 
must be careful not to do so. However, one 
problem is that inadequate funding often 
limits researchers in the number of questions 
they can ask, the number of variables they 
can consider and manipulate, and the level of 
understanding they can attain regarding the 
factors associated with the various problems 
the study populations may experience. 
Therefore, smaller, more specialized, and 
ethnographic-oriented studies need to be 
implemented in order to gain a better work- 
ing knowledge of the different problems that 
surface on a daily basis. 

Comment: The practice of grouping Hispan- 
ics under either African-American or 
Caucasian labels for Government research 
purposes is a problem that leads to the 
substantial growth of continued problems in 
terms of research inaccuracies. 

Risk and Protective Factors in 
Adolescent Drug Use and Abuse 

Moderator: 311 Amsel. Sc.D. 
Speakers: Laurie Chassln, Ph.D. 

Kevin Haggerty. M.S.W. 

Ralph Tarter. Ph.D. 
Respondent: George Hamilton. M.A.. L.P.C. 
July 15, 4:45 p.m.-6:15 p.m. 

Speaker: Ralph Tarter. Ph.D. 

The Center for Education and Drug Abuse is 
currently funded at $1 million per year by 
NIDA. The center tracks and identifies 
10-year-old youth with high- and low-risk 
statuses and identifies the risk and protec- 
tive factors that determine outcomes. These 
youth are characterized by biomedical, 
physiological, neurophysiological, genetic, 
psychological, cardiovascular, psychiatric, 
family interaction (captured on videotape), 



134 



Summaries of Research Awareness Seminars 



and peer relationship factors. This charac- 
terization, along with a teacher report and 
environmental status reports, is compiled 
into a 28-hour evaluation. 

One part of this evaluation addresses 
temperament properties. When viewed from 
a research perspective, temperament is 
evaluated on a sliding scale that ranges from 
high to low levels, with a fulcrum of normal 
activity. To focus on how temperament 
properties influence outcomes and — more 
specifically — the likelihood of substance 
abuse, one must view it in context with 
environmental variables. We know that 
similar temperament levels will influence 
children in diverse environments differently. 
This makes research difficult because of the 
dynamic interplay of the variables. The 
multivaried model presented allows one to 
view the high- and low-risk factors and the 
interaction between the child and the envi- 
ronment that promotes these risk factors. 

Temperament properties are the building 
blocks of psychological development. They 
are the primary traits of the individual, are 
observable within the first 30 days of life, 
tend to be stable, have a high genetic influ- 
ence, are measurable, and provide a devel- 
opmental trajectory for the individual. Six of 
the traits among mammals have been identi- 
fied by the Colorado Adoption Study and the 
New York Longitudinal Study: (1) emotion- 
ality, (2) sociability, (3) attention span, 
(4) soothability, (5) reaction to food, and 
(6) behavioral activity level. 

Factors that produce severe or abusive 
behavior also can be determined by the level 
of behavioral activity, when viewed in con- 
text with social interaction. A conceptual 
model of behavioral activity can be viewed as 
a continuum ranging from high to low levels. 
Behavioral activity levels differ for males and 
females and breeds of animals, and the 
environmental context determines whether 
the behavior will be adaptive or maladaptive. 
A high level of behavioral activity in a child 
results in poor disciplinary practices, less 
maternal stimulation, roaming in the envi- 
ronment, and sensation seeking. Mapping 
the behavior of a child with a high level of 
behavioral activity can lead to a develop- 
mental trajectory resulting in substance 
abuse. 

The data on behavioral activity levels show 
that community-dwelling sons of alcoholic 
parents tend to have higher behavioral 
activity levels than those of nonalcoholic 



parents. High behavioral activity levels, or 
difficult temperament, contribute to dysfunc- 
tional family status and later to the propen- 
sity for associating with negative peer 
groups. A study of ninety 16-year-old chil- 
dren, both males and females, shows that 30 
percent of drug abuse severity is due to 
temperament severity. Results from this 
data also raise questions of social equity. 
For example, Euro-Americans are more likely 
to develop substance use problems than 
African-Americans and are more likely to 
receive treatment, while African-Americans 
are more likely to be placed in the judicial 
system. This is important because society 
tends to associate substance abuse with 
inner-city life, but this has not proved to be 
true. Males and females also are not shown 
to differ substantially in the amount of drug 
use. 

In conclusion, when discussing the liability of 
good and bad outcomes, one must look at a 
multivaried conceptual model — one aspect of 
which is temperament. Temperament is 
measurable and dependent on environmental 
context. It can be ranked according to sever- 
ity and can be used to target the magnitude 
of intervention. When working with drug 
abuse, one must view it as a symptom, and 
the intervention must apply to problem areas 
before focusing on the drug use. 

Speaker: Laurie Chassin, Ph.D. 

The Adolescent and Family Development 
Project focuses on substance use and abuse 
in children of alcoholics and the extent to 
which these children are at risk for using 
and abusing substances. The project seeks to 
identify those children at risk because of 
factors such as deficits in parenting control 
and support, self-regulation problems, and 
elevations of stress — which may lead to 
negative affective states and temperamental 
difference factors — and different results from 
drug and alcohol use and protective factors. 
The project achieves results by answering 
three questions: (1) Are children of alco- 
holics at higher risk for drug abuse? 
(2) What are the mediating processes that 
put these children at risk? and (3) What are 
the special links between parental alcoholism 
and child drug use and abuse? 

The most recent wave of samples consists of 
community-dwelling children with an aver- 
age age of 14.8. The study provides data 
outcome on their substance use and abuse 
during the past year. The children were 



135 



NIDA Conference Highlights 



divided into three groups. The first group 
consisted of children with no history of 
parental alcoholism, the second group con- 
sisted of children with no history of past 
parental alcoholism, and the third group 
consisted of children with a history of persis- 
tent parental alcoholism. The children in 
Group 3 already have been identified at high 
risk for alcohol and drug use. In fact, 34 
percent of the children in Group 3 have 
shown alcohol-related consequences and 18 
percent have shown drug-related consequen- 
ces. Of the children with a full-blown sub- 
stance abuse problem, all but one of them is 
in Group 3. Group 2 has shown a lower 
prevalence for drug and alcohol use and 
abuse, but not as low as Group 1. When one 
focuses on the specificity of the project, one 
definitely can find examples, such as that the 
children diagnosed for depression are spe- 
cifically related to alcoholic parents. 

To identify the mediating mechanisms that 
put these children at risk, a technique was 
used — termed latent growth curve 
modeling — which helps determine etiology. 
This modeling procedure graphs a substance 
use slope, which helps predict the rate a 
child will accelerate his/her drug use over 
time and determine the chain of events 
related to parental alcoholism. This tech- 
nique may not predict the onset of drug use 
when a child is among drug-using peers but 
will predict at what rate his/her drug use 
will accelerate. Though the model presented 
is multivaried, a direct correlation between a 
father's alcoholism and a child's attitude and 
reaction toward substance use and abuse is 
presented. 

The protective factors shown for this popula- 
tion are those that limit the levels of drug 
use. For example, high levels of family 
organization, or a regular family schedule, 
will block the effects of parental alcoholism 
on the child. A high sense of perceived 
control also has surfaced as another strong 
protective factor. The use of negative peer 
examples was identified as a successful 
protective factor in Group 2, the past paren- 
tal alcoholism group, but in no other. The 
services provided to alcoholic families by 
intervention programs may be a protective 
factor by producing recovery of an alcoholic 
parent or by increasing already available 
protective factors. 

In addition, this project identified the need to 
focus on peer influence in intervention pro- 
grams. While peer influence is not the most 



dominant factor, it does have an influence. 
It would be wise to be cautious about the use 
of negative peer examples in intervention 
programs when not coupled with successful 
peer examples. There is a definite need to 
continue studying the risk and protective 
factors in children of alcoholics due to the 
amount of information still lacking and to 
study these children over the course of time. 

Speaker: Kevin Haggerty, M.S.W. 

The 2-year Focus on Families project studies 
risk and relapse factors in parents who are 
participating in methadone treatment pro- 
grams, and works to reduce the risk factors 
and increase the protective factors for their 
children. The current emphasis on preven- 
tion programs is to merge children with their 
families and to merge research with actual 
practice. The risk factors for this project 
required consistent longitudinal effects. 
Therefore, the risk factors targeted for child- 
ren were family history of substance abuse, 
parental attitudes, family management, 
organization and discipline, alienation, early 
antisocial behavior patterns, and academic 
failure. The risk factors targeted for the 
parents on methadone were peer drug use, 
high stress lifestyle, family conflict, low 
family bonding, lack of nondrug leisure 
activities, and isolation. When these factors 
are combined with the results of the study, 
interesting comparative data emerge. 

The initiation rates of substance abuse for 
the Focus on Families sample of 11- to 
14-year-old children was compared to a 
national survey of secondary school students 
in eighth grade. While cigarette and alcohol 
statistics were balanced between the two 
groups, marijuana use was nearly twice as 
high and opiate use was five times as high in 
the Focus on Families sample than in the 
secondary school sample. Comparative 
behavior patterns between the groups 
showed the Focus on Families sample to be 
6-percent higher than the secondary school 
students in suspension and expulsion, 
15-percent higher in initiating fights, and 
13-percent higher in police problem rates. 

The emphasis of the project has been on 
parents who are already dedicated to 
recovery, and the intervention has been 
developed to provide norms for the family. 
To this end, Focus on Families conducted 33 
sessions of clinic-based parent training ses- 
sions over 8 months combined with a 
home-based services component. When the 



136 



Summaries of Research Awareness Seminars 



project began, three assumptions were made 
about those seeking treatment: (1) those 
seeking treatment are primarily parents, 

(2) addicted parents with high family 
management skills can do more than those 
with low family management skills, and 

(3) parents do not want their children to 
become substance abusers. 

The best ways for parents to reduce the risk 
factors for their children is to eliminate 
substance use and increase family manage- 
ment skills. This can present a problem if 
not handled in a family context because of 
the likelihood of the children to rebel from 
increased parental involvement. Once in a 
family context, parents who have not 
acquired certain skills (e.g., refusal skills) 
must be taught parenting skills. The most 
successful approach to this so far has been 
teaching parents how to teach their children 
these same skills. These procedures eventu- 
ally will be able to break the cycle of drug 
abuse from parent to child and end the 
parent's perceived inevitability of drug abuse 
for their children. 

Questions, Answers, and Comments 

How were you able to establish the direction 
of relationships between difficult tempera- 
ment and family functioning? There is no 
clear way to determine whether family func- 
tion or dysfunction comes first. We can only 
look at association. 

Would it make sense to put children with a 
high behavioral activity level into an activity 
therapy intervention as opposed to other 
treatments? The community should provide 
an appropriate way for children to discharge 
energy, such as clubs, but in schools the 
children have no choice. 

How many of the 10-year-old children studied 
with high behavioral activity levels developed 
a problematic outcome? Because tempera- 
ment must be viewed in regard to environ- 
mental factors and outcomes must be viewed 
as dimensional variables of severity, it is 
difficult to determine exactly how many 
children develop a problematic outcome. 

What is the relationship between gender and 
temperament? Do females with a high 
behavioral activity level have a higher pro- 
pensity for bad outcomes? There is no dif- 
ference in severity of problems according to 
gender. In a complex breakdown, different 
genders appear to produce different 
problems. 



In the Adolescent and Family Development 
Project, how did you choose the second group 
of children? The parents of the children in 
Group 2 met lifetime diagnostic criteria for 
alcohol abuse. However, during the course of 
this study there was no amount of 
alcohol-related turbulence. 

How does the gender of the child effect the 
outcomes in the Adolescent and Family 
Development Project? With such a young 
sample, the effects of gender are extremely 
minor. 

What was the most common gender of the 
parents studied in the Adolescent and Family 
Development Project? This particular project 
focused solely on parental alcoholism in the 
fathers. 

RS37. The Drugs and Violence 
Connection: Underlying 
Psychosocial Factors 

Moderator: Mario De La Rosa. Ph.D. 
Speakers: Richard Dembo, Ph.D. 

Eloise Dunlap. Ph.D. 

Barry Spunt. Ph.D. 
Respondent: Ronald Brlnn. M.A. 
July 15. 1:15 p.m.-2:45 p.m. 

Speaker: Richard Dembo, Ph.D. 

One subset of data from a NIDA-funded 
longitudinal study examines ethnicity and its 
interactions with the selling and nonselling 
of drugs, substance use, and delinquent 
behavior. Programmatic implications involve 
determining the differential needs, if any, of 
African-American and Caucasian male youth 
who become involved in drug selling. 

The data set presented is part of a two-way 
longitudinal study of a group of juvenile 
detainees who entered a regionally based 
detention center in Tampa, Florida, in late 
1986 and early 1987. The youth were inter- 
viewed and tested (via urinalysis) at the time 
of the first interview and 1 year later. The 
first interview lasted 1 hour and 15 minutes 
and focused on self-reported delinquency, 
relationships with parents, self-image, sub- 
stance use, relationships with peers, educa- 
tional experience, psychosocial functioning, 
and urine test data. Approximately 89 
percent of eligible youth were interviewed 1 
year later. There were high interview suc- 
cess rates, as confidentiality was ensured 
and it was indicated that the data would be 
used to make more resources available for 
the community. A psychological assessment 



137 



NIDA Conference Highlights 



and screening triage unit at the detention 
center already had been established, so 
fortunately, many of the youth knew and 
trusted the program. This work already has 
led to the creation of many new services in 
the community, as agencies have used the 
data to demonstrate the need for more ser- 
vices that could respond to youth's needs. 
Such a relationship shows how researchers 
can work with practitioners to derive more 
resources. The data from this study compare 
the similarities and differences among Afri- 
can-American and Caucasian male youth, 
particularly regarding the selling of cocaine. 
The data also reveal the correlates of this 
phenomenon among African-American and 
Caucasian sellers and nonsellers. 

The study examined, in the year before the 
first interview and in the followup year, 
youth's reported selling of three categories of 
drugs — (1) marijuana, (2) cocaine, and 
(3) other hard drugs such as heroin or LSD. 
In the year preceding the interview, African- 
American male youth reported (in what is 
probably a conservative estimate) 32 sales, 
while Caucasian male youth reported 6 sales; 
however, Caucasian males sold more hard 
drugs than African-American males. In the 
followup period, African-American youth 
reported a higher rate of cocaine sales. At 
each threshold level of the frequency of 
reported sales, African-American male youth 
reported greater participation than Cauca- 
sian males. For example, 16 percent of the 
African -American youth and 3 percent of the 
Caucasian youth reported selling drugs 20 or 
more times before the first interview. In the 
followup interview, in response to the same 
question, 19 percent of African-Americans 
and 4 percent of the Caucasians reported 
selling drugs. Again, Caucasian males 
reported greater numbers of sales of hard 
drugs than African-American males. 

The study also examined at both interview 
times the relationship between selling and 
not selling cocaine among African-American 
and Caucasian youth, the youth's self- 
reported drug use and urine results, and the 
youth's self-reported delinquency. The 
results are clear and consistent. There is a 
large difference between those who are 
selling drugs and those who are not selling 
drugs, relative to their use of other substan- 
ces and self -reported delinquency. For exam- 
ple, in response to a question about youth's 
lifetime frequency of cocaine use (across 7 
categories of frequencies from never to 200 
times), among Caucasian male nonsellers, 



45.1 percent reported use, and 92 percent of 
sellers reported use. Eight percent of Afri- 
can-American nonsellers reported use, and 
43 percent of African-American sellers 
reported use. 

The research found significant differences in 
drug use and delinquency between Caucasian 
and African-American males. For most of 
the drug and delinquency variables, Cauca- 
sian males have higher rates of involvement 
with drugs, with two exceptions — the use 
and sale of cocaine at the followup interview 
were higher among African-American males 
than Caucasian males. Otherwise, Cauca- 
sian male youth are more involved in these 
activities. 

The research found that there are seller 
versus nonseller differences in terms of 
substance use and self-reported delinquency. 
It is apparent that in almost every variable 
of comparison, sellers are involved more 
seriously in substance use and delinquency 
than nonsellers. This constitutes high-risk 
involvement, with the associated commit- 
ment to a deviant lifestyle. 

The research found that Caucasian male 
drug sellers have higher rates of lifetime- 
reported cocaine use than any other group. 
It also was found that more psychosocio- 
logical difficulties and intrapersonal issues 
are associated with the deviant lifestyle of 
Caucasian drug-selling males. African- 
American youth most often have problems 
that are associated with social and contex- 
tual factors (i.e., more economically stressed 
environments). For example, African-Ameri- 
can male youth contend with a higher rate of 
poverty than Caucasian male youth. 

Thus, it appears that Caucasian male youth, 
especially sellers, would benefit from inter- 
ventions providing intensive individual, 
group, and family counseling to understand 
and address the underlying issues related to 
their lifestyles. African-American male 
youth may benefit more from interventions 
that aim to elevate their educational and 
vocational skills and increase their stake and 
commitment to participating in mainstream 
society. Another study in Florida, with 
youth in two public housing developments, 
found that more than 96 percent of the 
crack-cocaine dealers in the community sold 
the drug to earn money because legal jobs 
paid too little. More than 70 percent of these 
youth said that the social popularity and 
status associated with selling crack-cocaine 
were a factor. But these youth still were 



138 



Summaries of Research Awareness Seminars 



aware of the risks they faced, including 
violence, rejection, and falling into a material 
trap where they were increasingly unlikely 
to gain other employment or enhance their 
career chances and educational opportuni- 
ties. This and other studies indicate that 
different strategies are needed to address the 
needs of various groups of youth, based on 
their backgrounds and circumstances. Many 
youth in the early stages of drug involvement 
are reachable, but as they become more 
committed to the drug lifestyle, it becomes 
less likely that they can turn themselves 
around. 

Speaker: Eloise Dunlap. Ph.D. 

Data presented here come from a paper 
entitled "Aggression, Violence, and Family 
Life," which examines the transmission of 
behaviors in households that abuse and sell 
crack-cocaine. The paper states that in drug- 
abusing families, children are deprived of the 
opportunity to use adults as resources to 
learn conventional behaviors. Instead, the 
children learn aggressive and violent behav- 
ior from their parents and other relatives. 
Children in drug-abusing families remain 
excluded from learning those skills needed to 
survive in social circles where drug use is not 
a critical activity. The children do not have 
parents to train and guide them and often 
have to fend for themselves. The core of 
many drug problems has its origins in ag- 
gression, violence, and drugs, which are 
products of the family systems in which 
children grow up. 

The following data come from a NIDA-funded 
research project entitled "Natural History of 
Crack Distribution and Abuse," an ongoing 
ethnographic study of the structure, func- 
tioning, and economic aspects of crack- 
cocaine distribution in New York City, 
primarily in low-income, minority communi- 
ties. It must be remembered that the avail- 
able findings from the first 3 years of this 
research focus on only one segment of Afri- 
can-American family life and should not be 
generalized to all African-American families 
and communities. Drug users form no more 
than 15 percent of city populations. Families 
presented in these findings are not the norm, 
and they are not rare. 

A family chart of the Jones family provides 
insight about family/kin systems that are not 
conducive to raising children conventionally 
and thus can lead to another generation of 
drug abusers. In this family, each genera- 



tion is less attached to conventional behavior 
than the previous one. Much alcohol and 
substance abuse has occurred in the family 
line. For instance, in one family, the woman 
is not a heavy drug abuser, yet her husband 
and siblings are heavy alcohol abusers. The 
woman's son is a drug dealer and has three 
children by a woman who has three brothers 
who are drug dealers. The first generation of 
this family includes many heavy alcohol 
users, the next generation predominantly has 
heroin users, and the subsequent generation 
is involved in crack-cocaine. The alcohol- 
using generation provided for the emotional 
needs of family life, but in the generation of 
heroin users, one can begin to see forms of 
abuse. Finally, those in the crack-cocaine 
generation display no sense of responsibility 
for family life and have histories of substance 
abuse, violence, aggression, and neglect of 
offspring. These crack-cocaine users are 
heavily involved in the foster care and 
criminal justice systems, and their family 
members often sell drugs. 

Adults and parents in each generation exhi- 
bit modeling and ongoing behavior patterns 
that train people to survive in a world where 
aggression and violence prevail. For 
instance, Latisha trained her daughter, 
Barbara, to become a street prostitute. 
Latisha had begun to exchange sex for 
money during high school, and she gave 
birth to Barbara at around age 15. Her 
father had told her to do her homework and 
stay in school, but neither he nor others 
actively encouraged her to do so. Likewise, 
Latisha displayed and passed this attitude 
on to her children. By the age of 13, Barbara 
was a prostitute; at age 14, she had a son by 
a 35-year-old customer, so she dropped out of 
school. All of this behavior was modeled for 
her. When Barbara got pregnant, Latisha 
told her that she should finish school, but 
Latisha did nothing to help her. Further- 
more, Latisha grew up watching her parents 
heavily abuse alcohol, and Barbara grew up 
seeing her parents abuse heroin. Barbara 
hated heroin, but as she grew up she started 
snorting cocaine and smoking crack-cocaine. 
Thus, individuals in such households are 
socialized into general drug use; they do not 
necessarily use the drug that their parents 
used. Violence became part of Barbara's and 
Latisha's relationship. Shortly before 
Latisha's death, Barbara approached Latisha 
for money, but she did not have any. 
Barbara asked Latisha to obtain the money 
from her boyfriend, but he did not have any 



139 



NIDA Conference Highlights 



either. An argument and fight broke out, 
and Barbara ended up stabbing her mother's 
boyfriend in the leg. At Latisha's funeral 
1 month later, further aggression and threats 
of violence occurred. 

There is significant psychological and emo- 
tional neglect in alcohol- and drug-abusing 
households, as evidenced in early partici- 
pation in street life and early alcohol and 
drug use. Adults also alternate between 
hugging and kissing their children and 
cursing and beating them, the latter 
especially after drinking and using drugs. 
Mothers who are out on the street provide 
little or no emotional availability, love, or 
direction for their children. Furthermore, 
adults often use physical and sexual abuse as 
punishment. For instance, Latisha would 
punish her son by abusing his sexual organs. 

Verbal aggression is another factor in drug- 
abusing families. Children are scolded and 
complimented with abusive language, such 
as "You gonna be a pretty bitch when you 
grow up." Jokes and serious talk fall into 
one another and can lead to misunderstand- 
ings and fights. Male/female relationships 
generally are defined by their sexual content, 
and love is shown through sharing of drugs, 
even though fighting also occurs over drugs. 
Overall, there is an inability to relate to each 
other respectfully. 

Speaker: Barry Spun! Ph.D. 

The National Development and Research 
Institute, Inc. (NDRI), has been collecting 
detailed violent event and life history infor- 
mation from street drug abusers and incar- 
cerated homicide offenders through NEDA- 
funded research. The NDRI studies were 
structured according to Paul Goldstein's 
tripartite model of the relationship between 
drugs and violence, which classifies the 
relationship into three categories. First, 
violence is considered psychopharmacological 
when it results from short- or long-term 
ingestion of specific substances by the per- 
petrator or victim of the violent event. 
Second, economic/compulsive violence occurs 
when the drug user feels compelled to parti- 
cipate in economically oriented violence, such 
as robbery, to support costly drug use. 
Third, systemic violence results from tradi- 
tionally aggressive patterns of interaction 
within the system of drug distribution and 
use, such as turf wars and other disputes. 

The first two studies, conducted between 
1984 and 1988, examined the drugs/violence 



connection among street drug abusers living 
in or frequenting the lower east side of Man- 
hattan. The aim of the first project, DRIVE 
(Drug-Related Involvement in Violent Epi- 
sodes), was to learn about violent incidents 
in which drug abusers participated and 
whether the incidents were related to drug 
use. DRIVE studied violent perpetrations 
and victimizations of a sample of 152 males 
in the lower east side. A followup study, 
Fem-DRIVE, looked at the connection 
between drugs and violence among 133 
female drug users and distributors in the 
lower east side. The project established an 
ethnographic field site in the community and 
conducted life history interviews in 3- to 
5-hour sessions, focusing on respondents' 
drug use, dealing, treatment, health pro- 
blems, and so forth. Respondents returned 
weekly for 8 weeks and reported on violent 
events that had occurred in the previous 
7 days. 

Findings showed that about one-half of the 
violent events reported by males and a little 
more than one-third of those reported by 
females were drug related. Among both 
groups, incidents of psychopharmacological 
violence were reported most frequently, 
followed by systemic and economic/compul- 
sive violence. Also for both groups, alcohol 
was the substance most closely associated 
with psychopharmacological violence, 
whereas cocaine and heroin were most 
associated with systemic and economic/com- 
pulsive violence. 

These findings suggest that common assump- 
tions about street drug abusers may be 
slightly incorrect. For example, many people 
believe that a major threat to public safety is 
drug users' violent predatory acts to obtain 
money for drugs, yet this scenario occurred 
rarely in the samples relative to other types 
of violence. Also, it is commonly believed 
that public safety is endangered by people 
who are crazed due to drug use. However, 
violent events of this sort generally were due 
to drug abusers' use of alcohol, a legally 
obtainable substance. 

In 1988 NDRI decided to look at the 
drugs/violence connection from another 
angle — that is, talking with people who 
committed violent acts and asking them 
about their drug use. NDRI focused on 
homicide (including murder and manslaugh- 
ter), since it provided a small, manageable 
number of cases and also because perpetra- 
tors were more likely to be identified by 



140 



Summaries of Research Awareness Seminars 



arrest than perpetrators of other violent 
crimes and thus were easily located for 
interviews. The NIDA-funded DREIM (Drug 
Relationships in Murder) Project was con- 
ducted between 1988 and 1991 and focused 
on homicides committed in New York State 
in 1984. A sample of 430 perpetrators was 
selected, and 2-hour interviews were con- 
ducted with 268 of the perpetrators at 37 
New York State correctional facilities. 

DREIM results were similar to those of the 
DRIVE and Fem-DRIVE projects. About 
one-half of the homicides were drug related, 
most of which were of the psycho- pharma- 
cological kind, followed by systemic and 
economic/compulsive violence. Also, alcohol 
proved to be the substance most likely associ- 
ated with psychopharmacological violence, 
while cocaine was most associated with 
systemic and economic/compulsive violence. 
Alcohol was the primary drug in one-half of 
the drug-related homicides, and cocaine was 
the primary drug in one-third. 

In considering the methodological implica- 
tions of these data, self -reports (interviews) 
were shown to be valid and reliable sources 
of information. Trained interviewers rated 
only 13 percent of respondents as seeming 
dishonest. Therefore, self-reports have 
greater utility than criminal justice records 
for elaborating on the drugs/homicide connec- 
tion. It must be remembered that the 
DREIM sample was 97-percent male, as 
female homicides are fairly rare. Therefore, 
the NEDA-funded Fem-DREIM study to 
supplement DREIM research was begun in 
fall 1991. Interviews are being conducted 
with all the women currently incarcerated 
for homicide in New York State as well as 
some on parole in the New York City area. 
About 475 women are in the sample. Staff 
are conducting 2-hour, one-time interviews 
with the women on the same topics as well 
as on the topic of physical and sexual abuse. 
Thus far, 157 interviews have been com- 
pleted, with the rest scheduled to be com- 
pleted by fall 1993. 

Results from the first 50 completed inter- 
views indicate that female-perpetrated homi- 
cides are more complex than normally 
portrayed in the literature, which is based on 
official record data. Although it is commonly 
believed that most women Mil in domestic 
disputes and/or because they are battered, 
the women in this study killed many dif- 
ferent kinds of people for a variety of 
reasons. Adult intimates were victims in 



only 20 percent of the homicides, while 26 
percent of the homicides occurred in the 
context of criminal activity such as robbery. 
Less than one-half of the homicides were 
drug related. About two-thirds of the drug- 
related homicides appeared to be psycho- 
pharmacological violence. Again, alcohol was 
the substance most likely to be connected to 
psychopharmacological events. 

Three-fourths of the women had been regular 
users of some substance at some point in 
their lives prior to the homicide, and two- 
thirds had felt addicted to a substance, most 
likely cocaine. Forty percent of the entire 
sample had used powdered cocaine on a 
regular basis at some point in their lives, 
and about one-third had felt addicted to 
cocaine at some point. 

This research likely will facilitate the identi- 
fication of predisposing factors and of distinc- 
tions in homicides by women. It also should 
help professionals in the correctional, drug, 
and mental health fields to view female- 
perpetrated homicides in a less monolithic 
fashion and to enhance early drug and vio- 
lence intervention efforts. It is important to 
understand how different substances may be 
related to violence and the conditions under 
which drug-related violence is likely to occur. 
These studies should help policymakers 
develop new initiatives for dealing with the 
issue and help professionals target limited 
resources in a more efficient manner. For 
example, since it appears that few drug- 
related homicides are economic/compulsive- 
driven, new programs/policies focused on this 
area are of limited value. On the other 
hand, programs/policies that focus resources 
on controlling alcohol use could be very 
useful, as could the enhancement of penalties 
for violent offenders who commit crimes 
while under the influence of alcohol. 

In early 1994 NDRI hopes to initiate a study 
looking at the link between drug use and 
violence by youth. Youth remanded to New 
York State's Division for Youth Facilities for 
Violent Crimes will be interviewed for the 
study. 

Questions, Answers, and Comments 

To what extent is the marketing and adver- 
tisement of alcohol, particularly culturally 
associated advertisement, a driving force in 
communities afflicted with substance abuse 
and related problems? While there are no 
data from research on the issue, minimizing 
alcohol advertisements, especially in inner- 



141 



NIDA Conference Highlights 



city communities, would have a positive 
effect in reducing the attractiveness of the 
substance. However, even if alcohol adver- 
tisements are reduced, children still will 
learn about alcohol and other substance 
abuse from their families. More attention 
must be focused on changing these behaviors 
of adults before such behaviors are passed on 
to the children. 

What anecdotes or stories from working with 
people involved with drugs and violence may 
provide compelling lessons for others? The 
following story emphasizes the importance of 
a simple human touch in working with youth 
involved in drug use and violence. A 
distraught youth entered a detention center 
and said that his aunt, with whom he was 
living, did not know he was there. When a 
center staff person offered to visit his home 
to tell his aunt, neither the youth nor a 
friend could identify the exact address. The 
youth and his friend gave the staff person 
directions based on street turns, the color of 
the house, and the color of a bike on the 
porch. The staff person managed to find the 
home and inform the aunt of her nephew's 
whereabouts, and the youth was very grate- 
ful that someone had made a genuinely 
human response to his need to inform his 
aunt of his whereabouts. 

One researcher said he realized after about 
the first 50 of his interviews with drug users 
in Manhattan that they were not very dif- 
ferent from him. However, whereas the 
researcher came from a stable family life, 
they had grown up around alcohol and drug 
use, physical and sexual abuse, and other 
such factors. Another researcher emphasized 
that most of the people with whom she works 
do not intend to behave so destructively. 
However, she told the story of a small dog 
who was shaking uncontrollably on the porch 
of a house she was visiting. It turned out 
that the owners, while high, had pulled the 
dog's teeth out since the dog had bitten one 
of them. Later, she visited the house again, 
and the dog was dead because the owners 
had dropped the dog, breaking its neck. 

Comment: One must not generalize the 
results from the study of juvenile detainees 
to any larger groups of youngsters other than 
those who were interviewed and their kind of 
life circumstances. However, there do seem 
to be some broad differences between Afri- 
can-American and Caucasian youth that 
professionals should keep in mind when 
determining their specific needs for services. 



RS38. Physical and Sexual Abuse 

Moderator: Shirley Coletti 

Speakers: Karen Allen. R.N.. Ph.D.. CARN 

Dean Kllpatrick. Ph.D. 

Brenda Miller. Ph.D. 
Respondent: Pearle Lavery, M.S. 
July 16. 2:30 p.m.-4:00 p.m. 

Speaker: Karen Allen. R.N., Ph.D.. CAAN 

In 1982 it was determined that women repre- 
sented less than 20 percent of the people 
receiving substance abuse treatment. Since 
that time, many experts have worked on 
lowering the barriers encountered by women 
to substance abuse treatment. Barriers to 
treatment can be divided into two general 
groups: (1) external sources (e.g., treatment 
program or health care system) and (2) inter- 
nal forces (e.g., individual personalities, 
characteristics, or health beliefs). Physical 
abuse seems to be the most predominant 
barrier deterring women from attending 
substance abuse treatment programs. Physi- 
cal, emotional, and sexual abuse not only 
prevent some women from seeking substance 
abuse treatment but also have been known 
to cause some women to turn to substance 
abuse as an escape mechanism. 

The number of women receiving treatment 
for substance abuse in 1993 represents only 
a little over 30 percent of the entire popula- 
tion of patients, while the number of women 
represented in the Nation's alcohol abuse 
treatment programs is only about 22 percent 
of the entire population. These statistics 
would suggest that little progress has been 
made since 1982 in the area of making treat- 
ment programs accessible to women. A 
strong linkage has been found between 
substance abuse and women in domestic 
violence shelters. A survey of 2,600 women 
from numerous domestic violence shelters in 
Maryland revealed that 38 percent of them 
had a problem with either alcohol or other 
drugs. Of the shelters polled, 50 percent 
reported that women were told they were not 
allowed to use any kind of alcohol or drugs 
when they were in the shelters. Despite 
telling the women they were not allowed to 
use alcohol or drugs, many of these shelters 
did not have any type of program in place to 
help the women stay substance free. 

In addition to the lack of treatment programs 
present in these shelters, only about 33 
percent reported having a formal assessment 
process to define and seek help for any sub- 
stance abuse problems that incoming 



142 



Summaries of Research Awareness Seminars 



patients might be suffering. Virtually all of 
the shelters surveyed reported that nearly 
100 percent of the 2,600 women using the 
shelters had experienced some type of an 
abusive childhood. Fifty percent of these 
women cited domestic violence as the main 
reason for not entering some sort of treat- 
ment program for their addiction. These 
percentages indicate a crucial need for con- 
current treatment programs to address the 
needs of both domestic and drug or alcohol 
abuse. In addition to the fear of domestic 
violence, the women gave the following 
reasons for not entering treatment programs: 
child care needs, isolation, lack of services in 
the area, denial of a substance abuse pro- 
blem, and substance use with a domestic 
partner. 

Many female substance abusers who are 
domestically abused never receive any kind 
of treatment for their substance abuse pro- 
blems during their entire stay in domestic 
abuse shelters. More screening and assess- 
ment procedures need to be installed within 
the Nation's domestic abuse shelters in order 
to better address the various problems 
experienced by the women entering these 
shelters. A sharing of both oral and written 
information between the substance abuse 
and domestic violence shelters would be one 
method of allowing each service provider to 
reap benefits from the other. In the past, 
many domestic violence shelters have 
employed counselors whose main job was to 
address the substance abuse problems of 
women entering the shelters. Unfortunately, 
when funding for these shelters ran low, 
these counselors were the first employees to 
be cut. Research focusing on the problem of 
substance abuse within domestic violence 
shelters hopefully will lead to more funding 
that can be used to increase the number of 
joint programs that address both physical 
and substance abuse. 

Speaker: Dean Kilpatrick, Ph.D. 

Across the board, substance abuse has been 
tied to increases in violence. On the other 
hand, the following question also must be 
considered: To what extent does being a 
victim of violence lead battered individuals to 
drug and alcohol abuse? A recent 
NIDA-funded program known as the 
National Women's Study attempted to 
answer this question by surveying via tele- 
phone a nationally representative sample of 
4,008 randomly selected women. A number 
of different variables were addressed during 



the interviews. The goal was to determine 
the number of women who had been exposed 
during their lifetimes to the following forms 
of abuse or traumatic experiences: (1) sexual 
assault, including completed rape, contact 
molestation (the touching of one's sexual 
parts but without penetration), and noncon- 
tact, forcible molestation; (2) aggravated 
assault (i.e., an attack — including or not 
including a weapon — with the intent to kill 
or seriously injure the victim); (3) homicide 
death of a family member or close friend; or 
(4) alcohol and/or drug abuse problems. 

Of the women surveyed, 22.6 percent 
reported experiencing some sort of sexual 
assault during their lifetime. Based on the 
national population, this rate would translate 
to 22.7 million women in the United States. 
Of these women, 12.6 percent had been 
raped, which would be about 12.1 million 
women. Ten percent of the women had been 
a victim of an aggravated assault, and 13 
percent had witnessed the homicide death of 
either a family member or close friend. 
These percentages revealed that a combined 
total of more than one-third of the women 
polled (or an estimated 34 million women in 
the United States) had fallen victim to some 
sort of abuse or traumatic experience in their 
lives. Studies have shown that victims of 
abuse are 4.4 times more likely to develop 
two or more alcohol problems and 8 times 
more likely to develop two or more drug 
problems than are nonvictdms. How many of 
the first alcohol intoxications or drug experi- 
mentation occur after the first victimization 
incident? About two-thirds of the women 
surveyed reported using alcohol and mari- 
juana and about 80 percent reported using 
cocaine for the first time after they were 
sexually abused. 

Posttraumatic stress disorder can begin as a 
result of a traumatic experience. The dis- 
order's symptoms include the following: 
(1) reexperiencing the traumatic event in 
some way and (2) avoiding or numbing 
things associated with the traumatic exper- 
ience (this symptom can involve a number of 
physiological reactions that were not present 
prior to the traumatic occurrence). 

It was discovered that people who had devel- 
oped posttraumatic stress disorder tended to 
have higher incident rates of drug and alco- 
hol abuse problems as compared to people 
who had been victims of violence but were 
able to cope better. Crime victims with 
posttraumatic stress disorder were 6.3 times 



143 



NIDA Conference Highlights 



more likely than crime victims without 
posttraumatic stress disorder to have 
received treatment for their substance abuse 
problems; the former also were 17.4 times 
more likely to receive treatment for their 
substance abuse problems than noncrime 
victims. Improvements in crime prevention 
methods and drug or alcohol abuse treat- 
ments obviously are still needed. One recom- 
mendation would be to address the problem 
of posttraumatic stress disorder as part of 
substance abuse treatment. This could be 
done effectively by implementing systematic 
screening procedures for incoming substance 
abuse patients. The teaching of crime pre- 
vention and risk reduction techniques might 
be helpful in lowering the rate of revictimi- 
zation among female victims of violence. 

Speaker: Brenda Miller, Ph.D. 

The following three questions fuel the 
research efforts in the area of alcohol and 
drug abuse and its effect on family violence: 
(1) Do experiences of child abuse (physical 
and/or sexual) set the stage for women's 
alcohol and drug problems? (2) Do experi- 
ences of partner violence or adult victimi- 
zation increase women's substance abuse 
problems? and (3) Does a substance-abusing 
lifestyle make women more vulnerable to 
violent victimization? 

A NIDA-funded study, which currently is 
interviewing 600 women, is attempting to 
answer these questions. The findings up to 
this point have shown more father-to- 
daughter violence and sexual abuse for 
alcohol-abusing women as compared to non- 
alcohol abusers. On the other hand, there is 
not more mother-to-daughter violence and 
sexual abuse for alcohol users compared to 
the general public. There are a number of 
hypotheses as to why these relationships 
exist. Some experts believe that drugs and 
alcohol act as a medical device, aiding in the 
healing process that emerges as a result of 
childhood violence and sexual abuse. Others 
feel that women who were abused as chil- 
dren, either violently or sexually, develop 
feelings of dejection or of not being as good 
as others. This occurrence is known com- 
monly as the "spoiled goods syndrome." This 
dejected feeling is believed to cause children 
to turn to a peer group that they feel is more 
befitting their nature or their feelings of 
being physically or mentally "spoiled." These 
peer groups, which often use or abuse drugs, 
generally are seen by children to be "spoiled 



goods" themselves. The children, therefore, 
seek acceptance within such groups. 

Some experts theorize that drug and alcohol 
problems are passed from one generation to 
another via genetics or familial environment. 

Another factor that seems to play a signi- 
ficant role in dissuading women from enter- 
ing substance abuse treatment is partner 
violence. Rates of partner violence for 
women who use drugs on a regular basis 
tend to be much higher than for nonusers. 
Data pertaining to the rates of partner vio- 
lence experienced by women were obtained 
by interviewing women involved in three 
different types of programs. The women 
interviewed were involved in programs that 
dealt in the areas of alcoholism treatment, 
treatment of people who drive drunk, and 
outpatient mental health treatment. The 
female interviewees then were divided into 
two groups based on whether or not they 
were regular drug users. The condition a 
woman needed to meet in order to qualify as 
a regular drug user was that she used drugs 
at least once per week over a 1-month period. 
The only drug not considered when deter- 
mining whether or not a woman was a regu- 
lar drug user was marijuana. During the 
interview process, it was discovered that the 
women had a number of different partners 
throughout their lives. This presentation 
focuses primarily on women who have had a 
lifetime of any partner. The rates of partner 
violence were different among the women in 
the aforementioned programs who regularly 
used drugs, compared to women in those 
same programs who did not regularly use 
drugs. It was discovered that the women 
who had used drugs reported higher rates of 
partner violence, compared to the women 
who had never used drugs. About 75 percent 
of the women in treatment who also reported 
some drug use said they had experienced 
some form of partner violence. This percent- 
age is much higher than the 41 percent of 
the nondrug-using women in treatment who 
reported partner violence. Three other types 
of family violence (i.e., rape or attempted 
rape, physical assault, and assault with a 
weapon) also were seen to have higher inci- 
dence rates among women in treatment who 
used drugs on a regular basis, compared to 
the women who did not. 

Repeated violent episodes are experienced by 
many women throughout their lives. This 
unfortunate reality is something that treat- 
ment providers need to consider when 



144 



Summaries of Research Awareness Seminars 



designing new prevention and treatment 
programs that address the issue of physical 
and sexual abuse. Other areas that should 
be affected in terms of program design by the 
fact that women often experience repeated 
violence at the hands of their partners are 
drug treatment efforts, outreach efforts, HIV 
awareness efforts, and program and social 
planning practices. Women who have been 
living in an abusive environment for a long 
period of time may be distrustful of anyone 
who tries to help them. This means that 
treatment counselors and other care provid- 
ers need to be properly trained to deal with 
the possibility that they will not receive any 
cooperation on the part of the women the 
counselors/providers are attempting to help. 
There is a need for a joint effort between the 
substance abuse and family violence fields if 
any substantial improvements in the 
above-mentioned problem areas are to be 
seen. 

Questions, Answers, and Comments 

What rates are commonly found within 
female drug and alcohol treatment programs 
with regard to childhood sexual abuse? 
According to a number of national 
research-based interviews, about 70 percent 
of the women entering alcohol and substance 
treatment programs report some type of 
childhood abuse (physical or sexual). This 
rate is based simply on the information that 
women are willing to give during an inter- 
view. Speculation would suggest that within 
a clinical setting where women interacted 
with their care providers for a much longer 
period of time, the rate of reported childhood 
abuse would actually be higher. It is impor- 
tant that both the people conducting the 
interviews and those providing various types 
of care allow women to talk about any child 
abuse experiences. Letting a person talk 
about painful experiences acts as a kind of 
cleansing mechanism. Not allowing someone 
to express such feelings can be very detri- 
mental to both recovery and self-esteem. 

Has any work been done in targeting preven- 
tion efforts toward children? Occasionally 
researchers have performed studies in which 
children were followed in order to determine 
whether or not they were being physically or 
sexually abused. Problems, however, tended 
to arise when and if it was discovered that 
the studied children actually were being 
abused because the researchers were not 
trained to handle such a situation. 



RS39. 



In terms of the national household studies 
that have questioned women concerning any 
childhood abuses that they may have under- 
gone, were the women who admitted being 
abused referred to counselors who were quali- 
fied to help them deal with their problems ? 
A resource list was created and is given to 
every woman who participates in the inter- 
view regardless of whether or not she admit- 
ted to any childhood abuses. This list was 
designed to make treatment available to any 
woman who feels she has a need for it. 

Comment: More work needs to be done in 
the area of looking at not only male perpetra- 
tors in abuse cases but also male victims of 
child abuse. 

Have any programs dealing with physical 
and sexual abuse of women focused on dif- 
ferent ethnic groups? Baltimore had a shel- 
ter that mainly worked with African-Ameri- 
can women who were the primary resource 
providers in the household and were being 
abused by the men who lived with them. A 
number of similar shelters that were in 
operation in other parts of Baltimore worked 
with women from various ethnic back- 
grounds. Comparisons of collected data 
reveal that women, regardless of ethnic 
background, are abused. In terms of the 
Hispanic community, special attention often 
must be given to abused women because 
they, more so than any other ethnic group, 
do not like to disclose the nature of their 
family or childhood abuse history to 
researchers. 

communitywide drug abuse 
Prevention Approaches 

Moderator: Mary Ann Pentz, Ph.D. 
Speakers: Stacey Daniels. Ph.D. 

Luanne Rohrbach, Ph.D. 

Ruth Sanchez-Way. Ph.D. 
Respondent: Sallle McLaughlin 
July 16. 10:15 a.m.-ll:45 a.m. 

Speaker: Mary Ann Pentz, Ph.D. 
The Midwestern Prevention Project, a com- 
munitywide approach to drug prevention 
funded by the National Institute on Drug 
Abuse, the Kauffman Foundation, and the 
Eli Lilly Endowment, involves the communi- 
ties and school districts in the Kansas City 
and Indianapolis metropolitan areas. This 
project was designed to present a commun- 
itywide focus in the following five compon- 
ents: (1) an annual mass media campaign 
educating a city or community about drug 



145 



NIDA Conference Highlights 



prevention, (2) the introduction of each 
program component to the public, 
(3) community organization, (4) health policy 
change, that, in the late phases of commun- 
ity organization, functioning communities 
can effect all the way up to the State level to 
lobby for policy changes, and (5) mass media. 
The implementation of this project started 
with the first two components. These two 
program components are based in a school 
program that begins during the transition 
grades (i.e., sixth or seventh grade) and adds 
a parent education program that focuses on 
communication skills and parent support 
skills. 

In the first component, community leaders 
conducted a needs assessment on drug use in 
the community, either through a needs 
assessment evaluation performed among 
agencies or a baseline survey of the target 
population. The second component provided 
introductory training to prospective com- 
munity leaders involved in this effort. This 
training included drug use etiology and 
epidemiology so that community leaders 
could converse among one another about how 
drug use starts and spreads and give an 
overview of what current state-of-the-art 
prevention techniques exist. The third com- 
ponent established an operating community 
structure (e.g., whether it is called a task 
force, council, or coalition) that is formally 
recognized by the community. The next step 
was getting these people involved not only in 
planning community events but in helping 
train later program implementers, including 
teachers, health educators, and parents. The 
fourth component, health policy change, was 
accomplished through legislation which 
directed that revenues, collected through a 
special tax increase, be used for drug preven- 
tion. The mass media campaign, the fifth 
component, involved many public service 
announcements and a videotape highlighting 
the program. 

When the community organization was 
formed for the Midwestern Prevention Pro- 
ject, the initial structure was the Kansas 
City Drug Abuse Task Force, which started 
with a steering committee represented by 
businesspeople associated with Marion Labo- 
ratories and the Kauffman Foundation. This 
was a large working group of about 100 
people that cross-cut different areas of mass 
media, health agencies, schools, and treat- 
ment agencies. Working subcommittees were 
formed that carried out specific tasks in 
Kansas City, including the media, a minority 



issues subcommittee, research, legislation, 
curricula, support, education, and interven- 
tion. The Kansas City model was based at 
the community organization level with very 
strong and highly credible business support. 

A similar type of community organization, 
Lowe, was begun in Indianapolis. Lowe is 
similar to the Kansas City program in that it 
had government, media, and medical treat- 
ment committees. However, Lowe also 
formed a parent/family committee, a religious 
committee (one-half of Indianapolis' schools 
are private and parochial), a school education 
committee, a youth action committee that 
worked primarily on recreational activities, 
and a worksite. The Indianapolis model for 
organization started with school superinten- 
dents banding together to create a nonprofit 
organization with the State of Indiana. This 
second model is more replicable across com- 
munities because every community has 
school districts. In communities with highly 
credible business leaders, the Kansas City 
model may work equally as well or better. 
The progress was based on the objectives 
developed by the community council alone. 
The legislature worked to develop a tax 
initiative on beer in the State of Missouri 
and legislation for providing immunity to 
school staff who wanted to identify and refer 
students for potential drug abuse problems. 
No overt action had been taken, but commit- 
tees were established and recommendations 
were made to the mayor rather than the 
State. 

In the treatment and support sectors, it is 
known that prevention is inextricably linked 
to treatment. Prevention and treatment do 
not need to be considered separate in a 
community. The most prevalent question is 
whether drug prevention efforts work (a 
report that came out from the National 
Research Council suggests that no current 
efforts do). But there is over 15 years of 
prevention research that counter this argu- 
ment. It is probable that a community-based 
approach that includes schools and parents 
in other program components can maintain 
effects longer than a single-component 
approach alone and show more dramatic 
effects over time. One example is discussed 
below. 

In a community-based approach, by 5-year 
followup, almost 27 percent of the adoles- 
cents in a control group were smoking (out of 
a sample of 5,500). Of those who went to a 
full community intervention, only 18 percent 



146 



Summaries of Research Awareness Seminars 



still were smoking. The difference is statisti- 
cally and financially significant. Subtracting 
the rate of increase from year to year in the 
control group from the rate of increase in the 
program group, there is a net reduction. In 
estimating from year to year, if the school 
program effect is maintained alone, any more 
effects accrued from year to year should be 
attributable to the other program compon- 
ents introduced in that year. Over time 
there is an accumulative effect well beyond 
just a school program alone. In a summary 
of the study of the longest running school 
programs in the United States, Canada, and 
Finland, by 5-year followup (or 6 years 
into the study), none showed effects from 
the school program alone. The argument 
is fairly strong for a community-based 
approach. 

Speaker: Stacey Daniels, Ph.D. 

The approach presented makes community 
involvement meaningful in the research 
effort. Each year about 10,000 youth are 
surveyed in 15 school districts during grades 
8, 10, and 12 to show the community how 
well prevention efforts are working. Periodi- 
cal news conferences are held to inform the 
community about any improvements as well 
as any weaknesses and areas requiring 
research. Training is provided to teach 
people how to use this information. Before 
this information is released to the press, it is 
released to the individual school district 
representatives, who are walked through 
their report. Reports are initially only given 
to the individual school districts for confiden- 
tiality purposes; statistical information is 
interpreted to the representatives. About 
one-half of the school districts request to use 
report information and meet with parents or 
school district representatives. Forecasts 
also are made for the school districts to 
pinpoint future problem areas. In one case, 
because many eighth graders were using 
inhalants, planners decided to focus on 
elementary school education regarding the 
matter. In this situation, inhalant use went 
down. 

These results came from a survey of 148,000 
youth. Surveying this many youth required 
cooperation from the children and the school 
districts, which is not easily attainable. For 
an incentive, one school was given $1.00 for 
each survey returned, which went toward 
funding school activities. Eventually, the 
teachers wanted to provide their input as 
well, so a teacher survey was developed. 



Some of the student respondents felt strongly 
about the survey because it allowed them to 
see how their lives had changed. Other 
students did not reply on the survey because 
they were concerned about confidentiality 
(e.g., their parents might find out). The 
surveys must be conducted on varied levels 
in order to address the concerns of teachers, 
principals, and others involved. Partici- 
patory evaluations are conducted for pro- 
grams performing a new study. Information 
is attained from the youth by asking them 
how they would measure success. 

A 30-day ratings sweep based on prevention 
program reports takes place every year, 
comparing Kansas City's trends to national 
trends. For example, the comparison report 
may cite facts such as the following: cig- 
arette use is down in Kansas City, but 
among northcentral States, use has gone up; 
alcohol use has gone down in Kansas City, 
but not as much as in the northcentral 
States; marijuana use has declined in Kan- 
sas City as compared to national trends and 
northcentral States. Using multicultural 
people, data from 1984 were collapsed and 
compared to current data and presented to 
the superintendents for teaching curricula 
and conducting prevention efforts. Trends in 
all substances that are abused are down as 
compared with the national average. 

Speaker: Ruth Sanchez-Way, Ph.D. 

The community partnership program was 
developed in 1988 in response to Congress' 
request that OSAP (now CSAP) develop 
community prevention programs. The com- 
munity partnership program was based on 
research that previously had been conducted 
showing that partnerships, along with com- 
munity effort, would be a positive trend. A 
large national survey of over 26 communities 
had demonstrated effective multilevel, multi- 
disciplinary approaches to substance abuse 
prevention. There was also a 3-day national 
consensus meeting about where practitioners 
should be going. This is CSAFs largest 
grant program and is considered its flagship 
effort. A great deal was learned in the past, 
and a partnership was based on the premise 
that alcohol and drug abuse prevention 
efforts were best developed, implemented, 
and sustained through the coordinated 
efforts of a coalition of key organizations on 
the local level. In recognition of this com- 
plexity, the community partnership program 
required that there would be a community 
coalition consisting of at least seven mem- 



147 



NIDA Conference Highlights 



bers. These seven members were to repre- 
sent law enforcement agencies, schools, the 
religious community, health and social ser- 
vice agencies, youth coordinating organiza- 
tions, and local government. The funds were 
intended to help communities identify their 
prevention service needs, develop a strategy 
to address the substance abuse problems, 
establish priorities, and implement these 
programs. Over 2 years, CSAP funded ap- 
proximately 250 partnerships that are 3- to 
5-year programs. Ninety-five were funded in 
the first year, and 155 more were funded in 
the second year. 

The community partnerships are the vehicle 
for building coalitions and an environment 
where community empowerment can occur. 
All community groups are involved with the 
coalitions and partnerships, incorporating 
values and celebrating the different ethnic 
and cultural groups in their communities. 
Community empowerment no longer consid- 
ers that agencies and professionals are solely 
responsible for making the decisions in the 
community concerning substance abuse. The 
responsibility lies with the community itself 
and results can be obtained only through 
coalitions. 

A national evaluation was conceived at the 
beginning of the community partnership 
program consisting of two elements: 
(1) gathering data across all 250 partner- 
ships and (2) performing intensive site visits 
with data collection from up to 36 of the 
community partnerships. In 1992 a report of 
the results from the first 95 programs was 
produced. With the first 95 partnerships 
starting on their third year and the other 
155 just starting their second year, the data 
are very preliminary. It took at least 1 year 
for the partnerships to become functional. 
Most partnerships in the early or middle 
part of development may require 2 or more 
years to become fully functional (i.e., to 
create a strategic substance abuse prevention 
plan and implement activities based on that 
plan). The early efforts focused basically on 
internal, coalition-building activities. During 
these early years of the partnership program, 
most coalition members have devoted their 
time and energy to internal developmental 
activities that form and guide the partner- 
ships. Their focuses are on memberships, 
getting people involved, needs assessment, 
and planning. Development of a substance 
abuse prevention plan is a key step in the 
long-range work of a partnership. Most 
partnerships are developing a strategic 



comprehensive substance abuse plan, but 
less than 10 percent have completed their 
plan in the first year. The main features of 
these plans are that they cover the target 
area for multiple years, require coordination 
among local programs, and suggest various 
programs for implementation. 

There is considerable diversity among the 
partnerships in the plans. The average size 
is 50 members, but ranges from 7 to 236 
members. The members come from a wide 
variety of sources in the community, most 
commonly from civic or community organiza- 
tions, education, government, and human or 
social services. The partnerships rely 
heavily on their staff for guidance and 
organization, especially in the first year of 
development. Formal organizational struc- 
tures are becoming established, with elected 
officers of committees that are both admini- 
strative and topical. Recruitment of key 
community members is a crucial element of 
effectiveness. The participation of key mem- 
bers was the most frequently mentioned 
factor that facilitated effective partnership 
development and operations. Having the 
right members is also vital in the early 
stages. It was felt that the most essential 
members were on the partnership, but more 
important members were not yet on board. 
One finding shows that partnerships based 
on a strong agency do better. The most 
common problem is turf or personality dif- 
ferences. Major changes reported in the past 
year were most typically the loss of a project 
director, staff, or the local evaluator and 
appear to impede the development of the 
partnerships. Leadership -based partnerships 
cite these problems the least. 

The partnerships were divided into leader- 
ship-based, grassroots structures and part- 
nerships that are professionally based. The 
leadership partnerships tend to be more 
formal, bureaucratic, and experienced with 
working in formal relationships. The grass- 
roots partnerships comprise members who 
have not been part of a working group 
before. Members tend to view their partner- 
ship experiences as positive and productive, 
with a low level of conflict. These partner- 
ships felt as though they had an effect on the 
community, with an increase in interaction 
among agencies and a greater awareness of 
the constraints faced in agencies' work. 
Contact with other members is worthwhile 
and productive and helps people reach their 
goals. Prevention activities designed to give 
partnerships visibility and win community 



148 



Summaries of Research Awareness Seminars 



support were performed in the first year. 
The design of substance abuse activities was 
not a product of the strategic plan in the first 
year. Heightening member morale and 
winning the interest and support of the 
community were early success objectives. 
Many partnerships chosen to participate in 
the process appeared to be random choices 
and were unrelated to substance abuse 
activity, but they were seen as important for 
building a coalition in support of the com- 
munity in order for them to become visible. 
Issues of the future pertain to whether the 
partnership is (1) gaining the participation 
and support of key people and organizations 
in the community, (2) developing a process 
for moving the leadership away from the 
staff and to others in the community, 
(3) developing a means for achieving consen- 
sus on particular substance abuse areas and 
the consensus on the strategies to be 
adopted, and (4) successfully moving from 
the planning stages to implementation of 
prevention activities. 

The first national evaluation contract will 
end Fiscal Year (FY) 1993. The second 
contract, a continuation of the first, will 
begin looking at outcome measures in early 
FY 1994. The scope of the second national 
evaluation contract, however, will utilize all 
the plans and materials developed by the 
first contract. The second contract will be 4 
years in duration. 

Speaker: Luanne Rohrbach, Ph.D. 

Implementation issues in community-based 
drug abuse prevention projects, focusing on 
the Midwest Prevention Project and a com- 
munity partnership in Pasadena and Alta- 
dena, California, were discussed. There has 
been considerable effort devoted to the devel- 
opment, refining, and testing of 
community-based and school-based drug 
abuse prevention programs. Until recently 
the evaluations of these programs have 
focused on the outcomes they have produced. 
In many cases these programs have been 
shown to have an effect on drug use; how- 
ever, researchers either have not found the 
effects they expected or the effects have not 
been as strong as the researchers expected. 
In looking at some of the factors that influ- 
ence implementation and the relationships 
between implementation and outcomes, there 
are certain factors that are associated with 
both the quantity and quality of program 
implementation. These factors are the teach- 
ers' styles, experiences, and health practices. 



Organizational factors are important, such as 
morale and communication between faculty 
and staff or between faculty and administra- 
tion. A positive school climate is associated 
with implementation. There are 

program-specific factors, such as how com- 
patible the program is with what the teacher 
normally does or how enthusiastic the 
teacher or administration is about the pro- 
gram. These types of factors are all associ- 
ated with implementation. 

The implementation of the five main com- 
ponents of the Midwestern Prevention Pro- 
ject was looked at in the process evaluation, 
but emphasis is put on the school-based 
portion of the program. Implementation 
generally has been measured in terms of the 
quantity or quality of exposure to the pro- 
gram. Quantity was measured by how many 
sessions the teacher was involved in with the 
program and how much time was spent on 
each session. Quality was measured by 
classroom observation of the teacher and 
measures of such things as how the teachers 
and students interacted and how enthusi- 
astic the teacher or students are. A compo- 
site implementation score for each teacher 
who has implemented the program and the 
differences of those who score high versus 
low were compiled. 

Implementation of the Kansas City school 
component was measured as a quantity of 
exposure to the program. A high implemen- 
tation group was a group that implemented 
a greater proportion of the program; low 
implementation groups were groups of 
schools or students in schools that did not 
receive the program or were under delayed 
intervention control. High implementation 
classrooms demonstrated a stronger effect on 
all measures of drug use relative to low 
implementation classrooms. In a study, high 
implementation resulted in decreased cig- 
arette use 1 year following the program. 

In the case of the Indianapolis school com- 
ponent, study implementation was measured 
by observations in classrooms. Measurement 
affects the quality of implementation. With 
alcohol use as an example, there is a more 
typical pattern as the result of school-based 
programs. The implementation groups and 
the control groups both experienced an 
increase in drug use; however, the increase 
was not as great for the high implementation 
group. 

The first important message is not to say 
that a program was just simply done. The 



149 



NIDA Conference Highlights 



extent to which it was done, how well it was 
done, what was done, and an understanding 
of the implementation of a program and its 
outcomes need to be determined. Secondly, 
the messages attained from data show that 
the stronger the implementation, the 
stronger the effect. 

There are a couple of ways a commun- 
ity-based intervention program differs from 
a school-based intervention program. Com- 
munity-based programs are very complex 
and difficult to describe and categorize. 
There are multiple target groups that have 
comprehensive strategies focused on youth, 
the elderly, or specific cultural groups. 
These strategies address individual com- 
petencies and systematic changes. They are 
dynamic program models with no curriculum 
guide. They change and evolve as the needs 
assessment results come in and as members 
of the coalition come and go. There are 
multiple implementers in school-based 
research (i.e., teachers) and in community 
partnerships (i.e., agencies, organizations, or 
staff). The evaluation of implementation in 
community-based partnerships must be 
considered by both internal and external 
activities. Internal activities are partner- 
ship-building activities, such as recruiting 
members, developing commitment, building 
capacities of the members, garnering 
resources, and assessing needs and planning. 
These activities are taking partnerships at 
least 1 year to implement — perhaps several 
years for some organizations. These activi- 
ties may be the primary implementation 
outcomes that the partnership experiences. 
The external activities in which the partner- 
ships are involved include performing public 
education activities, organizing and empow- 
ering the community, targeting specific 
groups with specific programs, implementing 
school-based education and legislative policy 
change, coordinating, and training. Imple- 
mentation includes all of these internal and 
external activities, which need to be con- 
sidered when measuring the implementation 
of partnerships. 

The Year 2 report of the national evaluation 
shows that the four most important external 
activities community partnerships focus on 
are the following: (1) communitywide educa- 
tion, (2) coordination of prevention programs, 

(3) alternative activities for youth, and 

(4) training for members. Other studies of 
community-based partnerships around the 
country have shown that formalized rules, 
effective communication, a variety of leader- 



ship roles, the ability to exchange resources, 
the procedures established for conflict resolu- 
tion, active recruitment and training of 
members, representation of agencies and 
constituencies, and participatory decision- 
making are other factors involved in imple- 
mentation. The most important message is 
to evaluate the implementation and antece- 
dents of community conditions before form- 
ing the partnership and to evaluate the 
internal and external activities. Proximal 
and distal outcomes also need to be consid- 
ered and evaluated with the internal and 
external activities. When considering imple- 
mentation for designing a program, one 
should be specific about who the target 
individuals and organizations are, what the 
target behaviors or systems are, what the 
program strategy is, and who the individuals 
and organizations are that are responsible 
for implementation. 

Questions, Answers, and Comments 

Is there an identifier on each survey that 
compares students' responses from year to 
year, and what is it? Confidentiality is 
exercised when they need to track youth over 
time. A number is used to track each stu- 
dent's information. 

What data will be measured when evaluating 
outcome? Outcome has been incorporated in 
the original contract so the data flow from 
one partnership to the other. These data will 
not be a big burden on the existing com- 
munity partnerships. The existing contrac- 
tors are working on these data, which will be 
passed on to the next contractor. The actual 
data to be measured are not yet known. 

How easy is it for a grassroots organization 
to move into becoming an independent part- 
nership? It has not been an easy process. It 
is very difficult both for people who have 
invested their professional careers and for 
political leaders to give up that power of 
decisionmaking to someone else. In some 
instances, this could not be worked out, but 
in those that worked out, the partnerships 
eventually ended up being stronger. 

How are implementations measured in com- 
munity partnerships? Dosage does not seem 
to be as strong an indicator of outcomes as is 
quality or fidelity. Fidelity in school-based 
research makes more sense because the 
implementers are given a clearer curriculum 
and the research has a strong design. The 
fidelity measure looks at the extent to which 
the curriculum is delivered. There is r.o 



150 



Summaries of Research Awareness Seminars 



RS40. 



curriculum guide, but this will evolve as 
things progress. Quantity-type measures or 
exposure should not be considered as much 
as how the program is implemented and how 
it matches the design. Three new com- 
ponents to look at could be fidelity, amount 
of exposure, and reinvention. If there are 
highly empowered leaders who are confident 
in their skills to begin with, then the extent 
to which they reinvent, change, or tailor a 
program to their knowledge of a particular 
community or target probably will have 
better effects. On the other hand, people 
who reinvent in the opposite direction and do 
not want to reinvent or only want to do 
one-half the job will have low implementa- 
tion. A study looking at network analysis 
from the field of mass communications was 
done on community leaders. 

Comment: It was hypothesized that there is 
something particularly useful for partnership 
grantees and other types of projects to take 
a look at "critical mass" where there are 
complex systems and programs operating. 
This critical mass would be exemplified by a 
certain number of programs or proportion of 
people involved and committed to a program, 
providing effectiveness no matter what the 
strategies are. 

Family and School Prevention 
Programs for High-Risk Youth 

Moderator: Larry Seitz, Ph.D. 
Speakers: Judith De Jong. Ph.D. 

Leona Eggert. Ph.D.. R.N. 

William Hansen. Ph.D. 

Karol Kumpfer, Ph.D. 
Respondent: Jan McArdle, M.A. 
July 16. 8:30 a.m.-10:00 a.m. 

Speaker: Judith De Jong. Ph.D. 

Since its inception, CSAP has stressed the 
equality of both researchers' and community 
members' perspectives in the implementation 
of prevention studies. CSAFs mandate of 
intervention is to keep high-risk youth off of 
alcohol and other drugs (AODs). To this end, 
CSAP has funded more than 300 high-risk 
youth demonstration projects that target 
youth between 3 and 20 years of age. The 
intermediate outcomes expected of these 
programs are the following: to build in 
protective factors, to reduce risk factors, and 
thereby to build a healthy environment for 
high-risk youth. This broad perspective has 
led to a great variety in funded programs. 



In prevention studies, an emphasis on tradi- 
tional, linear research methodology and 
standardized tests may limit creativity and 
effectiveness and, in essence, trap 
researchers. Instead, CSAP emphasizes 
customization and use of complex models, 
which increase validity and quality of the 
data. Due to variation in interventions, it 
was recognized early on that cross-site fac- 
tors cannot be organized by intervention. 
Instead they were organized according to the 
problem which the intervention or interven- 
tions were intended to address. 

For clarification, this approach was contrast- 
ed with other approaches, services evalu- 
ation, and research using logic models to 
illustrate fundamental differences. First, the 
Services Logic Model assumes that the ser- 
vices are needed and measures delivery and 
procedures used. The Research Logic Model 
presents an initial hypothesis and uses fixed, 
predetermined interventions and random 
assignment to test the outcome of the hypo- 
thesis. The Demonstration Logic Model, in 
contrast, is focused on the problem, and 
interventions are allowed to evolve to maxi- 
mize outcomes and effect on the problems. 
These outcomes are defined as healthy fam- 
ily, school, and peer relationships and suc- 
cess for high-risk youth both inside and 
outside of the community. A matrix was 
presented that provides a framework for 
conceptualizing and evaluating prevention 
programs. 

Because this is not a classic intervention 
program, determining success is difficult. 
Success is judged by comparative studies and 
answers to questions regarding the initial 
goals (e.g., Did the program reduce AOD 
risk? Did it increase school success? Are the 
families' goals for the youth higher after 
implementation of the program than before?). 
This program is both highly successful and 
complementary to those of NIDA 

Speaker: Karol Kumpfer, Ph.D. 

In the past, family involvement in support 
programs has been largely ignored. To have 
a comprehensive support program, one must 
take into account the socialization of the 
youth, who is influenced primarily by the 
family. If a prevention model is to build on 
etiology, one must consider the major risk 
and protective factors. In a study of 1,800 
Utah students, the main factor leading to 
AOD use was negative peer influences; the 



151 



NIDA Conference Highlights 



choice of one's peer group primarily was 
attributed to the school and family environ- 
ments. A CSAP grant program for Hispanic 
youth found that, in families where there 
was a high rate of alcohol and drug abuse, 
the children showed a higher rate of AOD 
use. 

A program (not yet fully tested) currently 
under way is investigating factors that influ- 
ence resilience to AOD abuse. This pro- 
gram's intent is to reduce risk factors and to 
increase protective factors (e.g., a purpose in 
life or spirituality, problemsolving skills, 
high self-esteem, behavioral factors, and 
physical well-being). Grants funded by 
NIDA and NIMH to serve 900 families in 
Iowa are attempting to accomplish similar 
goals. 

CSAP and NIDA grant studies have deter- 
mined that the most critical risk factor is 
family conflict, while the most important 
protective factor is family organization. 
These studies have determined that there is 
a need to improve family-child relationships 
and strengthen family values. 

Most prevention programs that involve the 
family as a whole do so through parent 
training and skills training. While trying to 
determine the best prevention programs 
around the country, certain major types of 
programs emerged. These programs included 
media-based parent training, basic education, 
parent support groups, parent-peer support 
groups, family preservation, in-crisis case 
management, family residential treatment, 
and family intensive probation programs. 
These effective programs shared many 
characteristics: They were enduring and 
intensive; logically linked to risk and protec- 
tive factors; focused on children at an early 
age, before problems grow; culturally rele- 
vant; conducive to attendance; and support- 
ive to the community environment. 

In studying these programs, it is important 
to recognize that a comprehensive support 
program must include a family involvement 
component. 

Speaker: Leona Eggert. Ph.D., R.N. 

The program Reconnecting At-Risk Youth is 
funded by NIDA and NIMH and attempts to 
accomplish three co-occurring outcomes: 
(1) prevent drug use, (2) decrease the num- 
ber of school dropouts, and (3) decrease 
suicidal thoughts and behavior. To this end, 
high-risk youth are defined as potential 



dropouts. Indicators used to determine these 
youth include the following: (1) a decline in 
grades, (2) below-average credit accrual, 
(3) absenteeism, (4) a history of dropping out 
of school, and (5) teacher recommendation. 
The group chosen displayed a high rate of 
drug use, and approximately one-half of 
those chosen were seriously depressed to the 
point that they had suicidal thoughts and 
behavior. 

Challenges inherent in a program such as 
this one involve designing and testing a 
comprehensive program, designing 
approaches to deal with the problems pres- 
ented, and discovering which procedures and 
approaches work and why. 

The first aim of this particular program was 
to test program effectiveness. This was 
accomplished by efforts to decrease suicidal 
thoughts and behavior, depression, and drug 
involvement and efforts to increase school 
performance. 

The second aim was to test the intervention 
model through teacher and peer group sup- 
port and to produce outcomes from a combi- 
nation of life skills acquisition and school 
bonding. This intervention was presented as 
a personal growth class that youth could 
take for elective credit in their high schools. 
The class met every day for 1 semester (a 
total of 90 classes). Students were awarded 
letter grades (A through F) based on how 
well they met the objectives and how they 
helped their peers meet their objectives. The 
primary goal of the class was to increase 
students' attendance. The class focused on 
the following: experiential learning, feelings 
of group belonging, skills training, and moni- 
toring of students' drug use and depression. 
The model was based on studies that had 
shown success, including a blend of positive 
peer culture and fife skills training. 

The youth were divided into control and 
experimental groups, with a total of five 
groups. High-risk youth and those youth 
suffering from depression were put into both 
control and experimental groups. The stu- 
dents were given three tests over a total of 
15 months, one test every 5 months. The 
first test was made up of a three-part ques- 
tionnaire and an interview for those consi- 
dered at high risk for depression. The 
second and third tests were conducted in the 
same manner. Using trend analysis between 
the control and experimental groups, the 
following results were recorded: The stu- 
dents in the experimental group showed an 



152 



Summaries of Research Awareness Seminars 



increase in personal control, academics, peer 
bonding, and attendance and a decrease in 
drug use and depression. 

The results indicate that temporary interven- 
tion programs do not work and that some 
students would do well with personal growth 
classes throughout high school. In addition, 
this model should be tested alongside family 
involvement programs. 

Speaker: William Hansen, Ph.D. 

In the past 40 years, society has been 
through numerous changes. Since World 
War II, society has seen the rise and demise 
of large corporations, racial desegregation, 
equal rights for women, and other major 
shifts in the social structure that call for new 
strategies in drug abuse prevention. Effec- 
tive prevention programs require an under- 
standing of the problem and the knowledge 
to handle these problems. There are three 
basic steps to good prevention research: 
(1) understanding the social epidemiology of 
prevention, (2) understanding the develop- 
mental issues underlying prevention, and 
(3) developing effective prevention programs. 

To better understand the social epidemiology 
of prevention, a study of a sample of 6th and 
12th graders found a definite pattern of drug 
use. Inhalants, which may be "true" gateway 
drugs, are the most commonly used drug by 
this population, after alcohol and tobacco. 
Inhalant use generally has been overlooked, 
even though students who use inhalants 
suffer from a higher dropout rate. The use of 
alcohol, the most prevalent of all drugs used 
by this sample group, is still a growing 
problem. One-half of all high school students 
drink to get drunk. It is difficult to tell 
which students are using drugs, but there 
are strong indicators as to which students 
are most susceptible. For example, latchkey 
kids are twice as likely to use drugs. Drug 
use by one's friends is another strong indica- 
tor — if one student uses drugs, then it is 
likely that his/her friends do also. 

Three systems have shown to be accurate 
predictors against drug use. The first predic- 
tor is commitment programs (i.e., programs 
that ensure commitment from youth not to 
use drugs). The second predictor includes 
values programs, which show youth how to 
set goals and how drug use will hamper their 
goals attainment. The last includes systems 
based on normative beliefs. 



HIV/AIDS 

RS41. Substance Abuse and HIV/AIDS 

Moderator: Harry Haverkos. M.D. 
Speakers: Don Des Jarlais. Ph.D. 

Gerald Frledland. M.D. 

James Sorenson. Ph.D. 
Respondent: Sandra Drlgglns-Smlth 
July 16. 10:15 a.m.-l 1:45 a.m. 

Speaker: Don Des Jarlais, Ph.D. 

In a large number of international cases, 
HIV has not been prevented among local 
populations of drug injectors. The growth 
from under 10-percent HTV sero-prevalence 
to over 10-percent HIV sero-prevalence in 1 
year in the following major cities is astro- 
nomical: New York City went from 9 percent 
to 27 percent; Edinburgh, Scotland, from 
introduction of HIV to 40 percent; Bangkok, 
Thailand, from 2 percent to 40 percent; and 
Manipur, India, from introduction to 50 
percent. Some factors associated with very 
rapid transmission are the lack of AIDS 
awareness, the sharing of needles, and the 
scarcity of injection equipment mechanisms 
for rapid efficient mixing within the drug 
abuse population. 

HIV sero-prevalence data were accumulated 
from drug treatment programs and com- 
munity outreach questionnaires. Findings 
indicate that sero-prevalence has remained 
low and stable for 4 years throughout Glas- 
gow, Scotland; Lundt, Sweden; Sydney, 
Australia; and Tacoma, Washington — under 
2 percent in both Glasgow and Lundt and 
under 5 percent in Sydney and Tacoma. 
Each of these cities has conducted significant 
studies throughout its HIV population. 
Lundt estimates that it has tested more than 
90 percent of its injection drug abusers for 
HTV and has tested more than 80 percent of 
the drug injectors at least twice. Sweden 
maintains on file the names of all individuals 
who are HTV sero-positive and investigates 
every HrV sero-positive case to determine 
how and where the person became infected 
(e.g., whether the person became infected 
while living in the local area or was HrV 
positive before moving into the area). Swe- 
den also conducts HIV testing postmortem on 
all known drug injectors who die and has yet 
to find an HIV-positive, deceased drug injec- 
tor who was not already included in the HIV 
registry. 



153 



NIDA Conference Highlights 



A sense of trust between health care workers 
and drug injectors was established relatively 
early in these four cities. Prevention efforts 
began while sero-prevalence was still low 
and primarily involved going out into the 
community. Glasgow set up a drop-in center 
for HIV prevention, Lundt sent social work- 
ers into the community to recruit drug injec- 
tors into a syringe exchange program, 
Sydney set up an extensive network of injec- 
tion drug users who serve in an advisory 
capacity for HIV prevention efforts, and 
Tacoma established a syringe exchange 
service. 

Each of these four cities provides drug injec- 
tors with access to sterile injection equip- 
ment. Although Glasgow was initially 
limited in this regard, it has since developed 
a strong over-the-counter effort in which 
pharmacists are encouraged and trained to 
sell drug injection equipment. Lundt spon- 
sors a strong syringe exchange program with 
outreach to recruit injectors into the 
exchange, and both Sydney and Tacoma have 
strong syringe exchange efforts and 
over-the-counter sales. 

HIV counseling and testing are very inten- 
sive in Lundt, where injection drug users are 
encouraged to be tested every 3 months for 
possible sero-conversion. In Glasgow, Syd- 
ney, and Tacoma, HIV counseling and testing 
efforts are limited in terms of AIDS preven- 
tion. Drug abuse treatment is strong in 
Sydney but relatively limited in the other 
cities. For example, in Glasgow one must be 
HIV positive to receive methadone main- 
tenance. While these four cities do not 
consistently use drug abuse treatment as a 
way to prevent HIV infection, all of the cities 
have found that their HIV prevention efforts 
have led to increased demands for drug 
abuse treatment. 

Interviews with injection drug users from 
these four cities generally reported that the 
drug users changed their behaviors due to 
concern about AIDS. The most commonly 
reported changes were stopping the use or 
sharing of drug-injecting equipment and 
changing their sexual practices. Even with 
the increased awareness of AIDS, however, 
some risk behaviors still have continued. 
Although approximately 50 percent of the 
respondents reported that they still were 
using equipment already used by another 
drug injector, HIV-positive sero-prevalence 
has remained low in these areas. Public 
health goals should be set in terms of trying 



to keep HIV sero-prevalence at very low 
levels in all cities where it currently is at low 
levels. Early outreach and the development 
of trust between health care workers and 
injection drug users, as well as access to 
sterile injection equipment, appear to be 
critical components of successful prevention. 
All HIV infections may not be preventable, 
but sero-prevalence should be kept at low 
levels within local populations of drug injec- 
tors. The need for additional services will 
increase as demands are uncovered and as 
the need rises for an overall strategy in 
dealing with HIV infection and injection and 
noninjection drug use. 

Speaker: James Sorenson, Ph.D. 

Approximately one- third of all AIDS cases in 
the United States are linked to drug use. By 
the end of 1992, there were over 253,000 
such cases. Of these cases, 23 percent were 
injection drug users, 6 percent were injection 
drug users and homosexual, 3 percent were 
from heterosexual contact with an injection 
drug user, and approximately 1 percent were 
perinatal cases in which there was a link to 
injection drug use. There are many com- 
munity-based approaches to prevent and 
treat HIV infection that have kept this epi- 
demic from reaching disastrous proportions. 

For people with HIV infection, methadone 
maintenance has a drastic effect on injection 
drug use-related risk behavior, as shown 
through 20 years of research. Data indicate 
that using methadone maintenance 
decreased injection drug use by 71 percent, 
ultimately reducing the opportunities to 
share infected needles. Methadone main- 
tenance programs have spurned increases in 
medical visits and decreases in the no-show 
rates of drug users in medical care. Inte- 
grating primary care with drug abuse treat- 
ment is a developing trend and has proven to 
be successful in several major cities. 

The San Francisco General Hospital has a 
methadone maintenance program with an 
HTV focus in which currently 120 of 200 
patients have HIV or AIDS. With the 
patient population becoming more ill, a 
medical clinic was opened in 1990. Treating 
this many patients with HIV is difficult, and 
several types of problems have been 
observed. Feelings of denial, anger, depres- 
sion, and isolation are common among 
HIV-positive injection drug users. Patients 
he about complying with treatment or act out 
against the world. They often feel ostracized 



154 



Summaries of Research Awareness Seminars 



from society and from their fellow injection 
drug users. Depression has been treated 
using pharmacotherapy, psychotherapy, and 
psychosocial therapies. Staff who work with 
these patients also experience a variety of 
fears. Pear of infection is common and is an 
initial and continuing issue. A solution to 
this problem is developing good protocols for 
infection control and strictly adhering to 
them. Confidentiality regarding whether or 
not a patient's HIV status should be divulged 
is an issue and depends on which State the 
program is in. Goal conflicts exist about 
whether these patients should be treated for 
injection drug use or HIV infection. It can be 
difficult for staff to know their own limits 
regarding their relationships with the 
patients — for example, in meeting the fami- 
lies or attending patients' funerals. 
Programmatic strategies for dealing with loss 
have been developed. 

The drug treatment clinic at San Francisco 
General Hospital has made the admission of 
HrV-infected drug users a priority. The 
hospital has become a platform for providing 
medical and psychiatric care for patients and 
is a productive site for research, training, 
and the expansion of treatment programs. It 
recently has completed a randomized clinical 
trial to increase adherence of AZT (azide thy- 
midine) among HrV-infected patients who 
were not taking the drug and also is measur- 
ing bereavement reactions. 

Speaker: Gerald Friedland, M.D. 

HTV disease and its later clinical stage, 
AIDS, are treatable. Effective therapeutic 
advances and strategies for delaying the 
progression of HrV disease have been devel- 
oped and available for the last 6 years. 
Unfortunately this progress is limited, and 
prevention of infection remains the best 
weapon. Injection drug users have dispro- 
portionately benefited the least as compared 
to other populations in this country living 
with HIV disease. The goal in the next 5 
years is to bring injection drug users into the 
mainstream of HIV care and research 
through partnerships among the drug treat- 
ment communities and drug users 
themselves. 

Antiretroviral therapy has become extraordi- 
narily complex. There are experimental 
drugs that are active against HTV at dif- 
ferent stages of development testing, and 
much conflicting and confusing information 
exists about their efficacy and toxicity. In 



terms of their physical and chemical nature, 
the most important drugs are those called 
reverse transcriptase inhibitors, which in- 
hibit the viral enzyme reverse transcriptase. 

The first trials of AZT conducted with indi- 
viduals having HIV disease and AIDS proved 
that treatment could be effective. Studies 
have indicated a highly significant difference 
between the use of AZT and placebos in the 
development of HrV complications. However, 
controversy exists surrounding the use of 
AZT: (1) the drug is expensive and the side 
effects due to its toxicity can be extensive, 
(2) its benefits are time limited (i.e., although 
it is effective, it does not continue to work 
indefinitely), and (3) the appropriate time to 
start using AZT is unclear. One-year studies 
have demonstrated that AZT was effective 
early in the HrV infection before symptoms 
developed. The long-term benefits are not 
known; nevertheless, they have formed the 
basis of the use of AZT in the past 3 years. 
A European study conducted over a 3V6-year 
period demonstrated that AZTs benefits 
waned over time and that there is no 
long-term benefit to starting AZT earlier 
rather than later. 

Preliminary information suggests that 
switching to DDI when a patient's disease 
progresses is beneficial and further extends 
the period of delay in progression of HTV 
disease. The strategy of administering 
several drugs at the same time is under 
investigation, and very preliminary 
information indicates that there seems to be 
some benefits in taking two drugs instead of 
one. An important interaction occurs when 
AZT and methadone are combined. While 
AZT levels increase in the patient, metha- 
done levels are unaffected. 

Antiretroviral agents slow disease progres- 
sion, improve survival after illness begins, 
and may slow progression in certain patients 
before illness appears. The benefit is transi- 
ent but may be improved with additional 
drugs and new treatment strategies. Viral 
resistance may develop when the drugs are 
used for extensive periods of time. None of 
these drugs results in immune reconstitu- 
tion. The current drugs are not widely 
available for most people living with HIV 
disease, and all of them are very expensive. 
Probably equally important for injection drug 
users is the fact that access to and availa- 
bility of HP/ care are limited. One study of 
injection drug users in The Bronx, New York, 
showed that the proportion of injection drug 



155 



NIDA Conference Highlights 



users progressing to AIDS who were not 
taking AZT was significantly higher that 
those taking AZT. 

Injection drug users had similar but some- 
what different arrays of AIDS diagnoses than 
homosexual men. Most notably were the 
absence of Kaposi's sarcoma, less cyclomega- 
lovirus diseases, and an increase in fungal 
and bacterial infections. This is likely a 
function of past and recent exposure to infec- 
tions, which become active when the immune 
system wanes secondary to HIV. Certain 
infections become more apparent and are 
extraordinarily prevalent among injection 
drug users with HIV. Most dangerous are 
bacterial pneumonia and tuberculosis, which 
increase in frequency in injection drug users. 
For every 3.5 people dying of AIDS, 1 person 
dies of bacterial infection, pneumonia, tuber- 
culosis, or other illness before achieving an 
AIDS diagnosis. 

Questions, Answers, and Comments 

Comment: The AIDS epidemic still continues 
among drug abusers. Within the last several 
years, there have been some shifts in the 
AIDS epidemiology, with the greatest 
increases occurring among gay men and 
injection drug users. Over the last 4 years, 
the greatest increases now are occurring 
among heterosexuals who do not inject drugs 
and who do not report other risk factors. 
Initially these cases were largely connected 
with injection drug users, but now hetero- 
sexually transmitted cases are more evident. 
The epidemiology is shifting and is raising 
several issues. 

Comment: Drug abuse treatment has been 
proven to be effective in reducing both drug 
use and the sharing of needles. The longer 
patients are in treatment, the less likely they 
are to get HIV. 

What is a way or means to impact upon the 
Federal Government and State governments 
to increase the funding levels and encourage 
research for methadone maintenance pro- 
grams? In terms of getting money for 
methadone maintenance and research, there 
is a methadone treatment improvement 
project within SAMHSA that is providing 
technical assistance to programs and States. 
The research has been done, but political 
action now is needed. The next step is link- 
ing AIDS activism to the accessibility of drug 
abuse treatment. 



Is the proposal to use interim methadone as 
away to expand treatment valid? One study 
in the United States showed that interim 
methadone was beneficial. There is opposi- 
tion in that methadone alone or nicoderm 
alone has not been as effective as providing 
these pharmacologic agents with appropriate 
counseling services. There is not enough 
support from the political system to provide 
full-service methadone treatment; therefore, 
other approaches need to be considered. 

How does the use of methadone work for 
cocaine abuse? Methadone does not have 
any direct impact on cocaine use. There are 
not many good treatments for cocaine abuse 
right now, but it is a top priority for 
research. One approach has been the devel- 
opment of psychosocial treatments and 
experimentation with antidepressants. 

RS42. HIV/AIDS AND WOMEN 

Moderator: Rebecca Ashery. D.S.W. 
Speakers: Blanca Ortiz. M.A.. J.D.. Ph.D. 

Marsha Rosenbaum. Ph.D. 

Nancy Rosenshlne. M.S. 

Gloria Welssman. M.A. 
Respondent: Trlnita R. Waters, M.A. 
July 15. 3:00 p.m.— 4:30 p.m. 

Speaker: Marsha Rosenbaum, Ph.D. 
For years poor women who use drugs have 
faced anxiety about obtaining drugs; getting 
ripped off; receiving contaminated drugs; 
contracting sexually transmitted diseases or 
hepatitis; overdosing; and giving birth to 
addicted babies. Although women addicts 
today continue to confront these same issues, 
they also face increased poverty, increased 
powerlessness in their relationships with 
men, and increased risk for HIV/AIDS. 

Two recently conducted studies addressed 
these issues. One study examined metha- 
done maintenance and AIDS among 223 
subjects, one-half of whom were women, and 
the other study examined pregnancy and 
drug use among 120 women in various stages 
of pregnancy. To a large extent these studies 
involved ethnographic research through 
indepth interviews, with the primary goal of 
understanding the women's situations from 
their perspectives. The women's own words 
provide compelling evidence in the studies. 

This research has revealed that fear of 
HIV/AIDS is pervasive among women. 
Although the drug world already had been a 



156 



Summaries of Research Awareness Seminars 



risky environment for them, the threat of 
contracting AIDS has made it terrifying. As 
one women said, "I live with the fact that 
because of what I do, I could wake up one 
morning and be [HIV] positive." Women 
also are fearful of the ramifications of their 
past actions, since HIV has made them 
accountable for their activities. Another 
woman said, "Yeah, Fve been tested, but I 
want to get tested again now, which I know 
I will, but oh, I was scared, I was scared. I 
didn't know then, I didn't know about AIDS, 
and then when the big propaganda came up 
about the AIDS, I was scared to get tested 
because I thought about the stuff I did." 

In addition to fear, women's powerlessness 
renders them unable to engage in active 
prevention. A study on needle-sharing 
among pregnant women found that 63 per- 
cent of intravenous drugs used were with a 
needle shared with a lover or spouse. Most 
of the women did not define this as sharing 
or as risky behavior even though, in the 
majority of cases, the men used the needle 
first, thus leaving the women vulnerable to 
both the men's sexual infidelity and their 
intravenous drug use. As one woman noted, 
"Yeah, I was real aware about being careful 
about AIDS and didn't share with anybody 
except him and only using new needles, you 
know, between the two of us. I didn't know 
how bad he was. I found out later by observ- 
ing him in different situations. He shared 
with anyone and everybody." Even if women 
became aware of the risk of sharing needles, 
they often were reluctant to stop this prac- 
tice due to fear of their lovers' responses. 
For instance, if women became assertive 
about cleaning needles, their lovers would 
become violent: "Asking him to clean a 
needle is like asking for a beating." 

Many women who provide sex for money are 
aware of the risk of contracting HIV and 
therefore ask the men to use condoms. 
However, the women often will engage in sex 
even if the men refuse to use a condom 
because they want the money and, again, are 
afraid of the men becoming violent. Also, 
couples often will not use condoms because it 
may imply that they are not being monoga- 
mous. One woman noted, "I would use 
rubbers on guys that insisted to use rubbers 
or if there was a guy I really didn't like... .but 
if I liked him, I wouldn't use it." In addi- 
tion, women often are raped by men who do 
not use condoms. Thus, studies revealed 
that education about sharing needles and 
using condoms wasn't entirely effective in 



preventing risky behavior. The women in 
the studies often knew enough, but the 
powerlessness they felt under the threat of 
violence prevented them from acting asser- 
tively in their best interest. 

The study conducted on pregnancy and drug 
use found that pregnancy initiates and 
increases female drug users' fear of HIV, 
their concern about their past and current 
behavior, and their desire to be tested for the 
virus. One woman said, "I know they're 
going to test me 'cause they're going to test 
the baby to see, but it's like Fm concerned 
because I would die right then. I wouldn't go 
off and commit suicide, but it's like I would 
die. I wouldn't find it a reason to five any 
longer because Fm not going to be able to see 
my kids grow up." Women who are pregnant 
and use drugs face tremendous stigma and 
guilt about possibly transmitting HIV to 
their babies. Indeed, managing the guilt of 
using drugs during pregnancy is difficult, 
especially given the current political and 
social tide of the Nation. Still, many 
drug-using women judged other women who 
were using drugs while pregnant. Within 
the community of drug-using women, the 
risk of HrV during pregnancy becomes a 
divisive tool when some women consider 
themselves of higher moral standing than 
others. Although HrV-positive women in the 
study felt guilty about potentially handing 
their children a death sentence, the idea of 
terminating the pregnancies did not guaran- 
tee freedom from that guilt. Many of the 
women were opposed to abortion, felt pres- 
sured to perpetuate their family lineage, or 
wished to make up for the inevitability of 
their own death. 

The women in the pregnancy study had an 
average income of $417 per month. They 
were victims of violence: 62 percent were in 
abusive relationships at some point in their 
adult lives, and 26 percent were assaulted 
during pregnancy. In the past, drug treat- 
ment was unrealistically expected to solve 
problems due to poverty and a social system 
with a growing underclass which creates 
drug abuse. Treatment staff understand the 
complexity of the problems and the special 
issues that women face, but they need to 
adapt more of an explicit, harm reduction 
perspective. Treatment cannot solve major 
social problems, but it can help reduce the 
damage done by drugs even if just by provid- 
ing a respite from a chaotic life. Treatment 
should be open and available on demand. 
Methadone is becoming increasingly priva- 



157 



NIDA Conference Highlights 



tdzed, and its subsequent price precludes it 
as an option for some people. Also, treat- 
ment personnel must recognize that they 
may not be able to erase individuals' drug 
problems, but they realistically can reduce 
the harm that individuals face. For instance, 
one treatment provider allows drug users to 
stay in his methadone maintenance program 
even if they continue to use drugs because he 
believes methadone at least is reducing the 
harm done to them. 

Speaker: Blanca Ortiz. M.A., J.D.. Ph.D. 

A summary of preliminary findings from the 
Cultural Network Project is presented below. 
The longitudinal study aims (1) to identify 
the social, cultural, and practical boundaries 
to women's initial adoption and subsequent 
maintenance of HIV-risk reduction and (2) to 
identify the social, psychological, and cul- 
tural determinants of women's decisions to 
accept or refuse HIV counseling and testing. 
Staff interviewed 1,922 women at three sites 
in New York City. Preliminary findings 
indicate that HIV cannot be viewed outside 
the contexts of people's lives (i.e., without 
considering factors such as socioeconomic 
status, gender, ethnic and racial identity, 
social and interpersonal influences, access to 
health services, personal resources and social 
power, and participation in community 
organizations and institutions). Prevention 
strategies based on women's HTV/AIDS- 
related behaviors focus not on new strategies 
for individual behavior change but on the 
development of normative contexts that are 
conducive to individual risk reduction while 
respecting community values. Preliminary 
findings center on transculturation, social 
networks, resources and challenges, and 
organizational participation. 

With the understanding that HIV/AIDS 
primarily affects ethnic minorities, especially 
African-Americans and Latinos, this project 
examined the role of ethnic and cultural 
variables in HIV risk-reduction behavior. 
Transculturation was proposed as a way to 
understand the complexity of what happens 
when individuals try to reconcile their 
cultural background and history with the 
dominant surrounding culture. "Transcultur- 
ation" is a multidimensional construct that 
involves social relationships, language, use of 
the media, participation in rituals and group 
identification, or ethnic identity. Trans- 
culturation may occur in different degrees, 
and it is dynamic and dialectical. A trans- 
cultural person is better able to make the 



most of both cultures, such as having greater 
facility using public health services while 
still maintaining family, church, and com- 
munity support. 

The study examined this process with a 
subsample of 625 immigrant Latino women. 
Patterns observed of interactions with the 
dominant North American culture included 
the following: acculturated, bilingual women 
were indifferent about ethnicity; some 
women were proactive and others were 
insulated; and monolingual women were 
indifferent about ethnicity. Proactive women 
reported greater use, knowledge of, and 
intention to use condoms. Monolingual, 
insulated, and pseudoblended women 
reported less use of condoms and less drug 
use and were less aware of network norms 
regarding condom use. Acculturated women 
were more likely to have used drugs and less 
likely to use condoms but were more aware 
of the network norms. Proactive women 
were most concerned with protecting them- 
selves from HIV/ AIDS and received checkups 
more frequently. Insulated Latinos were the 
least concerned with self-protection and had 
less access to health insurance, but they 
reported problems less often with their 
health care providers. Monolingual and 
pseudoblended Latinos had less frequent 
checkups, whereas acculturated women 
reported the highest rate of health insurance 
coverage and were most concerned about 
HIV infection. 

These findings reinforce the fact that Latinos 
in the United States are not homogeneous. 
Transculturation appears to be more instru- 
mental in reducing HIV-related risks; there- 
fore, interventions that preserve Latinos' 
ethnic identity while facilitating access to 
aspects of the dominant culture that enhance 
knowledge about safer sex would be most 
appropriate. Interventions that counter their 
cultural norms might encounter more resis- 
tance than is normally expected. What 
appears most important is the value of the 
unique transactions that evolve between 
people and contexts from different ethnicities 
and cultures. The findings also have policy 
implications in that they suggest that when 
health care services are available and ade- 
quate, Latinos are willing to use them. This 
analysis will continue with African-Ameri- 
cans and Latinos born in the United States. 

Social networks provide an ecologically based 
means for investigating structural and func- 
tional aspects of social relationships and 



158 



Summaries of Research Awareness Seminars 



their relation to risk behavior. In the Cul- 
tural Network Project, women identified 
members of their social network, including 
their main partners and those who knew 
them well; provided demographic information 
about them; and rated their satisfaction with 
the relationships. Information was collected 
on 17,000 social network members. 

A questionnaire assessed positive and nega- 
tive interactions related to the respondent's 
HIV risk behavior. Findings indicate that 
interventions should encourage community- 
wide support for HIV prevention. Women 
who interact with people who encourage 
risky behavior or hinder prevention tend to 
engage in risk behaviors. Many women want 
to get out of relationships with such people 
but may find it difficult. Thus, interventions 
need to be developed that target social net- 
work members. Lower risk Latinos reported 
the lowest level of HIV-specific interactions. 
However, their risk might increase as they 
interact more with the dominant North 
American culture. 

The study also examined the personal, inter- 
personal, and community resources from 
which women could find support in dealing 
with demands and obstacles to HIV preven- 
tion. Prevention is difficult in the face of 
multiple barriers. An examination of these 
challenges and the strategies that women 
use to overcome them would be helpful in 
designing interventions more responsive to 
their reality. Challenges often include get- 
ting and staying off drugs, leaving a partner, 
finding a home and a job, going to school, 
and dealing with unplanned pregnancies. 
Strategies for overcoming these challenges 
include communicating, relying on religion 
and spirituality, relying on self-efficacy, win- 
ning custody, and seeking counseling. Inter- 
personal and community sources of support 
include partners, family, friends, drug pro- 
grams, churches, and the Cultural Network 
Project. Women appreciated receiving help 
in navigating through service systems and 
sharing experiences. These findings imply 
that future interventions should build on 
women's strengths and competencies, such as 
developing scenarios for women to share 
experiences or giving women active roles in 
determining how to engage in risk-reduction 
activities. Interventions also should incor- 
porate the importance of the church in en- 
couraging risk reduction and health pro- 
motion efforts, as well as the significance of 
children as an incentive in dealing with 
difficulties. Intervention mechanisms must 



be developed at the system level to support 
the strategies already used by women. 

Preliminary findings from the study indicate 
that 41 percent of participants reported 
participation in at least one social organiza- 
tion, with the most popular being church or 
other religious organizations, followed by 
neighborhood and school organizations. Most 
participants reported that at least one 
organization to which they belonged provided 
help in obtaining health and social service. 
Women in organizations that were involved 
with AIDS were more likely to engage in 
risk-reduction activities, such as using con- 
doms. Thus, it appears that women's partici- 
pation in organizations should be encouraged 
to link them to resources and empower them. 
It also would be helpful to explore the possi- 
bility of women transferring these skills to 
negotiations with their partners. 

Speaker: Nancy Rosenshine, M.S. 

The WHEEL (Women Helping to Empower 
and Enhance Lives) Project grew out of work 
begun in 1988 by a group of pioneers in the 
field of working with women at risk for HIV. 
At a conference in California in March 1989, 
these individuals presented an AIDS preven- 
tion model outline and received input from 
administrators of projects for female sexual 
partners of drug users. In October of the 
same year, a draft model was presented and 
feedback was solicited from the field. By 
January 1990, 17 experts worked together to 
produce a companion training curriculum. 
In February the training effort, "Preventing 
AIDS Among Female Sexual Partners of 
Injection Drug Users," was launched. 
Finally, in October 1990, the WHEEL Project 
was funded by NIDA The project is jointly 
administered by NOVA Research Company 
in Maryland and Prototypes in Los Angeles 
and is established at five sites: Boston, 
Massachusetts; San Juan, Puerto Rico; 
Juarez, Mexico; and San Diego and Los 
Angeles, California. Services already were 
available for women partners of drug abusers 
in each site except San Diego, which was 
eager for such a program. The WHEEL 
Project is unique in targeting "hidden 
women," who are not necessarily injecting 
drug users themselves but nonetheless suffer 
from their partners' use. 

WHEEL'S name was chosen to emphasize the 
importance of empowerment in programs for 
women. Women from the targeted communi- 
ties conducted most of the recruitment for 



159 



NIDA Conference Highlights 



the project. Prospective participants were 
screened with the Risk Behavior Assessment 
instrument and a women's supplement form 
and were paid an incentive for being inter- 
viewed. Random assignments then were 
made to either individual or group interven- 
tions, both of which initially began with 
individual sessions, needs assessment, risk 
assessment, and pretest counseling. It was 
very important that the women discuss their 
needs, top service priorities, and perceived 
risk for HIV infection. About one-half of the 
women in the WHEEL Project completed 
high school, while the other one-half had less 
than a high school education. More than 
one-half had their own homes, while some 
were transient. The overwhelming majority 
had children. 

All WHEEL participants, in either the indi- 
vidual or group interventions, were invited 
for a 6-month followup interview using the 
risk behavior and supplemental followup 
instruments. The group sessions consisted of 
seven possible modules, among which women 
could choose the following topics for discus- 
sion at their three meetings: health, addic- 
tion, sexuality, how to keep safe from 
domestic violence, relationships, survival, 
and parenting skills. Interventionists 
cofacilitated the first session with an out- 
reach worker, letting women vote on which 
two of the seven modules they most wanted 
to discuss, with the option to change their 
minds at the second session. The first two 
meetings were highly interactive with and 
respectful toward the women. At the end of 
each, the women were given peer education 
packets and asked to teach someone else 
about what they had learned in the sessions. 
Then in the third group session, called 
"teachback," the women were asked to teach 
project staff about the chosen topics. A 
graduation ceremony followed. 

Preliminary initial-to-followup data on 
behavior change have begun to be collected, 
and qualitative and quantitative analyses are 
being conducted. In addition, an ethno- 
graphic study soon will be completed of 189 
women across the 5 sites in both the individ- 
ual and group interventions. Preliminary 
findings indicate that women still were 
engaging in unprotected sex; therefore, there 
is much more work to do. Although targeted 
women are part of a fairly low drug-using 
population, findings revealed a drop in their 
use of drugs before sex. Also, women's wor- 
ries about getting AIDS increased, thus 
indicating that the project sensitizes women 



and personalizes the risk of HIV, particularly 
among the women at the Mexico and Puerto 
Rico sites. Finally, a reduction was found in 
women's feelings of no control over their 
lives. More indepth analysis of these and 
other results are upcoming. 

Speaker: Gloria Weissman, M.A. 

Although women have constituted the most 
rapidly growing group of persons with AIDS 
in the United States for the last several 
years, providing access to health care and 
getting women and HrV on the prevention 
and research agendas have been uphill 
battles. The risk to women has been over- 
looked, and attention instead has been 
placed on women as vessels of infection to 
men or babies. When women with AIDS and 
their care providers formed a critical mass, 
that attitude changed. Still, there is too 
little funding and public discourse on this 
problem. While there has been much pedi- 
atric care for babies with AIDS, there has 
been little care provided for their mothers. 
Last year saw the first largescale study of 
the natural history of HIV infection in wom- 
en; therefore, optimal care based on sound 
research is currently not largely available. 

Because women with HIV are stigmatized 
and suffer discrimination, it is difficult for 
them to seek and receive appropriate care. 
They face educational, cultural, economical, 
psychological, physical, and social barriers to 
accessing care. Furthermore, in addition to 
being drug users and partners of drug users, 
most HIV-infected women are ethnic 
minorities; have little formal education; have 
children or partners who also are infected; 
and have lost children or partners to vio- 
lence, foster care, and/or the criminal justice 
system. Many of these women do not have 
stable living situations, thus increasing the 
difficulty of complying with care. Some are 
not medicaid eligible and have to deal with 
transportation and child care costs as well as 
drug abuse and mental health services 
expenses. 

Women's ability to change risk behaviors, as 
well as service-seeking and health care 
behaviors, is affected by their cultural ori- 
entation, socioeconomic status, and sense of 
power and decisionmaking. More research is 
needed on prevention and factors that influ- 
ence women seeking and receiving care. 
Cultural competence is important in improv- 
ing access to care. Although most women at 
risk are members of ethnic minorities, they 



160 



Summaries of Research Awareness Seminars 



share the culture of gender. Women act in 
unique ways, as seen in their health care 
seeking behavior. For instance, women with 
HIV usually will seek care for their children 
and partners first and neglect their own 
health, resulting in their later entry into the 
HIV care system and shorter survival period. 
Women also have less power than men at 
every level (i.e., funding, focus of staff train- 
ing, and research projects). To talk about 
access to care for women without discussing 
these and other aspects of women's culture 
and women's reality is the height of cultural 
insensitivity. 

Another problem that cuts across ethnic 
boundaries is abuse. Many women have 
been victims of physical or sexual abuse by 
men and currently are in abusive relation- 
ships. It is important to examine how abuse 
affects their ability to seek and find care 
sensitive to their needs. Also, it is important 
to address HIV-infected drug users' drug 
problems, in addition to the virus. The lack 
of affordable and available drug treatment is 
a major issue in access to care. Since many 
women are unwilling or unable to get drug 
treatment, they must be actively recruited to 
health services. Such an effort requires 
extensive training of providers, pressure on 
the system by advocates (which are sadly 
lacking), and innovative outreach. 

Successful projects frequently use peer-led 
interventions and peer-support models. 
Other successful projects use indigenous 
outreach workers to serve as the bridge 
between women and providers, helping 
women get through service systems. These 
two strategies are equally valuable and 
should be integral parts of the continuum of 
HIV care. Programs must devote consider- 
able attention to advocacy efforts to build 
external resources needed to help 
HIV-infected women. 

In the continuum of care, at the time of 
pretest counseling, program staff have the 
best chance of ensuring access to care for 
HIV-infected women. If staff cannot ensure 
that appropriate services will be available for 
a woman, however, then they have an ethical 
duty not to encourage the woman to be 
tested for HIV. In doing so, they may be 
doing harm. Too often women are diagnosed 
with HIV and then given an informational 
pamphlet without receiving medical care 
until AIDS symptoms are evident. 

In February 1993, the Health Resources and 
Services Administration (HRSA) convened a 



workshop on access to health care issues for 
women with HIV. The meeting focused on 
priorities for evaluation research on access to 
care for HIV-positive women. Copies of the 
report are available from HRSA. Many 
studies proposed by the workshop group now 
are in progress (e.g., how the needs of women 
with HTV are being addressed in the Title I 
planning process). A new study is being con- 
ducted to determine whether any changes 
occur for HIV-infected women drug users in 
five cities that are just beginning to receive 
Ryan White Title I funding. It is important, 
however, not to wait for the results of these 
and other studies before aggressively work- 
ing to improve access to care. Women's 
needs must be heard and advocacy for 
women with HIV must be improved. 

RS43. Effectiveness of Teaching Safe 
Sex Practices with Drug 
Abusers 

Moderator: Ro Nemeth-Coslett. Ph.D. 
Speakers: Michael Dennis, Ph.D. 

Robert Mallow. Ph.D. 

Gloria Weissman. MA 
Respondent: Bill Taylor 
July 15. 4:45 p.m.-6:15 p.m. 

Speaker: Michael Dennis, Ph.D. 

A 1990-91 study focused on 53 male clients 
in a number of New Orleans inpatient pro- 
grams. The information obtained through 
this study was compiled into a number of 
6-hour videotapes dealing with the positive 
effects of psychoeducational and educational 
treatment approaches. These videotapes 
covered such topics as the susceptibility of 
African-Americans to the AIDS virus and the 
proper method of putting on a condom and 
allowed for many beneficial group inter- 
action, role-play, and question-and-answer 
periods. The ratio of clients to therapists 
was fairly high, and the therapists involved 
in the program were found to be primarily 
recovering addicts themselves. 

It was found that the best topographical 
determinant for the clients was whether or 
not they were at risk for contracting AIDS. 
If people did not use condoms 100 percent of 
the time, they were classified as "at risk." If 
people were monogamous (both partners), 
were not using intravenous (IV) drugs, were 
abstinent from all sexual activity, or used 
condoms 100 percent of the time, they were 
classified into a safe category. Of the 53 
people randomly assigned to the various 



161 



NIDA Conference Highlights 



psychoeducational groups, 40 (75 percent) 
were found to be at risk, while only 13 (25 
percent) were found to be safe. The results 
of a 3-month followup study revealed that 25 
of the 40 who were classified as at risk were 
no longer classifiable in this category. This 
meant that only 32 percent of the original 53 
people remained at risk. Inpatient clients, 
upon completing a 28-day followup program, 
then were treated as outpatients through 
aftercare methods. Three months after this 
conversion from inpatient to outpatient care, 
the clients' progress was assessed. The 
following factors were determined to be the 
most important mediating variables for risk 
reduction: (1) knowledge, (2) susceptibility, 
3) anxiety, (4) response efficacy, (5) self-effi- 
cacy, (6) communication skills, and 
(7) condom use skills. 

Changes in the mediating variables were 
seen during the periods between preinterven- 
tion and postintervention for the people 
treated with both the educational and the 
psychoeducational videotapes. Although the 
psychoeducational group showed a little more 
positive change than its educational counter- 
part, it was difficult to determine what 
exactly caused the change. Length of stay in 
treatment, however, often is cited as a pre- 
dictor to success. 

Indepth investigation into the perceived 
levels of motivational behavior change on the 
part of the clients has led to the formulation 
of a three-stage regression model: (1) sus- 
ceptibility stage, (2) commitment stage, and 
(3) enactment stage. Continuing study is 
going into the understanding of these highly 
differing stages of client development. Con- 
trols dealing with age, education, and IQ 
(intelligence quotient) level are being applied 
to each stage to determine what the effects 
will be. The ongoing results of these studies 
can be used as a model for other needy 
treatment facilities. 

Speaker: Gloria Weissman, M.A. 

The two main programs cited in this speech 
are the National AIDS Demonstration 
Research (NADR) project (from 1987 to 
1992), which worked with women at risk, 
and NIDA's 3-year Women Helping to 
Empower and Enhance Lives (WHEEL) 
project, which also worked with women at 
risk. 

Women are the fastest growing group of 
HIV-positive people in the country. Despite 
this fact, AIDS funding for female treatment 



and research is fairly low. Due to the fact 
that female AIDS transmission never has 
received the attention that it deserves, time 
has been lost that could have been used to 
develop methods of blocking this growing 
epidemic. Contrary to common belief, lack of 
knowledge concerning risky behavior is not 
the main reason for the high female trans- 
mission rates. Very high levels of knowledge 
concerning this growing problem were found 
among 63 of the surveyed female treatment 
sites. The most predominant factors affect- 
ing women's susceptibility to HIV are the 
following: (1) culture, (2) risk-taking prac- 
tices, (3) socioeconomic status, and (4) deci- 
sionmaking regarding sexual behavior and 
drug use. 

Women, as a primary preventive measure, 
often are told by treatment clinicians to 
decrease their number of sexual partners. It 
was found that 47 percent of the women 
involved in the NADR project had only one 
sexual partner; thus, if this percentage is at 
all representative of the general population, 
then the above-mentioned advice would not 
be viable. The NADR project also points 
toward a higher level of condom use among 
women with multiple sexual partners. This 
fact could mean that either women with 
more than one sexual partner feel that they 
are at a greater risk or that women who 
have only one sexual partner feel that they 
are not at risk. Prevention efforts need to 
focus more attention on the educational side 
of HIV transmission. In doing this, women 
involved in monogamous relationships should 
be told that they may, in fact, be at risk 
despite how well they think they know their 
partners. 

The majority of the women at risk or already 
infected with HIV are cultural minorities. 
HIV transmission is especially high among 
minority women involved with crack -cocaine. 
One predictor to this unfortunate reality is 
the fact that many of these women have been 
either physically or sexually abused by men 
at one point in their lives. Of the 28,000 
women involved in the WHEEL project, 36 
percent experienced some sort of childhood 
sexual abuse. Forty-five percent of the 
women currently are physically abused, and 
another 31 percent are sexually abused. Due 
to these disturbing percentages, many 
women do not feel secure enough to promote 
the idea of condom use. 



162 



Summaries of Research Awareness Seminars 



More than 21,000 women have been studied 
in the NADR project. It has been found that 
the women most at risk for contracting the 
HIV virus are those who have the most 
difficulty changing their risky behavior. The 
majority of the women studied in this project 
reported some kind of sexual activity 6 
months before being interviewed. Of the 85 
percent of the IV drug-using women who 
reported having vaginal sex, only 11 percent 
admitted to using condoms every time. In 
comparison to this, of the 97 percent of non- 
IV drug-using women who reported having 
vaginal sex, only 8 percent said they used 
condoms every time. A 2-percent condom use 
rate was reported among the 13 percent of 
the IV drug users and the 15 percent of the 
non-IV drug users who stated they engaged 
in anal sex. A slightly higher level of con- 
dom use was detected among women who 
had multiple sex partners and by those who 
traded sex for money and drugs. The occa- 
sional or regular condom use percentages for 
the sexual partners of both the female IV 
drug users and the female non-IV drug users 
(these percentages rise or fall depending on 
the number of sexual partners the women 
have) are as follows: (1) partners of IV drug 
users — one partner, 82 percent; two or more, 
39 percent; and five or more, 74 per- 
cent — and (2) partners of non-IV drug 
users — one partner, 18 percent; two or more, 
33 percent; and five or more, 83 percent. 

As a result of the NADR project, 37 percent 
of the IV drug-using women and 45 percent 
of the non-IV drug-using women reduced the 
number of occasions in which they engaged 
in unprotected vaginal sex. The initial 
assessment period of the project pointed 
toward a one-in-four rate of daily unpro- 
tected sex. At project onset, one in five of 
these women reported engaging in unpro- 
tected sex. 

At the beginning of the WHEEL project, 41 
percent of the women involved reported 
having unprotected sex with an IV drug user 
within the past 30 days. This percentage 
had been reduced to 17 percent as the end of 
the project neared. The overall rate of 
unprotected sex decreased from 87 to 78 
percent. It would seem that the most impor- 
tant research goals should be the develop- 
ment of a female contraceptive that can be 
used to combat the risk of AIDS and the 
increased discovery of new populations of 
at-risk women. 



Speaker: Robert Mallow. Ph.D. 
A recent study of eight NADR-funded pro- 
jects (four were outreach and four were 
methadone maintenance) was conducted. 
The main goal of this study was to determine 
the differences, if any, between the IV drug 
users entering methadone maintenance 
programs and those entering outreach pro- 
grams. The variables considered were demo- 
graphics, sexual practices, and drug use. 
Many drug users in these two different kinds 
of programs were interviewed between 1988 
and 1991. The eight projects had many goals 
they wished to attain. One was to get the 
drug users to stay in their respective metha- 
done or outreach programs so that the users 
eventually would decrease their IV drug use. 
The second primary goal was to push toward 
safer sex practices through increased condom 
use within both sets of programs. 

Followup assessments were conducted for 
over 80 percent of the methadone main- 
tenance clients and 50 percent of the out- 
reach clients 6 to 18 months after they left 
their programs. It was found that the 
methadone maintenance clients, in terms of 
demographic differences, were generally 
older, female, and white or Hispanic. The IV 
drug users who had undergone outreach 
treatment were more likely to use non-IV 
drugs daily (e.g., alcohol or crack-cocaine). 
The IV drug users who had undergone 
methadone maintenance treatment, however, 
were found to be more likely to be using IV 
drugs (with the exception of cocaine) on a 
daily basis. In terms of the number of sexual 
partners, the outreach clients tended to have 
multiple partners, while the methadone 
clients generally had only single partners. 
In conjunction with this, the outreach clients 
were found to have a slightly lower rate of 
condom use than the methadone clients. 
Only 7 to 9 percent of the people assessed 
reported always using condoms. Sexually 
transmitted diseases are generally more 
predominant among outpatient clients, while 
such illnesses as tuberculosis, hepatitis, and 
pneumonia are more likely among metha- 
done clients. 

Other followup data revealed that most 
people in high-risk groups either increased or 
kept the same number of sexual partners. 
Low-risk celibacy or single partners also 
were seen to be in high numbers. Overall, 
24.0 percent of the outreach patients and 



163 



NIDA Conference Highlights 



16.8 percent of the methadone clients 
reduced their number of sexual partners. 
Generally, IV drug users are not known for 
using condoms, but there has been an 
increase in the number of outpatient and 
methadone clients who have been using 
condoms. This also is coupled with the 
encouraging fact that there has been a 
decrease in the number of methadone and 
outpatient clients who have been both using 
IV drugs and having multiple sex partners. 
There is an obvious need for further empha- 
sis to be put on risk reduction in both the 
methadone and outreach programs through- 
out the world. 

Questions, Answers, and Comments 

How is it possible that IV drug users have 
lower rates of sexually transmitted diseases, 
considering that they are generally known to 
engage in unprotected sexual activities? This 
is due to the fact that they tend to have 
either one or very few sexual partners. 

What approach to HIV education is more 
effective within the treatment facilities — 
group therapy or individual counseling? It 
depends on the receptiveness of the client. 
Group therapy, however, has been seen to 
have greater levels of effectiveness for long- 
term patients. 

RS44. HIV/AIDS OUTREACH 
Intervention Research 

Moderator: Richard Needle. Ph.D. 
Speakers: Robert Booth, Ph.D. 

Clyde McCoy. Ph.D. 

Ro Nemeth-Coslett, Ph.D. 
Respondent: Gerald Rlbeiro 
July 16. 2:30 p.m.-4:00 p.m. 

Speaker: Ro Nemeth-Coslett. Ph.D. 

For several years the Community Research 
Branch at NIDA has been involved with 
outreach targeted to drug users who are not 
in treatment through the National AIDS 
Demonstration Research (NADR) program. 
Prom 1987 through 1992, demonstration 
research projects were funded across the 
country, combining service and research. 
These demonstration projects recently were 
completed. Currently the Community-Based 
Outreach Intervention Cooperative Agree- 
ment Program is being conducted at 17 sites. 
Since participants in the NADR project 
completed extensive questionnaires, a large 
data base has been developed concerning this 
population of drug users. 



The role of the outreach workers in these 
projects is extremely important. Researchers 
are finding that outreach constitutes more of 
an intervention than mere recruitment to a 
project. The concept of outreach originated 
not with AIDS but with late 19th-century 
efforts to combat tuberculosis by educating 
the public. Now outreach workers work in 
many roles, such as health education aides, 
community health workers, home health 
guides, and other professional positions. 
They frequently come from the neighbor- 
hoods in which they work and are of similar 
ethnographic, cultural, and street environ- 
ments as their target populations. Some are 
former drug addicts themselves. Outreach 
workers form the core of their projects by 
serving as a link between the program and 
the community. Their primary responsibility 
is to gain community acceptance and encour- 
age involvement in the program. 

Outreach workers' initiatives differ according 
to the populations they serve. For instance, 
in reaching out-of-treatment drug users, 
outreach efforts emphasize case findings in 
several community settings. For instance, 
outreach occurs in "copping" areas, where 
illicit drug transactions openly take place 
regularly among users. To be successful, a 
program and its personnel must be trusted 
by both the users and public officials 
responsible for law enforcement; outreach 
workers negotiate with the former while 
program leaders should negotiate with the 
latter. Many programs also conduct outreach 
in other areas, such as the criminal justice 
system and hospital emergency rooms. 
Former drug users usually become credible, 
effective outreach workers because, as those 
in drug treatment say, "To talk the talk, you 
first have to walk the walk." 

Pretest and posttest data on about 16,000 
program participants show that most were 
male, African -American or Hispanic, of high 
school-level education, and unemployed. 
Nearly one-half had not had prior drug 
treatment. To reach these individuals, out- 
reach workers must be indigenous to the 
target area, be connected with the drug user 
contact networks, and have personal inter- 
actions with the users. Outreach workers 
engage in numerous activities such as mak- 
ing referrals; providing education on risk 
reduction; and distributing prevention litera- 
ture, condoms, and bleach for cleaning 
needles. They are a constant presence in 
neighborhoods with a high prevalence of 
drug use and HIV infection. 



164 



Summaries of Research Awareness Seminars 



Overall and perhaps most significantly, data 
have revealed the significance of the out- 
reach worker's impact in facilitating behav- 
ioral change even before actual program 
treatment begins. James Chen, of the World 
Health Organization (WHO), has said, 

We are all too willing to pour what will be 
billions of dollars into the pursuit of an 
AIDS vaccine but will not pour the same 
amount of money into education and be- 
havioral modification programs which in 
the long run will be more cost-effective. 
The general public and policymakers need 
to realize that even when and if an effec- 
tive AIDS vaccine or treatment should 
become available, it will not be the 'magic 
bullet' that will eliminate AIDS as a global 
problem. All of the global efforts to build 
public health infrastructures and to sup- 
port HIV prevention programs, which we 
have been slowly and inadequately trying 
to develop to limit the spread of HIV, 
must be continued and even intensified 
when an AIDS vaccine does become avail- 
able.... 

Thus, outreach workers must be trained at 
the community level in order to educate 
individuals about risk reduction. 

Speaker: Richard Needle, Ph.D. 

The National AIDS Commission recently 
released its final report with recommen- 
dations similar to those of WHOs James 
Chen, emphasizing the importance of behav- 
ioral change strategies and outreach as a 
risk-reduction strategy. NIDA's Community 
Research Branch can provide a number of 
documents that describe models of outreach 
among these kinds of projects. 

Speaker: Clyde McCoy, Ph.D. 
The public recently has begun to see a sig- 
nificant shift from demonstration projects to 
what appears to be an emerging public 
health model based on these outreach pro- 
jects. It is important that researchers start 
considering the projects' common elements 
that can make up a public health model and 
be adapted across the country. 

In order to meet the criteria for a public 
health model, at least four areas must be 
examined. First, accessibility is extremely 
important and will be a major plank in the 
new health care reform. Currently injecting 
drug users do not have access to health care, 
drug treatment, or even criminal justice 
programs that are targeting them for risk 



reduction. Current projects have demon- 
strated that, through proper access, an 
appropriate intervention model can be pro- 
vided for the reduction of risk among drug 
users. Second, one must examine a pro- 
gram's effectiveness and whether the pro- 
gram actually leads to reduced risk behavior. 
Third, programs must be of high quality and 
accepted by the target population. Even an 
effective program will not be successful 
unless the target population first accepts it. 
Programs therefore try to be sensitive to the 
populations that are being recruited so that 
these people will accept the interventions. 
Fourth, the programs must be cost-efficient. 
The most cost-effective means for providing 
health care is through prevention. If even 
two cases of AIDS are prevented every year, 
the programs will have more than paid for 
themselves at each site. However, it takes a 
substantial capital investment up front 
before one can see long-term benefits. There- 
fore, unlike public health programs that 
treat the same patients over a long time 
period, many private care providers do not 
invest in prevention. 

To develop a public health program, one 
should consider the results of these projects 
along with pre-existing literature in order to 
come up with a model that will meet societal 
goals. There are three primary components 
of all of these projects. First, recruitment 
and followup is important. Patients must be 
actively recruited. Second, it is important to 
consider the ecology, or the community 
cultural elements, when designing an accept- 
able program. Third, programs must be 
effective change agents to reduce the risk of 
HIV. 

Each of these components may have several 
elements. In developing a public health 
model, one must determine the contribution 
of each component. At this point, each com- 
ponent appears as important as the others. 
A fairly standard intervention protocol has 
been developed based on the results of 
NIDA's demonstration projects. Out of this 
protocol, however, researchers would like to 
discover additional components that con- 
tribute to project effectiveness. 

One unique aspect of the NADR and coopera- 
tive agreements is the degree to which NTDA 
became aware of the communities in which it 
was working. In doing so, practitioners 
became aware of what the communities 
found acceptable, which allows treatment to 
continue with followup services for both 



165 



NIDA Conference Highlights 



research and reinforcement. More must be 
learned about the effectiveness of reinforce- 
ment services, which appear to be so impor- 
tant to program success. As a change agent, 
practitioners do not address attitude and 
belief changes; rather, they try to achieve 
behavioral change. Thus, the model can be 
seen in two ways: teaching and promoting. 
Education incorporates very specific skills 
related to risk reduction that participants 
should retain in order to change their 
behavior. 

Because this program is long-term, each 
program is required to conduct 6-month 
followups. Data show continuous change in 
each of the outcome variables. Any preven- 
tion program must have similar durability to 
be successful. It is unclear how effective the 
6-month followups have been in effecting this 
change, but it does appear that regular 
booster sessions do promote the continuous 
change. In most of the programs, a session 
has been built in called "Enhance." Partici- 
pants in this group appear to be doing better 
than those in the standard programs. 

Needle-cleaning has been a paramount com- 
ponent of many programs. Recent studies on 
the use of bleach have countered the myth 
circulating among the field that bleach is not 
effective. The time of exposure has been 
refined for bleach. Studies show that with 
clotted and unclotted blood, if one cleanses 
one's works with two bleach rinses of 15- 
seconds' duration each, then the syringe is 
decontaminated. This protocol has been used 
without knowledge of exactly what time of 
exposure one should expect. But the proper 
time of exposure to the bleach now is known. 
Researchers are not confused about this 
issue, although some public health officials 
might want them to be. 

The United States cannot afford to look 
exclusively to its publicly supported treat- 
ment system to reduce HIV transmission 
cases arising from high-risk behaviors. 
There is little likelihood of expanding treat- 
ment capacity or changing intravenous drug 
users' attitudes. Thus, effective and afford- 
able intervention models of short duration 
must be implemented, as projects have 
demonstrated over the last several years. 

Speaker: Robert Booth. Ph.D. 

There are many important issues regarding 
program evaluation strategies for evaluating 
outreach programs. When NADR projects 
first were funded, most were demonstration 



projects. In running a project that was a 
demonstration project for its first 3 years, 
the speakers tried to determine whether one 
could access drug addicts and change their 
behavior, irrespective of the particular inter- 
ventions being used. Although changes were 
found, it was unclear whether they were due 
to social desirability, the interventions, the 
respondents' becoming used to the research- 
ers and the questionnaires, or other causes. 

It now appears to be time to move beyond 
demonstration projects with these kinds of 
outreach efforts. In the mid-1980s, the first 
literature that emerged about pretest/post- 
test changes in risk behaviors revealed that 
such changes were occurring prior to the 
implementation of federally funded interven- 
tions. Thus, current data about changes in 
the presence of interventions leave room for 
skepticism. In reviewing the literature on 
changing the risk behaviors of intravenous 
drug users and crack-cocaine smokers, the 
speaker found only two articles that dis- 
cussed process information, such as dosage 
(the degree of intervention necessary to 
cause change) of the intervention, in order to 
determine the extent to which the interven- 
tion could account for changes in behavior. 
Dick Stephens of Cleveland worked on both 
of these studies; Dwayne Simpson from TCU 
was involved in one. 

In 1978 Peter Rossie wrote an important 
article entitled "Issues in Evaluating Human 
Service Delivery Programs," which showed 
that the delivery of an intervention is as 
important as the intervention message in 
changing risk behaviors. Besides the inter- 
vention itself or the philosophy behind it, the 
way the intervention is delivered is signifi- 
cant. Peter Rossie pointed out situations in 
which an intervention may fail, such as 
when a project is not implemented, as 
expected. Also, the heterogeneity of how an 
intervention is delivered may complicate the 
evaluation of the intervention's effects. For 
instance, positive results may be due to the 
charisma of a outreach worker more than to 
the intervention he or she is using. Thus, it 
is very important to evaluate the process of 
the intervention being delivered. 

As an example, several years ago a program 
was evaluated that trained personal care 
boarding home operators in dealing with 
chronically mentally ill individuals. The 
researchers randomly picked one-half (five 
staff members) of the boarding home opera- 
tors in Denver to receive the intervention. 



166 



Summaries of Research Awareness Seminars 



Over 3 years the researchers were to conduct 
the interviews at both groups of homes (those 
receiving and those not receiving the inter- 
vention). The researchers found, however, 
that one-half of the homes in the experimen- 
tal groups were interested not so much in 
the services but in filling beds. Furthermore, 
many of the homes in the control group 
already offered more interventions than the 
researchers could provide. Using an evalu- 
ation form that obtained process information, 
no difference was found to exist between the 
two groups, but results did differ according 
to the amount of intervention dosage, regard- 
less of the group to which the homes were 
assigned. 

A second example can be found in the opera- 
tion of a program called Project Safe, which 
involved a targeted sampling. Indicator data 
on sexually transmitted diseases, intraven- 
ous drug users, and HIV/AIDS cases were 
obtained from city agencies. Staff gathered 
additional information on, for example, the 
frequency and types of drugs sold in city 
"copping" areas. The researchers then esti- 
mated the number of drug users in the 
targeted area and developed quotas so that 
injectors and smokers from the areas could 
be accessed proportionately. Next, the 
researchers hired outreach workers who were 
"indigenous," or familiar with the drug 
subculture. 

In the cross-over design, the study used two 
interventions: (1) NIDA's standard interven- 
tion, in which participants are shown how to 
use a condom and bleach and then rehearse 
these activities, and (2) the researchers' 
enhanced intervention, using the Chicago 
model in which outreach workers conduct 
individual risk assessments with clients 
(depending on their risk behaviors and the 
extent to which the clients allow the practi- 
tioners to intervene). The latter intervention 
was difficult to monitor due to the individu- 
alized treatment and the discomfort of some 
of the staff with the paperwork involved in 
evaluation. The researchers were careful to 
determine clients' exposure to other interven- 
tions both prior to and during the project. It 
was difficult to know whether clients in the 
enhanced program actually were receiving 
that intervention and whether those in the 
control group actually were receiving more 
services than just the standard intervention; 
therefore, the researchers tried to track 
dosage from the perspectives of both the 
client and the outreach worker. 



Several problems arose in evaluating the 
intervention from the clients' perspectives. 
First, outreach workers sometimes were 
possessive of their clients and did not want 
others initiating contact with them. Conse- 
quently, outreach workers recorded all of 
their significant contacts (5 or more minutes) 
at the end of each day to ensure that the 
researchers accurately monitored interven- 
tion dosages. Second, outreach workers 
worried that the researchers were monitoring 
their productivity and sometimes recorded 
contacts that did not appear significant. It 
continually had to be emphasized that the 
researchers were monitoring the clients, not 
staff. Third, the researchers and outreach 
workers needed to establish a common 
understanding of what constituted and 
should be recorded as an intervention or 
significant content, based on factors such as 
time spent with the client and subjects 
discussed. 

The study gathered several general princi- 
ples: (1) the examination of intervention 
exposure is as important as that of pretest/ 
posttest changes in risk behaviors, (2) it is 
important to assess intervention exposure 
from as many perspectives as possible, 
(3) this type of evaluation requires constant 
oversight, (4) it is critical that staff buy into 
the evaluation design and gather their 
insights concerning the data, (5) evaluation 
tools should serve as many purposes as 
possible (i.e., for the evaluation of interven- 
tion dosage, as a management tool, and as a 
case record), and (6) outreach workers need 
constant reinforcement in the evaluation 
process. 

Questions, Answers, and Comments 

Has there been any research into the length of 
time a person should be in recovery before she 
or he can become an outreach worker? And 
how long should that person be out on the 
street, with the threat of relapse? This is a 
major issue. Persons are not hired unless 
they have spent at least 1 year in recovery. 
This agency has a support system for out- 
reach workers, provides treatment when 
necessary, and gives time off for work-related 
stress. Furthermore, because this program 
is affiliated with a treatment agency, random 
urinalysis testing is conducted on outreach 
workers. 

Should active users be used to conduct out- 
reach? One program in the United States 



167 



NIDA Conference Highlights 



tried that approach unsuccessfully. This 
agency has had relapse among its outreach 
workers, which adversely affected other 
workers' morales and feelings of safety. 
Mixing active and recovering users, at least, 
creates a major problem among staff. 

Comment: Active users should not be used. 
The appropriate time that an outreach 
worker should have spent in recovery 
depends on the individual. Several years ago 
an outreach worker who had been in 
recovery for 10 years began missing work 
and, it turned out, had started using and 
dealing drugs. This worker was likely put 
into situations he should not have been in. 
One must be careful never to pair two former 
addicts in outreach efforts. The most impor- 
tant issue in choosing outreach workers is 
not whether they once were addicts but 
whether they are comfortable with the envi- 
ronment of drug users. 

Comment: Besides being comfortable with 
the environment of drug users, outreach 
workers must be extremely careful and quick 
when they are in these dangerous, as well as 
tempting, situations. 

How does one make the distinction between 
contacts and encounters and account for 
contextual effects that occur in an interaction 
that may cause confusion in monitoring 
contacts? A significant-contact form can be 
utilized, which has a series of check boxes to 
indicate what occurred in the interaction. 
The form is more or less limited to HIV/ ADDS 
issues to help the outreach workers establish 
boundaries in the interventions provided. 

What kind of criteria do you use in evalu- 
ating the appropriateness of both recovering 
addicts and nonaddicts for the outreach 
worker role? The field seems to be moving 
toward an unofficial certification for outreach 
workers. An extensive training manual for 
outreach workers is helpful, but workers also 
should be encouraged to take a certification 
course through a medical school. It is impor- 
tant that outreach workers receive training 
as well as continuing education. 

Comment: Evaluation of outreach workers 
often is based on instinct. It would be help- 
ful if NIDA were to develop a standard list of 
criteria for outreach workers. 

Comment: Mistakes often are made in Wr- 
ings. The agency has recruited outreach 
workers from Narcotics Anonymous and 
methadone programs. The agency pairs 



outreach workers and has a strong support 
system for the staff to try to prevent relapse. 

RS45. Substance Abuse, HIV/AIDS, 
and Tuberculosis 

Moderator: Alan Trachtenberg. M.D.. M.P.H. 
Speakers: Hannah Wolfe. M.S. 

Harry Haverkos. M.D. 

Peter Selwyn. M.D. 
Respondent: Glen Fischer 
July 16. 2:30 p.m.-4:00 p.m. 

Speaker: Harry Haverkos, M.D. 

Tuberculosis (TB), predominantly a respira- 
tory system infection, is a worldwide prob- 
lem. TB causes 3 million deaths each year, 
and 8 million new cases are diagnosed world- 
wide every year. Only in the industrialized 
world has much impact been made in com- 
bating the disease. From 1953 (the first year 
of national surveillance for TB) to 1991, 
remarkable success occurred with prevention 
and treatment programs. However, the 
mid-1980s saw a plateau in that success, and 
since 1989 there has been a growing increase 
in the number of TB cases. Although, 
because TB is preventable and treatable, 
there has been an increase of only several 
hundred cases each year, this upswing is 
appalling. 

Like most diseases, TB is more common 
among certain populations. For example, 
between 1985 and 1991, minority groups 
acquired TB more frequently than other 
groups. Also, in some cities the number of 
cases is growing, even though a larger num- 
ber of counties reported no cases of TB this 
year than in previous years. For instance, 
after a decrease of cases in the 1970s, Cen- 
tral Harlem in New York City began to show 
an increase. In addition, drug abusers tend 
to show higher rates of TB. 

There are two noteworthy sets of national 
surveillance data with regard to incidences of 
TB. First, one can look at reports of AIDS, 
since TB occurs more commonly among 
individuals with HIV infection, and because 
the percentage of intravenous drug users 
with both AIDS and TB tops all other groups 
in the United States, slightly ahead of gay 
men. The other helpful data set is the 
National TB Surveillance System run by the 
Centers for Disease Control and Prevention 
(CDCP), which collects information on all 
cases of TB. Only recently, however, has 
this system included questions about 
patients' use of drugs. 



168 



Summaries of Research Awareness Seminars 



The most clearly documented reason for the 
upsurge in TB is HIV infection. Researchers 
have shown that individuals infected with 
the HIV virus and TB typically convert from 
simply having the infections to having active 
TB (usually pulmonary TB) at a rate of about 
8 percent per year. Only about 5 to 10 
percent of the other 10 million TB-infected 
Americans progress to active TB during their 
lifetime. Since only individuals with active 
TB are infectious to others, more pockets of 
TB now are developing. 

The incidence of TB has increased for a 
number of reasons, including drug abuse; the 
increasing number of homeless people and 
those in crowded living conditions; and the 
deteriorating infrastructure of public health, 
with less money allotted for followup on TB 
cases. In addition, although TB is a treat- 
able disease, many treatments are not work- 
ing as well and as often as they have in the 
past. This is partly due to the developing 
resistance of the organisms to many of the 
antibiotics that have been developed in the 
past few decades, including INH and rifam- 
pin. The mortality rates are very high in 
these outbreaks, ranging from 43 percent to 
almost 90 percent in some hospital settings, 
with a mean interval between diagnosis and 
death of 4 to 16 weeks. 

In 1985, the last year of national surveillance 
of drug resistance to TB, there was 0.5 per- 
cent new TB cases nationwide. Surveillance 
was stopped because of this low rate. How- 
ever, the rate then jumped to 3.1 percent in 
1991. Recurrent cases, those that had 
received treatment previously, averaged 3.5 
percent in 1985 and now are at 7.4 percent. 
In some parts of the country, especially New 
York City, between 20 to 40 percent of iso- 
lates from new cases of TB now are resistant 
to INH and rifampin. 

Speaker: Peter Selwyn, M.D. 

HIV infection, according to World Health 
Organization projections, affects 12 to 20 
million people, mostly in the developing 
world. TB is the most common serious infec- 
tious disease, affecting one-third of the world 
population, or about 1.7 billion people. 
Between 4 and 5 million people have both 
HIV infection and TB. In every area in 
which the two diseases have coexisted, there 
has been a resurgence of TB in the past 
decade, particularly in sub-Saharan Africa, 
parts of Latin American and Southeast Asia, 
and inner-city communities in the United 



States. In developed countries, TB and HIV 
are concentrated among intravenous (IV) 
drug users and their sexual partners. Even 
before the ADDS epidemic, data linked TB 
with substance abuse, particularly drug 
injection. A study on methadone programs 
in New York found an increased risk of TB 
related to patients' drug injection, not to 
other associated demographic factors. Sur- 
veys at TB clinics from 1988 to 1990 showed 
that in the northeast and southeast, the level 
of HIV infection among individuals with 
active TB exceeded 20 to 30 percent. For 
instance, in New York, over 40 percent of all 
persons with TB were also HIV infected, due 
in part to the individuals' suppressed immu- 
nity, which made them more vulnerable to 
the development of active disease. Also, 
people with HIV but not TB are more sus- 
ceptible to becoming infected with TB and 
developing the active disease at a more rapid 
rate. 

Any infectious disease is like the balance of 
three points on a triangle: the host or sus- 
ceptible person, the agent or organism, and 
the environment in which they both exist. 
Anything that strengthens or weakens any of 
these elements can affect the overall progres- 
sion of an epidemic. In almost a systematic 
way, several factors have converged toward 
the further progression of TB related to HIV, 
such as infected persons' increased suscepti- 
bility to disease, reactivation of latent 
disease, and diagnostic delays due to the 
presentation of TB in more unusual and 
undiscernible forms. This diagnostic delay 
can be hazardous, because until individuals 
are put on therapy, they can continue to 
spread the disease to others. Also, 
HIV-infected individuals are more vulnerable 
to contracting TB, and if they do become 
infected, they tend to develop the disease at 
a more rapid rate. Also leading to the pro- 
gression of the TB epidemic is the develop- 
ment of multiple drug-resistant TB, possibly 
the result of many factors, including inade- 
quate therapy, lack of completion of therapy, 
and the greater prevalence of TB in general 
related to HIV. Also, environmental 
factors — such as poverty, homelessness, 
substance abuse, and lack of resources (e.g., 
primary care and preventive care) — have 
contributed to the spread of TB. Poor envi- 
ronmental hygiene can lead to increased 
transmission even among high-risk popula- 
tions in drug treatment programs and 
HlV-care programs. Finally, conflicting 
epidemic paradigms have been problematic 



169 



NIDA Conference Highlights 



in combatting TB. Public health interven- 
tions and approaches for blood-borne epidem- 
ics are very different from those for airborne 
diseases. These two paradigms sometimes 
come into conflict, thwarting efforts to con- 
trol either side of the epidemic. 

In a study published in 1985 by the Journal 
of the American Medical Association examin- 
ing drug use in relation to TB, John 
Livingood investigated INH-resistant TB in 
the Northwest among a group of Vietnam 
veterans. Smoking marijuana was shown to 
be a very effective way of transmitting TB. 
One hundred percent of people who smoked 
with the index case in the study contracted 
TB infection. Fifty percent of those living 
with the index case developed TB. In a 
different setting, in Contra Costa County in 
California, smoking of crack-cocaine was 
associated with TB transmission, possibly 
due in part to some smokers' HIV infection. 
Also, many individuals were "shotgunning," 
in which one person breathes in crack smoke 
and then exhales into someone else, an 
excellent method of transmitting TB. Thus, 
the behavioral features of drug use or the 
social environment in which drugs are used 
may contribute to the spread of TB. Drug 
injection itself also may be a risk factor, as 
evidenced by data showing that extrapul- 
monary TB is more common among drug 
injectors. This still needs further study. 

Many areas require further research and 
scrutiny. For instance, researchers should 
investigate whether TB transmission among 
drug users is related to the drugs them- 
selves, to the environment, or to underlying 
demographic features. Second, it should be 
explored how drug use itself may predispose 
people infected with TB to develop the active 
disease. It seems that drug use affects 
immunity; therefore, aside from the effects of 
HIV, the drugs may be related to TB. Third, 
people need to be screened effectively to 
control TB; if populations are not in contact 
with the health care system, it is hard to 
conduct screening or supervised therapy. 
Consequently, some people are trying to 
provide screening and therapy on outreach 
vans or during welfare screening. A few 
specific clinical issues exist related to phar- 
macological interactions. Most important, 
however, is the interaction between metha- 
done and rifampin, because if methadone 
doses are not appropriate, users may go into 
opiate withdrawal, leading to problems in the 
treatment of TB as well as drug use. 
Finally, researchers need to investigate drug 



resistance and whether it is related to inter- 
mittent therapy or other factors. 

Even though the news is grim about the 
spread of TB, the disease is treatable (even 
in HIV-infected persons) with rapid initial 
drug combinations and early diagnosis. 
Treatment does not vary much between 
HIV-infected and noninfected individuals, 
except for longer treatment and perhaps 
slightly different drugs. Thus, treatment 
and prevention can be done easily in drug 
treatment settings. Drug treatment workers 
can provide a great service by screening and 
providing followup for patients, as well as by 
providing supervision to keep them from 
getting TB. Observed therapy is important, 
as is repeat sputum examinations, for people 
with active disease. Drug treatment workers 
should review this clinically with someone 
experienced in treating TB. Finally, it is 
important to have infection control in drug 
treatment settings, including adequate air 
exchange and mixing, as well as negative air 
pressure that sends exhaust-contaminated 
air outside, not in the center. These are 
fairly simple techniques, but they are capital 
intensive. Such systems must be brought up 
to current standards to prevent TB, and staff 
must be trained on how to minimize the risk 
of transmission. Over all, drug treatment 
centers are vulnerable to the transmission of 
TB but also are very strategically placed to 
prevent and treat TB among drug users. 

Speaker: Hannah Wolfe, M.S. 

In showing the need for TB education of IV 
drug users and drug treatment program 
staff, the following story, from a study con- 
ducted by Drs. Rick Curtis and Don 
DesJarlais of National Development and 
Research Institutes, Inc., in Brooklyn, New 
York, between 1990 and 1993, is compelling. 
Miss J., an HIV-positive, African-American 
female IV drug user, was admitted to the 
hospital with a high fever. In the emergency 
room she was diagnosed with pneumonia and 
possibly TB. This was the first time she was 
told she might have TB. While still in the 
emergency room, after her fever subsided, 
she developed severe heroin withdrawal 
symptoms. She said she was told that she 
could not be detoxified and treated for TB at 
the same time, so she received no metha- 
done. When she wanted to leave, the doctor 
told her she could not go because she had TB 
and posed a threat to others. After her 
protests, she was given a small dose of 
methadone, which did not ease her symptoms 



170 



Summaries of Research Awareness Seminars 



significantly. One week after leaving the 
hospital, she developed a high fever again. 
The same hospital did the same tests with 
the same results: The doctor did not want to 
prescribe methadone. In frustration, she left 
the hospital and 2 weeks later called 
inpatient detoxification programs at other 
local hospitals. One refused to admit her 
because she admitted she had TB. She did 
not tell another hospital until after she was 
admitted. It should be pointed out that Miss 
J. believed that she had active TB, although 
medical records do not indicate she ever did. 
Thus, miscommunication occurred at some 
point. 

This story highlights the reluctance of some 
medical staff to prescribe methadone, leading 
to a problem with treatment compliance. 
Also, it shows how many drug users might 
fear involuntary detention and therefore 
avoid contact with the health care system. 
Many of these issues, especially the apparent 
confusion of Miss J., were mirrored in a 
knowledge, attitudes, and beliefs survey 
administered by New York University and 
Beth Israel Medical Center researchers to 
571 New York City IV drug users and their 
sexual contacts. The survey was conducted 
in late 1992 and early 1993 to determine 
what people in the cohort knew about TB. 
Most people in the sample were drug injec- 
tors. The survey was verbally administered 
and followed up with one-on-one TB educa- 
tion. Survey questions were taken from a 
survey being piloted by CDCP for the 
National Health Interview Survey. Almost 
all of the sample identified TB as an 
air-borne disease. Two-thirds of the sample 
were worried about contracting TB, and 
about one-third said they knew someone with 
TB. Most were aware that TB cases were 
increasing, and when questioned about the 
reason for this increase, the most frequent 
response was that people do not take care of 
themselves. Such a blame-the-victim men- 
tality reflects fear and confusion about the 
disease. Other reasons accurately cited were 
lack of medical care and prevention efforts 
and crowded living conditions. However, 
some persons also cited rats, prostitution, 
bad weather, oral sex, and flaws in the food 
chain. Over one-half of the sample endorsed 
the quarantine of people with TB, and 
two-thirds perceived TB as a severe social 
stigma. In response to questions about 
proper compliance with TB medication 
(therapeutic and prophylactic), most people 
rightly disagreed that persons should stop 



taking medication when they stop feeling 
sick. Also, most agreed that if people do not 
take their medicine for as long as prescribed, 
it will be harder to be treated. Although 60 
percent answered questions about prophy- 
lactic care, it is difficult to know whether 
these persons actually complied with such 
gui defines. 

The survey revealed that many people do not 
understand the differences between TB 
infection and the active disease. Nearly 
one-half of the sample agreed that a positive 
TB skin test means you will develop the 
disease. Also, many people incorrectly 
agreed that someone with a positive TB skin 
test can transmit TB to others. People seem 
to understand the least about this area. 
Only about one-fourth of the people in the 
survey sample really had a good understand- 
ing of the differences between infection and 
active disease. Using multivariate analysis, 
it was shown that people who had tested 
PPD (purified protein derivative of tuber- 
culin) positive were 7>A times more likely to 
understand the difference. 

To conclude, New York City's rV drug users 
correctly perceived themselves as vulnerable 
to TB and saw TB as potentially fatal. They 
identified some of the major reasons for the 
recent resurgence of TB. However, one-half 
had misconceptions about transmission. 
There are numerous implications for these 
results. The perceived social stigma associ- 
ated with TB may be causing people to avoid 
testing/treatment, as may their failure to 
understand the differences between infection 
and disease. Effective education does seem 
to be occurring at the time of skin-test read- 
ing. Finally, drug treatment programs have 
played a leading and effective role in HIV 
education and prevention. Similar education 
and prevention efforts must be made regard- 
ing TB, especially because of the considerable 
overlap of the two diseases. 

Questions, Answers, and Comments 

Should ultraviolet light be used with TB? 
This question is subject to debate. No 
human data demonstrate its efficacy, 
although animal data are suggestive of its 
benefits. Some hospitals now have instituted 
ultraviolet light fixtures in some areas. 
There are also new devices that contain 
enclosed light fixtures within boxes that 
draw air in, sterilize it, and put it out the 
other side, addressing concerns of radiation. 
Ultraviolet light is a very important consid- 



171 



NIDA Conference Highlights 



eration which may prove to be efficacious if 
one cannot afford expensive changes in 
ventilation. 

Dr. Currin ofCDCP said that HIV, TB, and 
substance abuse are "hanging out" together 
and are very bad influences on one another. 
How do substance abuse treatment centers 
begin to integrate TB into their facilities, and 
what are the obstacles? At a recent meeting 
of investigators with NIDA's Community 
Research Branch (part of a followup to AIDS 
education and outreach demonstration pro- 
jects), there was much resistance to incor- 
porating the issue of TB despite its relevance 
to the other subjects of study, including HIV 
prevention. However, the attenders finally 
agreed that TB should be included in the 
research. One barrier to addressing TB is 
resources. Funding is inadequate for drug 
abuse treatment, let along for TB screenings 
and other services. Also, many drug abuse 
treatment workers need more knowledge 
about TB on how to make diagnoses and 
provide therapy. Staff are at some risk for 
contracting TB, so they may be more reluc- 
tant to work with infected individuals. TB is 
such a critical health problem that these 
barriers must be overcome; otherwise, more 
and more outbreaks will take place. 

Also, a lack of communication often exists 
between methadone clinics and hospital 
medical units, such as with medical records 
being fragmented. Consequently, there 
should be better coordination in that area. 
There also may be more resistance on the 
part of the TB treatment and public health 
community to dealing with issues of drug 
abuse. The story of Miss J., whose doctor 
refused to treat her withdrawal with suffi- 
cient methadone, is typical of what one must 
call malpractice in dealing effectively with 
these patients. Some States have legal 
problems in the maintenance of addicts on 
methadone unless they are registered in a 
methadone maintenance program. But a 
very effective detoxification regimen will 
put the patient on an adequate dose to cover 
symptoms and then withdraw them 
gradually. 

In training around HIV disease and sub- 
stance abuse, it is amazing how many people 
in drug treatment programs are more con- 
cerned about contracting HIV than they are 
TB. Have there been any studies with staff 
like the one with IV drug users? Nothing 
seems to have been published, but such a 
study needs to be done. Probably similar 



findings would be revealed. Many people in 
high positions in the medical field do not 
understand the difference between TB infec- 
tion and TB disease. Many people simply 
never learned about TB in this country. 
Several interviewers for the IV drug user 
study felt uncomfortable wearing masks and 
taking other precautionary measures, so they 
would not put on their masks. If the person 
began coughing, the interviewers would just 
leave the room. In addition, in many parts 
of the country, people are seeing more deaths 
due to AIDS than to TB. 

One issue that is a barrier is the stigma on a 
client once the client has received treatment 
for HIV, and then the client is found to have 
TB too. This can be so overwhelming that it 
becomes a barrier for clients. Are there any 
comments on this? There are some biases 
among health care providers that jeopardize 
the provision of care to individuals at many 
levels. This is one of the main reasons TB is 
on the rise again. Patients who are HIV 
positive and in need of undergoing a TB 
regimen often think they should not even 
bother since they expect to die soon anyway. 
This problem also is a difficulty for coun- 
selors, who are overwhelmed with their 
patients' problems. 

However, there are data showing that the 
provision of comprehensive primary care is a 
positive force in treatment retention and 
compliance. Also, treatment centers should 
focus at least on not harming patients. Some 
people could be harmed by the presence of 
persons with active TB in a treatment pro- 
gram. This potential harm is also a concern 
for staff, since TB infection would affect their 
own health and their families' health. 

What is the progression of TB infection with 
and without intervention? In an otherwise 
healthy person who becomes infected with 
TB, there is only a 5- to 10-percent chance 
that during his/her lifetime he/she will 
develop a lung infection and other symptoms. 
TB also can cause symptoms in other organs, 
but most frequently symptoms occur in the 
lungs. 

An untreated HIV-infected person who gets 
AIDS faces an 8- to 10-percent probability 
each year that he/she will develop serious 
symptoms, usually in the lungs. For individ- 
uals with both TB and HIV, infection can be 
prevented from progressing to the disease by 
the use of prophylactic antibiotics, usually 



172 



Summaries of Research Awareness Seminars 



INH, provided the organism is susceptible to 
that drug. It is difficult to tell yet how to 
treat individuals with drug-resistant TB 
infection. 



173 



Summaries of Issues Forums 



SPECIAL POPULATIONS 

IF01. Addressing Special Population 
Needs: Gays and Lesbians 

Moderator: Jim Graham. J.D.. LLM. 
Speakers: Eileen Durkln, M.BA 

Michael Shrlver 
July 15, 10:30 a.m.-12:00 p.m. 

Speaker: Jim Graham, J.D., LL.M. 
The substance abuse community largely has 
underappreciated the significance of sub- 
stance abuse among gay men and lesbians. 
Compounding this problem, many stereotypes 
surround the gay and lesbian community. 
Many of these stereotypes are not accurate, 
and they are very damaging, especially with 
their link to racial stereotypes. For instance, 
many people associate AIDS among white gay 
men with homosexual activities, while many 
associate AIDS among African-Americans 
with intravenous (IV) drug use. Also con- 
trary to stereotypes, bisexuality is prevalent 
among whites as well as among Latinos and 
African-Americans. One barrier to a sophis- 
ticated understanding of homosexuality and 
substance abuse consists of personal preju- 
dices based in part on these stereotypes. 

It is estimated that over 30 percent of the gay 
and lesbian community has a substance 
abuse problem. One reason for this alarming 
rate of substance use is that the majority of 
socializing among the gay and lesbian com- 
munity traditionally has occurred in bar 
settings, where large amounts of alcohol and 
other substances are present. Therefore, the 
temptation for substance use is always 
present. 

Successful treatment for the gay and lesbian 
community must be conducted in an environ- 
ment that is free from the social stig- 
matization faced by this group in everyday 
life. For instance, substance abuse coun- 
selors must be sensitive to the complexities of 
gay and lesbian cultures. In Washington, 
D.C., one of the Whitman-Walker Clinic's 
earliest programs focused on alcohol and 
substance abuse services, including assess- 
ment of substance use, outpatient treatment, 
and aftercare. About 70 percent of parti- 
cipants in this program remained drug and 
alcohol free for at least 12 months after 
completing treatment. 



It can be very stressful for gay men and 
lesbians to cope with HIV/AIDS, and alcohol 
and drugs often offer an escape. Special 
community-based organizations that provide 
safe environments for alcohol and substance 
abuse treatment are critical. Traditional 
clinics too often are insensitive in their treat- 
ment of gay men and lesbians. 

It also is important to understand the prob- 
lem of IV drug users within the gay and 
lesbian community and the associated high 
risk of HTV infection. The Whitman-Walker 
Clinic worked early on with IV drug users, 
and today it operates the Max Robinson 
Center in Washington, D.C., an outreach 
program funded by CSAT for a largely under- 
served, African-American population of IV 
drug users who are HIV positive or at risk for 
becoming so. 

Speaker: Eileen Durkin, M.B.A. 

The Howard Brown Health Center — a com- 
munity-based health treatment facility in 
Chicago for gay men and lesbians — was 
founded in 1974 as the Gay Horizons Pro- 
gram, arising from the gay empowerment 
movement of the 1970s and responding to the 
need for culturally sensitive, gay-affirming 
care. In 1974 the center was open only one 
evening per week and saw an average of 20 
patients per week. By the end of that year, 
the average had risen to approximately 50 
patients per week. About one-half of those 
patients had one or more sexually transmit- 
ted diseases (STDs). By 1982 the center had 
expanded and the number of patients with 
STDs seen in the clinic had risen to an 
alarming 13,000 per year. 

The Howard Brown Health Center's mission 
statement states that the center is to promote 
the well-being of gay and lesbian people and 
to enhance their fives through the provision 
of health care, wellness programs (including 
clinical, educational, and social services), and 
research. Although the center serves other 
populations, it strives to provide culturally 
competent care to its primary clients of gay, 
lesbian, and bisexual individuals. The How- 
ard Brown Health Center also cooperates 
with other programs serving this community, 
such as Horizons, a mental health counseling 
center in Chicago. 



175 



NIDA Conference Highlights 



Besides providing health services, the How- 
ard Brown Health Center has become in- 
volved in research directed primarily at gay 
health issues. The center has conducted six 
major studies, all of which are longitudinal 
national studies. The first study was con- 
ducted in 1975 by Dr. David Ostrow. The 
study resulted in the development of a hepa- 
titis vaccine and clearly determined that the 
number of STDs increases the chances for 
HIV contraction in the gay male population. 
The second study is a multicenter cohort 
study sponsored by NIH. Currently in its 
ninth year, this study has been looking at the 
changes in sexual behavior and drug use 
among the gay community. About 40 percent 
of the men participating in this study are 
HIV positive, while 10 percent have AIDS- 
defining conditions. Eighty-six percent of the 
cohort is still participating in the study in its 
ninth year. A third ongoing study, begun in 
1984, examines how men cope with the stress 
of living with AIDS and their associated 
behavioral changes. A fourth study, spon- 
sored by the Centers for Disease Control and 
Prevention (CDCP), studies the health out- 
comes and mortality rates of individuals who 
first tested positive for HIV infection in 1975. 
A fifth CDC study is examining STDs among 
gay men, and a sixth project is studying the 
behavioral patterns of sexually active men 
in white, African-American, and Latino 
communities. 

In the third study concerning the coping 
strategies of gay men with AIDS over a 4V4 
year period, a substantial decrease in the use 
of recreational drugs occurred. Recreational/ 
psychoactive drug use has been associated 
with HIV-related illnesses and the infection 
rate among gay men. Therefore, the Howard 
Brown study examined the use of 10 recrea- 
tional drugs among, the frequency of alcohol 
use among, and the sexual behaviors of 
13,000 participants. The study found that 
the use of certain recreational drugs led some 
individuals to engage in unsafe sexual behav- 
iors. Individuals who used "poppers" (amyl- 
nitrate) and cocaine were more likely to 
engage in such practices than those who used 
other drugs. Over the time of the study, the 
use of poppers and cocaine decreased among 
the cohort, while the incidence of alcohol use 
remained constant and did not appear to 
impact sexual behaviors. Unfortunately, it is 
difficult to translate the results of this and 
other research into practical program prac- 
tices. The Howard Brown Health Center case 
manages over 320 clients, the majority of 



whom are gay males, and besides the usual 
difficulties of having such a large clientele, it 
is difficult to sort out the causes and effects 
of the behaviors being studied. Additionally, 
and quite simply, it is difficult to counsel 
such a drug-abusing population. However, 
staff are trying through culturally competent 
outreach and educational programs to trans- 
fer the knowledge gained through research 
into direct beneficial services for clients. 

In summary, the Howard Brown Health 
Center has a wealth of data demonstrating 
what many people intuitively know, such as 
the relationship between recreational drug 
use and unsafe sexual behaviors. Many 
clients' behaviors and practices, however, do 
not conform to those indicated by these data. 
Even with much knowledge, it is difficult to 
design programs that will reach a certain 
population, but the Howard Brown Health 
Center continues to try to do so. 

Speaker: Michael Shriver 

The 18th Street Services program in San 
Francisco began in the late 1970s as a refer- 
ral program for gay men and lesbians and 
quickly added cosexual (i.e., for both genders) 
outpatient and residential drug treatment 
services. Out of this program grew the Iris 
Project, a drug treatment facility designed 
specifically for lesbians and bisexual women. 
In 1984, 18th Street Services closed for finan- 
cial reasons, but in 1985 it received State 
funding. The program now operates the 
country's largest exclusive gay and bisexual 
men's outpatient drug treatment service and 
staffs San Francisco's largest street-based 
HIV and substance abuse prevention/educa- 
tion program. 18th Street Services operates 
under the harm reduction model, which 
originated in Europe. This model views 
chemical dependency as a disease marked by 
relapse and acknowledges that access to drug 
treatment is not the defining condition for 
access to services. The harm reduction model 
states that clients deserve to have their needs 
met and that clients know what their needs 
are. Providers must respond as adequately 
as possible to those needs defined by the 
clients. 

The client population of 18th Street Services 
is very multicultural: Caucasians make up 
70 percent, Latinos make up 15 percent, 
African-Americans make up 12 percent, 
Asian/Pacific Islanders make up 2 percent, 
and Native Americans make up 1 percent. 
Between 30 and 40 percent are IV drug 



176 



Summaries of Issues Forums 



users, with methamphetamines the primary 
drug of choice. Most clients do not share 
needles, however. Sixty-seven percent of the 
men reported that they always had sex while 
under the influence of drugs or alcohol, and 
only 24 percent reported never having sex 
while under the influence of drugs or alcohol. 
Furthermore, one-third reported that they 
had participated in unprotected anal inter- 
course within 90 days prior to entering drug 
treatment. The program retention rate is 
roughly 40 percent. 

Over 50 percent of 18th Street Services staff 
are gay and bisexual men of color. When 
three new clinical specialists were hired in 
1991 to focus exclusively on HIV-infected 
men, the program's clientele increased two- 
fold. Staff expected to see between 600 and 
800 (unduplicated) male clients in the clinical 
program in 1993. Most staff are not licensed 
psychotherapists, and several do not have 
bachelor's degrees. Most staff are in recovery 
and are HIV infected; therefore, these staff 
not only empathize with but share the exper- 
iences of the clients. 

One of 18th Street Services' programs, fund- 
ed by NIAAA serves as a model for the 
agency. Clients entering the program fre- 
quently report relapse into chemical depen- 
dency and inability to maintain safe sex 
practices. Either they became drunk or high 
and then had sex, or vice versa. The pro- 
gram therefore treats both conditions 
together. 18th Street Services does not 
discourage sex outside the treatment facility 
but views it as a healthy part of clients' lives. 
However, sex is forbidden between clients. 
The NIAAA-funded program at 18th Street 
Services focuses on delivering strong and 
explicit risk-reduction methods in a closed 
recovery setting, while at the same time 
addressing chemical dependence recovery and 
building self-esteem. The entire protocol for 
the program was developed and reviewed by 
clients. The program had operated on a 
two-tiered model, with constant individual 
counseling along with an early recovery 
group focused on group readiness and a 
closed recovery group focused on intensive 
therapy. With NIAAA support, staff found 
that most clients were asking for more early 
treatment, with the lowest threshold possible 
drug treatment early on. Now, as clients 
continue through the program, treatment 
becomes much more specialized and focused 
on chemical dependency, STDs, HIV infec- 
tion, and tuberculosis, as they relate to cli- 
ents' recovery. 



In all the communities impacted by HIV, 
chemical dependency is the constant. How- 
ever, it remains difficult to encourage HIV 
service providers to address chemical depen- 
dency and vice versa. 18th Street Services 
had no choice but to address both. 18th 
Street Services has begun to close the gap 
between the chemical abuse treatment field 
and the HIV treatment field by offering 
HlV-specific support groups, an outreach 
program focusing largely on HIV infection, 
and other services. The agency deals with 
seven key issues on a daily basis: sex, HIV, 
sexuality, relapse, partnership (i.e., between 
client and clinician), nonjudgmentalism, and 
positiveness about sex. 

Evaluation results of the 18th Street Ser- 
vices' program indicate that its clinical inter- 
ventions halved the rate of unprotected sex 
among clients from 33 percent to 17 percent 
after a 30-day followup, and then to 8 percent 
after a 60-day followup. As the 21st century 
approaches, it seems important to stress 
lowest threshold treatment — to find the kind 
of treatment that entails the lowest level of 
contractual requirements for clients and the 
highest level of comprehensive treatments. 
Additionally, more funding is needed specifi- 
cally in the area of substance abuse, so these 
service providers do not have to overem- 
phasize HIV issues, for which much funding 
does exist. More residential detoxification 
programs should be implemented to deal 
specifically with cocaine and metham- 
phetamine use among the gay and lesbian 
community. Also, gay youth must have 
increased accessibility into chemical depen- 
dency treatment programs. HIV, tuber- 
culosis, and STD prevention activities are 
needed from chemical dependency service 
providers, along with a change in perceptions 
of what constitutes successful treatment (i.e., 
not only graduation from treatment indicates 
success). Lastly, there should be an in- 
creased number of evaluations. 

Information gleaned from NIDA and other 
agencies must be complemented by insights 
from patients. Finally, it is important to 
remember that gay men and lesbians do not 
constitute a special population but are part of 
the normal population. 

Questions, Answers, and Comments 

What is the configuration of the 18th Street 
Services' outreach program? Six staff mem- 
bers are full-time, street-based outreach 
workers, and another staff person is a 20- 



177 



NIDA Conference Highlights 



percent time, street-based outreach worker. 
The program is moving from traditional infor- 
mal activities to a street-based, quantifiable, 
case management program. Outreach work- 
ers now carry a caseload of 10 to 12 men. It 
is important to try to evaluate outreach-based 
programs, for example, on the location of 
outreach activities. The outreach workers 
spend a great deal of time in bars, alleys, and 
parks; distribute thousands of condoms each 
year; and staff needle-exchange sites. Sev- 
enty-five percent of the outreach department 
consists of gay men of color, and all but two 
are in recovery. 

Is anyone bothered by the 30-percent preva- 
lence of addiction among the lesbian and gay 
community, and if so, how? Across the coun- 
try, due to financial problems, there is little 
opportunity to provide programs specifically 
for gays, lesbians, and bisexuals. Even agen- 
cies that try to identify themselves as gay 
and lesbian agencies encounter problems 
because of the enormous prejudices in their 
communities. It should be pointed out that 
most studies focus on gay males but not on 
lesbians. A needs assessment conducted by 
18th Street Services reaffirmed the 
30-percent figure for gay men addicted to 
drugs, while one in four lesbians and one in 
five bisexual women had an unhealthy rela- 
tionship with chemical substances. Bisexual 
women's drug-using patterns were more like 
those of gay and bisexual men than those of 
lesbians (i.e., bisexual women were less likely 
than lesbians to use drugs at home, to use 
drugs with a small circle of friends, and to 
face domestic violence). A large number of 
lesbian women reported using drugs and 
alcohol in order to avoid feeling the pain they 
experienced in their relationships with their 
partners. 

Is there a program model that suits the needs 
of both gay men and lesbian women, or is 
there a need to deal with each population 
separately in terms of treatment? There 
appear to be two separate sets of circumstan- 
ces with men and women. The female issues 
are very different from the male issues. 
However, there are several cosexual, residen- 
tial drug treatment models in San Francisco. 
Although cosexual programs are important, 
so are gender-specific programs, so that the 
continuum of care offers all options to clients. 
It is unrealistic that the models discussed in 
this forum can be replicated easily in other 
cities. It probably is more feasible for exist- 
ing agencies to become more culturally 
competent. 



Are there any other issues besides domestic 
violence that are specific to lesbians in terms 
of their substance abuse? Although research 
has been limited, a multiagency task force in 
Chicago on domestic violence was one of the 
first attempts at dealing with lesbian issues, 
and no connection was shown between sub- 
stance abuse and domestic violence. The 
Whitman- Walker Clinic in Washington, D.C., 
has seen an increasing number of lesbians in 
its alcohol treatment program, but they 
appear uncomfortable in the program. Sepa- 
rate programs may be necessary in many cir- 
cumstances. Although most gay men and 
lesbian women seek treatment in multicul- 
tural programs, such persons may be immed- 
iately turned off by a program if it displays 
insensitivity, such as by ignoring their grief 
over the loss of friends to AIDS. Intake 
forms also should be reviewed for sensitivity 
to gay and lesbian issues. Furthermore, 
demographics should be carefully tracked to 
reflect gay men and lesbians who reveal their 
homosexuality or change genders later. 
Individuals entering the Whitman-Walker 
Clinic must be ready up front to deal with 
their addiction and with their sexuality, but 
this is not always the case. 

CSAT is developing a Central Intake Assess- 
ment Instrument to address many of these 
concerns and facilitate a culturally sensitive 
intake process. 

What are the major obstacles to the develop- 
ment of culturally competent services for gay 
men and lesbian women? Homophobia is a 
major problem, even manifested in staff 
members' lack of knowledge concerning the 
gay and lesbian community. For instance, 
using the term "sexual preference" can be 
offensive to gay men and lesbians. Also, 
"heterosexism" assumes that homosexual love 
is somehow inferior to heterosexual love. In 
general, there is a lack of awareness with 
regard to terminology, which may not neces- 
sarily constitute homophobia but may lead to 
offensive language. So, there is real homo- 
phobia, and there also is ignorance. In addi- 
tion, many people working in treatment 
believe that sexual issues should be put on 
hold while a client addresses his/her addic- 
tion problem in treatment. The two issues 
are so intertwined that they must be ad- 
dressed together. Funding and staffing are 
not adequate, however, to provide such com- 
prehensive services. 

Comment: At 18th Street Services, homopho- 
bia, racism, and sexism are not tolerated at 



178 



Summaries of Issues Forums 



all and are viewed as breaches of the client 
contract. Counselors address these issues 
during treatment. 

Comment: Only about 10 percent of 18th 
Street Services' clients can pay for its ser- 
vices (i.e., through insurance). 

IF02. Addressing Special Population 
Needs: African -Americans 

Moderator: Flavla Walton. Ph.D. 

Speakers: Lawrence Brown, Jr.. M.D.. M.P.H. 

Janet Mitchell. M.D. 

William Sweatt 
July 17. 1 1:15 a.m.-12:46 p.m. 

Speaker: Lawrence Brown. M.D., M.P.H. 

African-American communities are never 
constant in the areas of language or country 
of origin. All too often when research studies 
are performed, African-American people are 
grouped as one common race. This process 
generally describes a group of people who 
have a common ancestry. However, the 
feelings and actions expressed by different 
African-American cultures are never univer- 
sal; therefore, each culture deserves separate 
attention. The vast array of Caucasian/ Afri- 
can-American study comparisons is a prime 
example of the need for increased cultural 
breakdown that would more accurately repre- 
sent the African-American population. The 
Nation's alcohol and drug abuse statistics 
pertaining to the African-American commun- 
ity should be examined with a touch of skep- 
ticism. This is especially true with regard to 
the calculated statistics on illegal drug use. 
The reason for this skepticism is the fact that 
the source of these statistics, as well as the 
methods by which they are calculated, is 
stigmatized and may be illegal. Based on 
this belief, it is widely believed that the 
statistics associated with the rates of 
African-American alcoholism and drug abuse 
may be inaccurate. Within this country, 
there are two main methods of calculating 
drug and alcohol abuse statistics: (1) the 
National Household Survey on Drug Abuse 
and (2) the Drug Abuse Warning Network. 
Unfortunately, in the past, difficulty has 
arisen in terms of incorporating all of the 
information gathered by these two services 
into one universally representative statistic. 

Keeping in mind the possible inaccuracies of 
the statistics, the incidence and prevalence 
rates point toward a lower level of consump- 
tion for the African-American community, as 
compared to the Caucasian community. The 



consequence rates, however, are predomi- 
nantly higher for the African-American 
community than those of the Caucasian 
community. Data collected through the 
National Drug and Alcoholism Treatment 
Utilization Survey (NDATAS) overrepre- 
sented the number of African-Americans that 
actually enroll in treatment programs. This 
overrepresentation is interesting because a 
large number of the Nation's African-Ameri- 
can communities have made it known that 
they do not wish to have treatment facilities 
in their neighborhoods. These communities 
believe that treatment facilities have detri- 
mental effects on the surrounding property's 
value. In addition, the number of African- 
Americans actually entering the treatment 
programs often is miscalculated. 

There are three main social and economic 
factors associated with drug use within the 
African-American community. They are the 
following: (1) high school dropout, (2) teen 
pregnancy, and (3) crime. 

Researchers need to consider these variables 
when developing new community interven- 
tion methods. All too often, emphasis is 
placed only on the medical aspects of clinical 
care. If other social factors are not ad- 
dressed, they eventually can negatively affect 
the various clinical methods of dealing with 
the physiological aspects of alcohol/drug use, 
abuse, and dependency. Treatment programs 
should offer educational tools within the 
community to deter resentment on the part of 
the community's occupants. Lack of knowl- 
edge as to what goes on in the treatment 
facilities often leads to ill feelings and resent- 
ment. Another aspect of community resent- 
ment that is present throughout a large 
portion of the country is the issue of racism. 
This subject must be addressed in order to 
improve the treatment facility's ability to 
interact freely within any community, no 
matter what race or color populates it. 

Speaker: Janet Mitchell. M.D. 
A service-oriented treatment program that 
began in 1985 has provided care to more than 
1,300 pregnant women. The average age of 
women who attended the four-sessions per- 
week program was 29 years. These women, 
although having experienced an average of 
five pregnancies, only had an average of two 
children. The various drugs used by the 
women treated in this program include the 
following: intravenous (IV) heroin, non-IV 
heroin, crack-cocaine, program-provided 



179 



NIDA Conference Highlights 



methadone, street-bought methadone, alcohol, 
marijuana, IV cocaine, and non-IV cocaine. 

A sample consisting of 610 pregnant women 
was analyzed to determine how many drugs 
were being used. With the exception of 
cigarette use, the alarming findings regarding 
their drug use were as follows: 48 percent 
used one drug only, 32 percent used two 
drugs only, 13 percent used three drugs only, 
6 percent used four drugs only, and 1 percent 
used five drugs. 

In connection with these unfortunate statis- 
tics, only 22 percent of these women were in 
a drug treatment program when they regis- 
tered for a prenatal program. Of that 22 
percent, only 19 percent remained in their 
respective programs through the duration of 
their pregnancy. Of the remaining 78 per- 
cent of the women who were not in treat- 
ment, 29 percent were persuaded to enter 
some kind of treatment program. An astoun- 
ding 49 percent of the women who were not 
in treatment refrained from entering any sort 
of treatment program until they delivered 
their babies. Only 47 percent of the women 
had custody of their children upon entry into 
a treatment program. The remaining 53 
percent of the women did not have custody of 
any of their children. Of the women who 
went on to deliver their children while in the 
program, 71 percent were able to take their 
children home with them, while the other 29 
percent had to give their children to the child 
welfare agency. One of the contributing 
factors to the high level of pregnancy among 
the women in the study was the importance 
placed on motherhood through many cultural 
aspects. It also was found that the majority 
of these women (who are on average older 
than the general obstetrical population) were 
first introduced to drugs by their significant 
others. 

The Caucasian concept of "empowerment," 
which goes against the cultural norms of 
African-American communities, has been 
detected within almost every existing treat- 
ment program. This fact has been cited as 
contributing to the need for repeated treat- 
ment visits on the part of African-American 
women. The goal of the aforementioned 
program is to motivate drug-using pregnant 
women to enter treatment. In attempting to 
accomplish this goal, researchers and prac- 
titioners must understand that many addic- 
tions are often intergenerational. Due to this 
fact, long periods of treatment often are 
required in order to break the chain of addic- 



tion. There also is a growing need to in- 
crease the number of African-American 
researchers and practitioners in the thera- 
peutic community. As a result, more ac- 
curate perspectives of what is happening 
within the Nation's African-American com- 
munities will be obtained. 

Speaker: William Sweatt 
HIV transmission within the African-Amer- 
ican community is due in large part to IV 
drug use and the unprotected sexual prac- 
tices of this population. (Experience in the 
Baltimore area points toward the dis- 
couraging fact that children as well as adults 
generally have not taken the "just say no" 
philosophy toward drugs.) The U.S. HIV 
transmission rate from mothers to their 
fetuses is between 13 and 43 percent; in the 
Johns Hopkins community, the HTV transmi- 
ssion rate is at a steady 20 percent. A large 
number of African-Americans in treatment 
are supported solely by social services. This 
fact, as well as the stereotypical belief that 
African-Americans are not the "type of peo- 
ple" to return for scheduled treatments, is 
often the main obstacle to accessing new 
treatment methods. There is a growing need 
for more African-Americans in the HIV re- 
search and teaching fields as well as a num- 
ber of other areas of treatment. Finally, 
more time, money, and effort need to be 
applied to HIV studies on vaccine develop- 
ment because the steps now being taken 
could be described at best as "questionable." 

Questions, Answers, and Comments 

Other than more training of African-Ameri- 
cans in the fields of treatment and research, 
what can he done to improve the relationship 
between the therapeutic community and the 
African-American community? It would be 
beneficial to bring the research more to the 
community level. By getting people more 
involved in research, they slowly will become 
more educated and in tune to the problems 
facing the African-American community. 
Also, the creation of programs free of environ- 
mental and cultural influences on treatment 
outcomes would be very helpful in gaining 
more of an honest representation of what is 
happening within the community and also 
would allow for a more comfortable environ- 
ment for people to enter. 

The Centers for Disease Control and Preven- 
tion funded two ethnographic research 
studies on infant mortality. They are the 
African-American community in Harlem, New 



180 



Summaries of Issues Forums 



IF03. 



York, and the Latino American community in 
Los Angeles, California. The first study 
found that infant mortality rates within the 
African-American community were almost 
twice as high as those of Caucasians. This 
startling finding was attributed mainly to 
preterm delivery. It is important to know not 
only what are the positive, protective aspects 
of treatment but also the negative aspects. 

Comment: Researchers and practitioners 
must begin to acknowledge that most litera- 
ture dealing with drug abuse and alcoholism 
is directed at Caucasian men. New literature 
must be produced that offers more updated 
and accurate perspectives. 

Comment: An overall increase in the amount 
of encouragement offered by leading medical 
advocates in the area of recruiting more 
minorities into the research and treatment 
fields could have a very positive effect on the 
number of new ideas being spawned within 
this area. 

What can be done to keep drug-using mothers 
in some sort of treatment program? Treat- 
ment facilities need to offer more flexible 
treatment schedules, some sort of child care 
system, and a less confrontational treatment 
environment. 

Comment: Another good idea would be to 
design programs around the clients' environ- 
ments instead of always having them adhere 
to the various stipulations put forth by the 
programs. 

Comment: More use should be made of the 
referral systems in order to best match cli- 
ents with the most appropriate treatment. 

Addressing Special Population 
Needs: Asians and Asian/ 
Pacific Islanders 

Moderator: Ford Kuramoto, Ph.D. 
Speakers: Marlssa CastTO 

Toshl Sasao. Ph.D. 
July 15. 3:00 p.m.-4:30 p.m. 

Speaker: Marissa Castro 

Asian-Americans and Asian/Pacific Islanders 
face many external and self-imposed barriers 
to receiving proper treatment for HTV/AIDS. 
Several brief examples illustrate this prob- 
lem: the gay Vietnamese immigrant who 
visits an AIDS health care agency and re- 
fuses the services of a gay Asian translator 
because he fears the translator will recognize 
him and reveal his condition to his family; 



the gay Hawaiian with AIDS who is admitted 
to a hospital and calls his mother, who re- 
fuses to talk to him; the woman with AIDS 
who is ostracized from her community be- 
cause people believe the disease is easily 
contagious and whose husband and children 
are exiled from the community upon her 
death. These examples illustrate the impor- 
tance of family and duty and the prevalence 
of fear, ignorance, and perceived importance 
of not disgracing one's family in the 
Asian-American and Asian/Pacific Islander 
community. These examples also highlight 
the challenge of developing cultural com- 
petency in programs to meet the needs of 
Asian-Americans and Asian/Pacific Islanders 
with AIDS, drug abuse, and other problems. 

According to the 1990 U.S. census, approxi- 
mately 3 percent of the U.S. population — 
about 7 million people — are Asian/Pacific 
Islanders. This population comprises many 
ethnicities but primarily are Chinese and 
Filipino. More than 2 million people in 
California, or 10 percent of the State's popu- 
lation, are Asian/Pacific Islanders, with about 
1 million Asian-Americans and Asian/Pacific 
Islanders in Los Angeles County alone — 10 
percent of the county's population. Of the 
188,000 legal immigrants from China, Thai- 
land, the Philippines, Vietnam, and Japan 
admitted to the United States in 1992, more 
than 13 percent settled in Los Angeles Coun- 
ty. Southern California is home to the most 
diverse of Asian/Pacific Islander communities; 
in order of size of population, these commu- 
nities include Filipinos, Chinese, Japanese, 
Vietnamese, Korean, and Asian Indians. The 
Asian/Pacific Islander community is expected 
to become the second largest ethnic minority 
community in California by the Year 2000. 

Hispanics have a universal language, most 
Caucasians share a similar Western culture, 
and African-Americans share common race; 
however, Asian/Pacific Islanders do not seem 
to share such commonalities. Asia and the 
Pacific Islands have many languages and 
dialects and therefore Asian/Pacific Islanders 
should not be categorized as one homogenous 
group. 

The general public's perceptions of Asian- 
Americans and Asian/Pacific Islanders 
include many myths (i.e., that they are all 
industrious, successful, and in excellent 
health — the model minority). Myths also 
pervade that Asian-Americans and Asian/ 
Pacific Islanders are not victims of AIDS and 
do not engage in injection drug use and 



181 



NIDA Conference Highlights 



unsafe sexual practices, when in fact these 
communities are plagued by drug abuse; 
gangs; substance abuse; and diseases, includ- 
ing AIDS. These myths have hindered Asian/ 
Pacific Islanders' access to services. While 
AIDS diagnoses are relatively low among this 
population, the alarming increase in the 
number of Asian-Americans and Asian/Pacific 
Islanders with AIDS has generated a growing 
sense of urgency. The rate of new AIDS 
cases per year among Asian-Americans and 
Asian/Pacific Islanders is one of the highest 
in the United States during the last 5 years, 
and no major Asian/Pacific Islander com- 
munity has been excluded from this problem. 
Between 1983 and 1987, AIDS statistics were 
kept only for Caucasians, African-Americans, 
and Hispanics, while other populations (in- 
cluding Asian/Pacific Islanders and Native 
Americans) were grouped together. As of 
February 1993, 1,610 Asian-American and 
Asian/Pacific Islander AIDS cases had been 
reported to the Centers for Disease Control 
and Prevention (CDCP), although under- 
reporting is widespread. A subgroup break- 
down is not available nationwide; however, in 
Los Angeles and San Francisco, the Filipino 
population is the group most affected by 
HrV/AIDS, followed by the Japanese and 
Chinese populations. About 75 percent of all 
adult cases of AIDS in these communities are 
attributed to male homosexual or bisexual 
contact. 

AIDS has revealed the inadequacy of health 
services for the poor and for other popula- 
tions. Asian/Pacific Islanders are hampered 
by insensitive attitudes and other obstacles, 
such as language barriers and many service 
providers are not aware of differences in cul- 
tures, languages, and nationalities among 
Asian-American and Asian/Pacific Islander 
populations. Many Asian/Pacific Islander 
clients also are reluctant to advocate for their 
needs. While translations services help, they 
do not address cultural inhibitions and nuan- 
ces critical to effective care. Sometimes the 
translation of words poses problems. For 
instance, the literal translation of "AIDS" 
written in Chinese means love, disease, or 
death and hence, can have mixed meanings. 
"Homosexual" literally translates in some 
languages to "deviant." Thus, pamphlets and 
other forms of communication for Asian/ 
Pacific Islander communities should be 
screened properly for appropriateness. 

Other problems besides communication bar- 
riers often arise. For example, dietary coun- 
seling and food banks that distribute food to 



people with AIDS sometimes provide foods 
such as milk that are unsuitable and indiges- 
tible to Asian/Pacific Islanders. Consequent- 
ly, Asian/Pacific Islander clients often 
underutilize or drop out of these programs. 
Because Asian/Pacific Islanders tend to be 
reluctant to access services on their own, 
direct outreach is critical. Many Asian -Amer- 
icans and Asian/Pacific Islanders do not 
disclose their illness out of fear of deportation 
by immigration officials; as a result, they 
tend to delay treatment until the last 
moment, missing early intervention. More 
flexibility is needed within existing services 
regarding recruitment and intake; for in- 
stance, programs should accommodate third- 
party intake and referrals, the method by 
which many Asian/Pacific Islanders access 
services. Another problem relevant in 
Asian/Pacific Islander communities is denial 
regarding homosexuality, substance abuse, 
and ADDS. Many Asian-Americans and 
Asian/Pacific Islanders also have a general 
sense of pessimism and lack of familiarity 
with U.S. health care agencies and Western 
medicine. Because most Asian/Pacific Island- 
ers believe that health services are only for 
emergencies and hospitals are places to die, 
they often do not receive proper preventative 
care. Gay Asian/Pacific Islander men often 
are pressured into marrying and having 
children; however, these men often still 
participate in homosexual relations, thereby 
creating a segmentation of their life roles. 
With their strong sense of privacy and con- 
fidentiality, many Asian-Americans and 
Asian/Pacific Islanders do not want people in 
the community to know that they are seeking 
services. Unfortunately, many people turn to 
suicide to try to save face and avoid causing 
shame to their families. 

Major barriers must be overcome in treating 
AIDS-infected Asian-Americans and Asian/ 
Pacific Islanders. The lack of funding, sen- 
sitivity, and understanding from public and 
private realms must be addressed. The 
"model minority" myth that is perpetuated by 
mainstream society and Asian/Pacific Island- 
ers must be dispelled. Finally, Asian-Amer- 
ican and Asian/Pacific Islander communities 
must build bridges with other communities. 

In closing, health care providers must con- 
sider alternating treatments for AIDS 
patients. A Filipino man who was diagnosed 
with AIDS in 1987 has been using an alter- 
native treatment that may suggest a possibly 
beneficial supplement to regular AIDS treat- 
ment. He takes the extract from a vegetable 



182 



Summaries of Issues Forums 



named bitter melon, which Asian cultures use 
for medicinal purposes, including as a treat- 
ment for diabetes. After learning that people 
in the Philippines use bitter melon to treat 
leukemia, he started taking the extract, and 
his T4 cell count has increased from 460 to 
1,060. While this substance may not be 
effective for everyone and should not replace 
regular treatment, there is no harm in trying 
it (the extract seems more effective when 
applied rectally rather than orally). 

Speaker: Toshi Sasoa, Ph.D. 

Upon reviewing the small number of research 
articles on Asian-American drug abuse, 
several concerns arise. First, drug abuse 
professionals need to refocus their prevention 
efforts on minimizing drug abuse and related 
problems among Asian/Pacific Islanders. 
Although risk factors among Asian- Americans 
have been identified, such as limited 
language abilities and low levels of accul- 
turalization, they have not been substan- 
tiated with actual empirical evidence. For 
instance, many Asian alcohol and drug abuse 
prevention programs focus on the develop- 
ment of Asian identity and acculturalization, 
but there is no empirical link between these 
factors and drug use — only anecdotal evi- 
dence. Furthermore, these risk factors 
primarily are discussed on the level of indi- 
viduals; although they also should be exam- 
ined in terms of the linkages between individ- 
uals and their families, schools, and local and 
mainstream communities. In other words, 
researchers should investigate more of the 
ecological and environmental factors that 
affect an individual's well-being, such as the 
social ecology and interracial climate in 
which people live, work, and study. 

A second concern is the need to examine and 
redefine what is meant by an Asian -American 
or Asian/Pacific Islander community. A 
community is not just a geographical area; it 
is multiethnic — a source of social relations 
and resources through various modes of 
contact, such as telephone or electronic com- 
munication. For instance, a Korean com- 
munity in Los Angeles is not confined to a 
geographical area, such as one neighborhood, 
and a geographical area is not the home for 
only one community. 

In conducting research, several methodolog- 
ical and conceptual issues should be con- 
sidered, particularly relating to the 
relationship between researchers and local 
communities. These groups need to under- 



stand each other to address the increasing 
diversity of clients, staff, and the contexts in 
which programs work. For example, Asian- 
American communities work alongside other 
ethnic communities. 

In conducting community -based research, the 
relationship between researchers and service 
providers also should be considered. An 
upcoming article in the American Journal of 
Community Psychology will present a re- 
search model, developed by Dr. Sasao, that 
addresses this relationship. This model 
suggests that researchers need to address 
drug abuse, AIDS, and related issues from a 
different perspective, with a different meth- 
odology, and in a different context than those 
used in the past. The model shows that 
service providers typically think that re- 
search does not apply directly to their pro- 
grams. They usually are more interested in 
ethnographically focused research that ob- 
tains indepth information from programs. 
However, both quantitative and qualitative 
methodologies must be integrated together. 
The latter methodology usually is used most 
effectively as a complement to data from 
traditional methodology. 

Community-based research can be concep- 
tualized as a three-dimensional figure repre- 
senting the types of questions researchers 
ask; the types of research methods used; and 
the context in which the methods are used 
(i.e., the "cultural complexity" of that con- 
text). In community-based drug abuse re- 
search, researchers usually ask the following 
three types of questions: (1) descriptive 
questions that address the context of a 
community needs assessment and the epi- 
demiology of abuse in the community; (2) eti- 
ological or explanatory questions, such as 
why Asians use or do not use drugs; and 
(3) prevention or treatment questions in 
terms of evaluation, such as which methods 
worked better with which clients. Depending 
on interests, location, and questions, re- 
searchers must be flexible in terms of meth- 
odology used in studies. 

However, researchers need to investigate 
beyond these questions and consider the 
issues of "cultural complexity" and the con- 
cept of community in their studies. These 
issues should allow for the identification and 
assessment of appropriate contexts in which 
ethnicity or culture is defined. In the past, 
culture or ethnicity was defined externally by 
looking at a person and then making assump- 
tions; but researchers also should consider 



183 



NIDA Conference Highlights 



the psychological definition of ethnicity and 
community. For instance, in a study of the 
Korean community in Los Angeles, Koreans 
in a wealthy area were more inclined to think 
of themselves not as Koreans but as part of a 
particular church or class level. Thus, cul- 
tural complexity may be defined at both an 
individual and sociological level. At the 
individual level, one considers the degree to 
which an individual is defined by a racial, 
ethnic, or cultural category and by his or her 
own interpretation of that category. 

In community-based research, it is important 
to define what it means to be acculturated. 
Many third- and fourth-generation Japanese 
Americans seem acculturated but cognitively, 
they may be very traditionally Japanese. At 
the sociological level in a broader setting, one 
considers the extent to which a relevant 
group is defined by itself or others vis a vis 
other relevant categories; the group is defined 
in terms of other groups around it. Further- 
more, there are three layers of cultural com- 
plexity: (1) the accultural level, at which 
most research has been conducted, looks at 
the imposed, external definition of a culture 
but not at the values in a cultural aspect of 
the community; (2) the premium of the ethnic 
cultural community looks at a culture and 
community as defined by the individuals in 
the community; and (3) the subcultural com- 
munity level, or the street culture, includes 
the homeless and youth gangs and their 
typical meshing of cultures. 

Researchers should conduct more studies 
focusing on the ecological context, such as the 
interracial climate. For example, a study last 
year of 2,000 students from three high 
schools in east Los Angeles — an area 
consisting primarily of Chinese, Vietnamese, 
and Hispanic populations — assessed standard 
demographic and school variables, differences 
according to schools, and other covariates. 
Among the findings, ethnic identification with 
Asian communities generally did not appear 
to be a strong predictor of drug abuse. His- 
panics in predominantly Asian schools tended 
to use drugs less than those in predominantly 
Hispanic schools. Peer pressure strongly 
influenced marijuana use, and students with 
low ethnic identification were more likely to 
use alcohol, thus supporting program inter- 
ventions that stress ethnic identity. How- 
ever, for Vietnamese, ethnic identification 
was not a predictor. 

Many graduate students have expressed 
interest in research on Asian-Americans 



because many of that population attend 
UCLA or the University of California at 
Berkeley. However, the university students 
are very different from Asian-Americans in 
other parts of California because they typi- 
cally are from upper-class families and are 
very bright. These students are not as useful 
as other Asian-Americans in research studies. 

Questions, Answers, and Comments 

Comment: Many Filipinos use traditional 
Filipino healers before seeking Westernized 
treatment. In Los Angeles, one Filipino 
healer trains police officers and treats them 
for injuries incurred in service, such as bro- 
ken bones. He is referred to as a "bone- 
setter." Better linkages are needed between 
traditional healers and other programs and 
medical services. Unfortunately, mainstream 
society in the United States has not yet 
integrated medical care such as what is 
provided by Filipino healers into its range of 
medical services. It simply will take time. 

Is it accurate to exclude students from UCLA, 
and other areas of California in research 
study samples? These students will fill out 
questionnaires appropriately, but the gener- 
alizability of their responses are questionable 
because many Asian-Americans do not have 
the same level of language abilities. 

Comment: It might be helpful to refine the 
definition of accuracy. University students 
probably are more acculturated and Western- 
ized than others in the community, but they 
still use drugs. Questions for them might be 
posed differently than questions for others in 
the Asian American community. It is dif- 
ficult to determine the best way to randomly 
sample Asian/Pacific Islanders for studies, 
and it is helpful to compare results from 
samples obtained in various ways. 

What role does religion play in drug use 
among Asians and Asian / Pacific Islanders? 
About 90 percent of the Korean population in 
Los Angeles belong to a Christian church, 
which serves a strong social control function. 
Many Korean youth who use drugs find it 
difficult at first because they are committed 
to attending church. The spiritual aspects of 
religion's role is difficult to assess because it 
is so individualistic. Asian and Asian/Pacific 
Islander churches generally are less involved 
in social services than African American 
churches tend to be. 

Comment: It is vitally important to collect 
clinical data on the efficacy of herbal 



184 



Summaries of Issues Forums 



medicine, but it is difficult to find fiinding for 
such studies. 

What are effective ways of collecting data 
from the Asian culture, which traditionally is 
very private? It is vitally important to have 
qualified interviewers who understand the 
language of the populations they are inter- 
viewing. Also, the ethnic and mainstream 
media usually cooperate well in communi- 
cating information about the survey prior to 
its implementation so people will not feel 
threatened. Community-based organizations 
also can disseminate survey information to 
the people they serve. Telephone interviews 
may be threatening because many people fear 
the interview relates to immigration prob- 
lems. 

What types of people generally respond to 
these surveys? Generally, those who are more 
acculturated understand the surveys better 
and are more likely to respond. Also, older 
people generally are happy to answer ques- 
tions because they view it as a form of social 
service. 

IF04. Addressing Special Population 
Needs: Hispanics 

Moderator: Eunice Diaz. M.S.. M.P.H. 
Speakers: Margarita Alegrla, Ph.D. 

Salrus Faruque, M.D. 
July 15. 4:45 p.m.-6:15 p.m. 

Speaker: Eunice Diaz, M.S., M.P.H. 

America's Hispanic community, the Nation's 
fastest growing minority population, has been 
hit hard by AIDS and drug abuse. Tech- 
nologies developed by NIDA's research and 
community demonstration projects are 
needed urgently, but several barriers impede 
the transfer of technology and knowledge to 
Hispanic communities. For instance, inade- 
quate resource allocation, lagging information 
transfer, and human and bureaucratic resis- 
tance all present challenges to the meeting of 
Hispanic needs. 

To use technology transfer strategies effec- 
tively with the Hispanic community, three 
factors must be well identified and under- 
stood from a cultural and psychological per- 
spective: (1) the special circumstances of 
HIV/AIDS and substance abuse in Hispanic 
communities; (2) the resulting special needs 
for research and community demonstration 
projects on AIDS and drug abuse within the 
context of NIDA's overall programs; and 
(3) the individual, group, and cultural values 



and behaviors within the Hispanic commu- 
nity that affect technology transfer. Further- 
more, community members must become 
more involved in setting appropriate research 
agendas. For this to happen, researchers, 
practitioners, and representatives of funding 
agencies such as NEDA must communicate 
better. Since 1989, when NIDA Director 
Charles Schuster met with representatives of 
the Hispanic community to address Hispanic 
needs relative to drug abuse, Hispanic indivi- 
duals have had ongoing communication with 
NEDA to present their special population 
needs. 

Speaker: Margarita Alegria, Ph.D. 

In 1986 the Anti-Drug Abuse Act augmented 
efforts to examine drug abuse in minority 
groups, including Hispanics. Since then, 
several major studies have provided infor- 
mation on the prevalence, risk factors, and 
developmental course of substance abuse. 
However, studies with Hispanics have in- 
volved small populations and people in 
restricted regions, and the studies have been 
skewed by differences in socioeconomic fac- 
tors and methodological pitfalls. For in- 
stance, when estimating the prevalence of 
drug abuse among Hispanics, many studies 
exclude from their samples high-risk groups, 
such as the homeless and the transient. 
Substance abuse is frequently underreported 
and uncertainty often exists over who a 
Hispanic categorization really represents. 
Problems also occur when self-administered 
instruments are used among groups with low 
literacy. Epidemiological studies among 
Hispanics show great variation regarding the 
prevalence of drug use; therefore, it is impor- 
tant to focus more attention on cultural 
patterns that may be relevant to service 
planning. Researchers commonly accept that 
individuals' responses to psychiatric, behav- 
ioral, and substance abuse problems are 
strongly influenced by culture and ethnicity. 
For instance, in a study in Puerto Rico, only 
1 out of 75 illicit drug users received special- 
ized mental health care services. Many 
studies similarly indicate that Hispanics 
appear to underutilize drug abuse treatment 
services; other studies, however, indicate the 
opposite. Differences also are evident among 
ethnic groups in their denial of a substance 
abuse problem and their perceived need for 
and benefit from treatment. For instance, 
after adjustinc for nonethnic predictors, 
Hispanic drug-using arrestees were less likely 
than Caucasians to have received treatment 



185 



NIDA Conference Highlights 



for drug dependence and to acknowledge that 
they needed treatment. 

Given this difficulty in engaging Hispanic 
substance abusers in treatment, increasing 
emphasis is needed on behavioral and com- 
munity intervention strategies. Most efforts 
have an individually focused, rational action 
framework — with the assumption that indi- 
viduals make rational choices to use drugs 
and that they can change their behavior 
simply with individually oriented interven- 
tions. However, such an approach minimizes 
the complexities of social life when, in fact, a 
contextualized view of individuals' actions is 
vital. Besides just the conduct of similar 
research in different cultural settings, 
researchers should conduct indepth analyses 
of interpersonal, intrapersonal, community, 
and institutional factors in drug abuse. 
Behavioral changes that individuals make 
often are not sustained because the environ- 
mental context that led to the drug abuse has 
not been changed. 

The results of a study in Puerto Rico show 
the extent to which societal context plays a 
role in substance abuse. The study, with a 
sample of impoverished Hispanic women and 
girls, provided information on familial, indi- 
vidual, school, and community factors that 
promote adaptation in the face of adversity. 
This kind of information would not be avail- 
able from more traditional methodologies and 
samples. The study revealed that the preva- 
lence rates of drug abuse among adolescents 
were considerably lower in Puerto Rico than 
in the mainland. While the reported fre- 
quency of alcohol and tobacco use in children 
ages 11 to 14 was lower in Puerto Rico, the 
rate among children ages 15 to 17 was sim- 
ilar to that on the mainland. Children in 
Puerto Rico did not appear to follow the same 
progression of drug use as children in the 
rest of the United States, who experienced 
alcohol and tobacco use during their preteen 
years and early adolescence followed by use 
of illicit drugs during their late adolescence. 
Hypotheses state that the strong familial 
influences and socially extended kinship 
system in Puerto Rico shield children from 
influences toward drug use. 

Such a shielding effect is not seen, however, 
among prostitutes in Puerto Rico. In one 
study, since February 1990 researchers fol- 
lowed adult women prostitutes from both 
street locations and brothels, and beginning 
in 1992 adolescent prostitutes were moni- 
tored. One pattern observed across all three 



cohorts was low education level. More than 
two-thirds of the prostitutes had dropped out 
of school prior to high school graduation, and 
more than one-half of the adolescent pros- 
titutes were two or more grades below their 
appropriate school levels. Four out of five of 
the adolescent prostitutes and two-thirds of 
the adult prostitutes were raised in a single- 
parent (usually female-headed) household. 
About 80 percent of the street adults reported 
the occurrence during their childhood of 
frequent family fights and alcohol and/or 
drug use by their parents. More than one- 
third of the adolescents reported suicidal 
thoughts or suicide attempts before age 14, 
and many of them had run away from home. 
About two-thirds of the adult prostitutes and 
three-fourths of the adolescent prostitutes 
had a friend who was a prostitute before they 
themselves became prostitutes. Also, 27 
percent of the adult prostitutes had a close 
relative involved in prostitution. Thus, 
susceptibility and exposure appear to trigger 
entrance into prostitution. 

Less than one-fourth of the adolescent pros- 
titutes and less than one-fifth of brothel 
workers had used drugs before becoming 
prostitutes. Once they became involved in 
prostitution, however, one-half of the adoles- 
cent prostitutes began experimenting with 
marijuana and cocaine, possibly due to the 
lack of support from traditional institutions 
and their increased exposure to drugs from 
other prostitutes. Thus, factors that should 
be included in the hypothesis model concern- 
ing the significance of susceptibility and 
exposure to prostitution and substance abuse 
are high community unemployment, acces- 
sibility to street soliciting, and the oppor- 
tunity for other illegal hustles such as theft. 
In looking at environmental factors, differ- 
ences in prostitution and drug abuse patterns 
among geographical areas are evident; pros- 
titution is more likely, for example, near 
naval bases in Puerto Rico than in rural 
areas. Such environmental factors are very 
important considerations in prevention and 
intervention efforts. 

It is hypothesized that an increased number 
of adolescent prostitutes will experience their 
first initiation into drug use and that they 
will develop a history of incarceration, high 
depressive symptoms, poor financial situa- 
tion, and one or more abortions. It thus is 
critical to prevent or counter the behaviors, 
social networks, and contexts that lead to 
substance abuse, for instance by targeting 
prevention efforts at school dropouts before 



186 



Summaries of Issues Forums 



they become entrenched in street life and 
criminal behavior. Schools need to provide 
the resources to deal with students who need 
help to stay in school. 

Also, service delivery systems that currently 
are based on policymakers' needs, not clients' 
needs, must be adjusted to include closer 
collaboration between the two groups in 
determining appropriate services. Adult 
prostitutes described their most urgent needs 
as money, housing, drug rehabilitation, work, 
and getting their children back from social 
service agencies, whereas adolescent prosti- 
tutes listed money, housing, work, clothing, 
and help in taking care of their children. 
Therefore, programs that primarily focus on 
changing women's behaviors do not actually 
target their greatest needs. Social programs 
tend to respond only to health service needs, 
rather than employment or housing, for 
example. However, the latter kinds of needs 
must be met if women are to have alterna- 
tives to prostitution. Women fail to change 
their behavior usually because economic and 
other needs seem more important. Alter- 
natives to prostitution are needed before 
prostitutes will be receptive to drug treat- 
ment and prevention efforts. Also, providers 
and clients must have the same treatment 
goals; sometimes clients may want to de- 
crease — not stop — their drug use. For many 
women, drugs present the only way for them 
to get away from the crises of everyday life, 
but the habit becomes both expensive and 
unmanageable. 

To address special population needs, research 
and intervention frameworks on substance 
abuse must change to include a more social 
context. Contextual factors may be more 
relevant than personal factors in preventing 
behaviors such as prostitution and drug use. 
Prevention efforts may need to be initiated 
earlier and focus not just on prevention and 
changing behaviors but also on the social 
networks and contexts tied to substance use. 
Service providers and clients both should 
participate in the design and implementation 
of services, which should focus on women's 
multiple needs. Only if frameworks are 
reformulated can Hispanics sensitively be 
integrated into AIDS and chemical depen- 
dence prevention, education, and treatment 
programs. 

Speaker: Sairus Faruque, M.D. 

The Centers for Disease Control and Preven- 
tion (CDCP) recently released data concern- 



ing substance abuse among various ethnic 
groups. Among young adult men between the 
ages of 25 and 44, the proportion of deaths 
due to HIV in 1990 was highest among His- 
panics. Twenty-two percent of deaths among 
Hispanics resulted from HIV, followed by 19 
percent among African-Americans and 15 
percent among Caucasians. Broken down 
into subgroups, 38.4 percent of deaths among 
Puerto Rican men in that age group and 40.3 
percent among Cubans resulted from HIV. 
Eleven percent of deaths among Hispanic 
women between the ages of 25 and 44 result- 
ed from HIV, a rate comparable to that of 
African-Americans. Therefore, HrV-related 
problems were the primary causes of death 
among young adult male Puerto Ricans and 
Cubans and female Puerto Ricans. These 
data reveal how much must be done to coun- 
ter the spread of HIV among Hispanics and 
point out the need to continually pressure 
researchers and practitioners for detailed 
data to understand the needs of various 
cultural groups. 

The Association for Drug Abuse Prevention 
and Treatment (ADAPT) conducted two 
outreach research projects in the streets of 
New York City, one project in east and cen- 
tral Harlem and the other project in the 
south Bronx, both of which have large Puerto 
Rican populations. ADAPTs crack and AIDS 
study in east and central Harlem included 
1,000 participants between the ages of 18 and 
29 and compared people who smoked 
crack-cocaine with (1) people who smoked 
crack-cocaine and injected drugs, (2) people 
who injected drugs but did not use crack- 
cocaine, and (3) people who did not use illegal 
drugs. Among the sample, 237 were female 
regular crack-cocaine users, of whom 77 were 
Puerto Rican and 160 were African-American. 
The Puerto Rican women were more likely to 
have been in jail during the past year, to 
have injected drugs, and to have engaged in 
sex without the use of a contraceptive or a 
condom. The African-American women were 
more likely to be single, homeless, sexually 
active, to have traded sex for money or drugs, 
and to have had syphilis. Furthermore, 
intravenous (IV) drug use was more preva- 
lent among the Puerto Rican women in the 
Harlem neighborhoods than among the Afri- 
can-Americans. Thus, it appears that even 
within certain geographical areas, different 
subgroups should be treated differently 
according to their needs and behaviors. 
Similar data were found among men: Puerto 
Rican male crack -cocaine users between ages 



187 



NIDA Conference Highlights 



18 and 29 were more likely to inject drugs 
than African-Americans. A related finding is 
that prostitutes were more likely to begin 
using drugs after, rather than before, be- 
coming prostitutes. 

In the South Bronx, ADAPT conducted an 
evaluation of a street outreach project on- 
going for the last few years. Researchers 
collected quantitative and qualitative infor- 
mation through approximately 60 interviews 
with IV drug users in the streets of the area, 
which is predominantly Puerto Rican. Of the 
60 participants in the sample, 31 were male 
and 29 were female, and most were Hispanic 
and under age 45. The project examined the 
awareness of outreach in the area. Only 14 
people in the sample reported that they had 
not seen an outreach worker in the area. 
Most respondents were appreciative of the 
outreach workers' efforts and perceived them 
as helpful and nonjudgmental. In addition, 
many participants in the study were engaged 
in a high level of needle risk behaviors. Only 
26 percent reported using a new needle with 
each drug injection; however, nearly 
two-thirds of the same population reported 
sharing needles. Discrepancies, such as 
these, in answers to the questionnaires re- 
sulted mainly from prostitutes, all of whom 
reported sharing needles. Out of the 60 
participants, 43 reported sharing or mixing 
prepared doses of drugs, and among the 
Hispanics, 34 reported doing so. 

When conducting interviews on the streets, 
researchers usually inquire about the pre- 
dominance of certain risk behaviors but not 
the reasons for engaging in these behaviors. 
In the study conducted in the Bronx, how- 
ever, researchers asked participants about 
the factors that helped people to stop sharing 
drugs and needles. Forty -eight out of the 60 
participants said that free needles and easier 
access to needles lessened their use of con- 
taminated ones. Consequently, it is possible 
that the availability of more condoms would 
reduce the rate of risky sexual behaviors, 
particularly among prostitutes. NIDA, 
CDCP, and CSAT have issued new guidelines 
for the use of bleach, indicating that the 
method that has been taught to clients for 
cleaning their needles is not as effective as 
once thought. Even then, bleach cleaning 
does not ensure protection against HrV; 
therefore, the availability of sterile needles is 
necessary. This is a complicated and contro- 
versial issue. ADAPT has started a needle 
exchange program in the east Harlem area 
and in parts of Brooklyn. This approach, 



combined with prevention messages, has 
seemed to be effective in building a trusting 
relationship with the clients and assisting 
them as best as possible. 

Questions, Answers, and Comments 

There are many different Hispanic cultures 
that cannot always be addressed in the same 
manner. Many treatment programs want to 
impose their own needs on clients rather than 
listen to the clients themselves. How can the 
Hispanic population as a whole be helped 
with the limited resources, such as housing 
and education, provided to its members? The 
Hispanic community is too complacent and 
should pressure for legislation to meet their 
needs. Hispanics should be more organized 
in their advocacy efforts. Programs should 
devote funds and resources to the continua- 
tion of their efforts once their funding ends, 
for instance by fostering grass roots organiza- 
tions. 

With the radical differences among Hispanic 
groups, what role do researchers have in 
educating Hispanic populations and the 
broader public about these differences and 
their significance in treatment? First, in 
research, samples should be very represen- 
tative and not simply lump all Hispanics 
together into one category. Distinctions must 
be made in terms of what interventions and 
outcomes apply to some groups but not to 
others. At the same time, breaking Hispanics 
down into subgroups poses the danger of 
impeding a strong Hispanic advocacy effort 
and lessening Hispanics' political power. 
Hispanics should be careful where they 
distinguish differences and where they see 
similarities among themselves. 

Comment: Through working on the National 
Commission on AIDS, it was evident that 
there was no unified action agenda among 
various Hispanic groups. And, as with sub- 
stance abuse, there are different manifes- 
tations of HrV depending on the various 
Hispanic subgroups. This year, however, 
dozens of Hispanic groups united to present 
a common agenda to Congress with 24 spe- 
cific recommendations. It was hard for 
Congress to ignore this advocacy effort. 
Therefore, there definitely is a need for such 
unified action, as well as for the distinction 
of culturally specific recommendations for 
subpopulations. 

Comment: Similar findings and implications 
occur among African-American youth. How- 
ever, Hispanics could use African-Americans 



188 



Summaries of Issues Forums 



as a model in being united in advocacy 
efforts. Although Hispanics have differences, 
their empowerment lies in education and in 
numbers, which will grow as Hispanics recog- 
nize their commonalities rather than their 
differences. 

Comment: The needs of the Latino popula- 
tion as a whole must be better addressed. 
Division based on many subgroups impedes 
Hispanics' efforts to acquire the services that 
they need. For instance, treatment for His- 
panics in a bilingual setting is important, but 
few programs offer treatment totally in Span- 
ish. Also, many Hispanics in jail do not 
receive treatment for medical reasons other 
than drug and alcohol abuse because the 
Government does not provide the bilingual 
people necessary to assess such problems. 
Hispanics must come together for such needs 
to be met. 

Comment: Many needs, such as child care, 
cross ethnic boundaries, while others are very 
specific in terms of treatment. Researchers 
should conduct studies with large enough 
samples of each Hispanic community to 
assess significant differences. Even data 
from Puerto Ricans in different parts of the 
country are not completely the same, indi- 
cating the significance of environmental or 
geographical factors. 

Comment: One study conducted early in 
1993 compared data produced by NIDA over 
several years to examine the significance of 
economic level. More commonalities are 
found on this level, in that poverty crosses 
ethnic boundaries. 

Comment: The moderator or speakers for 
this session can send information, including 
needs and strategies for NIDA and other 
Federal agencies, about the ongoing dialogue 
between Hispanic researchers and prac- 
titioners. NIDA needs to fill several gaps in 
fulfilling the needs of Hispanics. First, to fill 
the gap in the epidemiological gathering of 
data, information should be gathered collec- 
tively for the Hispanic population as well as 
separately for its subgroups. Gaps also exist 
in communication and information, and in 
NIDA's responsiveness to Hispanics' needs. 
A community education network exists within 
NIDA, but very few Latinos or Hispanics 
serve on this network; those that do are 
almost all Mexican-American. A strong 
advocacy effort, therefore, is vital to meet 
Hispanics' needs. 



IF05. Addressing Special Population 
Needs: Native Americans 

Moderator: Gary Peterson 
Speaker: Delmar Boni. M.Ed 

July 16. 8:30 a.m.-10:00 a.m. 

In this forum, participants discussed the 
delivery of drug abuse services in Native 
American communities. Topics discussed 
included culturally relevant research method- 
ologies and their application in Native 
American communities; culturally competent 
service delivery; and humor, wellness, and 
spirituality in the delivery of services in 
Native American communities. A demonstra- 
tion of Native American ritual was conducted. 

IF06. Substance Abuse and Disability 
Issues 

Moderator: Charles Sharp. Ph.D. 
Speakers: Stephen Gllson. Ph.D. 

Susan Hallman, M.Ed. 

Arthur MacNell Horton. Jr.. Ed.D. 
Respondent: Mel Tremper. Ph.D. 
July 16. 10:15 a.m.-ll:45 a.m. 

Speaker: Stephen Gilson, Ph.D. 

Recently there has been an awakening of 
interest within NIDA regarding the field of 
substance abuse in persons with disabilities. 
Currently there are no available studies on 
treatment or prevention dealing with this 
population, although persons with disabilities 
currently make up 10 to 12 percent of the 
U.S. population. Until now, substance abuse 
was not recognized as a risk to persons in 
this population, and the only statistical data 
available about this population's use or abuse 
of illicit substances emanate from surveys at 
trauma and rehabilitation centers for the 
disabled. Though recent advances with 
disabilities promote pride in this community, 
the powerful stigma attached to persons with 
disabilities is still very prevalent. 

To discover the risk of substance use and 
abuse in persons with disabilities, the 1991 
National Household Survey on Drug Abuse 
(NHSDA) was used as a template for data 
collection. The NHSDA included questions 
about the use of both illicit and licit drugs 
and evaluated their use in the following three 
categories detailing the recency of use: 
(1) ever used, (2) used within the past year, 
and (3) used within the past month. It 
included college students and military per- 
sonnel living in residences outside their 
homes, as well as those members of the 



189 



NIDA Conference Highlights 



population residing at home. The survey 
excluded hospitals, nursing homes, and treat- 
ment centers, as well as individuals who were 
unable to complete the form. The only repre- 
sentative category for people with disabilities 
on the survey was the "disabled, unable to 
work category," which actually represents 
only a small portion of those with disabilities. 

The resulting data were weighed according to 
the 1991 NHSDA. The data show that, of the 
persons with disabilities evaluated, 81.7 
percent use alcohol, 19.9 percent use 
crack-cocaine, 5.0 percent use heroin, 15.3 
percent use sedatives, and 15.5 percent use 
tranquilizers. On an odds ratio scale measur- 
ing the differences of use between persons 
with disabilities and those without (with 1.0 
showing equal use, greater than 1.0 showing 
a greater amount of use, and less than 1.0 
showing less amount of use), persons with 
disabilities scored a 90.2 for alcohol, 7.4 for 
tranquilizers, 4.2 for sedatives, 3.75 for 
crack-cocaine, and 0.74 for heroin. This 
study does not indicate whether substance 
abuse came before or after a disability. 

It is now necessary to expand the knowledge 
of substance use and abuse in persons with 
disabilities. 

Speaker: Susan Hailman, M.Ed. 

In the latter part of the 1980s, CSAP first 
became aware of the need for substance 
abuse services for persons with disabilities. 
Steps to provide these services began in 1990 
with the development of new training initia- 
tives to encompass the various needs and 
issues that would be tied to this previously 
unserved population. A review group made 
up of persons aware of the inherent needs of 
substance use in persons with disabilities was 
created to evaluate the sensitivity of CSAPs 
new training initiatives curricula. Prom this 
group meeting, a better understanding of the 
issues that pertain to this population 
emerged. The depth of need was greater 
than CSAFs training staff had thought. 
Also, it became apparent that there were no 
available resources to deal with persons with 
disabilities in the substance abuse 
community. 

In 1991 CSAP funded the first conference for 
the Institute on Disability and Alcohol and 
Drug Awareness. This conference included 
management staff from CSAP, many of whom 
became absorbed in the issue of substance 
abuse and disabilities. Then in June 1992 
CSAP convened Federal agencies for an 



issues forum that garnered abundant support 
from the disabled community. Through 
CSAFs involvement and linkages with per- 
sons from this community, in planning these 
events and in simply bringing persons with 
disabilities to the conferences, much was 
learned by CSAP about what is necessary for 
the integration of the disabled commu- 
nity into the substance abuse treatment 
community. 

To continue to develop approaches in pro- 
viding treatment services to disabled persons 
with substance abuse problems, there are 
several steps that must be taken. The first is 
to keep up an ongoing dialogue with the 
community to remain aware of the services 
that are most needed. Second, an internal 
plan must be developed as an agency to 
increase awareness, promote the sharing of 
individual knowledge, and promote the rele- 
vant issues to the substance use community. 
Third, external initiatives must be developed 
to change CSAP's approach to other agencies 
and to Congress regarding encompassing the 
needs of the disabled community. Fourth, 
people with disabilities must be hired in the 
substance use community. And lastly, com- 
mitments from the research community and 
the Administration are needed. 

Speaker: Arthur MacNeil Horton, Jr., Ed.D. 

Persons with disabilities face major barriers 
regarding substance abuse. The first barrier 
is access to care. Many persons with disabili- 
ties face an exclusionary situation at treat- 
ment centers due to the lack of beds available 
for persons with disabilities. The stigma 
attached to persons with disabilities also is a 
barrier that must be overcome, because many 
professionals who work with substance abuse 
simply do not want or know how to work 
with persons with disabilities. Another major 
barrier is resources. Many members of this 
population have to deal with an environmen- 
tal situation that does not compensate for 
their disabilities, and often treatment centers 
do not wish to allocate resources to providing 
the services needed. 

Problems with substance abuse are prevalent 
among spinal cord- and head-injured persons. 
Fifty percent of those with head injuries 
experience substance abuse problems prior to 
injury, and as many as one-third of the 
head-injured population leave treatment for 
their injuries due to substance abuse. Cover- 
tly disabled persons (i.e., those whose disabil- 
ities are not clearly evident) also face many 



190 



Summaries of Issues Forums 



problems with substance abuse treatment due 
to the small amount of information available 
for this population. 

Steps that might be considered to bring about 
a more positive situation for persons with 
disabilities and substance abuse are the 
mandatory inclusion of services for persons 
with disabilities in treatment centers and 
self-help groups that target this population. 

Questions, Answers, and Comments 

Is there any money currently allocated for 
disabled persons with substance abuse? 
NIDA has written a grant for that purpose, 
which will become a general announcement 
in the near future. NIDA currently is devel- 
oping either a Request for Applicants or a 
Request for Proposals. 

TREATMENT 

IF07. Current Perspectives on Models 
of Case Management 

Moderator: Arthur MacNelll Horton. Jr., Ed.D. 
Speaker: Rebecca Ashery. D.S.W. 

Peter Bokos. Ph.D. 

Harvey Segal. Ph.D. 
July 15, 10:30 a.m.-12:00 p.m. 

Speaker: Rebecca Ashery, D.S.W. 

The Joint Commission on Accreditation of 
Hospitals defines case management as includ- 
ing such components as assessment, plan- 
ning, linkage, monitoring, and advocacy (e.g., 
resource development). The National Assoc- 
iation of Social Workers (NASW) also defines 
case management to include assessment, 
arranging, monitoring, evaluation, and advo- 
cacy. NASW places emphasis on two dif- 
ferent levels when looking at case manage- 
ment: (1) the individual level, which can be 
described as the biopsychosocial level, and 
(2) the community level, which pertains to 
the various systems involved in case manage- 
ment. It must be understood that case man- 
agement is a process as opposed to a goal. 
The question of what makes case manage- 
ment a success needs to be addressed. 
Should a client who has been connected to an 
agency be considered successful even if he/she 
only attends one session and probably has not 
received the services needed for recovery? 

In the late 1960s and early 1970s, two occur- 
rences affected case management. First, the 
Anti-Poverty Program worked toward catego- 
rizing the services offered through case man- 



agement. Second, many mental patients who 
were in need of case management and other 
services were released from hospitals. The 
use of case management within hospital 
settings has been successful in lowering the 
length of stay for many patients. This is due 
in large part to the fact that case manage- 
ment works toward linking some patients 
with either nursing homes or home health 
care. Another program worth mentioning as 
representative of the care management model 
is the Treatment Alternatives to Street Crime 
program, which is used to detect and refer 
drug abusers to treatment in the criminal 
justice system. 

Two main events in particular made the use 
of case management important within the 
United States. The first was the spread of 
HIV and AIDS, which made it necessary for 
programs to be developed that offered the 
services of both treatment and health care 
facilities. The second event was the wide- 
spread use of crack-cocaine, which has 
greatly affected the Nation's child protective 
services. This is due in large part to the fact 
that crack-cocaine use by women has caused 
such problems as newborn crack-cocaine- 
addicted babies and the increase of children 
in foster care. These factors point toward a 
greater need to connect the services offered 
within both the child protective and the drug 
abuse treatment programs. 

A number of studies were conducted that 
focused on the chronically mentally ill. The 
case management results with regard to 
these studies have varied. The main areas 
looked at within these studies were relapse, 
the length of hospital stays, and the quality 
of life (e.g., home living arrangements, num- 
ber of friends, income level, and service 
utilization such as medical programs). The 
primary area in which differences were seen 
throughout the many studies was the length 
of stay in the hospitals. Cost containment is 
another big issue associated with case mana- 
gement. One study claimed to have saved 
about $5,500 per patient in terms of relapse 
into treatment, but this study neglected to 
mention the cost involved in keeping patients 
functioning within the community. No other 
major differences in cost have been cited 
within any of the studies. 

A study conducted by Bonne focused on three 
community health centers and found that one 
had no significant control and experimental 
group differences. It was discovered that the 
control group in the second health center had 



191 



NIDA Conference Highlights 



fewer hospital stays, whereas the third 
health center saw a lower rate of relapse 
among the experimental group. Another 
study, conducted by Boorelyn, devoted 5 
years to looking at case management and 
exhibited a one-to-one client-to-caseworker 
ratio. Within this study the number of days 
the clients spent in the hospital was seen to 
decrease by 75 percent. There was, however, 
a 193-percent increase in the overall amount 
of structural residential care days in the 
community. These findings revealed the only 
notable differences between the control and 
experimental groups involved in the study. 
The total hospital cost savings were seen to 
increase as a result of the cost with regard to 
community care. These various findings 
suggest that there are a number of factors 
that need to be considered if cost containment 
is to be adequately addressed. 

It should be mentioned that NIDA performed 
a technical review on research in progress for 
case management. Some of the many issues 
addressed during this technical review were 
cost containment, the experience and educa- 
tional backgrounds of case management 
workers, client-to-caseworker ratios, and 
community advocacy (e.g., resource develop- 
ment and the purchasing of services). The 
findings from this technical review can be 
obtained through NIDA's clearinghouse. 

Speaker: Peter Bokos. Ph.D. 

Two areas that deserve some attention are 
(1) improvements in programming and (2) the 
efficiency of drug treatment in terms of 
filtering clients through large treatment 
systems at a faster pace. This is the third 
year of a 5-year study that is performing 
research to help determine how effective case 
management might be in improving the two 
aforementioned problem areas. 

Treatment access is one factor that really 
prefaces the problem of getting clients 
through treatment at a decent speed. Client 
retention in treatment was seen as another 
problem area that needed some improvement. 
Factors associated with goal completion, 
which refers to a client's individual coun- 
seling goals, was another area that received 
a great deal of research. One of the factors 
studied was the effects that case managers 
have on clients with respect to the develop- 
ment of their individual goal completions. 
High-risk HIV/AIDS behavior was another 
area that was highly researched. It was 
determined that the main issues that needed 



to be addressed in order to substantially 
lower the rate at which HIV/AIDS was being 
spread was the decreasing of needle-sharing, 
high-risk sexual behavior, and the amount of 
illicit drug use. 

The question of whether or not this study is 
cost-effective still remains unanswered; 
however, a 15-to-l client-to-case-manager 
ratio has been recorded. It has been 
estimated that about $2,400 to $2,500 on 
average is being added to the cost of treat- 
ment for each patient annually. The main 
functions found within most case manage- 
ment models are the following: (1) assess- 
ment, (2) planning, (3) linking, (4) monitoring 
followup, and (5) advocacy. These core func- 
tions, with the exception of advocacy, were at 
the center of development for the case mana- 
gement/problemsolving model that was used 
in the program. Advocacy was not specific- 
ally considered when the model was being 
developed because it is something that all 
case managers must keep in mind anyway 
when they are dealing directly with their 
clients. 

The procedure involved in assessing the 
progress of clients is a meeting between 
clients and case managers that is meant to 
define what the clients' current situations are 
and what direction they need to go in terms 
of malting future progress. Following this 
meeting, the case managers then review the 
various options (e.g., different services) they 
have for treating the clients. Once the dif- 
ferent options are weighed, a plan of action 
finally is decided upon. This describes the 
cyclic model of assessment and treatment. 

Treatment access is a major problem that 
was encountered not only in this program but 
also in many similar programs. Unfor- 
tunately, the number of people in need of 
treatment far outweighs the number of treat- 
ment slots available throughout the country. 
Lack of documentation is another problem 
that has surfaced within many programs. 
Various forms of identification and records of 
previous treatment services received are 
generally two prerequisites to entering a 
treatment program. It is not uncommon for 
clients to be missing either some or all of 
these documents. Some other factors that 
occasionally pose problems for people who are 
attempting to enter a particular treatment 
program are comorbidity, HIV/AIDS, mental 
health problems, conflict with treatment 
expectations, and lack of transportation. A 
person possessing a negative reputation in 



192 



Summaries of Issues Forums 



terms of his/her relationship with past 
treatment workers and facilities also may 
hinder his/her chances of being admitted into 
future programs. 

A three-way contract was developed in this 
program among the case managers, the 
treatment program, and the clients. This 
contract was aimed at helping to minimize 
the aforementioned problem factors that often 
act as barriers to the positive progress that 
clients wish to experience within their indi- 
vidual treatment programs. Studies have 
shown that there are higher rates of treat- 
ment retention among clients who are 
involved with case managers. 

Speaker: Harvey Siegal, Ph.D. 

The Substance Abuse Intervention Project at 
Wright State University of Medicine worked 
in conjunction with a NEDA initiative focused 
on enhancing drug treatment. The two main 
goals of the NEDA initiative were (1) to 
increase the number of available drug treat- 
ment openings and (2) to develop a tool or 
service that could improve the overall quality 
of care. The factor that needed to be 
addressed in order to make progress toward 
these goals was the need to locate and define 
the most significant service gaps facing the 
project. Treatment of crack-cocaine users 
was found to be the most significant gap 
facing the project. The group primarily 
looked at within this project was drug- and 
alcohol-abusing male Vietnam veterans. 

There are two problems that often affect drug 
treatment programs. The first is program 
retention, which has been seen to be a fairly 
widespread problem throughout the Nation's 
drug treatment programs. This problem is 
especially apparent during the early stages of 
many programs. Many people end up drop- 
ping out of their respective programs after 
only a very short period of participation. 
This occurrence is commonly referred to as 
premature withdrawal from treatment. The 
second problem has to do with long-term drug 
treatment compliance on the part of the 
people involved in the programs. One 
method that seemed to help dissuade people 
from prematurely withdrawing from treat- 
ment was enrolling them into some type of 
treatment induction program with the intent 
of making them full-fledged drug treatment 
clients. Wright State's project, in attempting 
to increase retention rates, made use of an 
intervention program that had experienced a 



good deal of success in treating and retaining 
drunk and impaired drivers. 

In terms of the clinical side of the treatment 
equation, care providers must decide to either 
complement the treatment that clients 
already may have received or focus their 
efforts on new and additional modes of treat- 
ment. The issue of how to accomplish these 
treatment goals is an area that often poses 
many problems for care providers within the 
therapeutic communities. Complications 
often arise with regard to either getting 
treatment services to the clients or the clients 
to the services. There is also a question as to 
whether or not clients need to be taught 
skills that will help them to function more 
effectively within not only their respective 
treatment programs but also within the 
community. 

The Substance Abuse Intervention Project 
installed a model that incorporated a wide 
array of treatment and skill-building services 
for its clients. This model, a "strengths 
perspectives model," asks clients the follow- 
ing important question: "What is healthy 
about you and how can you use your 
strengths and assets to secure the resources 
you need?" The strengths perspectives model 
used within the Substance Abuse Interven- 
tion Project at the Wright State University of 
Medicine was designed around a model devel- 
oped by Rapp and Chamberlain. The model's 
two main principles are providing "disenfran- 
chised people" with support in (1) examining 
their own strengths and assets in order to 
gradually build and obtain various usable 
resources (e.g., housing and employment) and 
(2) asserting direct control in their attempts 
to build and obtain these resources. Three 
additional principles stressed within this 
model that focus on the improvement of 
individual strengths and self-determination 
are (1) showing the importance of positive 
relationships between the clients and their 
case managers, (2) reassuring clients that 
their community can provide a great number 
of resources instead of acting as a barrier, 
and (3) providing positive, interactive out- 
reach programs within the community. 

In adapting this model for use within the 
Substance Abuse Intervention Project, two 
concepts were added to act as a type of guide 
for practiced work. The first concept centered 
on the development of a definition for case 
management advocacy. This definition, 
which basically infused all of the aforemen- 
tioned core functions into a usable form, was 



193 



NIDA Conference Highlights 



somewhat influenced by the work conducted 
by Intagliata. The second concept centered 
on an area known as life domain, which 
refers to the general life skills needed to live 
comfortably (e.g., how to take care of one's 
self, how to cook dinner, and how to develop 
positive relationships). Drug treatment 
recovery also was included within this con- 
cept for the clients who needed it. This 
client-oriented model tries to focus on the 
strengths and assets of the clients and then 
build upon them. A strengths assessment of 
each client is conducted and the findings are 
turned over to the treatment workers in 
order to apply them toward both the develop- 
ment of more effective and individualized 
treatment services and the production of 
plausible case management plans. Upon first 
meeting their clients, the case managers' 
primary goals are to address the immediate 
needs that the clients may have (e.g., clothing 
retrieval, contacting friends or family mem- 
bers, and the updating of probation officers as 
to their clients' treatment statuses). 

Questions, Answers, and Comments 

Comment: About 30 to 35 percent of the 
people treated within the Chicago project are 
female. This percentage vaguely reflects the 
number of women in many of the Nation's 
treatment programs. The primary functions 
performed by the project's case managers 
were to develop both vocational and rehabili- 
tation programs for the clients. Basically, the 
various needs (e.g., child care services) of the 
clients are focused on by the case managers. 
One area of need that many clients in the 
Chicago project reported was transportation 
either to or from the treatment facility. The 
project's case managers remedied this prob- 
lem by providing subway tokens to those 
clients who reported a need. This solution 
has led to a substantial increase in the pro- 
ject's overall retention rates. Case managers, 
through providing the initial housing pay- 
ments and security deposits for subsidized 
housing, also have managed to lower the rate 
of homelessness among the project's clients. 

Has any work been done in the areas of man- 
aged care, medicaid, or medicare with respect 
to the Chicago project, and if so, what have 
the effects been? Managed care providers 
tend to try to control the lengths of stay for 
their clients. This is not really the tendency 
within the Chicago project, so the answer to 
this question would have to be "no." 



Have any differences been noticed between the 
rates of effectiveness for inpatient and out- 
patient treatment within any of the programs? 
Differences have been seen, but the exact 
numbers have not yet been tabulated due to 
the fact that only 3 years of the 5-year study 
have been completed. 

Is case management more effective if provided 
by a physician within a program or by an 
outside agency? Case management that 
occurs outside of a program but still is found 
to be moderately tied into the whole system 
of treatment is probably the most effective 
method of providing these services. 

What qualifications should case managers 
meet before they are assigned to work with 
clients? A wide array of qualifications have 
been seen within many highly effective case 
managers. A few of the many qualifications 
have been both bachelor's and master's 
degrees, experience in substance abuse coun- 
seling, and simply experience obtained 
through being actual drug and alcohol abus- 
ers. Various respect and interaction skills 
also are taught to the case managers for use 
when dealing with both clients and treatment 
staff. 

IF08. Methadone Treatment Issues 

Moderator: James Cooper. M.D. 
Speakers: Joseph Brady. Ph.D. 

Robert Lubran, M.P.A. 

Mark Parrlno. M.P.A. 
July 15. 10:30 a.m.-12:00 p.m. 

Speaker: Joseph Brady, Ph.D. 

This presentation explores an innovative 
delivery system that determines the effec- 
tiveness of drug abuse treatment in general 
and methadone treatment in particular by 
describing a mobile methadone treatment 
program already under way in Baltimore, 
Maryland. The results of the program are 
meant to assist States in the development 
and management of similarly successful 
programs across the Nation. 

Since access to drug abuse treatment services 
has proven to be difficult in the past, 2 years 
ago a demonstration project was conducted in 
order to examine whether successful metha- 
done treatment services could be carried out 
by way of mobile treatment units. These 
mobile units' fundamental purpose was to 
address the accessibility to the treatment 
facilities and the length of time that the 
patients remained in the programs. One of 



194 



Summaries of Issues Forums 



the measures by which the success of a pro- 
gram was judged concerned the duration of 
time that an addict stayed in a treatment 
program. This factor is as important as 
accessibility to the programs. 

Results from a recent study performed by 
Tom McLellan corroborated the importance 
that the length of time an addict spent in 
treatment had upon successful rehabilitation 
of the user. McLellan's study demonstrated 
that heavily addicted opiate users who 
entered the treatment program but dropped 
out after having received 90 or fewer days of 
treatment were worse off upon followup than 
a comparable group of addicts who had not 
received any treatment. Although this may 
seem paradoxical, it demonstrates the impor- 
tance of keeping drug abusers in treatment 
for a sufficient amount of time to enable 
successful rehabilitation to occur. 

In Baltimore, the mobile treatment units 
consist of two medication vans and two trail- 
ers. Although the mobile vans are constantly 
on the move, serving a wide population of 
some of the most difficult drug abusers, one 
medication van concentrates its efforts on the 
east side of town, while the other treats 
patients on the west side of town. Since the 
trailers are used only once a week for coun- 
seling purposes, they remain stationary in 
church parking lots (the clergy was the only 
part of the community willing to assist the 
methadone treatment programs). The mobile 
medication vans are supplied with equipment 
that fulfills all of the drug enforcement 
requirements, and aboard the units are com- 
puterized management information systems 
responsible for tracking all patient informa- 
tion. Everything is done onsite — prescribing 
medication; providing referrals; and perform- 
ing clinical work, such as tuberculosis test- 
ing. In all, about 200 patients are served by 
the mobile units. 

The intake procedure is an involved process. 
The patients must meet FDA requirements 
and must have been regular opiate users for 
at least 1 year prior to their admission; this 
information has to be verified by previous 
treatment programs. Next, an extensive 
Individual Assessment Profile (IAP) is admin- 
istered to the clients. Since it is difficult, due 
to both time and financial constraints, for the 
patients to transport themselves to the treat- 
ment facilities, the IAP (in addition to gather- 
ing demographic data) asks the patients to 
describe the length of time and the amount of 
money that they spent in order to arrive at 



the programs where they were previously 
treated. This question is meant to examine 
the amount of effort that the clients had to 
put forth in order to receive their treatment 
services. This measurable behavior is com- 
mensurate to the term "accessibility." The 
last item about which the patients are asked 
concerns the documentation of any differen- 
ces between the programs in which they 
previously have been involved. 

A vast number of the patients served by the 
methadone treatment programs are dropouts 
from prior programs. Some of the patients 
have been in the mobile treatment program 
for more than 1 year, and a number of them 
participate in what is called "within treat- 
ment evaluations," in which they self-report 
the success that the mobile program has had 
in reducing their own opiate intake. The 
findings from these evaluations suggest that 
there has been a dramatic decrease in the 
amount of time that the clients spend in 
drug-related activities, and there has been a 
significant increase in the number of patients 
involved in legitimate employment. The 
validity of these findings not only was meas- 
ured by self-reported client information but 
also by urinalysis testing. The next step in 
the treatment process will be to reduce the 
amount of cocaine found in virtually every 
methadone-treated patient. 

Data released by the State of Maryland 
concerning six other methadone treatment 
programs in Maryland provide a framework 
for comparing programs. Of the seven meth- 
adone treatment programs mentioned, the 
percentage of drug use measured upon admis- 
sion to the programs shows that the patients 
involved in the mobile units were among the 
heaviest of drug users. Also, the clients of 
the mobile units reported the highest levels of 
unemployment. Therefore, the mobile units 
treat the most serious daily users, a popula- 
tion that also happens to be largely unem- 
ployed. To make matters worse, the only 
category in which the mobile treatment units 
ranked lowest was in regard to whether the 
patients had received at least three previous 
admissions for treatment. In summary, while 
the clients receiving treatment from the 
mobile units are among the most seriously 
opiate-addicted patients, they have received 
the least amount of treatment for their dis- 
ease; consequently, they are among the most 
naive about their addiction. 

The clients treated by the mobile units 
reported having remained in treatment two 



195 



NIDA Conference Highlights 



or three times longer than the clients treated 
by the other methadone programs. In part, 
this may be due to the fact that the mobile 
units are the most accessible for clients and 
reach a different population than the other 
six treatment programs. When the clients 
were asked to describe their occupations, 35 
to 40 percent of the patients in the mobile 
clinics responded that they were home- 
makers, whereas in the other programs only 
5 to 10 percent reported similarly. Thus, the 
mobile units are treating a different popula- 
tion than the other methadone treatment 
facilities. Besides the fact that the patients 
treated by the mobile units were among the 
most serious drug users who received the 
least amount of previous treatment for their 
addictions, they remained in their respective 
treatment programs longer than the clients 
served by conventional treatment programs. 

Speaker: Mark Parrino, M.P.A. 

The beginnings of methadone treatment trace 
back to the early 1970s. Between 1971 and 
1973, there was a 20,000-patient influx into 
the methadone maintenance treatment pro- 
grams in New York City. Also at this time, it 
was found that criminal activity and the 
number of reported cases of hepatitis signifi- 
cantly decreased in the city. A major cor- 
relation was drawn between untreated heroin 
use and criminal involvement and hepatitis. 
In recent years, however, there has been a 
diminished interest in methadone main- 
tenance treatment. 

The rapid expanse of methadone treatment 
programs sprung under the Nixon Admin- 
istration and was based upon the successful 
decrease in crime reported in New York City, 
which was attributed directly to controlling 
the crime-ridden, heroin-addicted culture. 
But gradually the methadone maintenance 
programs diminished because of several 
factors. The programs expanded without 
providing the public with the information 
essential for bolstering the community sup- 
port necessary to implement successfully such 
an undertaking. Without the fundamental 
support of the community, the programs 
stood little chance of thriving. Furthermore, 
since the PDA did not step in to provide 
guidelines and standards, the programs 
lacked the structure to operate successfully. 
All of these factors led to the communities' 
overall distrust of methadone maintenance 
programs. 



Today there are 750 methadone treatment 
programs across the United States operating 
largely in 40 States and treating approx- 
imately 115,000 patients daily. Nationwide, 
there are great variations in prescribed 
dosages of methadone. A 1990 Government 
Accounting Office study evaluated 24 metha- 
done treatment programs. The results sug- 
gested that dosages varied widely, depending 
both on the programs and the individuals 
treated in the programs. While it is very 
important for facilities to prescribe effective 
dosages, low methadone dosages are typically 
found in programs in which there is a high 
incidence of heroin use. For instance, New 
York City is among the lowest in the Nation 
regarding prescribed dosages, but it has one 
of the highest levels of heroin use. 

There is great variability in the quality and 
effectiveness of methadone treatment across 
the United States. Another study, conducted 
by John Ball, documented the fact that meth- 
adone dosages depend upon the program, the 
city, and the State. There are some programs 
that have a tendency to compel people to 
leave the programs for one reason or another, 
and then there are some patients who detox- 
ify or drop out. It was further documented 
that 82 percent of patients who presently are 
in treatment will relapse after the conclusion 
of their methadone treatment. Thus, reten- 
tion of patients in treatment is critical, and 
consequently, policymakers must begin to 
address the maintenance of these patients in 
programs. Without sufficient time spent in 
the programs, the patients will simply 
relapse, and this subverts the whole treat- 
ment process. In the future, policymakers 
must ask what they should do in order to 
maintain the patients in the system and to 
guarantee the integrity of the program while 
also allowing the patients to want to remain 
in the treatment program. 

Another important factor that policymakers 
ought to discuss is a definition of the overall 
expectations of the methadone treatment 
programs. Without clear expectations, it is 
difficult to accomplish anything. The inte- 
grity of the treatment sites must be upheld, 
proper dosages of methadone must be pre- 
scribed, and patients must remain in the pro- 
grams long enough to respond successfully to 
treatment. In the future, an emphasis should 
be placed on reviewing relevant research in 
this area, and pertinent findings found in 
these studies should be translated into the 
field. In conclusion, in regard to available 



196 



Summaries of Issues Forums 



resources, the strategy of doing more with 
less is an antiquated and unrealistic outlook. 

Speaker: Robert Lubran, M.P.A. 

There are several ways in which to imple- 
ment research findings into practical use in 
the field or, as it is sometimes referred to, 
"moving from the bench to the trench." 
Treatment practices are uneven nationwide. 
It is very important to focus on strengthening 
States' abilities to regulate programs and/or 
the need to transfer information and educat- 
ional knowledge into the field. 

The project referred to in this session had 
three objectives, all of which related to the 
improvement of treatment systems across the 
United States. The program wants to help 
State alcohol and drug agencies that have 
funding and regulating responsibilities for 
treatment services in compliance with Fede- 
ral block grant requirements. These require- 
ments generally pertain to the use of Federal 
funds for intravenous drug use throughout 
the country. Also, in the interest of those 
States that have been unable to support 
training due to cutbacks, the program wants 
to use focused workshops at the State level 
rather than sponsoring workshops in Wash- 
ington, D.C. Third, the program seeks to 
develop guidelines in order to provide a 
means for translating policy-level documents 
at the Federal level. Consequently, those 
guidelines will be used to steer States in the 
directions that they should be moving. 

Questions, Answers, and Comments 

Where exactly can someone in need of mobile 
methadone treatment be referred for services? 
All of the clients make the initial contact by 
meeting the mobile units on the streets of 
Baltimore. Only after the addicts come to the 
van are they registered. And since there is 
already a waiting list holding the names of 
500 people, they do not have room for more. 

What is the difference between the mobile 
medication units in Baltimore, Maryland, 
and the units in Boston, Massachusetts? The 
primary difference is that the units in Boston 
simply deliver methadone to patients around 
the city, whereas the units in Baltimore also 
counsel their patients. 

With the wide variation of methadone dosages 
prescribed to patients across the Nation, what 
are the adequate levels to prescribe? The 
question of proper and effective dosage pre- 
scription is something that has to be meas- 
ured according to the individual. Since 



IF09. 



everyone has different rates of metabolism, 
absorption, and other factors, every individ- 
ual will require a personal assessment in 
order to ensure that the proper dosages are 
prescribed. NIDA recommends a range from 
50 to 120 mg. 

Cigarette Smoking Policies 
in Treatment Programs 



Moderator: 
Speakers: 



July 16. 4:30 p.m.-6:00 p.m 



Jack Hennlngfleld. Ph.D. 
Janet Bobo. Ph.D. 
Terry Rustin, M.D. 
Karen Sees, D.O. 
John Slade. M.D. 



Speaker: Karen Sees, D.O. 
The 1988 Surgeon General's report on nic- 
otine addiction revealed a number of interest- 
ing findings. Of our country's treatment 
counselors, a large number are working 
under the belief that individuals who are 
trying to quit using illicit drugs should not 
attempt to cease smoking at the same time. 
The fear is that these people will relapse into 
illicit drug use more often if they do not have 
cigarettes as a "diversionary tool." Surveys 
have found that less than 1 percent of 
patients who were not advised to quit smok- 
ing actually quit on their own. The number 
of patients who quit smoking after receiving 
minimal amounts of advice pertaining to the 
ill effects of smoking is about 3 to 5 percent 
per year. The smoking cessation rates rose to 
between 20 and 40 percent for patients who 
receive both advice and information about the 
health consequences of smoking. 

A recent study conducted by Drs. Bobo and 
Miller found that alcoholics can break their 
smoking habits successfully without hinder- 
ing their progress toward alcohol recovery. 
This study, along with the 1991 Sandor 
Study, revealed a tendency for alcoholics 
(who had quit smoking) to stay in treatment 
longer than alcoholics who still smoked. Why 
is there such a concern over nicotine addic- 
tion when there are so many other kinds of 
addictions which involve stronger drugs? 
Four reasons are as follows: (1) nicotine has 
psychoactive effects, (2) basic health con- 
cerns, (3) the addictive drug effects of nico- 
tine and other drug use, and (4) tobacco is 
the number one killer among all drugs. 

Among drug users, female smokers exceed 
the number of male smokers and smoke more 
cigarettes than males. It also has been seen 
that Caucasians smoke more than any other 



197 



NIDA Conference Highlights 



race, and that less educated people are more 
likely to smoke. 

Speaker: Janet Bobo. Ph.D. 

Of all Americans who are addicted to both 
alcohol and tobacco, millions risk developing 
some form of oral cancer or cancer of the 
esophagus. A statewide survey (conducted 
during 1991 and 1992) of all the drug abuse 
treatment counselors in the 69 treatment 
facilities in Nebraska offered a 95-percent 
response rate (771 counselors). The survey 
was in the form of a three-part questionnaire 
which pertained to the problem of dual addic- 
tion to alcohol and tobacco. The topics 
covered in the questionnaire included the 
following: (1) the respondents' personal 
experiences with alcohol and tobacco cessa- 
tion, (2) the professional opinions toward 
clients' dual tobacco use in conjunction with 
alcohol, and (3) the practice patterns toward 
having clients quit smoking while in treat- 
ment for alcoholism. 

The responses revealed a number of disturb- 
ing beliefs concerning the use of tobacco 
products in treatment facilities. An alarm- 
ingly low 35 percent of the 771 counselors felt 
that recovering alcoholics should be urged to 
quit smoking while still in treatment. This 
percentage rose to 77 percent for counselors 
who felt that those recovering alcoholics who 
had been alcohol free for 1 year or longer 
should quit smoking. Another set of ques- 
tions showed that only 49 percent of the 
counselors had ever advised a patient who 
smoked to quit as soon as possible, and only 
30 percent routinely advised patients to quit. 
The reasons why some counselors advise 
smoking cessation and others do not are 
affected by the following: (1) the counselor's 
personal experience with alcohol and tobacco, 
(2) the counselor's amount of health knowl- 
edge about tobacco, and (3) the treatment 
center policies toward smoking and tobacco 
use. It has been found time and again that 
those treatment center counselors who know 
more about the ill health effects of smoking 
are more likely to urge their patients to quit 
smoking. 

Speaker: Terry Rustin, M.D. 

There are two main reasons why nicotine use 
should be treated in substance abuse treat- 
ment programs. First, nicotine is an incred- 
ibly addictive chemical. If a treatment 
program claims that it helps with addiction 
problems, then it is hypocritical not to 
include addictive tobacco products. Second, 



tobacco is a very destructive drug in regard 
to physical health effects. 

A number of issues and other factors were 
crucial to the implementation of a smoke-free 
treatment program at the University of Texas 
Medical School; these also can be used as a 
guide for other treatment facilities that wish 
to do the same. First, convince yourself that 
this is the right thing to do. Second, define 
your mission. For example, what do you 
mean by "smoke free?" Are you going to 
create a program that does not allow patients 
to smoke on or off the treatment facility 
premises? Should staff be allowed to smoke 
at work or at all? At the University of Texas 
it was decided that staff were not permitted 
to smoke at work but could smoke outside of 
work as long as they did not display any sign 
of smoking once they arrived at work (i.e., no 
cigarettes brought with them and they could 
not smell like smoke). Third, convince the 
administration of the idea. If it happens that 
the person or persons in charge of making 
the decision smoke, then you will find that 9 
times out of 10, the idea will not be passed. 

Speaker: John Slade, M.D. 

Additional health problems that have been 
found to be fairly common among chronic 
alcohol and tobacco users are pancreatitis 
and cirrhosis. A New Jersey consultation 
service, supported by both the Health Depart- 
ment and the Robert Wood Johnson Foun- 
dation, helps alcohol treatment facilities 
address nicotine dependence issues. There 
are two main goals of the consultation ser- 
vice: (1) creating a smoke-free environment 
throughout all of the alcohol and drug treat- 
ment facilities and (2) helping treatment 
counselors address their patients' problems of 
nicotine dependence. There seem to be five 
main reasons for quitting smoking in treat- 
ment facilities: (1) quitting smoking can save 
fives, (2) many patients want to quit smok- 
ing, (3) tobacco smoke harms nonsmokers, 
(4) relapsing to nicotine in drug and alcohol 
treatment facilities is very high for exsmok- 
ers, and (5) tobacco use can lead to other 
kinds of drug use. 

Before the patients' problems of nicotine 
dependence can be adequately addressed, the 
staff need to first address their own problems 
of addiction. Therefore, aid programs should 
be set up for those staff members who need 
help in quitting smoking throughout all of 
the treatment facilities. 



198 



Summaries of Issues Forums 



Questions, Answers, and Comments 

Is there a preferred method for helping people 
to quit smoking? There have been no direct 
studies that have documented which methods 
work and which do not work, but personal 
experience has shown that quitting "cold 
turkey" seems to be the most effective 
method. Treatment counselors need to be 
sensitive to the client's readiness to quit 
smoking. If the issue is to be forced 
emphatically on people before they are ready 
to quit, it could have an adverse effect. 

What should be done about the treatment 
facilities that permit clients to go outside and 
smoke? Hopefully this can be viewed as a 
positive step in the process toward full 
integration of a completely smoke-free 
environment. 

Does going smoke free improve your standings 
with referral sources? In general it has been 
neutral; some referrals have risen and some 
have dropped. 

IF 10. Selecting Pharmacologic 
Treatments for Use in Drug 
Abuse Treatment Programs 

Moderator: David Gorellck. M.D.. Ph.D. 
Speakers: Jim Cornish, M.D. 

Thomas Kosten. M.D. 

Jeff Wllklns. M.D. 
July 15, 1:15 p.m.-2:45 p.m. 

Speaker: David Gorelick, M.D., Ph.D. 

The first issue to consider when selecting a 
pharmacologic treatment for a patient is 
whether or not medication actually is needed. 
If medication is found to be the most effective 
means for treating a patient, then the ques- 
tion of what medication to use must be answ- 
ered. Dosage and lengths of use also should 
be defined according to the need of each 
patient. If a medication is found to be unsu- 
ccessful in treating a patient, reevaluation of 
clinical status, compliance, and side effects 
are three areas to address. Outcome meas- 
ures often are helpful in determining the 
success patterns of different medications and 
any dangerous side effects. 

Treatment facility staff who begin using 
medications as one of the primary methods of 
treatment should be aware of a number of 
possible "impacts." The first impact is the 
fact that patients face a certain degree of risk 
when taking different medications. The 
second impact is an increase in procedures, 



costs, and visits that patients must undergo 
when using medications. The third impact 
affects treatment facility staff, who must be 
thoroughly trained to better understand 
medication uses and side effects. Sometimes 
an increase in a program's overall resources 
(i.e., funding, pharmaceutical facilities, and 
medical staff) is one of the most critical 
needs that result from the switch to using 
medications. 

Speaker: Jim Cornish, M.D. 

More treatments for cocaine dependence must 
be considered for use because an effective 
treatment has not been discovered to date. 
In treating cocaine dependence, medical 
evaluations help determine the extent of a 
patient's problem by obtaining current med- 
ical information and the patient's medical 
history. The information used to assess the 
extent of the patient's problem is based on 
medical, laboratory, and psychiatric evalua- 
tions. Studies show that the most severely 
dependent cocaine abusers often are fairly 
medically fit. However, those who are ill 
tend to have very serious problems. This 
indicates how valuable accurate medical 
exams and evaluations are. 

In treating drug and alcohol dependence, the 
Addictions Severity Index (ASI) is used to 
evaluate a patient's medical, employment, 
alcohol/drug, legal, family/social, and psychia- 
tric problems or needs. It is extremely 
uncommon for patients to have just one 
addiction problem. Instead, they normally 
have a few or all of the above listed problems. 
Based on the fact that no two patients tend to 
have the same problems, treatment facilities 
must develop individualized types of treat- 
ment strategies. 

During the past few years, the Nation's 
treatment facilities have expanded their focus 
to include nicotine addiction. An average 
90-percent rate of nicotine use among alcohol, 
opiate, and stimulant abusers has been iden- 
tified in many treatment facilities. Despite 
the widespread rate of nicotine use, treat- 
ment facilities that implement programs to 
help curb this addiction experience a measur- 
able degree of success. 

Speaker: Thomas Kosten, M.D. 

Methadone maintenance is considered to be 
the most effective pharmacotherapeutic 
method for treating opiate addiction. Dosage 
in methadone maintenance, as well as in all 
treatment medication programs, is very 



199 



NIDA Conference Highlights 



important. Methadone dosages, in general, 
need to be higher than other drug treat- 
ments. Duration of treatment also is a key 
issue to be considered when treating people. 
Some methadone maintenance patients, for 
example, need at least 2 years of treatment 
before they experience any success. Concur- 
rent psychosupport services also are an 
essential ingredient for the success of the 
average recovering patient. 

Several problems must be addressed in treat- 
ing opiate addiction. The development of 
other medications that last longer than 1 day 
is imperative if methadone treatment pro- 
grams do not allow patients to take home 
dosages of methadone. In addition, the 
unwillingness of many communities to accept 
the presence of methadone programs in their 
neighborhoods hinders treatment availability 
for opiate addicts. Changing the name of the 
drug may be a possible solution for making it 
more socially acceptable and working toward 
opening more methadone programs. 

Two medications are being considered as 
replacements for methadone — LAAM and 
buprenorphine. LAAM is a medication that 
performs the same function as methadone 
except that it can be taken every 2 days. Use 
of this drug helps to eliminate the need for 
take-home dosages of methadone. Unlike 
heroin, which is a drug that has a very fast 
onset, LAAM's chemical makeup causes a 
slower reaction within the patient's body. 
The fact that LAAM is taken orally also helps 
contribute to its slow onset. One drawback is 
that its initial effects take a while to be felt 
by the user. This is unlike methadone, which 
can normally be felt within the first day or so 
of intake. Due to the differences in onset 
periods, LAAM patients tend to have some- 
what lower retention rates than do metha- 
done patients. One possible method of 
solving this problem is to start patients on 
methadone and eventually switch them to 
LAAM. 

Buprenorphine is another medication that is 
being considered as a replacement for metha- 
done. One drawback to using this drug is 
that its users have been known to exhibit 
some abuse symptoms. It must be under- 
stood though that abuse depends solely on 
the level to which a particular drug is made 
available. In Europe, buprenorphine is 
highly abused because it can be attained as 
easily as aspirin. In the United States, 
where the use of buprenorphine is highly 
regulated, the number of abuse cases is 



extremely minimal. The advantage to using 
buprenorphine is that when it is taken in 
small dosages (i.e., 2 to 3 mg. per day), the 
effects are similar to those of methadone. 
When it is taken in higher dosages (i.e., 20 to 
30 mg. per day), it acts as a kind of opioid 
blocker. Consequently, if a person attempts 
to use heroin in conjunction with the bupren- 
orphine, he/she will not experience any of the 
normal effects of heroin. Another advantage 
to buprenorphine use is that it tends to have 
a lower rate of dependence when compared to 
methadone. This means that the detoxifica- 
tion periods are much easier to undergo. In 
fact, with the help of two other medications 
(Naltrexone and Clonidine), the detoxification 
period for buprenorphine can be decreased to 
about 8 hours. 

Another problem that methadone main- 
tenance programs experience is that a large 
percentage of the Nation's methadone main- 
tenance population has HIV or AIDS. The 
medication AZT is the most common form of 
treatment for this population. Unfortunately, 
when a person takes AZT along with metha- 
done, the person's AZT level increases as the 
result of an interaction. This often causes 
people to stop taking AZT because they begin 
to feel sick and think that the AZT is "cutting 
into" their methadone supply. Instead, what 
is happening is that the methadone is mak- 
ing the AZT increase to a level of toxicity. 
The way to remedy this problem is to simply 
prescribe lower dosages of AZT, with the 
knowledge that it will increase when it reacts 
to the methadone. 

Speaker: Jeff Wilkins. M.D. 

Some of the more common symptoms associ- 
ated with the use of hallucinogenic drugs are 
paranoia, auditory hallucinations, schizo- 
phrenia, negative feelings about life, blunting 
of emotions, and anxiety-based depression. 
There are few, if any, clinical studies focusing 
on the problem of hallucinogenic drug abuse. 
Because of this, a large amount of the infor- 
mation pertaining to this topic is provided by 
various users and abusers of these drugs. 
However, this method of acquiring informa- 
tion often is not completely accurate because 
a number of these people suffer from schizo- 
phrenia and, therefore, may not give accurate 
histories. Studies indicate that the reason 
many scliizophrenics continue using cocaine 
is that the euphoria created through cocaine 
use can help to temporarily relieve the dys- 
phoria associated with the anxiety, depres- 
sion, and blunting of emotions. A somewhat 



200 



Summaries of Issues Forums 



common mistake made by psychiatrists is to 
attempt to treat depression when in fact a 
client's cocaine-induced depression likely will 
disappear once he/she gets off the drug. 

Hallucinogenic drug abuse can be treated 
with pharmacotherapy and behavioral ther- 
apy. The use of pharmacotherapy is not 
always the best method of treatment. In 
some cases it can even be detrimental to a 
patient's speed of recovery. However, anti- 
depressive and antianxiety medications are 
beneficial when treating patients who are 
depressed to a level that might lead them to 
cause harm to themselves or to someone else. 
Behavioral therapy is probably equally impor- 
tant as a form of treatment to instill the use 
of medications. When these two methods of 
treatment are used in conjunction with one 
another, the results are generally very posi- 
tive. Although the combination of behavioral 
therapy and pharmacotherapy tends to be 
effective, avoiding the use of medications 
when treating people who are "cleaning out" 
their bodies of drugs is helpful. 

Complications occasionally arise when treat- 
ment staff use medications to treat various 
problems that recovering drug addicts might 
be experiencing (e.g., sleep disorders or anxi- 
ety). The most common complication is that 
patients who receive medications to help 
make their problems more bearable often 
become dependent on those drugs instead of 
the ones that they were previously using. 

Finally, in treating opiate-addicted pregnant 
women, most programs either do not give the 
women methadone or they drastically reduce 
the dosage levels. Preliminary study findings 
have shown that pregnant women actually 
need higher doses of methadone in order to 
maintain a relative comfort level. This need 
will vary from woman to woman. It is recom- 
mended that methadone programs do all they 
can to ensure that these women do not feel 
they have to turn back to heroin use in order 
to reach their comfort zone because health 
care providers agree that the effects of heroin 
use are much more harmful to a mother and 
her unborn fetus than are the effects of 
methadone. 

Questions, Answers, and Comments 

Comment: Some studies indicate that bupre- 
norphine has been more effective than metha- 
done in lowering addicts' cocaine use. An 
average of about 70 percent of the people who 
enter an opiate abuse treatment facility use 
cocaine. Whether treated with methadone or 



buprenorphine, an average of only 25 percent 
of these people still use cocaine upon comple- 
tion of their treatment program. This is 
obviously a drastic drop in the amount of 
recorded cocaine use; therefore, it would seem 
logical to continue using these two medica- 
tions when trying to treat the Nation's 
cocaine-addicted population. 

Comment: Despite the fact that intravenous 
drug-using AIDS patients' overall nutritional 
and immunological conditions improve with 
the use of methadone, methadone is not the 
next AZT. The positive effect that methadone 
has on these patients appears to be due more 
to the absence of heroin than to the presence 
of methadone in the patients' systems. 

Comment: Even though LAAM and metha- 
done basically perform the same functions, 
LAAM, upon receiving FDA approval, will 
probably be recommended for use by preg- 
nant women who need treatment. The rea- 
son for this is that LAAM does not metabolize 
quite as fast as methadone, which means that 
it will not have to be taken as often. LAAM, 
on average, only has to be taken about three 
or four times a week. This is beneficial for 
treating people because it helps eliminate the 
need for take-home dosages. 

How often do patients abuse the psychoactive 
therapeutic medications that are supplied to 
them by treatment practitioners? There are 
some medications that are commonly abused. 
Supplies of these drugs (i.e., benzodiazepines 
such as Xanax [alprazolam]) often are 
obtained from small practitioners and 
physicians. 

IF1 1. Acupuncture and Other 
Alternative Treatments 

Moderator: Debra Grossman. M.A. 
Speakers: A. Thomas McLellan. Ph.D. 

John Spencer, Ph.D. 

George Ulett. M.D.. Ph.D. 
July 15, 4:45 p.m.-6:15 p.m. 

Speaker: John Spencer, Ph.D. 

The main forms of alternative care being 
used throughout the world are generally 
suggestive forms of treatment. This simply 
means that these types of care — while often 
not as medically effective as more conven- 
tional treatments — may in fact produce the 
same positive effects for certain patients. 
This phenomenon can be attributed to the 
power of suggestion or the psychological 
beliefs of each individual patient. Some of 



201 



NIDA Conference Highlights 



the better known alternative treatments that 
tend to be used in conjunction with more 
common forms of care are herbal teas, hyp- 
nosis, relaxation therapy, and biofeedback, as 
well as massage therapy for the feet, back, 
and neck. One method for treating drug 
abusers and alcoholics is a practice by which 
treatment counselors attempt — through use 
of the previously mentioned alternative 
treatments — to alter a patient's alpha waves, 
thus causing him/her to experience a feeling 
of complete relaxation. Successful application 
of this treatment method causes the patient 
to relate his or her feelings of relaxation to 
abstinence. More than 500 applications of 
alternative treatments have been used at the 
National Institutes of Health for both health- 
and drug-related problems. 

What exactly constitutes an alternative 
medical practice? Using medical courses of 
action that are not conventionally or tradi- 
tionally taught in school would be one qual- 
ification for being labeled "alternative." An 
additional characteristic would be a transfor- 
mation from a retrospective to a prospective 
model either in or for evaluative purposes. 
Hopefully, as continued study leads to a 
better understanding of these so-called alter- 
native medical practices, State and Federal 
funding also will increase in those areas 
proven to be successful in treating health- 
and drug-related problems. 

Speaker: A. Thomas McLellan, Ph.D. 

Acupuncture use within the medical com- 
munity has spawned a continuing controversy 
between people who believe it is the best 
form of drug treatment available and those 
who feel that it is a fraud. The single best 
study that can be cited to support the effec- 
tiveness of acupuncture is one conducted by 
Dr. Milton Bullock of the Hennepin County 
Medical Center in Minneapolis, Minnesota. 
Dr. Bullock used an acupuncture method 
known as auricular to help treat 80 severely 
alcoholic patients. One-half (40) of the pa- 
tients were treated with auricular acupunc- 
ture, which — through the use of needles — 
pinpointed three substance abuse-specific 
locations on their body; the second half of 
patients received acupuncture that was not 
substance abuse specific. Upon completion of 
the patients' acupuncture treatments, they 
were asked to attend Alcoholics Anonymous 
(AA) meetings. Followup evaluations of this 
study revealed that 21 of the 40 patients who 
were treated with the acupuncture that pin- 
pointed substance abuse-specific body loca- 



tions completed all the AA meetings. Of the 
40 patients who were treated with acupunc- 
ture that did not pinpoint substance abuse- 
specific locations, only 1 finished all of the 
AA meetings. These findings suggest that 
acupuncture does possess some treatment 
capabilities and that the placement of the 
needles is also a valid consideration when 
planning treatment approaches. 

Assuming that acupuncture does work, how 
could it be used in treating substance depen- 
dence? Acupuncture could be applied effec- 
tively somewhere within the following three 
phases of treatment: detoxification/stabiliza- 
tion, rehabilitation, or aftercare (relapse 
prevention). 

Many different kinds of acupuncture tech- 
niques can be used, depending on the various 
reactions of the patients. Acupressure, for 
instance, applies the same treatment methods 
as acupuncture but does not involve needles. 
Acupressure, as indicated by the name, 
simply uses pressure as its treatment ap- 
proach. Bilateral acupuncture is another 
technique, which typically involves sticking 
five small needles in either one or both ear 
lobes. A third treatment technique worth 
mentioning is electroacupressure — a form of 
electrical stimulation without the use of 
needles. Lastly, neuroelectrical stimulation, 
a type of electrical stimulation, lacks any 
kind of puncture or pressure. 

What is needed in the field of acupuncture 
treatment? For one, a universal vocabulary 
should be implemented among all the active 
researchers and practitioners in this field. 
The reason is so that new advances can be 
understood thoroughly by all the people who 
will be affected. Secondly, a standard set of 
active points — which have been determined to 
be positively susceptible to pressure and 
puncture — should be documented. Once this 
has been done, further studies can be con- 
ducted that will elaborate on what little is 
known about this mysterious field. Finally, 
the question of what level of acupuncture is 
needed in order to make it work should be 
answered on a patient-by-patient basis. One 
way of doing this could be by designing a 
format for acupuncture studies that would 
randomly assign acupuncture use to a num- 
ber of patients; these results then would be 
compared to a number of randomly assigned 
patients treated with a placebo. 



202 



Summaries of Issues Forums 



Speaker: George Ulett, M.D., Ph.D. 

Of the 360 acupuncture points on the body, 
the 80 of them that are useful for treatment 
purposes are known as motor points. 
Dr. Han, who authored a 1985 publication on 
the neurochemical basis of acupuncture 
analgesia, believes that acupuncture, while 
not particularly point specific, is instead 
electrical frequency specific. The aforemen- 
tioned motor points are simply locations on 
the skin's surface that resemble electrical 
currents. The process of stimulating these 
points with electrically charged acupuncture 
can (when correctly executed) offer the same 
pain relief that small doses of morphine 
would. Evidence of this was seen in the 
1950s when the Japanese used acupuncture 
as a substitute for anesthesia during a 
surgery. 

Two years ago, Dr. Han conducted a study 
that compared the spinal fluids of 18 volun- 
teers who had received electrically charged 
acupuncture. The results revealed that those 
volunteers who endured a higher level of 
hertz electricity per second produced more 
spinal fluid than did those who had received 
a lower level. Based on this study, the belief 
would be that the greater the amount of pain 
experienced, the greater the amount of elec- 
tricity that should be applied. The reason for 
this is that past studies have shown that 
people who possess higher levels of spinal 
fluids also tend to have lower thresholds of 
pain. 

Another kind of acupuncture that has gained 
some recognition is ear acupuncture. This 
type of acupuncture, which stimulates either 
one or many of the 168 points on the ear, is 
supposed to correspond with different organs 
and parts of the body. In 1972 Dr. Wen was 
the first to use this acupuncture method as a 
means of treating drug abuse. 

It would seem that the main question that 
needs to be answered is whether or not acu- 
puncture is a mythical process in which the 
yin and yang are brought to more of a 
harmony or if acupuncture is an actual 
physiological method that, through the use 
of electrical stimuli, causes the central 
nervous system to release pain-relieving 
neuropeptides. 

Questions, Answers, and Comments 

How do FDA regulations differ in terms of 
electric acupuncture methods and nonelectri- 
cal needle acupuncture? All the electrical 
simulators fall under the category of inves- 



tigational, and none has been approved for 
use within common practice. While plain 
needle acupuncture also has been deemed 
investigational, there is not as much "red 
tape" to undergo in gaining FDA approval. 
The reason for this is that electrical stimula- 
tors for acupunctural reasons are treated 
with the same regulations as any other piece 
of electrical equipment. 

Electrical application on the head, by way of 
either needles or pads, does not seem to be as 
effective an application as using the hand. It 
would seem that the medical field should 
agree on one method of application that is 
deemed most effective and then simply make 
dose modifications as needed from one patient 
to another. 

IF12. Recovery With and Without 
Treatment 

Moderator: David Nurco. D.S.W. 
Speakers: Barry Brown. Ph.D. 

David Mactas. M.A. 
July 16. 10:15 a.m.-l 1:45 a.m. 

Speaker: David Nurco. D.S.W. 

This session focuses on the early manifes- 
tations of deviance, highlighting those behav- 
iors that distinguish future narcotic addicts 
from other children and providing a better 
understanding of the background of addicted 
individuals. 

The determination of the etiology of addiction 
has plagued the minds of researchers for 
many years. A recent University of Mary- 
land study differed from past etiological 
studies in the types of control groups it emp- 
loyed. The three urban male samples used in 
this study were as follows: (1) an addict 
communitywide sample of 255 narcotic add- 
icts, (2) peer controls — a group consisting of 
a matched sample of 147 never addicted ind- 
ividuals who were identified by the addicts as 
their associates at age 11, and (3) community 
controls — a group of 199 never addicted 
individuals who lived in the same neighbor- 
hood as the addicts at age 11 but did not 
associate with them. All participants in the 
study came from the Baltimore metropolitan 
area. Preliminary research for this study 
revealed age 11 as an age at which a process 
of selective association was operating already 
among peers who were destined to become 
narcotic addicts. In other words, potential 
addicts at that age demonstrated a strong 
disposition to associate with peers who also 
were likely to become narcotic addicts. 



203 



NIDA Conference Highlights 



Results regarding this study's peer control 
group reveal valuable information on "survi- 
vors" who resist addiction despite immediate 
and early exposure to drugs and peers who 
later become addicted. 

Prior to any analyses of the study samples, 
the researchers hypothesized that deviance 
rates would be higher among the addict- 
generated peer controls than among the 
community controls. The study compared the 
lifetime deviance rates among 11-year-old 
male associates of all study participants. In 
addition to narcotic addiction, the study 
inquired about the lifetime occurrence of the 
following: alcohol problems, heavy cocaine 
involvement or addiction, heavy barbiturate 
use or abuse, any other drug problems, and 
whether the individual obtained most of his 
income through criminal behavior. Any 
11 -year-old associate that possessed one or 
more of these characteristics was labeled 
"seriously deviant." The pattern of results for 
lifetime deviance almost mirrored the results 
obtained based on narcotics addiction alone. 
The 11-year-old associates of narcotics ad- 
dicts, for example, were found to have higher 
rates of both serious lifetime deviance and 
future narcotics addiction than did associates 
of the two control group members. For 61 
percent of the narcotic addicts, 31 percent of 
the peer controls, and 11 percent of the 
community controls, more than one-half of 
their associates exhibited serious deviance. 
To corroborate the self-reports, careful inves- 
tigation into Maryland State police files 
revealed that 56.5 percent of the addict- 
generated peer controls were known criminal 
offenders, as compared to only 16.7 percent of 
the community-generated controls. 

Subsequent data analyses focused on answer- 
ing the following four questions: How are the 
three study groups different with regard to 
the proportion of older (age 12 and older) 
friends at age 11? Are the older friends of 
members of the three groups significantly 
different with regard to deviant behavior? 
Are the close friends of members of the three 
groups at age 11 significantly different in 
age? Are the close friends of members of the 
three groups significantly different with 
regard to deviance? 

Findings indicated clear differences among 
the three groups with regard to the deviance 
of older and close friends. The deviance of 
both the close and older friends of the addicts 
was comparatively high. Among members of 
the peer control group, however, the closer 



friends exhibited higher rates of deviance 
than did the older friends. This finding was 
exactly the opposite among the community 
control group: The closer friends appeared 
less likely to be involved in deviant behavior 
than did their older friend counterparts. In 
addition, addicts were found to be more likely 
than members of the control groups to have 
older friends. These patterns were consistent 
among Caucasians and African-Americans. 

Participants in this study also were asked 
whether they, together with friends with 
whom they spent the most time, had partici- 
pated at age 11 one or more times in the 
following activities: drinking alcohol, using 
illicit drugs, and committing crime (from 
among 14 types, varying in levels of severity). 
Addicts consistently reported the highest 
amount of drug and criminal involvement at 
age 11, while community control group mem- 
bers demonstrated the least involvement in 
these behaviors. While both African-Amer- 
ican and Caucasian peer control group mem- 
bers showed an intermediate level of involve- 
ment in deviant activities at age 11, the 
African-Americans in this group were closer 
to the African-American addicts than to the 
community controls in their levels of devi- 
ance. Caucasian members of the peer control 
group, however, were closer to the community 
controls in their levels of deviance. 

Researchers for this study considered crim- 
inal activity, particularly serious crime, 
during early adolescence as a general indica- 
tor of precocity for deviance. Thus, it was 
expected that the prevalence and severity of 
precocious criminal behavior would be high- 
est among the most deviant — the addicts — 
and lowest among the least deviant — the 
community controls. Differences in criminal 
involvement at age 11 were found among the 
three groups. Only 27 percent of the commu- 
nity control group participants — but 50 per- 
cent of the peer controls and 58 percent of 
the addicts — reported criminal involvement at 
age 11. These results were significant and 
consistent across race. Addicts were most 
likely and community controls were least 
likely to have been involved in crime at each 
level of severity. Among addicts, those who 
reported onset of first addiction at an earlier 
age also reported the most involvement in 
crime, whereas addicts who reported first 
addiction at a comparatively older age 
reported the least criminal involvement. 
Moreover, those youngest at first narcotic 
addiction were most likely to have partici- 
pated in crime at a more serious level than 



204 



Summaries of Issues Forums 



those who were older at first narcotic 
addiction. 

Differences also were found among the three 
study groups in the amount and severity of 
criminal involvement between the ages of 12 
and 14. Of the three groups, addicts demon- 
strated the greatest increase in participation 
and severity of criminal involvement during 
those years. These increases in criminal 
behavior occurred prior to narcotic addiction. 
Again, these findings were consistent across 
race. The data further suggested that indi- 
viduals likely to become narcotics addicts, 
regardless of age of onset, may be identified 
by increases in criminal involvement at 
various levels of severity. Those individuals 
who engaged in the most serious forms of 
drug abuse also engaged in the most serious 
types of crime. Overall, three prominent 
characteristics associated with predisposition 
for serious deviancy are the early onset, 
persistence, and variety of antisocial behav- 
ior. Addicts were more likely than the con- 
trol group participants to have displayed 
these characteristics as early as age 11. 
Many members of the community control 
group avoided criminal involvement in early 
adolescence despite living in a high-risk 
neighborhood due to some sort of protective 
factors. The nature of these protective fac- 
tors will be explored in future papers. 

Speaker: Barry Brown, Ph.D. 

One of the most positive influences that is 
potentially lifesaving for any serious drug 
user is the decision to enter a drug abuse 
treatment program. However, two important 
issues to consider are the following: (1) the 
influences that are available to help drug 
addicts "kick the habit" without entering 
treatment and (2) if any of these influences 
exist, the ways in which they can be imple- 
mented into part of the drug abuse treatment 
effort. A recent Baltimore area study focused 
on people who exhibited decreased drug use 
to lower levels after being put on waiting lists 
to enter treatment programs. Surveys of 
these people revealed an underlying feeling 
that the ability to maintain low levels of drug 
use without the help of a treatment program 
would be difficult, if not impossible. 

A Waldorf and Biernacki study made a thor- 
ough investigation of a large number of 
heroin users within the community. It was 
found that 101 area heroin users had given 
up their habits without the aid of any formal 
treatment program. The average length of 



use among these people was 5V6 years. Fur- 
ther inquiry led to the discovery that 86 
percent of these users had been off heroin for 
at least 3 years and 58 percent of them had 
not used heroin for as long as 5 years. Many 
key factors enabled the respondents to acc- 
omplish these commendable feats. First, a 
user had to separate himself/herself either 
physically or psychologically from the 
drug-using community. By doing this, he/she 
was able to distance himself/herself to the 
point that he/she could self-impose a new 
sense of identity. The people that proved to 
be the most successful in avoiding relapse 
were those who exchanged their drug -infested 
environments for new ones consisting of 
positive, prosocial role models. Basically, 
these people had to establish new identities 
for themselves. Apparently one of three 
general characteristics were needed to estab- 
lish a new identity: (1) the ability to repos- 
sess or regain a previous identity (i.e., an 
identity that had existed prior to a user's 
involvement in drugs), (2) the ability to seek 
out and take hold of the positive identity that 
has been present somewhere in a user's 
psyche throughout his/her involvement in 
drugs, and (3) the ability to develop a whole 
new identity. 

There is also a great importance in positively 
organizing a user's leisure time in order not 
to allow the relapse temptation to be so 
significant. Future programs should place 
more emphasis on the support of the user by 
the family unit. Family strengths and weak- 
nesses should be employed in treatment, 
pinpointing both individual members and the 
entire unit. So too should there be more 
emphasis placed on the positive variables 
present in every community. A few examples 
of these would be athletic and social clubs 
and events, positive working organizations, 
and church groups. Finally, as in basically 
every field of treatment, there is an impera- 
tive need for increased research efforts. 

Speaker: David Mactas, M.A. 

A 1990 book published by the National Acad- 
emy of Sciences' Institute of Medicine (IOM) 
entitled Treating Drug Problems references 
recovery in the absence of treatment. How- 
ever, the IOM committee that produced this 
book concluded that drug treatment is just- 
ified and appropriate for an individual if 
clinical signs of dependence or chronic abuse 
is evident. 



205 



NIDA Conference Highlights 



The therapeutic community emphasizes that 
ultimately recovery and self-recovery are one 
and the same — that is, the client, not the 
treatment, is the more significant variable. 
Staff at therapeutic communities maintain an 
environment conducive to recovery, but cli- 
ents themselves are responsible for recovery. 
George DeLeon and Nancy Jainchill released 
a paper in 1986 that studied and stressed the 
importance of certain treatment variants 
(e.g., circumstance motivation, readiness, and 
suitability of treatment) for users' abilities to 
recover. This work is relevant to therapeutic 
communities, which generally view treatment 
in terms of stages. The paper emphasizes the 
role of the drug abuser in treatment. For 
instance, people entering a therapeutic com- 
munity for a second time attribute their 
success to a feeling of readiness in terms of 
wanting to recover from their addictions. 
These people tend to have better outcomes 
and retention rates as compared to addicts 
attending treatment for the first time. One 
reason for this is the fact that the second- 
time-around clients have more opportunity to 
help in creating their specific treatment 
program focus and tools. 

Dr. Barry Sugarman, who now runs the 
graduate program for management of chem- 
ical dependency programs for Lesley College 
in Cambridge, Massachusetts, conducted a 
study for Marathon, Inc., in 1976 that com- 
pared the followup outcomes of people who 
attended a therapeutic community for 12 
months but did not successfully complete the 
program with people who stayed in treatment 
an average of 26 months and graduated. On 
virtually every level of measurement (e.g., 
drug abuse and criminality), no significant 
differences in success rates existed between 
the two groups. As a result of these findings, 
the 26-month program studied by Dr. Sugar- 
man was modified to incorporate a new 
12-month regimen. 

Two other projects are worthy of mention. 
First, the National AIDS Demonstration 
Research (NADR) program, consisting of 
NIDA-funded AIDS outreach demonstration 
grants, was established in order to advance 
the AIDS outreach education efforts within 
the community and help prevent/minimize 
high-risk behavior. Marathon's NADR pro- 
ject resulted in a significant reduction in 
drug use, primarily injection drug use. An- 
other study, which Marathon began in 1989, 
is called Project Impact. The basis of this 
study is to determine the correlation between 



lengths of stay in treatment and the patients' 
outcomes when considering the various prob- 
lems being addressed. Project Impact is 
examining four treatment models: both the 
3-month and 6-month residential relapse 
prevention programs operated by Spectrum 
and the 6-month and 12-month treatment 
terms of Marathon's traditional therapeutic 
community. Study participants are randomly 
assigned into one of these four treatment 
models. (Researchers do not view the 
absence of a control group receiving no treat- 
ment as a hindrance to the integrity of this 
study. Ninety percent of participants in the 
Marathon program — regardless of successful 
completion of treatment — continue their 
engagement in the study.) 

One common misconception is the belief that 
reuse and relapse are synonymous terms. 
Occasional reuse on the part of a recovering 
drug addict should not be viewed necessarily 
as a lack of success on the client's part but, 
instead, as a simple setback. An occasional 
setback does not mean failure; it may suggest 
that more preventive measures may be need- 
ed. Too much emphasis is placed on striving 
for perfection. 

Questions, Answers, and Comments 

Comment: The capacity to mobilize commu- 
nity resources varies considerably across 
communities. It deserves more attention 
than it has received in the past for its role in 
helping individuals remain drug free after 
they leave drug abuse treatment. The 
relapse prevention movement is very exciting 
in this regard. Relapse prevention involves 
to a large extent behavioral skills training 
within treatment programs, not merely as a 
part of aftercare. Mobilization of community 
resources is very important for the prevention 
of relapse or reuse of drugs. 

In the study with addicts and their peers from 
age 11, why was age 11 chosen as the focus 
for the research? Researchers considered age 
11 the cusp of adolescence, when the per- 
tinent behavior would begin to be demonstra- 
ted. Additional studies probably should focus 
on age 5 or 6, when children are beginning 
school, to look for early manifestation of 
aberrant behavior. In a few studies that 
already have been done, teachers of Mnder- 
gartners and first graders demonstrated an 
ability to make distinctions, based on aggres- 
sive behavior, regarding children who are 
likely to display dysfunctional behavior, such 
as drug use. Thus, some people have argued 



206 



Summaries of Issues Forums 



IF13. 



for the establishment of programs for at-risk 
children at this age. 

To what extent does gender have to do with 
the shift toward criminality and other deviant 
behavior? Women, on average, only make up 
about 25 percent of the addict population. At 
the Marathon program, women generally stay 
in treatment longer than men, but the per- 
centage of women who actually complete 
their respective programs is much lower than 
that of men. 

Do heroin "chippers" (i.e., nonaddicted, casual 
users) need treatment? The IOM in the 1990 
report says that, unless an individual demon- 
strates chronic abuse, the IOM would not 
make a categorical statement about his/her 
need for treatment. Treatment should not 
necessarily be determined according to the 
frequency of use but, instead, by the effects 
that the use has on the user's everyday life. 

Comment: The issue of readiness for treat- 
ment must be handled carefully. Who has 
the responsibility for a client's readiness for 
treatment? It is a part of treatment and 
therefore is the program's responsibility. 
Programs should not have the attitude that 
the client bears the responsibility for becom- 
ing prepared for treatment. 

Comment: An important question is the 
following: Do some people outgrow their 
pathologies, manifested in addiction? One 
study that bears on this question involved 
different types of drug users. Those indi- 
viduals who were addicted less than 25 per- 
cent of the time during a 10-year period since 
onset of addiction were able to grow out of 
their addiction due to various circumstances. 
The support system around them apparently 
gave them the opportunity to leave their 
deviant subculture and become more 
productive. 

Patient Placement and Treatment 
Outcome 

Moderator: Dorynne Czechowlcz. M.D. 
Speakers: Norman Hoffman. Ph.D. 

Charlene Lewis. Ph.D. 

A. Thomas McLellan. Ph.D. 
July 17, 8:15 a.m.-9:45 a.m. 

Speaker: Norman Hoffman, Ph.D. 

The most imperative aspects to keep in mind 
when considering patient-to-treatment match- 
ing are not only applying viable treatments to 
different problems but also determining each 
patient's correct length of stay. Unfortu- 



nately, the continuum of care is a commonly 
overlooked treatment issue throughout the 
treatment field. Currently, a CATOR (Chem- 
ical Abuse/Addiction Treatment Outcome 
Registry) history form has been completed by 
more than 20,000 participants and systemat- 
ically stored into a risk index. The risk index 
only records information pertaining to 
people's various addictions. Future advances 
in interview and recording techniques should 
expose a greater diversity of patient charac- 
teristics, such as resistance to care/treatment, 
keys to motivation, and denial within a 
psychosocial environment. 

According to the Substance Use Disorder 
Diagnostic Schedule (SUDDS), the primary 
diagnostic indicators of drug and alcohol 
abuse include blackouts, getting into trouble 
when drinking or using drugs, excessive use 
of substances, job problems, neglect of respon- 
sibilities, morning drinking, objections by a 
doctor, use despite an illness, emotional 
problems, and interpersonal conflicts (e.g., 
marital problems). A review of the more than 
20,000 CATOR survey participants revealed 
that the inpatients appeared to suffer from 
more of these diagnostic indicators than did 
their outpatient counterparts due to the fact 
that high-range severity patients tend not to 
participate in outpatient programs. 

The issue of a continuum of care needs to 
receive higher levels of concern. Alcohol and 
drug problems should be considered chronic 
illnesses as opposed to acute illnesses. If this 
were a universal belief among all drug and 
alcohol treatment counselors, then the con- 
cept of aftercare as we know it now would 
become obsolete. Aftercare would no longer 
be necessary because treatment would be 
ongoing, much as it is for cancer or any other 
chronic disease. Studies have found that 
people suffering from serious alcohol prob- 
lems who received continuum care tended to 
be just as successful in terms of recovery 
rates as those suffering from minor alcohol 
problems who did not receive continuum care. 
The following findings were documented 
regarding the recovery rates of people who 
received continuum care: (1) 1 to 2 months of 
continuum care did not reveal any advantage 
over the people who did not receive con- 
tinuum care; (2) 3 to 5 months of continuum 
care showed substantial improvements for 
people who received it; and (3) 6 or more 
months of continuum care marked the great- 
est level of improvement for those who re- 
ceived it, and these people proved to have 



207 



NIDA Conference Highlights 



much higher rates of recovery than those who 
did not receive continuum care. 

It is imperative that treatment counselors 
keep in mind the vast amount of diagnostic 
indicators to drug and alcohol abuse, so that 
patient-to-treatment matching can be as 
accurate as possible. However, in this discus- 
sion, projections of medical comorbidity are 
not addressed. 

Speaker: Charlene Lewis, Ph.D. 

CSAT and the Department of Labor (DOL) 
are cosponsoring a project through DOL's Job 
Corps, an education and employment training 
program that builds vocational skills among 
disadvantaged youth. However, many of 
these youth disrupt their education and 
employment training through drug use when 
they leave the Job Corps campuses on week- 
ends. Through Job Corps, CSAT and DOL 
have set up a demonstration project at eight 
national sites. In each major region of the 
country, two Job Corps sites were 
selected — one for the demonstration program 
and one for the standard Job Corps program. 
The student population is similar at each of 
a matched pair of sites. The main objective 
of the demonstration program is to determine 
the effect of a continuum of comprehensive 
care on students' rates of job training and 
GED (general equivalency diploma) course 
completion. At each experimental center, 
comprehensive care is provided by a team of 
at least five staff members, including a sub- 
stance abuse specialist, an activities specialist 
to promote drug-free recreation, a life skills 
training teacher, an assessment worker, and 
a data entry specialist to enter the infor- 
mation collected in client interviews. This 
team assists the students with taking full 
advantage of what the Job Corps offers. 

Just over one-half of the youth entering the 
Job Corps programs report having used drugs 
on more than an experimental basis, with 
one-fourth testing positive for drugs on the 
day they enter Job Corps. The drugs used 
most prevalently include primarily alcohol, 
marijuana, and tobacco; however, substantial 
levels of cocaine, hallucinogens (mainly LSD), 
and methamphetamines also are being used 
by the student population. One-third of the 
students already have been arrested for some 
kind of criminal activity, 17 percent sell 
drugs, and 12 percent belong to gangs. 
Furthermore, about 8 percent have been 
sexually abused, although this is a conser- 
vative estimate. Some social indicators that 



seem to relate to the development of these 
statistics include the following: whether the 
student comes from a single-parent house- 
hold, whether the student has ever run away 
from home, whether the student's parents 
have ever kicked the student out of the 
house, and whether the student was placed 
outside of the home by the courts. 

Considering these indicators, the Job Corps 
students who use drugs were found to be 
three times worse off than either the students 
who just use alcohol or who use neither 
substance. 

When assessment determines that a student 
needs comprehensive support from the Job 
Corps treatment program, the staff decide the 
student's needs and the resources available to 
meet them. The student then meets with the 
substance abuse specialist and is asked to 
sign a behavioral contract, ensuring that the 
student attend, at minimum, four basic drug 
education sessions and four to six group 
counseling sessions, as well as undergo uri- 
nalysis for at least the first 6 weeks that 
he/she is at the Job Corps center. Each 
student participates in a wide range of activ- 
ities provided through the continuum of care. 
Few students have dropped out of this dem- 
onstration program. In fact, it is encouraging 
that students who are required to be in the 
enhanced treatment program now are staying 
with the Job Corps as long as students in the 
standard program. Thus far, about 125 
students have stayed in the treatment pro- 
gram for 6 months. 

Students who drop out of the Job Corps 
program generally are under 18 years of age, 
have been suspended from school, have chil- 
dren, and have tested positive for drug use in 
the last month. Job Corps is trying to 
address these factors in different ways, such 
as providing day care. 

Speaker: A. Thomas McLellan, Ph.D. 

Several important questions regarding 
patient-to-treatment matching were raised as 
a precursor to this discussion: What prob- 
lems do people bring to treatment versus 
what services are offered within the treat- 
ment facilities? Is there any common patient 
information that can be used as a predictor to 
determine the type of treatment needed for 
each individual? Do predictors vary between 
inpatient and outpatient settings, and if so, is 
a detailed evaluation of the services provided 
within these vastly different settings needed? 



208 



Summaries of Issues Forums 



A number of predictors of success level hold 
true for both the adult inpatient and out- 
patient participants. These include psychia- 
tric problems, addiction severity, employment 
problems, and family problems. A recent 
study by Arthur Alterman discovered better 
inpatient completion rates for alcohol-depen- 
dent male veterans who were assigned 
randomly to inpatient and outpatient detoxifi- 
cation units. Two other studies, focusing on 
rehabilitation, also were conducted. One 
study, a 28-day inpatient program, offered 
group and individual therapy for alcohol- 
dependent individuals. The second study, a 
37-hour-per-week outpatient program, also 
offered group and individual therapy for 
alcohol-dependent individuals. It was found 
that there were no real differences between 
the success rates for people treated through 
inpatient and outpatient programs. The 
reason for this is that virtually identical 
services were offered within each program. 
Another look at four randomly selected, 
private inpatient and outpatient programs 
revealed that the following services almost 
exactly mirrored the ones offered in public 
programs: medical, employment, alcohol, 
drug, legal, family, and psychiatric. 

With the exception of 10 occasions, the 
amount of medical services offered in in- 
patient care as opposed to outpatient care in 
both the public and private sectors was virtu- 
ally equal. This leads to the conclusion that 
it does not really matter where a client goes 
for treatment, it is what he/she is getting 
while there. 

Questions, Answers, and Comments 

Comment: In the last few years, the overall 
recovery rate has been decreasing among 
privately funded programs. 

With unlimited resources, where should 
efforts be centered (e.g., on family, psychiatric, 
or employment issues)? According to data, 
severe psychiatric problems are the worst 
problems because they seem to relate to 
problems in other areas. The next important 
area to address is employment. With jobs, 
many people might find it easier to recover. 
Programs generally should be full-service pro- 
grams, evaluating all of the clients' needs and 
ensuring that those needs are met somehow. 
This is an expensive venture, as evidenced by 
the Job Corps program. 

Are any data available on the types of youth 
who apply for Job Corps, in terms of those 



who are coming out of treatment compared 
with youth who have never had drug or 
alcohol problems? Job Corps has a zero- 
tolerance policy for drug and alcohol use. 
Because addiction is a chronic relapsing 
disorder, it has been difficult to have youth in 
Job Corps who have drug problems. Job 
Corps is beginning to try to adapt to this 
problem — for instance, through the ongoing 
demonstration project. Interview-based data 
pertaining to this subject are available but 
have not yet been analyzed. In general, 
however, about 10 percent of incoming Job 
Corps youth have been in some form of drug 
treatment. 

While it is expensive to operate programs like 
Job Corps, it can be more expensive to society 
not to offer such programs. Are any studies 
currently tracking the cost-effectiveness of 
programs with these added services? Many 
such studies have been conducted. For 
instance, one study is focusing on a condition 
called alcoholic cardiomyopathy — which, if 
undetected, leads to many serious and expen- 
sive complications. When this condition is 
detected early, it leads to dramatic financial 
savings. With adolescents, financial savings 
usually occur in the school and legal systems, 
neither of which tend to fund treatment. 
Thus, the payback occurs in areas where the 
money is not actually spent to provide 
comprehensive services. 

Comment: The tolerance of the next genera- 
tion of youth for alcohol use is much higher 
than it is for cocaine, marijuana, or metham- 
phetamines use. It is much more socially 
acceptable. This circumstance should be 
studied further. 

IF14. Juvenile Justice 

Moderator: Michael Backenheimer. Ph.D. 
Speakers: Richard Dembo, Ph.D. 

Jim Inclardi. Ph.D. 

Dorothy Lockwood. Ph.D. 
July 17,8:15 a.m.-9:45 a.m. 

Speaker: Jim Inciardi, Ph.D. 

In order to be included in this study, partici- 
pants had to have been regular drug users 
who had used at least one illegal drug daily 
for the past 90 days prior to being inter- 
viewed. In addition, the participants had to 
have been involved in at least 12 Federal 
Bureau of Investigation Part I crimes in the 
year prior to the interview. Part I crimes 
include homicide, aggravated assault, auto- 
mobile theft, forcible rape, and arson. If the 



209 



NIDA Conference Highlights 



user did not fit the aforementioned descrip- 
tion, then he/she had to have committed at 
least 100 other lesser offenses within the 
year, such as prostitution or drug sales. 
Thus, the most serious juvenile offenders 
were assessed in this study. 

Speaker: Dorothy Lockwood, Ph.D. 

Research from this study provided data to 
examine many of the factors involved with 
delinquency as they pertained to drug use 
among the most seriously delinquent youth. 
Another research topic that can be explored 
within this data set is the difference between 
youth who have and have not been involved 
in criminal violence. Unfortunately, the 
existing juvenile delinquency theories fail to 
provide a framework from which to measure 
criminal violence as it relates to youth who 
have and have not been involved in criminal 
activity because the theories do not 
differentiate between various types of crimes. 
Violent crimes are different than nonviolent 
crimes; therefore, both should be viewed 
separately in order to delineate differences. 
Although the juvenile delinquency theories 
have not provided the necessary framework, 
a great deal of research has been performed 
on youth who have been involved in criminal 
violence. 

For purposes of this study, the correlates of 
criminal violence among juveniles fall under 
four categories. The first correlate concerns 
the demographics of the child, which include 
gender, ethnicity, and age. The second cor- 
relate addresses the living situation and/or 
the family situation of the child, since 
research indicates, for example, that the fre- 
quency of family arguments and the number 
of people living in the household contribute to 
the likelihood of criminal violence among 
juveniles. The third correlate assesses the 
social networks of the child, including his/her 
peers and friends. The last correlate deter- 
mines whether the child has been involved in 
any previous delinquent behavior, such as 
drug use or other criminal history. 

The research suggests that different cor- 
relates exist for males and for females who 
are involved in criminal violence. A greater 
number of men than women participated in 
the study. In order to reduce the probability 
that variables significant to the females 
would be lost when included with the dispro- 
portionate number of males, the results of the 
study were divided by gender in order to 
differentiate between the two. The most 



significant correlates that determined the 
likelihood that males would commit criminal 
violence were the following factors: ethnicity, 
peer relationships, and drug use. Insignifi- 
cant factors influencing males included living 
situation (i.e., whether they were living with 
their families), household income, age at 
which delinquency began, and participation 
in the drug business. The most significant 
correlates that influenced the likelihood that 
females would commit criminal violence were 
the following factors: living situation and the 
age at which their delinquency began. 

These results open the door for discussion on 
the topic of what this information means for 
practitioners, juvenile corrections officers, 
and those involved with youth and their 
treatment environment. The kind of data 
gathered for this type of study (i.e., data 
gathered from a street population) brings to 
question some of our traditional models of 
dealing with children. The "parens pati-ia" 
model, which aims to rehabilitate and/or cure 
children, may be very antiquated for this 
group of children because this model depends 
on benign authorities (e.g., schools and fami- 
lies) to help redirect the youth. In many 
cases, the youth have been expelled from 
their schools and/or their families, so this 
model typically proves to be ineffective. In 
fact, to rely upon these institutions would be 
unfair to both the youth and the institutions. 
On the other hand, the purely punitive 
response from the juvenile justice system 
would prove to be similarly ineffective. These 
institutions provide minimal treatment, and 
they may even create a more harmful situa- 
tion for the youth in that some of their 
delinquent peer relationships may be 
strengthened. 

Likewise, the family preservation model of 
child welfare, in which the primary goal is to 
keep the child in the family, is evidently 
ineffective also. Within this sample, 12.8 
percent of the youth reported no longer living 
with their families. Many relied upon drug 
sales or prostitution to support themselves. 
Due to these living situations and the fact 
that these youth are on their own without the 
necessary skills to integrate successfully into 
the workforce, policymakers should attempt 
to include a provision of marketable skills for 
youth when developing programs. Rather 
than concentrating all of their efforts on 
trying to reunify the families, policymakers 
should attempt to provide the offenders with 
the opportunity to begin some prosocial 
employment. Finally, the rehabilitation 



210 



Summaries of Issues Forums 



model of drug abuse treatment, which is 
based on the concept of teaching clients to 
use appropriate skills and behaviors (with an 
assumption that they already have learned 
these), also may be ineffective if the clients 
have not learned the appropriate skills and 
behaviors. 

Within these analyses there are several other 
important findings relevant to policymakers 
and service providers. The primary finding 
from the study is that a difference exists 
between the variables that are correlated 
with criminal violence for the females from 
those of the males. This has to be taken into 
account when developing future programs. 
Many of the females were living outside of 
the home, and some of their violent acts may 
be attributed to the fact that they were 
involved in prostitution or drug sales in order 
to support themselves. Therefore, in some of 
these instances, their violent acts may have 
been committed in self-defense. Among the 
male population, the primary correlate influ- 
encing their likelihood toward criminal activ- 
ity concerned their relationships with their 
peers. Consequently, future studies should 
examine the association between peer rela- 
tionships, drug use, and violent behavior. 

Speaker: Richard Dembo, Ph.D. 

In this session, a model of one community 
treatment agency was used as an example of 
how to address funding issues, experiences in 
establishing a similar facility, youth proces- 
sing procedures, and research activities. The 
program is an outcome development of a com- 
munity consensus taking place in Tampa, 
Florida, for about 6 years, of which the pri- 
mary aim is to educate the community and to 
drive more resources. Since various agencies 
have come to the understanding that a spirit 
of collaboration has to be developed, infor- 
mation sharing has become a top priority in 
order to meet future goals. 

The facility in Tampa holds a maximum of 20 
beds. The program is a 24-hour-per-day, 
7-day-per-week detoxification facility for 
youth undergoing withdrawal, and it is 
staffed by nurses with medical, psychiatric, 
and psychological backgrounds. On average, 
youth remain in the facility for 3 to 4 weeks. 
There are four holding cells in the basement, 
but they are seldom used. The top floor of 
the facility is divided into two components: 
One is a secure area for youngsters arrested 
on delinquency charges, and the other is a 
nonsecure area where a variety of other 



categories of youth, primarily truants, are 
located. All youth picked up on a given day 
in the area for truancy are brought to the 
program. Youth are assessed with parental 
consent. Upon admission to the facility, the 
youth undergo a three-part, comprehensive 
information process that includes a prelimi- 
nary screening, an indepth assessment, and 
a referral outcome measure. 

Delinquent arrestees are brought to the 
facility as well, which is notified beforehand 
through the control room's onsite computer 
contact with the State attorney's office, the 
Florida Department of Health and Rehabilita- 
tive Services' (HRS') central information 
system, and the educational computer to 
access the school system. Herein, it is evi- 
dent that information sharing is beginning to 
pay off. As a result of networking, legislative 
changes often occur as problems arise. For 
every youth who is brought into the facility, 
the Florida Department of HRS delinquency 
intake unit provides an abuse and delin- 
quency history of the youth. 

A typical case scenario runs as follows. A 
police officer calls the control room and 
informs officials that an arrested youth is 
being brought into the facility. The youth is 
then brought up to the locked facility where 
the arresting officer registers him/her and 
assigns the arrestee an event number. The 
screening process is completed in about 2 
hours. If the youth meets the detention 
criteria, he/she then is driven to the deten- 
tion center. Within 24 hours, the youth 
appears in court, and the judge decides 
whether to release the youth or keep him/her 
in detention. Usually the youth sits in deten- 
tion for 21 days while the juvenile court 
decides what to do with the youth's case. 
Once the youth is assigned to the detention 
center, he/she is assigned an HRS case mana- 
ger who represents the youth's interests in 
court. If the youth does not meet qualifica- 
tions for the detention center, the parents are 
called to come pick up the youth. 

When the arrested youth is brought into the 
facility, the computer system provides access 
to both his/her police department and educa- 
tional records. Within a short period of time, 
the youth's delinquency history is matched 
with the juvenile assessment center register 
number assigned to the arrested youth. 
Immediately the State's attorney is notified 
that the youth has been arrested and is in 
custody. Subsequently, a breathalizer test 
and drug tests are administered (due to the 



211 



NIDA Conference Highlights 



fact that there has been some concern ex- 
pressed about civil liberty violations, adminis- 
tration of drug tests has been suspended 
indefinitely even though there is a State of 
Florida legislative mandate that requires all 
arrested youth to be tested). 

The first step in the process is to determine 
the immediate placement of the arrested 
youth. In doing so, there are three possi- 
bilities: The youth either could be (1) sent to 
the detention center, (2) released on a non- 
secure home detention/home arrest, or (3) re- 
leased to a parent or guardian. The second 
step in the process is an indepth assessment 
of the youth. The purpose of this assessment 
is to determine whether or not the arrested 
youth could be a potential problem in the 
facility. Factors such as previous delin- 
quency and past drug use help determine the 
potentially problematic youth, and these 
youth undergo further assessments. Last is 
the referral of outcome measure, which is 
compiled to document the child's delinquency 
history and is sent to the manager at HRS. 
When complete, the client's episode history 
goes to the agency worker, and as the youth 
moves through the system, his/her paperwork 
follows. 

This innovative community treatment agency 
has been quite effective thus far and prom- 
ises, with future developments, to become 
even more so in the future. 

Questions, Answers, and Comments 

Are these data from the Florida community 
treatment agency online with the Florida 
system? No. Currently, the information 
system created within the program is used 
only for self-stored information. A committee 
has been established to look at relevant 
statutes and decide which agencies should 
have access to which sectors of data and for 
what purposes. Appropriate protection of the 
youth and their confidentiality rights are 
being upheld. Dr. Dembo explained that he 
is very interested in clinical access to the 
data and the use of data in a way that will 
respond to the needs of the youth without 
creating additional impediments to the 
youth's safety. He explained that their aim 
is to put together a subcommittee in order to 
ensure the proper identification and interpre- 
tation of the statutes, with appropriate legal 
opinions and interpretations consonant with 
the protection of the youth's interests. 

Are there official arrest rates that document 
the ratio of women arrested compared to men? 



Concern was expressed in regard to male 
youth being introduced to rehabilitation more 
often than female youth because the males 
are being arrested more often. Since females 
are not arrested as frequently, they tend not 
to be introduced to the rehabilitation re- 
sources offered to those who are arrested, and 
thus the females may be missing out on 
available treatment. Future development 
must make resources available to the females 
who are in need. 

Comment: Although no association was 
found between participation in the drug 
business and violence, there was a very 
strong relationship between drug use and 
participation in the drug business, parti- 
cularly with the use of crack -cocaine. The 
people involved in the crack-cocaine business 
tend to be among the most deviant of crim- 
inals; therefore, the drug attracts some of the 
most difficult youth. 

Comment: The Florida agency tries to match 
youth with other agencies that can meet at 
least some of their specific needs. The bot- 
tom line of the program is not data collection 
but the connection of youth with needed 
services. The spirit of cooperation among 
State agencies and other agencies and pro- 
grams has been exemplary. 

Comment: The Florida program has not yet 
implemented urine testing due to questions of 
informed consent and whether parental 
approval is needed. However, Florida has 
mandated that all youth arrestees be 
assessed for, among other things, substance 
abuse. 

Comment: Miami's violent crime rate has 
been declining since 1979, whereas this rate 
appears to be increasing in many other cities. 
Also, gangs don't seem as prevalent. In 
general, gang involvement in drug trafficking 
is related to how tightly controlled trafficking 
is in the community as a whole. Because in 
Miami the Colombian cartel controls drug 
trafficking, youth stay out of it for the most 
part (except for the trafficking of 
crack-cocaine). 



212 



Summaries of Issues Forums 



IF15. Evaluation Results To Improve 
Program Functioning 

Moderator: Barry Brown. Ph.D. 

Speakers: Arthur MacNelll Horton, Jr., Ed.D. 

Gerald Soucy. Ph.D. 

Roger Straw. Ph.D. 
July 16. 8:30 a.m.-10:00 a.m. 

Speaker: Gerald Soucy. Ph.D. 

In the future, if program officials are to 
perform their jobs effectively, they will need 
to receive information about how successfully 
and with whom the programs are achieving 
their objectives. The first step in evaluation 
is to define the questions that need to be 
answered. The quality of these questions 
plays a vital role in the quality of the evalua- 
tion. The questions, in turn, have implica- 
tions for the design, data to be sought, and 
resources that will be needed when under- 
taking the evaluation. 

Several generic themes underlie the develop- 
ment of evaluation questions. The first 
theme concerns the content of the program 
and addresses the exact nature of what the 
program is doing. The second theme ascer- 
tains whether the program is operating as 
intended. The third theme examines the 
measures of program outcomes — that is, what 
the program is achieving. The last theme 
pertains to more sophisticated evaluations, 
including financial or cost components, and 
whether services are being delivered as 
efficiently as possible (i.e., with cost-effective- 
ness). For agencies that are not tied into 
comprehensive management information 
systems, questions pertaining to cost are 
usually beyond the resources and the tech- 
nical expertise of the program trying to 
undertake the evaluation. Agencies without 
technical expertise in the area of cost-benefit 
analysis should stay away from such analyses 
with the exception of providing budget 
summaries. 

The evaluation questions need to be devel- 
oped specific to the program's functioning. To 
aid in this development, a basic framework 
describing the program's mission statement, 
goals, and objectives should be drafted. This 
framework is useful in many ways. For 
instance, if a person were to provide the 
program's evaluation results, explaining that 
the results demonstrate the program's effec- 
tiveness, a technical expert might ask about 
the program's mission statement, goals, and 
objectives in order to determine whether the 
program's results are commensurate to the 



goals set forth in the mission statement. 
Therefore, the framework that defines the 
program's overall intentions is useful in 
providing a general context for the program 
and can be referred to throughout the pro- 
ject's history. 

The aforementioned framework should or- 
ganize and define program goals in such a 
way that, upon examining the evaluation 
report, one can easily review whether the 
intended goals met with the end results. 
Although program goals and objectives some- 
times change over time, the documentation of 
the program's original intentions serves the 
purpose of tracking the program's direction 
and makes programmatic changes all the 
more obvious. 

The terms "process outcome" and "formative 
outcome" refer to those evaluation questions 
focused on effort and effectiveness, respec- 
tively. Effort questions examine whether a 
program is concentrating its efforts on the 
targeted client population and the types of 
activities or services that the program is 
providing to that population. These questions 
are designed to look at the process or opera- 
tion of the program by examining the services 
being provided, the persons to whom services 
are being provided, and the amount of ser- 
vices being provided. Effort questions include 
everything that a program is doing. Outcome 
evaluation questions are known as effective- 
ness questions. For instance, if there is a job 
employment component to a program, a 
question could inquire as to the percentage of 
clients who did something or the impact that 
a certain variable had upon client function- 
ing. Efficiency questions can extend the 
information obtained through outcome evalu- 
ation by incorporating issues of service costs. 

The first step in designing evaluation ques- 
tions is to write out a rough draft of ques- 
tions to be addressed and determine whether 
each question is consistent with the pro- 
gram's mission statement and goals. If the 
two do not overlap, either the mission state- 
ment should be reviewed and appropriately 
modified (because it is possible that the 
program has changed) or alternative evalua- 
tion questions should be considered. If the 
two are consonant, one should determine 
whether the question has an effort, effective- 
ness, or efficiency focus. If a question is a 
compound one, it should be broken into 
simple, single questions and examined to 
determine whether any comparisons exist 
that are worth mentioning. These compari- 



213 



NIDA Conference Highlights 



sons can either be across groups or across 
time. 

In summary, one should always define com- 
parison questions and revise all questions as 
needed. If one lacks technical expertise and 
is just beginning to undertake an evaluation, 
then it is best to keep the evaluation simple. 
Second, one should use available resources 
and ask for feedback. In terms of refining 
questions, it is also important to involve staff 
and gatekeepers, since the program's goals 
and objectives may change over time. Final- 
ly, one should involve other important people 
in the process, including board members and 
anyone else who might provide useful input. 

Speaker: Roger Straw, Ph.D. 

A frequently asked question in regard to the 
evaluation of program outcomes is as follows: 
How does one go about changing a treatment 
program in order to make improvements? 
The term "outcomes" is used here in its 
broadest sense. Frequently funders tend to 
ask whether people stay drug free. A more 
important concern may be how to keep people 
in treatment. 

When a change in outcome appears to have 
occurred in a given program, the next step is 
to determine the exact variable that caused 
the change. This line of inquiry should 
address whether something changed as the 
result of a single, measurable variable or 
whether another equally plausible reason 
could account for the change. The last ques- 
tions that evaluators should address are 
whether the program was worth it and 
whether it is possible to produce similar 
results for less money. When evaluators talk 
about these kinds of questions, they are 
suggesting causal relationships. In order to 
feel confident that a causal relationship 
exists, three things need to be done. First, 
whatever it is that one thinks caused the 
change must be seen as consistently preced- 
ing that change. Next, a clear statistical 
relationship must be found between the 
presumed cause and the effect. Last, one 
must consider whether the change in outcome 
could be the consequence of another equally 
plausible variable or set of factors. 

When using evaluations to improve programs, 
evaluators should keep the evaluation simple 
and should approach program improvement 
in terms of problemsolving. In addition, all 
variables should be capable of being exam- 
ined separately in order to determine the 
exact cause of any change that appears to 



have occurred. Furthermore, evaluators 
should approach program improvement 
systematically, in much the same way as 
they approached the program's original 
development. 

Before making changes, there must be a 
reasonable measurement of how well the 
program is doing already. Program evalua- 
tors must then decide what needs to be 
altered in order to accomplish the desired 
change in outcome. Next, one must deter- 
mine the level of certainty necessary to deter- 
mine the variable responsible for creating the 
change. Finally, the program must be given 
enough time to mature and for the staff to 
develop the necessary skills to make all of 
this possible. 

Speaker: Arthur MacNeill Horton, Jr., Ed.D 

Guidelines are helpful for selecting evalu- 
ation consultants. First, consultants' attire 
should be neither slovenly nor overly dressed, 
for this may be seen as a reflection of their 
work. Next, by researching previously pub- 
lished work of the prospective consultants, a 
clearer picture emerges as to the company's 
capabilities. In addition, the consultants 
should be aware of statistical packages, such 
as SAS (Statistical Analysis System) and 
BMS programming, and should be able to 
provide the names of at least five satisfied 
customers. In summary, consultants are 
chosen for their brains and not their beauty. 

Some necessary resources exist for conducting 
evaluations. In regard to providing feedback 
to program staff, clinical staff should be 
involved whenever possible. Since they are 
the ones being evaluated, their input is 
crucial in order to construct the most effec- 
tive delivery of services. Also, there should 
be a record of findings and implications, and 
all that is learned must be made available. 
In addition, since suggestions are being made 
in order to improve the means by which 
services are to be delivered, precautions 
should be taken to ensure that the program- 
matic changes be presented in a nonjudgmen- 
tal fashion, cognizant of the fact that the 
people currently involved in the program may 
feel defensive about any program altera- 
tions — especially in programs that already 
are operating smoothly. 

Questions, Answers, and Comments 

Often in the community setting, the incremen- 
tal approach will not work. For example, in 
order to apply for a particular grant from the 



214 



Summaries of Issues Forums 



Federal Government to serve a particular 
population, several components will need to be 
added to the existing program. In these 
situations, an evaluation must be designed 
that is specific to the program that is being 
put into place and the requirements of the 
funding agency. Program improvement, as 
opposed to grant development, should be an 
incremental process. 

Generally, when should the evaluator be 
brought in? It rarely benefits the program's 
development to bring in an evaluator on a 
post-hoc basis. It would be similarly ineffec- 
tive to bring in an evaluator too early — that 
is, before the program has had enough time 
to grow to maturation. 

One recommendation was that available 
resources be used. Please specify. In terms of 
available resources, involve the academic 
community whenever possible. Use the 
resources found within the universities. 
Enlist prospective doctoral students who are 
looking for dissertation topics. Be sure to 
formulate the question to be answered and 
set up the ground rules so that the hired 
consultants work for the person who hired 
them and perform the work they are hired to 
do. 

How should a portion of the community be 
involved that has voiced the opinion that it 
does not want to be involved in the evaluation 
process? First, determine whether this por- 
tion of the community is an integral part of 
the study. If it is, there may be a misconcep- 
tion of what the evaluation is doing. Conse- 
quently, meet often and at length to explain 
the evaluation more clearly. Work at be- 
friending the community; likely you need its 
assistance more than it needs yours. 

What should be done if the community is too 
involved and continually asks whether it is 
getting enough out of its evaluation? An 
overactive community, wanting more "bang 
for the buck," must be convinced that it is 
being served well and shown the positive 
impact that is being created. Demonstrate 
that you are providing information to the 
community that will move it in the direction 
in which it wants to move. Often this is all it 
takes. 

What can be done in terms of building con- 
trols into the sampling design with regard to 
the methodology in order to guarantee that 
one does not engage in a type of "creaming" in 
order to satisfy the needs of the agency that is 
being evaluated? This question presumes 



external pressures that would drive the 
program to "cream" in order to appear suc- 
cessful. Sampling strategies exist to reduce 
bias in the selection of clients for an evalua- 
tion study; however, it will be important to 
make certain that the evaluation is seen as 
being on the side of program improvement 
rather than a monitoring function involving 
penalties for "inadequate" performance. 

IF16. Treatment and Prevention 
in Rural Settings 

Moderator: Elizabeth Steel. M.S.W. 
Speakers: Jean Carney. M.P.A. 

Virginia McCoy. Ph.D. 

Martha Rueter. Ph.D. 
July 16. 2:30 p.m.-4:00 p.m. 

Speaker: Jean Carney, M.P.A. 

A demonstration project conducted in 1989 
focused on the treatment and prevention 
needs of many rural settings