The Effectiveness of Drug Abuse Treatment:

Implications for Controlling AIDS/HIV

Infection

September 1990

OTA-BP-H-73

NTIS order # PB91-104885
The Effectiveness of Drug Abuse Treatment:

Implications for Controlling AIDS/HIV Infection

Jane E. Sisk, Project Director

Evridiki J. Hatziandreu, Study Director

Rita Hughes, Research Assistant

Other Contributing Staff

Sharon Hamilton, Research Assistant

Virginia (Cwalina, Office Administrator

Eileen Murphy, P.C. Specialist

Carolyn Martin, Word Processor Specialist

Angela Dantzler, Secretary

September 1990

A Background Paper in OTA’s

Series on AIDS-Related Issues

The views expressed in this Background Paper do not necessarily

represent those of the Technology Assessment Board, the Technology

Assessment Advisory Council or their individual members.

This paper was prepared for desk-top publishing by Carolyn Martin and Eileen Murphy.
The impact of AIDS an d

immunodeficiency virus (HIV) on

other disease associated with the huma n

the Nation’s health and health care resources is

continuing. Congress has responded to the AIDS crisis with large increases in

Federal funds for basic and applied research and education and has begun to

grapple with the difficult issues involved in financing AIDS-related health care.

AIDS is on the agenda of a large number of congressional committees and raises

numerous important issues that require congressional attention and decisions.

These developments led to a recommendation, in May 1987, by OTA’s Technology

Assessment Board, with encouragement from the Legislative Subcommittee of the

House Appropriations Committee, that OTA provide assistance on AIDS-related

issues to Congress on a sustained basis. That request led to OTA’s series of

studies on AIDS-related issues. This Background Paper is the sixth in that series.

In 1989, the Board extended the OTA project on AIDS for another 2 years.

This Background Paper examines the evidence of the effectiveness of drug

abuse treatment; it also evaluates the role that such treatment might play in

reducing the spread of HIV. Because most intravenous drug users are not in

treatment, the paper also examines other approaches to HIV prevention among

this high-risk group.

The preceding papers in this series were Do Insects Transmit AIDS? (September 1987); AIDS and Health Insurance - An OTA Survey (February 1988); How

Effective Is AIDS Education (June 1988); The Impact of AIDS on the Kaiser

Permanence Medical Care Program (Northern California Region) (July 1988); and

How Has Federal Research on AIDS/HIV Disease Contributed to Other Fields?

(April 1990) (see inside back cover for information on how to order these publications). Previous OTA reports addressing AIDS-related issues include: 1) Blood

Policy and Technology (January 1985), 2) Review of the Public Health Service’s

Response to AIDS (Technical Memorandum, February 1985),3) The Costs of AIDS

and Other HIV Infections: Review of the Estimates (Staff Paper, May 1987), and 4)

Medical Testing and Health Insurance (August 1988).

~zf AJ$La? -2

OHN H. GIBBONS

~Director
CONTENTS

Chapter Page

1. Introduction and Summary....* .*...*.. *e*** ****. *.*... ***** ***. **.** *****e**.********.************. .**..   .** ************-1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .*. . . . . . . . . . ● . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● * . . . . . . . . . . ● . . . . . . . . . •, .................1

Summary of the Findings. .*. . . . . . . . . . . . . . . . . . . . . ● *.... ● *. . . . . . . . . . . . . . . . . . . . . . . . . . . ● . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .* . . . . . ..**. . . . . . . . . ● ● . . . . . . . .* , . . . . 2

Magnitude of the Problem ● . ● . . . . . . . ● . . . . . . . . . . ● . . . . . ● ., . . . . . . . . . ● . . ● . . . . . . . . . . . . . . . . . . . . . . . . . ● . . . . . . . ● ● . . . . . . . . ● ● . . . . . ● . . ● . . . . . . . ● . . . . . . . . ● ● . 2

Assessing the Effectiveness of Drug Abuse Treatment. . . . . ● . . . . . . . . . . . . . . . . . . . . . . ● . . . . ● ● ● . . . . . . . . . ● . . . . . . . . . ● . . . . . . . . . . . . .2

Implications of the Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .**. ● *... . . . ● . . . . . . . ● . . . . . . . . . . . ● . . . . . . . . . . . . . .*. ..*** . . . . . . . . . . ● ** . . . . . . . . . . . . .* . ● . . . 8

Reaching People Not in Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .* . . . . . . . . ● . . ● . . . . . . . . . . ● . ● ● . . . . . . . ● . . . . . . . . . . . . . . . . . . . . . . 8

Improvement in Quality. . . . . . . . . . ● . . . . . . . . . . . . . . ● . . ● . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● . . . . ● , . . . . . . . . . . . . . . . . . . . . . ● . ● . . . . . ● . ● . . . . . . . . . . . . . . . ● ● . . . . . . . 9

Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... 10

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............... .......... ● .. 10

2. Drug Use and HIV Infection: The Current Situation. . . . . . . . . . . ● .000..0..00 .0.0000 .0......0...0.. . . . . . . . . . . . . . . . ● 0.....0.. ● O..*..**. ● ..*.*******. ● 13

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .............. .............. 13

Use of Illegal Drugs in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Substance Dependence, Substance Abuse, and Casual Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Drugs of Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........ 13

Magnitude of the Drug Abuse Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Drug Use and HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Routes of Transmission That Link Drug Use to AIDS, . . . . . . . . . . . . . . . . . ● . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Estimates of IV Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Estimates of Risk Behaviors Among Drug Abusers. . . . . . . . . . . . . . . . . . . . ... , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

HIV Seroprevalence Among Drug Users . ● . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

AIDS Cases Reported to the Centers for Disease Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● . . . . . . . . . . . . . . . . . 34

Cost Estimates of Drug Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● . . . . . . . . . . . . . . . . . . . . . . . . .* . . . 38

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .............. ................... 39

3. Treatment for Drug Abuse in the United States ● . . . . . . . . . . . . . ● ***.. ***.*..** ● .*.** *.*.....* ● ***** *.***...* . . . . . . . . . . . . . . . . ● .*..*.**.***** .  ** ..**.41

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........... .................. 41

Treatment Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........... 41

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............ 41

Role of Detoxification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Pharmacotherapy Treatment Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Drug-Free Treatment Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

The Role of Multimodality Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Treatment Programs in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............. 49

NDATUS: Description and Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

SADAP: Description and Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

The Extent of HIV Testing and Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Shortages of Treatment Slots. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Information on the Cost of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Summary of the Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .... 58
CONTENTS-Continued

4. The Effectiveness of Treatment for Drug Abuse ● ***.*********..****************** ● ***..*.************.**..*****.* ● ***** *****0 ..*..* ***** *****w**e** 59

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............. ..........**.*..59

Natural History of Drug Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . **.............*.***** . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

Overview of Drug Abuse Careers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ... *o.. *.*o.. O***..* . . . . . . . . . . 59

Heroin Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .*..... *+*** . . . . . . . . . . . . . . . . . . . . . 60

Cocaine Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... **.  .............. **  . . . . .61

Methodologies.1 Problems in the Evaluation of Treatment Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

DARP

Study Design. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............. 62

Definition of Treatment and Outcome ● . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............... .... 64

and TOPS: A Description of the Two National Multimodality Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Drug Abuse Reporting Program (DARP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Treatment Outcome Prospective Study (TOPS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........ *.. ****. *...... .*.. **.***65

Treatment Effectiveness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........

6 6

Methadone Maintenance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Other Pharmacological Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Therapeutic Communities (TCs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ’79

Outpatient Drug Free (ODF) Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .*, .. ** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84

Results Combining Treatment Modalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............. 88

Parameters Related to Treatment Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Matching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............... .*.. 89

Other Contemporary Issues Related to Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .** 96

Summary and Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

5. Treatment for Drug Abuse as a Strategy to Prevent HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . ●  e O** o*o*.e*o*o** *. ”**e..eoee*o . . . . . 101

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .............. ..........*** 101

Methodological Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● **. .*....... 102

Study Design Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Study Outcome Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Measurement Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... **.* 103

Validity of the Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Effectiveness of Drug Abuse Treatment to Prevent HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Reduction in Drug Use and Risk Behaviors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● * O . . . . . . . . . . . 104

HIV Infection and Entry Into Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .*.. 105

Medical Maintenance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Interim Methadone Maintenance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Additional Approaches to Prevent HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

The Importance of Preventing IV Initiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Risk Reduction Through Needle-Exchange Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Sale and Possession of Injection Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...*.,..*.*.. 111

The Role of Outreach Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................... ........... 113
CONTENTS--Continued

Appendix

A. Method of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● . . . . . . . . . . . . . . . . . . . . . . .......... .... ● 115

B. Workshop Participants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *. *...*.... . . . . . . . . . . . . .*. . . . . . . . . . . . . . . . . . . . . . . . . ....0,.,., . . . . . . . . . . . . . . . . . . . . . . ,, .,....0.. . . . . . . . . . . . ,.*. * 116

C. Acknowledgements. . . .** . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . , , . . . . . . . . . . . . . . . . . . , , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● ● . . . . . . . . . . . .*. . . . . . . . ● ** . . . . . . . . . ● . . . . . ● . . . . . . . . . 117

D. Glossary of Abbreviations and Terms . . . . . . . ● . . . . . . . . . ● . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● . . . . . . . . . ● . . . . . . . . . . . . ● ● . . . . ● . ● . . . . . . . . . ● ● . . . . . . . . . . . . . . . . ● 118

E. Psychoactive Drugs Other Than Narcotics and Stimulants . . . . . . . . . . . . . . ● . . ● . . . . . . . ● , . . . . . . . . . . . .* . . . ● . . . . . . .* , . . . . ● ● . . . . . . . . . . . . . ● . . . . . 122

F. Cost Benefit Analysis of Drug Abuse Treatment: Declines in Criminal Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125

G. Highlights From the 1989 National Drug and Alcoholism Treatment Unit Survey (NDATUS) ................127

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ ................*.*.... ...,, 128

Boxes

Box Page

2-A. American Psychiatric Association’s Diagnostic Criteria for Psychoactive Substance Dependence ..........14

2-B. Other Information Systems on Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● 20

5-A. Drugs of Abuse and the Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Figures

Figure Page

2-1.

2-2.

2-3.

2-4.

2-5.

2-6.

2-7.

2-8.

2-9,

2-1o.

2-11.

2-12.

2-13.

3-1.

3-2.

Use of Any Illicit Drug During the Past Year, National Household Survey, 1985 and 1988......................fi

Any Illicit Drug Use by High School Seniors, 1975 to 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Percent of Population Reporting Heroin Use in Lifetime by Region and Age Group, 1985 and 1988....23

Percent of Population Reporting Heroin Use in Lifetime by Sex and Race/Ethnicity, 1985 and 1988....23

Drugs Mentioned Most Frequently in Emergency Rooms Episodes, by Percent of Total Episodes........24

Trends in Cocaine and Heroin Emergency Room (ER) Mentions 1984 to 1988 . . . . . . . . . . . . . . . . . . . . . . ● . . . . . . . . . . . . . . . . . 25

Percent of Population Reporting Cocaine Use in the Past Month by Sex and Race/Ethnicity,

1985 and 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................ ......*. 25

Cocaine Users During Past Year, 1985 and 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Cocaine Use by High School Seniors, 1975 to 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Cocaine Trends in Past Year Among High School Seniors, 1975 to 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Emergency Room Mentions of Cocaine and Heroin by Route of Administration, 1988 32

AIDS Cases in Adults and Adolescents by Risk Factor, June 1989 through May 1990

. . . . . . . . . . . . . . . . . . . . . . . . . . .

● .... **... *.... *.*.. *.... ● ..,.34

Reported AIDS Cases Associated With IV’ Drug Use per 100,000 Population United States, 1988........36

Drug Abuse Clients in Treatment by Setting and Modality According to the National Drug

and Alcoholism Treatment Unit Survey (NDATUS), Oct. 30, 1987 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Admissions of Drug Abuse Clients by Setting and Modality According to the State Alcohol

and Drug Abuse Profile (SADAP), Fiscal Year 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .***..... ..**.... 55
CONTENTS--Continued

Tables

Table

1-1.

1-2.

1-3.

2-1.

2-2.

2-3.

2-4.

2-5.

3-1.

3-2.

3-3.

3-4.

3-5.

3-6.

4-1.

4-2.

4-3.

4-4.

4-5.

4-6.

4-7.

4-8.

4-9.

4-1o.

4-11.

4-12.

Page

Percent of Self-Reported Outcomes by Clients in Methadone Maintenance

Treatment, Selected Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Percent Self-Reported Outcomes by Clients in Therapeutic Communities, Selected Studies ...................6

Percent Self-Reported Outcomes by Clients in Outpatient Drug-Free Programs, Selected Studies ........7

Trends in Hospital Emergency Room (ER) Mentions of Cocaine Reported to the Drug

Abuse Warning Network (DAWN), by Metropolitan Area, 1984 to 1988. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Percent Self-Reported Drug Injection and Needle-Sharing in Male Arrestees, Selected

U.S. Cities, January to March 1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Number and Rate Per 100,000 Population of AIDS Cases Associated With IV-Drug Use,

by Census Region and Race/Ethnicity, 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Projected Number of AIDS Cases, Persons Living With AIDS, and Deaths Attributable to AIDS

After Adjustment for Underreporting, 1989 to 1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Projected Number of AIDS Cases by Risk Group, 1989 to 1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Drug Development Program of the National Institute on Drug Abuse (NIDA), 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Information on Drug Abuse Treatment Units, from the National Drug and Alcoholism

Treatment Unit Survey (NDATUS),, Oct. 30, 1987. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 51

Number of Alcohol or Drug Treatment Units by State Alcohol or Drug Agencies According

to the State Alcohol and Drug Abuse Profile Data (SADAP), Fiscal Year 1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Estimated Admissions of IV Drug Abusers and Total IV Drug Abusers, by State, Fiscal Year 1988....54

Drug Treatment Centers Providing Human Immunodeficiency Virus (HIV) Counseling, Testing,

and Partner Notification in Selected State and New York City, 1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Estimates of Waiting Lists for Alcohol and Other Drug Abuse Treatment, Sept. 29, 1989 .....................57

Percent Self-Reported Heroin Use and Crime by Males by Time in Methadone Maintenance

Treatment, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................. 68

Percent Self-Reported Opiate Use, Criminal Activity, and Employment by Males

in a Methadone Maintenance Treatment, DARP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Percent Self-Reported Drug Use, Criminal Activity, and Employment by Methadone

Maintenance Clients Treated at Least 3 Months, TOPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Odds Ratio for Post-Treatment Outcomes in the First Year after Methadone Maintenance

Treatment, by Treatment Duration, TOPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Percent Success Among Program Graduates, Phoenix House . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., .4$.0 79

Percent Success Among Program Dropouts, Phoenix House . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

. 80

Percent Self-Reported Opiate Use, Criminal Activity, and Employment by Males

in Therapeutic Communities, DARP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Percent Self-Reported Drug Use, Criminal Activity, and Employment by Therapeutic

Community Clients Treated at Least 3 Months, TOPS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Odds Ratio for Post-Treatment Outcomes in the First Year After Residential Treatment,

by Treatment Duration, TOPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Percent Self-Reported Opiate Use, Criminal Activity, and Employment by Males

in Outpatient Drug-Free Treatment, DARP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Percent Self-Reported Drug Use, Criminal Activity, and Employment by Outpatient Drug-Free

Clients Treated at Least 3 Months, TOPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Odds Ratios for Post-Treatment Outcomes in the First Year After Outpatient Drug-Free

Treatment, by Treatment Duration, TOPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Chapter 1

Introduction and Summary

INTRODUCTION

Two health epidemics in the United States have

overlapped with disastrous results: drug abuse, a

chronic relapsing disorder, and human immunodeficiency virus (HIV) infection, the cause of AIDS.

Because these epidemics have affected a wide range

of areas from medical care to law enforcement, the

cost to society is substantial, both in tangible and

intangible terms. A fatal link between the two

epidemics compounds the problem, as the multiplicity of HIV transmission modes makes drug users,

intravenous (IV) drug users in particular, a critical

group in the spread of HIV infection.

Three modes of transmission connect drug abuse

. and HIV infection. One occurs among IV users of

drugs, primarily heroin and cocaine, who share

injection equipment that is contaminated with

infected blood. Through sexual transmission, the

second mode, infected IV drug users may pass HIV

to their sexual partners. In particular, crack, a smokable and powerful form of cocaine, is associated with

sexual behaviors at high risk of HIV transmission.

The third mode of transmission occurs during pregnancy or shortly after birth, when women infected

through IV drug use or by IV drug-using sexual

partners may transmit the virus to their infants.

The use of psychoactive substances ranges from

casual and recreational use to abuse and dependence

or addiction. Although all degrees of drug use, if

associated with certain behaviors, put users at risk of

HIV infection, more frequent high-risk behaviors, of

course, increase the likelihood of viral transmission.

Substance dependence, the most severe condition, is

characterized by compulsive use and loss of control

over drug use (6). Continued use despite adverse

consequences, failed attempts to stop, considerable

time spent procuring the drug, and symptoms of

tolerance and withdrawal are characteristic of substance dependence. A substance abuser continues

use despite social, occupational, psychological , or

physical problems or despite recurrent use in physically hazardous situations. Casual users, the least

serious category, take certain drugs only occasionally

or in low or moderate doses, usually in social contexts, and do not exhibit the maladaptive behavior

patterns associated with substance dependence and

substance abuse. Casual use still poses risks to the

individual and society since any needle-sharing or

drug-associated high-risk sexual behaviors may

transmit HIV and other infections.

In this Background Paper, the terms drug abuse

and drug dependence are used interchangeably, and

the term drug abuser also includes drug addicts, who

have lost control over their substance use.

Drug abuse is a chronic relapsing disorder; its

pattern of relapses and remissions resembles other

chronic diseases, such as arthritis and chronic

depression. Similarly, no treatment exists to totally

eradicate the condition. Unlike treatment for acute

conditions, such as a broken leg or a simple infection,

treatment for drug abuse shares the same objectives

as treatment for other chronic conditions: 1)

amelioration of symptoms (e.g., impaired functioning) and 2) prolongation for as long as possible of

symptom-free intervals (e.g., maintenance of the

desired behavior changes).

Preventing the spread of HIV among drug

abusers is a formidable task. That drug abuse is a

chronic relapsing condition and that drug abusers are

a heterogeneous population with other social and

behavioral problems pose obstacles to effective

treatment. Moreover, the increasing use of

injectable and smokable cocaine, coupled with the

lack of an effective medication to treat cocaine

abuse, makes even more difficult the control of HIV.

Sexual behavior appears more difficult to modify

than needle-sharing behavior. This fact further

underscores the diligence required to halt this

tremendous public health challenge (341).

-1-
2- The Electiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

This OTA Background Paper has a dual role: it

examines evidence for the effectiveness of treatment

for drug abuse and evaluates the role of drug abuse

treatment as a strategy to prevent HIV spread.

Because most IV drug users are not in treatment, the

study also examines other approaches to HIV prevention among this high-risk group.l

The remainder of this chapter summarizes the

main findings. Chapter 2 reviews the current

situation regarding drug use and HIV infection in the

United States. Chapter 3 provides background

information about the drugs of abuse and various

treatment modalities. Chapters 4 and 5, respectively,

review the existing literature on the effectiveness of

drug abuse treatment and on its role in preventing

HIV infection. The various appendixes describe the

method of the study; acknowledge experts in the field

“who provided valuable advice; describe drugs of

abuse other than opiates and cocaine; summarize a

cost-benefit analysis of drug abuse treatment; and

review highlights from the most recent National

Drug and Alcoholism Treatment Unit Survey.

SUMMARY OF THE FINDINGS

Magnitude of the Problem

HIV is transmitted through sharing contaminated

needles and other equipment used to inject drugs.

The sharing of injection equipment is a common

practice throughout the United States in areas of

high and areas of low HIV seroprevalence, with

reported rates of sharing among IV drug users as

high as 70 to 100 percent (8). Heroin and cocaine

alone or in combination are the most common

injectable drugs, while amphetamines are popular in

certain parts of the country. Overall, the estimated

number of IV drug users in the United States ranges

from 1.1 to 1.8 million (64,220,307). Using data

through 1985, the National Institute on Drug Abuse

(NIDA) estimated that there are 500,000 IV heroin

addicts; 250,000 IV heroin users who are not addicts;

475,000 IV cocaine users; 150,000 overlapping IV

1This paper does not examine issues related to drug abuse and

HIV infection among adolescents. These issues are addressed in

an upcoming OTA Report on adolescent health expected to be

published in early 1991.

cocaine and heroin users; and 25,000 IV users of

other drugs (282). Given estimation problems and

the passage of time, however, the actual number of

IV drug users may differ substantially (282).

Of all IV drug users, 80 to 90 percent are not in

treatment at any given time (216a,332a,341). Among

users not in treatment who volunteered to participate

in U.S. urban outreach programs from 1987 to 1989,

34 percent injected predominantly heroin, 31 percent

cocaine, 33 percent combinations of heroine and

cocaine, and 2 percent amphetamines or other drugs

(340). Heroin was the predominant drug for almost

60 percent who reported daily drug injection. Most

of these volunteers, 60 percent, had previously been

in treatment. Substantial proportions engaged in

behaviors that put them at high risk of contracting or

transmitting HIV: 78 percent reported sharing drug

injection equipment with another IV drug user; 20

percent shared equipment with strangers; and 48 to

85 percent, depending on the type of sexual activity,

never used a condom (340).

Of approximately 350,000 drug clients in

treatment in fall 1989, about 41 percent had used

drugs intravenously (332a). Public and private facilities across the country reported treating almost 1

million drug users of all kinds during the year ending

with September 1989.

The association between drug use and HIV

infection is not confined to IV drug use. Sexual

behaviors associated with the crack epidemic, such as

sex for drugs, casual sex with multiple partners, and

careless sex while high on drugs, put drug users at

increased risk of HIV infection (112). In 1988, about

1 million people in the United States had used crack

in the past year, and about 0.5 million had smoked it

in the past month (330). Among 1988 high school

seniors, about 3 percent reported having smoked

crack during the previous year (320a).

Counting drug users and their sexual partners, an

estimated 1.8 million people are at risk of contracting

HIV (318). Currently, IV drug use is the second

most common risk behavior reported for AIDS cases

in the United States, surpassed only by unsafe sex

among homosexual or bisexual men. In several

Northeastern States and Puerto Rico, the number of
Chapter 1--Introduction and Summary 3

adult AIDS eases among IV drug users exceeds those

among homosexual men (335). Among women with

AIDS through May 1990, about 70 percent were

associated with IV drug use or an IV drug-using

sexual partner (349). Moreover, about 70 percent of

the children with AIDS who were presumably

infected through perinatal transmission had mothers

who were IV drug users or sexual partners of IV

drug users.

African-Americans and Hispanics constitute 20

percent of the U.S. population, but 44 percent of

AIDS eases through May 1990 (304a,349). In AIDS

associated with drug use, these groups have also been

disproportionately affected; they have accounted for

79 percent of AIDS among IV drug users, 77 percent

of AIDS among heterosexual partners of IV drug

users, and 85 percent of children presumably infected

through mothers who were IV drug users or sexual

partners of IV drug users (349).

Because of AIDS’ long gestation period, current

AIDS cases reflect drug use patterns and high-risk

behaviors that occurred 5 or more years ago. The

impact of more recent trends of heavy cocaine and

crack use, which are associated with high-risk

behaviors for transmitting HIV, is yet to come.

Although declining trends in casual use of illicit

drugs have been reported from national surveys,

these figures may underestimate the magnitude of

the problem. The major surveys exclude certain population groups that have a higher likelihood of drug

abuse, such as homeless people and those in prisons

and jails (304,330). In addition, the magnitude of

underreporting may have increased in recent years,

as social tolerance toward illicit drug use has

decreased (304).

Assessing the Effectiveness

of Drug Abuse Treatment

This Background Paper focuses on the three

treatment approaches that have been subjected to

the most evaluation: outpatient methadone

maintenance programs, residential therapeutic communities (TCs), and outpatient drug-free (ODF)

programs. Although other medications besides

methadone are being developed and evaluated, none

is in widespread use. Traditional TCs and ODFs fall

into the category of programs that on philosophical

grounds do not employ medications.

Evaluations of the effectiveness of treatment

assess whether a particular treatment approach has

reduced behaviors associated with drug abuse, chiefly

the frequent use of heroin or cocaine. Certain methodological problems handicap interpretation of the

results. Almost all evaluations have studied groups

of people entering treatment programs and compared their behaviors before and after treatment.

Recovery from drug abuse, however, may be influenced by many factors, such as previous treatment

episodes, involvement with the criminal justice

system, pressure from family and friends, and religious involvement. These factors may interact or

operate independently.

Without randomly assigning people to treatment

and having a control group for comparison, one

cannot separate the effect of treatment from the

effect of other factors that might affect behavior,

such as the individual circumstances of the people

who choose treatment (see ch. 4). Interpretation is

rendered more difficult by the lack of information

about the history of drug abuse careers. Although

some people reduce or eliminate drug use without

treatment, not enough is known about the natural

history of this chronic, relapsing condition to

estimate how many would improve regardless of the

intervention. In addition, the results generally

consist of behaviors reported by the drug abusers

studied, reports that may be biased. On average,

however, these self-reports have been found to

conform to other sources of information (149,267).

Although research on drug abuse has intensified,

no completed studies have evaluated treatment for

crack. Nor are evaluations of more recent variations

in traditional approaches, such as shorter residential

programs and self-help groups, yet available.

Methadone Maintenance

Efficacy and Effectiveness--Methadone is a

synthetic narcotic used to treat dependence on

opiates. Heroin, the most frequently abused opiate,

is administered mainly by injection. When

administered regularly in adequate doses, methadone

can reduce the craving for heroin, prevent the onset “
4-- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

of opiate withdrawal symptoms, and block euphoria

from heroin. Daily methadone is administered

orally, usually to outpatients. By reducing drug

craving and fear of withdrawal and blocking euphoria

from heroin, methadone enables heroin abusers to

reduce IV drug use and associated risky behaviors.

Although all methadone maintenance programs

share the objective of reducing opiate use and

changing behavior, they vary in their orientation, with

some emphasizing eventual cessation of drugs,

including methadone, and others accepting indefinite

maintenance on methadone. In addition, methadone

maintenance programs vary in methadone dose,

counseling and other rehabilitative services, policies

regarding discharge and readmission, take-home

privileges, and frequency of urine testing.

Methadone’s ability to reduce use of heroin and

other illicit opiates has been shown in numerous

studies over 25 years. Consistent evidence and

strong study designs bolster this conclusion.

For example, in a randomized controlled trial of

maintenance on methadone v. placebo, after 3 years,

56 percent of those maintained on methadone

remained in treatment, while only 2 percent given

placebo remained (227). Although monthly heroin

use among those on methadone stabilized at about

35 percent, 63 percent of the control group compared

with only 5 percent of the methadone maintenance

group were removed from treatment because of persistent heroin use. A natural experiment comparing

clients involuntarily discharged when a clinic closed

with a matched sample in a continuing clinic found

similar results (207). Of those involuntarily discharged, 55 percent resumed heroin addiction compared with 31 percent in the continuing clinic.

Reports of opiate use before and after treatment

have found the same pattern (see table l-l). On

average, 75 percent of the clients in long-term

methadone maintenance have ceased illicit opiate

use (258). Methadone maintenance programs also

retain 55 to 85 percent of their clients for a 2-year

Table l-l-Percent Self-Reported Outcomes by Clients in Methadone Maintenance

Treatment, Selected Studies

DARPa TOPSb Ball Studyc

Before Year after Year before Year after In treatment In treatment

Category treatment treatment treatment treatment 0.5 to 4.5 years over 4.5 years

Opiate used. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 36 63.5 16.7 15.8 3.4

Cocaine used. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA NA 26.4 17.5 26.6 17.2

Criminal activity . . . . . . . . . . . . . . . . . . . . . . . . . 88 27 31.8 19.0 11.1 9.4

Employment f.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 57 24.2 20.1 NA NA

ABBREVIATION: NA = Not available.

aDARP, the first federally funded national multimodality study of treatment effectiveness, began in 1%9. Findings refer to white and

black males only. Data refer to all clients who were admitted to treatment, regardless of the length of time spent in treatment. Average

followup rates were 79 percent for cohorts admitted to treatment from 1%9 to 1971 and from 1971 to 1972 and 64 percent for the cohort

admitted in 1973 to 1974.

b TOPS, a federally funded national multimodality study, began in 1979. Results pertain to the 68 percent of clients who stayed in

treatment at least 3 months. The average response rates for a sample of 1,539 clients, regardless of time in treatment, were 80 percent

for the year before treatment and 75 percent for the year after treatment.

cBall and colleagues conducted a cross-sectional study of six programs in the Northeast. The study sample was a representative sample of

clients including new admissions and clients already in treatment.

‘Daily opiate use for DARP, weekly or more frequently for TOPS, and use during the past 30 days for the Ball study.

‘Criminal activity refers to any arrest during one’s lifetime before treatment or in the year following treatment in the DARP study; selfreported involvement in predatory crimes, excluding crimes related directly to drug use, in the TOPS study and any criminal activity in

the past 30 days in the Ball Study.

‘Employment refers to employment half-time or more during the year before treatment or during the year after treatment in the DARP

study, and to full-time employment in the TOPS study.

SOURCE: Ball, Corty, Meyers, et al. (20); Hubbard, Marsden, Rachal, et al. (149); Simpson, and Sells (272).
Chapter 1--Introduction and Summary- 5

period, rates far higher than those of other

modalities for treating drug abuse (258). These

retention rates may in part be related to patient

selection. Since Federal guidelines for methadone

maintenance specify that clients must have received

previous treatment, they may be older and further

advanced in the addiction career compared with

other drug abusers (13).

Methadone maintenance’s role specifically as a

means to prevent HIV infection has been examined

in about a dozen studies. In New York City, San

Francisco, Sweden, and Italy, drug abusers who have

entered treatment early in the epidemic and

remained in treatment have consistently had lower

seroprevalence rates than those who entered later

(1,36,40,132,228,291,295,374,376). Methadone

maintenance thus may have exerted a protective

effect by reducing IV drug use.

Although IV heroin use can be curtailed with sufficiently high doses of methadone, methadone cannot

address pharmacologically the concurrent IV or nonIV use of other drugs, most notably cocaine. It has

been observed, however, that a proportion of IV

drug users stop using IV cocaine while on methadone

maintenance (149). The use of IV cocaine is of particular relevance to efforts to halt the spread of the

HIV epidemic, since IV cocaine use appears to be

associated with a greater frequency of injections and

sharing of injection equipment (110). It has also

been associated with an increased risk of HIV

infection among methadone maintenance clients

(49,276). These complexities further underscore the

need for a range of prevention interventions to

reduce the spread of HIV transmission.

OTA finds that there is strong and consistent evidence that methadone maintenance treatment can

reduce illicit opiate use and HIV transmission. This

protection is a direct result of methadone

maintenance’s ability to reduce or eliminate abusers’

desire to inject drugs, heroin in particular. In

addition, studies have shown methadone

maintenance clients reducing their criminal activity

and living stable and productive lives.

Methadone Dosage--Research establishes

whether an intervention is efficacious in achieving its

goals. Even an efficacious intervention, however, if

employed sub-optimally, may prove ineffective.

Despite methadone’s ability to reduce heroin use,

considerable variability exists in reported rates, with

as high as 57 percent of clients reporting some level

of heroin use in some programs (21). Although this

variability may be attributed to client characteristics,

evidence points to non-client related variables (21).

Such variation suggests that somewhere in the implementation process, effectiveness may have been compromised.

Insufficient methadone dosage may at least partly

explain the differences observed. An adequate

dosage is needed to prevent drug craving and withdrawal symptoms and block heroin’s euphoria.

Methadone dosage has been shown to be related to

effectiveness, clients’ remaining in treatment, and

HIV seropositivity (40,66,69,98,130,376).

Research indicates that a daily dosage in the

range of 50 to 100 mg, with a mean of 80 mg, is sufficient for most patients (130). A daily dose of 60 mg

is considered to be close to the lowest effective dose

(257). Pooled data on dosage from 6 methadone

programs found an inverse relationship between

daily methadone dose and frequency of heroin use

(98). At a daily dose of 35 mg or less, a little over

one-third of the clients used heroin regularly. By

contrast, at 80 mg per day, there was practically no

opiate use. A recent survey of 24 methadone

maintenance programs around the country revealed

that daily average dosages ranged from 21 to 67 mg,

and 21 of the 24 programs administered an average

daily dose below 60 mg (299).

Interim Methadone--The concept of interim

methadone calls for temporary provision of

methadone and HIV counseling, without additional

ancillary services, to IV drug users who are on

waiting lists until treatment space in a comprehensive

program becomes available. Interim methadone,

which has been proposed exclusively as an alternative

to continued heroin injection in the street, has the

potential to contribute to HIV prevention efforts. In

a randomized experiment among those on waiting

lists in New York City, prevalence of heroin use,

needle use, and mean number of days since last

injection were lower in the interim methadone group

than the control group (264).
6- The Effectiveness of DrugAbuse Treatment: Implications for Controlling AIDS/HIV Infection

Concerns have been expressed that adopting

interim methadone would worsen methadone

maintenance programs, for example, by permanently

reducing the services provided (235,241a,363). These

concerns are worth considering. The urgency of the

HIV epidemic, however, adds an additional

dimension and warrants a clear focus on societal

priorities. Individuals who respond to methadone

will reduce IV use of heroin. Any sustained

reduction in injection frequency is likely to reduce

the rate of HIV transmission and shrink the pool of

people at risk. From a public health perspective, this

is a need that should not be ignored. Interim

methadone may be more appropriate for certain

areas with large number of IV drug users and waiting

lists, such as New York City. Nevertheless, interim

methadone is an immediate response to an urgent

situation.

Other Treatment Modalities

Therapeutic Communities--Traditional TCs are

residential programs with a planned duration of

treatment of approximately 18 to 24 months. The

fundamental philosophy of these programs is that

drug abuse reflects personality problems and chronic

long-standing deficiencies in social, educational, and

marketable skills. TCs provide a highly structured

and often confrontational environment, where peer

pressure along with counseling and therapy is

intended to produce attitude and value changes and a

drug-free lifestyle.

Although methadone acts only on narcotics

abuse, TCs serve individuals with a host of different

primary drugs of abuse. Evaluations conducted in

the 1970s and 1980s consistently found substantial

reductions in heroin and cocaine use among people

who remained in treatment (table 1-2) (76,81,149,

272). Clients of Phoenix House, a large traditional

TC, reduced heroin use from 86 percent before

treatment to 5.8 percent 2 years after treatment (76).

Similarly, according to a national study begun in

1979, TC clients who remained in treatment at least 3

months reduced heroin use from about 31 percent 1

year before treatment to about 12 percent the year

after treatment and cocaine use from about 28

percent before to about 16 percent the year after

treatment (149). These studies also found reductions

in criminal activity and increases in employment.

Table 1-2-Percent Self-Reported Outcomes by Clients in Therapeutic

Communities, Selected Studies

DARPa TOPSbPhoenix Housec

Before Year after Year before Year after Before 2 yearn after

Category treatment treatment treatment treatment treatment treatment

Opiate used. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 39 30.9 11.5 86.0 5.8

Cocaine used. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA NA 27.6 155 NA NA

Criminal activitye

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 33 60.9 28.9 76.2 29.8

Employmentf. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 61 15.3 27.7 26.4 48.8

aDARP, the first federally funded national multimodality study of treatment effectiveness, began in 1%9. Findings refer to white and

black males only. Data refer to all clients who were admitted to treatment, regardless of the length of time spent in treatment. Average

followup rates were 79 percent for cohorts admitted to treatment from 1%9 to 1971 and from 1971 to 1972 and 69 percent for the cohort

admitted in 1973 to 1974.

b TOPS, a federally funded national multimodality study, began in 1979. Results pertain to the 45 percent of clients who stayed in

treatment at least 3 months. The average response rates for a sample of 1,282 clients, regardless of time spent in treatment, were 88

percent for the year before treatment and 81 percent for the year after treatment. c Study conducted at Phoenix House, one of the largest traditional therapeutic communities in New York City. A sample of 1974 to 1975

admissions was followed and results pertain to both graduates and dropouts. The followup rate was 67.1 percent.

‘Daily opiate use for DARP, weekly or more frequently for TOPS, and daily use for the Phoenix House study ec~minal acti~ty ~fem t. any amest during one’s lifetime before treatment or in the year following t~atment in the DARP ‘tudfi *lfreported involvement in predatory crimes, excluding crimes related directly to drug use, in the TOPS study and at least one episode of

criminal activity during any month of observation in the Phoenix House study. fEmplowent refem t. emploment halftime or mow during the year before treatment or during the year after t~atment ‘n ‘he ‘Aw

study, and to full-time employment in the TOPS study, and to employment full-time for at least 50 percent of employable months in the

Phoenix House study.

SOURCE: De Leon, (76); Hubbard, Marsden, Rachal, et al. (149); Simpson and Sells (272).
Chapter 1--Introduction and Summary 7

It should be noted, however, that TCs’ contribution is clouded by high dropout rates among the

clients. Approximately 30 to 50 percent of those who

enter leave within the first 30 days. Overall, the

retention at 1 year is between 15 and 25 percent, and

actual completion rates for programs of 18 to 24

months range from 10 to 15 percent (75). This

limited ability to retain clients is related to the

rigorous, demanding, and confrontational nature of

the TC environment. Apparently, retention rates

reflect considerable self-selection by clients. At least

in the early 1980s, TC residents had more severe

problems than clients in methadone maintenance

and ODF programs (149). This factor may influence

the size and the direction of the observed treatment

effect and retention rate. Measured improvements

in drug use, criminal activity, and employment have

also been observed in 30 to 35 percent of individuals

who leave treatment without completing the 18 to 24

months planned duration (76,80).

The consistency and magnitude of the results is

consistent with the effectiveness of TCs in reducing

drug abuse among its clients. It is difficult, however,

to interpret the evidence. Given the high dropout

rates and lack of an external comparison group, one

cannot rule out the possibility that some would have

improved without treatment or that those who

remained and improved were unusual in some way.

Based on available evidence and their knowledge of

drug abuse patterns, many experts in this area have

concluded that TCs in fact reduce heroin and cocaine

use (33,75,76,77,84,149,248). But until further studies

address the outstanding methodological problems,

OTA cannot come to a firm conclusion regarding the

relative contribution of TCs to reducing heroin and

cocaine abuse.

Outpatient Drug-Free Programs--ODF programs

represent a diverse collection of programs with little

uniformity, whose common denominator is their

drug-free philosophy and outpatient nature. They

vary from casual drop-in centers and recreational

facilities to highly demanding daytime programs with

structures similar to TCs.

The majority of ODF clients do not use drugs

intravenously; in 1987, only 17 percent were IV drug

users (332). Among ODF clients in a national study

(TOPS) who remained in treatment at least 3

months, only 8.6 percent used heroin the year before

treatment, and 4.9 percent the year after treatment

(see table 1-3) (149). Similarly, 12.8 percent

reported cocaine use a year before and 8.1 percent

Table 1-3-Percent Self-Reported Outcomes by Clients in Outpatient

Drug-Free Programs, Selected Studies

DARPa TOPSb

Before Year after Year before Year after

Category treatment treatment treatment treatment

Opiate Usec

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 44 8.6 4.9

Cocaine Usec. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA NA 12.8 8.1

Criminal activityd. . . . . . . . . . . . . . . . . . . . . . 87 34 33..5 18.7

Employment e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 52 27.1 38.5

aDARP, the first federally funded national multimodality study of treatment effectiveness, began in 1%9. Findings refer to white and

black males only. Data refer to all clients who were admitted to treatment, regardless of the length and time spent in treatments.

Average followup rates were 77 percent for cohorts admitted to treatment from 1%9 to 1971 and from 1971 to 1972 and 70 percent for

the cohort admitted in 1973 to 1974.

b TOPS, a federally funded national multimodality study, began in 1979. Results pertain to the 36 percent of clients who stayed in

treatment at least 3 months. Average response rates for a sample of 1,449 clients, regardless of time spent in treatment, were 72 percent

for the year before treatment and 82 percent for the year after treatment.

c dailyopiate use for DARP and weekly or more frequently for TOPS.

Criminal activity refers to any arrest during one’s lifetime before treatment or in the year following treatment in the DARP study, and

self-reported involvement in predatory crimes, excluding crimes related directly to drug use, in the TOPS study.

‘Employment refers to employment half-time or more during the year before treatment or during the year after treatment in the DARP

study, and to full-time employment in the TOPS study.

SOURCE: Hubbard, Marsden, Rachal, et al. (149); Simpson and Sells (272)
8-- The Effectiveness of DrugAbuse Treatment: Implications for Controlling AIDS/HIV Infection

the year after treatment By the end of the fourth

week, however, 36 percent of clients admitted to

ODF programs in the TOPS study had dropped out,

and by the end of the frost year, 86.6 percent had discontinued treatment (149,150).

To interpret the treatment results from ODF programs, several considerations should be kept in mind.

People attracted to ODFs compared with other

modalities may have less severe problems and better

societal functioning and be more amenable to change

(149). Moreover, because of the great variety in

ODF program content and the absence of a standardized treatment process, conclusions regarding

ODF effectiveness may be more tentative than for

the other modalities. Research to compare ODF

programs requires more systematic data and

exploration of organizational elements that may contribute to treatment effectiveness.

IMPLICATIONS OF THE FINDINGS

Reaching People Not in Treatment

Policies to control HIV infection must recognize

that most IV drug users are not in treatment. Only

10 to 20 percent of the estimated 1.1 to 1.8 million IV

drug users in the United States are in treatment at

any time (216a,307,332a). By implication, as many as

1 million or more individuals are engaging in

behaviors that place them at high risk for contracting

or transmitting HIV. From mid 1988 to early 1989,

among IV drug users not in treatment, 69 percent of

the women and 75 percent of the men who

volunteered information on all risk factors were

rated at high risk of HIV infection (325). These

high-risk people reported engaging in three risky

behaviors: sharing needles, using rented or borrowed needles, and not using bleach to clean their

needles.

In demonstration projects conducted since 1987,

NIDA has used community-based outreach workers

to study interventions to reduce risky behaviors

among drug abusers not in treatment (341). From

1987 to 1989, substantial proportions of IV drug

users not in treatment in certain U.S. cities reported

decreasing IV drug use, from

cisco to 75 percent in Miami.

tions also reported decreases

49 percent in San FranSimilarly, high proporin sharing or borrowing

injection equipment (341). In another outreach

program in San Francisco, IV drug users followed

needle hygiene 13 percent of the time in 1986, but 80

percent of the time in 1989 (362). It should be note&

however, that reported reductions in sexual risk

behaviors occurred to a lesser degree than drugassociated risk behaviors (341).

Outreach programs have demonstrated the

feasibility of reaching people who have traditionally

been difficult to contact. Compared with periods

before treatment, program participants increased

entry into treatment and reduced high-risk behaviors.

But given other influences in the community, the relative contribution of the outreach programs to

changes is not clear.

These outreach programs have compared

behaviors reported by IV drug users randomly

assigned to a standard intervention v. an enhanced

intervention, which includes more intensive

counseling and education (38). At the 6-month followup in two Ohio cities, the frequency of sharing

injection equipment, use of shooting galleries, and

use of speedball (heroin and cocaine combined) were

significantly lower, and the use of bleach to disinfect

injection equipment was significantly higher among

those receiving the enhanced intervention.

In light of the large number of IV drug users continuing risky behaviors, it is desirable to explore a

variety of settings to reach them, such as public

health clinics, free-standing HIV counseling and

testing programs, correctional facilities, and healthcare facilities (341). Opportunities available through

drug treatment have not been realized. Although IV

drug users are at high risk for HIV infection, in 1989

only 3.5 percent of HIV counseling and testing sites

were located in drug treatment centers. In New

York City only 13 out of 713 drug treatment centers

(approximately 2 percent) provide HIV counseling,

testing and partner notification (350).

Despite the desire to enter treatment, some drug

abusers cannot do so because space is not available

(239,307). In September 1989, facilities for drug

abuse clients were operating at close to 80 percent of

budgeted capacity (332a). Utilization rates vary by

State, public v. private program, for-profit v. not-for-
Chapter 1--Introduction and Summary - 9

profit status, and inpatient v. outpatient setting (44a).

For example, in October 1987, rates ranged from as

low as 28 percent in South Dakota to 98 percent in

New York and 109 percent in Puerto Rico and from

88 percent in public State and local units to 61

percent in private for-profit units. Financial barriers

also impede treatment for drug abuse. Research has

shown that when financial barriers are reduced, drug

users who have never been treated seek to enter

treatment (341).

Waiting lists and the unavailability of treatment

should not be allowed to serve as deterrents to

seeking help. Although motivation for entering

treatment may vary among abusers, providing

treatment achieves the clear benefit of being in

contact with drug abusers and exposing them to the

benefits of treatment. Subsequent interaction

between client and treatment may enhance

motivation to stay in treatment. Exposure to

treatment may have a positive effect even for those

who eventually drop out, since previous treatment

episodes may exert a cumulative beneficial effect on

the individual. Thus, contact with the drug abusing

client in a controlled environment, if effectively

utilized, presents tremendous opportunities to both

prevent HIV infection and reduce illicit drug use.

Improvement in Quality

Currently, there is shared concern by experts in

the field about deterioration in the quality of existing

programs, especially among methadone maintenance

programs (59,67). The services provided in various

drug treatment centers in the United States are by no

means uniform. Even within the same modality, differences exist in the number, type, and training of

staff and the existence of medical, psychological,

vocational, and rehabilitative services. Furthermore,

the mere provision of these services is not

synonymous with quality, as the way they are provided is also important.

Regulations of the Food and Drug Administration (FDA) and NIDA that set minimum requirements for the use of methadone are not always

enforced (FR 54(10):8954-8971, March 1989)

(67,299). These regulations are mandatory for any

organization dispensing methadone, regardless of

whether the program accepts public funding. The

regulations address a variety of issues, such as

minimum standards for admission, guidelines for

patient evaluation, and minimum standards for the

services provided (counseling, vocational, rehabilitative and other social and support services).

These regulations do not ensure, however, that

the patient receives an individually determined and

medically appropriate dose. This problem has been

well recognized. In 1988, AIDS experts in the Public

Health Service recommended that Federal methadone regulations be revised to provide more flexible

and tailored patient care (307). Both the Public

Health Service and the Presidential Commission on

the HIV epidemic also recommended establishing

quality-of-care guidelines for methadone

maintenance and other drug treatment programs

(239,307). Besides methadone dose, other components of treatment, such as a case management

approach, individual assessment of co-morbidity and

severity of addiction, and program staffing and

structure, may be related to increased effectiveness

(67).

The Methadone Maintenance Quality Assurance

System, a new project initiated by NIDA, will collect

and publish standardized data from all the methadone maintenance clinics on urine testing and

retention by the client’s severity and treatment

duration (323). These data will allow methadone

maintenance programs to be compared and States to

make licensing, inspection, and funding decisions

(323).

The Presidential Commission on the HIV

epidemic has recommended that the scope of programs to treat drug abuse should be expanded to

respond to the HIV epidemic (239). These recommendations are supported by the current complexities of drug abuse patterns and the belief that a

more comprehensive approach to drug treatment

may be needed to effectively address the many

problems that drug abusers face. To be effective in

reducing drug use and HIV transmission, treatment

programs need to recognize and address the high

prevalence of multiple drug use, psychiatric comorbidities, other social deficiencies, and the interaction of these factors.
10-- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

Future Research

During the past 30 years, research on drug abuse

treatment has evolved gradually from anecdotal,

uncontrolled studies with poor study methods to

studies that attempt to conform more closely to

research principles. Advances in the sophistication

of study design and data analysis will allow future

research to address issues that so far have not been

adequately researched.

Overall, high quality studies are needed on ways

to improve treatment effectiveness and efficiency. It

is important to be able to dissect treatment programs

to identify their most effective components and to

determine which components are most effective for

various client groups. With the exception of

methadone maintenance for opiate abusers, the relative effectiveness of approaches for different

patients and drugs has not been subjected to rigorous

analysis. More information is needed on the process

of recovery from drug abuse, both natural and

treatment-assisted. Better understanding of the

natural history of drug abuse would help in designing

interventions and evaluating them. Ultimately,

research on drug abuse treatment should lead to

what has been a common practice in medicine,

namely a ease management approach with an individually tailored plan to maximize the likelihood of

treatment effectiveness.

Knowledge about the relative effectiveness of different programs is also important because of the

implications for the cost of treating drug abuse. As

outpatient approaches, ODF and methadone

maintenance programs do not entail the costs of

inpatient or residential care. In 1987, annual operational costs per patient position were estimated to be

$3,000 for methadone maintenance, $2,300 for

ODFs, and $14,600 for TCs (217). To assess the

cost-effectiveness of these interventions, however,

requires information about the relative effectiveness

of these programs and their respective costs for different types of patients and drugs.

The development and evaluation of techniques to

prevent relapse is of crucial importance because of

the chronic relapsing nature of drug abuse. The

development of medications to assist recovery from

drug abuse is essential, especially with regard to

cocaine and crack, drugs whose increasing use is

linked to high HIV risk through both IV use and

sexual practices.

Federal research underway is addressing many of

these areas. NIDA is funding studies to evaluate different approaches to treating cocaine abuse and different interventions to reduce the risk of HIV

exposure, especially among African-Americans and

Hispanics (327a). Some of this research involves

controlled trials. Research is assessing treatment

components, such as relapse prevention, behavioral

techniques, family therapy, and support groups. Substance abuse treatment among women is also being

studied. Other areas covered include improvement

in methods to study drug abuse and to enhance the

data collection in different States.

Improving technical assistance, to support technology transfer in the field of drug abuse and to

encourage implementation of quality assurance

mechanisms in treatment is part of the mission of the

Federal Office for Treatment Improvement, which

was created in January 1990 (332b). This Office is

also supporting projects to reduce waiting lists for

drug abuse treatment. For fiscal year 1990, it

planned to provide grants for treatment improvement demonstration projects in metropolitan areas;

for critical populations, such as racial and ethnic

minorities, adolescents, and residents of public

housing projects; and for criminal justice populations.

It should be noted, however, that the fruits of

these efforts will not materialize unless larger

numbers of abusers are willing or able to enter and

remain in treatment. Thus, research to increase

recruitment and retention in treatment is also

essential.

CONCLUSIONS

Methadone maintenance is clearly efficacious in

reducing opiate use and associated IV use of heroin.

Its effectiveness, however, may sometimes be compromised by inadequate doses of methadone. Philosophical and political differences about the use of

methadone, such as concerns about substituting one
Chapter l–Introduction and Summary- 11

opiate for another and fears of illegal diversion, have

inhibited administration of adequate methadone

doses. As a result, methadone’s potential to prevent

HIV is probably not being realized.

Although methadone is effective for opiate use, it

is not a treatment for abuse of cocaine, a pharmacologically different drug. No clearly efficacious

treatment for cocaine, whose use in IV and smokable

forms is associated with behaviors at high risk of

transmitting HIV, is yet available.

Research findings are consistent with the effectiveness of TC and ODF programs. Compared with

results for methadone maintenance programs, interpretation of these results is more difficult because

low percentages of clients remain throughout the

treatment program and the studies lack external

control groups. The possibility thus remains that

clients who stayed throughout these programs may

have improved without treatment. On the other

hand, the possible contribution of treatment in

assisting these individuals should not be overlooked.

Treatment for drug abuse is not a panacea. Not

even methadone maintenance eliminates drug abuse

for all clients. Yet any continued sharing of injection

equipment or risky sexual behavior associated with

drug use places people at risk for HIV transmission.

Such a risk is substantial for frequent drug users

(abusers and addicts) and smaller but still present for

casual users.

Even if treatment for drug abuse is not 100

percent effective, it may markedly decrease drug use

for extended periods, and, therefore, decrease the

probability of HIV transmission. It should be

emphasized that when these interventions are

applied on a very large scale, to hundreds of thousands of people, the public health impact of an intervention with even limited effectiveness can be substantial.

Drug abuse, a condition with a long course characterized by relapses to drug use, occurs in people

with a variety of other problems, such as psychiatric

and non-psychiatric illnesses and family, financial,

employment, and legal difficulties. Recovery from

drug dependence is not an overnight event, but a

dynamic process that occurs over time. The road to

recovery may require multiple treatment episodes,

with approaches tailored to the needs of different

people. Moreover, the treatment needs of an individual and the appropriate interventions may change

over time. Responding to these realities, experts

advocate an integrated, comprehensive, flexible

treatment network (ll,149,169,241a).

The United States is confronted with an ongoing

epidemic of HIV infection, whose control requires

consideration of the medical and epidemiologic characteristics of the disease. Strategies to prevent HIV

infection must acknowledge these complexities. Preventing further spread of HIV increases the pressure

for reexamination and scientific evaluation of public

policies with regard to the availability of syringes and

needles. Temporarily providing methadone and

counseling, without the additional ancillary services

ordinarily part of methadone maintenance, to IV

opiate users who are on waiting lists for treatment

merits strong consideration.

Only consistent and persistent efforts over time

have the potential to break the chain of HIV transmission and stem this lethal infection from spreading

further. The impact of incremental, even partial, but

sustained reductions due to methadone maintenance

and perhaps other drug treatment approaches can be

substantial in achieving this goal.
Chapter 2

Drug Use and HIV Infection: The Current Situation

INTRODUCTION

Reliable estimates of the nature and extent of the

drug abuse problem in the United States are vital to

the formulation of an effective national drug control

policy. Some of the estimates important to

policymaking are current rates of drug use and

trends in use, specific populations and age groups at

risk, and major health consequences associated with

drug abuse. Data on trends in drug usage help

provide useful information on the natural social

course of drug epidemics and the effectiveness of

Federal anti-drug efforts. Data collectors face

certain barriers, however, including the illegal nature

of drug use, which leads to questions of the reliability

of self-reported drug use, and the difficulty reaching

certain populations with standard survey techniques,

including homeless people and people not in school.

The connection between intravenous (IV) drug

use and human immunodeficiency virus (HIV)

infection has added urgency to the need to combat

drug abuse. IV drug abuse has been described as the

“engine of the current HIV epidemic,” because

equipment-sharing and certain sexual practices of IV

drug users constitute high-risk behavior for HIV

transmission (145). The acquired immunodeficiency

syndrome (AIDS) epidemic, which runs about 5 to 10

years behind the HIV epidemic, has also shown a

growing proportion of IV drug users among new

cases. IV drug users now account for one-third of all

AIDS cases and are the second highest risk category

for AIDS, exceeded only by homosexual and bisexual

males (349). Non-IV drug use has also been connected to the spread of HIV infection through sexual

transmission. Cocaine use, especially in the form of

crack, has been linked to increased sexual activity,

multiple partners, and an increased likelihood of

spreading the virus to drug-using and nondrug-using

sexual partners. Understanding the links between

drug abuse and HIV infection and the magnitude of

the problem is a necessary first step in determining

the best strategy for reducing the spread of HIV

among drug users.

This chapter describes of the use of illegal drugs

in the United States, with a focus on heroin and

cocaine because of their frequent IV administration

and connection with HIV transmission. A discussion

of measurement issues associated with drug abuse

and an overview of rates and trends in use are also

provided. The chapter then addresses the critical

link between drug use and HIV infection, including a

discussion of the routes of HIV transmission;

estimates of the number of IV drug abusers, risk

behaviors, and prevalence of HIV-infected drug

abusers; and a review of AIDS cases reported to the

Centers for Disease Control. The chapter concludes

with a brief discussion of the cost of drug abuse to

society.

USE OF ILLEGAL DRUGS IN THE

UNITED STATES

Substance Dependence, Substance Abuse,

and Casual Use

Substance dependence, substance abuse, and

casual use are three categories that are often used to

classify the use of illegal drugs. Patterns of

psychoactive substances use actually fall along a continuum, ranging from experimental, occasional, and

recreational use to abuse and dependence. Defining

these terms and developing treatments have been

particularly difficult because the causes and consequences of drug use vary so extensively with the

substance used, the user, the dose, the route of

administration, and the social circumstances of initial

and sustained use (133).

The concept of addiction has undergone many

revisions, from theories of personal responsibility in

the early 1900s to an appreciation of environmental

and societal influences in the aftermath of the

Depression and World War II and a theoretical preference for physiological explanations of addiction

during the 1970s and early 1980s (including genetic

and chemical predispositions) (266). With the

increasing problem of cocaine abuse, the concept of

addiction has more recently evolved to a concept of

-13-
14- The Effectiveness of DrugAbuse Treatment: Implicationsfor Controlling AIDS/HIV Infection

the ‘dependence syndrome.” As Shaffer and Jones

note, the World Health Organization’s emphasis on a

syndrome of dependence “recognizes the inefficiency

and futility associated with trying to determine the

distinction between psychological and physiological

dependence” (266). The dependence syndrome

concept incorporates quantitatively defined patterns

of behavior, neuroadaptation (as evidenced by

tolerance or withdrawal syndrome), and

psychological drug craving or dependence (266).

Although the American Psychiatric Association’s first

two diagnostic manuals classified drug dependence

and alcoholism as personality disorders, it has now

“become clear that there is no single type of addictive

or dependence-prone personality, no personality

traits that reliably indicate in advance who is likely to

use or misuse drugs” (134).

In its latest Diagnostic and Statistical Manual for

Mental Disorders (Third Edition Revised) (DSMIIIR), the American Psychiatric Association defined

psychoactive (mind-altering) substance dependence

as “a cluster of cognitive, behavioral, and physiologic

symptoms that indicate that the person has impaired

control of psychoactive substance use and continues

use of the substance despite adverse consequences”

(6). According to the American Psychiatric Association’s substance dependence criteria, at least three

of the nine characteristic symptoms of dependence

must be present for diagnosis (box 2-A). Some of

these symptoms include failed attempts at controlling

excessive drug use, substantial time spent procuring

the substance (including theft, taking the drug, and

time recovering), and a variety of social, psychological, and physical problems. Symptoms of the

,

I

I

~

I

1

I

I

Box 2-A--American Psychiatric Association> Diagnostic Criteria

for Psychoactive Substance Dependence

At least three of the nine characteristic symptoms of dependence (below) are necessary to make the diagnosis of substance dependence (6). In addition, some symptoms of the disturbance must have persisted for at

least 1 month or have occurred repeatedly over a longer period of time.

Symptoms of dependence:

1.

2.

3.

4.

5.

6.

7.

8.

9.

substance often taken in larger amounts or over a longer period of time than the person intended;

persistent desire or one or more unsuccessful efforts to cut down or control substance use;

a great deal of time spent in activities necessary to get the substance (e.g., theft), taking the substance (e.g., chain smoking), or recovering from its effects;

frequent intoxication or withdrawal symptoms when expected to fulfill major role obligation at work,

school, or home (e.g., does not go to work because hung over, goes to school or work “high,” intoxicated while taking care of his or her children), or when substance use is physically hazardous (e.g.,

drives when intoxicated);

important social, occupational, or recreational activities given up or reduced because of substance

use;

continued substance use despite knowledge of having a persistent or recurrent social, psychology@

or physical problem that is caused or exacerbated by the use of the substance (e.g., keeps using

heroin despite family arguments about it, cocaine-induced depression, or having an ulcer made

worse by drinking);

marked tolerance: need for markedly increased amounts of the substance (i.e., at least a 50 percent

increase) in order to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount;

characteristic withdrawal symptoms (see specific withdrawal syndromes under Psychoactive

Substance-induced Organic Mental Disorders);

substance often taken to relieve or avoid withdrawal symptoms.
Chapter 2--Dreg Use and HIV Infection: The Current Situation- 15

dependence syndrome include, but are not limited to,

the physiologic symptoms of tolerance and with-’

drawal. Symptoms of tolerance occur when the

same amount of a particular drug produces less

effect. This often leads the individual to take

increasingly larger or more frequent doses of the

drug in order to obtain the effect of the original dose.

Withdrawal symptoms can result either when users

come down from an acute intoxication or when

regular users of heavy doses stop taking the drug

entirely (abstinence syndrome).

Psychoactive substance abuse is a subset of drug

dependence. Substance abuse is characterized by

maladaptive patterns of behavior that have not met

the American Psychiatric Association’s criteria for

dependence. Indicators of maladaptive patterns

associated with substance abuse include evidence of

continued use despite knowledge of persistent or

recurrent social, occupational, psychological, or

physical problems caused or exacerbated by drug

use, or recurrent use in situations in which use is

physically hazardous (e.g., driving while intoxicated)

(6). Some symptoms must have persisted for at least

1 month or have occurred repeatedly over a long

period to support a diagnosis of substance abuse.

Finally, casual or recreational use includes users

who take certain drugs only occasionally or in low to

moderate doses and can usually stop without formal

intervention (e.g., treatment) when the dangers begin

to outweigh the advantages. Casual users do not

exhibit the seriously maladaptive patterns of drug

consumption and resultant behaviors associated with

substance dependence or substance abuse. They may

be at risk, however, for health problems and later

developing substance dependence (238).

Dependence has also been defined by the 3-Cs:

continued use in the face of adverse physical or

psychic reactions; compulsion to use drugs; and

feeling of being out of control regarding drug use

(266). Other researchers stress the inability to

1 Although the degree of tolerance varies with the drug used and

other circumstances, almost all drugs eventually produce

tolerance for two reasons: 1) the liver produces more of the

enzymes that break a drug down (metabolic tolerance), and 2)

the brain becomes adapted to the new chemical environment

created by the drug and no longer responds to it so intensely

(central nervous system tolerance)(133).

remain abstinent as a primary indicator of dependence (226). Studies have shown that heavy use of

certain drugs (including opiates, amphetamines, and

cocaine) is more likely to lead to dependence than

others (133). In addition to individual biological differences, the route of administration of the drug is

also an important variable in determining whether

drug use will result in dependence. “In general,

routes of administration that produce more rapid

and efficient absorption of the substance into the

bloodstream tend to increase the likelihood of an

escalating pattern of substance use that leads to

dependence” (6). For this reason, a person is much

more likely to develop dependence on heroin or

cocaine if they are smoked or taken intravenously

than when they are sniffed or taken orally (see ch. 4).

Once drug dependence develops, it often persists as a

chronic condition, with relapse being the rule (13).

Although the term addiction is often used interchangeably with dependence, addictive behaviors can

be identified by the high frequency of their occurrence, not by the presence of physical dependence

(266).

Drugs of Abuse

Accurate assessment and appropriate treatment

of drug-using clients requires a working knowledge

of the commonly used psychoactive drugs and their

effects. Although almost all the currently used

recreational drugs have been extensively investigated,

drugs are continuously being used in new ways and in

combination with different drugs. Understanding

the distinctions among the various drug categories

and being able to identify signs of intoxication, withdrawal, and overdose are essential, both for

treatment and for data collection.

For medical and psychiatric purposes, commonly

used drugs are often grouped into the following six

categories, reflecting the primary action of each:

1.

2.

3.

4.

5.

6.

narcotics (opiates, including heroin) and

related analgesics ;

stimulants (including cocaine, amphetamines, nicotine, and caffeine);

sedative-hypnotics (including alcohol, barbiturates, non-barbiturate sedatives, and

minor tranquilizers);

hallucinogens (including lysergic acid diethylamide (LSD));

phencyclidine (PCP); and

cannabis (marijuana) and inhalants.
16- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

Other classifications of drugs may vary from

this one, depending on how broadly or narrowly the

groups are defined. Distinguishing among drugs

based on their effects may also be complicated by the

fact that the intoxication effects of one drug (e.g.,

hallucinogen intoxication) may be quite similar to the

withdrawal symptoms associated with another type of

drug (e.g., the disorientation and hallucinosis associated with sedative-hypnotic withdrawal) (6). Diagnosis is further complicated by the use of multiple

substances (polydrug abuse), often with a second

drug being used to enhance the “high” or to

counteract the lingering unpleasant effects caused by

the first drug.

One common feature of all abused drugs is that

they function as behavioral reinforcers. As the

effects of the drug strengthen the behavior that leads

to their administration, deeply-ingrained behavior

may result over time (238). This view helps explain

how experimenting with abused drugs can lead to

drug dependence. In general, the effects of drug use

can be either acute (resulting from a single dose or a

series of short or episodic doses) or chronic

(resulting from long-term use) and can affect

physical, psychological, and social health (133).

Because it is primarily the route of drug administration that links drug use to HIV transmission and

not the drug itself, the following discussion will focus

on narcotics and stimulants because drugs in these

categories (e.g., heroin, cocaine, and amphetamines)

are associated with IV drug use and the spread of

HIV infection. Sexual transmission of HIV has also

been associated with the effects of the stimulant

crack cocaine, which often lead users to engage in

increased sexual activity and to have multiple sexual

partners (193). A brief description of the patterns of

use, effects of the drug, symptoms of use and withdrawal, and health consequences of narcotics and

stimulants follows. (App. E describes comparable

information related to the other drug categories.)

Narcotics (Opiates) and Related

Analgesics

Narcotics, also called opiates, are a class of

drugs used medically to relieve pain, but also have a

high potential for abuse. Heroin accounts for the

majority of the opiate abuse in the United States.

The preference for injection as the primary route of

heroin administration can lead to serious health consequences, most notably increased exposure to HIV

through needle-sharing among IV drug users and

other infections resulting from the use of contaminated apparatus (e.g., hepatitis, bacterial

endocarditis, meningitis, and tetanus). Heroin is

commonly sold in an adulterated form, “cut” with

volume-expanding substances, such as quinine, that

are known to cause toxic and allergic effects in some

users. Another practice with dangerous consequences is the use of narcotics with other drugs,

such as alcohol and cocaine.

Narcotics produce euphoria in users by

activating the region of the brain responsible for

producing pleasurable sensations (317). Several

opiate receptors and endogenous neurotransmitters

have been connected with opiate abuse and dependence and the development of tolerance to opiates

(178). Within 2 to 5 minutes of IV opiate use, the

user typically experiences euphoria that may last 10

to 30 minutes, followed by a longer period (2 to 6

hours) of lethargy, somnolence, and apathy (6).

Constricted pupils, drowsiness, slurred speech, and

impairment in memory and attention are also

common symptoms of narcotic use. It is not

uncommon for users to go “on the nod,” going back

and forth between feeling alert to drowsy. Regular

use of narcotics can lead to high levels of tolerance.

The need for readjustment after drug withdrawal usually produces symptoms roughly opposite

to the drug effect (133). With narcotics withdrawal,

abusers generally become anxious and restless and

experience symptoms of watery eyes, runny nose, loss

of appetite, diarrhea, abdominal cramps, chills,

sweating, and nausea. Although most users initially

take heroin because it produces euphoria, subsequent use is often driven. by the desire to avoid the

painful consequences of narcotics withdrawal. As

with all the drug categories, the health consequences

of narcotic use depend on the specific drug used, the

dosage level, and the mode of administration. In

addition to the risk of HIV and other infections mentioned earlier, narcotics users may develop skin

abscesses and congested lungs. Although

uncomfortable, in the absence of complicating

medical conditions, physical withdrawal from narcotics is usually not life threatening.
Chapter 2--Drug Use and HIV Infection: The Current Situation- 17

Opiate-dependent pregnant women are often

debilitated and tend not to obtain perinatal care and

to have inadequate nutrition. As a consequence they

suffer more often from anemia, heart disease,

diabetes, pneumonia, and hepatitis than nonusers,

and they have more spontaneous abortions, breech

deliveries, caesarean sections, premature births, and

stillbirths (312). Unless the mother has been withdrawn from opiates, the infant is likely to experience

withdrawal symptoms (neonatal abstinence

syndrome) and to be below normal birthweight.

Central Nervous System Stimulants

Stimulants, often called “uppers,” refer to drugs

that tend to increase alertness and physical activity.

Cocaine and amphetamines are the two most

common of the central nervous system stimulants.

Three neurotransmitters have been implicated in the

psychoactivity and withdrawal from stimulants;

dopamine, norepinephrine, and serotonin (178).

Severely dysfunctional stimulant use occurs in

episodic, prolonged binges that disrupt sleep rather

than in the regular daily use patterns seen with

opiate dependence (116). Ingestion of high doses of

these drugs in nontolerant persons can produce

effects ranging from enjoyable subjective states of

euphoria to acute psychotic states, seizures, cardiovascular collapse, and death (166).

Cocaine stimulates certain neurons in the

central nervous system and causes the user to experience a sense of pleasure. When taken

intravenously, cocaine produces a characteristic

“rush” of well-being, confidence, and in some cases,

euphoria (6). The physical effects of cocaine use

include dilated pupils and increases in blood

pressure, heart rate, breathing rate, and body

temperature (312). Cocaine overdose deaths are

often the result of multiple seizures followed by

respiratory and cardiac arrest.

Unlike heroin, cocaine has not been associated

with a clear-cut withdrawal syndrome, but it is not

uncommon for stimulant users to experience a

marked period of depression, often referred to as

“crashing,” following a period of binging or cessation

of drug use. Gawin and Kleber have identified a

regular sequence of symptoms that occur in both the

immediate and prolonged period after cessation of

cocaine use and have classified the symptoms into

three phases: the crash, withdrawal, and extinction

phases (116). The crash phase, lasting from only a

few hours to 4 days, is characterized by agitation,

depression, anorexia, and high cocaine craving during

the early stages, followed by fatigue, depression,

insomnia, and no cocaine craving in the later stages.

During the withdrawal stage, lasting from 1 to 10

weeks, sleep normalizes, but the potential for relapse

increases as anxiety and cocaine craving increase.

The final phase, extinction, lasts between 3 and 12

months, and relapse to cocaine use becomes more

closely tied to environmental cues that stimulate

cocaine craving (116).

Cocaine and its derivative “crack” have become

a focal point of the U.S. drug problem in recent

years. Crack is the street name for freebase cocaine

that has been processed from cocaine hydrochloride

to a base, using ammonia or baking soda and water

and heating it to remove the water (316). Cocaine

hydrochloride powder is sniffed or injected, while

cocaine alkaloid (“freebase” or “crack”) is smoked.

Although average street-level purity of cocaine more

than doubled from 1981 through 1986, prices for the

drug declined, according to the Drug Enforcement

Administration, indicating increased availability

(298). Recent trends, however, show a sharp rise in

cocaine prices, which are approaching their highest

level since mid-1985, and a decline in cocaine purity

levels at all levels of the distribution chain (46).

Maternal cocaine use is associated with poor

pregnancy outcome. Maternal use of cocaine and

crack may adversely affect the fetus either through

the pharmacological action of the drugs (e.g., high

blood pressure, reduced uterine blood flows resulting

in lower fetal oxygen levels) or because of the

mother’s behavior while taking the drug (e.g., poor

appetite, less likely to seek prenatal care) (301).

Several studies have shown cocaine use during pregnancy to increase the risk of both pre-term delivery

and intrauterine growth retardation (53,1%,236,380).

In a study of patterns of cocaine use in pregnancy,

Chasnoff, et al., found that infants born to mothers

who used cocaine (either during the first trimester

only or throughout pregnancy) demon-strated significant impairment of orientation, motor skills, and
18- The Effectiveness of Drug Abuse Treatment: Implicationsfor Controlling AIDS/HIV Infection

the ability to remain alert. Infants born to women

who have used cocaine throughout pregnancy were

also more likely to have low birthweights, decrements in length, and smaller head circumferences

(53,236,380).

Like cocaine, amphetamines may produce

feelings of euphoria and heightened energy. The

physical effects of amphetamines include decreased

appetite 2 and increased heart and breathing rates

and blood pressure, and users usually report feeling

restless, anxious, and moody. Both cocaine and

amphetamines, when used in large doses over a long

period of time, can lead to hallucinations and

paranoia. When people stop using amphetamines,

they may sleep for long periods and feel hungry,

irritable, and depressed. Like narcotics,

amphetamine use can slowly lead to high tolerance.

Amphetamines are usually sold in tablet or capsule

form, but users may also sniff the crystals or inject

them.

Magnitude of the Drug Abuse Problem

Measurement Issues

Statistics on the drug problem are particularly

difficult to compile and interpret (289,293). The

primary measurement problem stems from poor self

reporting, a consequence of the illegal nature of drug

use. Finding survey respondents who are willing to

participate and answer questions honestly, which in

some instances requires admitting to illegal behavior,

is a definite stumbling block. Two of the major

methodological issues in the collection of data are

validity (whether a variable measures what it purports to measure) and reliability (the consistency of

measurement) (251). Reassuring respondents of the

confidentiality and anonymity of their responses has

been one means of increasing response rates and the

validity of the data. Using drug testing to validate

self reports is another. Significant progress has also

been made in the past 2 decades in utilizing standard

definitions and methodologies in drug surveys, thus

making comparisons and integration of data more

feasible (293).

2Amphetamines are often first taken for their appetitesuppressant effect in an attempt to lose weight.

Major Surveys on Drug Abuse

Information on the use of illegal drugs in the

United States is based on a family of surveys that

focus on drug use within a particular population (e.g.,

high school seniors) or at a particular setting (e.g.,

hospital emergency rooms). Some of the surveys

overlap, and some populations, such as high school

dropouts and homeless people, are difficult to reach

and may go uncounted. Taken alone, none of the

current studies provides a complete picture of drug

abuse in the United States; however, when viewed

together, these studies provide an overview of the

drug problem and its evolution (289,293).

The two major national surveys of the

prevalence of drug use are 1) the National

Household Survey on Drug Abuse and 2) the High

School Seniors/Monitoring the Future Survey

(306,330). In addition, the Drug Abuse Warning

Network (DAWN) provides useful data on drugrelated hospital emergencies and deaths (328).

Important features of each data source are

highlighted below.

National household survey

o covers the general household population aged

12 years and older living in the continental

United States;

o conducted every 2 to 3 years since 1971;

o sample sizes ranging from 3,186 (1971) to 8,814

(1988), half white and half evenly split between

blacks and Hispanics;

o face-to-face interviews and self-administered

written questionnaires;

o populations excluded: the homeless, military

personnel living on base, and those i n

dormitories, hospitals, treatment centers, and

jails;

o beginning with the 1985 survey, only one

respondent was interviewed per household;

o questions respondents about their past drug

use, attitudes, and consequences of drug use;

o conducted by the National institute on Drug

Abuse (NIDA’s) Division of Epidemiology and

Prevention Research.
Chapter 2--Dreg Use and HIV Infection: The Current Situation- 19

High school seniors survey

o high school senior population (aged 17 to 18);

o conducted every year since 1975;

o Sample Size about 16,000 (130 to 140

public/private schools);

o self-administered questionnaire completed

during class time;

o populations excluded include dropouts and

absentees;

o through a longitudinal study of a subsample of

each class, maturation factors associated with

drug abuse are monitored (about 2,400

participants of each graduating class are chosen

for followup study, half of the sample being surveyed continually on even-numbered years and

half being surveyed on odd-numbered years);

o research is performed by the University of

Michigan’s Institute of Social Research and is

funded largely by NIDA.

Drug Abuse Warning Network (DAWN)

o reports the consequences of drug abuse as

reflected by emergency room (ER) episodes for

drug-related problems and medical examiner

reports of drug-related fatalities;

o ongoing since 1972;

o nonrandom sample of about 600 ERs in 21

metropolitan areas and on national panel

(statistical sample being implemented in ERs);

o nonrandom sample of medical examiners in

about 85 jurisdictions in 26 metropolitan areas;

o records mention of drugs being ingested up to 3

days prior to hospital ER visit;

o Up to four different substances can be specified

for each ER episode, and six substances can be

reported for each death;

o conducted by NIDA>S Division of Epidemiology

and Prevention Research.

It is generally believed that both the household

survey and the high school senior survey provide conservative estimates of the general level of drug use.

In fact, neither survey purports to measure the

nation’s total drug-abusing population. Tomas and

Kozel identify two reasons that the true level of drug

abuse may be greater than these surveys indicate.

The first reason is that the drug-abusing population

is difficult to reach, especially through traditional

survey techniques (293). Young males are the least

likely group to be found at home to take the

household survey, yet they are the highest age-gender

drug-using group (293). The household survey also

excludes residents of many places (prisons, jails,

homeless shelters, and drug treatment centers)

where one would expect to find greater prevalence of

drug addicts (34). School dropouts who are missed

by the high school seniors survey are also known to

have higher drug use rates than nondropouts (293)?

To the extent that this is true, the senior survey may

underestimate the extent of drug abuse among this

age group.

The second reason for possible underreporting

with surveys on drug abuse relates to self-reporting

methods. As mentioned earlier, certain respondents

may be hesitant or unwilling to admit to illegal

behavior or have trouble recalling specific times and

drug use patterns (293,308). This would be particularly true of young respondents answering questions

in the presence of a parent or teacher, even though

answers to questions concerning illicit drug use are

recorded on paper, not aloud.

It is also important to note that DAWN is not a

representative sample, and therefore its data cannot

be extrapolated to all the ER cases in the United

States (293). Also, the number of ER episodes

reported by DAWN should not be assumed to equal

the number of individuals involved, since one person

may make repeated visits to an ER (328). Incomplete reporting, despite specific procedures for

identifying drug abuse episodes and reporting delays

of up to 1 year for some medical examiners are two

of DAWN’s limitations. Also, there is no distinction

made between licit and illicit drugs or drug use that

is and is not believed to be related to the complaint.

In other words, a stabbing victim will be reported if

use of heroin, cocaine or legally dispensed

methadone is reported, even if the stabbing had

nothing to do with such use. To the extent that this

occurs, it lessens the value of DAWN as a reflection

of the true health consequences associated with drug

use. Of particular relevance to this report is the fact

that 1988 medical examiner reports exclude data on

deaths involving AIDS.

3According to the Digest of Education Statistics, 8 percent of the

population aged 16 and 17 were not enrolled in school in October

1986, and in some urban sub-populations, up to 40 percent are

not in school (305).
20- The Effectiveness of Drug Abuse Treatment: Implicationsfor Controlling AIDS/HIV Infection

Box 2-B summarizes the purpose and adminis- as heavy users and selected minority groups (308).

tration of other major drug use information systems. Because “hidden” groups are difficult to reach

through conventional survey methods, special

Data Gaps and Developments approaches and targeted, smaller studies may be

necessary (308). Because national estimates may

The Public Health Service report on improving mask the- differences that occur among metropolitan

drug abuse statistics highlighted the need for addi- areas, there is also a need for surveys of major

tional prevalence data on school-based populations metropolitan areas. The Public Health Service is

and special subgroups and hidden populations, such currently involved in initiating several major data colBox 2-B--Other Information Systems on Drug Use

In addition to the household survey, the high school seniors survey, and DAWN, several other sources of

information on drug use in the United States help give a more complete picture of the drug problem. Some of

these include:

o National Drug and Alcoholism Treatment Unit Survey (NDATUS). Periodical survey of all known alcohol

and other drug units since 1973. Information is collected on services available, funding sources, utilization

rates, and client characteristics (see ch. 3).

o State Alcohol and Drug Abuse Profile (SADAP). Annual survey of State alcohol and drug abuse agencies

conducted by the National Association of State Alcohol and Drug Abuse Directors since 1984. Collects

information on funding and program and client characteristics for units that receive at least some funds

administered by the State alcohol and drug agency (see ch. 3).

o Drug Use Forecasting program. The National Institute of Justice monitors drug use among recently

arrested persons in selected cities. Staff obtain voluntary, anonymous urine specimens and interviews from

a sample of arrestees in booking facilities in 22 cities throughout the United States. For most drugs,

including cocaine and heroin, the urine test can detect use in the prior 2 to 3 days.

o Treatment Client Data System”. This data system is composed of the remnants of the former Client

Oriented Data Acquisition Process (CODAP). From 1973 to 1981 all treatment programs receiving

Federal funds were required to report client admission data to NIDA. Following the Omnibus Reconciliation Act of 1981, which deleted various State reporting requirements including CODAP, only six States

continue to share data with NIDA on client information.

o Community Epidemiology Work Group. Researchers from selected metropolitan areas of the United

States meet semiannually with NIDA staff, experts from European countries, and representatives from

other interested groups to assess the drug abuse picture in their respective areas. The Community

Epidemiology Work Group provides for the transfer of epidemiolic information that can identify new drug

abuse patterns and trends and groups most likely to be affected.

o Military personnel survey. Office of the Assistant Secretary of Defense. Four waves between 1980 and

1988. Prevalence of drug use among military personnel worldwide.

o Hispanic Health and Nutrition Examination Survey. National Center for Health Statistics. One-time

household survey, 1982 to 84. Included survey supplement from the Alcohol, Drug Abuse, and Mental

Health Administration on use of drugs by Hispanics.

o National Maternal and Infant Health Survey. National Center for Health Statistics National probability

survey of registered births in 1988 (live births, stillbirths, and infant deaths before 1 year of life).

Information on the use of tobacco, marijuana, and cocaine during pregnancy.
Chapter 2-Drug Use and HIV Infection: The Current Situation- 21

lection efforts. One such effort is the development of

the Metropolitan Area Survey, a Iarge-scale comprehensive study of prevalence, incidence, and consequences of drug abuse in the Washington, DC

metropolitan area. This survey will be unique in its

attempt to assess drug abuse in some “hidden” populations, including persons who are homeless,

transient, chronically mentally ill, high school

dropouts, and criminal offenders. The In Utero

Drug Exposure Survey is another new initiative that

will acquire data on the prevalence of prenatal

exposure to all major drug types, the temporal patterns of that exposure, and the demographic characteristics of the exposed infants and their mothers.

An Overview of Drug-Use Rates and

Trends

Any Illicit Drug--According to the 1988

household survey, 72 million Americans age 12 or

older (37 percent of the population) have tried

marijuana, cocaine, or other illicit drugs at least once

in their lifetimes (330). Twenty-eight million (14

percent) had used some type of illicit drug at least

once in the past year, and 14.5 million (7 percent)

had used drugs within the 30 days prior to the administration of the survey (defined as current use).

Demographic subgroups with elevated rates of

current use include males (9 percent), those in large

metropolitan areas (9 percent), those living in the

West (10 percent), those employed part time (9

percent), and unemployed people (18 percent).

Among the 20- to 40-year-old age group of full-time

employed Americans, 12 percent were current users

(10 percent used marijuana and 3 percent used

cocaine, not mutually exclusive). Among the nearly

60 million women 15 to 44 years of age, the childbearing years, over 5 million (9 percent) were

current users, almost 1 million (2 percent) having

used cocaine within the previous month.

Statistics on current use of illicit drugs continued

a declining trend that began in the early 1980s and

accelerated between 1985 and 1988 (306). Comparison of the 1988 household survey with the previous 1985 survey shows a major decrease in illicit

drug use noticeable in an almost 25-percent decrease

in use of any illicit drug at least once in the past year

(from 37 million to 28 million) and a 37-percent

decrease in the use of any illicit drugs during the past

month (from 23 million to 14.5 million) (see fig. 2-1

for trends in use of illicit drugs during the past year).

The decline in current drug use between 1985 and

1988 was seen in all segments of the population--

among both men and women; for all race and ethnic

groups; throughout all regions of the country; and for

all levels of educational attainment.

Figure 2-2 illustrates the trends in lifetime,

annual, and current illicit drug use from 1975

through 1989 for high school seniors, all of which

peaked during the late 1970s and early 1980s and

have been steadily decreasing since (306). Between

1988 and 1989, annual use of illicit drugs among high

school seniors decreased from 38.5 percent to 35.4

percent, and current use decreased from 21.3 percent

to 19.7 percent.

Heroin--About 2 million household members (1.0

percent of the population aged 12 and older) have

tried heroin in their lifetimes (330). Trends in the

prevalence of lifetime use between 1985 and 1988

showed a decreasing trend among males and people

in the 18 to 25 and 26 to 34 age groups, but increases

for those in the 12 to 17 and > 35 age groups, among

blacks, and to a lesser extent, among Hispanics and

among people living in the Northeast region (see figs.

2-3 and 2-4). The increase in heroin use during one’s

lifetime for 12 to 17 year olds reflects increasing use

among young people, while increasing trends for

people age 35 or older mean that use rates in their

youth were high. Decreasing trends for 18- to 34-

year olds mean use rates in youths were smaller a

decade or 2 ago than they were before. According to

the 1989 high school seniors survey, 1.3 percent of

seniors had tried heroin at least once (306).

Although cocaine mentions increased dramatically as a percentage of the total ER mentions

between 1984 and 1988, heroin mentions continue to

account for about 13 percent of all ER mentions (see
22- The Effectiveness of Drug Abuse Treatment: Implicationsfor ControllingAIDS/HIV Infection

Figure 2-l--Use of Any Illicit Drug During the Past Year, National

Household Survey, 1985 and 1988

Millions of

people

40

30

20

10

0

37 Any Illicit Drug Use

—..— .-. —

“~;: :

12 Cocaine

(-33%)

1985 1988

DHHS, NIDA (330,331).

Figure 2-2--Any Illicit Drug Use by High School Seniors, 1975 to 1989

Percent

100 f

--------------- - --- . --- --- - . . . - - - . . . - . - - - . - . . . . . - --- - . - . - - . .

8 0-

------- ------- ------------ - .. ---- ----- -- --- . --- - - --- ---------------- - .

------- -- - . -- -- ---- . - . . - - - - . 65.4 Lifetime . .- . ---- . ---- . --------

. ’ .::::%+ ’ .m g o

. o. oomaoomoemoee e

.aa.9.. ~amm@~mm0m0m*mmge.. 60.6

6o - .5s:2;*#:~:::- -- --““ - “ “ --- “ - --“ --- - - ----- . -------- .

● ,** \ 53.1

, /@~’-a ~

Annual 5O.9

45.0 ,~---- - “ --“. “ --” --- “ “ - !-$-~ -

% .

46.3 ~ -. . --- . .- . . --- . -*

p , ~

4 0- .

----- . . . . . -. - . 37.2 . .- . . . . ------

30.7

----- ---- ------- . . . . -. . .- ---- . . . .- . . --------

20 -

--------- . ---- . . . . . . . . . - - -- ---- . -- - . - --- . - - . - - . . -. . --- . . ----

------- - - --- . . . - - - - . . - . - . . - . . - -- . - . . . . - . . . . -- . . -- . --- ----- .

0 I 1 I I I 1 1 I 1 I I i t

1975 1980 1985 1989

Us. DHHS (306).
Chapter2--Drug Use and HIV Infection: The Current Situation- 23

Figure 2-3--Percent of Population Reporting Heroin Use in Lifetime by Region

and Age Group, 1985 and 1988

Percent of population

● go 12 ● and older

3

2.6

t

2.5 “—”-”

n

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .—”.. ”... ”--.———

2.1

SOURCE:

0 I---– -

..--—- — — “ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - - . . - ” . - . . - — . . - - —

I

4 1.1 1.2 1

Total North North South West 12-17 18-26 26- 34 236

population East Central

U.S. DHHS, NIDA (330,331).

Region

- 1985 = 198 8

Age Group

Figure 2-4--Percent of Population Reporting Heroin Use in Lifetime by Sex and

Race/Ethnicity, 1985 and 1988

Percent of population

age 12 and older

3

2.5

2

1.5

1

0.6

0

Total I Male Female II White Black Hispanic I

population Sex Race/Ethnicity

- 1985 _ 198 8

SOURCE: U.S. DHHS NIDA (330,331).
24- The Effectiveness of Drug Abuse Treatment Implications for Controlling AIDS/HIV Infection

fig. 2-5). The total number of heroin mentions

increased 133 percent between 1984 and 1988, with

58 percent of that increase coming between 1987 and

1988 (see fig. 2-6).

In 9 of the 14 cities included in a Drug Use Forecasting study in the first quarter of 1989, less than 10

percent of male arrestees had positive urine tests for

opiates (see box 2-B for a description of this study)

(336). Of those who tested positive for opiates, 81

percent also tested positive for cocaine.

Cocaine--An estimated 21.2 million people (11

percent of the household population aged 12 or

older) have tried cocaine during their lifetimes, while

8.2 million (4.1 percent) have used cocaine at least

once during the past year, and 2.9 million (1.5

percent) have used the drug at least once during the

past month (330).

The number of household members who used

cocaine within the past year dropped 33 percent

between 1985 and 1988 (from 12.2 million to 8.2

million). The percent of household members

reporting cocaine use during the past month

decreased by about 50 percent between 1985 and

1988 for both males and females, with males still

twice as likely to be current users as females (see fig.

2-7). Another noticeable trend between the 1985 and

1988 household survey was the increased prevalence

of cocaine use among Hispanics Although lifetime

prevalence of cocaine use remained stable for whites

and blacks, there was an increase among Hispanics

between 1985 and 1988 (from 7 percent to 11

percent). The Hispanic population was also the only

race/ethnic group that did not experience a decrease

in current cocaine use during this period (see fig. 2-

7).

Despite the declining trend in the number of

cocaine users, an increasing percentage used cocaine “

more frequently. Among the 8.2 million people who

used the drug within the past year, in 1988 862,000

people (11 percent) used the drug once a week or

more (compared with 5 percent in 1985), and 4

percent used the drug daily or almost daily (compared with 2 percent in 1985) (see fig. 2-8) (330,

331).

Figure 2-5--Drugs Mentioned Most Frequently in Emergency Rooms Episodes, by Percent of

Total Episodes

H Heroln/morphine

Dlazepa

Cocai cohol in

combinatio

m (Valium)

Marijuana

PCP/PCP W 36% /

combination \ /

Heroin

In

Coca

is%R& Alcohol in

. combination

Marljuana/hashis

7

h 7% PCP/PCP

combination

Others

h

Others

198 4 1988

SOURCE: U.S. DHHS, NIDA (329).
Chapter 2-Drug Use and HIV lnfection: The Current Situation-25

Figure

ER

2-6-Trends in

mentions

Cocaine

(thousands)

40

30

20

10

0

and Heroin Emergency Room (ER) Mentions 1984 to 1988

I 46.02 0

1984 1986 1986 1987

- Cocaine = Heroi n

SOURCE: U.S. DHHS, NIDA (329).

Figure 2-7--Percent of Population Reporting

Race/Ethnicity,

Percent of popu1ation

age 12 and older

Cocaine Use in the Past

1985 and 1988

1988

Month by Sex and

4

2

1

Total I Male Femalel I White Black Hispanic b I I

Sex Race/Ethnicity

-1985 _ 198 8

SOURCE: U.S. DHHS, NIDA (330,331).
26- The Effectiveness of Drug Abuse Treatment: Implicationsfor Controlling AIDS/HIV Infection

Figure 2-8--Cocaine Users During Past Year, 1985 and 1988

Number of Past Year Cocaine Users

L~~

122

12 ——— ———..-—. - —

10 .—-—— .- —— —..

.

8

8.2

— -

SOURCE: U.S. DHHS, NIDA (330,331).

One noted limitation of the household survey is

that it does not measure those who are arrested,

homeless, or in treatment--places where one would

expect to find disproportionate numbers of cocaine

addicts (303). A recent staff report by the Senate

Judiciary Committee, which attempted to take these

“hidden” populations into account, put the total

number of heavy cocaine addicts at 2.2 million about

2.5 times the number estimated by the 1988 household survey (303). Based on the estimate of 2.2

million heavy cocaine addicts, 1 out of every 100

Americans is a weekly user of cocaine (303). The

Committee’s estimate was based on four main

sources of data including the nation’s drug treatment

centers, the homeless population, the criminal justice

system, and NIDA’s household survey. Most of the

difference between the Committee’s estimate and the

household survey estimate comes from including an

estimate of cocaine-using arrestees generated from

the Drug Use Forecasting system of the National

Institute of Justice (172). Although the Committee’s

estimate correctly emphasizes the need for better

estimates of hard-to-reach populations, their means

of deriving this estimate have been questioned and

should be regarded with caution (146).

Weekly Use Among Past Year Cocaine Use

Millions

‘1---”:4’------{

t

0.6 -- –----——— —-. .— ..— . -——-——.. —

1

0.2 I

Figure 2-9 shows the trends in cocaine use among

high school seniors between 1975 and 1989, illustrating the marked decline in cocaine use (lifetime,

annual, and current use) since the peak in 1985. The

percentage of high school seniors who have used

cocaine at least once in their lifetimes dropped from

12.1 percent in 1988 to 10.3 percent in 1989 (306).

Current use of cocaine also decreased from 3.4

percent in 1988 to 2.8 percent in 1989.

Even among young adults, the age group with the

largest number of drug users, cocaine use was

reported to decline over the past year. In the followup study of high school seniors who are now age

19 to 28, current cocaine use declined from 5.7

percent in 1988 to 3.8 percent in 1989, and use in the

last year declined from 13.8 percent in 1988 to 10.8

percent in 1989 (306).

Although the declines in cocaine use over the past

few years are encouraging, a note of caution in interpreting the survey results is warranted. The

unreliability of self-reported declines in drug use, one

of the methodological problems associated with

underreporting, could exaggerate actual declines in
Chapter 2-Drug Use and HIV Infection: The Current Situation- 27

Figure 2-9--Cocaine Use by High School Seniors, 1975 to 1989

P

E

R

c

E

N

T

20

15

10

5

0

i7. 3 ----------- . . ------------- .- . . . . . . --- . . --- . ------ ----- --- . . . . . . . . . .

s

e s

” ”

m g

~ ee

15.<*.**% .... m.m*moa9•.● S* ●*

.mg*. -m Lifetime %*

------------ --- . *- - -- - -- - - . . - - . A* -- --- -- -- ----- . .- f“. -. . . . . . *

●“ ●

● * 13.1 t

12.3 ------------- . . . - ●,

“,-+a~ ,

“’”” r

... .7

.e~.\#. ... -”:$. .

●

* < ;( =

; ~ .

.

\

●

●

/

●

● * Annual

].’J #*~: -- - ... *

*

\

----- - . - -. . ------- ----- ---------

I0.;**4

,*.O

.. / K

/

.>, ~.~ . . . . . . . . . -- . . . ---- . . . ---- . . . . ----

-. 6.7------------

\ 4

,- -----

1 1 I i I 4 I I I I 1 I I

1975 1980

SOURCE: U.S. DHHS (306).

drug use. There may be reason to believe that selfreports are less reliable today than they were prior to

1986, given a dramatic change in the social climate

toward illegal drug use. Kleiman notes that the size

of the underestimate is probably growing and will

continue to grow in conjunction with decreasing

social tolerance for drug use and the continuing

decline in the average social status of heavy cocaine

users (172). As figure 2-10 illustrates, the perceived

risk of cocaine use among high school seniors has

increased dramatically since 1986, a trend that coincides with the cocaine-induced death of college basketball star Len Bias in the summer of 1986. The

reported use of cocaine during the past year among

seniors declined as the perceived risk of using

cocaine once or twice increased (fig. 2-10). Although

it is likely that the prevalence of cocaine use has

declined as the major surveys show, it is also possible

that a greater portion of those surveyed today are

unlikely to report illegal drug use given the current

social attitude.

1985 1989

Statistics reported by DAWN show that the drugs

most frequently mentioned in ER episodes have

changed dramatically in recent years (see fig. 2-5).

Cocaine went from third with 11 percent of ER mentions in 1984 to first with 39 percent of ER mentions

in 1988 (329). In 1985, cocaine surpassed

heroin/morphine as the drug appearing most often

in ER episodes (see fig. 2-6). The number of people

admitted to hospital ERs following cocaine use, as

reported by DAWN, increased more than fourfold

over the 5-year period from 1984 to 1988 (from 8,831

cocaine mentions to 46,020 mentions) (table 2-l).

Between 1987 and 1988, the total number of ER

cocaine mentions increased 33 percent (from 34,661

to 46,020). The five metropolitan cities with the

largest number of ER mentions of cocaine in 1988

include: New York (6,540), Washington, DC (5,221),

Detroit (4,422), Philadelphia (4,156), and Chicago

(3,907) (table 2-l). The trends in cocaine mentions

varied by city. In New York and Los Angeles the

two metropolitan cities with the highest number of
28- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection 

Figure 2-10--Cocaine Trends in Past Year Among High School Seniors, 1975 to 1989

use’ Riskb and availability c

s o

100

-90

40- -80

- 7 0

3 0 - perceived ● vailability -60

u

a

3

-50 :

Perceived risk ,4

- 4 0

- 3 0

10- -20

- 1 0

0 ’

!

c I I 1 1 1 1 1 1 I I 1 I 1 1 0

'75 ’76 '77 '78 '79 '60 ’81 '82 ’83 ’84 ‘85 ’86 ’87 ’88 ’89

a percent

b

Percent

c Percent

SOURCE:

using once or more in past 12 months.

saying great risk of ham in using once or twice.

saying fairly easy or very easy to get.

U.S. DHHS (306).

cocaine mentions in 1984, the increase between 1984

and 1988 was relatively small. The cities with the

greatest increase in cocaine mentions during this 5-

year period include Dallas, Baltimore, Philadelphia,

and Washington, DC (see table 2-l).

Cocaine was the most prevalent drug detected in

male arrestees in the Drug Use Forecasting survey of

14 cities during the first quarter of 1989 (336). Urine

tests positive for cocaine were most common in

arrestees in New York (76 percent), Philadelphia (74

percent), and the District of Columbia (65 percent),

and least likely in the smaller cities of Indianapolis

(26 percent) and San Antonio (24 percent) (336).

Crack--According to the 1988 household survey,

approximately 2.5 million (1.3 percent of the population aged 12 and over) have used crack at some

time in their lives, 1 million (0.5 percent) in the past

year, and 480 thousand (0.2 percent) during the past

month (330). Data from the 1989 high school seniors

survey report that 4.7 percent of seniors have used

crack at least once in their lifetimes, and 1.4 percent

have used the drug during the past month. The 1989

senior survey showed little change in lifetime, arnnual,

and current use of crack from the 1988 data.

The DAWN network reported a stark rise in

crack-related episodes from 549 in 1984 to over
Chapter 2-Drug Use and HIV Infection: The Current Situation-29

Table 2-l--Trends in Hospital Emergency Room (ER) Mentions of Cocaine Reported to the Drug

Abuse Warning Network (DAWN), by Metropolitan Area, 1984 to 1988

New Washington, Phila- New Los

Years York DC Detroit delphia Chicago Orleans Angeles Baltimore Dallas Seattle Totala

1984 . . . . . . . . . . . . . . . . . . . . 2,643 522 600 399 521 477 1,006 148 n

1985 . . . . . . . . . . . . . . . . . . . . 2,944

238 8,831

793 992 570 714 501 1,606

1986 . . . . . . . . . . . . . . . . . . . .

221 157 246 11,099

4,315 1,350 2,596 1,306 1,635 442 2,339 498 480 434 20,383

1987 . . . . . . . . . . . . . . . . . . . . 6,486 3,182 4,633 2,670 2,817 1,907 2,248 %2 985 839 34,661

1988 . . . . . . . . . . . . . . . . . . . . 6,540 5,211 4,422 4,156 3,907 3,221 2,988 1,841 1,381 1,321 46,020

Percent change,

1984-88 . . . . . . . . . . . . . . . . + 15 + 9.0 + 6.4 + 9.4 + 6.5 + 5.8 + 2.0 + 11.4 + 16.9 + 4.6 +4.2

aBased on consistently-reporting ERs with at least 90 percent reporting in the first 12 months, the second 12 months, and the last 36

months. The metropolitan areas listed made up 76 percent of ER mentions made during the 1988 calendar year.

SOURCE U.S. DHHS, NIDA (329).

15,000 in 1988 (329). In 1988, crack mentions

represented 32.5 percent of cocaine mentions.

Heroin and Cocaine (“Speedballing”) --Although

there are few data on the prevalence and trends in

the use of heroin and cocaine together, there is some

indication of the trends in health consequences associated with this combination of drugs. DAWN ER

episodes involving both cocaine and heroin increased

almost 200 percent, from 2,646 mentions in 1984 to

7,748 mentions in 1988 (329).

DRUG USE AND HIV INFECTION

Routes of Transmission That Link

Drug Use to AIDS

The association between drug use and HIV transmission is well established. Three modes of transmission link drug use and HIV infection. The transmission of HIV infection among IV drug users

occurs primarily through the sharing of contaminated

injection equipment. Sexual transmission of HIV

from an infected IV drug abuser to his or her partner

and from an infected mother to her baby are two

other modes of HIV transmission connected with IV

drug use. The multiplicity of transmission modes

makes drug users and, especially, IV drug users

critical groups in the spread of AIDS.

At the core of the problem lies the use of substances that can be administered intravenously. A

distinction may be unwarranted between licit and

illicit substances, because the intravenous use of

anabolic steroids is also a potential vehicle for HIV

transmission among groups such as adolescents and

athletes who otherwise might not be at high risk for

HIV infection. It should be emphasized that any

form of IV drug use that involves the sharing of

injection equipment has the potential for HIV transmission. It appears that the individual or combined

use of two powerful and highly addictive illicit substances, heroin and cocaine (either injectable or

smokable as crack) pose the greatest risk of HIV

infection. Both of these drugs place users at

increased risk of the equipment-sharing and sexual

behaviors responsible for HIV spread.

Drug use practices vary throughout the United

States, at least partly because of regional and cultural

differences (26). The sharing of injection equipment,

however, is a common practice throughout the

country, in both low and high HIV seroprevalence

areas (28). Various studies reported sharing rates

between 70 and 100 percent (8). Injection equipment

that may transmit HIV infection includes not only

needles and syringes, but also other elements of the

drug injection process, such as cotton, water, or the

“cooker” used to mix the drug (26,174). Any contaminated blood remaining in the equipment can

transmit the virus from one user to another. Both

practical and economic reasons (limited availability

of necessary tools) and social reasons (feeling of

camaraderie and trust) are contributing factors to

this well-established behavior in the drug abusers’

subculture (26,174). “Shooting galleries,” usually

vacant buildings or alleyways, are common sites for

such activities.
30- The Effectiveness of Drug Abuse Treatment: Implicationsfor Controlling AIDS/HIV Infection

The other major avenue of HIV spread among IV

drug users is through sexual transmission among IV

drug users and to non-drug-using partners. It

appears that a current epidemic of sexually transmitted diseases (STDs) facilitates further the spread

of HIV (120,143). A recent report from two STD

clinics in Baltimore showed that among heterosexuals who were not IV drug users, those who suffered from syphilis were seven to nine times more

likely to have AIDS than other patients in the clinic

(143). The increase in STDs is attributed to the

increasing rates of cocaine use, both intravenously

and in smokable form (crack) (260). Cocaine has

been linked to increased sexual activity and multiple

sexual partners (193). Furthermore, the exchange of

sex for money or drugs is an additional force

spreading HIV and other STDs (120,143).

The risk of contracting HIV infection from drug

use relates to the user’s needle-use behaviors and

sexual practices. In both cases, the risk depends on

the prevalence and infectiousness of HIV infection

among the drug users or sexual partners. The risks

associated with needle use depend on the number of

persons sharing equipment, the use of rented or borrowed needles, the frequency of injection, and the

frequency and effectiveness of needle-cleaning practices. The risk of HIV transmission through one

needle-stick inoculation, which is comparable to

one IV drug use, is estimated at about 0.4 percent

(108a,200a). By sharing needles and injecting multiple times each day, IV drug users may frequently be

exposed to HIV. The risks associated with sexual

activity depend on the type of sexual practice, the

number of partners, and the frequency of preventive

measures, such as condom use. Research has

estimated that the risk for HIV transmission through

male-female vaginal intercourse is about 0.2 percent

for each sexual encounter (141,145a). Researchers

have noted that once HIV becomes established in a

local area among IV drug users, they quickly become

the primary source of heterosexual and in utero

transmission (89).

Differences in HIV seroprevalence by primary

and other drugs used are mediated through these

risk behaviors. For example, the pharmacological

properties of cocaine (strong reinforcer, short

duration of action) lead to more frequent use and

binges. These patterns in turn are associated with

increased HIV risk behaviors (3,372). Data from

1,878 active IV users of cocaine not in treatment in

Chicago found that cocaine injectors used shooting

galleries and shared drug paraphernalia more frequently than non-cocaine injectors (372). Recent

studies from New York City found that crack use and

crack-related sexual behavior were associated with

HIV infection (48,255)

A recent study examined differences between

seropositive and seronegative clients in a 1988 cohort

of 222 admissions to methadone clinics in New York

City (222). The results support previous findings that

HIV infection is strongly associated with needlesharing behaviors and the use of heroin and cocaine

together ("speedballing”). A similar analysis of 218

subjects admitted in 1987 revealed that IV cocaine

users were significantly more likely to be HIV positive than those who smoke or snort cocaine (221).

A seroprevalence study of IV drug users admitted

to methadone clinics in 8 cities between 1987 and

1988 revealed that 71.3 percent reported using

“speedball” during the past 5 years (24). These users

were more likely to be seropositive, more involved

with drugs, and engaged in high-risk drug-using and

sexual behavior.

The potential for rapid spread of HIV infection

among IV drug users should be emphasized (94).

Explosive increases of HIV infection among IV drug

users in Bangkok have been reported, with increases

in HIV prevalence from 1 percent in late 1987 to 44

percent in September 1988. Sharing of injection

equipment was identified as the primary risk factor

(237,353). The investigators of a recent study that

examined trends in HIV infection and AIDS risk

behaviors among IV drug users in selected U.S. cities

stated that although New York City and Ashbury

Park already have high HIV-positive rates, Baltimore, Chicago, and Trenton, “may be approaching

a ‘critical mass’ of infection which could result in

rapid escalation” (29).

Seroconversion rates among IV drug users range

from 3 to 10 percent or more per year and vary

among different groups and cities (145). Analysis of

data from 616 seronegative IV drug users not
Chapter 2--Dreg Use and HIV Infection: The Current Situation- 31

enrolled in treatment in Chicago showed a 23-

percent probability of seroconversion 25 months

after entry into the study. This rate is almost tenfold

higher than the rate reported in a cohort of gay men

in Chicago during a similar time period (371).

HIV transmission has declined in homosexual

men because of behavior changes since 1984, in

hemophilia men because of heat treatment of clotting

factors, and in transfusion recipients because of

screening of blood collected since March 1985 (73,

253,360). A major route of HIV transmission now

appears to be through exchange or sharing of needles

used for IV drugs. Rates of seroconversion among

drug users have remained high in recent years, and at

least in some cities have not abated (145,371).

Through May 1990, about 31 percent of AIDS cases

were directly or indirectly associated with IV drug

use (349). Thus, sharing injection equipment directly

or indirectly has been a major vehicle for HIV transmission in the United States (349).

Estimates of IV Drug Abuse

Rates and trends in the usc of needles as a route

of drug administration are particularly important

given the link to HIV spread. The accuracy of such

estimates is not clear, because the estimates are

based largely on guesses (282). The estimates

depend on, among other variables, the definition of

IV drug users and how seroprevalence rates are

estimated.

According to estimates provided by State alcohol

and drug abuse agencies to the National Association

of State Alcohol and Drug Abuse Directors as a part

of the 1988 State Alcohol and Drug Abuse Profile

(SADAP),4 the number of IV drug abusers across

the country was reported to be greater than 1.3

million in 1988 (see ch. 3 for a description of SADAP

and results) (45). The Research Triangle Institute,

after reviewing existing studies and methods for the

estimation of the number of IV drug users, suggested

a total current estimate of approximately 1.8 million

(64).

4 Thirty-six Stats, the District of Columbia, and Guam provided

estimates of the number of IV drug abusers (45).

Results from the 1988 household survey show

that approximately 2.5 million people aged 12 and

older (1.3 percent of the population) have used

needles as a method of drug administration

sometime during their lifetimes (330). About

500,000 (0.3 percent of the population) used needles

during the year prior to the survey, with needle use

most prevalent among males, 18- to 34- year olds,

and blacks. Approximately 1.9 million (8 percent of

lifetime cocaine users) have used cocaine

intravenously at some time in their lives, and 2

percent have done so during the past year (326).

According to the DAWN network, injection was

the route of administration in about 80 percent of

heroin ER mentions and 25 percent of cocaine mentions in 1988 (fig. 2-11). It should also be noted that

the closeness of such estimates should not be

regarded as persuasive, because they cannot be

regarded as independent estimates (i.e., different

guesstimates are based on some of the same indicators or correlates of IV drug user prevalence) (282).

Estimates of Risk Behaviors Among

Drug Abusers

Data available from the National AIDS

Demonstration Outreach Research Project, the

largest outreach program for IV drug users not in

treatment, document the extent of IV drug-specific

use (340). Of the 16,998 IV drug users studied

between 1987 and 1989, 98 percent had injected

heroin or cocaine, either mixed or sequentially. Only

2 percent reported injecting amphetamines or other

drugs. Of all IV drug users who reported injecting

heroin or cocaine, heroin was the predominant drug

for 34 percent, cocaine for 31 percent, and heroincocaine combinations for 33 percent. More than half

(59 percent) reported daily drug injection. Heroin

was the predominant drug for those who reported

drug use on a daily basis (38).

Preliminary results about risk behaviors of drug

abusers not in treatment come from 10 cities

involved in NIDA’s National AIDS Outreach

Demonstration Research Project in 1989. An initial

assessment was conducted of 3,724 IV drug users not

in treatment to measure behaviors that place the

population at risk for AIDS (325). Only 16 percent

of the men and 15 percent of the women reported
32- The Effectiveness of Drug Abuse Treatment: Implicationsfor ControllingAIDS/HIV Infection

Unknow

15%

Figure 2-11 -- Emergency Room Mentions of Cocaine and Heroin

by Route of Administration, 1988

Sniffed Other

3.2% 2%

Heroin

SOURCE: U.S. DHHS, NIDA (330).

ction

8%

that they did not share needles. Seventy percent and

63 percent, respectively, said that they had shared

needles with 2 or more IV drug users during the previous 6 months. Similarly, a substantial majority of

both males and females (77 and 72 percent, respectively) reported use of rented or borrowed needles,

and 69 percent of males and 34 percent of females

did not use new or bleach-cleaned needles. Based on

a composite index of the 3,611 IV drug users who

reported all of the above three risk behaviors

(sharing needles using rented or borrowed needles,

and not using bleached cleaned needles), 75 percent

of males and 69 percent of females were classified as

being at high risk for HIV infection (325). More

recent data from the same project, which includes

16,998 IV drug users, showed that 78 percent

reported sharing drug-injection equipment and 20

percent reported sharing with strangers (340).

Another study of needle-sharing practices among

IV drug users seeking treatment in 5 cities revealed

an overall prevalence of needle-sharing at least once

in the past 30 days of 64 percent, with a range of 45

to 95 percent (254).

Similar patterns are reflected in the data from the

Drug Use Forecasting program of the National

Institute of Justice. Among male arrestees from 14

Other

27.3%

Cocaine

n

cities in the first 3 months of 1989, 81 percent of

those who tested positive for opiates also tested positive for cocaine (336). Drug injection at some point

during their lives was reported by 15 to 38 percent of

male arrestees (table 2-2). In 10 of the 14 cities,

cocaine was more frequently reported to be injected

than heroin. In 11 cities, more than 20 percent of

injectors reported sharing needles (336).

A self-administered anonymous questionnaire

was used by departments of education in 30 States,

10 cities, and two territories from February through

May 1989 to assess HIV-related knowledge and

behaviors among high school students (343)5

.Most

students knew that AIDS or HIV infection can be

transmitted by sharing needles used to inject drugs

(93 to 100 percent). Rates of reported IV-drug use

varied: between 2 to 5 percent of students reported

ever injecting cocaine, hero@ or other illegal drugs,

and 0.2 percent to 3 percent reported sharing needles

to inject drugs. Despite survey limitations (e.g., a

range of sampling schemes and response rates,

‘School response rates ranged from 27 to 100 percent; student

response rates ranged from 41 to 92 percent; and sample sizes

ranged from 303 to 10&9 students (343).
Chapter 2--Drug Use and HIV Infection: The Current Situation- 33

Table 2-2--Percent Self-Reported Drug Injection and Needle-Sharing in Male Arrestees,

Selected U.S. Cities, January to March 1989

Percent injectors who ever injected: Percent injectors

Percent ever who currently

City injected Cocaine Heroin Amphetamines share needles

Cleveland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Dallas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Detroit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

District of Columbia . . . . . . . . . . . . . .

Indianapolis . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kansas City . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

New Orleans . . . . . . . . . . . . . . . . . . . . . . . . . . .

New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Philadelphia . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Phoenix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Portland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

San Antonio . . . . . . . . . . . . . . . . . . . . . . . . . . . .

San Diego . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

St. Louis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17

15

19

19

17

18

18

21

19

25

30

24

38

18

74

67

60

78

81

66

80

91

83

89

71

68

57

91

71

46

95

78

44

39

69

89

64

57

64

76

70

64

15

51

5

5

46

61

s

19

44

43

70

36

49

40

l5

36

10

22

26

16

33

30

24

20

29

48

34

24

SOURCE: U.S. DHHS, CDC (336).

limited sample sizes, and the problem of reliability of

self-reports and missed populations (those not in

school), these data indicate that many students are at

risk for HIV infection because they use IV drugs.

Data from the National AIDS Outreach

Demonstration Research Project documented the

extent of sexual practices that relate to HIV spread.

Between 1987 and 1989, 29 percent of male and 34

percent of female IV drug users not in treatment

reported two or more IV drug-using sexual partners.

Furthermore, 59 percent of male and 48 percent of

female IV drug users said that they had engaged in

sexual activity exclusively with non-IV drug users.

With respect to condom use, only 11 percent of men

and 17 percent of women indicated that they always

used condoms (325). Overall, the analysis showed a

correlation between high-risk sexual behavior and

high-risk drug use behavior.

HIV Seroprevalence Among Drug Users

Unlike AIDS cases, which are reported to the

CDC, there is no comprehensive system for

monitoring the prevalence of HIV infection.

According to the various assumptions used in the calculation, the estimate of HIV-infected IV drug users

varies from 61,000 to 398,000 (126). The prevalence

of HIV infection among IV drug users in treatment

varies widely by geographic area, with the highest

rates observed in the Northeast (10 to 65 percent)

and the lowest in areas of the West, Midwest and

South (some areas less than 5 percent) (126). An

ongoing survey of clients entering treatment in 41

clinics in 21 metropolitan areas and an examination .

of 7,000 sera revealed a range of seroprevalence

rates among IV drug users of O to 48 percent, with a

median rate for all clinics of 2.9 percent (4). IV drug

users in clinics in New York City and Newark,

however, typically had rates over 40 percent. Rates

as high as 50 to 60 percent have been reported from

addicts in treatment in these areas (89).

A separate study of seroprevalence in IV drug

users entering treatment between 1988 and 1989

examined the association between HIV-positive

status and the primary drug of abuse. It showed that

although heroin was associated with the highest

median HIV-positive rates (4 percent), it was followed closely by cocaine, with 3.1 percent (4).

Of the 1.8 million IV drug users estimated by the

Research Triangle Institute in 1989, 902,000 were

estimated to use IV drugs occasionally and an additional 893,000 individuals were estimated to use

needles frequently enough to place them at risk for

HIV infection (64).
34- The Effectiveness of Drug Abuse Treatment: Implicationsfor ControllingAIDS/HIV Infection

AIDS Cases Reported to the Centers for

Disease Control

The Centers for Disease Control (CDC)

estimates that there are currently about 1 million

persons in the United States who are infected with

HIV (338). When reviewing statistics on AIDS

reports, one should note that AIDS diagnosis typically lags 5 or more years behind actual infection

with HIV and may not reflect the most up-to-date

information on current ways the virus is spreading.

From diagnosis of the first AIDS case in 1981

through May 1990, 136,204 AIDS cases were

reported to the CDC, including 2,315 pediatric eases

(4).6 There have been 83,145 AIDS-related deaths

reported through May 1990, including 1,239 pediatric

fatalities. Rates of reported AIDS cases were

highest for blacks and Hispanics; for persons 30 to 39

years of age; in the Northeast region and in U.S. territories (primarily reflecting rates in Puerto Rico); in

6

For the purpose of the CDC’s AIDS case definition, pediatric

cases are those Occurnng in children under the age of 13 (349).

the largest metropolitan areas; and for men. Rates

vary tremendously among and within States.

IV Drug Use as an AIDS Risk Factor

IV drug use is the second most common risk

behavior among cases of AIDS in the United States,

surpassed only by men having sex with other men. In

1988 and 1989, one-third of all reported AIDS eases

were associated with IV drug use (4). Between June

1989 and May 1990, health departments of the 50

States, the District of Columbia, and U.S. territories

reported 12,985 cases of AIDS in IV drug users, their

sexual partners, and babies born to mothers who

were IV drug users or sexual partners of IV drug

users. IV drug use was a risk factor in 33 percent of

the 39,203 AIDS cases reported during that 12-

month period. Among the 38,524 adult and

adolescent AIDS eases reported from June 1989 to

May 1990, 9,072 (24 percent) were female or

heterosexual male IV drug users, 2,221 (6 percent)

were male homosexual/bisexual IV drug users, and

1,275 (3 percent) were attributed to heterosexual

contact with an HIV-infected, IV drug-using partner

(see fig. 2-12). Furthermore, of the 590 pediatric

Figure 2-12--AIDS Cases in Adults and Adolescents by Risk Factor,

June 1989 through May 1990

Homosexual/Bisexual

2

IV dr

9,072

SOURCE: U.S. DHHS, CDC (349).

ther:

,230

IX W i

s

th IV drug user

1,275

Homosexual/Bisexual and

IV drug user

2,221
Chapter 2--Drug Use and HIV Infection: The Current Situation- 35

AIDS cases presumably associated with perinatal

transmission, 70 percent (417 cases) had mothers

who were IV drug users or sexual partners of IV

drug users (349).

The same pattern pertains to cumulative U.S.

AIDS cases reported to the CDC. Through May

1990, 27 percent of AIDS cases among adult men

and 71 percent of AIDS cases among adult women

were directly or indirectly associated with IV drug

use (349). In addition, 71 percent of children who

were presumably infected through perinatal transmission had mothers who were IV drug users or

sexual partners of IV drug-users (349).

Trends in AIDS Cases

IV drug use has been associated with a growing

percentage of AIDS cases. During the 3-year period

between December 1986 and December 1989, the

percentage of AIDS cases reported in female or

heterosexual male IV drug users increased from 17

percent to 23 percent (344,345). The increasing proportion of IV drug use in total AIDS cases from 1986

through 1989 has to some extent been mediated by

the 1987 change in the CDC’s AIDS case definition

(see below). The increase in AIDS eases associated

with IV drug use parallels an increase in cases

attributed to heterosexual contact with IV drug users

and an increase in AIDS cases in children of women

who were IV drug users or sex partners of IV drug

users (338).

Geographic Concentrations of AIDS Cases

In 1988,4.3 cases of IV drug use-associated AIDS

per 100,000 population were reported to the CDC

(335). Rates of IV drug use-associated AIDS varied

widely by area; rates in Puerto Rico, New Jersey,

New York, and the District of Columbia were >10

cases per 100,000 population (fig. 2-13). Rates were

highest in the Northeast region, where there were

almost 12 eases per 100,000 population (table 2-3).

Although the Northeast represents 19.7 percent of

the population of the United States and its territories, 54.5 percent of IV drug use-associated cases

of AIDS were reported there (335). Reported AIDS

cases associated with IV drug use were concentrated

in a few large metropolitan areas; however, there is

recent evidence of increasing AIDS cases in small

metropolitan and rural areas (3). In several Northeastern States and Puerto Rico, the number of AIDS

cases in IV drug users exceed those in homosexual

men (335).

Prevalence of AIDS Among Blacks and

Hispanics

The original AIDS case definition was standardized on gay men, and until the ease definition

was revised in 1987, AIDS surveillance probably

resulted in a large underestimation of AIDS in IV

drug users, blacks, and Hispanics by failing to

attribute death among these groups to AIDS (286).

In spite of possible underestimation, selected racial

Table 2-3-Number and Rate Per 100,000 Population of AIDS Cases Associated

With IV-Drug Use, by Census Region and Race/Ethnicity, 1988

Number of cases (rate)

Race/ethnicity Northeast Midwest South West Total a

White b

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,203 ( 2.9) 217 ( 0.4) 687 ( 1.2) 719 ( 2.2) 2,826 ( 1.6)

Blackb

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,929 (62.0) 294 ( 5.5) 1,318 ( 9.5) 277 (125) 4,818 (18.4)

Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,699 (65.2) 69 ( 5.4) 135 ( 3.0) 159 ( 2.5) , 2,062 (14.1)

Asian/Pacific Islander . . . . . . . . . . . . . . . . . . . 6 ( 1.1) o ( 0.0) o ( 0.0) 6 ( 0.3) 12 ( 0.3)

American Indian/’

Alaskan Native . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ( 1.2) 2 ( 0.8) o ( 0.0) 6 ( 0.8) 9 (0.6)

Unspecified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 0 0 2 25

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,861 (11.9) 582 ( 1.0) 2,140 ( 2.8) 1,169 ( 2.7) 9,752 ( 4.3)

a Total cases and total rates exclude territories. Rates are based on the U.S. census.

Non-Hispanic.

SOURCE: U.S. DHHS, CDC (335).
36- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

.

04

\ ai

‘7”1 0.a l

. ) Q

d

—Im l

I o“ I

o *

r0“ 0“ 0

-

Lo.

T*

o . .

. .
Chapter 2--Drug Use and HIV Infection: The Current Situation- 37

and ethnic minorities are over-represented in AIDS

case reports compared with the general population.

As table 2-3 indicates, the rate of IV drug useassociated AIDS is higher for blacks and Hispanics

than for whites.’ Blacks make up 12.2 percent of the

U.S. population, but account for 27.8 percent of total

AIDS cases and 45.2 percent of AIDS cases where

IV drug use has been listed as a risk factor (349).

Hispanics make up 8.1 percent of the U.S. population, but account for 15.7 percent of total AIDS

cases and 25.9 percent of cases where IV drug use

has been listed as a risk factor (349). The proportion

of AIDS cases among minorities is even more

dramatic for pediatric AIDS cases. Over half of

pediatric AIDS cases reported through May 1990

(51.7 percent) were blacks, 25.5 percent were

Hispanics, and 21.9 percent were whites (349).

Effect of the 1987 Revision of CDC’s AIDS

Case Definition

CDC’s 1987 revision of the AIDS case definition

appears to have increased the number of AIDS cases

reported in IV drug users, blacks and Hispanics, and

persons living in the Northeast (337). Previously,

7A future Staff Paper in the Office of Technology Assessment’s

AIDS series plans to analyze HIV rates among blacks and

Hispanics.

these groups and areas were thought to be greatly

underestimated by the AIDS surveillance, because

deaths among IV drug users with AIDS did not meet

the earlier ease definition. In August 1987, the CDC

surveillance ease definition for AIDS was expanded

to include additional AIDS-indicator diseases (e.g.,

HIV dementia, wasting syndrome, extrapulmonary

tuberculosis) and to accept some other indicator diseases as presumptive diagnoses of AIDS (e.g.,

Pneumocyctis carinii pneumonia, Kaposi’s sarcoma,

esophageal candidiasis) when tests for HIV are positive (334).

Of the IV drug-use-associated AIDS cases

reported in 1988, 4,682 (43.6 percent) met the case

definition solely on the basis of criteria added by the

1987 case definition revision (335). The proportion of

IV drug-use-associated AIDS cases has been higher

in the Northeast than in other regions. Since the

beginning of 1988, the number of AIDS cases associated with IV drug use has equalled or exceeded all

other cases reported in the Northeast. The new

criteria captured persons who eventually would

progress to meet the previous definition and those

who never would have met the previous definition.

The latter has been noted to be particularly

important in IV drug users, who may use health care

services for HIV-related illness later and may die of

HIV-related opportunistic infections before they are

diagnosed as having AIDS.

Table 2-4-Projected Number of AIDS Cases, Persons Living With AIDS, and Deaths Attributable to

AIDS After Adjustment for Underreporting, 1989 to 1993a

AIDS cases

Year New casesb Alivec Deaths

1989 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44,000- 5o,ooo 92,000- 98,000 31,000- 34,000

1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52,000 - 57,000 101,000-122,000 37,000- 42,000

1991 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56,000- 71,000 127,000-153,000 43,000- 52,000

1992 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58,000- 85,000 139,000-188,000 49,000 - 64,000

1993 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61,000- 98,000 151,000-225,000 53,000- 76,000

Through 1993d . . . . . . . . . . . . . . . . . . . . . . . . . 390,000-480,000 285,000-340,000

“Projections are adjusted for unreported diagnoses of AIDS by adding 18 percent to projections obtained from reported cases (corresponding to 85 percent of all diagnosed cases being reported: 1/0.85=1.18) and rounded to the nearest 1,000. bNumber of Cases diagnosed during ‘the year.

d ’

c Persons with AIDS alive during the year.

Rounded to the nearest 5,000. Includes an estimated 120,000 AIDS cases diagnosed through 1988,48,000 persons alive with AIDS at the

end of 1988, and 72,000 deaths in diagnosed patients through 1988.

SOURCE: U.S. DHHS, CDC (338).
38- The Effectiveness of Drug Abuse Treatment: Implicationsfor Controlling AIDS/HIV Infection

Projected AIDS Cases

Following a meeting in Atlanta in the fall of 1989,

Federal scientists revised their estimates of the

number of new U.S. AIDS cases in the next 3 years.

Although the number of new cases is still expected to

rise sharply, the total number is expected to be 10 to

15 percent fewer than previously expected (338).

The following explanations have been suggested to

have contributed to the decline:

 o preliminary estimates made in 1986 by the

Public Health Service were too high because

data used to make the predictions were

imprecise. The CDC revised estimates of

Americans infected with HIV in 1986 from

between 1 million and 1.5 million to about

750,000;

o the use of drugs, such as zidovudine, has

delayed the onset of AIDS symptoms that

would qualify individuals for the AIDS-case

definition;

o changes in behavior to reduce the spread of

AIDS, particularly among male homosexuals,

have decreased the spread of the disease

beyond what was expected; and

o the epidemic has slowed because the most susceptible have already been infected (338).

CDC estimates that between 1989 and 1993 there

will be somewhere between 390,000 and 480,000 new

AIDS cases (338). Deaths attributable to AIDS are

expected to be between 285,000 and 340,000 during

that period (see table 2-4 for yearly breakdowns).

Table 2-5 contains the projected number of AIDS

cases by risk-behavior group from 1989 through 1993.

Cost Estimates of Drug Abuse

Although there is little disagreement that drug

abuse in the United States has become a major

public health problem, estimating the cost to society

is a difficult task. Over the past 20 years, numerous

studies have assessed the economic costs of drug

abuse and other illnesses (e.g., alcohol abuse and

mental illness). These studies differed in their

content, theoretical approach, and relevance to policy

decisions, and worked around data limitations and

the necessary assumptions involved in estimating

intangible costs (108).

According to French and his co-investigators, past

studies of the cost of the drug abuse problem have

significantly underestimated the true cost to society

by failing to estimate certain tangible costs (e.g.,

reduced property value in high drug use communities; the real and opportunity cost of educational programs to reduce the consequences of drug

abuse; and the costs of complications related to

secondary diseases, such as AIDS) (108). Because of

the difficulty and controversy associated with developing methods to estimate intangible costs to the

individual drug user and society (e.g., depression,

extended isolation, physical disability, and other

forms of pain and suffering), these have rarely been

included in cost estimates. More specific costs of

drug-related treatment, better information on worker

absenteeism, and drug-related budgets for local,

State, and Federal criminal enforcement, however,

have helped to make recent analyses more accurate

(188).

Table 2-5--Projected Number of AIDS Cases by Risk Group, 1989 to 1993a

Homosexual/bisexual men

Not IV IV Heterosexual IV Heterosexual

Year drug users drug users drug users transmission Pediatric

1989 . . . . . . . . . . . . . . . . . . . 26,000-28,000 2,600-2,800 11,000 2,700-2,900 1,000-1,100

1990 . . . . . . . . . . . . . . . . . . . 29,000-31,000 2,700-3,000 13,000-14,000 3,800-4,100 1,300-1,400

1991 . . . . . . . . . . . . . . . . . . . 30,000-38,000 2,600-3,300 14,000-18,000 5,000-6,400 l,5oo -2,000

1992 . . . . . . . . . . . . . . . . . . . 30,000-43,000 2300-3$00 16,000-23,000 6300-9,300 1,800-2,600

1993 . . . . . . . . . . . . . . . . . . . 30,000-48,000 2,400-3,500 17,000-27,000 8,100-13,000 2,000-3,200

a

Predictions are adjusted for unreported cases.

SOURCE: U.S. DHHS, CDC (346).
Chapter 2--Drug Use and HIV Infection: The Current Situation- 39

The approach that most analysts have used to

estimate costs of alcohol abuse, drug abuse, and

mental illness is based on the cost-of-illness methodology that estimates the aggregate monetary burden

to society of the health effects of illness. This methodology recognizes direct tangible costs, such as the

value of resources needed to treat the disease, and

indirect tangible costs, such as the value of output

lost due to mortality and morbidity. Recently,

researchers have used the cost-of-illness approach to

measure consequences not related to health (e.g., the

linkages between drug abuse and crime, motor

vehicle accidents, and social welfare problems) (108).

French and his co-investigators have outlined a

conceptual framework to help make the process of

estimating the social costs of drug abuse more

uniform and to capture some of the tangible and

intangible costs that were previously not included

(108). The first step of their framework calls for categorizing the adverse health and nonhealth consequences into one of three classes: physical health

problems (e.g., death, brain damage, AIDS-related

diseases); mental health problems (e.g., neurotic and

emotional disorders); and social problems (crime,

reduced job performance, family and community disruptions). The second step in their framework is the

identification and classification of associated costs

according to private tangible and intangible costs and

external tangible and intangible costs. The final step

to their approach requires selecting and developing

methods to estimate each of the social cost elements.

Here, French and his colleagues recommend combining and extending new and existing methods for a

more comprehensive estimate of social cost.

In a contract report for the Alcohol, Drug Abuse,

and Mental Health Administration, Harwood, et al.,

estimated the economic costs to society of drug

abuse in 1983 to be close to $60 billion (136). A substantial part of the total cost (over $33 billion) was

attributed to reduced productivity. The cost of crime

attributed to drug abuse was another major contributing cost. The latest study on the cost of drug

abuse by NIDA should be released in late summer

1990. (See app. F for findings from a cost-benefit

analysis of drug abuse treatment.)

One of the rising costs associated with drug abuse

is the treatment of addicted infants. Estimates of the

number of babies exposed to illicit drugs vary. In a

survey of 36 hospitals conducted in 1988 by the

National Association for Perinatal Addiction

Research and Education, 11 percent of pregnant

women had exposed their fetuses to one or more

illegal drugs, with cocaine or crack as the primary

drug used (75 percent of cases) (301). Estimates of

the number of infants born each year to mothers who

use drugs range from 200,000 to 375,000 (41,104).

The President’s National Drug Control Strategy

report estimates that 100,000 cocaine exposed babies

are born each year (104). Some of the costs associated with fetal exposure to illicit drugs include

medical treatment of fetal withdrawal symptoms,

out-of-home care resulting from child abuse and

neglect, and the treatment of special medical, educational, and psychological needs of drug-exposed

babies.

SUMMARY

Certain behaviors associated with IV drug use

are major vehicles of HIV transmission in the United

States. IV drug use is the second most common risk

behavior among AIDS cases and has been associated

with a growing percentage of AIDS cases. Through

May 1990, 27 percent of AIDS cases among adult

men and 71 percent of cases among adult women

were directly or indirectly associated with IV drug

use (349). Moreover, 71 percent of children with

AIDS who were presumably infected through

perinatal transmission had mothers who were IV

drug users or sexual partners of IV drug-users (349).

In several Northeastern States and Puerto Rico, the

number of AIDS cases among IV drug users exceed

those in homosexual men. In examining current

AIDS cases, one should also keep in mind that they

reflect what occurred 5 to 7 years ago. According to

the CDC, many of the current cases among IV drug

users may reflect the HIV epidemic among a cohort

of heroin users who started heroin use in the mid1960s to mid-1970s (335). The impact of more

recent trends of IV cocaine use, which is associated

with more frequent injection and needle-sharing, and

the impact of crack cocaine use and associated sexual

activity with the potential for increased sexual HIV

transmission are yet to come.
40- The Effectiveness of Drug Abuse Treatment: Implicationsfor Controlling AIDS/HIV Infection

Although each of the major studies of drug use

and consequences in the United States (the

household survey, high school seniors survey, and

DAWN) has recognized limitations, they do provide

“a general overview of the problem, follow the

evolution, and point out areas in which more

knowledge is needed” (293). The Senate Judiciary

Committee’s recent attempt to develop a more complete estimate of the number of cocaine addicts

included, in addition to the household survey

estimate, estimates of cocaine addicts in drug

treatment centers, the homeless population, and

those who had come in contact with the criminal

justice system via arrests (304).

As William Bennett remarked on the release of

the 1988 National Household Survey on Drug Abuse,

“There’s some very good news, and some very bad

news” concerning the state of the nation’s drug

problem (30). The good news is that recent surveys

have found illegal casual use of most drugs to be on

the decline. The bad news in this evolving story is

that the number of cocaine addicts has increased in

recent years, and the costs associated with drug

treatment, productivity losses, and crime have risen

dramatically.

The number of household members reporting

current cocaine use dropped 50 percent, from 5.8

million in 1985 to 2.9 million in 1988 (330,331).

Although the declining trends in casual cocaine use

are indeed encouraging, new reason for concern

centers on the increasing frequency of cocaine use

among current users. Estimates of the number of

addicts (people who use cocaine at least once a

week) range from 862,000 to 2.2 million (304,330).

ER mentions associated with cocaine use have risen

sharply in recent years (increasing fourfold from

8,831 mentions in 1984 to 46,020 mentions in

1988)(329).

According to 1988 household survey data, 2

million people (about 1 percent of the population)

have tried heroin at least once during their lifetimes

(330). Heroin ER mentions increased much more

slowly than cocaine mentions, and in 1985, cocaine

surpassed heroin as the most frequently mentioned

drug in ER episodes (329).

The estimated number of IV drug users in the

United States ranges from 1.3 to 1.8 million (64,145).

A major route of HIV transmission in this group is

the sharing of injection equipment. Sharing of

injection equipment, which occurs for practical, economic, and social reasons, is a common practice

throughout the country in both low and high HIV

seroprevalence ares. Various studies reported

sharing rates ranging from 70 to 100 percent (8).

DAWN statistics show that injection was the route of

administration in about 80 percent of heroin ER

mentions and 25 percent of cocaine mentions in 1988

(328). Prevalence and trends in IV drug abuse are

not well documented, but of great importance given

the connection with HIV spread. The potential for

rapid escalation of HIV infection among IV drug

users, as did occur in New York City, Thailand, and

elsewhere, is always a possibility. Intense prevention

efforts are necessary to control further spread of

HIV among those not yet infected.
Chapter 3

Treatment for Drug Abuse in the United States

INTRODUCTION

This chapter describes the primary drug

treatment modalities and examines information on

treatment programs in the United States. The goals

and characteristics of the major treatment modalities

are distinguished, and the client characteristics currently associated with each are described.

Given what is known about the extent of the drug

abuse and human immunodeficiency virus (HIV)

epidemics (ch. 2), the next logical question is

whether the drug treatment system in the United

States has the capacity and flexibility to meet the

demand for treatment. Data limitations on the

capacity, need for, and cost of treatment services are

an impediment to answering this question and to

more accurate planning to increase the availability

and accessibility of treatment services to drug

abusers.

TREATMENT MODALITIES

Introduction

Treatment for drug abusers has traditionally been

categorized into three major modalities: outpatient

methadone maintenance, residential therapeutic

communities (TCs), and outpatient drug-free (ODF)

treatment. A common distinction among programs

has been whether they use medicines to treat drug

abuse (pharmacotherapy) or are “drug-free. ”

Methadone maintenance treatment, which uses daily

doses of the synthetic narcotic methadone, is the

dominant pharmacotherapy for the treatment of

opiate abusers. Within the drug-free category,

residential TCs, which are distinguished by their

highly demanding and confrontational approach, and

ODF treatment, which includes a very heterogeneous

group of programs, have been the most popular

treatment modalities. Both TCs and ODF programs

treat all types of drug abusers, not just narcotics

abusers.

Although these three modalities are still the most

prevalent forms of drug abuse treatment (45),

changes are beginning to occur in the drug abuse

treatment system in response to a changing client

population (e.g., the increased prevalence of cocaine

abusers). The spread of HIV has also added

pressure to the need for innovative psychological and

pharmacological approaches for intravenous abuse of

opiates and stimulants (178). Innovative approaches

are being tried in an attempt to meet diverse client

needs. For example, methadone maintenance programs and TCs have rarely collaborated in the past.

In a research project in San Francisco from 1981 to

1984, however, an attempt was made to help clients

on methadone detoxify to a drug-free life while

residing in a TC (279). Two treatment approaches

that have become popular are 28-day residential hospital programs and Narcotics Anonymous, self-help

support groups patterned after Alcoholics

Anonymous (AA). A variety of ODF treatments that

provide intermediate levels of care (including day

care, evening care, and halfway housesl

) have also

become more common (203). New pharmacotherapies are being studied and tested for their effectiveness in treating cocaine and polydrug abusers in

addition to heroin addicts. In a few areas of the

country, a multi-modality treatment approach has

been tried in which the area’s various treatment programs operate under a central referral center.

The need for a range of treatment options stems

from the diversity that exists among drug abusers.

Abusers differ, among other variables, in the drugs

they use, the presence or absence of psychiatric disorders, educational and occupational achievements,

and family and social support systems (319).

Although many drug abusers require multiple

treatment episodes to combat the chronic relapsing

nature of drug abuse, other drug abusers may require

a single treatment episode of relatively short

duration (154). Different treatment approaches

might also be appropriate at different points in the

individual’s addiction career.

.

1 Day care is treatment for drug abusers who spend the day in

treatment and return home in the evening; evening care is for

those who work during the day and spend a few hours in

treatment at night; and halfway houses are for people who reside

in the treatment house and go out to work during the day (203).

-41-
42- The Effectiveness of Drug Abuse Treatment: Implications for Controlling HIV Infection

In general, drug treatment centers serve a predominantly young adult, poorly educated, male

clientele; however, State drug agency directors and

treatment program administers report that today’s

clients are more likely to use multiple drugs and to

be female than they were a decade before (149).

Although each of the modalities treats a variety of

patients, some client characteristics are disproportionately represented in specific modalities.

Because of the pronounced differences in treatment

approaches and client populations, this chapter and

the following chapters on treatment effectiveness

consider each modality separately.

Role of Detoxification

Detoxification is often the first stage in the

treatment process. The primary goal of

detoxification is to stabilize the drug abuser while a

drug-free state is being reached. Detoxification programs use licit drugs (e.g., methadone or clonidine)

on a short-term basis to help manage withdrawal

symptoms while the abused drug is being eliminated

and the body adjusts to its absence (13). Although

some people view detoxification as a modality in and

of itself, others see the value of detoxification as a

“gateway” to more intensive treatment interventions

(13). For example, detoxification must be completed before entry into TCs, ODF programs, and

certain pharmacotherapies (170). To date,

detoxification using substitute medications is only

truly available for opiates, sedative-hypnotics, and

alcohol. Although short-term residential programs

frequently say they offer cocaine detoxification, technically they do not use pharmacologic agents to

achieve detoxification (35).

The ideal detoxification agent would be completely effective in relieving symptoms of withdrawal,

orally active, long-acting, safe, and of low addiction

potential (178). Since no single agent meets all of

these characteristics, a search continues for new

pharmacologic agents to treat drug abuse.

Because methadone is a narcotic, it is a controlled substance in the United States. Any organization dispensing methadone, whether for

detoxification or maintenance treatment and

regardless of whether the program accepts public

funding, must abide by mandatory regulations concerning minimum standards for admission, urine

testing frequency, patient evaluation guidelines, and

provided services (counseling, vocational, rehabilitative, and other support services) (54 FR 8954). It

should be noted that these Federal regulations cover

the use of all narcotics; thus detox-ification or

maintenance with Levo-Alpha-Acetyl-Methadol

(LAAM), burprenorphine, or any other narcotic

would also be covered. The Narcotic Addict

Treatment Act of 1974 (Public Law 93-281), which

requires the registration of practitioners conducting

methadone treatment programs, defined

detoxification treatment as:

the dispensing for a period not in excess of 21 days, of a

narcotic drug in decreasing doses to an individual in

order to alleviate adverse physiological or psychological

effects incident to withdrawal from the continuous or

sustained use of a narcotic drug and as a method of

bringing the individual to a narcotic drug-free state

within such a period.

In March 1989, the Food and Drug Administration (FDA) and the National Institute on Drug

Abuse (NIDA) issued a final rule on conditions of

methadone use, in which the length of detoxification

treatment was expanded to include short-term

detoxification treatment (not in excess of 30 days)

and long-term detoxification treatment (between 30-

180 days) (54 FR 8960).

Although methadone is still widely used,

clonidine has become a standard method of opiate

detoxification in many places (179). Because

clonidine is not a narcotic or a controlled substance,

it can be used by a wider range of physicians and in

treatment settings that are not licensed to dispense

narcotics (171). One advantage that clonidine has

over methadone is that it shortens the period of time

necessary for withdrawal (from 20 to 30 days to 10 to

14 days) (171).

Clonidine is also being studied in combination

with naltrexone as a nonopiate detoxification

method. This approach has an advantage over other
. .

Chapter 3-Treatment for Drug Abuse in the United States- 43

detoxification methods in that complete detoxification can be achieved in just 3 to 4 days instead of 21

days with methadone or 14 days with clonidine alone

(178).

Because opiate detoxification has been a shortterm therapeutic approach, the provision of support

services has not usually been stressed to the extent

that it is in some of the longer-duration treatment

modalities. It is hoped that recently available longterm detoxification will provide the flexibility for programs to aid those drug abusers who require more

extensive treatment (35).

Detoxification may take place in outpatient settings or in hospital inpatient or other residential programs. The Office of National Drug Control Policy

has stated that most patients can be detoxified in less

expensive outpatient programs, but offered no supporting evidence (105).

A controversial issue associated with detoxification has been how the programs are used by

clients. It has been reported that certain opiate

addicts entering detoxification are unwilling to make

a commitment to give up their addiction and merely

seek a break in the stressful life of hustling for drugs

or a reduction in their tolerance so that they can

achieve euphoria with smaller quantities of narcotics

(223). Detoxification treatment, however, offers the

opportunity to counsel these clients about the risks of

drug abuse (including HIV infection), orient them to

long-term modalities, and facilitate referrals

whenever they seem appropriate.

Pharmacotherapy Treatment Approaches

Medication to treat drug abuse was first used in

the mid-1960s with heroin abusers. Methadone and

naltrexone, both of which are used to treat narcotic

abuse, are the only two drugs currently approved by

FDA for drug abuse treatment. In response to the

continuing drug crisis, NIDA’s Drug Development

Task Force has explored further research and development of pharmacotherapies that:

o

0

0

0

0

block the effects of abused drugs,

reduce the craving for abused drugs,

moderate or eliminate withdrawal symptoms,

block or reverse toxic effects, and

prevent, under certain conditions, initial drug

abuse (320).

Although more research is needed, some

progress has been made in recent years in understanding how drugs act on the brain to create a

“reward system,” in which the experience of pleasure

caused by the drug reinforces drug use (303).

Understanding how drugs initiate chemical reactions

in the brain that cause compulsive drug-seeking

behavior is thought to hold the key for the development of treatments that can interfere with those

processes and stop the addictive cycle (320). NIDA

is currently overseeing the research and development

of 28 pharmacotherapeutics (see table 3-l).

Pharmacotherapies are commonly viewed as an

adjunct to more traditional psychosocial treatment

methods. One way that pharmacotherapies may

support other treatment methods is that, by reducing

abusers’ intense craving for drugs, they may make

patients more receptive to psychological counseling

and other rehabilitative services (303).

Pharmacotheraphy for Narcotics Abuse

Through advances made in the mid-1970s, drug

abuse researchers have observed that exogenouslyadministered opiates, such as heroin, may lead to

addiction through actions on endogenous opiate

peptide and receptor systems of the brain (333).

These discoveries have guided the use of two general

types of narcotic pharmacotherapies: narcotic

agonists, which have narcotic effects, and narcotic

antagonists, which block the effects of narcotics. By

binding to the same receptors as illicit narcotics, narcotic agonists replace the addict’s physiological

requirement for narcotics (e.g., heroin), thereby preventing the onslaught of a painful withdrawal

syndrome. They also reduce narcotic hunger or

craving and, as tolerance increases, offer a blockade

to injected heroin (35). Narcotic antagonists, on the

other hand, block the euphoria caused by narcotics

by preventing the access of these drugs to opiate

receptor sites, but have no intrinsic effect of their

own.

Methadone Maintenance--Methadone is a longacting narcotic agonist that was first studied for its

effectiveness in treating long-term opiate abuse in

the mid-l960s (100). Of all the treatment modalities,

methadone maintenance has been subjected to the

most extensive research and evaluation.
44- The Effectiveness of Drug Abuse Treatment: Implications for Controlling HIV Infection

Table 3-l-Drug Development Program of the National Institute on Drug Abuse (NIDA), 1988

Therapeutic status of Original owner

Drug indication FDA process of patent

Opiate treatment agents

Methadone and naxolone

Depot Naltrexone

Chlonidine

Buprenorphine

Metkephamid

Acetorphan

Cocaine treatment agents

Desipramine

Imipramine

Carbamazepine

Mazindol

Flupenthixol

Fluoxetine

Nifedipine

Buprenorphine

Verapamil

Diltiazem

Sulpiride

SCH23390

L-tryptophan

Amantadine

Bromocriptine

Methyiphenidate

L-DOPA

Opiate maintenance therapy

Lower abuse potential

Long-term opiate blockade

Opiate maintenance therapy

Opiate detoxification

Opiate detoxification

Opiate maintenance & blockade

Opiate maintenance therapy

Opiate maintenance therapy

Treat withdrawal

Treat withdrawal

Treat withdrawal

Treat withdrawal

Treat withdrawal

Treat cocaine & PCP withdrawal

Block euphoria

Block euphoria

Block euphoria

Block euphoria

Block euphoria

Block euphoria

Functional antagonism

Maintenance therapy

Maintenance therapy

Maintenance therapy

Replacement therapy

Approved but not marketed

Standard drug approved

Phase 111 completed

Currently in use in open trials

Phase 11

Phase I

Animal testing

Phase 11

Phase 11

Phase I

Phase I

Clinical evaluation

Clinical evaluation

Phase 11

Clinical evaluation

Animal Testing

Animal Testing

Animal Testing

Animal Testing

Phase 11

Phase I

Phase I

Phase I

Clinical evaluation

Bristol

DuPont

Public

Boehringer

Norwich

Eaton

Lilly

Merrell Dow

Geigy

Geigy

Sandoz

Merrell Dow

Dista/Lilly

Pfizer

Norwich Eaton

Searle

Marion

Delegrange

Schering

Public

Endo

Sandoz

CIBA

Roche

ABBREVIATION: FDA = Food and Drug Administration.

aAdministration of Naltrexone in a depo form, i.e., skin implants that gradually release the drug into the bloodstream.

SOURCE: US DHHS, NIDA (320).

Methadone has proven to be a good maintenance

agent. It can be administered regularly (usually once

a day) by oral administration as a substitute for the

illicit narcotics. Although the effect of a single

heroin injection usually lasts 4 to 6 hours, methadone

remains active for more than 24 hours. As an

agonist, methadone produces a cross tolerance with

narcotics to reduce withdrawal symptoms and block

the effects of heroin. Because methadone produces

minimal euphoria when taken orally, patients can

continue to work or go to school (170).

As mentioned in the discussion of detoxification

programs, because methadone is a narcotic, Federal

regulations govern its administration. Conditions for

the use of methadone in maintenance treatment (2I

CFR Part 291) require that clients entering methadone maintenance programs prove that they are currently narcotic dependent (i.e., that they physiologically need heroin or a morphine-like drug to prevent

the onset of signs of withdrawal) and that they

became dependent at least 1 year before admission

to maintenance treatment (54 FR 8960-8964).

Federal regulations include requirements for

client treatment plans, mandatory counseling sessions, and routine urine testing. Federal regulations

also require that methadone maintenance clinics

provide “a comprehensive range of medical and rehabilitative services” to those in need of such services

who receive methadone treatment (54 FR 8966).

Despite these regulations, however, methadone

maintenance clinics vary extensively in the selection

and emphasis on the support services they provide

(e.g., counseling, vocational and educational training)

and in their program structure (e.g., dosage levels,

frequency of urine tests, take-home policies).
Chapter 3-Treatment for Drug Abuse in the United States- 45

Methadone maintenance programs also differ in

the extent to which detoxification from methadone is

the ultimate treatment goal. Although Federal

regulations state that an eventual drug-free state is a

realistic goal for many people, they also recognize

that some patients may need to stay on methadone

for long periods (45 FR 62717). There are two

general types of methadone treatment programs. In

long-term methadone maintenance, clients are

expected to continue on methadone indefinitely. A

different approach is taken by methadone-toabstinence programs, where the goal is eventual

drug-free living. Although long-term maintenance

programs typically prescribe high doses of

methadone to block the effects should a client

attempt to use heroin, methadone-to-abstinence programs typically prescribe as low a level as the patient

can take to prevent withdrawal (149). Average time

in treatment varies among programs and patients

even within these two approaches.

Individual State regulations also govern the use of

methadone. A NIDA survey of State methadone

treatment programs found that several States did not

provide methadone treatment programs and that a

large majority of those that did had some type of

regulation of methadone programs, including

allowable dosage levels and mandatory inspections

(213). Of the authorities that responded from 39

States, the District of Columbia, Puerto Rico, and

the Virgin Islands, 6 States (Arkansas, Maine,

Montana, 2 North Dakota, South Dakota, and

Wyoming) had no methadone treatment programs.

At least 2 of the 11 States that did not respond (Mississippi and New Hampshire) also do not provide

methadone treatment programs. Three States

(Oklahoma, Vermont, and West Virginia) had

methadone detoxification programs but not

maintenance programs.

Although the substitution of methadone, a licit

opiate, for illicit opiates, such as heroin, is the most

common technique for the treatment of narcotic

addicts, it remains a controversial issue (see ch. 4).

Methadone itself is a dependence-producing drug,

2Montana stated that its hospitals use clonidine to detoxify

patients. Although this survey was not able to determine why

particular States did not provide methadone, some State statutes

preclude the use of methadone, while other States responded that

they do not have a narcotics problem (214).

and patients experience withdrawal symptoms when

they stop methadone treatment. There is a common

misconception that methadone provides euphoria

which in turn spurs an illicit market for the drug.

Most experts agree, however, that the black market

for methadone stems more from methadone’s ability

to relieve withdrawal then from its euphorigenic

effects (87). Since some people regard any drug use

pejoratively, methadone programs have often used

low doses, which have resulted in insufficient

treatment (10). As noted above and discussed in

chapter 4, daily doses below 30 to 50 mg are considered inappropriate, and effective daily doses have

been found to average about 80 mg (66,130).

All methadone maintenance clients are opiate

abusers and an increasing number of them use other

drugs, including cocaine (184). Compared with

clients of other treatment modalities, outpatient

methadone maintenance clients were more likely to

be older, black or Hispanic, and married and to have

had prior treatment admissions (149). It should be

noted that generalizations about typical client characteristics may be confounded by such issues as the

geographic location of programs (112).

Naltrexone--Naltrexone is a pure narcotic

antagonist that was developed for the treatment of

narcotics addiction in the early 1970s and approved

by FDA in 1984. Naltrexone has the ability to block

the euphorigenic and dependence-producing properties of opiates. Because antagonists are structurally

similar to narcotics, they can occupy the same opiate

receptor sites as narcotics. Even if heroin is used, as

long as the dose does not exceed the amount blocked

by the narcotic antagonist, the patient will not experience the pleasurable effect of the heroin.

One caveat about naltrexone’s administration and

potential benefit is that it must be given to persons

who are no longer physically dependent on opiates. If

naltrexone is administered to a heroin-dependent

person, the familiar opiate withdrawal symptoms will

develop. These symptoms can be reversed by a large

dose of heroin (or other opiate) (247). In order for

3A pure or full antagonist is a drug that has only antagonist

actions, whereas a partial antagonist has both agonist and

antagonist actions.
46- The Effectiveness of Drug Abuse Treatment: Implicationsfor Controlling HIV Infection

naltrexone to block opiates’ effects without

producing unpleasant withdrawal symptoms, patients

must be off all narcotics for a period of at least 5-IO

days before naltrexone is administered. When taking

naltrexone, the individual knows that the euphorigenic effect of heroin is no longer available and may

stop taking heroin (35). The potential usefulness of

narcotic antagonists lies in helping former opiate

users remain abstinent after detoxification (247).

A single dose of naltrexone effectively blocks

opiates for up to three days and produces few side

effects (247). Narcotic antagonists, such as

naltrexone, are not dependence producing. Although

this is a positive facet of the drug, it has the

drawback of lacking the built-in compliance

mechanism associated with methadone (303). Thus,

individuals can easily stop taking naltrexone without

any ill effects if they want to use heroin. In fact, poor

compliance with naltrexone treatment has been a significant issue and strategies to improve compliance

with narcotic antagonists are being explored (180).

Addicts who are very motivated to stay off drugs arc

most likely to benefit from naltrexone treatment.

Levo-Alpha-Acety l. Methadol (LAAM)--

Developed in Germany around 1948 as a potential

painkiller, LAAM, like methadone, is a narcotic

agonist . Of the drugs under investigation by NIDA,

LAAM is the agency’s most immediate priority

(320). Problems with policies allowing narcotics

abusers to take methadone home, such as accidental

poisoning and street diversion of methadone,

prompted the search for a longer-ac(ing methadone

substitute (194). Because LAAM can suppress withdrawal symptoms for up to 3 days after oral administration, it needs to be administered only 3 times a

week instead of 7 (320). Less frequent doses free

staff to engage in more therapeutic activities, such as

counseling and other support services. It also helps

break the drug abuser’s routine of ingesting a drug

daily and decreases the degree of psychological

dependence (194). LAAM’s longer action seems to

produce a smoother, flatter effect with slower onset

than methadone (35).

LAAM’s side-effects are generally those seen

acutely with opiates, including nausea, vomiting, constipation, excessive sweating, and decreased sexual

interest (194). The possibility of acute overdose,

especially with sedative-hypnotics during the

beginning of LAAM’s treatment, is one of LAAM’s

major problems. Patients should be especially

warned against using additional opiates and centra1

nervous system depressants, such as alcohol, for

several hours after taking LAAM (194).

Biometrics Research Institute has recently been

awarded a NIDA contract to sponsor LAAM

thorough the remainder of its required FDA

approval and to undertake the manufacturing and

marketing of the drug (35). If approved by the FDA,

LAAM would provide an additional agonist besides

methadone to treat narcotic abuse.

Pharmacotheraphy for Cocaine Abuse

Although FDA has approved no medications for

the treatment of cocaine abuse, NIDA is investigating numerous possibilities (see table 3-l). Most

of these drugs are only in the early stages of development, and more research is needed to understand

exactly whether and how they work to combat

cocaine abuse. Many researchers feel that the

potential effectiveness of these medicines lies in their

ability to reduce the intense craving for cocaine that

abusers experience during and after withdrawal

(303). Although not much is known about the

specific physiological mechanisms that induce

craving, neurotransmission (the body’s means of

translating experience into sensations) is thought to

play an important role. Three neurotransmitters

have been implicated in the psychoactivity and withdrawal from stimulants: dopamine, norepinephrine,

and serotinin (178). Researchers hypothesize that in

order to reduce the pleasurable effects of cocaine,

and thus the craving for the drug medications will

have to counter the effects of cocaine on neurotransmission, possibly by altering the production or

receetion of dopamine (303).

Many of the drugs under investigation for cocaine

abuse treatment are FDA-approved for other

illnesses. The most promising of these drugs have

been antidepressants, such as desipramine and

imipramine (303). Although research data are

limited, initial clinical trials have suggested that

desipramine offers promise as a way of initiating
Chapter 3--Treatment for Drug Abuse in the United States- 47

abstinence and the process of recovery in cocainedependent outpatients by decreasing cocaine use and

craving (115,117,176). Desipramine therapy

represents a new class of substance abuse treatment

that speeds the recovery of the central nervous

system (117).

Pharmacotheraphies for Polydrug Abuse

Although the efficacy of methadone treatment for

controlling opiate abuse has been well documented

(see ch. 4), many clinicians have observed that

methadone alone is poorly suited to control concurrent cocaine, alcohol, or other drug abuse among

opiate addicts (182,184). Although methadone

blocks the euphoria produced by heroin through

cross tolerance, cocaine euphoria is not dampened by

methadone (184).

Buprenorphine has been the most promising drug

under development for users of both heroin and

cocaine. Buprenorphine is a partial agonist, meaning

that it has less agonist effect as the dose of buprenorphine increases (35). Researchers have hypothesized

that the effectiveness of buprenorphine lies in its

ability to deprive cocaine users of the relief that

heroin use can provide in alleviating post-cocaine

depression, thus indirectly making cocaine use less

enticing. Like methadone, one dose of buprenorphine blocks withdrawal symptoms for 24 hours.

Buprenorphine also offers two improvements over

methadone. Buprenorphine has less chance of

stimulating an illicit market, because its agonist

effect is weaker than methadone’s, and it entails a

smaller chance of overdose (211).

Because depression appears to be associated with

escalating cocaine use among methadone patients,

desipramine and other antidepressants may also be

helpful in treating cocaine-abusing, methadonetreated patients (184).

Drug-Free Treatment Approaches

Unlike detoxification and other pharmacotherapies, which rely on medications to treat withdrawal, drug-free treatments have traditionally

allowed the use of chemical agents for only medical

or psychiatric reasons. Because detoxification should

be completed before entry into drug-free programs

and clients should be considered manageable without

the use of medications, the emphasis of these programs has been on developing a responsible drugfree lifestyle, not on managing the withdrawal

process.

Therapeutic Communities (TCs)

The first well-known self-help TC was Synanon,

which started in 1958. Daytop Village, Phoenix

House, and many other residential TCs have patterned themselves after the general Synanon

approach. The philosophy behind the TC is the

belief that drug abuse is a disorder of the whole

person, reflecting psychological dysfunction affecting

some or all areas of function, including chronic

deficits in social and occupational skills (76,155).

Unlike pharmacotherapies, which consider drug

abuse a medical condition, TCs view abuse as a

symptom of underlying personality and behavioral

problems that can and should be changed.

Cole and James identified three approaches to

residential TCs that are distinguished by length of

treatment and treatment goals (61).

o

0

0

Traditional TCs generally entail at least 15

months in treatment. The primary goal of traditional TCs is a complete change in lifestyle,

reflected in abstinence from drugs, elimination

of antisocial (criminal) behavior, and development of employable skills, self-reliance, and

personal honesty (83). The abuser’s return to

society as a productive and independent individual (habilitation and rehabilitation) is

regarded as feasible and is encouraged.

Modified TCs usually last 6 to 9 months. The

modified TC approach has more limited goals

that emphasize leading a drug-free life and

acquiring practical skills to help the abuser

function in society (149).

Short-term TCs typically last 3 to 6 months.

This type of TC does not emphasize

resocialization, but instead concentrates on

eliminating drug use, reestablishing family relations, and developing useful skills (149).

Residential TCs are distinguished from other

treatment modalities by their highly structured

approach. Members are assigned work duties, participate in group counseling, recreational, and other
48- The Effectiveness of Drug Abuse Treatment: Implications for Controlling HIV Infection

activities, and attend educational and vocational

training. The community itself functions as the

primary therapeutic milieu. TCs have historically

relied on program graduates who are ex-abusers to

act as counselors, administrators and, most importantly, as role models for incoming clients.

Increasingly, however, as the spectrum of individuals

entering TCs has broadened, non-TC persons are

constituting a larger portion of the staffing, both

clinical and auxiliary (155). Confrontation and peer

pressure are commonly used to socialize individuals

into more productive behavior.

Within the general TC structure, individuals are

expected to pass through basic phases of treatment.

The Phoenix House Program in New York City, the

nation’s largest TC treatment system, leads residents

through three phases of treatment (76). In the

Induction Phase (lasting 1 to 30 days), members are

oriented to the concepts, rules, and resources of the

TC. Individuals are assessed according to the extent

of psychological disturbance and social deficits rather

than by patterns or types of drug use as is common in

pharmacotherapy modalities (76). During the

Primary Treatment Phase (2 to 12 months of

residency), members work toward the achievement

of social and psychological goals through participation in daily activities. The principles of self-help

(the person’s readiness and commitment to change),

motivation (the use of positive and negative pressures to change), and social learning (the emphasis

on lifestyle changes, increased social responsibility,

and establishment of new social contacts) are all considered essential to the rehabilitative approach (76).

Finally, the Re-entry Phase (13 to 24 months) emphasizes vocational, educational, and job development

skills (emphasis varies depending on the program) in

addition to work and group therapy. Ways to deal

with the stresses and frustrations that will occur

when patients leave the program are dealt with

during this final phase of treatment (76).

Unlike methadone maintenance programs, which

are only applicable to narcotic abusers, residential

TCs serve a wider variety of patients (149,170).

According to a study by Hubbard et al., residential

clients were somewhat more likely to be male and to

have been more criminally active (probably

reflecting the courts preference for this modality as a

referral for individuals involved with the criminal

justice system) and heavy alcohol users before

entering treatment (149). Compared with outpatient

methadone maintenance and ODF clients, residential

clients were least likely to be married, perhaps

indicating the difficulty married clients have leaving

their families to live in a 24-hour residential facility.

Outpatient Drug-Free (ODF) Treatment

ODF programs represent a diverse collection of

programs with little in common beyond their drugfree approach and outpatient setting. ODF programs were originally developed as a low cost

alternative to residential care, to serve nontraditional, nonopiate abuser clients (13). The primary

goal of ODF programs is abstinence from illicit

drugs. These programs typically offer short-term

treatment (less than 6 months), encourage

involvement with self-help groups, such as AA, and

make referrals to community agencies for health,

educational, housing and other services rather than

providing those services in house. Like TCs, ODF

programs vary in their approaches and intensity.

As noted earlier, day care, evening care, and

halfway houses are becoming more common. Other

types of ODF programs include mental health

treatment centers, vocational programs, and family

therapy for adolescents (203).

ODF clients have been more likely to be white,

better educated, and seeking treatment for the first

time than clients of other treatment modalities (149).

Again, some of these generalizations about client

characteristics may be confounded by the geographic

location of ODF programs.

Other Inpatient Programs

The two main types of inpatient programs are ’12

step” and psychiatrically-oriented programs (170).

Developed in the 1950s for the treatment of

alcoholism, the Minnesota Model or “l2-step”

approach is becoming more common, especially

since the onset of the cocaine epidemic (105). These

short-term residential facilities provide intensive

structured treatment for chemically dependent individuals. The programs typically operate in hospitals
Chapter 3-Treatment for Drug Abuse in the United States- 49

or free standing units and last from 25 to 35 days

(357). The counseling and other activities of these

programs are derived from AA’s “12 steps to

recovery,” which include the admission of addiction,

acknowledgement of one’s impotence to stop it

without the help of a higher power, and the need to

confront the harm one has done (105).

In an analysis of inpatient treatment programs in

Minnesota, the typical client was noted to be a white

male, 18 to 29 years of age, who has never been

married and who has obtained a high school diploma

(357). Following completion, patients are usually

referred to AA or Cocaine Anonymous groups.

Inpatient residential programs are almost exclusively

private and are not part of the publicly funded

treatment system (105). They have been used

primarily to treat alcoholics and more recently to

treat cocaine abuse. An explanation for the scarcity

of narcotics abusers in this modality is that some

residential programs are not able or willing to use

methadone and may not want to wait to detoxify

heroin addicts (35).

Psychiatric inpatient programs appear to be

geared towards older or middle class drug abusers,

adolescents drug users, and drug abusers with significant psychiatric problems (170). These programs

usually begin with detoxification, followed by a

variety of approaches (e.g., individual, group, and

family counseling; education; required attendance at

AA, Narcotics Anonymous, or Cocaine Anonymous

meetings), and typically last between 4 to 12 weeks

(170).

Self-Help Groups

These mutual-support groups grew out of the 12-

step philosophy of AA programs. Most AA, Narcotics Anonymous, and Cocaine Anonymous programs are based on volunteer activities run by

recovering abusers and are rarely linked to established social service agencies (149). Although selfhelp programs can be the primary source of

treatment for some abusers, they also can serve as

adjuncts or aftercare to other, more intensive

treatment programs. The philosophy that underlies

these programs is that there is no cure for drug

dependence and that even if a drug-dependent

person is no longer abusing drugs, she or he will

always live with that dependence. One of the

hallmarks of AA programs is that they do not believe

in treating chemical dependencies with chemicals,

but rather stress social and community support.

The Role of Multimodality Treatment

The forerunners of the relatively new and still

infrequent multimodality programming were experimental treatment programs run by Jerome Jaffe in

Chicago and Herbert Kleber in New Haven. These

programs had a central admission unit where abusers

received information about treatment options and

were evaluated by staff to determine which program

seemed best for the patient (170). The multimodality process offers the possibility of transferring

patients between programs as their needs indicate

(170). This approach has the added benefit of facilitating standard assessment procedures that can

enhance evaluation and research (170). Such

treatment systems, though in their infancy, move

toward achieving what many experts find extremely

desirable, a treatment system that is integrated, comprehensive, flexible, and based on a long-term case

management approach (11).

TREATMENT PROGRAMS IN THE

UNITED STATES

Introduction

The number of treatment facilities for drug abuse

in the United States is not well documented, and

information on private clinics and self-help programs

is especially limited (13). Information on the cost of

drug treatment is also scarce. Two national surveys

provide the most useful information available on substance abuse treatment centers, namely the National

Drug and Alcoholism Treatment Unit Survey

(NDATUS) and the State Alcohol and Drug Abuse

Profile (SADAP). Both NDATUS and SADAP

analyze data voluntarily submitted from States and

report current information on funding, services provided, client characteristics, and other important

issues regarding treatment for abuse of alcohol and

other drugs. NDATUS is a point-prevalence survey

that reports on clients in public and private treatment

at a point in time. SADAP surveys State alcohol and

drug abuse directors about admissions to programs
50- The Effectiveness of Drug Abuse Treatment: Implications for Controlling HIV Infection

that received public funds during the previous fiscal

year. Because any one person could have multiple

admissions during the year, SADAP does not reflect

the number of people in treatment.

NDATUS: Description and Results

NDATUS is conducted with the cooperation of

NIDA, the National Institute on Alcohol Abuse and

Alcoholism (NIAAA), the Veterans Administration,

the Federal Prison System, and the State Alcohol and

Drug Agencies (332). NDATUS has been conducted

periodically since 1973. The most recent NDATUS

report is based on information collected from

treatment programs as of October 30, 1987.

Although the capability of the Federal Government

for routine monitoring of treatment clients was

eliminated in 1981 with the advent of the Federal

block-grant program, that capability was restored

with the Anti-Drug Abuse Act of 1988 (Public Law

100-670), which mandates States to collect client data

as well as annual surveys (NDATUS) of services provided in drug treatment programs. Information on

the location and type of the treatment units, sources

of funding, client characteristics, client capacity, and

utilization is collected from alcohol and other drug

treatment programs in all 50 States, the District of

Columbia, and Puerto Rico. NDATUS is the only

survey that includes privately as well as publicly

funded programs. One of the primary uses of

NDATUS is to update NIDA’s master file of all

known alcoholism and other drug treatment and prevention facilities. This list is used to provide referrals

to persons seeking help for drug dependency

problems (332).

According to the latest NDATUS report, in

October 19871,075 units for the treatment of drugs

of abuse other than alcohol and 4,083 combined

alcohol and other drug units were serving 263,510

drug abuse clients (332). A total of 4,403 units

reported funds for drug abuse treatment totaling

$1.31 billion. State funds (including Alcohol, Drug

Abuse, and Mental Health Services (ADMS) block

grants4) accounted for the highest proportion (27.1

percent) of drug treatment funds that the centers

received. Federal funds other than block grants

accounted for 3.6 percent; local government and

State/local government fees for services 10.6

percent; other public funds, including public welfare

and public third-party payers 14.9 percent; private

funds, including donations, private third-party payers,

and client fees 40.6 percent; and other funds 3.1

percent (see app. G for 1989 NDATUS results).

A total of 5,015 units (1,067 drug abuse units and

3,948 combined alcohol and other drug abuse units)

provided information on budgeted capacity,

utilization rates, and treatment modality. These

units reported 260,151 drug abuse clients in

treatment in October 1987. A very high proportion

of these clients (85.5 percent) were served in outpatient settings (figure 3-l). The treatment modality

serving the largest number of drug abuse clients was

drug-free treatment, which includes drug-free

treatment in both outpatient and inpatient settings,

(64.5 percent), followed by methadone maintenance

(31.5 percent) and detoxification (4.0 percent) (figure

3-l). Utilization rates (percent of capacity filled)

varied considerably by treatment modality, from 89.3

percent in methadone maintenance to 76.8 percent in

drug-free treatment and 55.9 percent in

detoxification programs. According to drug

treatment center ownership, private, non-profit units

accounted for the largest number of drug treatment

units, treated the largest number of clients, and had

the largest capacity (see table 3-2). The lowest total

utilization rate among drug treatment only units was

observed among private, for-profit units (73.2

percent), while the highest utilization rate was for

private, non-profit units (94.0 percent), followed by

public, State/local units (93.7 percent) (table 3-2).

4 The Omnibus Reconciliation Act of 1981 (Public Law 97-35)

provided that ADMS block grants be administered by the individual States rather than using NIDA to administer funds (292).
Chapter3-Treatment for Drug Abuse in the United States- 51

Oul

Figure 3-1--Drug Abuse Clients in Treatment by Setting and Modality According

to the National Drug and Alcoholism Treatment Unit

Survey (NDATUS),a Oct. 30, 1987

Setting Modality

patient 85%

222.342

Hospital

Inpatient 4%

10.679

Detoxificatlon

10,368

sidential 10%

27,230

Methadone malntenence 31%

81,862

aNDATUS reports information COllected from both privately and publicly funded alcohol and other drug

treatment programs. These data were reported by 5,015 units (1,067 drug treatment only units and 3,948

combined alcohol and other drug treatment units).

SOURCE : U.S. DHHS, NIDA and NIAAA (332)

Table 3-2--lnformation on Drug Abuse Treatment Units, from the National Drug and Alcoholism

Treatment Unit Survey (NDATUS),a Oct. 30, 1987

Unit ownership

Private Public

Unit orientation For-profit Non-profit State/local Federal Total

Dregs other than alcohol

Number of units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Number of clients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14,372

Budgeted capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19,629

Percent of capacity used. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73.2

Alcohol and Other Drugs Combined

Number of units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 645

Number of clients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14,498

Budgeted capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27,621

Percent of capacity used. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525

Total

Number of units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 728

Number of clients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28,870

Budgeted capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47,250

Percent of capacity used. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61.1

705

87,843

93,426

94.0

2,595

71,235

105,154

67.7

3,300

159,078

198,580

80.1

266

39,202

41,844

93.7

604

24,875

30,699

81.0

870

64,077

72,543

88.3

13

1,846

2,286

80.8

104

6,280

8,179

76.8

117

8,126

10,465

77.6

1,067

143,263

157,185

91.1

3,948

116,888

171,653

68.1

5,015

260,151

328,838

79.1

aNDATUS is a point-prevalence survey that reports information collected from both privately and publicly funded alcohol and other drug

treatment programs. Data in this table relate only to units that reported budgeted capacity.

SOURCE: US DHHS, NIDA and NIAAA (332).
52- The Effectiveness of Drug Abuse Treatment: Implications for Controlling HIV Infection

NDATUS data support the findings that

residential and inpatient clients tend to be younger

than outpatient clients and that the proportion of

females is lower in inpatient settings. Overall, twothirds of the clients for whom sex was known were

males. Blacks represented about one-fourth and

Hispanics about one-sixth of the drug abuse clients

for whom race or ethnicity was known, with the proportion of blacks and Hispanics especially high in

methadone maintenance programs.

Overall, the estimated 110,816 intravenous (IV)

drug users represented 42.1 percent of the total

number of drug abuse clients (332). Although just

17.3 percent of clients in drug-free treatment were

IV drug users, the percentages were much higher in

detoxification and methadone maintenance programs, 43 percent and 90 percent, respectively.

SADAP: Description and Results

The other national survey on drug abuse centers

in the United States is SADAP, which has been conducted annually since 1984. SADAP is based on a

National Association of State Alcohol and Drug

Abuse Directors (NASADAD) survey of State

alcohol and drug abuse agencies regarding alcohol

and other drug abuse treatment expenditures and

admissions. Unlike NDATUS, which collects

information on both private and public treatment

facilities, SADAP looks only at those programs that

received at least some funds administered by the

State alcohol and drug agency (45). Although a substantial number of programs are not captured in the

State reports, SADAP results represent the majority

of programs using public funds (13). NASADAD

receives support for SADAP activities from NIAAA

and NIDA.

Forty-eight States, the District of Columbia,

Guam, Puerto Rico, and the Virgin Islands participated in the fiscal year 1988 SADAP. According to

reports from the alcohol and drug abuse agencies in

these States and territories, 1,614 drug treatment

units other than alcohol units and 3,506 combined

alcohol and other drug treatment units received State

alcohol and drug abuse agency funds in fiscal year

1988 (see table 3-3 for the number of drug treatment

units in 1988 according to State) (45).

In 1988, 518,851 drug client admissions were

reported by agencies in 47 States, the District of

Columbia, Guam, Puerto Rico, and the Virgin

Islands (45). Although drug use and client treatment

admission patterns vary greatly across States, some

general patterns emerge. In terms of treatment

setting, nearly 70 percent of client admissions were to

outpatient settings and 23 percent were to residential

facilities (figure 3-2). Client admissions by treatment

modality showed that 69 percent of clients were

admitted to drug-free treatment programs, almost 20

percent to detoxification programs, and 10 percent to

methadone maintenance programs (figure 3-2).

Two-thirds of admissions to drug treatment were

males, while 52.7 percent were white, 25.3 percent

were black, and 11.8 percent were Hispanic.s

In 1988, cocaine surpassed heroin as the drug that

clients entering drug treatment cited most often as

the primary drug of abuse (139,663 v. 116,854) (45).

Cocaine admissions as the primary drug of abuse

were up 55 percent in fiscal year 1988, while heroin

admissions increased 19 percent during the year.

States varied in their drug abuse patterns. Cocaine

was the primary drug of abuse other than alcohol

related to treatment admissions in 18 States, the District of Columbia, and the Virgin Islands; heroin was

the primary drug of abuse in 8 States, Guam and

Puerto Rico; and marijuana and hashish was the

primary drug of abuse in 15 States.

For fiscal year 1988, 43 respondents reported

162,929 IV drug abuser admissions to State-funded

programs. According to estimates from 36 States,

the District of Columbia, and Guam, the total

number of IV drug abusers across the country was

greater than 1.3 million (table 3-4) (45). The highest

estimates of IV drug abusers were provided by New

York (260,000), California (222,000), and Pennsylvania (115,000), while the lowest estimates were provided by West Virginia (200), Nebraska (870), and

Maine (950) .

5Asian or Pacific Islanders accounted for 0.4 percent of admissions, Native Americans 0.9 percent, and others 0.4 percent. The

percentage of clients that did not specify race/ethnicity was 8.4

percent (45).
Chapter 3-Treatment for DrugAbuse in the United States- 53

Table 3-3-Number of Alcohol or Drug Treatment Units by State Alcohol or Drug Agencies According

to the State Alcohol and Drug Abuse Profile Data (SADAP), Fiscal Year 1988

Alcohol Other drug Combined alcohol/other Total

State treatment units treatment units drug treatment units treatment units

Alabama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Arkansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Colorado . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Connecticut . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Delaware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

District of Columbia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Florida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Guam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hawaii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Illinois . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Indiana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Iowa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Kentucky . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Louisiana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Minnesota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mississippi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Missouri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Montana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nebraska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

New Hampshire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

New Jersey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

New Mexico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

New York (A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New York (D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

North Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

North Dakota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oklahoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Pennsylvania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Puerto Rico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rhode Island . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

South Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

South Dakota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tennessee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Vermont . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Virgin Islands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Virginia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Washington . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . West Virginia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wisconsin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Wyoming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Totals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent of total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22

0

26

635

51

27

4

NA:.

o

0

1

0

166

0

0

2

0

0

0

93

0

0

0

26

2

1

0

5

0

151

NA.

311

0

23

0

103

N A

32

26

12

15

2

0

0

2

8

0

NA.

17

35

0

0

NA.

1,806

26.l%

6

2

18

282

6

32

4

14

NA.

4

0

1

0

70

0

0

1

0

0

0

154

7

0

0

0

4

3

0

1

5

69

NA.

o

544

7

0

151

NA.

4

21

146

9

0

0

0

0

1

0

NA.

12

29

0

2

NA.

1,614

23.3%

67

39

112

0

35

37

7

8

105

41

1

16

45

34

60

30

40

132

43

39

85

241

283

232

53

62

26

118

20

29

16

NA.

59

41

11

67

48

90

276

3

22

38

25

48

101

53

23

4

58

72

70

322

3,506

50.6%

95

41

156

917

92

96

15

26

105

45

1

18

45

270

60

30

43

132

43

39

332

248

283

232

79

68

30

118

26

34

236

NA.

370

544

71

11

321

48

126

323

161

46

40

25

48

103

62

23

4

87

136

70

324

NA.

6,929

loo.o%

ABBREVIATION: NA. = Information not available.

SOURCE: Butynski, CanOva, and Jensen (45).
54- The Effectiveness of Drug Abuse Treatment: Implications for Controlling HIV Infection

Table 3-4-Estimated Admissions of IV Drug Abusers and Total IV Drug Abusers,

by State, Fiscal Year 1988a

Estimated number of admissions of IV drug abusers

Total number of

State State-funded programs Other programs IV drug abusers

Alabama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA

Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564

Arizona . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,336

Arkansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 815

California . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38,058

Colorado . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 819

Connecticut . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,833

Delaware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,489

District of Columbia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,638

Florida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,511

Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,600

Guam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Hawaii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446

Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630

Illinois . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,994

Indiana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,026

Iowa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,294

Kansas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 700

Kentucky . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

Louisiana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA

Maine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA

Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8,105 Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,044 Michigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,000 Minnesota ................................................................~........... 1,5oo Mississippi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA Missouri 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,500 Montana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600

Nebraska . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

Nevada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 870

New Hampshire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220

New Jersey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,125

New Mexico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA

New York . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14,970

North Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA

North Dakota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA

Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,047

Oklahoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA

Oregon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,253d

Pennsylvania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12,500

Puerto Rico . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,942

Rhode Island . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,649

South Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,000

South Dakota . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Tennessee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,729

Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,8o7

Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 840

Vermont . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Virgin Islands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA

Virginia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,400

Washington . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA

West Virginia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

Wisconsin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3,175

Wyoming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . s 162,929e

NA

118

NA

N A

29,071

NA

241

NA

NA

3,059

NA

o

NA

NA

695

4,233

1,200

1,255

NA

NA

NA

1,439

2,000

3,000

1,500

NA

4,900

NA

NA

200

352

250

NA

2,208

NA

NA

NA

NA

NA

200

NA

NA

NA

41

NA

4,800

NA

NA

NA

NA

NA

NA

125

NA

60,887f

10,250

3,410

38,263

8,150

222,000

12,000

35,000

13,368

16,000

65,614

27,600 C

75

10,OOO

2$17

92,000

28,220

20,783

NA

5,000

NA

950

42,000

40,000

NA

4500

NA

22,000

2,500

870

5,800

9,843

40,000

NA

260,000

NA

5o,loo

NA

NA

25,000

115,000

NA

8,245

NA

1,530

NA

60,000

NA

NA

NA

25,000

200

21,000

NA

l,344,788g

a Figures were compiled from estimates provided by State alcohol and drug agencies.

B Methadone clients only.

c 

Admissions only for metro Atlanta.

Excludes IV drug abusers in drug detoxification.

e Based on responses from agencies in 40 States, the District of Columbia, Puerto Rico, and Guam.

Based on responses from 21 States and Guam.

g Based on responses from 36 States, the District of Columbia, and Guam.

SOURCE: State Alcohol and Drug Abuse Profile, FY 1988 as cited in Butynski, Canova, and Jensen (45).
Chapter3--Treatment for DrugAbuse in the United States- 55

Figure 3-2--Admissions of Drug Abuse Clients by Setting and Modality According —

to the State Alcohol and Drug Abuse Profile (SADAP),a Fiscal Year 1988

Setting Modality

Unspecified 18,157

Hospital 4%

20,464

Residentlal 23%

121,706 Detoxification 18%

95,932

Methadone

maintenance 3%

47,608

a

Includes data only for programs that received funds from State alcohol and drug ● gencies. Based on data

collectad from 46 State agencies, the District of Columbia, Guam, Puerto Rico, and the Virgin Islands.

SOURCE: U. Butynski, D. Canova, and S. Jensen (45).

Data submitted from 25 States, the District of

Columbia, and Puerto Rico indicate that many States

already have high rates of HIV infection among IV

drug abusers (rates of infection were estimated to be

as high as 60 percent in New York, New Jersey, and

Puerto Rico) (45). Furthermore, these rates varied

tremendously both across and within States. A total

of 19 State agencies reported having at least one drug

treatment program plan or model program on HIV

and acquired immunodeficiency syndrome (AIDS)

(ranging from State policies on AIDS and

HIV/AIDS transmission prevention programs to

surveys of AIDS-related knowledge).

Some of the most frequently mentioned policy

issues identified by respondents to NASADAD’S

1988 SADAP data collection effort include needs in

the following areas:

o new or expanded treatment services (48 states);

o prevention and treatment services for Special

populations (e.g., indigent, homeless, polydrug

users, women, and criminal justice clients)(23

States);

o funding and improved resource allocation (19

States);

o prevention and treatment services for youth (16

States); and

o expanded seervices related specifically to AIDS

and N drug users (16 States) (45).

The Extent of HIV Testing and Counseling

As of April 1990, the Centers for Disease Control

(CDC) supported 63 HIV prevention programs
56- The Effectiveness of Drug Abuse Treatment: Implications for Controlling HIV Infection

through the health departments in 50 States, 4 cities,

the District of Columbia, 7 territories, and Puerto

Rico (342).6 CDC funds States and cities for HIV

prevention and HIV/AIDS surveillance activities

through cooperative agreements. The total dollar

amount earmarked for counseling, testing, and

partner notification for all types of sites was $89.24

million for fiscal year 1989. Of this total, drug

treatment centers received 15 percent ($13.5 million)

for HIV counseling and testing and an additional

$5.0 million for health education and risk reduction

(including street outreach) (350). In fiscal year 1990,

$98.87 was awarded to all sites for these activities,

with 15 percent ($15.056 million) going to drug

treatment centers for HIV counseling and testing

and $4.3 million for health education and risk

reduction.

From 1985 through 1989, the number of

counseling and testing sites in the 63 programs

increased from 1,577 to 5,013. Despite the fact that

drug users are at high risk for HIV infection in 1989,

only 173 (3.5 percent) of these sites were in drug

treatment centers. The percentage of counseling and

testing sites in other settings included:

o

0

0

0

0

0

0

0

0

0

0

free-standing HIV counseling and testing sites

(25.9 percent)

sexually transmitted diseases clinics (17.5

percent),

family planning clinics (12.6 percent),

other health department sites (10.4 percent),

prenatal/obstetric clinics (10.1 percent),

tuberculosis clinics (8.8 percent),

private physicians offices and clinics (3.7

percent),

other nonhealth department testing sites (3.2

percent),

prisons (2.2 percent),

colleges (0.6 percent), and

unclassified facilities (1.6 percent) (342).

6 In addition to the HIV counseling and testing sites included in

the CDC programs, a large but unknown number of persons are

tested in hospitals, outpatient medical facilities, physicians’

offices, blooddonation centers, military facilities, and other settings (342).

As of July 1990, at least 253 drug treatment

centers throughout the country were providing HIV

counseling and testing (113). In New York City,

approximately 2 percent (13 out of 713 drug

treatment centers) provide HIV counseling and

testing, while in the State of Connecticut, as many as

24 percent (9 out of 37 drug treatment centers)

provide such services (350) (table 3-5). It is not

uncommon, however, for programs to refuse to

admit drug abuse clients if they test positive for HIV

infection (87).

Shortages of Treatment Slots

In certain areas of the country with large

numbers of drug abusers, especially in large

metropolitan areas, publicly funded treatment programs are filled to capacity. Waiting lists for

admission to treatment programs are one indication

that the treatment system is not meeting the demand

for treatment. During this waiting period, many

intravenous drug abusers continue to put themselves

at risk of contracting and spreading HIV by using

drugs intravenously, and may also lose their resolve

to enter treatment. There are several problems,

however, with using waiting lists to measure unmet

demand for treatment. Waiting lists may

underestimate shortages of treatment slots to the

extent that lengthy lists deter drug abusers from

applying. Programs are also not required to keep

waiting lists, and some programs that do keep them

stop adding to the list after a certain point.

Table 3-5--Drug Treatment Centers Providing

Human Immunodeficiency Virus (HIV)

Counseling, Testing, and Partner

Notification in Selected States

and New York City, 1990

Number (percent) Total number

of drug treatment of drug

centers with HIV treatment

State/city services centers

Connecticut . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 (24%) 37

Ftorida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 (ll%) 216

Houston ...........................+....... 6 (8%) 79

New York City . . . . . . . . . . . . . . . . . . . . . . . . . 13 (2%) 713

Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 (7%) 365

SOURCE: US DHHS, CDC (350).
Chapter 3--Treatment for Drug Abuse in the United States- 57

Despite these limitations, waiting lists do provide

a measure of the unmet demand for treatment. The

most recent national information available is from a

NASADAD survey conducted in September 1989.

Estimates from respondents of 44 States and the District of Columbia put the total number of people on

treatment waiting lists at almost 67,000 (table 3-6)

(252). Approximately 50 percent of those on waiting

lists had been waiting for treatment for at least 30

days. New York, New Jersey, and the District of

Columbia estimated that the average time between

request and admission to outpatient programs was

two months and Michigan estimate it to be three

months. Several other States indicated that waiting

lists for outpatient drug treatment was not a

problem. Estimates of the time between request and

admission to residential programs were generally

longer than for outpatient treatment, with several

States indicating average waiting times of three to

four months.

Information on the Cost of Treatment

Treatment costs vary across cities and programs

due to differences in staff salaries, cost-of-living,

specific services provided, the age and type of

building, and other related factors (217). Few

estimates of program costs are available. In addition,

existing cost estimates are often outdated, based on a

limited number of programs, or only the best guesses

of treatment experts (359). Besides cost per day and

cost per year estimates, cost per treatment episode is

also relevant, as the average length of treatment

varies by modality. Suggestions for improving

measures of drug treatment costs and a review of

current cost estimate research efforts are presented

in Wallack’s testimony before the House Government Operations Committee in April 1990 (359).

Past estimates have suggested that, per person, the

cost of residential drug treatment is about three

times the cost of outpatient methadone or ODF

treatment (149,359).

From a meeting of experts sponsored by

NASADAD in September 1987, the estimated

annual cost of drug treatment per treatment slot for

needle users was $2,300 for ODF treatment, $3,000

for outpatient methadone maintenance, $14,600 for

adult non-hospital residential drug-free treatment,

and $18,000 for adolescent non-hospital residential

drug-free treatment (252). Average length of stay

was not taken into account in these estimates.

Table 3-6-Estimates of Waiting Lists for Alcohol

and Other Drug Treatment, Sept. 29, 1989a

Estimated average days

between request for and

Total number

admission to treatment

on waiting list Outpatient Inpatient

Alaska . . . . . . . . . . . . . . . . . . . . . . . . . . 386 14 66

Arizona . . . . . . . . . . . . . . . . . . . . . . . . . 4,418

Arkansas . . . . . . . . . . . . . . . . . . . . . . 246

California . . . . . . . . . . . . . . . . . . . . 6,000

Connecticut . . . . . . . . . . . . . . . . . . 1,100

Delaware . . . . . . . . . . . . . . . . . . . . . 575

District of Columbia . . . 773

Florida . . . . . . . . . . . . . . . . . . . . . . . . . 2,040

Georgia . . . . . . . . . . . . . . . . . . . . . . . . 1,000

Hawaii . . . . . . . . . . . . . . . . . . . . . . . . . . 200

Idaho . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24)0

Indiana . . . . . . . . . . . . . . . . . . . . . . . . . . 1,285

Iowa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,892

Kansas . . . . . . . . . . . . . . . . . . . . . . . . . 250

Kentucky . . . . . . . . . . . . . . . . . . . . . . 659

Louisiana . . . . . . . . . . . . . . . . . . . . . 1,500

Maine . . . . . . . . . . . . . . . . . . . . . . . . . . . l,20o

Maryland . . . . . . . . . . . . . . . . . . . . . . 3,350

Massachusetts . . . . . . . . . . . . . . 1,200

Michigan . . . . . . . . . . . . . . . . . . . . . . 7,500

Minnesota . . . . . . . . . . . . . . . . . . . . 198

Mississippi . . . . . . . . . . . . . . . . . . . 556

Missouri . . . . . . . . . . . . . . . . . . . . . . 898

Montana . . . . . . . . . . . . . . . . . . . . . . 300

Nebraska . . . . . . . . . . . . . . . . . . . . . 100

Nevada . . . . . . . . . . . . . . . . . . . . . . . . . 750

New Hampshire . . . . . . . . . . 200

New Jersey . . . . . . . . . . . . . . . . . . . 1,593

New Mexico . . . . . . . . . . . . . . . . . 485

New York - drug . . . . . . . . . 4,891

New York - alcohol . . . . . 2,166

North Carolina . . . . . . . . . . . . 2,096

North Dakota . . . . . . . . . . . . . . 135

Ohio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,208

Oregon . . . . . . . . . . . . . . . . . . . . . . . . . 2,887

Pennsylvania . . . . . . . . . . . . . . . . 1,500

Rhode Island . . . . . . . . . . . . . . . 500

South Carolina ........... 300-500

Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,277

Utah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

Vermont . . . . . . . . . . . . . . . . . . . . . . . 108

Virginia . . . . . . . . . . . . . . . . . . . . . . . . 2,829

Washington . . . . . . . . . . . . . . . . . 115

West Virginia . . . . . . . . . . . . . . 110

Wisconsin . . . . . . . . . . . . . . . . . . . . 5,070

Wyoming . . . . . . . . . . . . . . . . . . . . . 300

Total . . . . . . . . . . . . . . . . . . . . . . . . 66,766

36

0

NA

10

49

60

30

0

7

15

21

5-10

30

7

14-21

40

14

90

3

37

14

10

3

10

14

59C

6

NA

10

7

26

3-5

51

NA

NA

NA

21

14

NA

2

34

15-25

15-30

(ave.) 22

79

22

NA

15

120

90-120

60-90

21

14

25

24

30

30-45

16

38

0-90

30

45

120

25

18

45

60-90

m

40

40

13d

NA:

22

50-60

35

14-30

56

45-60

NA

NA

20

NA

30

65

20-40

(ave.)45

ABBREVIATIONS: ave. = average; NA = not available.

a voluntary reports from public and private treatment Programs

in 44 States and the District of Columbia. Waiting lists most

likely underestimate the number who cannot obtain treatment

b because of a shortage of treatment positions (see text).

Percent waiting at least 30 days is for public residential proc Average for outpatient and residential..

Waiting list number reflects survey of 89 percent of publicly

funded programs.

SOURCE: Rua (252).
58- The Effectiveness of Drug Abuse Treatment: Implications for Controlling HIV Infection

SUMMARY OF THE FINDINGS

The diverse treatment needs of drug abusers have

led to the development of a variety of treatment

modalities and programs in the United States. The

primary treatment modalities have been methadone

maintenance for opiate abusers (primarily heroin

abusers) and residential TCs and ODFs for both

opiate and nonopiate abusers.

The treatment system has evolved somewhat

during the past decade, partly in response to the

spread of HIV, the increasing number of cocaine

abusers, and innovative treatment approaches are

being tried. Research is currently underway to

develop medications for treatment of cocaine for

which no effective medications currently exists and to

develop alternative medications for treatment of

heroin addiction. In addition to methadone

maintenance, several other pharmacological treatments have been developed based on an understanding of the basic neurology of opiate dependence, including clonidine for detoxification, rapid

detoxification using naltrexone with clonidine, and

reduction in opiate dependence using the partial

agonist buprenorphine (178). One of the

pharmacotherapies that has shown promise in

reducing cocaine craving and use is the

antidepressant desipramine. A diverse group of

ODF programs and short-term inpatient programs

are also becoming more popular.

Needs for services concerned with AIDS are

more likely to appear in methadone treatment than

in ODF programs (240). Methadone maintenance

programs serve drug users at highest risk of HIV

infection, including intravenous heroin users and an

increasing number of intravenous cocaine users.

Since methadone maintenance programs operate as

outpatient facilities, the annual cost per treatment

slot for needle users is much lower than that of

residential programs, by one estimate, $3,000 compared with $14,600 (252).

Several States do not have methadone programs.

In 1988, at least 8 States had no methadone programs and 3 States had methadone detoxification but

no maintenance (213). Federal, State, and individual

program policies regulate allowable methadone

dosage; a thorough evaluation of State regulations of

methadone programs would greatly enhance understanding in this area (214). It appears that only a

small number of drug treatment programs (about

250) provide HIV counseling and testing despite the

high risk that drug users have of contracting HIV

infection.

Total clients in treatment programs according to

NDATUS in October 1987 was about 260,000, while

the number of drug abuse admissions according to

SADAP for fiscal year 1988 was about 519,000.

Because SADAP is a voluntary survey and includes

only programs that receive at least some funding

from State alcohol and drug agencies, 519,000 should

be considered an underestimate of the actual number

of drug admissions during 1988. Both NDATUS and

SADAP report that the vast majority of clients were

enrolled in outpatient programs (85 and 69 percent,

respectively) and that greater proportions were in

drug-free treatment than methadone maintenance

(65 v. 31 percent and 69 v. 9 percent, respectively).

In October 1987, IV drug users were 42 percent

of all drug abuse clients reported through NDATUS.

The percentage of IV drug-using clients was highest

in the detoxification and methadone maintenance

modalities (332). Estimates from 36 States, the District of Columbia, and Guam responding to the 1988

SADAP put the total number of IV drug abusers at

1.3 million, with estimates varying extensively by

State. Rates of HIV infection among IV drug

abusers varied as well, with estimates as high as 60

percent in New York, New Jersey, and Puerto Rico.

The need for services related specifically to AIDS

and IV drug users was listed as a top priority by 16

States (45). Although waiting lists have limitations as

a measurement of unmet demand, they do provide

an indication of the extent of the problem. One

study showed that almost 67,000 drug abusers were

on waiting lists to enter treatment programs, with

some States having average time between interview

and admission of 2 months or more (252).
Chapter 4

THE EFFECTIVENESS OF TREATMENT FOR DRUG ABUSE

INTRODUCTION

This chapter examines the effectiveness of

treatment for drug abuse and dependence as a first

step in examining its role in preventing the spread of

human immunodeficiency virus (HIV) infection (see

ch. 1). This chapter begins with an overview of the

natural history of drug abuse, particularly with

respect to heroin abusers. Next a discussion of the

major methodological problems in examining the

effectiveness of drug abuse treatment is presented.

The core of the chapter describes the results from

major studies and addresses other issues related to

treatment for drug abuse.

NATURAL HISTORY OF DRUG ABUSE

Overview of Drug Abuse Careers

Drug abuse is a complex, multidimensional,

chronic condition. Several theoretical models have

been proposed to explain the causes of drug abuse

(13,169,367). They range from theories of genetic

predisposition and metabolic deficiencies to theories

based on psychoanalytic principles and social

learning. The lack of agreement on a single cause of

drug abuse has been likened to Voltaire’s saying that,

“A long dispute means that both parties are wrong.”

It might be more appropriate, however, to conclude

that both parties are right. The empirical evidence

does not exclusively support one model over the

others, but rather suggests that elements from all the

models play a role in the initiation and maintenance

of abusive behavior.

The enormity of the problem lies, in part, in the

fact that drug abuse is a condition that has a long

course, in most cases lasting a decade or more. A

simple framework highlights the necessary

ingredients in the making of a drug abuser, namely “a

susceptible person, an abusable drug, and some

mechanism to bring the two together” (169). These

three factors interact during the whole course of drug

abuse. Multiple paths lead in and out of this career,

which is characterized by four stages: initiation,

maintenance, cessation, and relapse (65,158,267,268).

Findings of a landmark study on drug abuse showed

that the average length of time from first use to last

daily opiate use was almost 10 years, and that over

the course of a 12-year followup, over two-thirds of

clients had relapsed one or more times to daily

opiate use (157,267,268). Individual susceptibility to

relapsing into drug use is at the core of this cycle and

can be explained by a variety of factors that may

interact or operate independently (169). These

factors may stem from biological, psychological, or

socioeconomic conditions, and their roles may vary

during the different stages of the abuse career.

Not everyone who experiments with drugs will

become a casual user, and not all casual users will

escalate into full-fledged abuse or dependence

(addiction) (13,104). Abuse refers to a pattern of use

that results in harm to the user; the user continues

use despite adverse consequences. Dependence, on

the other hand, is characterized by compulsive

behavior and the active pursuit of a lifestyle that

centers around searching for, obtaining, and using

the drug. Dependence refers to the most severe

state in the drug-use spectrum; the patterns of use of

psychoactive substances range from experimental,

occasional, and recreational use to abuse and to

compulsive use, which characterizes dependence.

Although treatment is intended for those dependent

on drugs, the term drug abuse as used in this report

encompasses both abuse and dependence.

Not all substances have the same potential for

dependence, and individual biological differences

may affect whether particular individuals become

dependent on a drug. There is inadequate research

to determine precisely the likelihood that a casual

user will become addicted to various substances.

Some experts hypothesize that upper estimates may

be 1 out of 10 persons for alcohol or marijuana,

about 3 to 5 out of 10 persons for intranasal use of

cocaine and about 8 to 9 out of 10 for those who

smoke or inject heroin or cocaine or smoke crack

(169).

-59-
60- The Effectiveness of Drug Abuse Treatment: Implications for ControllingAIDS/HIV Infection

The emerging consensus with respect to cessation

of daily opiate use is that it “is not simply a direct

result of growing older or ‘maturing out’ of abuse”

(267,268). Detailed and long-term followup studies

with regard to cocaine are not available. Overall,

however, it appears that the process of phasing out

drugs is a function of a wide range of factors that

also play a role in an abuser’s decision to seek

treatment. A “threshold point” usually arrives when

the negative consequences of drug abuse outweigh

the rewards derived from drug use (169,267). Previous treatment episodes, criminal justice

involvement, life events, and other social conditions

may converge towards slowing, or completely discontinuing drug use (11).

Natural history studies are extremely helpful in

gaining insight and understanding the course of drug

abuse. Clearly there is a need for more such studies,

especially with regard to cocaine abuse and its routes

of administration.

In general, according to the Office of the

National Drug Control Strategy, not everyone who

has a serious drug problem, defined as using drugs at

least 200 times in the preceding 12 months, will

require formal treatment to overcome the problem

(104). Some (perhaps one out of four such users)

may be able to overcome their drug problems with

their own psychological resources and the help of

friends, clergy, and other support groups (104).

Drug treatment is intended mainly for people who

are drug dependent (238). Because of the chronic

relapsing nature of drug abuse, however, a single

treatment episode will usually be insufficient; an individual may require multiple courses of treatment to

move towards recovery (149,201).

Several studies have examined the course of drug

abuse careers. Most of them, however, are over 20

years old and may not reflect current patterns. The

majority studied samples of predominantly heroin

abusers who received treatment for drug problems

that in most of the cases started before 1%0 (268).

Similar studies are not available for those who abuse

cocaine. Some of the reported studies on heroin use

suffer from a variety of methodological problems,

including presenting the findings in general descriptive form and rarely employing sophisticated

quantitative analyses, such as multivariate analysis

(268).

Heroin Abuse

Overall, these long-term followup studies have

showed a trend towards reduced narcotic use and

increased abstinence with the passage of time

(197,268). Vaillant summarized the results from

several American and European studies of heroin

abusers who were hospitalized to be treated for their

heroin abuse. He concluded that following initial

hospital treatment, 10 percent of the narcotic abusers

would never relapse, another 15 percent would be

abstinent by the fifth year after treatment, and an

additional 15 percent would be abstinent by the tenth

year (352). Vaillant also claimed that almost 50

percent of narcotic abusers who achieve abstinence

for one year would eventually relapse. Based on an

18-year follow-up of treated heroin abusers, Vaillant

estimated that the annual recovery rate is 2 percent

(352). Thus, the 10-year recovery rate ranged from

22 to 40 percent, depending on which study was used

to derive the estimate. One should keep in mind,

however, that these studies are over 20 years old and

may not reflect current characteristics of drug users

and patterns of drug use (e.g., use of multiple drugs)

(203).

In contrast to the above studies, which examined

the course of treated abusers, Waldorf and Biernacki

studied the natural recovery from opiate abuse.

They analyzed data from a non-random sample of

142 former heroin abusers (355,356). Half had been

treated before, and half had never received formal

treatment. The two samples were matched by age,

sex, and race. There were no major differences

found between the two samples with respect to background variables that reflected the extent of drug

abuse, work experience, and education. Although

there were no differences in the variables that

measured motivation, more heroin abusers in the

treated sample than the untreated sample established

new relationships (71 percent v. 54.9 percent, respectively) and used social services, which may reflect

referrals from the treatment centers. In-depth interviews revealed three distinct lifestyles of opiate

abusers: the street abuser, the middle-class abuser,

and the situational abuser. In contrast to the other

two types, the situational abuser uses drugs in certain

occasions depending on availability and has not

developed the stereotype lifestyle or philosophy associated with drug use. Overall, six different patterns
Chapter 4--The Effectiveness of Treatment for Drug Abuse -61

of recovery were identified in their sample: 1) developmental change, which is basically maturation; 2)

conversion to a spiritual, religious, or ideological

group; 3) behavioral change as a result of environmental changes; 4) maintenance of the lifestyle, but

cessation of drug use; 5) occurrence of alcoholism or

mental illness; and 6) drifting into the mainstream of

society.

Cocaine Abuse

Cocaine use is characterized by a binge pattern

(241). Cocaine may be used continuously until either

physiological exhaustion occurs or the drug or money

is depleted. Following a binge, users go through

several well-defined stages; relapse may occur at any

time. Initial depression and high cocaine craving followed by a clinical syndrome resembling a retarded

depression characterize the post-cocaine crash, which

lasts up to 4 days. Next comes a withdrawal phase,

lasting up to 10 weeks, which is characterized by

initial euphoria and a false sense of control followed

by increased cocaine craving and an associated

syndrome characterized by anhedonia and

dysphoria. 1 During the third stage of abstinence, the

subject returns to normal mood; however, occasional

craving for cocaine may be triggered by myriad conditional cues reflecting the extremely reinforcing

nature of cocaine. “A potential for relapse continues

as long as conditioned cues exist to produce craving”

(114,116).

The natural history of cocaine abuse has not been

extensively studied. Thus, knowledge about how the

course of cocaine abuse may differ between treated

and untreated individuals and according to the route

of the drug’s administration is limited. A recent

study shed some light on cocaine abusers who enter

treatment. The study examined the pre-treatment

natural history of cocaine abuse in 285 male veterans

who were admitted during 1988 and 1989 to the

Veterans Administration (VA) Medical Center in

Los Angeles (165). The investigators examined the

1 Anhedonia is the absence of feelings of pleasure in acts that

normally give pleasure, Dysthymia is an emotional state with

depression of less intense degree than seen in manic-depressive

disorders.

period between first cocaine use and entry into

treatment. The majority of the study subjects (95

percent) were entering treatment for the first time.

The mean age of first cocaine use for this group

was 24, and the average total time from first cocaine

use to treatment entry was 11.5 years (165).

Intranasal cocaine and crack were the most prevalent

forms of cocaine use (74 and 72 percent, respectively), with subjects reporting more than one route

of administration. It was observed, however, that

from first use to treatment entry and as subjects

approached treatment, crack use increased and

shifted from intranasal use and other routes of

administration to crack smoking.

Four patterns of progression in cocaine use were

identified: mild-moderate-severe, mild-severe,

moderate-severe, and instantly severe (165). Fortyfour percent of the sample reported that they started

cocaine use at a mild level and subsequently engaged

in severe use. An additional 30 percent started

instantly with severe use; 17 percent was classified

into the mild-moderate-severe group; and the

remaining 10 percent started with moderate use that

was followed by severe use. The results indicated

that although the majority of cocaine abusers were

able to maintain mild use for a considerable length of

time, once they engaged in a level of moderate use,

they escalated fairly rapidly to severe use.

METHODOLOGICAL PROBLEMS IN

THE EVALUATION OF TREATMENT

EFFECTIVENESS

Evaluation research involving human behavior

poses great difficulties. The core of the problem lies

in the difficulty of establishing a causal relationship

between the intervention (e.g., treatment for drug

abuse) and the observed outcome (e.g., reduction in

drug use or criminal activity). Ideally, in an experimental setting the scientist can control relevant conditions that may affect the outcome, thus making the

link between cause and effect easier to establish.

This is not always the ease with human subjects; the

investigator may be either unaware of or unable to

control all extraneous factors that relate to the intervention and the outcome. Such factors may distort

the observed findings and make the connection

between treatment and observed outcome less clear.
62- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

The main objective of evaluation research is to

analyze whether there is a causal link between an

intervention and an observed outcome. First and

foremost, causal interpretation relies on the premise

that in the absence of the intervention (treatment),

the treated would have had the same outcomes as the

untreated. Second, in the event of an observed

treatment effect, the aim is to identify the factors that

may have caused this effect. In study design, the

primary concern is to ensure the internal and

external validity of a particular study. Internal

validity has been described as the sine qua non of

causal inference (63). It refers to the likelihood that

an observed outcome can be attributed to the specific

intervention and not to some extraneous factor.

External validity, on the other hand, refers to the

generalizeability of the observed results to different

settings and populations. It is concerned with the

issue of whether the inference drawn from the actual

subjects of the study may also be applied to people

outside the study population.

Biases in the design and implementation stages of

a study may seriously threaten internal validity.

These biases, which have particular relevance to the

evaluation of treatment for drug abuse, fall into three

main categories: selection bias, information bias, and

confounding factors (249).

Selection bias refers to any recognized or

unrecognized, measured or unmeasured correlates of

the study subjects that influence the probability of

their being part of the study or choosing a specific

treatment intervention and that may also influence

the treatment outcome. Strong personal motivation

to enter treatment combined with self-selection into

a particular modality or facility is a predominant

example. Special elements in this category with

direct relevance to the treatment of drug abuse are

factors relating to the history (specific events

occurring during the course of drug abuse) and

maturation (possible biological and psychological

processes and changes within subjects during the

course of drug abuse) of subjects. These factors

affect the natural history of the condition. In

addition, they may either directly or indirectly

influence both the decision to seek treatment and the

outcome of treatment.

Information bias refers to any distortion in the

process of getting the necessary information to

evaluate the effect of the intervention. For example,

researchers may perform a more aggressive and

probing interview for only some of the subjects or

may extract outcome information from available

records that are incomplete or unavailable for all the

subjects.

Lastly, confounding refers to the distortion of the

findings by any extraneous factor other than selfselection that is related to the treatment and is also

predictive of the outcome. An example is a low,

ineffective dose of methadone. Reduction of opiate

use is related to adequate methadone dose, usually

higher than 60 mg per day (257). On the other hand,

in many methadone clinics the mean average dose is

well below 60 mg (see section on methadone

maintenance below) (299). Thus, results from

evaluation studies that do not control for daily

methadone dose may inaccurately suggest that

methadone is ineffective.

Problems relating to the feasibility of various

study designs and the assessment and measurement

of treatment and its outcomes are additional hurdles

in evaluating the effectiveness of treatment for drug

abuse. Treatment outcomes may also be influenced

by a variety of intrapersonal, social, and environmental factors.

Study Design

The ideal experimental study of the effectiveness

of treatment for drug abuse would use a random

sample of all drug abusers randomly assigned to the

various treatment modalities. Random assignment

would improve internal validity by equally distributing or at least having minimum variation in, those

extraneous factors that may affect the validity of the

comparisons among different groups. Random

sampling would improve external validity by generating a representative sample of all abusers.

The nature of drug abuse often makes such a

study difficult. Drug use is an illicit behavior, and

drug abusers are a heterogeneous group with multiple personal and social problems. Identifying all
Chapter 4--The Effectiveness of Treatment for DrugAbuse -63

drug abusers to draw a representative sample,

gaining their cooperation, and sustaining their commitment to treatment may not be realistic goals.

Whether a sample of drug abusers is representative,

however, bears on the generalizability of the results,

not on the internal validity of the study and not on

the immediate question of treatment effectiveness.

On the other hand, even if a non-representative

group is willing to enter treatment, the ability to

assess a treatment’s effectiveness is compromised if

drug abusers refuse to enter the treatment modalities

assigned.

When an experimental design is not a feasible

option, the best alternative is the quasi-experimental

design, which is based on epidemiologic principles

and observational research. It should be stressed,

however, that the further removed the design is from

the sound principles of experimental research, the

harder it is to establish a causal link between

treatment and outcome. Epidemiologic studies try to

simulate as much as possible the setting of an experimental design. Although the investigator does not

have control over all of the relevant variables and circumstances, partial control can be accomplished

through careful identification, documentation, and

measurement of the known relevant factors that may

influence the outcome. The essence of the situation,

however, is that when non-equivalent groups are

studied, biases are more likely to occur. It thus

becomes harder to separate the effect of treatment

from the effect of those factors that are associated

with the initial non-comparability of the study

groups.

Prospective studies usually offer a more complete

picture of treatment effectiveness than retrospective

studies. Although a prospective design has the

potential to eliminate some major sources of bias, it

is not trouble-free. For example, adherence to the

study protocol is essential to ensure that it was the

intended treatment that produced the observed

findings. Another problem that can seriously

hamper interpretation is the attrition of patients

during treatment and followup. If, for example, the

patients who drop out of treatment early or who are

harder to locate afterwards are those who were

resistant to treatment and poorly motivated, then the

results would tend to overestimate the impact of

treatment.

Another critical issue is whether direct comparisons may be made among the different

modalities with regard to their effectiveness. There

is considerable evidence that the various modalities

attract different client groups (128,149). This

heterogeneity in the baseline population can compromise the comparative interpretation of any differences, since they may involve non-comparable

groups.

The majority of treatment effectiveness studies

use a quasi-experimental research design. Randomization among drug abuse treatment modalities

has been employed in two studies. One randomized

patients to methadone maintenance or residential

treatment, yet produced results that were hard to

interpret because of poor adherence to the study

design (19). The other, a randomized blinded study

of methadone v. placebo, produced meaningful

results (227). Randomized studies are more

common in the evaluation of specific treatment components (59,140,202,375).

Although earlier studies suffered from an

abundance of methodological problems, considerable

progress has occurred with advances in the

measurement of variables, study design, and

statistical analysis of the results.

Definition of Treatment and Outcome

The actual definition, measurement, and

assessment of both treatments and outcomes pose

additional challenges. Treatment for drug abuse is a

process that occurs over a period of time. Multiple

treatment episodes may be needed for improvement

or abstinence from drug use. Defining the treatment

period and deciding when to measure the results of

treatment may greatly influence the results. For

example, for methadone maintenance (whose goal is

to reduce or eliminate heroin use while the patient is

receiving methadone, measurement of outcomes has

occurred during ongoing treatment; however, for

therapeutic communities (whose goal is a drug-free

lifestyle after treatment completion), outcome

measurement has begun after the client has left or

completed the program. Choice of followup time

after treatment is also a challenge. Outcome

estimation after l-year followup may more accurately
64- The Effectiveness of DrugAbuse Treatment: Implications for ControllingAIDS/HIV Infection

reflect a treatment’s impact than outcomes at longer

followups, which may reflect a combination of the

treatment’s impact and other influences on the drug

abuser’s life (271).

A critical issue is the use of subjective or

objective measures in measuring the outcome of

interest. Ideally, an experimental study would

include objective measures of outcome that can be

easily reproduced. Although someone would expect

that self-reports of illegal behaviors, such as drug use

or criminality, could severely compromise scientific

studies by underreporting, at least for opiates,

“measurement research indicates strong agreement

between addicts’ self reports and other sources of

information on their opiate use, employment, and

crime” (202). Another expert review on measurement in drug abuse surveys concluded that an investigator through careful, thoughtful planning and use

of creative procedures, “should be able to collect

acceptably reliable and valid data on the drug-using

behavior of respondents in most populations” (161).

Caution, however, is warranted, and corroboration of

self-reports with objective measures is always a

desirable ingredient in drug abuse studies.

The challenge of treatment effectiveness research

is not only to establish whether any observed changes

are attributed to the intervention but also to identify

the most effective and most ineffective elements of

treatment. Treatment consists of several components, such as drug education and counseling;

urine testing; psychotherapy; medications; and educational, vocational, and other social support (13).

Modalities also vary in the goals of treatment (most

notably drug-free v. maintenance). Moreover, even

within the same modality, there is variation in the

provision and quality of services and the settings in

which they are offered.

Drug abuse is a disorder that affects many

aspects of abusers’ lives and the society within which

they function. This reality has certain implications

for the objectives of drug abuse treatment. The first

and foremost goal of drug treatment is cessation of

illicit drug use. Also important are other outcomes,

including a decrease in criminal activity, increase in

social productivity, and improvements in mental and

physical health (13). Defining and measuring these

outcome categories further complicate the task of

treatment evaluation.

An additional factor in reviewing evidence of

treatment effectiveness is the possibility of publication bias. To the extent that publications reject

studies that report negative findings (no treatment

effect), the published literature will overestimate

treatment effectiveness.

Summary

In summary, the evaluation of drug abuse

treatment poses significant challenges. Controlled

experiments, although difficult to design and

conduct, are increasingly becoming more common.

A wide array of factors complicate the assessment of

treatment effectiveness. The chronic relapsing

pattern of drug abuse, the heterogeneous composition of the drug-abusing population, and the

problems created by patient self-selection of

treatment modalities are some of the problems

researchers face. In addition, the difficulty of

specifying often intangible treatment components,

such as the overall profile of the program with the

complex interactions of patient expectations and

staffs abilities and attitudes, may further exacerbate

the evaluators’ task (13).

Improvements in study design and analysis are

expected to strengthen the validity of research

results. In the meantime, evaluations of adequately

designed and implemented studies that provide consistent evidence may provide useful information for

social policy. When one analyzes existing scientific

knowledge on the effectiveness of treatment of drug

abuse and its policy implications, it is useful to recall

the words of Bradford Hill, one of the pioneers in

establishing standard criteria for causal inference:

All scientific work is incomplete-whether it be observational or experimental. All scientific work is liable to

be upset or modified by advancing knowledge. That

does not confer upon us a freedom to ignore the

knowledge we already have, or to postpone the action

that it appears to demand at a given time (142).
Chapter 4-The Effectiveness of Treatment for DrugAbuse -65

DARP AND TOPS: A DESCRIPTION OF

THE TWO NATIONAL MULTIMODALITY

STUDIES

Much of the collective knowledge of treatment

effectiveness, such as general characteristics of

clients in the various modalities, the natural history

of abuse, and factors related to treatment effectiveness, stems from two large federally-funded

studies. The Drug Abuse Reporting Program

(DARP) begun in 1%9 and the Treatment Outcome

Prospective Study (TOPS) begun in 1979 examined

different treatment modalities throughout the United

States. Because of their significant contribution to

the field of drug abuse research, these two studies

are described in detail below.

Drug Abuse Reporting Program (DARP)

DARP, the first comprehensive large-scale

evaluation project, was initiated in 1%9 as a national

data collection system to evaluate community-based

treatment centers (268). The need for such action

arose after the treatment expansion that took place

during the late 1960s. Funded by the National

Institute on Drug Abuse (NIDA) and conducted by

the Institute for Behavioral Research of the Texas

Christian University, DARP provided valuable

information on a substantial segment of the clients in

publicly funded drug abuse treatment centers.

DARP also documented changes over time in

treatment clientele and drugs used.

Between 1969 and 1974, approximately 44,000

clients in 52 treatment centers around the country

were described and assessed (268). Standardized

data collection instruments were used at client

admission and bimonthly while clients were in

treatment. These instruments measured” client characteristics, type of drug used, alcohol consumption,

productive activity (employment), and criminality.

These initial data served as a baseline for a series

of followup studies on three admission cohorts

clients entering treatment during 1%9-71, 1971-72,

and 1973-74 (269,270,271). Followup studies

initiated in 1974 examined outcomes associated with

the various treatment modalities. Followup

assessment included a complete history of the type

and duration of drug abuse treatment and gathered

additional information on illegal drug use,

criminality, and employment. Outcomes were

reported only for people who, during the year of followup, had been out of treatment or out of jail for at

least 3 months.

A total of 6,402 clients from 34 treatment centers

participated. This randomly drawn sample included

both males and females and was stratified for age,

race-ethnicity, treatment type, length of time spent in

treatment, and geographic location of the program.

Overall, 83 percent (5,340 of those selected) were

located, and 73 percent were interviewed face-toface. All the major modalities were represented.

Subsequently, there was also a 12-year followup

study on a targeted sample of 697 black and white

daily opiate users. Of this sample, 70 percent were

interviewed; the remaining either refused (2

percent), were not located (20 percent), or were

deceased (8 percent) (261,270,271). Although

outcome measurement relied on self-reports, the

investigators state that comparisons of a sample of

self-reported data with urine testing results and

criminal justice records provided evidence for the

accuracy of self-reported data (267).

As the first large-scale, field-based evaluation of

drug abuse treatment, DARP contributed substantially to the field of drug abuse research by

addressing major methodological problems. For

example, it established criteria for the definition and

measurement of treatment, its characteristics, and

associated outcomes.

It should be noted that the DARP findings presented in this report pertain mainly to users of

opiates and only to white and black males, since

these subgroups were consistently represented in all

treatment groups in the followup samples.

Treatment Outcome Prospective Study

(TOPS)

Conducted from 1979 to 1981, TOPS was the

second large-scale, comprehensive, longitudinal

evaluation study. This study built on the experience

of the DARP study. Funded by NIDA and conducted by the Research Triangle Institute, TOPS

provided more extensive information than DARP

about the natural history of drug abusers (details
66- The Effectiveness of DrugAbuse Treatment: Implicationsfor ControllingAIDS/HIV Infection

about drug abusers’ lives before, during, and after

treatment) and drug abuse treatment.

The study population included 11,750 clients from

41 programs across the country. Although these programs were purposely selected and did not represent

a random sample of all publicly funded programs,

the authors stated that they accurately reflected the

types of clients and the range of treatment services

available between 1979 and 1981 (147,149). The

investigators arrived at this conclusion by comparing

TOPS programs and clients with available national

data on treatment programs and client characteristics.

Three admission cohorts were formed based on

whether the clients entered treatment in 1979, 1980,

or 1981. Clients in the three admission cohorts were

interviewed at initial contact, 1 month into treatment,

and at 3-month intervals while in treatment.

Information was gathered on the types of drugs used,

alcohol consumption, mental health, criminal

behavior, and economic productivity. Those clients

who entered the TOPS programs and completed the

initial interview made up the population from which

the followup samples were drawn. A total of 4,270

people formed the three stratified samples. Followup occurred at 3 months, 1 year, 2 years, and 3 to

5 years after leaving treatment. Response rates

varied by modality and length of time since leaving

treatment, with somewhat lower rates for methadone

clients than those in therapeutic communities and

outpatient drug-free programs (see ch. 3 for descriptions of the major treatment modalities). Of the

initial sample, response rates ranged from 70 to 80

percent in each followup period up to 2 years and

were about 65 percent for the 3- to 5-year followup.

The investigators compared characteristics of

respondents and non-respondents and concluded that

the resulting bias from the non-respondents would

not distort the study’s conclusions.

The results from the TOPS study reported later

in the chapter were based on approximately 10,000

clients in 37 programs representing all the major

modalities and refer to those patients who spent at

least 3 months in treatment. Three outcome

measures, including drug use, criminal activity, and

productivity, were used. Reductions in drug use were

documented separately for heroin and cocaine.

Criminal activity was measured as the self-reported

involvement in predatory crimes (such as robbery,

burglary, larceny), thus excluding crimes related

directly to drug use, such as drug dealing. Productivity was measured by weeks of full-time

employment. With respect to the reliability and

validity of the self-reported data, the investigators

stated that, “varied analyses demonstrate that the

TOPS data are on the whole reliable and valid

(149).”

In addition to reporting the prevalence of the

above outcome measures, the investigators calculated

l-year abstinence and improvement rates. The

abstinence rate for a specific drug is the proportion

of people who were regular users in the year before

treatment and who did not use the drug at all in the

year after treatment. The improvement rate, a less

strict criterion, is the proportion of regular users in

the year prior to treatment who either ceased use

completely or decreased the frequency the year following treatment. In contrast with the prevalence

rates, which provide a robust picture of drug use, the

latter measures provide information on changes

among individuals who engaged in this behavior prior

to treatment. It should be kept in mind that the

abstinence and improvement rates reported in the

following sections pertain to treatment clients who

spent at least 3 months in treatment. The exact proportion of clients who remained in treatment for at

least 3 months at each modality is reported separately in the respective sections.

TREATMENT EFFECTIVENESS

This section describes the results from the major

studies on the effectiveness of drug abuse treatment.

In evaluating treatment effectiveness, one should

keep in mind that treatment goals differ among

modalities. Treatment duration and graduation are

basic concepts of therapeutic communities and outpatient drug free programs; the ultimate goal is drugfree status after treatment completion. For

methadone maintenance, however, the goal is

reduction or elimination of opiate use during

treatment. In addition, drug-free status is a goal for

some methadone maintenance programs.
Chapter 4-The Effectiveness of Treatment for DrugAbuse -67

Since most of the studies on treatment effectiveness are modality-specific, each of the major

modalities will be addressed separately: methadone

maintenance; other pharmacological agents including

Levo-Alpha-Acetyl-Methadol (LAAM), naltrexone,

and pharmacotherapies for cocaine abuse;

therapeutic communities, and outpatient drug-free

programs. A review of research on specific

modalities is followed by a review of studies that

relate to more than one modality. Next, results of

the most recent cost-benefit analyses related to drug

abuse treatment are presented. Finally, other contemporary issues related to treatment are addressed,

including treatment of special populations, dual morbidity (the coexistence of both substance abuse and a

psychiatric disorder), polydrug use (the concurrent

use of more than one drug), relapse prevention, and

aftercare services.

Methadone Maintenance

This treatment modality is directly related to prevention of HIV infection. Methadone maintenance

is intended to curtail heroin use. Since most heroin

abusers administer the drug intravenously,

methadone maintenance by reducing heroin use, has

the potential to interrupt a major route of HIV transmission.

Since 1964, when the first studies by Dole and

Nyswanter were reported, hundreds of thousands of

heroin abusers have been managed by methadone

maintenance, and numerous articles have been

written about this treatment modality. A literature

search revealed approximately 13,000 articles on substance abuse in general, 4,000 of which referred to

methadone maintenance (246). Methadone

maintenance, “has been evaluated as much as any

human service modality in history” (262). These

evaluations have been either part of large multiprogram national studies or individual studies of

specific programs. Many thorough reviews have

examined the collective evidence for methadone

maintenance effectiveness (13,39,66,68,262). This

section will analyze findings from some of the major

studies along with results reported by the review

articles.

Randomized Experiments

Methadone Maintenance and Placebo--The first

randomized, double-blind study of methadone

maintenance effectiveness was conducted in Hong

Kong between 1972 and 1975 among 100 heroin

addicts who volunteered to participate (227). After

all were stabilized on a daily dose of 60 mg of

methadone, they were randomly assigned to two

groups. The first group received methadone with an

average dose of 97 mg per day. The second group,

the control group, had their methadone gradually

reduced by 1 mg per day to no methadone and thereafter were maintained on placebo. Both groups had

access to a wide range of ancillary services and were

followed for 3 years.

At the 8-month followup, there was a marked difference in the proportion of patients continuing

treatment between the two groups (10 percent and

76 percent for the placebo and methadone

maintenance groups, respectively) (227). After 3

years, 56 percent of the methadone group was still in

treatment, in contrast to 2 percent of the control

group (1 out of 50 placebo clients was still in

treatment). With respect to illicit narcotic use, the

investigators noted that evidence for persistent use of

heroin (measured by urine testing) accounted for 31

of the 49 discharges (dropouts) of the control group.

Among the treatment group, the proportion of

patients with one or more urine samples positive for

heroin rose initially to almost 60 percent but declined

sharply and stabilized around 35 percent after the

fourth month. Criminal activity, measured by the

rate of convictions per man-month of enrollment, for

the placebo group was more than double that for the

treatment group (3.17 v. 1.41).

Methadone Maintenance and Therapeutic Communities--In 1980, Bale and his colleagues attempted

to overcome the major methodological obstacles and

perform a systematic comparison of methadone

maintenance and therapeutic communities (19).

They designed a prospective study, employing

random assignment to the two modalities, and a followup of all patients regardless of retention in

treatment. The study population comprised 585
68- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

male veterans who used heroin. These individuals

were randomly assigned either to methadone

maintenance or to one of three therapeutic communities participating in the study. Data were collected on drug use, criminal behavior, and work and

school attendance. Patients were followed up to 1

year.

Only 108 patients entered the treatment modality

to which they were initially assigned; another 103

waited a required period of 30 days and then they

exercised their options to enter a different program

(19). The methadone program retained 31 percent

of those originally assigned, while 21 percent

switched to residential treatment. With regard to

those assigned to residential programs, 39 percent

remained in the residential programs, and 9 percent

entered methadone treatment. Forty-two percent of

the sample spent no time in any treatment, except a

detoxification program.

Among those in treatment, retention problems

occurred. Although 74.5 percent of the total

methadone maintenance clients remained in

treatment for the first year, only 20 percent were still

in therapeutic communities TC programs after the

first 6 months. The l-year outcomes (drug use,

criminal activity, and work or school attendance) for

all subjects in therapeutic communities and

methadone maintenance showed no statistically significant differences. Overall, the study was severely

compromised, especially because of veterans’ refusal

to enter the assigned treatment, high dropout rates,

and the option to switch modalities. Because of

these methodological problems, the results with

respect to treatment effectiveness were rendered

almost uninterpretable (13,128).

Multi-Program Nonrandomized Study

Ball and colleagues assessed the effectiveness of

methadone maintenance in a cross-sectional study of

six methadone maintenance programs in the

Northeast (20). The study sample of 617 heroin

abusers consisted of a stratified sample of new

admissions and longer-term clients already in

treatment for at least 6 months. The sample was

further classified with respect to time in treatment

with 126 new admissions, 342 moderate-stay clients

(those with an average stay of 0.5 to 4.5 years), and

149 long-term clients (those with an average stay

over 4.5 years). The l-year retention rate was 63.4

percent for the moderate stay clients and 86.3

percent for the long-term group. The mean number

of years of heroin use was 11.1 for. the whole sample.

Of those newly admitted, 66.7 percent said they had

used heroin in the past 30 days, and 14.5 percent

reported using other opiates. The prevalence of

opiate use in the past 30 days was less than 100

percent because this sample included drug users who

were in a transition period from jail, other

incarceration, or detoxification to methadone

maintenance. In addition to heroin use, 58 percent

of those newly admitted reported using cocaine, and

38.7 percent reported using alcohol to intoxication.

Table 4-1 presents the findings of the study according

Table 4-l-Percent Self-Reported Heroin Use and Crime by Males by Time

in Methadone Maintenance Treatment, 1985a

Last addiction New admission In treatment In treatment

period sample 05 to 4.5 years 4.5 years

Status in past 30 days (N=617) (N=126) (N=342) (N=149)

No heroin use or crime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA 25.4 655 83.2

Only heroin use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.0 37.3 15.8 3.4

Only crime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NA 7 . 9 11.1 9.4

Both heroin use and crime . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.0 29.4 7.6 4.0

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0

ABBREVIATION: NA = not available from the reference.

a The Chi square value for this table is 303.8, which is significant at the .01 level.

b The authors described this group as having been in transition during the previous 30 days.

SOURCE: Ball, Corty, Meyers, et al. (20).
Chapter 4--The Effectiveness of Treatment for DrugAbuse -69

to length of stay in methadone maintenance. There

were four outcome measures: heroin use; criminal

activity; both heroin use and criminal activity, and

success, defined as no heroin use or criminal activity

during the past 30 days.

Of those with moderate stays (0.5-4.5 years), 15.8

percent reported using heroin in the past 30 days and

an additional 7.6 percent were involved with both

heroin and crime (20). Overall, 65.5 percent of the

moderate-stay sample were defined as successes,

with no heroin use or criminal activity in the past 30

days. Even larger improvements were reported

among those who remained in treatment for more

than 4.5 years. Overall, 83.2 percent of these longterm clients were classified as successes. Heroin use

was reported by only 3.4 percent of long-term clients,

while an additional 4 percent were involved in both

heroin and crime. The investigators also reported

similar patterns of smaller rates of cocaine use and

to a lesser degree alcohol use. Substantial differences in both heroin use and criminal activity were

observed, especially for long-term methadone

maintenance clients.

National Studies

DARP Study--The reported findings of the firstand third-year followups pertain to only white and

black males who were admitted to treatment,

regardless of the time they spent in treatment. Interviews were conducted with 73 percent of the sample

targeted for followup (a random sample of all those

who originally entered treatment) (see table 4-2)

(272). Daily opiate use declined from 100 percent 2

months before treatment to 36 percent and 24

percent at the first and third years of followup,

respectively.

Criminal activity was measured as the percentage

of clients undergoing any arrest or incarceration

during the year of followup. Of those entering

methadone maintenance, a substantial majority (88

percent) had reported at least one arrest in their

lifetimes (272). This proportion reporting any arrest

was 27 and 20 percent, respectively, during the first

and third years of followup. Similarly, any

incarceration declined from 50 percent prior to

treatment to 28 and 30 percent at 1- and 3-year followups.

At baseline (previous 12 months), 33 percent

were employed half-time or more (272). During the

third year after treatment, the proportion rose to 58

percent.

TOPS Study--The impact of methadone

maintenance on heroin and cocaine drug use,

criminal activity, and economic productivity are presented in table 4-3 (149). These findings pertain to

Table 4-2-Percent Self-Reported Opiate Use, Criminal Activity, and Employment

by Malesa in Methadone Maintenance Treatment, DARP

Pre-treatment b

During 1 year During 3 yearn

Category period after treatment after treatment

Daily opiate use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 36 24

Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 27 20

Incarceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 28 30

Employment half-time or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 57 58

a Statistics refer only to white and black males.

b The pre-treatment periods varied: 2 months for opiate use, lifetime for arrest and incarceration, and previous 12 months for

employment.

cAverage followup rates were 79 percent for cohorts admitted to treatment from 1%9 to 1971 and from 1971 to 1972 and 64 percent for

the cohort admitted in 1973 to 1974.

SOURCE: Simpson and Sells (272).
70- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/ HIV Infection

Table 4-3--Percent Self-Reported Drug Use, Criminal Activity, and Employment by Methadone

Maintenance Clients Treated at Least 3 Months, TOPSa

Year before 3 months in 3-months l-year 2-year 3-5 year

Category treatment treatment followup followup followup followup

Regular heroin use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63.5 5.9 16.0 16.7 14.9 175

Regular cocaine useb. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26.4 9.4 17.4 17.5 12.0 16.5

Serious predatory crimes . . . . . . . . . . . . . . . . . . . . . . . 31.8 9.8 18.8 19.0 15.2 16.2

Full-time employment . . . . . . . . . . . . . . . . . . . . . . . . . . 24.2 25.9 16.5 20.1 29.3 17.7

ABBREVIATION: NA = not available.

aNo statistics on followup rates for clients treated at least 3 months were presented. For all those on methadone maintenance regardless

of the duration of treatment, followup rates ranged from 75 percent for 3 months followup to 65 percent for 3-5 year followup.

“Weekly or more frequent use.

SOURCE: Hubbard, Marsden, Rachal, et al. (149).

methadone maintenance clients who had remained in

treatment for at least 3 months; these clients

represent nearly 69 percent of the sample targeted

for followup (a stratified sample of those who completed intake procedures). The median time spent in

treatment was approximately 7 months (147,149,150).

The followup sample, however, includes those who

were in long-term maintenance (approximately 25

percent of the sample).

During the year before admission to methadone

maintenance, 63.5 percent of clients used heroin regularly. At 3 months after entry, only 5.9 percent were

regular users (weekly or more frequent use) (149).

This proportion increased gradually after treatment

and stabilized at 17.5 percent (a threefold decrease

from the pre-treatment level) at the 3- to 5-year followup (measured from date of admission).

Improvement was also reflected in two other

outcome measures, the abstinence and improvement

rates. Of regular heroin users during the year before

treatment, more than half had ceased heroin use

altogether the year after treatment (abstinence rate).

Similarly, 70 percent had either stopped or decreased

their use in the year subsequent to treatment.

The original proportion of regular cocaine users

during the year prior to treatment was 26.4 percent

(149). This rate dropped to 9.4 percent after 3

months in treatment and increased gradually to 16.6

percent at the 3- to 5-year followup. The l-year

abstinence and improvement rates were 40 and 70

percent, respectively. This pattern of cocaine

increase may reflect the resurgence and higher

initiation rate of the drug in the early 1980s (149).

Criminal activity (measured as involvement in

serious predatory illegal acts) showed similar

decreasing patterns. During the year prior to

treatment, 31.8 percent engaged in such activity

(149). After being in treatment 3 months, the proportion dropped to 9.8 percent. Thereafter, the rate

increased and stabilized at 16.2 percent at the 3- to 5-

year followup (half of the rate during the year before

treatment). Similarly, the investigators noted that

two out of three clients reporting illegal acts prior to

admission had ceased their involvement the year

after treatment.

There was no major difference in the percentage

of fully employed clients l-year before admission and

at the 3- to 5-year followup. In fact, a decrease was

observed (24.2 declining to 17.7) (149). The

improvement rate indicated that 18 percent of the

clients had more weeks of full-time employment in

the year after treatment. The strict outcome

criterion (full-time employment) together with the

lack of an adequate control group and the multitude

of factors that influence employment may help

explain the contrasting outcomes between the significant improvements in drug use and criminality, on

one hand, and the overall unchanged level of economic productivity on the other.

Additional Studies on Crime Reduction

Anglin cites several additional studies from a

variety of geographic locations across the country

that demonstrate the effectiveness of methadone

maintenance in reducing crime (13). In a study in

San Antonio, Maddux and Desmond found that
Chapter 4-The Effectiveness of Treatment for DrugAbuse -71

methadone maintenance treatment rates were

inversely related to community crime rates (198).

Moreover, when funding reductions forced

premature discharge of clients in the community,

crime rates increased. Another study by Hunt and

colleagues compared methadone maintenance clients

with narcotic users not in treatment (151).

Methadone maintenance clients were involved in less

criminal activity, especially for serious crimes, such

as robbery, burglary, and drug dealing. Finally, in

summarizing the overall effects of methadone

maintenance on crime, Ball and colleagues, in the

study described earlier, found a consistent and

uniform decrease in the 14 types of crime that they

examined (20). Prior to treatment, people in the

sample were involved in 306.8 mean crime days per

year. For those in treatment for at least 6 months

and less than 4.5 years, the reported mean crime days

plummeted to 24 per year. A further reduction to 18

days was reported for those in treatment for more

than 4.5 years.

Natural Experiments

The shortcoming of not having randomly assigned

groups or an adequate control group is uncertainty in

the interpretation of positive findings. In order to be

able to conclude that treatment was the contributing

factor, other plausible explanations should be

excluded. Studies that take advantage of a policy or

program change (natural experiment) and examine

subsequent outcomes may provide less equivocal

results (13,17,149). In his most recent review of the

effectiveness literature, Anglin describes such

studies. One study by McGlothlin and his colleagues

examined the consequences of the involuntary

termination of a methadone maintenance clinic in

California (207). The 94 clients who were forcibly

discharged were compared with a matched sample of

83 clients from another operating clinic. The 2-year

followup showed that 54 percent of those forcefully

discharged had reverted to heroin abuse. Those discharged were almost two times more likely to be

arrested or incarcerated than the comparison group.

Similar findings were reported from another study in

San Diego, where some of the clients of a closed

clinic transferred to private methadone maintenance

programs, while others were unable or unwilling to

do so (14). Higher rates of illicit drug use, crime,

and drug dealing, and more contact with the criminal

justice system were reported for those who did not

transfer.

Maximum Achievable Effectiveness of

Methadone Maintenance

For a recent presentation at a NIDA conference

on treatment improvement, Kreek compiled the best

reported outcome levels that properly run

methadone maintenance programs can be expected

to achieve (187). A distinction between primary and

secondary treatment goals was made. The primary

goals were reduction in heroin use and voluntary

retention for more than 2 years. The best observed

outcome with respect to the proportion of

methadone maintenance clients abstaining from

heroin was 85 to 98 percent (299). Overall, 2-year

retention rates exceeded 65 percent. Secondary

goals and the achieved levels were 1) reduction in

cocaine use (30- to 40-percent decline) and alcohol

abuse (20- to 30-percent decline); 2) reduction in

criminality and antisocial behavior (more than a 70-

percent decline in criminal acts and arrests reported

in some programs); and 3) improvement in

socialization and productivity including employment,

resumption of education, and homemaking (60-

percent improvement observed in some programs).

Factors Related to Treatment Effectiveness

of Methadone Maintenance

Methadone maintenance clinics provide a wide

spectrum of ancillary services to their clients, though

they vary in the type, intensity, and quality of services

offered. The core of these programs is the daily

administration of methadone as a pharmacologic

means of blocking the effects of opiates while simultaneously avoiding withdrawal, thus reducing their

USC. Variables related to the provision of both

methadone and ancillary services have been

identified as influencing treatment outcome to one

degree or another. This section will focus on the

methadone-related parameters. Other factors that

relate to treatment effectiveness and cut across

modalities will be reviewed at the end of the

treatment effectiveness section (see section on Parameters Related to Treatment Outcome).

Methadone Dosage--There is great variability in

the way individuals metabolize drugs, and this is

certainly true for methadone. Beyond individual differences, some of the factors that have been found to

influence the clearance of methadone from the body

include other concurrent conditions, such as chronic

diseases, the intake of other pharmacologic agents,
72- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

and pregnancy. Due to individual differences in the

rate of methadone removal, what constitutes a

dosage of methadone adequate to exert its

pharmacologic action may differ from person to

person. If the dose is inadequate, the methadone

concentration in the blood may fall below a critical

level before the administration of the next day’s

dosage, and the patient may experience symptoms of

abstinence, which can lead to heroin use to relieve

them (97,98,262). This pharmacologic reality supports the notion that methadone maintenance should

be viewed as a procedure similar to providing

pharmacotherapy to stabilize and maintain any other

chronic condition, such as diabetes.

This view, which has a profound impact on how

to determine an appropriate dose, is not shared by

everyone. There have been two main arguments

posed by methadone opponents: 1) that methadone

is bad because it simply substitutes one opiate for

another (which technically speaking is true) and 2)

that providing methadone, and especially higher

doses, will lead to increased illegal diversion of

methadone (18).

The interplay of scientific, moral, and political

arguments in the evolution of methadone policies has

been examined and analyzed by Attewell and Gerstein (18). With respect to dosage policies, they note

that the mean dosage levels of programs “became

strategic symbols of their toughness and desire to

wean abusers from methadone” (18). The authors

argue that methadone dosage became “a pawn in an

organizational struggle” that resulted in a steady

decline in the average dose over the years.

A low dose of methadone has traditionally been

one that is less than 40 mg a day, while a high dose

has been defined as a dose over 60 mg a day (170).2

The role of methadone dosage has been thoroughly

examined in a critical review by Hargreaves, which

was part of NIDA’s landmark conference “Research

on the Treatment of Narcotic Addiction: State of the

2 The distinction between low and high dose used in the literature

should not be confused with the distinction between effective and

ineffective dose Ievels, as studies have indicated that 60 mg of

methadone per day may be the lowest effective dose (2S7).

Art” (130). With the research question “What evidence do we have that various methadone dose practices are more effective than others," a careful and

analytic review of 22 studies covering 11 years of

research was conducted. All 22 studies were

evaluated for their quality and strength of evidence.

The conclusion was that there is a dosage effect,

especially early in treatment. The participating

researchers further agreed that a daily dosage in the

range of 50 to 100 mg with a mean around 80 mg

would be sufficient for the majority of the patients.

Evidence suggested, however, that for a substantial

minority (10 to 30 percent) of patients, doses as high

as 100 mg per day were superior to 50 mg, especially

for the first 5 to 10 months of treatment. Furthermore, the researchers also agreed that higher

dosages enhance retention in treatment, especially in

the early phase, and lower rates of illicit drug use.

The final conclusion stated that, “no single

methadone dose is best for all patients” (69).

Researchers suggested that dosages be individualized

for each patient. Although a daily dose of 100 mg or

less is thought to be sufficient in most cases, some

circumstances might require higher doses. On the

other hand, methadone doses below 50 or 30 mg per

day, are considered to be inappropriate (69).

The study of six methadone maintenance clinics

in the Northeast by Ball and colleagues also

examined the effect of dosage on opiate use (98).

The data on dosage were pooled over all the programs, which had different policies and support services. Although these were cross-sectional data,

there was a striking inverse relationship between

daily methadone dose and the frequency of heroin

use. At a daily dose of 35 mg or less, a little over

one-third of the clients used heroin regularly. By

contrast, at 80 mg per day, there was practically no

opiate use.

With respect to dosage changes, a recent review

of methadone maintenance treatment by Kreek

further recommends that dose changes should not be

used as a reward or punishment, but rather that

dosage should be determined after a careful and

scientific evaluation (186). The scientific reasoning

for such a policy is that stable doses play a crucial

role in normalizing the heroin-induced changes of
Chapter 4-The Effectiveness of Treatment for DrugAbuse -73

many physiological functions. Thus, an abrupt disruption of stable plasma levels could lead to relapse

by initiating drug hunger and drug-seeking behavior.

Retention In Treatment--The study of the association of remaining in treatment with the degree of

treatment effectiveness is a good example of the

inherent limitations of drug abuse research. Many

factors that may play a role in retaining clients in

treatment (e.g., patients’ characteristics, program

variables, dosage, and other policies) may also have

an impact on the outcomes and thus confound the

real association between treatment retention and

positive outcomes. Nevertheless, it is noteworthy

that a wide variety of studies with different designs

and data analysis sophistication have consistently

found duration of treatment associated with outcome

improvements. Retention rates in methadone

maintenance, although higher than the other

modalities, vary among different programs. Overall,

the reported range for a 2-year period is from 55 to

85 percent (258). Retention is influenced by both

client and treatment characteristics (68). Client

factors associated with retention and better

adjustment to methadone maintenance were older

age, low criminal background, better employment

history, and lack of psychopathology.

It should be noted that methodological problems

impede generalizations and predictions. The most

appropriate design, a randomized clinical trial, may

be difficult to achieve. Even in observational or

epidemiologically designed prospective studies, from

which most of these results come, the existence of an

unmeasured metabolic deficiency or biochemical difference could seriously confound and invalidate any

prognostic ability of other factors. With respect to

program characteristics, programs with more flexible

strategies, including dosage policies, are reported to

have superior retention records (13). A study comparing three programs found that flexible policy programs retained clients, on the average, 9 months

longer than other programs (13). A multivariate

analysis of the non-compliant clients in the study by

Ball, et al., found that those patients on lower doses

(less than 30 mg per day) had the higher risk of noncompliance, while program affiliation was not a significant factor. By contrast, however, noncompliance

in the mid- and high-dose programs, was program

related. The authors suggest that program policy,

treatment procedures, and staffing patterns seemed

to influence compliance rates (294).

At the NIDA “State of the Art” conference, there

was also agreement that research findings indicate

that patient performance (measured by drug use,

employment, and criminality) is a good predictor of

retention while the patient is still in treatment (69).

The majority of researchers at the conference also

agreed that the longer the duration of treatment, the

more likely it was that a positive outcome would be

sustained following treatment (66,72). The findings

from the more recent TOPS study support these conclusions (149). Multivariate regression analysis of

the TOPS data, which controlled for several factors,

demonstrated that time in treatment was the

strongest predictor of favorable outcomes (table 4-4).

Significant results were demonstrated for those who

Table 4-4-Odds Ratios for Post-Treatment Outcomes in the First Year after Methadone

Maintenance Treatment, by Treatment Duration, TOPS

Time in treatment

Comparison group >52 weeks Long-term

< 1 week 1-13 weeks 14-52 weeks and discharged

Outcome

maintenance

n=8 6 n = 161 n = 268 n = 137 n = 183

Regular heroin useb

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 1.16 0.83 0.47c

0.23d

Regular cocaine Use.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 1.2 1.05 059 1.11

Predatory crimes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 0.81 0.81 0.59 O.36d

Full-time employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 0.70 1.13 1.74 1.44

a self reports from 835 of the 1,539 clients who were sampled for followup.

b Weekly or more frequent use.

c <.05

p c .001

SOURCE: Hubbard, Marsden, Rachal, et al. (149).
74- The Electiveness of Drug Abuse Treatment: Implications for ControllingAIDS/HIV Infection

had been in treatment continuously for 2 to 3 years,

as is shown in table 4-4. Indeed, those in long-term

maintenance were four times more likely to have

decreased their regular heroin use (odds ratio =O.23)

than those with less than 1 week in treatment (the

comparison group). Similarly, those with more than

52 weeks in methadone maintenance were two times

less likely to be engaged in regular heroin use (odds

ratio =O.47) than the comparison group. Moreover,

these long-term maintenance clients were three

times less likely to engage in predatory illegal activity

(odds ratio= O.36). With respect to client characteristics, it was found that females, Hispanics, users of

heroin only, those with three or more previous drug

abuse treatments, and those who were not heavy

alcohol users were more likely to remain longer in

treatment (149). All the above conclusions were the

product of a multivariate analysis of a carefully

designed prospective study, which further

strengthened the existing evidence.

Other Treatment Correlates--Methadone

maintenance programs differ substantially in their

general program policies regarding dosage,

admission, discharge, readmission, detoxification,

urine testing, take-home privileges, and the provision

of other positive or negative incentives to their

clients. With the exception of dosage, none of these

components have been extensively studied. Overall,

though, it appears the answer is “a qualified yes” that

the above elements do, indeed, affect treatment

outcome (72). With respect to the provision of

incentives, the evidence is neither consistent nor

clear-cut. Stitzer and Kirby in a recent review

reported that both positive incentives (such as takehome privileges) and negative incentives (threat of

treatment termination) “have been shown to promote

abstinence among some proportion of treatment

patients” (285). Since the positive findings are not

valid for all clients, however, the challenge is to

identify and characterize those clients who can

benefit the most from such measures. Similarly,

more research is needed to establish whether and for

whom the various policy components influence

treatment outcomes.

Methadone maintenance programs also differ in

various program characteristics that are part of the

overall treatment environment (e.g., the type, range,

and quality of services provided; the patient-to-staff

ratio; and the staff background, expertise, and attitudes). The dynamic interplay of these factors constitutes what Anglin calls ‘program personality.”

Although these elements are not easily measurable

or quantifiable, they have been found to influence

treatment outcome (13,68). The extent to which

these variables render their influence directly or

indirectly by increasing retention and the duration of

treatment is less clear. Ball’s study of the six

methadone maintenance programs described earlier

provides evidence about the influence of program

characteristics on treatment outcome (21). This

study, despite its cross-sectional nature, suggests the

extent to which differences among treatment programs may result in differences in effectiveness.

Regardless of the initial selection of well-established

methadone maintenance programs with above

average patient-to-staff ratios, there was a wide disparity in each clinic’s ability to decrease drug use.

The proportion of current users while in treatment

varied among the programs from 9.8 to 57.1 percent.

Although it was hypothesized that the most powerful

predictor of success would be patient characteristics,

subsequent analysis suggested that certain program

variables were more closely related to program

success rates. The identified variables were dosage,

retention rates, staff turnover rates, and the closeness

of the relationship between staff and patients.

According to the investigator, the study highlighted

the importance of staff characteristics in influencing

treatment outcomes. Anecdotal evidence from confidential interviews with program personnel also

revealed a relationship between program morale and

treatment effectiveness (21,241a).

Achieving a Drug-Free State--Researchers differ

on what the ultimate goal of methadone treatment

should be. Studies indicate that a drug-free state

may not be a totally realistic goal, at least not for the

majority of the patients, because of relapse (130).

The overwhelming evidence is that the beneficial

effects of methadone are mainly confined to the time

when the client is still in treatment. In a review

primarily of studies of methadone maintenance programs in New York City, which examined the fate of

methadone maintenance clients who had left

treatment or been discharged, the author states that

“a consistent finding is that in NYC it is really hard to
Chapter 4-The Effectiveness of Treatment for Drug Abuse -75

achieve abstinence even for those clients who complete methadone maintenance and detoxify

voluntarily” (130). Even those who have been

favorably discharged face a less than 50 percent

chance of maintaining abstinence for 3 years.

Between 70 and 80 percent of discharged patients

return to illicit opiate use within 1 to 2 years after

leaving methadone maintenance (187,309). A study

by Dole and Joseph, which examined the pattern of

heroin use among patients with at least 3 interrupted

cycles of treatment, found decreases in opiate use

while in treatment, with subsequent increases in

usage after leaving treatment (99).

Stimmel and his colleagues studied 335 former

methadone maintenance clients to determine their

ability to remain abstinent from narcotic use (283).

The subjects were classified according to the reason

that they were detoxified from methadone and left

treatment: 17 percent were considered to have completed treatment, 30 percent were voluntarily discharged, another 30 percent violated the rules, and

24 percent were arrested. The followup rate was 80

percent with approximately 26 months followup time.

At the end of the study period, 35 percent of the followup sample were narcotic-free, 58 percent had

relapsed to narcotics, 4 percent were incarcerated,

and another 4 percent had died. It should be noted

that the mean duration of followup for those who

remained narcotic-free was shorter than for those

who relapsed. Thirty-five percent of relapses

occurred among the group with 3 or more years of

followup. Discriminant analysis was performed to

identify factors associated with drug-free status. The

dominant variable was reason for detoxification, followed by duration of methadone maintenance, and

length of followup. Indeed, of those methadone

maintenance clients that the program staff considered as having realized the full benefit from

methadone maintenance, 83 percent were able to

maintain abstinence, in contrast to 14 to 21 percent

of those detoxified for other reasons.

As to what types of clients are more likely to

achieve the goal of abstinence, researchers have

found the most encouraging results with clients who

are older, who have been stabilized in methadone

maintenance for at least 2 to 3 years, who have

psychological support, and who have demonstrated

less criminality and better social functioning

(13,187,262).

Medical Maintenance

An alternative experimental approach to the traditional daily dispensing of methadone at clinics is

based on the concept of medical maintenance. This .

approach calls for stable, non-drug using, socially

rehabilitated patients to take home as much as a 28-

day supply of methadone from a physician at a

primary care setting. Methadone is dispensed in

tablet form and can be taken on a daily basis by the

patient. The first published evaluation study

examined 40 former heroin abusers who entered the

program after they had met several well-defined

criteria (230). The followup time ranged from 12 to

55 months. These preliminary results showed an

annual retention rate of 94 percent. Overall, 8 of 40

patients (20 percent) relapsed into illicit drug use.

This estimate includes five patients who returned to

traditional methadone maintenance because of

cocaine use. The authors argue that this approach

has benefits for the clients (decreased frequency of

visits and increased self-esteem), as well as for

society (reduced cost and increased availability of

methadone maintenance slots). There are, however,

certain limitations of medical maintenance, probably

the most important of which is the likelihood of

illegal diversion of the large doses of methadone,

whose street value can reach $2,400 for a 28-day

supply (366)?

The medical maintenance concept has the

potential for being a beneficial treatment approach

for some clients. However, there is clearly a need to

replicate the above findings, to address the various

methodological concerns, and, most importantly, to

identify those patients for whom it would be most

helpful.

3 The distribution of methadone, a synthetic opiate, is tightly

controlled by Federal regulations. Methadone may be diverted

into illegal channels because of demand created by people who

seek to control withdrawal symptoms, to detoxify themselves, or

to obtain the pleasant altered state of consciousness that

methadone produces (68a).
76- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

Summary of Methadone Maintenance

Effectiveness

Methadone maintenance has been used to treat

hundreds of thousands of heroin abusers over the

past 25 years in a wide variety of social, economic,

and geographical settings. Its safety and effectiveness have been established in numerous studies

(13,66,68,69,72,170,262). For a substantial majority

of opiate abusers, who enter methadone maintenance, drug use and criminality decrease and

health status improves. On average, three-fourths of

the clients on long-term maintenance cease illicit

opiate use (258).

The consistency of the scientific literature

regarding the safety, efficacy and effectiveness of

methadone is overwhelming, yet some still consider

methadone a controversial treatment modality (299).

Methadone has been criticized for simply substituting

one abuse with another, for not being as beneficial

for cocaine and other drug abuse as it is for opiate

abuse, for not producing a robust improvement in all

the maladaptive behaviors associated with substance

abuse, and for not achieving high enough outcomes

even with regard to opiate use. As stated in NIDA’s

landmark review, although some criticism of

methadone maintenance is warranted, much of it is

not supported by the scientific data (66,72,167).

With the connection between intravenous (IV) drug

use and AIDS, the importance of resolving the issues

of what can and cannot be accomplished with

methadone treatment and how methadone

maintenance’s fullest potential can be achieved is

becoming more prominent.

Two basic distinctions about methadone

maintenance are important for evaluating this

modality. The first distinction concerns the premise

that methadone is a cure or a “magic bullet” for the

drug epidemic as opposed to a pharmacologic substance to counterattack illicit opiate dependence.

The second distinction concerns methadone’s

efficacy as opposed to its effectiveness.

Methadone, a synthetic opiate, can prevent both

drug hunger and opiate withdrawal symptoms for 24

to 36 hours. When administered to tolerant patients,

it causes no euphoria or sedation and in adequate

doses can block the effects of heroin (187). This

property makes methadone a drug-replacement

therapy that allows an “illicit short-acting opiate

administered with needles to be replaced with a legal

long-acting safe, and orally administered substance”

(379). Consequently, methadone “frees the abuser

from the vicious cycle of always chasing a ‘fix’ and

from vacillating between being sick and being high”

(167). Both the individual and society can benefit

substantially from this substitution, with benefits continuing to occur as long as the patient is in treatment.

Because of drug abuse’s chronic relapsing nature,

methadone is frequently compared to insulin therapy

for diabetes and to anti-hypertensive treatments

(224,238,258). This analogy is relevant because it not

only increases understanding of methadone’s role,

but also helps to clarify the way that methadone

should be evaluated. Both hypertension and insulindependent diabetes can be controlled by appropriate

medication. Although some patients may be able to

discontinue insulin or anti-hypertensive treatment at

some point, others, probably the majority, will continue indefinitely on adequate doses of medication to

control their disorders. Accordingly, the effectiveness of their prescribed medications is assessed

while the patient is still in treatment, by measuring

blood sugar or blood pressure. Even with these

treatments, however, not all patients show the same

response to treatment, which can be more or less

successful for certain patients.

The second distinction, between methadone’s

efficacy and effectiveness, also entails important

policy implications. The concepts of efficacy and

effectiveness stem from randomized clinical trial

research. 4 The efficacy of treatment refers to the

observed results of experimental research done

under ideal conditions and circumstances. When an

efficacious treatment is implemented in the real

world, the magnitude of the effect may differ due to

4Efficacy is the probability of benefit to individuals in a defined

population from an intervention applied for a given problem

under ideal conditions of use. Effectiveness, on the other hand,

is the probability of benefit to individuals in a defined population

from an intervention applied for a given problem under average

or actual conditions of use.
Chapter 4--The Effectiveness of Treatment for DrugAbuse -77

contamination from other real life parameters and

inappropriate implementation. This is especially true

for methadone maintenance, whose effectiveness has

been said to vary from 40 to 98 percent (21,299). It is

conceivable that this variability may partially be

attributed to different population characteristics.

The evidence, however, points to non-client related

variables. Ball’s study found that differential effectiveness was related both to length of a patient’s stay

and the quality of provided treatment.

Even an ideal methadone maintenance program

has two distinct yet interrelated components. One is

the administration of the pharmacologic substance,

and the other is the variety of ancillary services that

are offered. Methadone is a synthetic opiate with a

very clear pharmacologic role: to bind to the opiate

receptors, reduce drug craving, and inhibit the occurrence of the painful opiate withdrawal syndrome. On

the other hand, biological and psychosocial vulnerabilities make drug abuse a multi-dimensional

disorder. Drug abuse occurs in people who enter

treatment with a variety of other problems (e.g.,

existing psychiatric and non-psychiatric illnesses and

family, financial, employment, and legal difficulties).

Ancillary services are intended to address these

problems. The goals of methadone maintenance

treatment vary from decreasing illicit opiate use (as a

direct effect of methadone’s action) and related

criminal activity to increasing employment, social

integration, and the quality of life. The extent of a

program’s success depends also on other program

and staff-related variables, patient-related variables,

and societally influenced factors beyond methadone’s

influence.

Ample evidence testifies to the high success rates

of the whole package of methadone maintenance

treatment. With regard to specific treatment components, evidence about the importance of adequate

dosage is particularly strong. Experimental studies

are needed, however, to examine the interaction of

methadone dose with other non-pharmacological

treatment elements, such as take-home policies; frequency of urine testing;, the availability, type, and

intensity of support services, and human factors,

from program management to staff’s attitudes and

qualifications. Random assignment of drug abusers

to different treatment plans within the same modality

seems to be more practical than random assignment

to different modalities (59).

The great variation in success rates suggests that

somewhere in the implementation process, effectiveness may have been compromised. More than

700 methadone maintenance programs operate in the

United States, with great variability in their policies

(13,21,187,299). Foe example, a 1989 survey by the

U.S. General Accounting Office of 24 methadone

maintenance programs revealed that daily average

dosage levels ranged between 21 to 67 mg (299). At

21 of the 24, the average dose was below 60 mg per

day, which according to C. Schuster, the NIDA

Director, “more studies have found to be the lowest

effective dose” (257). Counselor-to-patient ratios

ranged from 1:15 to l:96. Less than one third of the

programs surveyed provided on-site educational and

vocational services (6 and 4, respectively), and only

one program had separate aftercare services. At the

same time, continued heroin use by the patients

ranged from 2 to 47 percent.

These results suggest that in many programs

methadone maintenance does not reach its potential.

This finding also begs the question of whether

scientific evidence guides the operation of these programs. Research findings have produced strong evidence of the importance of adequate methadone

dosage in reducing opiate use. Although increasing

treatment slots and improving the quality of the

existing services are important steps in the battle

against opiate abuse, flexible dosage policies have the

potential to rapidly improve the effectiveness of

methadone maintenance. Administering a sufficiently high dose for methadone to achieve effectiveness assumes particular importance in light of the

HIV epidemic.

Other Pharmacological Agents

Medications can have a substantial effect on the

treatment of drug abuse. Medications can be

administered easily and can complement other

medications, behavior modification, or

psychotherapy. Moreover, they may provide

opportunities to intervene in various stages of the

recovery process in order to prevent relapse.
78- The Effectiveness of Drug Abuse Treatment: Implications for ControllingAIDS/HIV Infection

Naltrexone

Naltrexone blocks the effects of heroin by binding

to the narcotic receptors, but does not produce

euphoric effects and is not addictive (see ch. 3).

Naltrexone can be used as a short-term blockade

agent during the transition from drug use to

abstinence, as an occasional blockade agent for highrisk relapse situations, or as a long-term maintenance

agent to protect against relapse.

In contrast to its efficacy, its effectiveness maybe

more limited. Although naltrexone is an efficacious

pharmacological agent and has been observed to

decrease opiate use and reduce drug craving, it has

not been well accepted by heroin abusers (123,168).

In practice, high dropout rates occur, especially

during the induction period; 40 percent of patients

often discontinue treatment by the end of the first

month (168). This phenomenon may result partly

from naltrexone’s producing opiate withdrawal if the

client has used heroin within the last 3 to 7 days (35).

Depending on the type of patient and the level of

support, average retention rates range from 1 to 6

months or longer (168). Higher retention rates have

been found for health professionals and business

executives, for whom success rates as high as 75

percent have been reported (168). The common

denominator of success appears to be a highly

motivated patient with family support. Strategies to

improve compliance with naltrexone, such as individual and group counseling, family therapy, and contingency contracting are discussed in more detail in

a review by Kosten and Kleber (180).

To realize naltrexone’s potential, further efforts

are needed to “demonstrate the range of patients for

which the drug is best suited, and the setting and supportive approaches that should be administered”

(168). Another promising option for enhancing

naltrexone’s effectiveness is the current development

of its administration in a depot form (i.e., skin

implants that gradually release the drug into the

bloodstream) (238). Such an approach might extend

the drug’s action and require less frequent administration.

Levo-Alpha-Acetyl-Methadol (W)

Like methadone, LAAM is a narcotic agonist

intended to occupy the narcotic receptors, prevent

withdrawal symptoms, and block heroin effects. The

main difference between the two drugs is that

LAAM is longer acting and can be administered just

3 times a week instead of daily, thus reducing the

need for take-home methadone and the likelihood of

diversion (121). NIDA has recently awarded a contract to Biometrics Research Institute to sponsor

LAAM to the Food and Drug Administration for

marketing approval (see ch.3) (35). Patient acceptance of programs administering LAAM and

retention rates (varying from 17 to 77 percent),

however, are a problem. Abuse patterns, possible

metabolic differences, and patient lifestyles and

treatment expectations (e.g., some clients may need

daily contact with the clinic, while others may find it

annoying and disruptive) may play a role in overall

effectiveness (121,164,290). Thus, methadone and

LAAM may not be equivalent interventions for all

heroin abusers. This reality underscores the importance of further research to identify those patients

for whom each agent is more appropriate and to

match them accordingly.

Pharmacotherapies for Cocaine Abuse

Several medications under development or in the

early stages of testing may assist the treatment of

cocaine abuse. In fact, the latter category includes

certain drugs already used to treat other disorders,

especially depression.

The potentially useful drugs for cocaine abuse are

employed to ameliorate cocaine-associated

anhedonia, depression, or craving. Some clinical

studies have found that certain currently used antidepressants decrease cocaine craving and depression,

thus facilitating the abstinence process. The most

promising drugs so far are the tricyclic antidepressants desipramine and imipramine

(114,115,117). Another drug that may reduce withdrawal distress and craving is bromocryptine, a drug

used to treat Parkinson’s disease (106). Bromocriptine works faster than desipramine, but wears off

more quickly. This pattern suggests that

bromocryptine may be more effective in the early

phases of withdrawal, while desipramine may be

more helpful in the later stages of cocaine abstinence

(106).

Although initial results are promising, thorough

scientific evaluations, with randomized placebocontrolled double blind studies and longer followup
Chapter 4--The Effectiveness of Treatment for Drug Abuse -79

times, are necessary to establish efficacy and to

identify groups that are most likely to benefit.

Combined Therapy for Heroin and

Cocaine Abuse

A potentially helpful drug for treating the dual

abuse of heroin and cocaine is buprenorphine (see

ch. 3). This drug is a partial opiate agonist, that is, it

has a diminished opiate effect compared with full

agonists, such as methadone. Its slow onset entails a

minimal risk of overdose and minimal withdrawal

(35). It produces a generalized feeling of contentment and has been used effectively to detoxify

heroin abusers (181,259). In addition, buprenorphine has the potential to facilitate the transition

from opiate abuse to drug-free status, naltrexone, or

methadone maintenance (310). During clinical

studies, buprenorphine seemed to decrease cocaine

use among opiate users (181). Results from another

study of daily administration of buprenorphine to

rhesus monkeys that were self-administering cocaine

showed that cocaine use was suppressed during the

daily administration of buprenorphine (211).

Summary of the Effectiveness of Other

Pharmacotherapies

Despite the potential that pharmacotherapies

other than methadone hold for drug abuse

treatment, their promise has not fully materialized.

Further research is needed to show how these

pharmacotherapies can be used in appropriate ways

as adjunct to longer term treatment. Many of these

promising medications are currently undergoing

controlled clinical trials. It is imperative that evaluations be conducted to establish not only their efficacy

but also their effectiveness in actual treatment

environments.

Therapeutic Communities (TCs)

Transmission of HIV infection is not confined to

IV heroin use. Sharing of injection equipment

regardless of the choice of drug (heroin, cocaine,

amphetamine) and crack-related high-risk sexual

behaviors all relate to HIV spread. Treatment in

TCs does not target specific drugs of abuse; rather it

aims at a complete behavior change and a drug-free

lifestyle. Thus, TCs have the potential to contribute

to efforts to prevent HIV infection among the populations they serve.

Information on the effectiveness of TCs comes

primarily from two national evaluation studies

(DARP and TOPS) and program-specific evaluations

conducted mainly by De Leon (76). This section

presents separately the findings for each study. All

the evaluations reviewed here involve TCs with

planned durations of stay exceeding 12 months.

Program-Specific Studies

In the early 1970s, a series of evaluation studies

were conducted at Phoenix House, the largest TC in

the country. Two cohorts, one admitted in 1970-71

and the other in 1974, were followed to examine

treatment effectiveness. The majority, 85 percent, of

the admitted population of the 1970-71 cohort were

heroin abusers, while 53 percent of the 1974 cohort

abused heroin. These proportions reflect the predominance of heroin as the primary drug of abuse

during the 1970s and the changing patterns of drug

use in the middle of the decade. The early cohort

was followed for 5 to 7 years, and the second cohort

(1974) was followed for 2 years. Followup rates of

the original samples were 80 percent (76,80). The

outcome measure was absolute success throughout

the years of followup (not at year of followup like

other studies), defined as self-reported achievement

of total abstinence from drugs and no criminal

activity, a rather stringent criterion.

Tables 4-5 and 4-6 present the findings for

program graduates and dropouts, respectively,

according to the type of drug and time spent in

treatment. After two years of followup, 95 percent of

the 1970 cohort and 90 percent of the 1974 cohort

program graduates were abstinent from opiates and

had no involvement with criminal activity. When

Table 4-5--Percent Success Among Program

Graduates, Phoenix House

Percent Successa

Cohort Years to followup Opiates All drugs

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . 2 95 89

. . . . . . . . . . . . . . . . . . . . . . . . . . 5-7 (mean = 6.4) 79 75

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . 2 90 68

aDefined as self-reported achievement of total abstinence from

drugs and no criminal activity. The traditional period of TC

treatments is 18 to 24 months.

SOURCE: De Leon (76); De Leon and Jainchill (82); and De

Leon, Wexler, and Jainchill (84).
80- The Effectiveness of DrugAbuse Treatment: Implications for ControllingAIDS/HIV Infection

Table 4-6--Percent Successa Among Program

Dropouts, Phoenix House

Months in treatment

Cohort Years to followup < 12 > 1 2

1970 . . . . . . . . . . . . . . . . . . . . . . . . . 3-6 (mean = 4.7) 17 42

1974 . . . . . . . . . . . . . . . . . . . . . . . . . 2 25 52

aDefined as self-reported achievement of total abstinence from

drugs and no criminal activity.

SOURCE De Leon (76); De Leon and Jainchill (82); De Leon,

Wexler, and Jainchill (84).

non-opiate drugs are taken into account, 89 percent

of the 1970 cohort and 68 percent of the 1974 cohort

were successes. After a mean of 6.4 years of followup of the 1970 cohort graduates, the success rate

for those whose primary drug of abuse was heroin,

was 79 percent, while it was 75 percent from all graduates regardless of the primary drug of abuse. The

results for those who did not complete treatment

(dropouts) according to the time they spent in

treatment are shown in table 4-6. The mean followup time was 4.7 years for the 1970 cohort

dropouts and 2 years for the 1974 cohort dropouts.

For the earlier cohort, the success rate at followup

for those who remained in treatment fewer than 12

months was 16 percent, compared with 42 percent

for those in treatment at least 12 months. Similarly,

of the 1974 cohort 25 percent who spent fewer than

12 months in treatment v. 52 percent of those who

spent at least 12 months in treatment remained successful 2 years after dropping out of the program.

Multiple regression analysis of the data found that

time in treatment was the most significant predictor

of success (76,77,79,84,89).

DeLeon also conducted an extensive review of

the literature on the effectiveness of TCs. The

review examined studies that varied considerably in

study design, sample size, length of followup, and

degree of sophistication in the data analysis (75).

DeLeon concluded that all studies showed consistent

findings with regard to treatment effectiveness. Drug

use and criminal behavior decreased, while social

functioning (employment or school involvement)

increased. Consistent results pointed towards significant improvements on most psychological scales

during treatment and followup. Self-esteem, ego

strength, socialization, and depression scores all

improved, although they did not reach normal,

healthy levels (75,78). Furthermore, those studies

that compared program graduates with program

dropouts found significant positive differences on all

outcomes for those completing the planned duration

of treatment.

DARP Study

The reported findings from this large-scale

national evaluation pertain to white and black males

only. It should also be noted that these outcomes

pertain to all clients who were admitted to treatment

regardless of the length of time they spent in

treatment. The outcome measure was daily opiate

use and is reported for the 2 months before entering

treatment and during the first and third year posttreatment. Table 4-7 presents the findings.

Although the prevalence of daily opiate use was 100

percent before treatment in TCs, it dropped to 39

percent during the first year after treatment and

dropped further to 26 percent during the third year

post-treatment. The prevalence of any lifetime arrest

Table 4-7--Percent Self-Reported Opiate Use, Criminal Activity, and Employment by Malesa in

Therapeutic Communities, DARP

Category Pre-treatment periodb During 1 year after treatment During 3 years after treatment

Daily opiate use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 39 26

Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 33 23

Incarceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 33 32

Employment half-time or more . . . . . . . . . . 20 61 68

a

Statistics refer only to white and black males. b The Pre-treatment periods varied: 2 months for opiate use, lifetime for arrest and incarceration, and previous 12 months for

employment.

cAverage followup rates were 79 percent for cohorts admitted from 1%9 to 1971 and from 1971 to 1972 and 69 percent for the cohort

admitted in 1973 to 1974.

SOURCE Simpson and Sells (272).
Chapter 4--The Effectiveness of Treatment for Drug Abuse -81

or incarceration was 95 percent and 62 percent,

respectively, among clients entering treatment.

These arrest and incarceration rates were reduced to

23 and 32 percent, respectively, during the third year

after treatment. The rate of incarceration was higher

than the rate of any lifetime arrest during the third

year. This may be a reflection of no new arrests for

some abusers during that year, at the same time that

some may have been in jail serving time from arrests

in previous years. The proportion of clients who

were employed half-time or more at baseline (previous 12 months) was 20 percent. During the third

year after treatment the proportion more than

tripled to 68 percent (272).

TOPS Study

Drug Use--The results for drug use are reported

separately for heroin and cocaine (see table 4-8).

These results pertain to those who stayed in

treatment at least 3 months. By the end of the third

month, however, 56 percent of the TC clients discontinued treatment. The median time spent in

treatment of the total TC sample was 11 weeks

(147,149,150). The findings from those who

remained fewer than 3 months are similar with

respect to heroin use to those who stayed 3 months

or more. With regard to cocaine use and criminal

activity, however, those who spent fewer than 3

months had worse results than those who remained

more than 3 months (149).

One year before treatment, the prevalence among

TC clients of heroin use was 30.9 percent and

cocaine use was 27.6 percent. After 3 to 5 years of

followup, the numbers of regular heroin and cocaine

users (weekly or daily use) decreased about two

thirds to a prevalence of 11.8 and 9.6 percent, respectively. These improvements are also reflected in the

l-year abstinence rate, Of those using heroin l-year

prior to treatment, more than 50 percent ceased

using it the year after treatment; the equivalent

figure for cocaine was 47 percent. The overall

improvement rate (those who either stopped or

decreased use during the year after treatment) for

those who remained in treatment for at least 3

months was 70 percent for heroin and 68 percent for

cocaine.

Criminal Activity--More than half of the

residential clients of TCs (60 percent) were involved

in some kind of criminal activity in the year prior to

treatment (table 4-8). This proportion plummeted to

3.1 percent while in treatment, increased gradually to

2$.9 percent at 1 year after treatment, and dropped

again to 19.8 percent at the 3- to 5-year followup. Of

those who engaged in criminal activity during the

year prior to treatment, 75 percent had not been

involved in criminal activity during the year after

treatment.

Employment--Only a small proportion (15.3

percent) of the clients entering residential TC

treatment were employed full-time the year before

entry (table 4-8). The proportion of full-time

employed clients more than doubled immediately

after treatment, and although it fluctuated subsequently, it stabilized at 38.7 percent at

year followup (approximately 2.5 times

originally).

the 3- to 5-

higher than

Table 4-8-Percent Self-Reported Drug Use, Criminal Activity, and Employment

by Therapeutic Community Clients Treated at Least 3 Months, TOPSa

Year before 3 months 3-month l-year 2-year 3-5 year

Category treatment in treatment followup followup followup followup

Regular heroin useb........... . . . . . . . . . . . . . . . . . . . . 30.9 0.3 10.7 11.5 13.2 11.8

Regular cocaine use.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.6 0.1 12.9 15.5 8.0 9.6

Serious predatory crime . . . . . . . . . . . . . . . . . . . . . . . . 60.9 3.1 25.2 28.9 24.0 19.8

Full-time employment . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.3 2.2 35.8 27.7 20.9 38.7

ABBREVIATION: NA = not available

aNo statistics on followup rates for clients treated at least 3 months were presented. For all those in therapeutic communities, regardless

b of the duration of treatment, followup rates ranged from 81 percent for 3-months followup to 65 percent for 3-5 year followup.

Weekly or more frequent use.

SOURCE: Hubbard, Maraden, Rachal, et al. (149).
82- The Effectiveness of DrugAbuse Treatment: Implications for Controlling AIDS/HIV Infection

Time in Treatment and Outcome--Several studies

that examined “time-in program” factors have been

reviewed by DeLeon and Anglin (13,75,77). Although

the magnitude of the effect of time in treatment

varied across studies, few studies failed to

demonstrate a positive effect. The authors concluded that time spent in treatment was the most

powerful predictor of a favorable outcome (13,77,82).

It should be noted, however, that establishing the

causal link between time in treatment and treatment

effectiveness is methodologically a formidable task.

Factors external to treatment that influence the

natural history, such as self-selection and motivation,

can confound the results by contributing to observed

outcomes.

One of the more methodologically sound studies

that attempted to overcome these limitations was

conducted by Holland in 1983 (144). The study

sample consisted of 400 former residents of Gateway

House, a TC in Illinois with a planned duration of

treatment of 2 years. Three admission cohorts were

included according to the year of first admission to

the facility (1968-1970, 1970-1972, and 1972-1974).

The subjects were further classified into four groups

according to the time spent in the program (fewer

than 3 months, fewer than 9 months, more than 9

months but not treatment completion, and graduation from treatment). To measure treatment effectiveness, composite indexes were constructed for the

following outcome measures: drug use, alcohol use,

criminality, employment, and social stability. Data

analysis was performed in two stages. The initial

analysis examined changes in the outcome criteria

between baseline and followup. Post-treatment

improvements in all areas except alcohol use were

observed for all four groups. The degree of

improvement increased with increasing time in

treatment. In the second stage, the investigator

attempted to evaluate alternative hypotheses that

could have explained the observed treatment effects.

Multiple regression analyses and time-series analysis

examined the validity of several rival hypotheses: an

interaction between maturation and selection; differences in time between discharge and followup

among the four groups; differential followup completion rates for the above groups, and differential

validity of the self-reported data. The conclusion of

the study was that, “data probes revealed that, in

general, time in program was the single best predictor of post-treatment outcome and that the data

failed to support the rival hypotheses” (144).

Data from the TOPS study were also analyzed

through multivariate regression analysis to examine

factors associated with the observed outcomes and

behaviors. These independent variables consisted of

sociodemographic measures, prior treatment

episodes, sources of referral, pre-treatment drug

abuse patterns, treatment durations, and subsequent

treatments. The analysis of these data (shown in

table 4-9 supports the conclusion that for heroin

abusers, time spent in treatment was the primary

factor associated with treatment effectiveness.

Table 4-9--Odds Ratios for Post-Treatment Outcomes in the First Year After Residential Treatment, by

Treatment Duration, TOPS

Time spent in treatment

Comparison group

1-13 weeks 14-26 weeks c 1 week 27-53 weeks >52 weeks

Outcome n=6 0 n = 325 n = 137 n = 95 n = 114

Regular heroin useb

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 0.69 0.43 052 0.28C

Regular cocaineb

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 0.98 1.04 O.85 0.38

Predatory crimes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 1.07 0.61 0.43C

0.29d

Full-time employment . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 0.57 0.87 0.90 2.65e

a Self reports from 731 of the 1,282 clients who were sampled for followup.

Weekly or more frequent use.

>< .0s

p <.001

e p <.01

SOURCE: Hubbard, Marsden, Rachal, et al. (149).
Chapter 4--The Effectiveness of Treatment for Drug Abuse -83

Overall, positive results were more likely to be

achieved by those who remained in treatment for

more than 52 weeks. Clients who spent more than 52

weeks in treatment compared with those who left

prematurely within the first week were 72 percent

less likely to use heroin, 70 percent less likely to be

involved in criminal activity, and 165 percent more

likely to be fully employed. Although they were also

60 percent less likely to use cocaine, this difference

did not reach statistical significance (149).

Dropout Rates--Although people treated in TCs

have successfully achieved a variety of positive outcomes in addition to reducing drug use, their overall

impact is severely impaired by their limited ability to

keep clients in treatment, either for the whole

planned duration or for a time sufficient for

treatment to exert some positive influence. Research

shows that clients leave treatment prematurely for

both personal and program-related reasons (79).

This difficulty retaining clients is certainly related to

the rigorous, demanding, confining, and confrontational nature of treatment in the TC environment.

There is a consistent temporal pattern of

dropping out of TCs. A compilation of studies

showed that the sharpest dropout rate occurs during

the first 30 days after admission, during which 35 to

50 percent leave. The dropout rate continues to

increase further, so that by the end of the third

month into treatment, the cumulative dropout rate

ranges from 50 to 70 percent. Thereafter, the rate of

leaving treatment slows. The retention at 1 year is

between 15 and 25 percent, and actual completion

rates range from 10 to 15 percent. Recent reports

indicate that there was an improvement in retention

rates in the latter part of the 1980s (79). Although it

is hard to identify the exact reasons for such an

improvement, it is speculated that the improvement

may be partially attributed to client characteristics

(e.g., an aging opiate-users cohort, fear of relapsing

into cocaine and crack abuse) and improved staff

training (79).

Predictors of Retention--Research on predicting

retention and identifying client attributes that

influence retention in TCs has not been particularly

informative, with a few possible exceptions (75,79).

A distinct client profile does not seem to exist;

however, client variables such as severe criminality

and psychopathology do appear to be negatively

associated with retention. Factors such as personal

motivation (intrinsic pressure), readiness (one’s perceived need for assistance to change), and suitability

(the appropriateness of the client-treatment match)

may influence the decision not only to enter but also

to remain in treatment as well (156). Data from

TOPS indicated that older clients, those who were

not married at the time of treatment, those who were

not depressed at entry into treatment, and those who

were referred by the criminal justice system were

more likely to remain longer in treatment (149) In

addition to the influence of client characteristics on

retention, it has been suggested that program parameters related to quality (e.g., staff composition,

experience, and administration) might play a role,

but these factors have not been fully evaluated. De

Leon noted that although there are limitations in

prediction studies, “Psychological, motivational, perceptual and other ‘dynamic’ variables appear more

relevant to retention, than do ‘freed’ variables such as

demography, drug use pattern, and family background” (79). An ongoing NIDA-funded study,

which uses an experimental design to examine the

effect of three interventions on modifying early

dropout from a TC, has shown some encouraging

results (79).

Summary of TC Effectiveness

The substantial improvements among drug

abusers who continue in TCs and the persistence of

these changes years after treatment are consistent

with TCs’ effectively reducing drug use, at least

among those who commit themselves to complete

the whole course of treatment. It is noteworthy,

however, that, a sizable minority of dropouts, 30 to

35 percent, also appear to be successful during the

followup period (76). Of all those admitted to

treatment, regardless of time in treatment, 30

percent achieved absolute success (no drugs, no

crime), with improvement rates ranging from 50 to

60 percent (76,81). Success rates do not vary considerably (no more than 15 percent variation) among

specific programs (80). In judging these results, one

should keep in mind that the program-specific

evaluations probably were performed in the more

research-oriented programs that had the drive and
84- The Effectiveness of DrugAbuse Treatment: Implications for Controlling AIDS/HIV Infection

capability to evaluate themselves. Program-specific

results might therefore show higher effectiveness

rates than would those present in the average TC

facility. On the other hand, results from the national

studies are averages over several programs that may

also include some shorter term or modified

residential programs (149). These results may

therefore dilute the effectiveness of the more traditional, homogeneous, and higher quality programs.

It should be noted that these high success rates

were observed among abusers who completed

treatment in TCs. Although real improvements are

also seen among clients who spent some time in

treatment but left prematurely, the self-selection of

clients remaining in treatment may directly influence

the direction and the size of the observed beneficial

effect of treatment (242). It should be further noted

that the likely cumulative effect of time in treatment

relates mostly to heroin use.

It is indeed a severe limitation of the TCs that

only a small minority of their clients remain in

treatment long enough to realize the associated

benefits (10 to 15 percent of those admitted).

Whether these highly motivated individuals would

attain the same improvements in the absence of the

specific intervention is unclear. It should also be

noted that TOPS data showed that TC residents

were characterized by greater problem severity

among m any dimensions, including more

involvement with multiple drug abuse (149). These

factors may influence retention and contribute to

high drop-out rates.

Factors that influence retention other than client

characteristics (e.g., treatment environment variables) should also be identified. Efforts should be

made to identify those patients for whom this structured residential program would be most beneficial.

Increasing retention rates in TCs might play a significant role in reducing the use of drugs and associated crimes.

Finally, although the effectiveness of the traditional TCs has been evaluated, the same cannot be

said for the shorter-term residential programs. As

yet no studies have evaluated the effectiveness of the

21-day, 30-day, or 6-month residential programs.

Outpatient Drug-Free (ODF) Programs

Data regarding the effectiveness of outpatient drugfree (ODF) programs are sparse and stem primarily

from the two large-scale national multi-modality

studies (DARP and TOPS) that included ODFs in

their evaluations. It should be kept in mind that the

reported effectiveness of ODFs pertains to an

amalgam of centers, a diverse collection of programs

with little uniformity, whose common denominator is

their drug-free philosophy and outpatient nature. As

mentioned in chapter 3, ODFs usually provide some

or all of the following services: counseling therapy,

education, ancillary services, and a 12-step program.

These services are not dependent on the type of drug

of abuse.

DARP Study

Pre-treatment and 1- and 3-year post-treatment

outcomes for opiate addicts with respect to daily

opiate use, employment, and criminality of ODF

clients are presented in table 4-10. These findings

Table 4-10-Percent Self-Reported Opiate Use, Criminal Activity, and Employment by Malesa

in Outpatient Drug-Free Treatment, DARP

Category Pre-treatment periodb During 1 year after treatment During 3 years after treatment

Daily opiate use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 44 28

Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 34 22

Incarceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 34 36

Employment half-time or more . . . . . . . . . . 24 52 66

a Statistics refer only to white and black males.

The pre-treatment periods varied: 2 months for opiate use, lifetime for arrest and incarceration, and previous 12 months for

employment.

cAverage follow-up rates were 77 percent for cohorts admitted to treatment from 1%9 to 1971 and from 1971 to 1972 and 70 percent for

the cohort admitted from 1973 to 1974.

SOURCE: Simpson and Sells (272).
Chapter 4--The Effectiveness of Treatment for Drug Abuse -85

pertain to white and black males only and refer to all

clients admitted to treatment. Daily opiate use

declined from 100 percent prior to treatment to 44

and 28 percent 1 and 3 years after treatment, respectively. The proportion of those who were employed

half-time or more rose from 24 percent at baseline to

53 percent during the third year after treatment.

Both measures of criminality also improved: any

arrest declined from 87 percent to 22 percent during

the third year post-treatment, and arty incarceration

dropped from 62 to 32 percent at the same time

interval (272).

TOPS Study

Table 4-11 shows the TOPS findings relating to

ODF programs with respect to drug use, criminality,

and employment. These findings refer to those who

spent at least 3 months in treatment (149). By the

third month, nearly 64 percent of the clients had

either dropped out, transferred, or completed

treatment; the median time spent in treatment for

the total ODF sample was 7.9 weeks (149,150). For

people who spent fewer than 3 months in treatment,

the magnitude of the observed improvement in all

three outcome measures was smaller than the

improvement observed among those who remained

in treatment more than 3 months.

Drug Use--The prevalence of heroin and cocaine

users among ODF clients was small; however, within

this group both heroin and cocaine use decreased.

Among those who entered ODF programs, 8.6

percent used heroin and 12.8 percent used cocaine

regularly (weekly or more frequently) the year before

(the majority of clients were using marijuana and

prescription drugs) (149). The prevalence of regular

users of both drugs declined by half at the 3- to 5-

year followup to 4.6 and 5.6 percent, respectively, for

heroin and cocaine. Because of the relatively small

numbers of heroin users, abstinence and

improvement rates could not be calculated.

Measurement of abstinence and improvement rates

were possible for cocaine users who remained in

treatment at least 3 months. Of those who used

cocaine regularly during the year before treatment

and who stayed in treatment at least 3 months, 42

percent ceased use the year following treatment

(abstinence rate), and a total of 77 percent either

stopped use completely or decreased it during the

year after treatment (improvement rate).

Criminal Activity and Employment--During the

year preceding treatment, 33.5 percent of ODF

clients were involved in a predatory illegal act (149).

This proportion declined to 7.6 percent at the 3- to 5-

year followup. Similar improvement was observed

among ODF clients with respect to full-time

employment. Although 27.1 percent were fully

employed 1 year before treatment, almost twice as

many (49.7 percent) were fully employed 3 to 5 years

after treatment. These improvements are reflected

in the abstinence rate for illegal activity (for those

who spent at least 3 months in treatment). Almost

two-thirds of the clients reporting illegal acts the year

prior to treatment had eliminated their criminal

involvement the year after treatment. Similarly,

more than one-third (35 percent) of those who were

not fully employed the year before treatment had

engaged in more weeks of full-time employment in

the year after treatment.

Table 4-1 l-Percent Self-Reported Drug Use, Criminal Activity, and Employment by Outpatient DrugFree Clients Treated at Least 3 Months, TOPSa

Year before 3 months in 3-month l-year 2-year 3-5 year

Category treatment treatment followup followup followup followup

Regular heroin Useb

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6 3.0 5.1 4.9 4.9 4.6

Regular cocaine Useb

. . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.8 3.5 9.0 8.1 2.9 5.6

Serious predatory crimes . . . . . . . . . . . . . . . . . . . . 33.5 9.4 11.0 18.7 14.5 7.6

Full-time employment . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.1 36.0 38.2 ‘ 385 39.4 49.7

ABBREVIATION: NA = not available

aNo statistics on followup rates for clients treated at least 3 months were presented. For all those in outpatient drug free programs,

regardless of the duration of treatment, followup rates ranged from 84 percent for 3-month followup to 65 percent for 3-5 year followup.

Weekly or more frequent use.

SOURCE: Hubbarrd, Marsden, Rachal, et al. (149).
86- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

Dropout Rates--Although perhaps to a lesser

degree, outpatient drug-free programs suffer from

the same drawback as TCs, namely a limited ability

to retain clients in the program for the planned

duration of treatment. The TOPS data showed that

within a week or less, 21 percent, and by the end of

the first month, 36 percent had dropped out

(147,149,150). By 3 months, approximately 64

percent of the clients had either dropped out, transferred, or completed ODF treatment. Overall,

longer stays of treatment were related to factors such

as older age, female sex, education beyond high

school, criminal justice referrals, and no heavy

alcohol use (149,150).

Treatment Duration and Outcome--A multivariate analysis of the TOPS data examined the

effect of treatment duration on various outcome

measures (table 4-12). In contrast with the other

modalities, the analysis indicated that length of

treatment was a statistically significant predictor of

both criminal activity and full-time employment, but

not of heroin or cocaine reduction (149). Those who

stayed in the program more than 26 weeks were half

as likely to be involved in illegal activity, and almost

twice as likely to be fully employed than those with

less than l-week attendance. Client population characteristics (better educated, most likely to be first

treatment episode) or the absence of a real length of

treatment effect may account for the observed lack of

an association between time in treatment and lower

heroin and cocaine use.

Summary of ODF Effectiveness

Interpretation of treatment results of the ODF

programs is hampered by the lack of uniformity

among ODF programs. Based on the DARP evidence, Anglin and Hser in their review stated that

although the ODF modality appeared to be as

effective as the other modalities, the number of

clients served was usually small, and the most

favorable outcomes were observed among those

clients who used opiates less than daily, usually

together with other drugs, or who used only nonopiates (13). The more recent TOPS data suggest

lower drug use and other favorable outcomes for the

drug users treated in this modality. However, direct

comparison with the other modalities may not be

appropriate because of the self-selection of patients

to each modality and the subsequent differences

among the client populations. The investigators

suggest that clients attracted to ODF treatment are

people with less severe problems and better societal

functioning who may be more amenable to change

(149). Positive outcomes for those who remained in

treatment for at least 3 months were reflected in the

improvement rate for cocaine (77 percent of regular

users in the year before treatment who ceased or

reduced drug use the year after treatment) and the

levels of employment (a doubling of the pretreatment proportion at the 3- to 5-year followup)

(149).

Although the drug use, criminal activity, and

social productivity, of those in ODF programs

improve at least for the specific and selective client

Table 4-12-Odds Ratios for Post-Treatment Outcomes in the First Year After Outpatient Drug-Free

Treatment, by Treatment Duration, TOPS

Time spent in treatment

Comparison group

< 1 week 1-13 weeks 14-26 weeks >26 weeks

Outcome n = 183 n= 344 n = 165 n = 162

Regular heroin use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 1.03 1.43 0.35

Regular cocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 1.14 1.15 0.76

Predatory crimes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 0.73 0.63C

0.47d

Full-time employment . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.00 0.90 1.35 1.95C

a Self reports from 854 to 1,449 clients who were sampled for followup.

Weekly or more frequent use.

<.0 5

p c .01

SOURCE: Hubbard, Marsden, Rachal, et al. (149).

.
Chapter 4--The Effectiveness of Treatment for DrugAbuse -87

population they serve, more needs to be learned with

respect to the diversity among ODF programs and

their clients. Furthermore, because studies of ODF

programs, unlike those of methadone maintenance

and TCs, have not documented treatment content,

conclusions about ODFs maybe more tentative.

Organizational and structural elements that may

contribute to treatment effectiveness are not clearly

known.. To this end, program-specific research that

takes into account program content may shed light

on ODF effectiveness. This knowledge, while currently limited, is of extreme importance because of

the potential that outpatient programs hold for a

more cost-effective provision of drug abuse

treatment.

Results Combining Treatment Modalities

Some studies report overall treatment effectiveness without distinguishing among treatment

modalities. These studies are summarized below.

In a carefully designed prospective study,

McLellan and colleagues examined the effect of substance abuse treatment on several outcomes,

including alcohol and drug use and the use of

medical, legal, employment, family, and psychiatric

support services (209). They compared a group of

225 mostly heroin abusers with a comparable group

of 57 abusers who received fewer than 15 days of

treatment. The followup time was 6 months.

Admission and followup data were based on the

addiction severity index, a standardized instrument

based on self-reported data from a 30- to 40- minute

clinical interview. This useful diagnostic tool, whose

reliability and validity have been demonstrated,

measures problem severity in six areas (i.e., medical,

legal, employment, family, psychological, and substance abuse) and yields a 10-point rating of the

above dimensions (208). The treatment programs

included a methadone maintenance clinic, a shortterm 45-day intensive therapy group based on Narcotics Anonymous principles, and a 60-day drug

abuse rehabilitative program offering a variety of

ancillary services. Assignment to a program was

based on a combination of personal preference,

clinical judgment, and chance. Overall, 13 percent of

the drug abusers dropped out of treatment, but the

dropout rates did not differ significantly among the

various programs (209).

The investigators stated that the observed positive

findings pertained to all of the above programs. The

results for the treated group suggested major

improvements in most areas, notably a decrease in

the average days of opiate use (in the past 30 days)

from 13 to 3 days and increased employment days (in

the past 30 days) from 3 to 10 at the time of the 6-

month followup. In addition, the comparison of the

two samples revealed significantly better posttreatment outcomes and larger treatment effects

across all seven outcome dimensions.

Kosten and his colleagues at the Substance Abuse

Treatment Center of the Connecticut Mental Health

Center followed 150 opiate abusers for 2.5 years

(183). Their facility included inpatient detoxification,

methadone maintenance programs, a naltrexone outpatient program, and a therapeutic community

program. The patients were assessed at admission

and at followup with the addiction severity index, At

the 2.5 year followup, significant improvements had

occurred in drug use and legal and psychological

problems. At admission, the mean days of opiate use

were 23.7 in the last 30 days, which after 2.5 years

dropped to 4.9 days, a statistically significant difference. Likewise, the mean number of crime days

declined from 14 to 3.8, and the mean number of

anxiety days declined from 11.7 to 5.8 (both of the

above improvements were statistically significant).

The investigators of the DARP study presented a

comprehensive summary across treatment modalities

of a 12-year followup of a sub-sample of the stratified

random sample of 4,107 patients who were selected

for the 6-year followup study (270). This sub-sample

comprised 490 patients who were all daily opiate

users at the time of admission. Daily opiate use

decreased from 100 percent to 28 percent at the 3-

year followup and decreased further to 24 percent at

the 12-year followup. Although nonopiate use initially declined from 55 percent to 35 percent at the 6-

year followup, this trend was reversed to 47 percent

at the 12-year followup. Since greater use of cocaine

accounted for this increase, clients may have been

substituting cocaine for heroin use. Similarly, the

employment pattern fluctuated during these years of

followup from 36 percent of clients reporting 6 or

more months of employment pre-DARP to 61

percent at year 3 and 54 percent at year 12. Finally,

criminal involvement, measured as percent with any
88- The Effectiveness of DrugAbuse Treatment: Implications for Controlling AIDS/HIV Infection

arrest, decreased steadily from 87 percent pre-DARP

to 22 percent and 13 percent at the 6- and 12-year

followups, respectively.

Acupuncture

It has been suggested that acupuncture can serve

as an alternative mode of drug abuse treatment

(275). Acupuncture for drug abuse treatment

involves the insertion of three to five special needles

under the surface of the external ear for a period of

time, a process that can be performed on an outpatient basis. Proponents of this technique claim

that it can control withdrawal symptoms and drug

craving and reduce the fears and hostilities that are

usually present in traditional drug abuse treatment

settings (275).

Advocates view acupuncture as an adjunct

treatment during detoxification. It is further considered to be only one component of drug abuse

treatment, which includes such activities as daily

urine testing, counseling, participation in Narcotics

Anonymous, and educational and employment

referrals (275).

l-he efficacy and effectiveness of acupuncture in

treating drug abuse, however, have not been established (368). Recently, in 1989, encouraging results

were reported from a placebo-controlled study with

regard to treatment of alcoholism (43). Eighty subjects described as severe recidivist alcoholics were

randomly assigned to a treatment (acupuncture at

specified ear points) and a control group

(acupuncture at non-specific ear points). Treatment

duration was 8 weeks, and followup time was 6

months, with a followup rate of 77.5 percent.

Retention and program completion differed significantly between the two groups, with 21 of the 40

patients in the treatment group and only 1 of the 40

in the control group completing treatment. At the 6-

month followup, control patients had more than

twice the number of drinking episodes and admissions to a detoxification center.

Additional research is needed to provide conclusive evidence about. the short- and long-term

effectiveness of acupuncture in treating drug abuse.

Randomized controlled studies seem to be a feasible

option in the evaluation of this technique. Further,

studies could be done on a blinded basis, since a

sham acupuncture process can be used as a placebo,

while all drug abuse clients receive the other

treatment elements.

Parameters Related to Treatment Outcome

Almost all of the studies that evaluated treatment

effectiveness also examined whether other factors

related to clients or programs influenced treatment

outcomes. This distinction may overlook possible

interaction between these sets of variables. Proving

that a certain factor relates to-treatment outcome is a

very challenging methodological endeavor, even for

the most soundly designed studies. Even if there

were no interactions among variables, it would be

difficult to dissect their contributions due to the lack

of a strict experimental setting and procedures. One

of the most problematic factors of abuse research is

clients’ self-selection of treatment modalities, which

has a profound potential to confound the findings of

any study that does not use random allocation to ,

treatment. Despite these problems, the strength and

consistency of the evidence provided and reproduced

by a variety of studies, especially those employing

prospective designs and sophisticated analysis, may

overcome some of these limitations. The following

section describes some additional characteristics in

addition to those highlighted earlier in the modalityspecific research.

Patient Characteristics

A spectrum of individual characteristics may

influence treatment outcome. Some characteristics

relate to the social environments of abusers (e.g.,

social support systems). Demographic factors, such

as age, gender, ethnicity, and education may also be

important. Finally, there are more dynamic characteristics, such as an abuser’s motivation, severity of

abuse, and psychopathology. Not surprisingly, the

former characteristics have been more extensively

examined than the latter, since their measurement is

more simple and feasible. The evidence thus far, as

summarized by Anglin and Hser in their review of

treatment effectiveness, is that, “abusers who have a

more stable family background, an intact marriage, a

job, a history of minimal criminality, less evidence of

alcohol or polydrug use, and less severe psychiatric

disorders are more likely to achieve a better outcome
Chapter 4-The Effectiveness of Treatment for DrugAbuse -89

in most programs (13).” Thus, this circularity

resembles the “rich get richer, and the poor get

poorer” phenomenon; the attributes of a better

outcome may be the same factors that influence the

decision to seek and remain in treatment in the first

place. The real challenge for drug abuse treatment is

to achieve or improve success with the “poorer”

clients as well.

Program Characteristics

In the same review, Anglin and Hser state that

certain program elements (e.g., psychotherapy, urine

testing, legal coercion, and program policies and

staffing), when implemented appropriately, have

been found to exert a beneficial effect (13).

Psychotherapy addresses the “broader range of

psychiatric symptoms that are prominent among drug

abusers” (234). The majority of evidence suggests

that psychotherapy may be related to improved outcomes for selected groups of abusers. It appears that

especially for abusers with moderate to severe

psychiatric problems, psychotherapy has the potential

to improve treatment outcomes (234,377).

Monitoring illicit drug use while in treatment

through urine testing is a common practice. The

existing evidence suggests that urine testing alone

does not improve treatment outcome; however, there

is evidence that linking urine testing results with positive or negative contingencies does influence

treatment outcome (13,285).

With regard to whether those who enter

treatment under some form of legal coercion tend to

benefit from treatment, the reviewers note that the

majority of the findings, especially from the better

designed studies, “generally support the idea that a

collaborative relationship between the Criminal

Justice System (CJS) and community treatment

delivery systems produces, at an aggregate level,

enhanced treatment outcomes” (13). In other words,

the results tend to be at least comparable to outcomes produced from those who enter treatment

voluntarily.

Matching

A major area that holds promise for increased

treatment effectiveness and efficiency is matching

individual clients to specific treatment and treatment

components according to their needs. Two related

and well designed studies conducted by researchers

at the VA Medical Center in Philadelphia and the

Department of Psychiatry of the University of

Pennsylvania are relevant to this issue.

A retrospective analysis was performed in a 1978

cohort of 282 drug-dependent male veterans treated

in the VA treatment network to identify possible

program-patient matches that were associated with

favorable or unfavorable results (210). Patients were

evaluated with the addiction severity index both at

admission and at 6-month followup. Initial analysis

indicated that a patient’s psychiatric severity as

estimated at admission was the single best predictor

of most outcome measures. Based on this finding,

the sample was classified into low, mid, and high

psychiatric severity groups, and the data were

reanalyzed. Results of the second analysis revealed

that the low severity group improved significantly

regardless of the modality, while the high-severity

group showed poor outcomes regardless of their

treatment program. In contrast, specific program

factors related to improved outcomes were identified

in the group with the mid-level of psychiatric severity.

The findings from this retrospective study were then

used to develop treatment assignment criteria and

were subsequently tested in a prospective study.

The prospective study involved 321 drugdependent patients, all male veterans who were

evaluated at intake with the addiction severity index

instrument and were eligible in 1980 for assignment

to one of the programs in the VA treatment network

(210). These programs included a combined

alcoholism-other drug abuse 60-day inpatient

treatment program, a 60-day TC, and a methadone

maintenance clinic. A matching strategy was devised

according to psychiatric severity and severity of other

problems, such as medical condition, employment,

alcohol use, other drug use, legal status, and family

relations. Of all patients entering drug abuse

treatment, 48 percent were matched to the program
90- The Effectiveness of DrugAbuse Treatment: Implications for Controlling AIDS/HIVInfection

that was predicted to be the best for them. Reasons

for not matching were lack of a treatment slot in the

assigned program (27 percent), patients’ refusal (13

percent), and assignment errors (7 percent).

Matched patients were compared with the mismatched during treatment and 6-month followup. It

should be noted that treatment staff were blind to

the matching status. Followup information was

obtained for 94 percent of the subjects. Outcome

criteria included psychiatric adjustment, alcohol use,

other drug use, medical condition, employment, legal

status, and family relations.

Overall, people in drug abuse treatment

improved regardless of the client matching status and

type of program. Treated patients showed decreases

in both opiate and non-opiate drug use (67 and 50

percent, respectively), a 67-percent decrease in

criminal activity, and a 20-percent increase in earned

income. With regard to the patient matching status,

the performance during treatment revealed that

matched patients were more motivated during

treatment, stayed in treatment longer, and had fewer

irregular discharges than the mismatched patients.

The 6-month followup results showed that matched

patients had better outcomes in all categories than

the mismatched . Matched patients had 27 percent

better outcomes than the mismatched patients. The

beneficial effects of matching were not confined to a

particular treatment program or a particular patient

group.

Such studies are of particular importance to the

drug abuse treatment field and are long overdue.

Additional research is needed to identify and test

initial matching criteria. Criteria may be used to

assign a particular type of patient not only to a

treatment program but also to the appropriate

treatment components and to the appropriate level

of needed services. Research is also needed to

identify whether additional factors particular to

certain groups, such as racial or ethnic minorities or

women, should be included in the matching strategy.

To utilize the potential knowledge gained from

research, a referral and treatment network,

community-based and coordinated needs to be in

place. Such a network could also reassign clients to

another component or form of treatment if the initial

treatment episode was not effective, or to aftercare

services when the client was considered fit to reenter

the community. All this research ultimately could

lead to a practice that has been common for a long

time in the management of other medical conditions,

namely an individually tailored treatment plan that

takes into account the drug abuser’s history and

needs.

Other Contemporary Issues Related

to Treatment

Special Populations

Women--Substance abuse among women has not

received adequate attention (160,311,314). Although

the prevalence of illicit drug use is higher among

men than women, the extent of the problem, the

rising trends (especially for cocaine and crack use),

and the consequences of drug abuse among women

are alarming. The HIV epidemic has increased concerns about female drug use. Female abusers can be

infected via drug-related or sexual behavior and subsequently transmit the virus to their partners and

infants.

In 1988, approximately 9 percent (5.4 of the 60

million women of childbearing age (age 15 to 45)

reported using an illicit drug in the past month (330).

One million of these women had tried cocaine. A

substantial majority of women seeking mental health

services have had alcohol and other drug problems,

which constitutes the second most frequent reason

after depression for seeking treatment (32,212).

Recent studies estimated that every year, 375,000

infants are exposed to illicit drug use in utero, nearly

one-third of whom (100,000) are exposed to cocaine

(51,53,122). Babies born to drug-using mothers tend

to suffer higher mortality and morbidity rates. The

consequences depend on the drug of abuse, the

duration of use, and the dose taken. Death rates for

infants of drug-using mothers are reported to be 4

times higher than for infants born to non-drug using

mothers (160). Infants of abusers, especially of

women using heroin, experience severe withdrawal

symptoms after birth. In addition, in utero exposure

may result in a spectrum of short- and long-term

health impairments (219,277). At least one hospital

study demonstrated that women using illicit drugs

come from all socio-demographic groups (301). The

rate of exposure among patients of private and public
Chapter 4-The Effectiveness of Treatment for DrugAbuse -91

hospitals was the same. Furthermore, there were no

major differences in exposure between black and

white women. Of those reporting illicit drug use, the

majority of women in the above study (75 percent)

reported use of cocaine (301).

With respect to drug use and HIV infection, the

statistics are equally troublesome. Women make up

20 to 30 percent of the regular intravenous heroinusing population, an estimated 100,000 to 150,000

users (153). Currently, approximately 10 percent of

all acquired immunodefeciency syndrome (AIDS)

cases are women. About half of them (52 percent)

were IV drug users, and an additional 20 percent

were infected by heterosexual contact with an IV

drug-using partner (349). Furthermore, of the 2,258

AIDS pediatric cases as of May 1990, nearly 60

percent were caused by exposure to HIV that was

related to IV drug use (IV drug use by the mother or

her sexual partner).

Between 1985 and 1988 the death rate among

women of reproductive age (15 to 44 years of age)

due to HIV infection quadrupled (60). In contrast,

rates of other causes of death among women of

reproductive age have remained relatively constant in

the last decade. In 1988, the death rate of black

women was nine times the rate of white women (60).

Young black women in New York were nearly four

times more likely to die of HIV infection than young

white women (30 per 100,000 v. 8 per 100,000 respectively). If current mortality trends continue it is

estimated that HIV/AIDS will become one of the

five leading causes of death by 1991 among women of

reproductive age (60).

Medical costs for children born to drug-using

mothers can be substantial. One study in Los

Angeles estimated in 1986 that the hospital care for

the extended stay of 915 drug-exposed babies (70

percent were exposed to cocaine) totaled $2.2 million

(127). A report by the Office of the Inspector

General for the U.S. Department of Health and

Human Services Administration estimated that the

health care and special services of crack babies will

soon reach $500 million (122).

Despite the significance of the female drug abuse

problem, the issue has not been extensively studied

until recently (32,160). It appears that the causes of

drug use, the natural history, and the needs of the

female drug abuser are different from those of men

(71,212). These differences have profound implications for appropriately addressing drug abuse

treatment and prevention of HIV infection for

female abusers. More specifically, research indicates

that women are often influenced by intimate partners

or male relatives to initiate and continue drug use

and that their drug use serves a coping function in

part as well as a desire to “get high.” Women are

more likely than men to use drugs at home, alone, or

with intimate friends. Women’s drug supplies

depend primarily on their partners and friends.

Female abusers also tend to have feelings of powerlessness and low self-esteem. They often lack a

social network and face difficulties in maintaining

intimate relationships. They tend to be very emotionally and sexually dependent on males

(71,153,212). They often neglect themselves, and it is

not uncommon for pregnant female abusers to delay

identifying their condition and to wait until late in the

course of pregnancy to seek prenatal care.

With respect to drug abuse treatment, women are

often unrepresented and underserved (72,288).

There are barriers for those women seeking

treatment, and even for those who are admitted.

Only a few centers provide a range of services

tailored to their unique needs. According to one

researcher, "male program staff... employed a confrontational therapeutic style uncomfortable for

women, and directed them into gender stereotyped

tasks and training” (56). Furthermore, treatment

programs do not address the important issues of

sexual exploitation and violence in which female

abusers often live (56).

Most of the information on treatment effectiveness comes from studies with overwhelming

majorities of male subjects. Some studies have found

gender-related differences. One prospective study of

urban black youth found that the benefits of

treatment for heroin abuse were more evident

among females than men (42). After entering

treatment, the annual probability that a woman

would be abstinent increased and was somewhat

greater than men’s, Similarly, in another prospective

study of male and female drug abusers in a TC, De

Leon and Jainchill found that females entered

treatment with greater degrees of psychopathology,
92- The Effectiveness of DrugAbuse Treatment: Implications for Controlling AIDS/HIVInfection

but at followup showed greater improvement than

males and seemed to require less time in treatment

to achieve the same goals. Women’s improvement

appeared to be related to social role functions that

were modified during residency at the TC (82).

Obstacles that have made it difficult to get

women into treatment include their inadequate

knowledge about drug abuse and its optimal management; lack of interest, insensitivity, and negative

attitudes towards women; and insufficient resources

(288). The hurdles pregnant abusers face in getting

treatment for their abuse were illustrated in a recent

study in New York City (54,57). According to a

survey of 78 programs, fewer than one-half (46

percent) were accepting pregnant women. Furthermore, not all of these programs were equipped

to address the special needs of pregnant women (less

than half of the programs that did accept pregnant

women provided prenatal care). Only two programs

had provisions to accommodate the children of their

female clients. Moreover, as the author states,

“effective availability was further limited by restrictions on method of payment or specific substance of

abuse” (55). Access to treatment was especially difficult for those women on Medicaid and using crack

(56)

In 1989, the National Association of State

Alcohol and Drug Abuse Directors estimated that

the total number of women per year, including

pregnant women, who are currently receiving

treatment for alcohol and substance abuse is almost

550,000, with the total number of pregnant women

being nearly 30,000. It was also estimated that 4

million women need treatment, of whom about

250,000 are pregnant (218).

Regardless of pregnancy, it is imperative that the

needs of female abusers be addressed by the drug

abuse treatment system and that they be reflected in

the types of services offered by drug treatment programs. These needs can be identified by understanding the social, economic, psychological, and

physiological dimensions of female drug abuse. Programs that tailor their services to women could

integrate medical and reproductive care with

psychiatric and counseling services, parenting

training, day care, and social and rehabilitative services. A substantial amount of research on female

drug users has been compiled, and comprehensive

treatment programs, especially for crack and cocaine,

have been proposed (358). Since no effective

pharmacotherapy for cocaine is yet available, it is

imperative that these programs be carefully

evaluated.

Studies that examined the impact of comprehensive programs for treating drug abuse in pregnant

women (especially heroin abusers) have found positive results, both in lowering mortality and in overall

improvement of pregnancy outcomes (52,85,287).

Reviewers state that studies demonstrate that when

the health, legal, and child care needs of women have

been addressed, treatment programs’ retention and

effectiveness rates have improved (13,149).

Both the cocaine and crack epidemics and the

HIV epidemic have helped bring this issue to the

forefront and may motivate the treatment system to

better address the problem of female substance

abuse. This multifaceted problem will require a multidimensional treatment approach that addresses

women’s special needs.

Populations Involved With the Criminal Justice

System--There is an undeniable link between drug

abuse and criminal activity. Heroin and cocaine

abusers are among the most serious street criminals

(190,304). It is estimated that each daily heroin user

annually commits more than 100 crimes, such as

burglary and theft (159). Furthermore, during

periods of daily use, drug abusers’ crime rates and

incomes have been 2 to 6 times higher than during

periods of nonuse or less than daily use. Less than

one percent of self-reported crimes by cocaine and

heroin abusers resulted in an arrest (159). A substantial majority of arrestees, however, also reported

drug use. The Drug Use Forecasting program of the

National Institute of Justice monitors recent drug use

among a sample of persons arrested in selected U.S.

cities. Data indicate that about 60 percent of

arrestees in 1987 were using drugs other than alcohol

before the time of their arrest (190). As noted in

chapter 2, more recent data from 14 cities showed

that the prevalence of cocaine use (confirmed with
Chapter 4--The Effectiveness of Treatment for DrugAbuse -93

urine testing) among arrestees was more than 50

percent in 7 cities. Although less than 10 percent of

arrestees in 9 cities had positive urine tests for

opiates, an overwhelming majority of those (81

percent) also tested positive for cocaine (336).

The reported statistics are similar with respect to

inmate populations. Of all State prisons’ inmates

sampled in 1986, 62 percent reported having ever

used illicit drugs on a regular basis; 43 percent

reported daily use during the month before the most

recent offense; and 35 percent were under the

influence of a drug at the time of the offense

(190,351).

In 1987, nearly 2 percent of the adult population

in the United States (about 3.5 million) were under

some form of correctional supervision (on probation,

in jail or prison, or on parole) (336). Since drug use

is so extensive among individuals in contact with the

criminal justice system, an opportunity exists to fight

the problem by providing drug treatment for this

population. Although permanent abstinence may be

an unlikely outcome for many of them, their drug use

and criminality may be reduced. According to

experts, there is currently limited treatment available

for the drug abuse offender (12,13). It has been

estimated that 11 percent of the total inmate population of State prisons are under substance abuse

treatment (351). The majority of treatment programs consist of drug education, counseling group

therapy, and Narcotics Anonymous groups. Those

who are not incarcerated but still in contact with the

criminal justice system may be legally required to

enter treatment in a community setting (351).

With respect to evaluation of prison-based programs, a recent review notes that, “outcome evaluations of prison-based programs also show reductions

in criminal recidivism rates and that time in

treatment is positively related to increased time until

arrest” (351). This review was part of a planned

study to evaluate the Federal Bureau of Prisons’ drug

abuse treatment programs. The evaluation will

examine the effectiveness and efficiency of TC programs for substance abusers who are within 18

months of release from prison. This well-designed

evaluation will provide valuable information on postrelease drug use, criminal behavior, occupational and

social functioning, and mental and physical health. It

will also identify client characteristics and treatment

components associated with positive outcomes.

Arrested drug abusers may be legally required to

enter treatment for their abuse. In 1982, almost 30

percent of the clients who entered treatment programs were on probation, parole, or mandatory

release (190). Evaluations specific to the legally

coerced clients have been conducted. One form of

legal coercion was the civil commitment programs of

the 1960s. Civil commitment is defined as “a legal

procedure that allows narcotics abusers or other drug

abusers to be committed to a compulsory drug

treatment program, typically involving a residential

period and an aftercare period in the community"

(12). Three different programs were established in

the United States. As Anglin notes, however,

although the intent of the enabling legislation and the

design were quite similar, actual implementation differed and fell short for some of the programs (12).

Of all three, the California program seemed to

have been the most successful. Addicts were

admitted to the program and were subsequently

released into the community under supervision.

Daily narcotics use and property-related crime

among the program participants receiving

methadone maintenance during the 7 years of the

commitment period were reduced by 21.8 and 18.6

percent, respectively (12,192). A comparison group

comprised of abusers who were admitted to the

program but were discharged because of legal errors

reduced their daily use just by 6.8 percent and their

criminal activities by 6.7 percent. Thus, there was a

threefold improvement in the outcome measures for

the program group as compared with those who were

not involved in a program (12,13). Further analysis

indicated that supervision with objective monitoring

(i.e., urine testing) was found to be an important

component of civil commitment (192). Leukefeld

notes that although civil commitment may reduce IV

drug abuse, it should not be considered a panacea.

This point reinforces the experts’ view that no

panaceas exist for the drug problem as a whole.

Rather, it seems that a balanced combination of

several approaches has the potential to achieve the

most benefit.
94- The Effectiveness of DrugAbuse Treatment: Implications for Controlling AIDS/HIV Infection

Another approach, the Treatment Alternative to

Street Crime (TASC), has been described as another

milestone in linking the criminal justice system and

drug abuse treatment (190). These Federally funded

and locally administered programs were initiated in

1972. Before Federal funding was withdrawn in

1982, 130 cites in 39 States had TASC projects; by

1987, 18 States had operational TASC programs

(62). TASC is a bridging and coordinating

mechanism between the criminal justice system and

drug abuse treatment that employs an individualized,

case management approach. Its function is to

“identify, assess, and refer appropriate drugdependent offenders accused or convicted of nonviolent crimes to community-based substance abuse

treatment” (62). TASC acts as an alternative or supplement to existing criminal justice sanctions and

reports treatment results to the referring justice

system component. Those who do not comply or

violate regulations are returned to the criminal

justice system to continue their legal processes or

sanctions (62). Unfortunately, the program does not

include comprehensive long-term evaluation. Several

evaluations of TASCs have found that the programs

provided a less costly alternative to incarceration and

that TASC clients remained in community treatment

longer than non-TASC clients (192).

A sample of TASC clients were in treatment programs participating in the TOPS study (in a limited

number of cities and modalities). Some comparisons

were possible between clients involved in TASC and

other justice system supervision and voluntarily

admitted clients. Multivariate analysis found that, in

general, association with the criminal justice system

was a significant predictor of retention (149). TASC

clients were estimated to stay nearly 2 months longer

in residential treatment and 45 days longer in ODF

treatment than non-TASC clients. Furthermore,

clients referred by the criminal justice system were

significantly less likely to report weekly or more frequent use of their primary drug of abuse during the

year after treatment. The investigators concluded

that reduced criminal activity for criminal justice

clients, both during and after treatment, ’’argues for

the use of drug abuse treatment as alternative crime

control technique” (149).

The TOPS study provided evidence that compared with other clients, those referred by TASC and

the criminal justice system tended to be not as

heavily immersed in their abuse careers and to be

receiving treatment for the first time. This early

interruption of the drug abuse career may account

for the positive results that were found from this

group. Researchers have suggested that these programs have a great potential to interrupt the abuse

cycle and to produce long-term benefits by

decreasing both drug use and crime among treated

offenders (149,190).

Dual Morbidity

An association exists between psychiatric conditions and drug abuse. Persons with mental illness of

virtually all ages and categories have a markedly

elevated incidence of serious substance abuse (333).

At the same time, there is a growing recognition that

clients entering drug abuse treatment have a variety

of psychiatric disorders. The prevalence of these

dual-diagnosis patients appears to be increasing,

perhaps due to better diagnostics (156,175). Kosten

reports that opiate abusers with severe drug abuse

are more likely to be depressed (175). Among opiate

addicts, major depression was most common (54

percent), followed by alcoholism (35 percent),

antisocial personality disorders (26.5 percent), and

phobias (16 percent). He further notes that the proportion having any lifetime disorder (87 percent) is

higher than among alcoholics. For cocaine abusers,

Kosten reports a 30-percent prevalence rate of major

and minor depression, and a 10- to 20-percent

prevalence of bipolar disorders (manic-depression)

(175). In general, it seems that the dually diagnosed

patient falls along a continuum that ranges from mild

psychiatric disorder and mild substance abuse to

severe mental illness and a severe substance abuse

problem (333).

Research indicates that the coexistence of

psychiatric disorders appears to be a strong prognostic factor influencing the outcome of drug abuse

treatment and the likelihood of relapse (149,175).

This evidence makes it imperative that patients who

enter treatment for drug abuse have a psychological

assessment. If a co-existing psychiatric condition is

diagnosed, then their treatment plan could include

appropriate psychiatric care.

Polydrug Use

The increased prevalence of multiple drug abuse

by the same individual (polydrug use) constitutes a

major problem that carries serious consequences.
Chapter 4--The Effectiveness of Treatment for DrugAbuse -9.5

Drugs are used concurrently for a variety of reasons.

They can be used, for example, to enhance or

counteract the effect of the primary drug (as the case

with the cocaine-heroin combination) or to serve as a

temporary substitute for the drug of choice, which

may not be available (149,177). Of particular

concern is the increasing practice of injecting a

mixture of cocaine and heroin (“speedballing”) (24).

Other common substances used by heroin and

cocaine abusers are alcohol and sedatives, especially

benzodiazepines (177).

An indication of the extent of the polydrug abuse

problem is provided by data from the TOPS study.

An overwhelming majority of clients entering

treatment in methadone maintenance, TC, and ODF

programs (over 70 percent) abused two or more

drugs in the year prior to treatment. In all, 50 to 70

percent of the clients in each treatment modality

used alcohol or marijuana in addition to their

primary drug of abuse. The analysis of the data concerning drug use patterns indicates a reduction in the

severity of drug use after treatment and substantial

improvement, mainly accomplished by patients

switching to less serious drugs and less complex patterns of use (shifting to alcohol and marijuana and

becoming minimal users) (149).

Polydrug abuse complicates treatment, from the

stage of detoxification to relapse prevention (177).

Moreover, higher rates of psychiatric co-morbidity

have been reported among polydrug users, which

further exacerbate the problem (177). More

research is needed to devise ways to treat this crucial

problem. In the absence of “magic bullets,”

researchers have suggested that a combination of

treatment regimens and strategies (from

pharmacotherapy and psychotherapy to behavioral

techniques) may help increase effectiveness

(177,285).

Prevention of Relapse

Relapse, defined as the resumption of substance

abuse following a period of abstinence, is the rule

and not the exception among abusers entering or

completing treatment (250). Thus, relapse can be

considered to be a major factor contributing to the

drug abuse problem. Indeed, without recurrence and

relapse, “substance abuse treatment could be limited

to a small subspecialty of medicine that concentrates

on detoxification, handled in medical wards, emergency rooms, and outpatient clinics” (250).

Relapse to drug use is a complex, dynamic

process that may involve several stages from the

initial slip to readdiction (129,367). Several

theoretical models based on genetic and metabolic or

social learning theories have been proposed to

explain relapse (129,367). Although the research in

this area is not extremely advanced, partly because of

methodological impediments, factors associated with

relapse have been identified. The prevalence of a

psychiatric disorder is a strong predictor of relapse,

along with socially related parameters, such as commitment and motivation on the patient’s part, the

existence of social support networks and employment

opportunities. Another category of relapse predictors includes variables associated with “cue reactivity.” Relapse can be triggered by responses to

environmental cues that act as “reminders.” These

are situations that over the course of the abuse

career have been strongly associated with drug use.

Conditioned cues may range from being in areas

where drugs were purchased and being with drugusing friends to viewing money, white powder, or any

item ever associated with drug use. Depending on

the abuser, then, almost anything can produce drug

use memories, strong urges, and cravings that might

lead to drug-seeking behavior, even years after a successful treatment episode (58,232).

Because drug abuse is a chronic relapsing disorder, it should be regarded in a similar fashion as

other chronic diseases (e.g., diabetes, arthritis,

bipolar disorders, or chronic depression)

(149,191,233,250). The pattern of relapse and

remission resembles the nature of chronic diseases’

patterns of remission and flare-up periods. AS with

many chronic conditions, no cure exists to eradicate

the causes of drug abuse or the problem once it surfaces. The recognition that there is no perfect

treatment for drug abuse has important implications

for drug abuse treatment objectives. Two distinct yet

interrelated objectives of drug abuse treatment are 1)

the amelioration or reduction of symptoms (e.g.,

drug use) and 2) the prolongation of symptom-free

intervals (e.g., maintenance of the desired behavior

changes).
96- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

There is a growing consensus that relapse prevention techniques ought to be incorporated into the

existing treatment system and taught to clients

(129,149,233). Preliminary results from experimental

studies have been promising (202,206,232).

Nevertheless, more research is essential to gain a

better understanding of the process of relapse and to

identify which techniques are most suitable for particular patients. This knowledge could increase both

the effectiveness and the efficiency of treatment.

Relapse prevention becomes even more important in

view of the cocaine surge because of cocaine’s powerful reinforcing properties and the current lack of

any pharmacologic treatment (58).

From both the treatment and policy perspectives,

it is encouraging that many of the factors associated

with relapse are environmentally influenced and thus

amenable to various degrees of control. Therefore,

interventions targeted to change these factors might

play a significant role in reducing the demand for

drugs, either by totally preventing relapse for some

individuals or by considerably prolonging drug-free

intervals for others. In both cases, society and the

individual gain.

Aftercare Services

One dimension of relapse prevention is the provision of aftercare services. Aftercare can be conceptualized as long-term treatment or extended care

similar to the management of other chronic conditions, such as bipolar disorders (manic depression).

The most vulnerable time for relapse is during the

first 3 months after leaving treatment, when the

former abuser no longer has the protected

environment of the treatment program (191). The

purpose of aftercare services is to facilitate the

treated abuser’s integration into society. Provision of

aftercare is based on the assumption that “continuing

assistance following treatment can remove or reduce

posttreatment factors which are associated with

relapse, or strengthen those posttreatment factors

which are associated with maintenance of sobriety”

(140). This is accomplished by keeping contact with

the treated individual and helping drug abusers make

major life changes and cope with the personal,

family, social, and professional challenges that they

face during the recovery process. Model programs

for aftercare treatment have been devised based on

followup meetings, training sessions, drug-free social

and community activities, vocationally focus

strategies, social support strategies, and development

of support systems through former abusers (140,378).

The empirical evidence is encouraging that

aftercare services may reduce relapse rates

(2,140,250,378). In a randomized trial of newly

recovering opiate addicts who had been assigned to

an experimental aftercare program and a control

situation, McAuliffe found that the “intervention significantly reduced the probability and extent of

relapse, helped unemployed subjects find work, and

reduced self-reported criminality” (202). Clearly,

more research is needed to formally evaluate a

variety of such programs and to identify the most

effective elements of their services.

TOPS data indicate that few clients from any

treatment modalities received any type of aftercare

services (149). It seems that scarce resources and

more urgent competing needs have led to poor development of these services (378). Experts in the field

agree that the current knowledge of relapse prevention that includes aftercare needs to be integrated

into existing treatment packages (149,191).

Aftercare programs can also take the form of consortia serving clients from multiple treatment

facilities (140).

Given the potential that both relapse prevention

and aftercare services hold for strengthening

treatment’s effectiveness and efficiency, the existing

lack of applied research necessary for implementation is a severe stumbling block to further progress.

Future Research

It is apparent that much more can be done to

increase treatment’s effectiveness and efficiency.

The conference “What Works: An International Perspective on Drug Abuse Treatment and Prevention

Research,” held in October 1989, identified major

issues likely to lead to the achievement of these goals

(195). One suggestion dealt with ways to increase

the dissemination and use of information that has

already been gathered on drug abuse treatment.

Such suggestions included creating the environment
Chapter 4--The Effectiveness of Treatment for Drug Abuse -97

for technology transfer and creating ways to facilitate

the diffusion of tested and established knowledge.

With respect to a future research agenda, the

proposed topics emphasized research that would

produce knowledge to improve treatment effectiveness and efficiency. Such research areas include

the natural history of drug abuse (stages and process

of recovery) among different sub-populations and the

possible effectiveness of patient-program and

patient-staff matching schemes. More researches

clearly needed on the process of treatment, to understand why some treatment works, which elements

make it work, what does not work, and, most importantly, to identify those treatment components that

are effective for various groups. Research is also

lacking on staff turnover, staff attitudes, program

flexibility about treatment options, contact between

staff and patients, and family involvement in

treatment (241a).

Research on relapse prevention and aftercare also

holds great importance. Moreover, there is a need to

evaluate for different groups the safety, efficacy, and

effectiveness of new techniques and alternative

treatment methods (e.g., behavioral techniques such

as contingency management and conditioning,

acupuncture, and hypnosis). More information is

also needed on those who do not seek treatment and

the way they recover and on better techniques to

attract and retain clients in treatment (195). Finally,

the technology of conducting randomized studies in

the field of drug abuse needs to be strengthened.

The Drug Abuse Treatment Outcome Study

(DATOS), the third national study on treatment

effectiveness following DARP and TOPS, is expected

to address some of the areas previously identified as

needing further research (322). Differential subgroup analyses will be performed, variables related

to treatment retention and outcome will be

examined, and treatment effectiveness will be compared with the drug use patterns of those who

received no treatment. Further research will

examine the prevalence of behaviors associated with

the spread of HIV and investigate the effectiveness

of treatment interventions designed to reduce these

high-risk behaviors.

DATOS is being funded by NIDA and implemented by the Research Triangle Institute. The

investigation will cover an estimated 20,000 clients

enrolled in approximately 50 treatment programs

(322). Five modalities will be included in the investigation: short- and long-term methadone

maintenance, short and long-term TCs, and ODF

treatment. The goal is to determine treatment effectiveness according to the illicit drug(s) used type of

treatment, and the degree of client impairment. An

additional goal is to examine the process of

treatment, especially as it relates to treatment

outcome. Although a relatively short followup is

planned (6 months), it is anticipated that longer followup studies will evolve from this data set.

Large national studies and smaller-scale studies

are equally important in drug abuse treatment

research. Although they may overlap, national and

smaller-scale studies are able to address different

kind of questions. Collective knowledge derived

from both types of studies might provide answers to

a variety of issues and strengthen drug abuse

treatment.

SUMMARY AND POLICY

IMPLICATIONS

Research has demonstrated that drug users are a

heterogeneous group with multiple problems

(78,149,271). The three major treatment modalities,

which have changed little over the past 20 years, tend

to attract clients with different sociodemographic and

other personal characteristics and, therefore, serve

diverse client types (149). Methadone maintenance,

if properly implemented, can dramatically reduce

illicit opiate use. High proportions of successful outcomes have also been observed among TC clients.

These substantial improvements, however, are

clouded by the low retention record of TCs. Many of

the people attending ODF programs have also

reduced their drug use and some of its consequences.

This chapter reviewed the evidence of drug abuse

treatment effectiveness in general. Chapter 5

addresses the specific question of drug abuse

treatment and implications for HIV spread.

Treatment for drug abuse has the potential to
98- The Effectiveness of DrugAbuse Treatment: Implications for ControllingAIDS/HIV Infection

interrupt transmission of HIV infection by

decreasing the frequency of drug use, especially IV

drug use. These decreases imply reductions in

sharing injection equipment, the primary vehicle of

HIV transmission among IV drug users. Although

methadone curtails heroin use, the lack of an

effective and fast-acting treatment for cocaine may

have dire consequences for those at risk.

The last few years have witnessed an evolution of

new treatment programs and variations in the traditional treatments. Twenty-eight-day residential programs have become the most common form of

treatment, and self-help groups, such as Narcotics

Anonymous, have become prevalent. Intermediate

levels of care, such as day-care, evening care, or halfway houses are becoming increasingly important

(203). Linkages between self-help groups and

methadone maintenance as an adjunct or aftercare

service to long-term stabilized clients have been

developed (231). There are TCs with planned

treatment durations of 3 or 6 months. ODF programs have been tailored to treat cocaine abuse

treatment (204,241). Although formal evaluations of

these entities are not yet available, research is currently being conducted that may shed some light on

the efficacy, effectiveness, and perhaps costeffectiveness of the new approaches to drug abuse

treatment.

Across all modalities in TOPS, of the clients who

spent at least 3 months in treatment, 40 to 50 percent

of regular (weekly or more frequent use) heroin and

cocaine users stopped use completely 1 year after

treatment, and an additional 30 percent reduced

their use (149). Drug abuse and criminal activity

consistently decreased. Dramatic improvements

occurred during treatment, with some degree of

deterioration immediately after and stabilization in

the following years. Improvement was maintained

up to five years after treatment (149).

Drug abuse treatment is intended mainly for

people who are drug depended. Natural history

studies have shown that some people may discontinue drug use without any formal type of treatment.

Overall, it appears that the process of phasing out

drugs is a function of a wide range of factors.

These factors may be previous treatment episodes,

criminal justice system involvement, critical life

events, such as confrontation from family and

friends, religious involvement, and other social conditions.

Drug abuse has been described as a “final

common pathway, where genetics, psychological

factors, or social environment might get you there,

but once you’re there, you’re there” (167). Low

retention in treatment and relapse have consistently

hampered treatment efforts. Retention rates vary

among modalities. An estimated 80 to 85 percent of

entrants have dropped out of traditional TCs before

1 year, whereas a reported 60 percent of ODF clients

have dropped out, transferred, or completed

treatment by the third month (79,150). Methadone

programs have experienced lower dropout rates, with

a range of 15 to 45 percent for a 2-year period.

Methadone dosage has influenced retention (low

doses are associated with lower retention)

(130,257,258).

Relapse to drug use is a major characteristic of

drug abusers. As the DARP study showed, 75

percent of the followup sample relapsed one or more

times over 12 years (267). Total abstinence may be

hard to achieve, often requiring multiple treatment

episodes (149,267). DARP data indicated that over

10 years, opiate abusers averaged 6 treatment

episodes. Approximately 60 percent of those leaving

treatment had another treatment episode in the subsequent 6 years (157,201). Similarly, almost 33

percent of TOPS clients returned to drug treatment

in the year after leaving the program (149).

Even for those who cannot achieve total and

permanent abstinence, treatment may be beneficial.

In the TOPS study, all outcome measures dramatically improved during treatment. The long-term

analysis of the DARP sample showed that more than

58 percent of all abusers in recovery at year 12 had

quit while they were in a treatment program (267).

Each treatment episode may lead to a drug-free

interval in the drug-abuse career. Thus, treatment

may initiate, facilitate, and accelerate the recovery

process. The DARP analysis also demonstrated that

the longer the duration of abstinence, the more likely

the recovering abuser will continue being abstinent.

Findings from research in a related area, nicotine
Chapter 4--The Effectiveness of Treatment for DrugAbuse -99

abuse and smoking cessation, provide further support

to the above conclusions (118).

Drug abuse is clearly a condition of multiple

dimensions both in its etiology and in its expressed

outcomes and consequences. Drug abuse treatment

performs well in many drug abusers but cannot affect

all behavioral dimensions. “The major modalities

have had more limited success in rebuilding the lives

of drug abusers and reintegrating them into society”

than reducing drug use (149). The interplay of

factors beyond the reach of treatment (e.g., personal

and social environment) may undermine recovering

abusers’ efforts to stay drug-free and become productive members of the society.

Confronting and treating drug abuse is a very difficult and demanding task. To sustain any behavior

change requires a major commitment. Even relatively benign behavioral changes (e.g., exercise,

weight loss) attempted by healthy and stable individuals may take time and several attempts to

achieve improvement. A proportion may reach their

goals and be able to maintain their desired behaviors

(e.g., permanently quitting smoking), but others

experience short periods of improved behavior followed by relapses into old behavior patterns.

In summary, different interventions seem to work

for different groups of drug-abusing clients. Overcoming drug abuse may require multiple treatments

and the provision of relapse prevention and aftercare

services. Treatment for drug abuse is not a panacea.

Rather it is an integral component of a long and

committed effort to recover from drug abuse.
Chapter 5

Treatment for Drug Abuse as a Strategy to Prevent HIV Infection

INTRODUCTION This chapter briefly reviews the association

The critical role of intravenous (IV) drug use in between drug use and increased morbidity, addresses

the spread of the human immunodeficiency virus some of the methodological obstacles to the

(HIV) is well recognized and documented (216,239).

Reflecting this reality, the Presidential Commission

on the Human Immunodeficiency Virus Epidemic

stated that the nation’s ability to control the HIV

epidemic depends on its ability to control the IV

drug use problem (239). Providing treatment is

indeed a cornerstone of any adequate strategy (105).

Hubbard and colleagues proposed that treating drug

abuse may have important direct (reduction of drug

use) and indirect (improvement of immune function)

effects on the HIV epidemic (see box 5-A) (148).

Decreasing drug use for both HIV-positive and HIVnegative drug users is of great importance. In low

prevalence areas, a window of opportunity exists to

control the spread of the virus, so that the course of

the epidemic will not parallel the past rises in

seroprevalence rates seen among IV drug users in

the already highly infected areas (25,28,68). In high

prevalence areas, curtailing drug use could reduce

further transmission of HIV.

evaluation of drug abuse treatment as a strategy for

HIV prevention, and reviews the relevant studies.

Finally, the chapter examines other approaches to

HIV prevention among IV drug users.

A decrease in drug use will most likely produce

benefits besides decreasing the risk of spreading

HIV. A threefold increase in overall mortality rates,

AIDS incidence, and AIDS mortality rates was

reported among IV drug users in methadone

maintenance clinics in New York City between 1984

and 1987 (263). Similarly, from 1981 to 1986,

narcotics-related deaths from AIDS and other

causes, especially other infectious diseases, increased

on average 32 percent. The investigators speculated

that these deaths from other causes may also have

been associated with HIV infection (286). For drug

users in treatment, death rates were about 1.5

percent per year in contrast to the 3.5 to 8 percent

for those not in treatment (88).

.

Box 5-A--Drugs of Abuse and the Immune System

There is evidence that opiates, as well as other drugs of abuse, exert immunosupressive effects on the

immune system. These effects may be related to the drug itself, to some of the toxic substances used to process

it, or to another factor associated with drug use (186,364). A related finding of importance is that methadone

doses lower than 75 mg per day may reverse the immunosupressive effects of heroin, which suggests that

methadone may in fact provide benefits besides curtailing heroin use to those in treatment (101). An effective

dose is usually over 60 mg (257). Moreover, it has been reported that those in methadone maintenance

treatment who are HIV positive and do not continue to inject drugs have a better functioning immune system

than those who continue IV drug use (95).

A recent prospective study from Switzerland showed that cessation of IV drug use is associated with lower

risk of disease progression among HIV positive subjects (365). For a median time of 19 months, researchers

followed 355 HIV-positive patients who were not taking any antiretroviral therapy and fell into three categories:

former IV drug users, enrollees in methadone maintenance during the study period, and continued users of IV

drugs. Multivariate regression analysis showed that the latter group was almost 80 percent more likely to

progress to acquired immunodeficiency syndrome (AIDS) than the groups who ceased IV drug use (odds ratio

= 1.76). Lifetable analysis also revealed a significantly lower probability of disease progression among those

who had stopped using IV drugs. After 3 years, the probability of progression to AIDS was 19 percent in

former IV drug users, 24 percent in the methadone group, and 41 percent in the persistent IV drug use group

(365).

-101-
102- The Effectiveness of DrugAbuse Treatment: Implicationsfor Controlling HIV Infection

Historically, IV drug users have had higher death

rates from a variety of causes (overdoses, injuries,

infections). They have suffered from an increased

incidence of a range of infectious diseases, from all

types of hepatitis and endocarditis to sexually transmitted diseases (gonorrhea, syphilis); central nervous

system disorders; and skin, bone, and joint infections.

All of these diseases have been reported to increase

in recent years (139). Furthermore, recent studies

indicate the presence of human T-lymphotropic

viruses (HTLV-1 and HTLV-2) in some populations

of IV drug users. These viruses have been associated

with a necrologic disorder and with adult T-cell

leukemia and lymphoma (139).

METHODOLOGICAL PROBLEMS

Any study of the effectiveness of treating drug

abuse to prevent HIV infection involves a series of

major methodological obstacles. The difficulty of

establishing a cause-effect link in human studies, as

discussed in chapter 4, is further exacerbated by the

complex nature of HIV disease.

As is the case in other fields, the inclusion of an

evaluation component in AIDS intervention programs is the exception rather than the norm

(220,296). Despite the challenges that this type of

evaluation poses, it is essential to conduct rigorously

designed evaluation research with sufficient

resources to provide policymakers with information

necessary for the more effective and efficient use of

resources.

Identifying the possible contribution of drug

abuse treatment to the prevention of HIV infection

relies on answering the following question: Did

treating drug abuse with a particular modality have

an effect in reducing the spread of the virus? The

issue is whether the observed change was a direct

consequence of the treatment or a result of one or

more external, non-treatment related factors. The

challenges that these question raise are discussed

below.

Study Design Issues

Major difficulties in study design include the following: identifying members of a hard-to-reach population, such as drug users; recruiting them; and

eliciting their cooperation for a study that could last

several years. Such a study requires truthful answers

about some compulsive and clandestine behaviors

and practices, practices that may subject individuals

to legal or social sanctions.

Random assignment to treatment modalities and

control groups is not always possible. Many factors--

personal, social, psychological, and legal--influence

an addict’s decision to enter and remain in

treatment. The alternative to a randomized controlled experiment is the quasi-experimental design.

Trade-offs between feasibility and the likelihood that

the study will provide valid evidence of the

treatment’s effect become a necessity. Moreover, the

more removed the study design is from a randomized

clinical trial, the more prospects for a truly valid

comparison fade. Subsequently, since the observed

findings may not be attributed directly to treatment,

alternative plausible explanations need to be considered to critically evaluate and perhaps explain any

findings.

Study Outcome Issues

After the type of design option is settled, the next

major question concerns choosing the types of outcomes that best demonstrate the effectiveness of the

treatment. A number of potential outcomes exist

and have been classified into three categories:

biological, behavioral, and psychological (220).

Since, at present, preventing AIDS means halting

the spread of the virus, the most direct measure of

outcome is the actual seroconversion of abusers

under treatment and not in treatment to HIVpositive status. Seroconversion, however, may be a

rare event even among high risk-groups (220). On

the other hand, annual rates up to 10 percent or

more have been reported (145,203). Very low rates

of seroconversion require that for researchers to be

able to observe meaningful statistical differences,

large numbers of subjects need to be recruited and

retained for followup for a long time. Such a study is

accompanied by the logistical and financial problems

of testing and retesting people at frequent intervals

for HIV infection (220).
Chapter 5-- Treatment for Drug Abuse as a Strategy to Prevent HIV Infection- 103

An alternative option to the use of seroconversion

or seroprevalence as an outcome measure in

evaluation studies is the use of a surrogate disease

with the same transmission patterns, such as hepatitis

B. Another option is to use intermediate outcomes

relating to behavior, such as sharing drug-injecting

equipment or having unprotected sex, to measure the

reduction of risk behaviors that lead to HIV

infection. A last option is to use psychological outcomes that measure awareness or knowledge about

the behaviors that lead to infection (220). It should

be noted, however, that although awareness or

knowledge may be important for some people, they

do not necessarily induce behavior change (205).

Which outcome measure to use is also a decision that

involves trade-offs between feasibility and obtaining

direct evidence. By employing behavioral and, even

more so, psychological outcomes, researchers can

examine more immediate impacts. On the other

hand, the evidence for the treatment’s effectiveness

then becomes indirect.

Regardless of the outcome measure used,

another serious question is the duration of the study.

What is a sufficient time, not only to observe differences in behavior but also to maintain them, and

how often should outcomes be measured during the

study period?

Measurement Issues

Measurement of any type of outcome raises

issues of reliability and validity (173,249). Reliability

is the reproducibility of the results over repeated

measurements and relates to the lack of random

error over these repeated measurements. Validity

refers to the lack of systematic error, that is, whether

the measurement reflects what it is intended to

measure. These common issues are of particular

concern when self-reported data are used, in this

case behaviors that may be private and illegal. In

addition, the retrospective collection of information

exacerbates problems of recall.

There is evidence that reliability maybe less of a

concern than validity when people report drugrelated behavior (220,296). In some studies, data

collected from drug treatment centers under conditions of confidentiality have correlated well with

urine testing results (200). In another study,

however, the results were conflicting and produced

evidence that several variables influence accurate

self-reporting. In this study, the validity of selfreporting depended on the type of drug examined,

with self-reporting for opiates less valid and for

cocaine highly valid. Younger age and the use of

paraprofessional staff were associated with a

decreased rate of underreporting (199). Similarly, in

an experiment at San Francisco General Hospital’s

methadone detoxification clinic, the rates of selfreported needle-sharing increased from 40 to 60

percent when the patients were interviewed by staff

not affiliated with the clinic instead of clinic staff

(189).

Another critical issue in these types of evaluations

is whether to focus the measurement and the analysis

on the individual or the total population of drug

users and partners in a specified area. It is suggested

that because the final outcome of transmission

reduction is a function of the drug-using and sexual

behaviors of both HIV-positive and HIV-negative

individuals, the unit of measurement should be the

community rather than the individual (296).

However, it seems that both measures have a useful

role to play in treatment evaluation. In addition,

community-based research is a task with its own

challenges.

Validity of the Results

The goal of a well-designed and thoroughly

executed study is to eliminate or at least reduce possible sources of bias. Reducing biases ensures

internal validity by decreasing the likelihood that the

results are distorted and lead to misleading conclusions. But not all factors are amenable to control.

Of particular concern in researching AIDS issues is

the “background noise,” which refers to the mass of

information about the epidemic and its associated

risk behaviors. This background noise has the

potential to confound the outcome, thus making it

almost impossible to attribute any effect solely to the

treatment or other intervention under study (215).

Randomized controlled trials usually can overcome

these difficulties.

After the validity of the results is addressed, the

task remains of extrapolating them to other populations (external validity). Those drug abusers who
104- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIV Infection

were accessible, available, motivated, and willing to

cooperate and complete the study may have some

unique known or unknown characteristics that make

them different from other abusers who did not participate. As in any study, caution should be exercised

in generalizing the results to other groups in the

same city, let alone to different regions of the

country.

EFFECTIVENESS OF DRUG ABUSE

TREATMENT TO PREVENT HIV

INFECTION

There is a growing body of literature on programs

to prevent HIV infection among IV drug users. The

data demonstrate that drug users are capable of

altering behavior to protect themselves and their

partners (91,273). It is of concern, however, that

drug users are less likely to change sexual practices

than injection practices. A variety of studies indicate

that a higher proportion of IV drug users change

practices to reduce needle-sharing or clean

equipment than practices related to heterosexual

transmission (26,27,341).

Despite the relative availability of studies examining behavior changes for HIV prevention among

IV drug users, few studies have examined the role of

drug abuse treatment in preventing HIV infection.

These few studies have employed different designs

and different outcome measures. All but TOPS

examine the effect of one treatment modality,

methadone maintenance, on reducing IV drug use,

and with varying strength of evidence, all point to the

conclusion that methadone maintenance is beneficial

in halting the spread of HIV.

Reduction in Drug Use and Risk Behaviors

The Treatment Outcome Prospective Study

(TOPS) provided useful data for examining the effect

that treatment regardless of modality had on

behavior associated with HIV transmission, and

more specifically, on IV drug use (149). During the

year preceding admission, approximately 65 to 70

percent of all clients in the three admission cohorts

who responded to the interview (80 percent of all

clients entering treatment) were regular IV drug

users. The proportion of IV drug users in various

time periods (up to 3 to 5 years) after treatment was

approximately 25 to 30 percent of the clients sampled

for followup. This decline of IV drug use was similar

for the three cohorts that entered treatment in 1979,

1980, and 1981.

The investigators suggest that this marked decline

in IV drug use was a direct result of treatment and

not of fear and awareness of AIDS, since these

changes were similar across the three admission

cohorts before and after widespread knowledge of

AIDS. Treatment may exert a beneficial effect by

reducing overall drug use, thus leading to reductions

in IV drug use. The investigators suggest that

treatment for drug abuse, “is an effective means of

reducing the risk of exposure to HIV infection”

(149). Without a comparison group of untreated IV

drug users, however, the role of other factors is not

clear.

It is troubling that those who remain regular IV

drug users seem resistant to changing the route of

drug administration (149). Although treatment

improvements may reduce even further the number

of these hard-core users, different approaches may

be needed to reduce the risk of HIV infection among

this group.

Ball and colleagues conducted a carefully

designed 3-year study of 6 methadone clinics in 3

Eastern U.S. cities to evaluate the effectiveness of

methadone maintenance not only in reducing drug

use but also in reducing needle-sharing (20,21). In

the winter of 1985-1986, 633 male methadone

patients, including those already in treatment and

new admissions, were interviewed, and 506 (80

percent) were reinterviewed 1 year later. Of those

reinterviewed, 107 had ceased treatment at the time

of followup. Although 98 percent of the patients had

been IV users, the prevalence of IV drug use at

admission was 81 percent because some abusers had

been incarcerated or in another drug treatment

program prior to their admission. For those who

remained in treatment, the mean time in treatment

was 45 months. Overall, among the 388 patients (61

percent) who remained in treatment for 1 year or

more, the prevalence of IV drug use decreased by 71

percent. The largest drop in prevalence occurred

during the admission period (from 81 percent with

IV use to 63 percent), and subsequently the decline

continued at a slower rate to 29 percent for those in
Chapter 5--Treatment for DrugAbuse as a Strategy to Prevent HIV Infection - 105

treatment 4 years or longer. In contrast, the annual

relapse rate for those who ceased treatment was 82

percent, and the probability of relapse was directly

related to the time out of treatment.

Patients were classified into 5 groups according to

treatment status at last IV drug use (before current

admission, at admission, during treatment, last year,

and current IV drug use). A sizable proportion, 36.4

percent of the 324 patients for whom information

was available on sharing practices, reported that they

shared needles during their last or current, period of

IV drug use; however, only 9 percent of all patients

in treatment were currently sharing needles (2 I).

The investigators also compared the frequency of

needle-sharing among these groups. The results

showed that the frequency of needle-sharing days per

month was significantly lower for those patients

whose last IV drug use occurred after admission to

treatment compared with the needle-sharing days of

those patients whose last IV drug use occurred at or

before admission. This finding suggests that

treatment had a positive effect in reducing this highrisk behavior even among those who continued IV

drug use while in treatment. In grave contrast, for all

those who had been out of treatment for 10 to 12

months, the proportion of needle-sharers was 48

percent (21).

A special methadone maintenance clinic for IV

drug users who are infected with HIV, have

symptoms of the disease, or have AIDS has been

operating at the San Francisco General Hospital

(23). An evaluation of 42 people enrolled in this

program at 3 and 12 months showed that heroin use

in the past 30 days had decreased from a mean of 28

days use to 7 days, a statistically significant difference. Cocaine use decreased, but to a lesser

degree. Sexual activity had also decreased overall,

but the rate of condom use remained the same. The

12-month results were quite similar to the 3-month

findings (280).

HIV Infection and Entry Into Treatment

The next set of studies provide indirect evidence

of methadone maintenance’s protective effect. These

studies looked at cohorts entering methadone

maintenance at different times and observed that

those who entered treatment earlier in the course of

the epidemic and remained in treatment had lower

HIV infection rates. This finding implies that

methadone maintenance had a beneficial effect in

preventing infection by reducing IV drug use, especially at the time of HIV spread. Although those

who remain in treatment longer maybe self-selected,

nevertheless these studies underscore the importance

of having the drug user in treatment early in the

spread of HIV in a specified area for treatment to

exert its maximum protective effect.

A retrospective followup study of 995 patients

entering methadone maintenance in the Bronx

between 1978 and 1987 was conducted (132). The

analysis showed that the year of entry into treatment

was the strongest predictor of AIDS incidence: 11.4

per 1,000 person years for those entered before 1983

as opposed to 33.0 per 1,000 person years for later

entrants. Regression analysis, which controlled for

age, sex, race, entry selection factors, and length of

treatment, showed that the year of entry was a

stronger predictor of AIDS than race, with odds

ratios of 2.6 and 1.1, respectively. One subgroup of

362 patients was enrolled in a longitudinal

seroprevalence study to examine the association

between methadone maintenance and HIV status.

Data from this group showed an inverse relationship

between the length of time in methadone

maintenance and HIV seropositivity (132).

In a similar study, 239 methadone maintenance

patients in a New York hospital were interviewed

between 1986 and 1987 and classified into cohorts

according to the year of entry into methadone

maintenance. Among the three cohorts entering

methadone maintenance before 1982, between 1982

and 1984, and after 1984, the HIV-seropositive rates

at entry were 35 percent, 54 percent, and 57 percent,

respectively (l). Lower seroprevalence rates among

the earlier cohorts who continued methadone

maintenance at a time of rapid spread of HIV in

New York City testify to the protection offered by

this modality.

Another study tested clients from 28 methadone

maintenance centers in New York City for HIV from

June 1988 to January 1989 and found that new

entrants were 1.7 times more likely than longer-term

clients to be HIV-positive (295).
106- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIV Infection

In a similar analysis, 2,430 patients enrolled in

methadone maintenance between 1972 and 1988

were studied to examine the relationship of IV

cocaine use to HIV infection and AIDS. IV cocaine

use was significantly associated with both HIV

infection and AIDS mortality. Subsequent analysis

revealed that entrance into methadone maintenance

after 1980 was an independent predictor of HIV

status and of AIDS and pneumonia deaths, with odds

ratios exceeding 2.0 Low daily methadone dose (less

than 60 mg) was also found to be associated with

HIV antibody and with testing positive for heroin

and cocaine use (376). In addition, those on 60 mg

or more per day were less likely to relapse and more

likely to remain in treatment (327).

A study of 454 people in drug abuse treatment

clinics in New York City in 1989 examined

demographic, behavioral, and clinical features of

HIV infection. Multivariate analysis revealed that

lower methadone dose and shorter period of drug

treatment enrollment were significant predictors of

HIV-positive status (40).

Also in New York City, Novick and colleagues in

1985 reported that the prevalence of HIV antibodies

was 23 percent among patients in methadone

maintenance as opposed to 47 percent among those

not in treatment. The lowest rates were observed

among those who had the longest treatment stays in

methadone maintenance (228).

History of methadone maintenance treatment

and HIV serostatus were examined in a cohort of

2,112 heterosexual IV drug users in San Francisco

from 1985 to 1989. Those who had spent more than

60 months in methadone maintenance had half the

risk of being HIV positive of those with less than 60

months (odds ratio = 0.5, confidence interval 0.35 to

0.70) (374).

The same pattern of lower seroprevalence rates

among drug abusers who entered treatment early in

the epidemic and remained in treatment has been

observed in other countries. In Sweden, patients

were tested at admission and retested during subsequent treatment. The prevalence of HIV-positive

patients admitted before 1983 was 3 percent, but it

was 16 percent for those admitted in 1984 and 1986

and 57 percent for those admitted in 1987 (36).

There was no seroconversion to HIV-positive status

among those who tested negative upon admission

since 1984 and were still on the program in

December 1987. Likewise in Italy, the HIV rate was

21 percent for the 1981 to 1985 entrants into

methadone maintenance, and 62 percent for those

entering after 1987 (291).

Medical Maintenance

The concept of medical maintenance has been

described in chapter 3. Stable, non-drug using,

socially rehabilitated methadone maintained subjects

receive their methadone from a physician in intends

as far apart as 28 days. It is reported that among the

58 respondents from the qualified group of socially

rehabilitated and stable methadone maintenance

clients who received their methadone at the office of

a primary care physician, none was HIV-positive

(229).

Interim Methadone Maintenance Program

The interim methadone maintenance program is

a measure proposed by the National Institute on

Drug Abuse and the Food and Drug Administration

that is intended to curb the spread of HIV among IV

drug users, especially among those on waiting lists

for methadone maintenance. This concept calls for

faster provision of methadone and HIV counseling

without additional ancillary services (counseling,

vocational and educational training, urine testing)

until treatment space in a comprehensive program

becomes available. This proposal by the U.S.

Department of Health and Human Services in 1989

raised considerable debate and sharply divided the

drug treatment community. The Department has

since withdrawn the proposal for interim methadone.

The issue nevertheless arises here because of its

implications for preventing HIV infection among IV

drug users.

Two relevant studies provided what seemed to be

conflicting results with respect to the benefits of

providing methadone alone. A closer examination of

these studies, however, reveals that there is not

necessarily a conflict between their findings, as they

address different issues. The first study was conducted in New York City and provided evidence of a
Chapter 5-Treatment for Drug Abuse as a Strategy to Prevent HIV Infection- 107

beneficial effect (264). IV drug users on a waiting

list to enter methadone maintenance were randomly

assigned to two groups. One (36 subjects) received

methadone daily, urine testing twice a week, and an

interview, and the other (26 subjects) received only

urine testing twice a week and an interview. At

baseline, needle use averaged 95 times per month for

both groups; at followup (after at least 30 days),

needle use had decreased to 33 times per month for

the methadone group but remained almost

unchanged, 87 times per month, for the control

group. The prevalence of heroin use for the experimental group dropped from 60 percent to 29 percent,

while it remained almost stable from 62 to 60 percent

for the control group. Cocaine use continued the

same for both groups. It was also reported that the

mean number of days since last drug injection was 33

days for the treatment group, significantly longer

than the mean of 7 days for the control group. In

addition, improvement in quality-of-life scores was

observed for the methadone group.

Preliminary results from an ongoing study in

Philadelphia have been used to argue against interim

methadone. This study is designed to identify the

“active ingredients” of a methadone maintenance

program (59). To accomplish this, three levels of

methadone maintenance services are being compared: 1) minimum methadone maintenance, with

only methadone, emergency counseling, and referral

services; 2) basic methadone maintenance, with

counseling and urine testing, but no other additional

services (family or employment counseling); and 3)

enhanced methadone maintenance, with a more

comprehensive set of services (medical and

psychiatric care, social work, family therapy). Those

who participate in the study are randomly assigned to

one of these methadone maintenance levels. The followup time is 6 months, and outcome measures

include IV drug use and high-risk behaviors for HIV

infection.

This is an ongoing study, and data collection is in

very early stages. One interim outcome measure is

the proportion of patients who required “protective

termination.” According to the investigators, this

outcome indicates an unacceptable level of illicit

drug use. The criteria used were 1) either 8 total or

4 consecutive opiate-positive urine tests during the

24-week intervention, 2) either 12 total or 6 consecutive cocaine-positive urine tests during the same

time period, or 3) 3 or more psychiatric emergencies.

Investigators observed that more than half the

participants in the minimum methadone

maintenance group met the “protective termination W

criteria, while none in the enhanced methadone

maintenance did so. This finding pertains to a small

number of patients but is statistically significant. Of

the 15 patients assigned to minimum methadone

maintenance so far, 9 met the protective termination

criteria, while 2 of the 12 assigned to basic

methadone maintenance did so. None of the 15

assigned to the enhanced methadone maintenance

met the requirements. Although the interim report

stated that blocking doses of methadone were

offered, it did not report the mean dose or mention

dose as a possible factor in interpreting the results.

Because inadequate dosage can confound the results,

evaluating the non-pharmacological components of

methadone programs requires provision of an adequate dose and controlling for dose in data analysis.

When completed, this study is expected to

provide useful insights regarding the relative effectiveness of methadone maintenance programs and

their effects on HIV-related high-risk behaviors. If

the results demonstrate the increased effectiveness of

the more comprehensive methadone maintenance

services, they will be in accordance with previous

findings that program factors, more than client characteristics, play a major role in reducing IV drug use

among methadone maintenance clients and in

improving treatment effectiveness (21). On. the other

hand, such findings and preliminary results would not

provide evidence that an interim methadone program

is ineffective, since at least 40 percent of those in the

minimum methadone maintenance reduced or

eliminated their IV drug use (6 out of 15 who

remained on minimum methadone maintenance).

From the public health perspective, it would be a

gain if a similar proportion of IV drug users on a

methadone maintenance waiting list in a highly

infected area abstained from IV drug use and

needle-sharing. Such a reduction would be another

step in breaking the chain of HIV spread.

Those who support the interim concept argue

that existing capacity cannot accommodate everyone
108- The Effectiveness of Drug Abuse Treatment: Implications for Controlling HIV Infection

who seeks treatment. For those who want to enter

methadone maintenance and are placed on a waiting

list, the alternatives are limited. To the extent that

their physical dependence on opiates leads them to

continue shooting heroin intravenously to alleviate

drug hunger and withdrawal symptoms, they continue to engage in the high-risk behavior of needlesharing (225). The provision of interim methadone

and HIV counselling to those individuals who cannot

be admitted because no comprehensive treatment is

available attempts to offer an immediate response to

this urgent situation.

Opponents of interim methadone argue that the

multiplicity of problems that drug abusers bring with

them into treatment--psychiatric disorders, multiple

drug abuses, other illnesses, limited or no education,

unemployment, legal problems, and homelessness--

calls for an uncompromised, comprehensive

approach to the whole problem. During current

efforts to expand treatment capacity and improve its

quality, some have argued that relaxing drug

treatment requirements through an interim program

would send the wrong message and “undermine the

foundation of treatment structure” (235,363).

Moreover, there is the danger that the existence of

an interim methadone program in a given treatment

facility would increase pressure on the staff to discharge clients prematurely and to admit those who

are on the waiting list. More importantly, opponents

argue, despite the intention of patients to transfer to

a more comprehensive setting, given the existing

realities, they might remain on interim status

indefinitely. Thus, the interim methadone program

might evolve from a temporary substitute for comprehensive treatment to a “permanent and less costly

part of the treatment system” (235,363).

All these concerns are worth considering. The

HIV epidemic, however, adds an additional

dimension to the problem and warrants a clear focus

on societal priorities. Of the estimated 500,000

heroin users in the United States, approximately

400,000 are not currently in treatment (225). The

increased outreach efforts initiated by the HIV threat

are, and will continue, bringing more people to

treatment. It is unclear whether and how the system

is prepared to respond in a timely fashion. Interim

methadone has been proposed exclusively as an

alternative to continued heroin injection in the street

by the hundreds of thousands of heroin users who do

just that three or more times every day.

It is important to note that since methadone has

no pharmacological action against cocaine, IV use of

cocaine may continue. Thus, the argument is used

that interim methadone will have a minimum impact

on IV drug use, and will not protect against HIV

spread. Not all heroin users, however, also abuse

cocaine intravenously. Rates of IV cocaine use, are

lower in most narcotics addicts than their rate of

injecting heroin (9). A survey in 1989 of 24

methadone maintenance centers around the country

revealed that the prevalence of concurrent use of

cocaine varied from O to 40 percent (299). In 8 programs, the prevalence ranged from 20 to 40 percent;

in the remaining 16, it ranged from O to 15 percent.

In 5 methadone maintenance clinics surveyed in New

York City, the proportion of cocaine users was

between 8 and 21 percent in 4 of the programs and

40 percent in the fifth (299). It seems, however, that

cocaine abuse may fall while heroin abusers attend

methadone maintenance, most likely among those

who use one drug to mitigate the effects of the other.

TOPS data showed that the proportion of regular

cocaine users decreased from 26.4 percent 1 year

before methadone maintenance treatment to 9.4

percent at 3 months in treatment (149).

The potential for HIV spread exists each time

needle-sharing and injection occur. These are practices in which people both outside the treatment

milieu and those on waiting lists for methadone

maintenance engage. With respect to the latter,

findings from a still unpublished study are of particular concern, although the numbers are small.

This study showed that of those opiate abusers

seeking treatment in New Haven in 1988 who were

not IV drug users at the time of clinic intake, 35

percent (6 of the 17 patients who were intranasal

heroin users) either started or resumed IV drug use

by the time of admission, 1 to 4 months later (256).

Pharmacologically, an adequately high dose of

methadone addresses the biochemical aspects of

heroin abuse by blocking drug hunger and the onset

of opiate withdrawal symptoms. In practical terms,

those individuals who respond to methadone will
Chapter 5-Treatment for Drug Abuse as a Strategy to Prevent HIV Infection - 109

stop the IV use of heroin, breaking one link in the

transmission chain of HIV. Any sustained reduction

in injection frequency reduces the rate of HIV transmission. In medical and epidemiologic terms, this is

a very important step toward shrinking the pool of

people at risk of spreading or contracting HIV

infection. From a public health perspective, this is a

need that cannot be ignored. It is possible that

interim methadone maintenance programs may be

more appropriate for certain areas, such as those

with a large number of IV drug users and long

waiting lists (for example, for New York City as

opposed to a rural community) (see ch. 3). Concerns

for deterioration of existing services because of

interim methadone might be addressed by the “development of appropriate guidelines for both interim

and comprehensive maintenance treatment and

monitoring by an appropriate quality assurance

agency” (9).

ADDITIONAL APPROACHES TO

PREVENT HIV INFECTION

To understand better the contribution of drug

abuse treatment as a strategy to prevent HIV

infection, one must consider a framework of policies.

These policies in turn should be based on consideration of the following facts: that the probability of

contracting HIV is a function of many variables and

that drug users in treatment may differ in attitudes

and motivations from drug users not in treatment.

The probability of contracting HIV from drug use

is a function of both the risk from needle use and the

risk from sexual practices. In both cases risk

depends on the prevalence of HIV infection among

partners and their infectiousness. The risk from

needle use also depends on the number of persons

sharing equipment, the use of rented or borrowed

needles, the frequency of injection, and the frequency

and effectiveness of needle-cleaning behaviors. The

risk from sexual practices depends on the type of

practice, the number of partners, and the frequency

of preventive measures, such as condom use.

Moreover, drug users differ widely in their attitudes and practices. Some drug users smoke or sniff

heroin, cocaine, or amphetamines but do not yet

inject them. In addition, of those who are using

drugs intravenously, the vast majority are not currently in drug treatment; some have a desire to enter

but cannot, due to the lack of available space, and

some simply do not want to get treatment for their

drug abuse (45,239,324,332a). Of those who are in

treatment, some actively sought it and are motivated

to complete it. Others are not personally motivated;

although some kind of family, social, or legal

pressure brought them into treatment, they also may

respond to treatment. Finally, some enter treatment

for temporary relief from the “hustle” of drug use or

to reduce their tolerance to the abused drugs

This diversity makes it essential from a public

policy perspective to distinguish between risk

elimination and risk reduction, with the latter being a

viable and vital public health objective. The

justification for such a distinction is further reinforced by the reality that there is no immediate,

effective way to treat cocaine abuse, a tragic reality

that has direct consequences for the spread of HIV

infection.

From the public heath perspective, the objective

is to control the HIV epidemic. A comprehensive

HIV prevention strategy needs to keep a sharp focus

on this objective and to recognize all the above

realities. Both the urgency of the epidemic and a

realistic assessment of drug abuse dictate that there

should be a hierarchical structure of tactics against

HIV infection, and appropriate multiple policies

should take account this structure. As Sorensen has

stated with regard to drug use, tactics include total

abstinence, not injecting drugs, not sharing needles,

and, if sharing needles, then cleaning needles effectively. With regard to sexual activity, the hierarchy

consists of abstinence, monogamous relationships,

and safer sexual practices, including use of condoms

with casual and regular partners (281).

The Importance of Preventing IV Initiation

Preventing drug sniffers and smokers from

switching to injection can eventually reduce the pool

of eligible people at risk of spreading HIV. The

most common factors mentioned among heroin

sniffers that promote initiation of IV use are fear of

tolerance to sniffed heroin and social pressure from

friends who inject drugs. Clearly, programs are
110- Effectiveness of DrugAbuse Treatment: Implications for Controlling HIV Infection

necessary to address these issues, perhaps by emphasizing techniques to cope with social pressure and

providing counseling about HIV infection (93).

Risk Reduction Through

Needle-Exchange Programs

To prevent HIV transmission, short of

abstinence, risk reduction implies safer drug and

sexual practices. One approach is to provide the

means for safer practices, in an attempt to reduce the

harm associated with IV drug use to both the user

and society. The means for safer practices are clean

needles, bleach to disinfect used equipment, and

condoms. The provision, especially of materials

related to safer IV drug use, is considered controversial because of the argument that the mere

provision of injection equipment encourages drug

use and consequently leads to increased use. There

is no empirical support, however, for such an

argument.

Needle exchange programs in which a person can

exchange used needles for new ones have been operating in England, Holland, Australia, and a few sites

in the United States. The premise is that scarcity of

injection equipment contributes to sharing and multiple uses, thus increasing the chances of HIV transmission. Those who support these programs view

them as one of the many HIV prevention strategies

making up a comprehensive strategy to halt the

spread of the infection. These programs are targeted

specifically to the large numbers of drug users who

are not in treatment and who continue to inject drugs

and share needles. In fact, these programs may

provide the vehicle for educating people not in

treatment and for recruiting them into treatment.

The underlying philosophy is that, “keeping drug

users alive is more important than keeping them

clean. Recovery is possible after relapse, but it is not

possible after death” (278).

Opponents argue that providing injection

equipment sends wrong messages, since abstinence

from drug use is inconsistent with exchange of

needles. They argue that these measures may be

perceived as condoning drug use and that the provision and availability of needles will lead to

increased drug use:

The evaluation of needle-exchange programs

raises serious methodological problems and is often

hard to conduct. Biased selection into the program

and high turnover of this population with losses to

followup are major obstacles to valid evaluations.

Furthermore, even if these programs are shown to be

effective in reducing high-risk behaviors that lead to

HIV infection, it is even harder to identify their contribution to slowing HIV infection in a community.

Nevertheless, advances in research methods have

allowed rigorous research, including randomized

controlled studies, to be conducted in areas, such as

treatment for drug abuse, previously considered

impractical. Methodological problems, therefore,

should not stymie efforts to evaluate needleexchange programs.

Despite methodological problems, studies have

been performed both in Europe and the United

States. An evaluation of a program in London found

that in the year prior to the exchange scheme, 49

percent of 133 participants had shared needles (131).

Seventy-six of the initial sample of 133 were reinterviewed for a second time. Approximately 1 month

and 4 months into the program, 85 and 89 percent

respectively, had not shared needles in the 4 weeks

before the interview. An evaluation was also performed of a program in Tacoma, Washington (%).

The evaluation examined the number of

opportunities for HIV infection, i.e., the frequency of

injection with used or borrowed equipment, among

106 participants. A statistically significant decline

was observed from a frequency of 62 injections per

month with used or borrowed equipment before the

exchange to 44 per month after the exchange.

Another analysis of drug use trends from the same

program found no significant difference in the overall

rate of drug injection before and after participation

in the program (125). Findings from all these

studies, however, come from self-reported behavior.

None of the studies had a control group, and the representativeness of the IV drug users interviewed was

not clear.

It is difficult to evaluate the effect of such programs in slowing the rate of HIV transmission in a

particular community, especially because of the long

latency period of HIV infection. Hepatitis B

infection is transmitted among IV drug users through
Chapter 5-Treatment for Drug Abuse as a Strategy to Prevent HIV Infection- 111

the same routes as HIV and has a considerably

shorter latency time. A 1989 evaluation of the

Amsterdam needle-exchange program, which was

initiated in 1984, included an assessment of the

annual incidence of hepatitis B infection. The

incidence of hepatitis B infection declined steadily

from 49 per 10,000 drug users in 1984 to 9 per 10,000

in 1989. This decline, as the authors state, “indicates

that a change in injecting behavior indeed seemed to

occur among IV drug users in Amsterdam” (70).

Summarizing presentations at the Fifth International Conference on AIDS in 1989, Wohlfeiler commented that needle-exchange programs may serve as

contact points for education and referral (Wohlfeiler

1990). In the recent “What Works” conference on

drug abuse treatment, Stimpson examined strengths,

limitations, and areas of further development with

respect to these programs. Based on information

from Europe and Australia, the author concluded

that syringe exchange programs have attracted

people with lower levels of risk behavior and have

experienced high turnover and low retention rates.

Stimpson found that injectors who attend syringe

exchange programs reported desirable, although

small, changes in behavior (272). A recent

evaluation study was particularly enlightening in

understanding needle-exchange programs (354).

This study showed that needle-exchange programs

did not automatically lead to sweeping changes in

high-risk behaviors, although the proportion

reporting borrowing or lending of syringes decreased

over time among participating IV drug users (354).

The authors speculated that a combination of

providing the means to reduce risk and intense

counseling may be needed to produce the necessary

drastic changes in risk behavior. Their point underscores the importance of comprehensive strategies

that consider the complexities of drug abuse.

Overall, available studies do not provide evidence

to support claims that provision of needles makes

non-IV drug users switch to IV use or that such provision leads to increased drug consumption. In fact,

decreases in the frequency of sharing have been

reported. On the other hand, available studies do

not allow one to conclude that needle-exchange programs alone reduce risky behavior. The design of

the studies so far has not allowed researchers to

separate the effects of the program from other

influences, such as the characteristics of the users

who continue to participate. This situation has often

characterized community intervention studies.

Needle-exchange programs have raised heated

debates. The urgency and threat of the HIV

epidemic, however, make it even more important

that innovative prevention approaches have a fair

chance to be tested and evaluated.

Sale and Possession of Injection Equipment

Public policies in the United States limit

availability of injection equipment. It is illegal in all

but 11 States to sell syringes without a prescription

(87). Furthermore, drug paraphernalia laws make

possession of injection equipment illegal in almost all

States (87).

Certain European countries do not have laws

restricting the sale and possession of injection

equipment. Research conducted in France, Austria,

and Scotland, countries that allow over-the-counter

sales of syringes, assessed the impact of programs

that educate pharmacists about the need to prevent

HIV. There were large increases in the number of

drug users purchasing and using sterile injection

equipment (87).

Paraphernalia laws that make it illegal to possess

injection equipment are impeding evaluation of overthe-counter sale of syringes in those States

permitting purchase without a prescription. The

clear and present danger of the HIV epidemic

increases the pressure for reevaluation of public

policies with regard to the purchase and possession

of syringes, especially since there is no empirical

support to claims that mere availability of injection

equipment leads to increased injections (27,87).

Since sharing occurs because of scarce injection

equipment and for social reasons, preventing the

spread of HIV infection among IV drug users maybe

enhanced by complementary measures to providing

treatment or just providing the means for safer practices, such as interventions to change social patterns

with regard to sharing. Wiebel states that “social

networks of IV drug abusers as a whole should begin

to discourage the sharing of drug injection

equipment--including rinse water, cookers and
112- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIV Infection

cottons--or at least the sharing of syringes that have

not first been disinfected” (372).

The Role of Outreach Programs

Implementing effective strategies to prevent HIV

infection calls for access to as many IV drug users as

possible, both those who are in treatment and those

who are not. Drug treatment programs provide the

means for the former, while outreach programs may

accomplish the latter.

An estimated 130,000 clients in drug and alcohol

treatment facilities as of Sept. 30, 1989 were IV drug

users at the time they started treatment (332a). On

the other hand, the estimated number of IV drug

users in the United States ranges from 1.1 to 1.8

million (45,64,324). That 10 to 20 percent of IV drug

users in the United States are in treatment at any time

implies that at least one million or more are not in

treatment. Since it is estimated that approximately

80 percent of IV drug users have sexual partners that

are not using drugs, a target population of over 1.8

million may be engaging in high-risk behaviors for

contracting HIV (318). Estimates of IV drug users

and their sexual partners at risk of HIV infection

have reached as high as 4.5 million (243).

Because so many IV drug users are not in

treatment, outreach programs could make a substantial contribution. In Chicago, 42 percent of those

contacted through an AIDS outreach project had

never been in treatment (370). Similarly, in New

Jersey, 40 percent of those persons redeeming

vouchers for a free detoxification program had never

been in treatment (152).

A variety of community-based programs in more

than 50 cities in the United States are tailored to

reach drug users not in treatment and their sexual

partners. The majority of trained community outreach workers are ex-abusers themselves. The effort

to reach those groups takes workers to shelters,

street corners, and shooting galleries. The operating

premise is first to reach the addict, next to gain his or

her confidence, and then to provide a series of HIVprevention activities. Such programs offer individual

or group educational sessions with instructions on

safer drug use and safer sexual practices, HIV testing

and counseling, and referrals to drug treatment and

other social services. Outreach programs through

their contacts with drug users who are not in

treatment are a key vehicle for applying measures

that may be appropriate for successful risk reduction

efforts, such as information on AIDS prevention,

provision of the skills to accomplish desired behavior

change, and reinforcement for long-term

maintenance (92).

The National AIDS Demonstration Research

Project, an ongoing program, is the largest U.S.

intervention program relating to IV drug users not in

treatment (340). As of July 1990, 41 communitybased projects throughout the country have enrolled

38,635 IV drug users and their sexual partners (341).

According to one of its principal investigators, it has

already demonstrated that it is feasible to identify

and educate active drug users in the community

setting (369). Preliminary results show that IV drug

users not in treatment can modify their behavior to

reduce the risk of HIV infection (369). The data

have indicated that 50 percent or more of those who

received an intervention reduced the frequency of IV

drug use. The intervention included intensive

counselling, skills training, educational materials, and

peer group support (37).

Preliminary data based on followup interviews of

1,584 IV drug users who were recruited between

1987 and 1989 and who had completed both the

initial and first 6-month followup interviews are

available from five cities: San Francisco, Chicago,

Miami, Philadelphia, and Houston (341). Followup

rates in all cities but Houston were greater than 65

percent (45 percent for Houston). Substantial proportions reported decreasing IV drug use, from 49

percent in San Francisco to 75 percent in Miami.

These figures include complete cessation of all IV

drug use from 16 percent of followup respondents in

Chicago to 47 percent in Miami. Similarly, the proportion reporting either never sharing or never borrowing “works” increased between baseline and followup. Substantial percentages of respondents

reported decreases in sharing or borrowing injection

equipment. Of those respondents who continued to

inject drugs at followup, except for those who

reported always using new needles, 20 to 39 percent

reported increased use of bleach. Reported use of

condoms also increased in all five cities. Overall,
Chapter 5--Treatment for DrugAbuse as a Strategy to Prevent HIV Infection- 113

however, reported reductions in sexual behaviors

(use of condoms with steady or multiple partners)

lagged behind reduction of high-risk drug use

behaviors.

There is also evidence that outreach programs,by

encouraging drug abusers to seek treatment, have

increased the demand for treatment (107). For

example, in Tacoma, Washington, of 218 treatment

vouchers distributed, 75 percent were redeemed and

led to detoxification treatment. Almost half of those

who entered detoxification treatment (48 percent)

were subsequently transferred to methadone

maintenance (244). Nearly 50 percent of 1,884 IV

drug users in New Jersey redeemed their coupons for

free and immediate entry to 21- or 90-day

methadone treatment (341). The proportion of individuals in the National AIDS Demonstration

Research project entering formal drug treatment

varied from 14 to 35 percent, with the lowest rates in

Miami and Houston (14 and 15 percent, respectively), where the capacity of publicly funded drug

abuse treatment programs is reported to be limited

(341).

Similarly encouraging results are reported by

Watters and colleagues from a community-outreach

program in San Francisco (361,362). Elements of the

outreach program included provision of bleach and

condoms and a clandestine needle-exchange

program. A series of seven cross-sections of 2,114

heterosexual IV drug users, 57 percent of whom were

not enrolled in treatment programs at the time of the

interview,’ between 1986 and 1989 revealed a change

in HIV high-risk behaviors (362). The proportion

reporting no needle-sharing gradually increased from

8.8 percent in 1986 to 53 percent by late 1989.

Decreases in needle-sharing were also reported

among IV drug users entering treatment in San

Francisco (124). A combined measure of needle

hygiene, which included frequency of use of bleach,

no needle-sharing, and cleaning syringes with

alcohol, increased nearly five times. At baseline in

1986, needle hygiene was reported 13 percent of the

time, while in 1989 it was reported 80 percent of the

time (362). Frequency of injection for both those in

treatment and those not in treatment declined over

time. Condom use increased significantly over time

from 4 percent to nearly 30 percent by late 1989.

Hepatitis B eases among injection drug users diagnosed at San Francisco General Hospital declined

from 36 percent in 1987 to 23 percent in 1989.

Although HIV seroprevalence almost doubled from

7 to 13 percent between 1986 and 1987, it thereafter

remained at about the same level, 11.4 percent in

1989 (362). Overall, it has been reported that

seroconversion in San Francisco has also leveled off

at 2.4 percent annually (124). These reported major

behavior changes of key risk behaviors coincided

with the implementation of outreach efforts.

It should be noted that providing the means for

IV drug users not in treatment to switch to safer

behaviors (bleach, condoms) reaches those at high

risk of contracting and transmitting HIV. These

people may include those who want treatment and

are on waiting lists, those who are contemplating and

with some encouragement may seek treatment, and

those who currently do not have a desire to stop

using drugs. From the public health perspective,

provision of material on safer practices is a justified

action. Overall, these outreach programs may lead

to behavior changes, perhaps not for all users and

perhaps not each time they engage in drug or sexual

activities. Because AIDS is such a lethal infectious

disease, any gain in delaying the infection from

spreading to more people is important. “Any

decrease in injection frequency is likely to reduce the

risk of further HIV spread.

SUMMARY

The findings of available studies are consistent,

despite the various designs and outcome measures

used. Methadone maintenance has a positive effect

in reducing the spread of the HIV virus, because, if

properly implemented, methadone maintenance can

help reduce or even eliminate abusers’ desire to

inject drugs. Time spent in treatment and adequate

methadone dosage have been consistently found to

be important predictors of successful outcomes, in

particular, reduction of drug use and needle-sharing

practices.

No studies similar to the ones described above for

methadone maintenance clinics have been performed

among patients of therapeutic communities or outpatient drug-free programs. With an average stay of
114- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIV Infection

18 to 24 months in traditional therapeutic communities, a study would require a long followup time.

Risk behaviors leading to HIV infection are not

confined to IV drug users seeking methadone

maintenance treatment. It has been reported that 20

percent to 75 percent of those entering therapeutic

communities report either IV drug use or

unprotected sex (22,33). It would be reasonable to

assume that, given the substantial drug-free rates for

those who complete treatment or even stay a substantial amount of time in treatment, this modality

has the potential to reduce the high-risk behaviors

associated with the spread of the HIV, at least

among those who stay in treatment for a certain

time.

From the public health perspective and for

society’s benefit, spread of HIV infection needs to be

halted. Prevention and control of the HIV epidemic

among IV drug users, their partners, and offspring

require comprehensive strategies that reflect the

epidemiological characteristics of HIV infection and

the complexities of drug abuse. Drug treatment

alone, despite its effectiveness in reducing IV drug

use and needle-sharing is not sufficient. The fact is

that an overwhelming majority of IV drug users are.

not in treatment (45,218,332a,341). As many as 1

million or more not in treatment engage every day in

behaviors that place them at high risk of contracting

or transmitting HIV. Outreach programs are an

integral component of intervention strategies aimed

at those IV drug users not in treatment. Preliminary

results from different parts of the country have found

that IV drug users not in treatment are either

stopping drug use or changing their behavior to

reduce the risk of HIV infection (341). Outreach

programs also generate demand for treatment (341).

Experience from New Jersey and Washington has

shown that when financial barriers to treatment are

reduced, drug users who have never been in

treatment come forth and enter treatment.

Finally, it is increasingly important to reconsider

the desirability of additional interventions aimed at

IV drug users not in treatment, such as needleexchange programs and providing methadone and

HIV counseling to those on waiting lists. Fears that

exchange programs will lead to increased injection

are not supported by empirical evidence. Providing

blocking doses of methadone to heroin users on

waiting lists seems to be a better public health

measure than having them continue daily injections

of heroin. In light of the urgency of the epidemic, it

is reasonable to consider these and other programs

to reduce drug users’ risk of contracting HIV.

Overall, it should be emphasized that regardless

of the intervention to prevent HIV spread, what is

ultimately important in medical and epidemiologic

terms is the fact that any sustained reduction in

injection frequency is likely to reduce the rate of

HIV transmission. Such efforts need to be consistent

and persistent over time to break the chain of HIV

transmission.
Appendix A

Method of the Study

The Office of Technology Assessment undertook

this Background Paper in response to a request from

the House Committee on Government Operations,

Subcommittee on Human Resources and Intergovernment Relations. The Subcommittee asked

OTA to examine what is known about the effectiveness of treatment for drug abuse and analyze the

implications for controlling the spread of human

immunodeficiency virus (HIV) which causes

acquired immunodeficiency syndrome (AIDS).

The analysis was based on information gathered

from a wide range of sources. The process included

review of published and unpublished studies and

related material

researchers in the

academia.

In July 1990,

and extensive discussions with

field, both from Government and

OTA convened a workshop to

discuss a draft of the report. Workshop participants

included researchers in the field of drug abuse and

AIDS from academia, research organizations, and

the Government. The draft report was sent for

review to the workshop participants and other

experts from a range of disciplines and interests.

During July and August 1990, OTA staff revised the

report on the basis of the workshop discussion and

the comments of other reviewers.

-115-
Appendix B

Workshop Participants

A workshop to review and discuss the draft report was held on July 10, 1990. OTA would like to express its

gratitude and appreciation to the following participants for their review and advice: Jerome Jaffe

Lincoln Moses, workshop chair Assistant Director

Professor of Statistics Office for Treatment Improvement

Stanford University Alcohol, Drug Abuse, and Mental Health

Stanford, CA Administration

Rockville, MD

Douglas Anglin

Director Nancy Jainchill

UCLA Drug Abuse Research Group Senior Research Scientist

Neuropsychiatric Institute Therapeutic Communities of America

Los Angeles, CA New York, NY

Carl Leukefeld

Diane Canova Deputy Director

Director of Public Policy Division of Clinical Research

National Association of State Alcohol National Institute on Drug Abuse

and Drug Abuse Directors Rockville, MD

Washington, DC

Don Des Jarlais

Director of Research

Chemical Dependency Institute

Beth Israel Medical Center

New York, NY

Jessica Gardom

Public Health Advisor

Center for Prevention Services

Office of the Director (HIV)

Centers for Disease Control

Atlanta, GA

Scott Holmberg

Chief, Special Studies Section

Epidemiology Branch

Division HIV/AIDS

Centers for Disease Control

Atlanta, GA

Robert Hubbard

Senior Social Psychologist

Center for Social Research and

Policy Analysis

RTI

Research Triangle Park, NC

Linda Lewis

Assistant Deputy Director for Treatment

Office of National Drug Control Policy

Executive Office of the President

Washington, DC

William McAuliffe

Principal Investigator

Project Outreach

Cambridge, MA

Robert Newman

President

Beth Israel Medical Center

New York, NY

Richard Rawson

Executive Director

Matrix Center

Beverly Hills, CA

Claire Sterk

Visiting Scientist

Center for Prevention Services

Division of STD/HIV Prevention

Centers for Disease Control

Atlanta, GA

-116-
Appendix C

Acknowledgements

In addition of the workshop participants listed in appendix B, OTA would like to thank the following individuals for their valuable contributions in the preparation of this Background Paper:

Robert Battjes

Assistant ‘Director for

Planning

Division of Clinical Research

National Institute on Drug Abuse

Rockville, MD

John Ball

Senior Scientist and Professor

Addiction Research Center

Baltimore, MD

Vincent Biase

Supervising Director,

Technical Services

DAYTOP Village

New York City, NY

Jack D. Blaine

Chief, Treatment Research Branch

Division of Clinical Research

National Institute on Drug Abuse

Rockville, MD

Graham Coltidz

Assistant Professor of Medicine

Harvard Medical School

Boston, MA

James Cooper

Assistant Director for Medical

and International Affairs

Office of the Director

National Institute on Drug Abuse

Rockville, MD

James Curran

Director

Division HIV/AIDS

Centers for Disease Control

Atlanta, GA

George De Leon

Director of Research and Training

Therapeutic Communities of

America

New York, NY

Sam Di Menza

Assistant Deputy Director

Office for Treatment Improvement

Alcohol, Drug Abuse, and Mental

Health Administration

Rockville, MD

Mindy Fullilove

Assistant Professor of Clinical

Psychiatry and Public Health

Columbia University

New York, NY

Henrick J. Harwood

Senior Policy Analyst

Office of National Drug

Control Policy

Executive Office of the President

Washington, DC

Harry Haverkos

Director

Division of Clinical Research

National Institute on Drug Abuse

Rockville, MD

Steven Jones

Medical Epidemiologist

Office of the Director (HIV)

Center for Prevention Services

Centers for Disease Control

Atlanta, GA

Herbert Kleber

Director for Demand Reduction

Office of National Drug Control

Policy

Executive Office of the President

Washington, DC

Thomas Kosten

Assistant Professor

Department of Psychiatry

Director of Research

Frederick Mosteller

Roger I. Lee Professor Emeritus

of Mathematical Statistics

Technology Assessment Group

Harvard School of Public Health

Boston, MA

Gary Noble

Deputy Director for AIDS

Centers for Disease Control

Atlanta, GA

Roy Pickens

Director

Addiction Research Center

Baltimore, MD

Richard Schottenfeld

Assistant Professor of Psychiatry

Yale University School of Medicine

Connecticut Mental Health Center

New Haven, CT

Joanna Siegel

Post Doctoral Fellow

Department of Health Policy and

Management

Harvard School of Public Health

Boston, MA

Dwayne Simpson

Director

Institute of Behavioral Research

Texas Christian University

Fort Worth, TX

James Sorensen

Professor

Department of Psychiatry

University of California,

San Francisco

San Francisco, CA

Michael Torny

, Professor of Law

University of Minnesota and

Yale University School of Medicine Castine ‘Research Corp.

New Haven, CT Castine, ME

-117-
Appendix D

Glossary of Abbreviations and Terms

Glossary of Abbreviations

--Alcoholics Anonymous

ADAMHA --Alcohol, Drug Abuse, and Mental

Health Administration (PHS,

DHHS)

ADMS --Alcohol, Drug Abuse, and Mental

Health Services

AIDS --acquired immunodeficiency syndrome

APA --American Psychiatric Association

CA --Cocaine Anonymous

CDC --Centers for Disease Control (PHS,

DHHS)

CJS --Criminal Justice System

CODAP --Client Oriented Data Acquisition

Process

DARP --Drug Abuse Reporting Program

DATOS --Drug Abuse Treatment Outcome

Study

DAWN --Drug Abuse Warning Network

DHHS --Department of Health and Human

Services

DSM-IIIR --Diagnostic and Statistical Manual for

Mental Disorders (Third Edition

Revised)

ER --emergency room

FDA --Food and Drug Administration (PHS,

DHHS)

HIV --human immunodeficiency virus

HTLV-1 --Human T-cell lymphotropic virus-1

HTLV-2 --Human T- cell lymphotropic virus-2

IV --intravenous

LAAM --levo-alpha-acetyl-methadol

LSD --lysergic acid diethylamide

ME --medical examiner

mg --milligram

NA --Narcotics Anonymous

NADAR --National AIDS Demonstration

Research

NASADAD --National Association of State Alcohol

and Drug Abuse Directors

NDATUS --National Drug and Alcoholism

Treatment Unit Survey

NIAAA

NIDA

ODF

OTA

OTI

PCP

PHS

RCT

SADAP

STD

TASC

TC

THC

TOPS

VA

--National Institute on Alcohol Abuse

and Alcoholism (ADAMHA, PHS,

DHHS)

--National Institute on Drug Abuse

(ADAMHA, PHS, DHHS)

--outpatient drug free

--Office of Technology Assessment

(U.S. Congress)

--Office of Treatment Improvement

(ADAMHA, PHS, DHHS)

--phencyclidine

--Public Health Service (DHHS)

--Randomized Controlled Trial

--State Alcohol and Drug Abuse

Profile

--sexually transmitted disease

--Treatment Alternative to Street

Crime

--therapeutic community

--delta-9-tetrahydrocannabinol

--Treatment Outcome Prospective

Study

--Veterans Administration (now

Department of Veteran Affairs) -

Glossary of Terms

Alcoholics Anonymous (AA): A self-help support

group for assisting recovery from alcoholism. The

process is based on the 12 steps to recovery, which

include admitting addiction, acknowledging one’s

impotence to stop without the help of a higher

power, and confronting the harm one has done.

Acute: A condition that has a sudden onset, sharp

rise, and short course (compare chronic).

Acquired immunodeficiency syndrome: see AIDS.

Aftercare: Program services that concentrate on a

successful transition between program completion

and reentry into the community.

Agonist: A substance that occupies receptors in the

brain and activates the receptor eliciting a drug

effect or action (compare antagonist).

-118-
Appendix D-Glossary of Terms and Acronyms -119

AIDS (acquired immunodeficiency syndrome): A

disease caused by the human immunodeficiency

virus and characterized by a deficiency of the

immune system. The primary defect in AIDS is

an acquired, persistent, quantitative functional

depression within the T4 subset of lymphocytes.

This depression often leads to infections caused

by micro-organisms that usually do not produce

infections in individuals with normal immunity.

Antagonist: A substance that tends to nullify the

action of another, i.e., a drug that binds to a cell

receptor without eliciting a biologic response, and

competitively blocks access to that receptor for

other drugs or displaces them from the receptor

terminating their action (compare agonist).

Chronic: Lingering and lasting, as opposed to acute.

A term used to describe persistent disease.

Cocaine: An addictive psychoactive substance that is

a central nervous system stimulant.

Cocaine Anonymous: Self-help support groups for

cocaine abusers patterned after the Alcoholics

Anonymous approach.

Co-morbidity: See dual-diagnosis

Control group: In a randomized clinical trial, the

group receiving no treatment or some treatment

with which the group receiving experimental

treatment is compared. The control treatment is

generally a standard treatment, a placebo, or no

treatment.

Cost-benefit analysis: An analytical technique that

compares the costs of a project or technological

application to the resultant benefits, with both

costs and benefits expressed by the same measure.

This measure is nearly always monetary.

Crack A smokable form of cocaine converted from

cocaine powder by mixing it with baking soda or

ammonia and water and heating to remove the

water.

Drug abuse: According to the American Psychiatric

Association’s diagnostic manual (DSM HI-R),

drug abuse is characterized by maladaptive patterns of psychoactive substance use that have

never met the criteria for dependence for that

particular class of substance (see drug dependence). Drug Abuse refers to a pattern of drug

use that results in harm to the user; the user continues use despite persistent or recurrent adverse

consequences.

Drug addiction: See drug dependence.

Drug dependence: A disorder in which a person has

impaired control of psychoactive substance use

and continues use despite adverse consequences.

It is characterized by compulsive behavior and the

active pursuit of a lifestyle that centers around

searching for, obtaining, and using the drug.

According to the American Psychiatric Association, diagnosis of drug dependence is established

if at least three out of nine defined symptoms have

been persistent for at least one month or have

occurred repeatedly over a longer period of time.

The range of symptoms include inability to control

use, compulsive use, continued use despite

knowledge of adverse consequences, tolerance,

and physical dependence (compare drug abuse).

Dual diagnosis: Coexistence of drug abuse or

dependence and psychiatric disorder.

Effectiveness: Same as efficacy (see below) except

that it refers to average or actual conditions of

use.

Efficacy The probability of benefit to individuals in

a defined population from an intervention applied

for a given problem under ideal conditions of use.

Efficacy is generally evaluated in controlled trials

of an experimental therapy and a control condition.

Epidemic: A sudden increase in the incidence rate

of a human illness, affecting large numbers of

people, in a defined geographic area.

Heroin: An addictive psychoactive substance derived

from opium. Heroin is administered mainly

intravenously.

Human immunodeficiency virus (HIV): The virus

that causes AIDS.

Inpatient care: Care that includes an overnight stay

in a medical facility.

Interim methadone: A concept that calls for

providing methadone and HIV counseling without

additional ancillary services to IV drug users on

waiting lists, until treatment space in a comprehensive program becomes available.

Intravenous: Injected into or delivered through a

needle into a vein.

In utero: Literally, “in the uterus; referring to procedures that are performed or events that take

place within the uterus.
120- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

Low birthweight babies: Live births weighing less

than 5-1/2 pounds (2$0 grams).

Maturation: In evaluation studies, the impact on

outcome of the passage of time, independent of

the intervention being evaluated.

Medical maintenance: An approach that calls for

stable, non-drug using, socially rehabilitative

methadone-maintained patients to receive their

total methadone dosage from a physician at a

primary care setting at intervals as far apart as 28

days.

Methadone maintenance: Pharmacotherapy for narcotics addicts that employs a synthetic opiate,

methadone, to stabilize clients and help them to

function in the community. In addition to daily

oral doses of methadone, methadone maintenance

programs have traditionally included counseling

and other support services.

Modality: In this report, a type of treatment for drug

abuse.

Mortality rate: The death rate, often made explicit

for a particular characteristic, e.g., age, sex, or

specific cause of death. A mortality rate contains

three essential elements: 1) the number of people

in a population group exposed to the risk of death

(the denominator); 2) a time factor; and 3) the

number of deaths occurring in the exposed population during a certain time period (the

numerator).

Naltrexone: A pharmacologic substance that is a

narcotic antagonist.

Narcotics: A class of drugs that when administered

therapeutically can lessen sensibility, relieve pain,

and produce sleep. The term narcotic is used

interchangeably with the term opiates. In a legal

context, the term narcotics is used to refer to any

substance that can causes dependence.

Narcotics Anonymous: Self-help support groups for

narcotics abusers patterned after the Alcoholics

Anonymous approach.

Natural history: The course of a condition, such as

drug abuse, that occurs without any intervention.

Odds ratio: A measure of association closely related

to relative risk. It is the ratio of the odds of a

disease’s occurring in individuals exposed to the

risk relative to those unexposed.

Opiate: Any substance deriving from the opium

poppy. Opiate drugs (e.g., morphine and heroin)

bind to specific receptors on nerve cells scattered

throughout the brain to reduce pain and produce

euphoria. Repeated use of these agents maybe

associated with biological tolerance and dependence. Naturally produced molecules (e.g.,

endorphin, encephalic) bind to the same nerve

cell receptors and are called endogenous opiates

or opioid drugs. See narcotics.

Outpatient care: Care that is provided in a hospital

or other medical facility that does not include an

overnight stay.

Outpatient drug-free (ODF) program: A diverse

group of drug abuse treatment programs operating on an outpatient basis, with emphasis on

counseling.

Perinatal: Pertaining to or occurring in the period

shortly before or after birth; variously defined as

beginning with the completion of the 20th to 28th

week of gestation and ending 7 to 28 days after

birth.

Pharmacotherapy The use of mediation to treat a

medical disease or disorder.

Placebo: A drug or procedure with no intrinsic

therapeutic value. In a randomized clinical trial, a

placebo may be given to patients in control groups

as a means to blind investigators and patients as

to whether an individual is receiving the experimental or control treatment.

Polydrug abuse: Substance abuse characterized by

use of multiple drugs.

Premature births: Babies born between 20 to 36

weeks gestation.

Prevalence: In epidemiology, the number of eases of

disease, infected persons, or persons with disabilities or some other condition, present at a particular time and in relation to the size of the population.

Psychoactive substance: A substance that has moodaltering abilities.

Randomized clinical trial: An experiment designed

to test the safety and efficacy of an intervention in

which people are randomly allocated to experimental or control groups, and outcomes are compared.

Reliability Refers to the reproducibility of results

over repeated measurements, and relates to the

lack of random error over these repeated

measurements.
Appendix D-Glossary of Terms and Acronyms -121

Selection bias: A distortion of study results by correlates of the study subjects that influence the

outcome and the comparability of the experimental and control groups.

Seroconversion: The initial development of

antibodies specific to a particular agent.

Seropositive: In the context of HIV, the condition in

which antibodies to the virus are found in the

blood.

Seroprevalence: Prevalence based on blood tests.

Shooting gallery Location where drug abusers meet

to inject (shoot) drugs, often sharing needles.

Therapeutic community (TC): Residential

treatment programs lasting approximately one

year or more and characterized by a highly structured and confrontational approach. The TC philosophy views drug abuse as a reflection of personality problems and chronic deficiencies in

social, educational, and marketable skills.

Tolerance: Increasing resistance to the effects of a

drug. An outstanding characteristic of opiates and

amphetamines, it results in a need for increasing

dosage to maintain or recapture the desired drug

effect.

Validity: A measure of the extent to which an

observed situation reflects the “true” situation.

Internal validity is a measure of the extent to

which study results reflect the true relationship of

an intervention to the outcome of interest in the

study subjects. External validity is a measure of

the extent to which study results can be

generalized to the population which is represented

by individuals in the study.

Withdrawal symptoms: Symptoms associated with

abstinence from a drug on which a patient is

physically dependent.
Appendix E

Psychoactive Drugs Other than Narcotics and Stimulants

Chapter 2 presented information about illicit

drugs whose use has been most frequently associated

with the transmission of the human immunodeficiency virus (HIV). In addition to narcotics and

related analgesics, including heroin, and central

nervous stimulants, including cocaine and crack,

psychoactive drugs fall into four additional categories: sedative-hypnotics, hallucinogens, phencyclidine, and cannabis and inhalants. This appendix

reviews the major characteristics of substances in

each of these four categories.

Sedative-Hypnotics and Other Central

Nervous System Depressants

Sedative-hypnotics are sometimes referred to as

tranquilizers and sleeping pills. Barbiturates

(“downers”) and benzodiazepines are the two major

categories of sedative-hypnotics. These drugs are

usually sold in capsules and tablets. Like narcotics,

sedative-hypnotics can cause both physical and

psychological dependence and tolerance.

The effects of sedative-hypnotic drugs vary

enormously with dosage. When taken in low-tomoderate doses, these substances tend to decrease

inhibitions and relieve anxiety. In higher doses, barbiturates may cause slurred speech, staggering gait,

and uncertain reflexes--effects that make driving a

car or operating machinery particularly dangerous.

The main danger and fatal consequences of these

drugs reside in their depressant action on central

nervous system sites. The combined depressant

effect of taking significant doses of two drugs from

this class, e.g., alcohol and diazepam (Valium), can

be fatal. Unlike narcotics, “sedative-hypnotics have a

withdrawal syndrome that is life-threatening, specifically as a result of seizure and delirium tremens” (6).

Hallucinogens

Hallucinogens or psychedelics, which are usually

taken orally, do not resemble any of the other classes

of drugs mentioned above, though they are frequently contaminated with other drugs, such as phencyclidine (PCP) and amphetamines. Profound

changes in mood, thought content, perception, sensations, and emotions are common effects of hallucinogens. First-time users of these drugs in

particular have been known to experience “bad trips”

where the drug user experiences feelings of panic,

confusion, paranoia, anxiety, and helplessness. The

effects of psychedelics are often unpredictable and

depend on the amount taken and factors relating to

the user’s mood and surroundings. Although

researchers have found some changes in the mental

functions of heavy users of lysergic acid diethylamide

(LSD), it is not yet known whether such changes are

permanent or disappear when LSD use is stopped

(312). Although psychedelic drugs are quick to

produce high tolerance, there is no hallucinogen

withdrawal reaction as there is with narcotics,

stimulants, and sedative-hypnotics, and hallucinogens

rarely produce a full dependence.

Phencyclidine PCP

Phencyclidine, commonly referred to as PCP or

“angel dust,” was developed in the 1950s as an

anesthetic, but was subsequently taken off the market

for humans in 1967 when it was discovered that the

drug caused hallucinations in some individuals. PCP

is sometimes classified as a hallucinogen “because in

toxic doses it typically produces severe agitation,

excitement, and quasi-psychotic reactions including

paranoid delusions and auditory hallucinations” (6).

In low doses, however, PCP may simply cause drowsiness or excitability but no hallucinosis effect. PCP

is available in a number of forms, and it can be swallowed, smoked, sniffed, or injected, and is often

mixed with other drug such as marijuana and other

hallucinogens. Although PCP is illegal, it is relatively

easy to synthesize and is manufactured illicitly in

basements, vans, and garage-type laboratories all

over the country (315).

PCP has two distinctive use patterns. PCP has a

street reputation as a “bad” drug and after trying it

once, many users will not try it again. Others,

however, use PCP chronically. It is not yet fully

understood why toxic PCP doses vary from one

person to the next, and why its effects are so highly

unpredictable. “Because PCP is an anesthetic compound it produces the inability to feel pain which can

lead to serious bodily injury,” especially since the

effects of the drug tend to cause unpredictable outbursts, bizarre behavior, and disorientation (315).

-122-
Appendix E-Psychoactive Drugs Other than Narcotics and Stimulants -123

Evidence is inconclusive as to whether tolerance and

withdrawal symptoms result from PCP use.

PCP-addicted expectant mothers have been

known to deliver babies with visual, auditory, motor

disturbances, and symptoms similar to adult users of

PCP (e.g., agitation and rapid changes in awareness).

Results from the 1988 household survey indicated

that an estimated 6.1 million (3.1 percent of people

over the age of 12) have tried PCP at least once in

their lifetimes and that about 377 thousand (0.2

percent) have used PCP during the past year. The

prevalence of PCP use in one’s lifetime increased

from 1985 to 1988 from 2.8 percent to 3.1 percent,

with the percentage of Hispanics report having used

 PCP sometime within their lifetimes more than doubling (from 1.4 percent in 1985 to 3.0 percent in

1988). Regional trends show that between 1984 and

1988, the prevalence of lifetime PCP use increased in

the Northeast (2.4 percent to 4.3 percent), in the

North Central region (3.0 percent to 3.8 percent),

and in the West (3.2 percent to 3.7 percent), but

decreased in the South (2.7 percent to 1.7 percent).

These figures may reflect selective emigration of

drug users or a change in reporting bias instead of a

real reduction in the percent of lifetime users. PCP

was the only drug category reporting an increase in

use among high school seniors from 1988 to 1989

(current use rose from 0.3 percent to 1.4 percent and

annual use rose from 1.2 percent to 2.4 percent).

This increase followed a decreasing trend in lifetime

prevalence among high school seniors since 1980.

The number of PCP-related emergencies reported by

the Drug Abuse Warning Network increased

somewhat from 6,242 mentions in 1984 to 8,403 mentions in 1988.

Cannabis and Inhalants (Toxic Vapors)

Substances made from the cannabis plant

(including marijuana and hashish) and inhalants have

been grouped into a category of their own because

they do not readily fit into any of the other drug categories.

The main psychoactive ingredient in marijuana is

THC (delta-9 -tetrahydrocannabinol). The present

strength of marijuana, which is determined by the

amount of THC in the drug, is up to ten times

greater than marijuana used in the early 1970s (312).

Several researchers and laboratories have recently

made progress in determining how marijuana acts on

the brain (321). Researchers have found that THC

changes the way sensory information gets into and is

acted on by the hippocampus, the component of the

brain that facilitates learning, memory, and the

integration of sensory experiences with emotions and

motivation (321). Their findings help explain the

symptoms of lethargy and attention and memory

problems associated with acute marijuana use.

There is little evidence that marijuana produces

tolerance or severe physical withdrawal symptoms,

though long-time users may become psychologically

dependent on the drug.

Although cannabis is sometimes regarded as a

substance of low abuse potential, it does have some

serious health dangers. Inhaling the drug can be

harmful to the lungs. Researchers at the University

of California, Los Angeles, “found that the daily use

of 1 to 3 marijuana joints appears to produce approximately the same lung damage and potential cancer

risk as smoking 5 times “as many cigarettes: (321).

Very few, however, use at this rate. After smoking

marijuana, users may experience faster heartbeat (an

increase by as much as 50 percent) and pulse rate,

bloodshot eyes, lack of concentration, and impaired

reaction time and motor coordination. It is also

known that chronic use of marijuana may cause

babies to be born prematurely, shorter in length, and

with below average birthweights (380).

The intentional use of inhalants, such as glue

sniffing is popular among some adolescents, in part

because these chemicals are readily available and

inexpensive (312). Other substances known to be

inhaled include gasoline, paint thinners, and cleaning

fluids. Nearly all of the abused inhalants produce

effects similar to anesthetics, which slow the body’s

functions. Initial effects may also include nausea,

sneezing, coughing, nosebleeds, lack of coordination,

and loss of appetite. Some of the more serious

effects of inhalants include damage to bone marrow,

kidneys, liver, central and peripheral neural tissue,

and even death from suffocation or fatally depressed

central nervous system functioning. Tolerance is also

likely to develop in regular users.
124- The Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIVInfection

Marijuana remains the most commonly used

illicit drug in the United States. Almost 66 million

Americans (33 percent) have tried marijuana at least

once in their lives according to the 1988 household

survey (330). An estimated 21 million people (11

percent of the population aged 12 and over) had used

marijuana in the last year, and 12 million (6 percent)

had used marijuana at least once during the past

month. Of the 21 million people who used marijuana

at least once in the past year, almost one-third (6.6

million) used the drug once a week or more.

Lifetime rates of marijuana use have been steadily

declining for the 12-17 age group (from 24 percent in

1985 to 17 percent in 1988) and for the 18-26 age

group (from 60 percent in 1985 to 56 percent in

1988), while the rates for the age 26 and over

category have been increasing along with the aging

pool of individuals who began using marijuana in

previous years. Current use of marijuana continued

to decrease for all age groups in the household

survey.

The high school seniors survey has consistently

shown a negative correlation between the perception

of risk associated with regular marijuana use and

actual rates of marijuana use reported by seniors

(306). The percentage of seniors who have experimented with marijuana went from a peak of 60.4

percent in 1979 down to 43.7 percent in 1989, and the

annual and current rates (use during the month

before the survey) were 29.6 percent and 16.7

percent, respectively. The percentage of seniors

using marijuana daily also decreased from 10.3

percent in 1979 to just 2.9 percent in 1989.

In the list of most frequently mentioned drugs in

ER episodes, marijuana went from eighth (with 4.36

percent of ER mentions in 1984) to fourth (with 6.69

percent of ER mentions in 1988) (see fig. 2-5) (329).

The increased percentage of ER cases associated

with marijuana use may be a reflection of the

increased strength of the street drug. Marijuana is

about 10 times stronger today than it was in the early

1970s (312). The increased strength of marijuana

would also help explain the increased perceived risk

of regular marijuana use noted among high school

seniors (306).
Appendix F

Cost-Benefit Analysis of Drug Abuse Treatment:

Declines in Criminal Activity

The consequences of the drug abuse and human

immunodeficiency virus epidemics further accentuate

the need for policy decisions based on proper

scientific assessments. The foundation of sound

policy decisions is program evaluation. One of the

cornerstones of this type of evaluation is economic

assessment.

The most recent analysis that examined economic

benefits to society of drug abuse treatment used data

from the Treatment Outcome Prospective Study

(TOPS) (135,149). This analysis focused only on the

economic benefits derived from a decrease in

criminal activity during treatment and 1 year after

treatment. It compared the average cost of substance abuse treatment in each treatment modality

with the savings associated with the observed

reduction in predatory illegal acts.

With respect to the social costs of drug-related

crime, three cost components were included: costs

related to the crime victim (e.g., value of destroyed

or stolen property, medical treatment, lost productivity), costs associated with the criminal justice

system (police services, adjudication, incarceration),

and costs related to crime career productivity, which

are basically losses of legitimate productivity for the

drug abuser involved in predatory crime (149).

Additional cost components included in the analysis

were expenditures on illegal drugs, the value of theft,

illegal income, and legal earnings. Estimates for

these costs were based on self-reported data.

Estimates for the victims’ costs and costs of the

criminal justice system were based on data from the

U.S Department of Justice. Crime career productivity costs were calculated for each drug abuser.

This estimate was the difference between the selfreported legitimate income and the expected national

average for individuals of the same age and sex.

There were two perspectives used in the analysis: the

cost to law-abiding citizens, which has as a primary

component and is thus influenced by crime-related

costs; and the cost to society, which is dominated by

the degree of the abusers’ participation in the legitimate economy.

Costs of treatment and benefits derived from

treatment were estimated for each treatment

modality for a treatment episode of average duration.

Benefits derived from treatment were estimated

separately for the time while the client was in

treatment and 12 months after treatment.

Regression analyses were used to calculate the posttreatment benefits. The analyses controlled for

sociodemographic factors, previous treatment

episodes, pretreatment crime involvement, and the

length of time spent in treatment. Regardless of the

perspective and modality, with one exception, the

benefit-cost ratio was larger than one (149). This

finding implies that the benefits from reducing crime

that are derived from treatment outweigh the cost of

providing treatment. From the perspective of the

law-abiding citizen, for each dollar invested in

treatment, estimated savings of $0.30 to $4.00

(according to the modality) are produced. It should

be noted that under the societal perspective, the

estimated post-treatment benefits for methadone

maintenance clients did not reach statistical significance and were not included in the benefit-to-cost

ratio. Thus, the 0.92 benefit-cost ratio includes only

benefits derived while the client is in treatment. A

possible explanation for this finding is that the

societal perspective is influenced by the societal

integration and legitimate productivity of the drug

abuser, an area in which methadone maintenance

had limited success (see ch. 4). On the other hand,

the benefit to cost ratio to law-abiding citizens

(influenced by crime-related costs) for methadone

maintenance clients is 4.04, which reflects the

reduced criminal activity observed among methadone

maintenance patients. Overall, the authors state that

the reduction in crime-related costs “appears to be at

least as large as the cost of providing treatment and

much of the expenditure is recovered during the time

the drug abuser is in treatment.”

-125-
126- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIVInfection

It should be noted that the analysis did not

control for differences among patient subgroups and

relied heavily on self-reported data. In addition, the

measurement of costs has been estimated on an

aggregate level and was criticized as “primitive” (17).

It is argued that the overall results should be considered tentative (17). The time frame of the

analysis was 1 year. Although the associated benefits

can be expected to continue over time for those who

do not engage in drug use, they maybe offset by the

costs associated with those who relapse. On the

other hand, benefits other than reduction in crime

were not factored into the analysis. There are a

variety of tangible and intangible potential benefits

that can materialize from the reduction of drug use,

both to society and the individuals involved, from

increased productivity to the prevention of HIV

infection.
Appendix G

Highlights From the 1989 National Drug and Alcoholism

Treatment Unit Survey (NDATUS)

The most recent findings of the 1989 National

Drug and Alcoholism Treatment Unit Survey

(NDATUS) were released in July 1990 (332a).

These findings are based on data collected as of the

point-prevalence date of September 30, 1990. A total

of 9,608 facilities reported to the 1989 survey. Drug

treatment was provided by 6,287 facilities, including

drug-only and drug-and-alcohol combined facilities.

Overall, 79.4 percent of all reported drug treatment

capacity was being utilized; however, the utilization

rate for drug-only units was 90.1 percent. A 12-

month total of 995,994 drug abuse clients treated at

5,024 facilities was reported to NDATUS (332a).

A total of 351,430 drug abuse clients were in

treatment at these facilities on September 30, 1989.

The large majority of these clients, 84.6 percent,

were in an outpatient environment; 11.6 percent were

in a residential environment; and 3.8 percent were in

a hospital inpatient environment. Drug-free

treatment was the most common form of treatment

with 68.6 percent of all drug abuse clients. Of

clients in drug-free programs, the majority 81.1

percent were receiving outpatient treatment; 15.5

percent were in residential treatment and 3.4 percent

were in hospital inpatient programs. Of all drug

abuse clients, 27.1 percent were in maintenance and

4.4 percent in detoxification. Nearly all clients in

maintenance, 97.6 percent, were in an outpatient

setting. Of all the detoxification clients, 57.7 percent

were in an outpatient environment (332a).

Because of concerns about the spread of HIV

infection, the 1989 survey asked treatment facilities

to report the percentage of their clients who were

intravenous (IV) drug users at the time they started

treatment. The estimated number of clients as of

September 30, 1989 who were intravenous drug users

at the time they started treatment was 129,985. Of

these 112,257, 86.3 percent, were listed as drug

clients, and 17,728, 13.7 percent, were listed as

alcohol clients (332a).

-127-
1.

2.

3.

4.

5.

6.

7.

8.

Abdul-Quader, A. S., Friedman, S. R., Des

Jarlais, D., et al., “Methadone Maintenance and

Behavior by Intravenous Drug Users That Can

Transmit HIV,W Contemporary Drug Problems

pp. 425-433, fall 1987.

The Addiction Letter. “Parkside Outcome Study

‘Full Service’ Treatment,” 771e Addiction Letter

6(7): 4-5,1990.

Allen, D. M., Medical Epidemiologist, HIV

Seroepidemiology Branch, Division of

HIV/AIDS, Centers for Disease Control,

Public Health Service, U.S. Department of

Health and Human Services, Atlanta, GA, personal communication, July 2, 1990.

Allen, D.M., Onorato, I., and Sweeney, P.A.,

“Seroprevalence of HIV Infection in IVDUS,

United States, 1988-1989,” paper presented at

“The Annual Meeting of the American Public

Health Association,” Chicago, IL, October 1989.

American Medical Association, Council on

Scientific Affairs, “Reducing Transmission of

Human Immunodeficiency Virus (HIV) Among

and Through Intravenous Drug Users,” AIDS

and Public Policy Journal 4(3):142-151, 1989.

American Psychiatric Association, “Psychoactive

Substance Use Disorders,” Diagnostic and

Statistical Manual for Mental Disorders (DSM111) (Washington, DC: American Psychiatric

Association, 1987).

American Society of Hospital Pharmacists,

American Hospital Fornudary Service (AHFS)

Drug Information 86, G.K. McEvoy and G.M.

McQuarrie (eds.) (Bethesda, MD: American

Society of Hospital Pharmacists, Inc., 1986).

Amsel, Z., “Introducing the Concept

‘Community Prevention,’” AIDS and

Intravenous Drug Use: Future Directions for

Community-Based Prevention Research, C.G.

Leukefeld, R.J. Battjes, and Z. Amsel (eds.),

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, U.S. Department

of Health and Human Services, NIDA

Research Monograph 93, 1990, DHHS Pub. No.

(ADM) 90-1627 (Rockville, MD: 1990).

9.

10.

11.

12.

13.

14.

15.

16.

17.

Anglin, D. M., Director, UCLA Drug Abuse

Research Group, Los Angeles, CA, “Statement~

hearing before the Food and Drug Administration on “Interim Maintenance Treatment:

February 1990.

Anglin, M.D., Director, UCLA Drug Abuse

Research Group, Los Angeles, CA, “Letter to

the Honorable Charles D. Rangel, Chairman,

Select Committee on Narcotics Abuse and

Control,” May 30,1990.

Anglin, M. D., Director, UCLA Drug Abuse

Research Group, Los Angeles, CA, personal

communication, July 1990.

Anglin, M. D., and Hser, Y., “Legal Coercion

and Drug Abuse Treatment: Research Findings

and Social Policy Implications,” Handbook on

Drug Control in the United States, J. Inciardi

(cd.) (Westport, CT: Greenwood Press, in

press).

Anglin, M. D., and Hser, Y., “Treatment of

Drug Abuse,” Crime and Justice, M. Tonry and

J.Q. Wilson (eds.), in press, September 1990.

Anglin, M.D., Speckart, G.R., Booth, M.W., et

al., “Consequences and Costs of Shutting Off

Methadone;’ Addictive Behaviom 14(3):307-326,

1989.

Annis, H. M., “Relapse Prevention: A CognitiveSocial Learning Approach,” paper presented at

the “What Works: An International Perspective

on Drug Abuse Treatment and Prevention

Research” conference sponsored by the

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, U.S. Department

of Health and Human Services, New York, NY,

October 1989.

Anthony, J.C., and Petronis, K.R., “Cocaine and

Heroin Dependence Compared: Evidence from

an Epidemiologic Field Survey,” Am. J. Public

Health 79(10):1409-1410, October 1989.

Apsler, R., and Harding, W. M., “CostEffectiveness Analysis of Drug Abuse

Treatment: Current Status and Recommendations for Future Research,” paper presented at

the “Annual Advisory Committee Meeting,

NIDA Center for Drug Abuse Services

Research,” Brandeis University, Boston, M&

January 1990.

-128-
References -129

18.

19,

20.

21.

22.

23.

24.

Attewell, P., and Gerstein, D.R., “Government

Policy and Local Practice,” American

Sociological Review 44(2):311-327, April 1979.

Bale, R.N., Van Stone, W.W., Kuldau, J.M., et

al., “Therapeutic Communities vs Methadone

Maintenance,” Arch. Gen. Psychiat~ 37(2):179-

193, February 1980.

Ball, J.C., Corty, H.B., Myers, C., et al., “The

Reduction of Intravenous Heroin Use, NonOpiate Abuse and Crime During Methadone

Maintenance Treatment: Further Findings,”

Problems of Drug Dependence 1987, L.S. Harris

(cd.), National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human Services,

NIDA Research Monograph Series 81, DHHS

Pub. No. (ADM) 88-1564 (Rockville, MD: 1988).

Ball, J. C., Myers, C.P., and Friedman, S.R.,

“Reducing the Risk of AIDS Through

Methadone Maintenance Treatment,” Journal of

Health and Social Behavior 29(3):214-226, September 1988.

Barton, E. M., “Drug Treatment as an AIDS

Intervention Strategy,” paper presented at the

“What Works: An International Perspective on

Drug Abuse Treatment and Prevention

Research,” conference sponsored by New York

State Division of Substance Abuse Services and

the Narcotic and Drug Abuse Research, Inc.,

New York City, NY, October 1989.

Batki, S., Sorensen, J., Coates, C., et al.,

“Methadone Maintenance for AIDS-Affected IV

Drug Users: Treatment Outcome and

Psychiatric Factors After Three Months,”

Problem of Drug Dependence, 1988, L.S. Harris

(cd.), National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human Services,

NIDA Research Monograph Series 90, DHHS

Pub. No. 89-1605 (Rockville, MD: 1988).

Battjes, R.J., Amsel, Z., and Pickens, R.W.,

“’Speedball’ Use and HIV Risk Among IVDAS,”

poster presented at the Annual Meeting of the

American Public Health Association, Chicago,

IL, October 1989.

25.

26.

27.

28.

29.

Battjes, R.J., Leukefeld, C. G., and Amsel, Z.,

“Community Prevention Efforts to Reduce the

Spread of AIDS Associated with Intravenous

Drug Abuse; AIDS and Intravenous Drug Use:

Future Directions for Community-Based Prevention Research, C.G. Leukefeld, RJ. Battjes,

and Z. Amsel (eds.), National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human Services,

NIDA Research Monograph 93, 1990, DHHS

Pub. No. (ADM) 90-1627 (Rockville, MD: 1990).

Battjes, R. J., and Pickens, R. W., “NeedleSharing Among Intravenous Drug Abusers: An ~Á•Œ0Á•Œ0

Overview,H Needle-Sharing Among Intravenous

Drug Abusers: National and International Perspectives, R.J. Battjes, and R.W. Pickens (eds.),

National Institute on Drug Abuse, Alcohol, Drug

Abuse, and Mental Health Administration,

Public Health Service, U.S. Department of

Health and Human Services, NIDA Research

Monograph 80, DHHS Pub. No. (ADM) 88-1567

(Rockville, MD: 1988).

Battjes, R. J., and Pickens, R. W., “NeedleSharing Among Intravenous Drug Abusers:

Future Directions,” Needle-Sharing Among

Intravenous Dntg Abusers: National and International Perspectives, R.J. Battjes, and R.W.

Pickens (eds.), National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human Services,

NIDA Research Monograph 80, DHHS Pub.

No. (ADM) 88-1567 (Rockville, MD: 1988).

Battjes, R.J., Pickens, R.W., and Amsel, Z.,

“Introduction of HIV Infection Among IVDAS

in Low Prevalence Areas, ” Journal of the

Acquired Immunodejiciency Syndrome 2(6):533-

539, December 1989.

Battjes R. J., Pickens, R. W., and Amsel, Z.,

“Trends in HIV Infection and AIDS Risk

Behaviors Among IVDUS in Selected U.S

Cities,” poster presentation .at the Sixth International Conference on AIDS, San Francisco, June

1990.
130- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIV Infection

30.

31.

32.

33.

34.

35.

36.

Bemett, W.J., Director, Office of National Drug

Control Policy, Executive Office of the President, statement presented at the press conference at the release of the 1988 National

Household Survey on Drug Abuse, Washington,

DC, Ju]y 31,1989.

Berkelman, R.L., and Curran, J.W., “Update--

HIV Infection and AIDS,” Epidemiologic

Reviews, H.K. Armenian, L. Gordis, M.B. Grew

and M.M. Levine (eds.) 11:222-228, 1989.

Beschner, G.M., Glover, R.B., and Mondanano,

J., Treatment Services for Drug Dependent

Women, National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human Resources,

DHHS Pub. No. (ADM) 87-1177 (Rockville,

MD: 1981).

Biase, D. V., “AIDS and the Therapeutic Community Response. Issues, Policy and Practices,”

paper presented at the “AIDS Plenary Session,

4th Conference of the European Federation of

Therapeutic Communities,” Dublin, Ireland,

September 1987.

Biden, J. R., Chairman, Senate Judiciary Committee, U.S. Congress, “Foreward,” Hard-Core

Cocaine Addicts: Measuring--And Fighting-7he

Epidemic, Committee on the Judiciary, Senate,

U.S. Congress, Staff Report, S. Prt. 101-6

(Washington, DC: U.S. Government Printing

Office, May 10, 1990).

Blaine, J., Chief, Treatment Research Branch,

Division of Clinical Research, National Institute

on Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Administration, Public Health

Service, Rockville, MD, U.S. Department of

Health and Human Services, personal communication, July 1990.

Blix, O., and Gronbladh, B.A., “AIDS and IV

Heroin Addicts: The Preventive Effect of

Methadone Maintenance in Sweden,” abstract

presented at the Fourth International Conference on AIDS, Abstract No. 8548, Stockholm,

Sweden, June 1988.

37.

38.

39.

40.

41.

42.

43.

Brown, B., Chief, Community Research Brand

National Institute on Drug Abuse, Alcoho~ Drug

Abuse, and Mental Health Administration,

Public Health Service, U.S. Department of

Health and Human Services, Rockville, MD,

statement before the National Commission on

Acquired Immune Deficiency Syndrome, Mar.

15,1990.

Brown, B., Chief, Community Research Branch,

National Institute on Drug Abuse, Alcoho~ Drug

Abuse, and Mental Health Administration,

Public Health Service, U.S. Department of

Health and Human Services, Rockville, MD,

personal communicatio~ May 31,1990.

Brown, B. S., and Czechowicz, D., Research on

the Treatment of Na~otic Addiction State of the

Art, J.R. Cooper and F. Altman (eds.), National

Institute on Drug Abuse, Alcohol, Drug Abuse,

and Mental Health Administration, Public

Health Service, U.S. Department of Health and

Human Services, Treatment Research

Monograph Series, DHHS Pub. No. (ADM) 87-

1281 (Rockville, MD: 1983a).

Brown, L. S., Chu, A., Nemoto, T., et al.,

Demographic, Behavioral, and Clinical Features

of HIV Infection in New York City Intravenous

Drug Users, abstract presented at the “Fifth

International Conference on AIDS,” Abstract

No. WDP 68, Montreal, Canada, June 1989.

Brown University Child Behavior and Development Letter, “Crack and Alcohol Abuse

Fueling Crisis in Child-Care System,” 7he Brown

University Child Behavior and Development Letter

6(1):5-6, January 1990.

Brunswick, A.F., and Messeri, PA., “Pathways to

Heroin Abstinence: A Longitudinal Study of

Urban Black Youth,” Advances in Alcohol and

Substance Abuse 5(3):111-135, spring 1986.

Bullock, M. L., Culliton, P. D., Olander, R.T.,

“Controlled Trial of Acupuncture for Severe

Recidivist Alcoholism,” Lancet 1(8653):1435-

1438,1989.
References -131

44. Buning, E. C., Van Brussel, G. H.A., and Van

Santen, G., “Amsterdam’s Drug Policy and its

Implications for Controlling Needle Sharing,”

Needle Shan”ngAmong Intravenous Drug Abusem

National and International Perspectives, R.J.

Battjes and R.W. Pickens (eds.), National

Institute on Drug Abuse, Alcohol, Drug Abuse,

and Mental Health Administration, Public

Health Services, U.S. Department of Health and

Human Services, NIDA Research Monograph

80, 1988, DHHS Pub. No. (ADM) 88-1567

(Rockville, MD: 1988).

44a. Butynski, W., “Drug Treatment Services:

45.

46.

47.

48.

49.

50.

Funding and Admissions,” paper prepared for

the “NIDA RAUS, Improving Drug Abuse

Treatment,” sponsored by the National Institute

on Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Administration, Public Health

Service, U.S. Department of Health and Human

Services, Bethesda, MD, August 1989.

Butynski, W., Canova D., and Jensen, S., State

Resources and Services Related to Alcohol and

Drug Problems Fiscal Year 1988: An Analysis of

State Alcohol and Drug Abuse Profile Data

(Washington, DC: National Association of State

Alcohol and Drug Abuse Directors, Inc., August

1989).

Caffrey, R., Deputy Assistant Administrator for

Operations, U.S. Drug Enforcement Administration, “Statement: Recent Developments in the

National Effort Against Drugs,” hearing before

the Committee on the Judiciary, Senate, U.S.

Congress, Washington, DC, July 17,1990.

Campbell, R.J., Psychiatric Dictionary (5th cd.)

(New York, NY: Oxford University Press, 1981).

Chaisson, M., “Heterosexual Transmission of

HIV Associated With the Use of Smokable

Freebase Cocaine (Crack),” abstract in the Sixth

International Conference on AIDS, San Francisco, June 1990.

Chaisson, R.E., Bacchetti, P., Osmond, D., et al.,

“Cocaine Use and HIV Infection in Intravenous

Drug Users in San Francisco,” JA.M.A. 261:561-

565, Jan. 27,1989.

Charney, D.S., Sternberg, D.E., Kleber, H.D~, et

al., “Naltrexone Precipitated Opiate Withdrawal

51.

52.

53.

54.

55.

56.

57.

58.

59.

in Methadone Addicted Human Subjects: Evidence for Noradrenergic Hyperactivity,W Lije

Sci. 35:1263-1272 1984, as cited in Koste~ T.R.,

“Neurobiology of Abused Drugs: Opioids and

Stimulants, W Journal of Nervous and Mental

Disease 178(4):217-227, April 1990.

Chasnoff, I., “Drug Use and Women: Establishing a Standard of Care,” Annak New York

Academy of Science 562:208-210, 1989.

Chasnoff, I.J. (cd.), Dregs, Alcoho4 Pregnancy

and Parenting (Boston, MA: Kluwer Academic

Publisher, 1989).

Chasnoff, I.J., Griffith D.R., MacGregor, S., et

al., Temporal Patterns of Cocaine Use in Pregnancy~J4.MA. 261(12):1741-1744, Mar. 24/31,

1989.

Chavkin, W., “Help, Don’t Jail Addicted

Women,” New York Times, p. A21, July 18,

1989.

Chavkin, W. “Drug Treatment in Pregnancy,”

me Baby Book (New York City, NY: March of

Dimes, 1990).

Chavkin, W., “Drug Addiction and Pregnancy

Policy Crossroads,” Am. J. Public Health

80(4):483-487, April 1990.

Chavkin, W., and Freudenber~ N., [Letter] N.

Engl. J. Med. 321(18):1266, Nov. 2,1989.

Childress, A., Ehrman, R., Mckllan, A.T., et

al., “Conditioned Craving and Arousal in

Cocaine Addiction: A Preliminary Report,”

Problems of Drug Dependence 1987, L.S. Harris

(cd.), National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human Services,

Research Monograph Series 81, DHHS Pub.

No. (ADM) 88-1564 (Rockville, MD: 1988).

Childress, A.R., McLellan, A.T., Woody, G.E.,

et al., “Are There Minimum Conditions

Necessary for Methadone Maintenance to

Reduce Intravenous Drug Use and AIDS-Risk

Behaviors?” paper presented at “NIDA RAUS,

Improving Drug Abuse Treatment,” sponsored

by National Institute on Drug Abuse, Alcoho~

Drug Abuse, and Mental Health Administration, Public Health Service, U.S. Department

of Health and Human Services, Bethesda, MD,

August 1989.
132- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIV Infection

60.

61.

62.

63.

64.

65.

66.

67.

Chu, S., Buehler, J.W., and Berkelman, R.L.,

“Impact of the Human Immunodeficiency Virus

Epidemic on Mortality in Women of

Reproductive Age, United States,” J.A.M.A.

264(2):225-229, July 1990.

Cole, S. G., and James, L. R., “A Revised

Treatment Typology Based on the DARP,” Am.

J. of Drug and A1coholAbuse 2(1):37-49, 1975.

Cook, L. F., and Weinman, B.A., “Treatment

Alternatives to Street Crime,” Compulsory

Treatment of Dmg Abuse: Reseaxh and Clinical

Practice, C.G. Leukefeld, and F.M. Tires (eds.),

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, U.S. Department

of Health and Human Services, Research

Monograph Series 86, DHHS Pub. No. (ADM)

88-1578 (Rockville, MD: 1988).

Cook, T. D., and Campbell, D. T., QuasiExpenmentation. Design and Analysis Issues for

Field Se/tings (Boston, MA: Houghton Mifflin

Company, 1979).

Cooley, C.P., Dunteman, G.H., Hamill, D.N., et

al., “A Review of Methodologies For Estimating

Drug Use Prevalence,” paper presented at the

“What Works: An International Perspective on

Drug Abuse Treatment and Prevention

Research,” conference sponsored by New York

State Division of Substance Abuse Services and

the Narcotic and Drug Abuse Research, Inc.,

New York City, NY, October 1989.

Coombs, R. H., “Drug Abuse as a Career,” J.

Drug Issues 11(4):369-387, Fall 1981.

Cooper, J. R., “Introduction,” Research on the

Treatment on Narcotic Addiction State of the Art,

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, U.S Department

of Health and Human Services, Treatment

Monograph Series, DHHS Pub. No. (ADM) 87-

1281 (Rockville, MD: 1983).

Cooper, J. R., “Establishing a Methadone

Quality Assurance System: Rational and Objectives,” paper presented at the “NIDA RAUS,

Improving Drug Abuse Treatment,” sponsored

by National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, Bethesda, MD,

August 1989.

68.

68a.

69.

70.

71.

72.

73.

74.

Cooper, J. R., “Methadone Treatment and

Acquired Immunodeficiency Syndrome,”

JA.W4. 262(12):1664-1668, Sept. 22/29, 1989.

Cooper, J.R., Assistant Director for Medical

and International Affairs, Office of the

Director, National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human Services,

Rockville, MD, personal communication, July

1990.

Cooper, J.R., Ahman, F., and Keeley, K. “Discussion Summary,” Research on the Treatment of

Narcotic Addiction. State of the Art, J.R. Cooper

and F. Altman (eds.), National Institute on

Drug Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Service,

U.S. Department of Health and Human Services, Treatment Research Monograph Series,

DHHS Pub. No. (ADM) 87-1281 (Rockville,

MD: 1983).

Coutinho, R.A., “Epidemiology and Prevention

of AIDS Among Intravenous Drug Users,”

Journal of Acquired Immune Deficiency

Syndromes 3(4):413-416, April 1990.

Da]ey, B., “cocaine-dependent Women Have

Unique Treatment Needs,” Addiction Letter

5(10):1-3, October 1989.

D’Amanda, C., “Program Policies and Procedures Associated with Treatment Outcome,”

NIDA State of the Ati Research on the Treatment

of Narcotic Addiction, Cooper, J. R., (cd.),

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Hcahh Service, U.S. Department

of Health and Human Services, Treatment

Research Monograph Series, DHHS Pub. No.

(ADM) 87-1281 (Rockville, MD: 1983).

Darrow, W.W., Echenberg, D. F., Jaffe, H.W, et

al., “Risk Factors for Human Immunodeficiency

Virus (HIV) Infections in Homosexual Men,”

Am. J. ojPublic Health 77(4):479-483, 1987.

Delaney, P., “NIDA-HRSA Join Forces in

Studies of AIDS Risk Behavior by IVDUS,”

Public Health Reports 264(2):225-229, 1990.
References -133

75.

76.

77.

78.

79.

80.

81.

De Leon, G., “Program-Based Evaluation

Research in Therapeutic Communities,” Dmg

Abuse Treatment Evaluation: Strategies,

Progress, and Prospects, F.M. Tires and J.P.

Ludford (eds.), National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Service,

U.S. Department of Health and Human Services, NIDA Research Monograph Series 51,

DHHS Pub. No. (ADM) 88-1329 (Rockville,

MD: 1984).

De Leon, G., The Therapeutic Community:

Study of Effectiveness, National Institute on

Drug Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Service,

U.S. Department of Health and Human Services, NIDA Treatment Research Monograph

Series, DHHS Pub. No. (ADM) 85-1286 (Rockville, MD: 1984).

De Leon, G., “Therapeutic Community

Treatment Research Facts: What We Know;

TC4 Newsletter, pp. 1-9, fall 1988.

De Leon, G., “Psychopathology and Substance

Abuse: What is Being Learned from Research

in Therapeutic Communities, ” Journal of

Psychoactive Drugs, special issue on Dual Diagnosis: Clinical and Research Perspectives, J.E.

Zweben and J. Wallace (eds.), 21(2):177-188,

April/June 1989.

De Leon, G., “Retention in Drug Free

Therapeutic Communities,” paper presented at

the “NIDA RAUS, Improving Drug Abuse

Treatment; sponsored by National Institute on

Drug Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Service,

U.S. Department of Health and Human Services, Bethesda, MD, August 1989.

De Leon, G., Director of Research and

Training, Therapeutic Communities of

America, New York, NY, personal eommunieation, March 1990.

De Leon, G., Andrews, M., Wexler, H., et al,

“Therapeutic Communities Dropouts; Criminal

Behavior 5 Years After Treatment,” Am. J. of

Drug and Alcohol Abuse 6(3)253-271, 1979.

82.

83.

84.

85.

86*

87.

88.

89.

90.

De Leon, G., and Jainchill, N., “Male and

Female Drug Abusers: Social and Psychological

Status Two Years After Treatment in a

Therapeutic Community; Am. J. of Dmg and

Alcohol Abuse 8(4);465-497, 1981-1982.

De Leon, G., and Rosenthal, M.S., “Therapeutic

Communities,” Handbook on Dmg Abuse, R.I.

Dupont, A. Goldstein, and J. O’Donnell (eds.)

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, U.S. Department of Health Education

and Welfare and Office of Drug Abuse Policy,

Executive Office of the President (Washington

DC: U.S. Government Printing Office, 1979).

De Leon, G., Wexler, H., Jainchill, N., “The

Therapeutic Community: Success and

Improvement Rates Five Years After

Treatment,w International Journal of the Addictions 17(4):703-747, 1982.

Deren, S., “Children of Substance Abusers: A

Review of the Literature,w J. Sub. Abuse

Treatment 3;77-94, 1986 as cited in Chavkin, W.,

“Drug Addiction and Pregnancy: Policy

Crossroads,” Am. J. Public Health 80(4):483-

487, April 1990.

Des Jarlais, D.C., “Stages in the Response of

the Drug Abuse Treatment System to the AIDS

Epidemic in New York City,” Journal of Dmg

Issues 20(2):335-347, 1990.

Des Jarlais, D. C., Director of Research,

Chemical Dependency Institute, Beth Israel

Medical Center, New York, NY, personal communication, July 1990.

Des Jarlais, D. C., Casriel, C., and Friedman,

S.R., “The New Death Among IV Drug Users:

AIDS: Principles, Practices and Politics, I.B.

Corless and M. Pittmann-Lindeman (eds.)

(Washington, DC: Hemisphere Publishing Corporation, 1989).

Des Jarlais, D. C., and Friedman, S.R., “AIDS

Prevention Among IV Drug Users: Potential

Conflicts Between Research Design and

Ethics,” IRB: A Review of Human Subjects

Research 9(1):6-8, 1987.

Des Jarlais, D. C., and Friedman, S.R., “HIV

Infection Among Intravenous Drug Users:

Epidemiology and Risk Reductio~” AIDS 1:67-

76, July 1987.
134- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIVInfection

91.

92.

93.

94.

95.

96.

97.

98.

99.

Des Jarlais, D.C., and Friedman, S.R., “HIV

and Intravenous Drug Use,” AIDS 2(suppl

1):S65-S69, 1988.

Des Jarlais, D.C., and Friedman, S.R., “The

Psychology of Preventing AIDS Among

Intravenous Drug Users. A Social Learning

Conceptualization,” American Psychologist

43(11):865-870, November 1988.

Des Jarlais, D.C., Friedm~ S.R., Casriel, C., et

al., “AIDS and Preventing Initiation into IV

Drug Use,W Psycho!o~ and Health 1(2):179-194,

1987.

Des Jarlais, D. C., Friedman, S. R., Novick,

D. M., et al., “HIV-1 Infection Among

Intravenous Drug Users in Manhattan, New

York City, from 1977 through 1987,” JAM.A.,

261:1008-1012, 1987.

Des Jarlais, D.C., Friedman, S. R., Sotheran,

J. L., et al., “The Sharing of Drug Injection

Equipment and the AIDS Epidemic in New

York City: The First Decade,” Needle-Sharing

Among Intravenous Drug Abusers: National and

International Pempectives, R.J. Battjes and R.W.

Pickens (eds.), National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Association, Public Health Service, U.S.

Department of Health and Human Services,

NIDA Research Monograph Series 80, 1988,

DHHS Pub. No. (ADM) 88-1567 (Rockville,

MD: 1988).

Des Jarlais, D.C., Hagan, H., Purchase, D., et

al., “Safer Injection Practices Among

Participants in the First North American

Syringe Exchange Program,” abstract presented

at the Fifth International Conference on AIDS,

Abstract No. TAO 20, Montreal, Canada, June

1989.

Dole, V. P., “Implications of Methadone

Maintenance for Theories of Narcotic

Addiction,” J.A.M.A. 260(20):3025-3029, Nov.

25,1988.

Dole, V. P., “Methadone Treatment and the

Acquired Immunodeficiency Syndrome

Epidemic,” J.A.M.A. 262(12):1681-2, Sept.

22/29, 1989.

Dole, V. P., and Herman, J., “Long-Term

Outcome of Patients Treated with Methadone

Maintenance;’ Anna!s of New York Academy of

Sciences 311:181-190, 1978.

100.

101*

102.

103.

104.

105.

106.

107.

108.

Dole, V.P., and Nyswander, M., “A Medical

Treatment for Diacetylmorphine (Heroin)

Addiction: Clinical Trial With Methadone

Hydrochloride,” J4.i’Kd. 193:646-650, 1%5.

Donahoe, R., “Opiates as Immunocompromising Drugs: The Evidence and Possible Mechanisms,” Problems of Drug Dependence 1988, L.S. Harris (cd.), National Institute

on Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Association, Public Health

Service, U.S. Department of Health and

Human Services, NIDA Research Monograph

90, 1988, DHHS Pub. No. (ADM) 89-1605

(Rockville, MD: 1988).

Dorland’s Illustrated Medical Dictiomwy (26th

cd. ) (Philadelphia, PA: W.B. Saunders

Company, 1981).

Espinoza, P., Bouchard, I., Ballian, P., et al.,

“Has the Open Sale of Syringes ModWled the

Syringe Exchanging Habits of Drug Addicts;

paper presented at the Fourth International

Conference on AIDS, Stockholm, Sweden, June

1988.

Executive Office of the President, Office of

National Drug Control Policy, Nationa2 Drug

Control Strategy (Washington, DC: September

1989).

Executive Office of the President, Office of

National Drug Control Policy, Understanding

Drug Treatment: An Office of National Drug

Control Policy W4ite Paper (Washington, DC:

June 1990).

Extein, I.L., and Gold, M.S., “The Treatment of

Cocaine Addicts: Bromocryptine or

Desipramine,” Psychiatric Anna/s 18(9):535-537,

September 1988.

Feldman, H.W., Powers, B., and Biernacki, P.,

“Stopping the Spread of AIDS Among

Intravenous Drug Users and Their Sexual

Partners: What Works? What Doesn’t?,” paper

presented at the “What Works: An International

Perspective on Drug Abuse Treatment and Prevention Research,” conference sponsored by

New York State Division of Substance Abuse

Services and the Narcotic and Drug Abuse

Research, Inc., New York, NY, October 1989.

French, M.T., Rachal, J.V., and Hubbard, R.L.,

“Conceptual Framework for Estimating the

Social Costs of Drug Abuse,” J. of Health and

Social Policy, in press, October/November

1990.
References -135

108a.

109.

110.

111.

112.

113.

114.

115.

116.

117.

Friedland, G. H., and Klein, R. S., “Transmission of the Human Immunodeficiency

Virus,” N. Engl. J. Med. 317(18):1125-1135,

Oct. 29,1987.

Friedman, S. R., Southeran, J. L., AbdulQuader, A., et al., “The AIDS Epidemic

Among Blacks and Hispanics,” 7?ze Milbank

Quatierly 65 (Suppl. 2): 455-499,1987.

Friedman, S.R., Sterk, C., Sufian, M., et al.,

“Effects of Changes in Drugs Injected on

Drug Using Environments and Risk

Reduction Among IV Users,” paper presented

at the Fifth International Conference on

AIDS, Abstract No. THD 013, Montreal,

Canada, June 1989.

Fuchs, D., Unterweger, B., Hinterhuber, H.,

et al., “Successful Preventive Measures in a

Community of IV Drug Addicts,” paper presented at the Fourth International Conference

on AIDS, Stockholm, Sweden, June 1988.

Fullilove, M., HIV Center for Clinical and

Behavioral Studies, New York State

Psychiatric Institute, Columbia University,

New York, NY, personal communication, July

1990.

Gardom, J., Public Health Advisor, Center for

Prevention Services, Office of the Director

(HIV), Centers for Disease Control, Public

Health Service, U.S. Department of Health

and Human Services, Atlanta, GA, personal

communication, July 19, 1990.

Gawin, F.H., “New Uses of Antidepressants in

C o c a i n e Ab us e,” Psych osom a tics

27(ll)(suppl.):24-29, November 1986.

Gawin, F. H., Byck, R., and Kleber, H.D.,

“Desipramine Augmentation of Cocaine

Abstinence: Initial Results, ” C/inica2

Neurophannacology 9(suppl. 4):202-204, 1986.

Gawin, P. H., and Kleber, H. D., “Abstinence

Symptomatology and Psychiatric Diagnosis in

Cocaine Abusers,” Arch. Gen. Psychiatry

43:107-113, February 1986.

Gawin F. H., Kleber, H.D., Byck R., et al.,

“Desipramine Facilitation of Initial Cocaine

Abstinence;’’ Arch. Gen. Psychiat~ 46:117-121,

February 1989.

118.

119.

120.

121.

122.

123.

123a.

124.

Giovino, GA., Marcus, S., Pierce, J.P., et al.,

“Lifetime Patterns of Smoking Cessation,”

data from the NHANES 1 Epidemiologic Followup Study, presented at the World Conference on Lung Health, May 23,1990.

Goldberg, D., Warson, H., Stuart, F., et al.,

“Pharmacy Supply of Needles and Syringes -

the Effect on Spread of HIV in Intravenous

Drug Misusers,” paper presented at the

Fourth International Conference on AIDS,

Stockholm, Sweden, June 1988.

Goldsmith, M.F., “Sex Tied to Drugs=STD

Spread; JA.M4. 260(14):2009, October 1988.

Goldstein, A., and Judson, B.A., “Critique,”

Research on the Treatment of Narcotic

Addiction. State of the Art, J.R. Cooper, F.

Altman, B.S. Brown, and D. Czechowicz

(eds.), National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human SeAces,

NIDA Treatment Research Monograph

Series, DHHS Pub. No. (ADM) 87-1281

(Rockville, MD: 1983).

Green, M. S., “Crack-Exposed Babies

Undercounted, Study Found,” Washington

Post, p. D4, Mar. 8,1990.

Greenstein, R.A., O’Brien, C.P., McLellan,

A. T., et al., “Naltrexone: A Short-Term

Treatment for Opiate Dependence,” Am. J.

DmgAlcoholAbuse 8(3):291-300, 1981.

Gustafson, J.S., “Do More... and Do Better:

Staff Related Issues in the Drug Treatment

Field Which Impact on the Quality and Effectiveness of Services,” paper presented at the

“NIDA RAUS, Improving Drug Abuse

Treatment ,“ sponsored by the National

Institute on Drug Abuse, Alcohol, Drug

Abuse, and Mental Health Administration,

Public Health Service, U.S. Department of

Health and Human Services, Bethesda, MD,

August 1989.

Guydish, J.R., Abramowit~ A.L., Goods, W.,

et al., “Changes in Needle Sharing Behavior

Among Intravenous Drug Users: San Francisco, 1986-88,” Am. J. Public Health 80(8):

995-997, August 1990.
136- The Effectiveness of Drug Abuse Treatment: Implications for Controlling HIV Infection

125.

126.

127.

128.

129.

130.

Hagan, H., Des Jarlais, D.C., Purchase, D., et

al., “Drug Use Trends Among Participants in

the Tacoma Syringe Exchange,” paper presented at the Fifth International Conference

on AIDS, Abstract No. ThD 013, Montre~

Cana@ June 1989.

Hahn, R.A., Onorato, I. M., Jones, S., et al.,

“Prevalence of HIV Infection Among

Intravenous Drug Users in the United States:

JAA4A. 261(18):2677-2684, May 12,1989.

Halfon, N., “Born Hooked: Confronting the

Impact of Perinatal Substance Abuse,”

testimony before the Select Committee on

Children, Youth and Families, U.S. House of

Representatives, U.S. Congress, Apr. 27,1989,

as cited in Gittker, J., “Drug-Exposed Infants

and their Mothers: Responses to the

Problem: Congressional Forum, January 1990.

Hall, S. M., “Clinical Trials in Drug Treatment:

Methodology, ” Drug Abuse Treatment

Evaluation: Stratep”es, Progress, and Prospects,

F.M. Tires and J.P. Ludford (eds.), National

Institute on Drug Abuse, Alcohol, Drug

Abuse, and Mental Health Administration,

Public Health Service, U.S. Department of

Health and Human Services, NIDA Research

Monograph Series 51, DHHS Pub. No.

(ADM) 88-1329 (Rockville, MD: 1984).

Hall, S.M., Wasserman, D.A., and Havassy,

B.E., “Relapse Prevention,” paper presented

at “NIDA RAUS, Improving Drug Abuse

Treatment,” sponsored by National Institute

on Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Administration, Public Health

Service, U.S. Department of Health and

Human Services, Bethesda, MD, August 1989.

Hargreaves, W.A., “Methadone Dose and

Duration for Maintenance Treatment,”

Research on the Treatment on Narcotic

Addiction State of the Art, National Institute

on Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Administration, Public Health

Service, U.S. Department of Health and

Human Services, Treatment Mongraph Series,

DHHS Pub. No. (ADM) 87-1281 (Rockville,

MD: 1983).

131.

132.

3.33.

134.

135.

136.

137.

Hart, G., Carvell, A., Woodward, N., et al.,

“Needle-Exchange in Central London: One

Year Follow-up,” abstract presented in the

Fifth International Conference on AIDS,

Abstract No. TAO 9, Montreal, Canad~ June

1989.

Hartel, D., Selwyn, PA., Schoenbaum, E.E.,

et al., “Methadone Maintenance Treatment

and Reduced Risk of AIDS and AIDSSpetilc Mortality in Intravenous Drug Users;

abstract presented at the Fourth International

Conference on AIDS, Abstract No. 8546,

Stockholm, Sweden, June 1988.

Harvard Medical School, “Drug Abuse and

Dependence--Part I: Harvard Medical School

Mental Health Letter 6(4):1-4, October 1989.

Harvard Medical School$ “Drug Abuse and

Dependence --Part 11,” Harvard Medical

School Mental Health Letter 6(5):1-4,

November 1989.

Harwood, H.R., Hubbard, R.C., Collins, J.J.,

et al., “The Costs of Crime and the Benefits of

Drug Abuse Treatment: A Cost-Benefit

Analysis Using TOPS Data,” Compulsory

Treatment for Drug Abuse: Research and

Clinical Practice, C.G. Leukefeld, and F.M.

Tires (eds.), National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Service,

U.S. Department of Health and Human Services, NIDA Research Monograph Series 86,

1988, DHHS Pub. No. (ADM) 88-1578

(Rockville, MD: 1988).

Harwood, H. J., Napolitano, D. M.,

Kristiansen, P.L., et al., “Economic Costs to

Society of Alcohol and Drug Abuse and

Mental Illness: 1980,” contract report

prepared for the Alcohol, Drug Abuse, and

Mental Health Administration, Public Health

Service, U.S. Department of Health and

Human Services, Contract No. ADM 283-83-

0002 (Rockville, MD: June 1984).

Hasin, D.S., Grant, B.F., Endicott, J., et al.,

“Cocaine and Heroin Dependence Compared

in Poly-drug Abusers,” Am. J. I%bZic Health

78(5):567-569, May 1988.
References -137

138.

139.

140.

141.

142.

143.

144.

1450

145a.

146.

147.

Haverkos, H.W., and Edelman, R., ‘The

Epidemiology of Acquired Immunodeficiency

Syndrome Among Heterosexuals,” J.A.M-A.

260(13): 1922-1929, Oct. 7,1988.

Haverkos, H.W., and Lange, W. R., “Serious

Infections Other Than HIV Among IV Drug

Users,” J. of Infectious Diseases 161(5): 894-

902, May 1990.

Hawkins, D.J., and Catalano, R.F., “Aftercare

in Drug Abuse Treatment; International J. of

the Ad2iictions 20(6&7): 917-945, 1985.

Hearst, N., and Hulley, S.B., “Preventing the

Heterosexual Spread of AIDS,” J.A.M.A.,

259(16):2428-2432, 1988.

Hill, B.A., “The Environment and Disease:

Association or Causation?” Proc. Res. Soc.

Med. 58:295-300, 1%5.

Hilts, PJ., “Spread of AIDS By Heterosexuals

Remains Slow,” New York 71mes, p. B5(N), p.

Cl(L) (co1. 4), May 1,1990.

Holland, S., “Evaluating Community-Based

Treatment Programmed: A Model for

Strengthening Inference About Effectiveness,”

Int. J. of Therapeutic Communities 4(4)Q85-

306,1983.

Holmberg, S. D., Chief, Special Section

Studies, Division HIV/AIDS, Centers for

Disease Control, Public Health Service, U.S.

Department of Health and Human Services,

Atlanta, personal communication, July 1990.

Holmberg, S.D., Horsburgh, C.R., Jr., Ward,

J.W., et al., “Biological Factors in the Sexual

Transmission of Human Immunodeficiency

Virus,” J. of Infectious Diseases 160(1):116-

125,1989.

Hubbard, R. L., Senior Social Psychologist,

Center for Social Research and Policy

Analysis, Research Triangle Institute,

Research Triangle Park, NC, personal communication, July 1990.

Hubbard, R.L., and Marsden, M. E., “Relapse

to Use of Heroin, Cocaine and Other Drugs

in the First Year After Treatment,” Relapse

and Recove~ in Drug Abuse, F.M. Tires and

C.G. Leukefeld (eds.), National Institute on

Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Administration, Public Health

Service, U.S. Department of Health and

Human Services, Research Monograph Series

72, DHHS Pub. No. (ADM) 86-1473 (Rockville, MD: 1986).

148.

149.

150.

151.

152.

153.

154.

Hubbard, R. L., Marsden, M.E., Cavanaugh,

E., et al., “Role of Drug-Abuse Treatment in

Limiting the Spread of AIDS,” Reviews of

Infectious Diseases 10(2):377-384,

March/April 1988.

Hubbard, R.L., Marsden, M.E., Rachal, J.V.,

et al., Dn~g Abuse Treatment. A National Study

of Effectiveness (Chapel Hill, NC: University

of North Carolina Press, 1989).

Hubbard, R.L., Rachal, J.V., Craddock, S.G.,

et al., ‘Treatment Outcome Prospective Study

(TOPS): Client Characteristics and Behaviors

Before, During and After Treatment,” Drug

Abuse Treatment Evaluation: Strategies,

Progress, and Prospects, F.M. Tires and J.P.

Ludford (eds), National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Service,

U.S. Department of Health and Human Services, NIDA Research Monograph Series 51,

DHHS Pub. No. (ADM) 88-1329 (Rockville,

MD: 1984).

Hunt, D.E., Lipton, D.S., and Barry, S., “Patterns of Criminal Activity Among Methadone

Clients and Current Narcotic Users Not in

Treatment,” Journal of Dmg Issues 14:68’7-702,

1984, as cited in Anglin, M. D., and Hser, Y.,

“The Efficacy of Drug Abuse Treatment,”

(Los Angeles, CA: Drug Abuse Research

Group, Ncuropsychiatric Institute, University

of California, Los Angeles, October 1989).

Jackson, J., and Rotkicwitz, L., “A Coupon

Program: Drug Treatment and AIDS Education,” abstract presented at the Third International Conference on AIDS, Abstract No.

156, Washington, DC, June 1987.

Jackson, J. F., and Geringer, W.M., “Women

Intravenous Drug Abusers and AIDS,” AIDS

Treatment and Community Support Unit,

Division of Narcotic and Drug Abuse Control,

Ncw Jersey State Department of Health,

November 1987.

Jaffe, J., Assistant Director, Office of

Treatment Improvement, National Institute

on Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Administration, Public Health

Service, U.S. Department of Health and

Human Scrviccs, Rockville, MD, personal

communication, July 1990.
138- The Effectiveness of Drug Abuse Treatment: Implicationsfor Controlling HIV Infection

155.

156.

157.

158.

159.

160.

161.

162.

163.

164.

Jainchill, N., Senior Research Scientist,

Therapeutic Communities of America, New

York, NY, personal communication, July

1990.

Jainchill, N., De Leon, G., and Pinkham, L.,

“Psychiatric Diagnoses Among Substance

Abusers in Therapeutic Community

Treat merit,” J. of Psychoactive Drugs

18(3):209-213, July/September 1986.

Joe, G.W., Chastain, R.L., Marshj K.L., et al.,

“Relapse,w Opioid Addiction and Treatment: A

12-Year Fe/low-up, D.D. Simpson and S.B.

Sells (eds.) (Melbourne, FL: Robert E.

Krieger Publishing Company, in press, 1990).

Joe, G.W., Chastain, R.L., and Simpson, D.D.,

“Reasons for Addiction Stages,” Opioid

Addiction and Treatment: A 12-Year Followup, D.D. Simpson and S.B. Sells (eds.) (Melbourne, FL: Robert E. Krieger Publishing

Company, in press, 1990).

Johnson, B. D., “What Works with Drug

Abusing Criminals,” paper presented at the

“What Works: An International Perspective

on Drug Abuse Treatment and Prevention

Research”, conference sponsored by New

York State Division of Substance Abuse Services and the Narcotic and Drug Abuse

Research, Inc., New York City, NY, October

1989.

Johnson, E. M., “Women’s Health: Issues in

Mental Health, Alcoholism, and Substance

Abuse,” Public Hea/th Reports (Suppl.),

July/August 1988.

Johnston, L. D., “Techniques for Reducing

Measurement Error in Surveys of Drug Use,”

Studying Drug Abuse, Robbins L.N. (cd.)

(New Brunswick, NJ: Rutgers University

Press, 1985).

Jones, S., Medical Epidemiologist, Center for

Prevention Services, Centers for Disease

Control, Public Health Service, U.S.

Department of Health and Human Services,

Atlanta GA, personal communication, July

1990.

Julius, DA., “Research and Development of

Naltrexone: A New Narcotic Antagonist,” Am.

J. Psychiatry 136(6):782-686, June 1979.

Karp-Gelernter, E., Savage, C., and McCabe,

O. L., “Evaluation of Clinic Attendance

Schedules for LAAM and Methadone: A Con165.

166.

167.

168.

169.

170.

171.

172.

173.

174.

175.

trolled Study,” Int. J. Addictions 17(5):805-813,

July 1982.

Khalsa, H.K., Anglin, D.M., and Paredes, A.,

“Pre-Treatment Natural History of Cocaine

Addiction,” proceedings of the 1990 Meeting

of the Committee on Problems of Drug

Dependence, Richmond VA, June 1990.

Khantzian, E.J., and McKenna, GJ., “Acute

Toxic and Withdrawal Reactions Associated

with Drug Use and Abuse,” Annaik of Zntemal

Me&”cine 90(3) :361-37~ March 1979.

Kim, T. F., “Methadone Maintenance

Treatment Remains Controversial Even After

23 Years of Experience, ” J. A.M.A.

260(20):2970-2971,2975, NOV. 25,1988.

Kleber, H. D., “Naltrexone,” J. Substance

Abuse Treatment 2(2):117-122, 1985.

Kleber, H.D., “From Theory to Practice: the

Planned Treatment of Drug Users,” Znt. J.

Addictions 24(2):123-166, February 1989.

Kleber, H.D., “Treatment of Drug Dependence: What Works,” International Review of

Psychiat~ 1(1-2):81-99, March 1989.

Kleber, H.D., Riordan C.E., Rounsaville, B.,

et al., ‘Clonidine in Outpatient Detoxifkation

From Methadone Maintenance,W Amh. Gen.

Psychiaty 42:391-394, April 1985.

Kleiman, M.A., “Introduction,” Hard-Core

Cocaine Addicts: Measuring--And Fighting--

The Epidemic, Committee on the Judiciary,

Senate, U.S. Congress, Staff Report, S. Prt.

101-6 (Washington, DC: U.S. Government

Printing Office, May 10, 1990).

Kleinbaum, D. G., Cooper, L. L., and

Morgenstern, H., Epidemiolo~”c Research.

Pn”nciples and Quantitative Methods (London,

England: Lifetime Learning Publications,

1982).

Kolata, G., “AIDS Strategy for Addicts Is

Faulted,” New York 71mes, p. 16(N), p. 19(L)

(co1. 1), Feb. 24,1989.

Kosten, T. R., “The Symptomatic and Prognostic Implications of Psychiatric Diagnoses in

Treated Substance Abusers,” Problems of

Drug Dependence 1987, L.S. Harris (cd.),

National Institute on Drug Abuse, Alcoho~

Drug Abuse, and Mental Health Administration, Public Health Service, U.S.

Department of Health and Human Services,

Research Monograph Series 81, DHHS Pub.

No. (ADM) 88-1564 (Rockville, MD: 1988).
References -139

176.

177.

178.

179.

180.

181.

182.

183.

184.

185.

Kosten, T.R., “Pharmacotherapeutic Intementions for Cocaine Abuse: Matching Patients to

Treatment,” The Journal of Nervous and

Mental Disease 177(7):379-389, July 1989.

Kosten, T.R., ‘Client Issues in Drug Abuse

Treatment: Addressing Multiple Drug Use;

paper presented at the “NIDA RAUS,

Improving Drug Abuse Treatment,”

sponsored by National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Service,

U.S. Department of Health and Human Services, Bethesda, MD, August 1989.

Kosten, T. R., “Neurobiology of Abused

Drugs: Opioids and Stimulants,” Journal of

Nervous and Mental Disease 178(4):217-227,

April 1990.

Kosten, T. R., Associate Professor of

Psychiatry, Yale University School of Medicine, Acting co-Director, Substance Abuse

Treatment Unit, New Haven, CT, personal

communication, July 2, 1990.

Kosten, T.R., and Kleber, H.D., “Strategies to

Improve Compliance with Narcotic

Antagonists,” Am. J. Drug Alcohol Abuse

10(2):249-266, 1984.

Kosten, T. R., and Kleber, H. D., “Buprenorphine Detoxification from Opioid Dependence: A Pilot Study,” Lye Sciences 42(6):635-

641,1988.

Kosten, T.R., Kleber, H. D., and Morgan, C.,

“Role of Opioid Antagonists in Treating

Intravenous Cocaine Abuse,” Life Sciences

44(13):887-892, 1989.

Kosten, T.R., Rounsaville, B.J., and Kleber,

H.D., “Multidimensionality and Prediction of

Treatment Outcome in Opioid Addicts: 2.5-

Year Follow-Up,” Comprehensive Psychiatry

28(1):3-13, January/February 1987.

Kosten, T. R., Rounsaville, B.J., and Kleber,

H.D., “A 2.5-Year Follow-up of Cocaine Use

Among Treated Opioid Addicts,” Amh. Gen.

Psychiatry 44:281-284, March 1987.

Kozel, N.J., and Adams, E.H., “Epidemiology

of Drug Abuse: An Overview, ” Science

234(4779):970-974, Nov. 21,1986.

186. Kreek, M.J., “Immunological Approaches to

Clinical Issues in Drug Abuse,” Problems of

Drug Dependence 1988, L.S. Harris (cd.),

National Institute on Drug Abuse, Alcoho~

Drug Abuse, and Mental Health Association,

Public Health Service, U.S. Department of

Health and Human Services NIDA Research

Monograph 90, 1988, DHHS Pub. No.

(ADM) 89-1605 (Rockville, MD: 1988).

187. Kreek, M.J., “Using Methadone Effectively

Achieving Goals by Application of

Laboratory, Clini@ and Evaluation Research

and by Development of Innovative Programs,”

paper presented at “NIDA RAUS, Improving

Drug Abuse Treatment,” sponsored by

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, U.S.

Department of Health and Human Services,

Bethesda, MD, August 1989.

188. Labaton, S., “The Cost of Drug Abuse: $60

Billion a Year,” New York Times, p. Dl, D6,

Dec. 5,1989.

189. Lampinen, T., Weibel, W.W., and Watters,

J.K., “Intravenous Drug Users, HIV Testing

and Counsel ing, ” (letter) J. A.M.A.

262(10):1331, 1989.

190. Leukefeld, C. G., ‘Opportunities for

Enhancing Drug Abuse Treatment with

Criminal Justice Authority,” paper presented

at the “NIDA RAUS, Improving Drug Abuse

Treatment,” sponsored by National Institute

on Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Administration, Public Health

Service, U.S. Department of Health and

Human Services, Bethesda, MD, August 1989.

191. Leukefeld, C. G., and Tires, F.M., “Relapse

and Recovery: Some Directions for Research

and Practice,” Relapse and Recove~ in Dmg

Abuse, F.M. Tires and C.G. Leukefeld (eds.),

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, U.S.

Department of Health and Human Services,

Research Monograph Series 72, DHHS Pub.

No. (ADM) 86-1473 (Rockville, MD: 1986).
140- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIV Infection

192.

193.

194.

195.

196.

197.

Leukefeld, C. G., and Tires, F.M. (eds.),

“Compulsory Treatment: A Review of the

Findings,” Compulsory Treatment of Drug

Abuse: Research and Clinical Practice,

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, U.S.

Department of Health and Human Services,

Research Monograph Series 86, DHHS Pub.

No. (ADM) 88-1578 (Rockville, MD: 1988).

Lewis, D.K, Watters, J.K., and Case, P., “The

Prevalence of High-Risk Sexual Behavior in

Male IVDUS with Steady Female Partners;

Am. J. Public Health 80(4):465-466, April

1990.

Ling, W., and Blaine, J. D., “The Use of

LAAM in Treatment,” Handbook on Drug

Abuse, R.I. Dupont, A. Goldstein, and J.

O’Donnell (eds.), National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, U.S. Department of

Healtb Education, and Welfare and Office of

Drug Abuse Policy, Executive Office of the

President (Washington, DC: U.S. Government Printing Office, January 1979).

Lipton, D. S., “Research Agenda for the

Nineties,” paper presented at the “What

Works: An International Perspective on Drug

Abuse Treatment and Prevention Research,”

conference sponsored by New York State

Division of Substance Abuse Services and the

Narcotic and Drug Abuse Research, Inc., New

York, NY, October 1989.

Little, B., Snell, L. M., Klien, V. R., et al.,

“Cocaine Abuse During Pregnancy: Maternal

and Fetal Implications,” Obstetrics and Gynecology, 73(2):157-160, February 1989.

Maddux, J. F., and Desmond, D.P., “Relapse

and Recovery in Substance Abuse Carrers,”

Relapse and Recovery in Drug Abuse, F.M.

Tires and C.G. Leukefeld (eds.), National

Institute on Drug Abuse, Alcohol, Drug

Abuse, and Mental Health Administration,

Public Health Service, U.S. Department of

Health and Human Services, Research

Monograph Series 72, DHHS Pub. No.

(ADM) 86-1473 (Rockville, MD: 1986).

198.

199.

200.

200a.

201.

202.

203.

204.

205.

Maddwq J.F., and Desmond, D.P., “Crime and

Drug Use Behavior: An Analysis, ”

Criminology 19:281-302, 1979, as cited in

Anglin, M.D., and Hser, Y., “The Efficacy of

Drug Abuse Treatment,W (Los Angeles, CA:

Drug Abuse Research Group, Neuropsychiatric Institute, University of Californi~

Los Angeles, October 1989).

Magura, S., Goldsmith, D., Casriel, C., et al.,

“The Validity of Methadone Clients’ SelfReported Drug Use,” The International

Journal of the Addictions 22(8) :’727-749,

August 1987.

Magura, S., Grossman, J.I., Lipton, D.S., et

al., “Correlates of Participation in AIDS Education and HIV Antibody Testing by

Methadone Patients,” Public Health Reports

104(3):231-240, May/June 1989. .

Marcus, R., and the CDC Cooperative NeedIestick Surveillance Group, “Surveillance of

Health Care Workers Exposed to Blood From

Patients Infected With the Human

Immunodeficiency Virus,” N. Engl. J. Med.

319(17):1118-1123, Oct. 27,1988.

Marsh, K.L., Joe, G.W., Simpson, D.D., et al.,

“Treatment History,U Opioid Addiction and

Treatment: A 12-Year Follow-up, D.D.

Simpson and S.B. Sells (eds.) (Melbourne,

FL: Robert E. Krieger Publishing Company,

in press, 1990).

McAuliffe, W., “A Randomized Controlled

Trial of Recovery Training and Self Help for

Opiate Addicts in New England and Hong

Kong; J of Psychoactive Dregs 22(2): 197-209,

April/June 1990.

McAuliffe, W., Principal Investigator, Project

Outreach, Cambridge, MA, personal communication, July 1990.

McAuliffe, W.E., Albert, J., Cordill-Londo~

G., et al., “Contributions to a Social Conditioning Model of Cocaine Recovery,”

Department of Psychiatry, Harvard Medical

School, Cambridge Hospital, Cambridge, M&

November 1989.

McAuliffe, W., Breer, P., and Dovering, S.,

“An Evaluation of Using Ex-Addict Outreach

Workers to Educate Intravenous Drug Users

About AIDS, ” AIDS and Public Policy

4(4):218-223, 1989.
References -141

206.

207.

208.

209.

210.

211.

212.

McAuliffe, W.E., Feldma~ B., Friedman, R.,

et al., “Explaining Relapse to Opiate

Addiction Following Successful Completion of

Treatment, w Relapse and Recovery in Drug

Abuse, F.M. Tires and C.G. Leukefeld (eds.),

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, U.S.

Department of Health and Human Services,

Research Monograph Series 72, DHHS Pub.

No. (ADM) 86-1473 (Rockville, MD: 1986).

McGlothlin, W. H., and Anglin, D. M.,

“Shutting Off Methadone: Costs and Benefits,”

Archives of General Psychiat~ 38:885-892,

1981, as cited in. Anglin, M.D., and Hser, Y.,

“The Efficacy of Drug Abuse Treatment,”

(Los Angeles, CA: Drug Abuse Research

Group, Neuropsychiatric Institute, University

of California, Los Angeles, October 1989).

McLellan, A.T., Luborsky, L., O’Brien, C.P.,

et al., “An Improved Evaluation Instrument

for Substance Abuse Patients: The Addiction

Severity Inde~” J. Nerv. Merit. Dis. 168(1):26-

33, January 1980.

McLellan, A.T., Luborsky, L., O’Brien, C.P.,

et al., “Is Treatment for Substance Abuse

Effective?” J.A.MA. 247(10):1423-1428, Mar.

12,1982.

McLellan, A.T., Woody, G.E., Luborsky, L., et

al., “Increased Effectiveness of Substance

Abuse Treatment: A Prospective Study of

Patient-Treatment ‘Matching,’” Journal of

Nervous and Mental Disease 171(10) ;597-605,

1983.

Mello, N.K., Mendelson, J.K., Bree, M.P., et

al., “Buprenorphine Suppresses Cocaine SelfAdministration by Rhesus Monkeys;” Science

245(4920):859-862, Aug. 25,1989.

Mendelson, J., “Some Special Considerations

for Treatment of Drug Abuse and Dependence in Women,” paper presented at “NIDA

RAUS, Improving Drug Abuse Treatment;’

sporisored by National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Service,

U.S. Department of Health and Human Services, Bethesda, MD, August 1989.

213.

214.

215.

216.

216a.

217.

218.

219.

220.

221.

Molinari, S. P., National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Service,

Department of Health and Human Services,

memorandum from the Regulatory Counsel

to the Director of NIDA, “Status of

Methadone Treatment Programs: Summary

of State Responses to iNIDA Letter,” Apr. 7,

1988.

Molinari, S. P., National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Service,

Department of Health and Human Services,

personal communication, July 18,1990.

Moss, R.A., and Chaisson, R.E., “AIDS and

Intravenous Drug Use in San Francisco,”

AIDS and Public Policy 3(2):37-41, 1988.

National Academy of Science, Confronting

AIDS: Directions for Public Health, Health

Care, and Research (Washington DC:

National Academy Press, 1986).

National Academy of Science, Confronting

AIDS, Update 1988 (Washington DC:

National Academy Press, 1988).

National Association of State Alcohol and

Drug Abuse Directors, “Reasonable National

Estimates of Annual Drug Abuse Treatment

Operational Costs by Environment and

Modality of Treatment for Needle Drug

Dependent Persons,” Washington, DC, Sept.

2,1987.

National Association of State Alcohol and

Drug Abuse Directors, “Highlights of Results

From NASADAD Survey on State Alcohol

and Drug Agency Use of FY 1989 Federal

and State Funds,” Washington, DC, July 1990.

National Maternal and Child Health Resource

Center, Impact of Family Drug Abuse on

Children: An Overview (Iowa City, 1A:

National Maternal and Child Health Resource

Center, January 1990).

National Research Council, Evaluating AIDS

Prevention Programs (Washington, DC:

National Academy Press, 1988).

Nemoto, T., Brown, L.S., Chu, A., et a$., “The

Role of Cocaine Use in HIV Transmission

Among IVDUS,” paper presented at “The

Annual Meeting of the American Public

Health Association,” Chicago, IL, October

1989.
142- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIV Infection

222.

223.

224.

225.

226.

227.

228.

229.

Nemoto, T., Brown, L.S., Foster, K., et al.,

“Behavioral Characteristics of Seroconverted

Intravenous Drug Users: 1987 and 1988

Cohort Study,” paper presented at the

American Public Health Association Annual

Meeting Chicago, IL, October 1989.

Newman, R.G., “Detoxification Treatment of

Narcotic Addicts,” Handbook on Drug Abuse,

R.I. Dupont, A. Goldstein, and J. O’Donnell

(eds.), National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, U.S. Department of Health,

Education, and Welfare, and Office of Drug

Abuse Policy, Executive Office of the President (Washington, DC,: U.S. Government

Printing Office, January 1979).

Newman, R. G., “Methadone Treatment,

Defining and Evaluating Success,” N. EngZ. J.

Med. 317(7):447-450, Aug. 13, 1987

Newman, R. G., President, Beth Israel

Medical Center, New York, NY, “Testimony:’

Methadone Maintenance, hearing before the

Select Committee on Narcotics Abuse and

Control, House of Representatives, U.S. Congress, New York, NY, March 1990.

Newman, R. G., President, Beth Israel

Medical Center, New York, NY, personal

communication, July 1990.

Newman, R. G., and Whitehill, W. B., “DoubleBlind Comparison of Methadone and Placebo

Maintenance Treatments of Narcotic Addicts

in Hong-Kong,” Lancer 2(8141):485-488, Sept.

8,1979.

Novick, D. M., et al., “Antibody to LAV, the

Putative Agent of AIDS in Humans, w

Problems of Drug Dependence, LS. Harris

(cd.), National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human Services,

NIDA Research Monograph 67, 1985, DHHS

Pub. No. (ADM) 86-1448 (Rockville, MD:

1986), as cited in Report on Effectiveness of

Drug Abuse Treatment as an AIDS Prevention

Strategy, National Institute on Drug Abuse,

1988.

Novick, D. M., Joseph, H., Croxson, T.S., et

al., “Absence of Antibody to HIV in LongTerm, Socially Rehabilitated Methadone

230.

231.

232.

233.

234.

Maintenance Patients,” abstract presented at

the Fifth International Conference on AIDS,

Abstract No. WDP 71, Montreal, Canada,

June 1989.

Novick, D.M., Pascarelli, E. F., Joseph, H., et

al., “Methadone Maintenance Patients in

General Medical Practice: A Preliminary

Report,” JAM4. 259(22):3299-3302, June 10,

1988.

Nurco, D.N., Stephenson, P., Hanlon, T.E., “

Contemporary Issues in Drug Abuse

Treatment Linkage With Self-Help Groups,

paper presented at the “NIDA RAUS,

Improving Drug Abuse Treat merit,”

sponsored by National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Services, U.S. Department of Health and Human

Services, Bethesda MD, August 1989.

O’Brien, C.P., Childress, A.R, McLellan, A.T.,

et al., “Progress in Understanding the Conditioning Aspects of Drug Dependence,”

Problems of Drug Dependence 1987, L.S.

Harris (cd.), National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Heahh Service,

U.S. Department of Health and Human Services, Research Monograph Series 81, DHHS

Pub. No. (ADM) 88-1564 (Rockville, MD:

1988).

O’Brien, C.P., Childress, A. R., and McLellan,

A. T., “Conditioning Factors May Help To

Understand and Prevent Relapse In Patients

Who Are Recovering From Drug Dependence,” paper presented at “NIDA RAUS,

I m proving D rug Abuse Treat merit,”

sponsored by National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Administration, Public Health Service,

U.S. Department of Health and Human Services, Bethesda, MD, August 1989

Onken, L.S., “Using Psychotherapy Effectively

in Drug Abuse Treatment,” paper presented

at “NIDA RAUS, Improving Drug Abuse

Treatment,” sponsored by National Institute

on Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Administration, Public Health

Service, U.S. Department of Health and

Human Services, Bethesda, MD, August 1989.
References -143

235.

236.

237.

238.

239.

240.

241.

241a.

242.

Parrino, M. W., President, N.E. Regional

Methadone Treatment Coalition, statement

before the Select Committee on Narcotics

Abuse and Control, U.S. House of Representatives, U.S. Congress, hearing on Methadone

Maintenance, New York, NY, Mar. 23, 1990.

Petitti, D.B., and Coleman, C., “Cocaine and

the Risk of Low Birth Weight,” Am. J. Public

Health 80(1):25-28, January 1990.

Phanuphat, P., Poshyachinda, V., Un-eklabh,

T., “HIV Transmission Among Intravenous

Drug Abusers,” abstract in the Fifth International Conference on AIDS, Montreal, June

1989.

Pickens, R., Director, Addiction Research

Center, National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human Services,

Baltimore, MD, personal communication,

November 1989; July 9, 1990.

Presidential Commission on the Human

Immunodeficiency Virus Epidemic, Repoti of

the Presidential Commission on the Human

Immunodeficiency Virus Epidemic (Washington, DC: June 1988).

Price, R. H., Burke, A. C., D’Aunno, TA., et

al., “Outpatient Drug Abuse Treatment Services, 1988: Results of a National Survey,”

paper presented at the “NIDA RAUS,

Improving Drug Abuse Treat merit,”

sponsored by National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Service, Public Health Services, U.S.

Department of Health and Human Services,

Bethesda, MD, August 1989.

Rawson, R.A., “Cut the Crack,w Policy Review

(51):10-19, winter 1990.

Rawson, RA., Executive Director, MATRIX

Center, Beverly Hills, CA, personal communication, July 1990.

Rawson, R.A., Obert, J.L., McCann, M.A., et

al, “Psychological Approaches For the

Treatment of Coc~ine Dependence: A

Neurobehavioral Approach,” presented at the

“What Works: An International Perspective

on Drug Abuse Treatment and Prevention

243.

244.

245.

246.

247.

248.

249.

Research” conference sponsored by the

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, U.S.

Department of Health and Human Serviees,

New York, NY, October 1989.

Raymond, C. A., “U.S. Cities Struggle to

Implement Needle Exchanges Despite

Apparent Success in European Cities,”

J.A.M.A. 260(18):2620-2621, NOV. 11,1988.

Reid, T., “Research Projects; Newsletter of the

International Working Group on ADS and IV

Drug Use 4(3):9-10, September 1989.

Research Triangle Institute, Na/iona/

Household Survey on Drug Abuse: 1988 Population Estimates U. S., prepared for the

National Institute on Drug Abuse, Alcoho~

Drug Abuse, and Mental Health Administration, Public Health Service, U.S.

Department of Health and Human Services,

(ADM) 89-1636 (Rockville, MD: 1989).

Research Triangle Institute, Center for Social

Research and Policy Analysis, Research Triangle Park, NC, “Increasing the Capability of

Methadone Maintenance Programs, ”

IDRAIT] Technical Document #5, July 1989.

Resnick, R.G., Washton, A.M., and SchuytenResnick, E., “Treatment of Opioid Dependence with Narcotic Antagonists: A Review

and Commentary,” Handbook on Dmg Abuse,

R.I. Dupont, A. Goldstein, and J. O’Donnell

(eds.), National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, U.S. Department of Health

Education, and Welfare and Office of Drug

Abuse Policy, Executive Office of the President (Washington, DC: U.S. Government

Printing Office, January 1979).

Rosenthal, M. S., President, Phoenix House

Foundation, testimony before the Select Committee on Narcotics Abuse and Control, U.S.

House of Representatives, U.S. Congress,

Serial No. 101-1-8, July 25, 1989 (Washington,

DC: U.S. Government Printing Office, 1989).

Rothman, K. J., Modern Epidemiology

(Boston, MA: Little Brown and Company,

1986).
144- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIVInfection

250.

251.

252.

253.

254.

255.

256.

257.

Rounsaville, B.J., ‘Clinical Implications of

Relapse Research,” Relapse and RecoveV in

Drug Abuse, F.M. Tires and C.G. Leukefeld

(eds.), National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human Services,

Research Monograph Series 72, DHHS Pub.

No. (ADM) 86-1473 (Rockville, MD: 1986).

Rouse, B. A., “Conducting Large Scale

Epidemiologic Studies of Drug Abuse} paper

presented at the “What Works: An International Perspective on Drug Abuse Treatment

and Prevention Research, ” conference

sponsored by New York State Division of

Substance Abuse Services and the Narcotic

and Drug Abuse Research, Inc., New York,

NY, October 1989.

Rua, J., Treatment Works: The Tragic Cost of

Undervaluing Treatment in the “Drug War”

(Washington, DC: National Association of

State Alcohol and Drug Abuse Directors,

March 1990).

Schimpf, K., Brackmann, H. H., Kreus, W., et

al. , “Absence of Anti-Hum a n

Immunodeficiency Virus Types 1 and 2

Seroconversion After the Treatment of

Hemophilia A or Von Willebrand’s Disease

With Pasteurized Factor 8 Concentrate;’ N.

Engl. J. Med. 321:1148-1152, 1989.

Schober, S. E., and Schade, C., “NeedleSharing Among Addicts Admitted to

Treatment,” paper presented at the Annual

Meeting of the American Public Health Association, Chicago, IL, October 1989.

Schoenbaum, E., “Crack Use Predicts Incident

HIV Seroconversion,” abstract in the Sixth

International Conference on AIDS, San Francisco, June 1990.

Schottenfeld, R.S., O’Malley, S., and AbdulSalaam, K., “Decline in Intravenous Drug Use

Among Opiate Addicts,” unpublished manuscript, 1989.

Schuster, C.R., “Methadone Maintenance. An

Adequate Dose is Vital in Checking the

Spread of AIDS,” NIDA Notes 14(1):3,33,

spring/summer 1989.

258.

259.

260.

261.

262.

263.

264.

265.

266.

267.

Schuster, C.R., Director, National Institute on

Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Administratio~ hearing before

the Select Committee on Narcotics Abuse and

Control on the Effectiveness of Methadone

Treatment, U.S. House of Representatives,

U.S. Congress, on The Effectiveness of

Methadone Treatment, Mar. 23,1990.

Science, “Magic Bullets for Addiction?”

Science 245(4925):1443, Sept. 29,1989.

Scribner, R., Cohen, D., and Dwyer, J., The

Streets of Babylon: Syphilis and Sex for Drugs

in Los Angeles County,” paper presented at

“The Annual Meeting of the American Public

Health Association,” Chicago, IL, October

1989.

Sells, S.B., and Simpson, D.D., “The Case for

Drug Abuse Treatment Effectiveness, Based

on the DARP Research Program,” British

Journal ofAddiction 75(2):117-131, June 1980.

Senay, E. C., “Methadone Maintenance

Treatmentj” Int. J. Addictions 20(6/7):803-821,

June/July 1985.

Selwyn, P.A., Hartel, D., Wasserman, W., et

al., “Impact of the AIDS Epidemic on Morbidity and Mortality Among IVDUS in a New

York City Methadone Maintenance Program;

Am. J. Public Health 79(10 );1358-1362,

October 1989.

Senie, R.T., Des Jarlais, D., Peyser, N., et al.,

“AIDS Risk Reduction Study-Interim

Methadone Clinic,” abstract presented at the

llth Scientific Meeting of the International

Epidemiologic Association, Helsinki, Finland,

June 1987.

Serraino, D., and Franceschi, S., “Methadone

Maintenance Programmed and AIDS,”

[Letter], Lancet 11(8678/9):1522-1523, Dec.

23/30, 1989.

Shaffer, H. J., and Jones, S. B., Quitting

Cocaine: 771e Struggle Against the Impulse

(Lexington, MA: Lexington Books, 1989).

Simpson, D. D., “Final Comments,n Opioid

Addiction and Treatment: A 12-Year Fo!lowup, D.D. Simps& and S.B. Sells (e&.) (Melbourne, FL: Robert E. Krieger Publishing

Company, in press, 1990).
References -145

268.

269.

270.

271.

272.

273.

274.

275.

Simpson, D. D., “Introduction,” Opioid

Addiction and Treatment:A 12-year Follow-up,

D.D. Simpson and S.B. Sells (eds.) (Melbourne, FL: Robert E. Krieger Publishing

Company, in press, 1990).

Simpson, D. D., “Research Design and

Methods: Opioid Addiction and Treatment: A

12-Year Follow-Up, D.D. Simpson and S.B.

Sells (eds.) (Melbourne, FL: Robert E.

Krieger Publishing Company, in press, 1990).

Simpson, D. D., Joe, G. W., and Lehman,

W. E. K., “Addiction Careers: Summary of

Studies Based on the DARP 12-Year Followup,” Treatment Research Report National

Institute on Drug Abuse, Alcohol, Drug

Abuse, and Mental Health Administration,

Public Health Service, U.S. Department of

Health and Human Services, DHHS Pub. No.

(ADM) 88-1420 (Rockville, MD: 1986).

Simpson, D. D., and Sells, S.B., “Effectiveness

of Treatment for Drug Abuse: An Overview

of the DARP Research Program,” Advances

in A[cohol and Substance Abuse 2(1):7-29,

Fall 1982.

Simpson, D.D., and Sells, S. B., Evaluation of

Dmg Treatment Effectiveness: Summa~ of the

DARP Followup Research NIDA Treatment

Research Repofi (Washington, DC: U.S. Government Printing Office, 1982), as cited in

Anglin, M. D., and Hser, Y., “Treatment Of

Drug Abuse,” Crime and Justice, M. Tonry

and J.Q. Wilson (eds.), in press, September

1990.

Sisk, J.E., Hewitt, M., and Metcalf, K.L., How

E#ective Is AIDS Education? Staff Paper #3

on AIDS-Related Issues, (Washington, DC:

Office of Technology Assessment, U.S. Congress, June 1988).

Sisk, J.E., Hewitt, M., and Metcalf, K.L., “The

Effectiveness of AIDS Education. Health

Afjaim 7(5): 37-51, Winter 1988.

Smith, M. O., Medical Director, Substance

Abuse Division, Department of Psychiatry,

Lincoln Hospital, New York, NY,

“Testimony,” Efficacy of Drug Abuse Treatment

Programs Part Z, hearing before the Select

276.

277.

278.

279.

280.

281.

282.

283.

Committee on Narcotics Abuse and Contro~

House of Representatives, U.S. Congress, July

25,1989, Serial No. 101-1-8 (Washingtorq DC:

U.S. Government Printing Office, 1989).

Snyder, F.R., Myers, M. H., and Young, P.,

“Risk Behaviors of IV Cocaine Users Versus

IV Heroin Users,” paper presented at the

Annual Meeting of the American Public

Health Association, Chicago, IL, October

1989.

Sonderegger, T.B., “The Effects of Drugs and

Alcohol on Pregnancy and Parenting” Zssues

in Public Health and the Law., Consotiium on

Chil&en, Families and the Law (Lincoln, NE:

University of Nebraska-Lincoln, January

1990).

Sorensen, J.L., “The Needle Exchange Issues,”

California Association of AIDS Agencies

Repotis 2(3):4, May 1988.

Sorensen, J.L., Acampora, A., and Iscoff, D.,

“From Maintenance to Abstinence in a

Therapeutic Community: Clinical Treatment

Methods,” Journal of Psychoactive Drugs

16(3):229-239, July/September 1984.

Sorensen, J.L., Batki, S.L., Gibson, D.R., et

al., “Methadone Maintenance and Behavior

Change in Seropositive Drug Abusers: The

San Francisco General Hospital Program for

AIDS Counseling and Education (PACE),”

abstract presented at the Fifth International

Conference on AIDS, Montreal, Canada, June

1989.

Sorensen, J.L., Heitzmann, C., and Guydis~

J., “Community Psychology, Drug Use and

AIDS,” Journal of Community Psychology, in

press, summer 1990.

Spenser, B.D., “On the Accuracy of Estimates

of Numbers of Intravenous Drug Users,”

AIDS: Sexual Behavior and Intravenous Drug

Use, C.F. Turner, H.G. Miller, and L.E.

Moses (eds.) (Washington, DC: National

Academy Press, 1989).

Stimmel, B., Goldberg, J., Rotkopf, and

Cohen, M., “Ability To Remain Abstinent

After Methadone Detoxification: A Six Year

Study,” J.A.M.A. 237(12): 1216-1220, Mar. 21,

1977.
146- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIV Infection

284.

285.

286.

287.

2880

289.

290.

Stimpson, G.V., “International Evidence on

the Effectiveness of Needle and Syringe

Supply Schemes,” paper presented at the

“What Works: An International Perspective

on Drug Abuse Treatment and Prevention

Research,” conference sponsored by New

York State Division of Substance Abuse Services and the Narcotic and Drug Abuse

Researclq Inc., New York NY, October 1989.

Stitzer, M. L., and Kirby, K. C., ‘Reducing

Illicit Drug Use Among Methadone Patients;

paper presented at “NIDA RAUS, Improving

Drug Abuse Treatment,” sponsored by

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, U.S.

Department of Health and Human Services,

Bethesda, MD, August 1989.

Stoneburner, R. L., Des Jarlais, D. C., Benezra,

D., et al., “A Larger Spectrum of Severe HIVI-Related Disease in Intravenous Drug Users

in New York City,” Science 242(4880):916-919,

Nov. 11,1988.

Suffet, F., and Brotman, R., “A Comprehensive Care Program for Pregnant Addicts:

Obstetrical, Neonatal and Child Development

Outcomes,” J. Addiction 19(2):199-219, 1984

as cited in Chavkin, W., “Drug Addiction and

Pregnancy: Policy Crossroads,” Am. J. Public

Health 80(4):483-487, April 1990.

Sutker, P. B., “Drug Dependent Women. An

Overview of the Literature,” Treatment Services for Dmg Dependent Women, Vol. 1, G.M.

Beschner, R.B. Glover, and J. Mondanaro

(eds.), National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human Resources,

Treatment Research Monograph Series

(Rockville, MD: 1981).

Teasley, D. L., “Extent of the Problem,” CRS

Review 10(10):4-5, November/December

1989.

Tennant, F., “IAAM Maintenance for Opioid

Addicts who Cannot Maintain with

Methadone,” Problems of Dtug Dependence,

1987, L.S. Harris (cd.), National Institute on

Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Administration, Public Health

291.

292.

293.

294.

295.

2%.

Service, U.S. Department of Health and

Human Services, NIDA Research Monograph

81, 1988, DHHS Pub. No. (ADM) 88-1564

(Rockville, MD: 1988).

Tidone, L., Sileo, F., Goglio, A., et al., “AIDS

in Italy,” Am. J. of Dmg and Alcohol Abuse,

13(4):485-486, 1987.

Tires, F. M., “Introduction,” Drug Abuse

Treatment Evaluation: Strate~”es, Progress, and

Prospects, F.M. Tirns and J.P. Ludford (eds.),

National Institute on Drug Abuse, Alcoho~

Drug Abuse, and Mental Health Administration, Public Health Service, U.S.

Department of Health and Human Sewices,

NIDA Research Monograph Series 51,

DHHS Pub. No. (ADM) 88-1329 (Rockville,

MD: 1984).

Tomas, J.M., and Kozel, NJ., “National Substance Abuse Epidemiology Initiatives in the

United States: What Works for what; paper

presented at the “What Works: An International Perspective on Drug Abuse Treatment

and Prevention Research,” conference

sponsored by New York State Division of

Substance Abuse Services and the Narcotic

and Drug Abuse Research, Inc., New York

City, NY, October 1989.

Tommasello, A., Nilsen, K., and Ball, J.,

“Relationship of Client Characteristics with

Non-Compliance in Methadone Maintenance

Treatment, W Problems of Dmg Dependence

1988, L.S. Harris (cd.), National Institute on

Drug Abuse, Alcohol, Drug Abuse, and

Mental Health Administration, Public Health

Service, U.S. Department of Health and

Human Services, NIDA Monograph Series 90,

1988, DHHS Pub. No. (ADM) 89-1605

(Rockville, MD: 1989).

Truman, B., Schman, J.S., Brown, L., et al.,

“HIV Infection Among Intravenous Drug

Users in NYC,” abstract presented at the

“Fifth International Conference on AIDS,”

Abstract No. TAP 54. p. 108, Montreal,

Canada, June 1989.

Turner, C. F., Miller, H.G., and Moses, L.E.

(eds.), AIDS: Sexual Behavior and Intravenous

Drug Use (Washington, DC: National

Academy Press, 1989).
References -147

297.

298.

299.

300.

301.

302.

303.

304.

304a.

305.

306.

UCLA Drug Abuse Research Group, “Ideas

for AIDS Risk Reduction Among IVDUS,”

paper prepared for the Office of AIDS, California State Department of Health Setices,

Los Angeles, October 1989.

U.S. Congress, General Accounting Office,

Controlling Drug Abuse: A Status Report,

GAO/GGD-88-39 (Washington, DC: March

1988).

U.S. Congress, General Accounting Office,

Methadone Maintenance, GAO/HRD-90-104

(Washington, DC: March 1990).

U.S. Congress, Library of Congress, Congressional Research Service, “’Crack Cocaine,”

prepared by E. Klebe, Washington, DC, Aug.

11,1989.

U.S. Congress, Library of Congress, Congressional Research Service, “Cocaine/Crack

Babies: Health Problems, Treatment, and

Prevention,” prepared by M. Littlejohn and K.

Thomas, Washington, DC, October 1989.

U.S. Congress, Library of Congress, Congressional Research Service, “Drugs and Babies:

Health and Legal Issues,” p~epared by M.

Littlejohn and K. Thomas, Washington, DC,

1990.

U.S. Congress, Senate, Committee on the

Judiciary, Pharmacotherapy: A Strategy for the

1990’s, S. Prt. 101-000 (Washington, DC: U.S.

Government Printing Office, December

1989).

U.S. Congress, Senate, Committee on the

Judiciary, Hard-Core Cocaine Addicts:

Measuring--and Fighting--77le Epidemic, S. Prt.

101-6 (Washington, DC: U.S. Government

Printing Office, May 10, 1990).

U.S. Department of Commerce, Bureau of

Census, Statistical Abstracts of the United

States: 1989 (109th edition), (Washington,

DC: 1989).

U.S. Department of Education, Office of Educational Research and Improvement, National

Center for Education, Digest of Education

Statistics 1988, CS 88-600 (Washington, DC:

U.S. Government Printing Office, September

1988).

U.S. Department of Health and Human Services, “1989 National High School Senior Drug

Abuse Survey,” HHS News, RP0689, Feb. 13,

1990.

307.

308.

309.

310.

311.

312.

313.

U.S. Department of Health and Human Services, Public Health Service, “Report of the

Second Public Health Service AIDS Prevention and Control Conference, Intravenous

Drug Abuse, ” Public Health Reports

103:Suppl(l):66-71, November 1988.

U.S. Department of Health and Human Services, Public Health Service, Improving Dmg

Abuse Statistics: Report of the PHS Task Fome

on Drug Abuse Data (Rockville, MD: February 1990).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Alcohol Abuse and

Alcoholism, “Methadone Maintenance and

Patients in Alcoholism Treatment,” A2coho2

Alert 1:1-2, August 1988.

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Alcohol Abuse and

Alcoholism, National Institute on Drug

Abuse, and National Institute on Mental

Health, “Buprenorphine Shows Potential as

Addiction Treatment Agent,” ADAMHA News .

14(11):1,3, Novcmber 1988.

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, Trea[ment

Services for Drug Dependent Women, Vol. 1

and 2, DHHS Pub. No. (ADM) 87-1177

(Rockville, MD: 1981). .

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, Hallucinogens and PCP, Inha[ants, Mar~uana,

Opiates, Sedative-Hypnotics, Stimulants and

Cocaine, 1P 334D (GO) (Rockville, MD:

1983).

U.S. Department of Health and Human Services, Public Hcahh Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, “Introduction,” NIDA State of tJle Art Resea~h on

the Treatment of Narcotic Addiction, Cooper,

J. R., (cd.), Treatment Research Monograph

Series, DHHS Pub. No. (ADM) 87-1281

(Rockville, MD: 1983).
148- The Effectiveness of Drug Abuse Treatment: Implications for Controlling HIV Infection

314.

315.

316.

317.

318.

319.

320.

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, Women

and Dnigs: A New Era for Reseaxh, BA. Ray

and M.C. Brande (eds.), NIDA Research

Monograph 65, DHHS Pub. No. (ADM) 87-

1447 (Rockville, MD: 1986).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, “PCP:

Update on Abuse,” NIDA Capsules, C-80-13

(Rockville, MD: April 1986).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, “Cocaine

Freebase,” NIDA Capsules, C-86-4 (Rockville,

MD: May 1986).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, “Heroin,”

NZDA Capsules, C-86-7 (Rockville, MD:

August 1986).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, 7he Prevention of AIDS Among Intravenous Drug

Abusers, Their Saual Patiners and Children. A

5-Year Strategy 1988 (Rockville, MD: 1988).

U.S. Department of Health and Human Services, Public Health Services, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, “Drug

Abuse Treatment,” NZDA Capsules, C-88-03

(Rockville, MD, June 1988).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, “NIDA

Launches $20 Million Program to Develop

Addiction Treatment Drugs,” NIDA Notes

4(1):1-2,4-5, winter 1988/89).

320a.

321.

322.

323.

324.

325.

326.

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, “High

School Senior Drug Use: 1975-1988: NIDA

Capsules, C-85-01 (Rockville, MD, April

1989).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, ‘Marijuana

Update,” NIDA Capsules, C-88-06 (Rockville,

MD: May 1989).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, DmgAbuse

Treatment Outcome Study (DA TO S),

Summary, and Statement of Work (Rockville,

MD: 1989).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, Methadone

Maintenance Quality Assurance System:

Project Description (Rockville, MD: 1989).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, Repoit on

HIV and Drug Abuse, Report to the House

Appropriations Committee, May 1989.

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, “NIDA

Outreach Demonstration Projects Provide

Insight into AIDS Risk Behaviors,” NZDA

Notes 4(1):1,4-9, spring/summer 1989.

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, “Highlights

of the 1988 National Household Survey on

Drug Abuse,” NIDA Capsules, C-86-13 (Rockville, MD: August 1989).

* U. S. Government P rlnting Off ice : 199(I - 725- 192/20596
References -149

327.

327a.

328.

329.

330.

331.

332.

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, “Cocaine

Use, Inadequate Methadone Dose, Increase

Risk for IV Drug Users in Treatmen$” NZDA

Notes 1(5):16-17, winter 1990.

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse,

unpublished data, (Rockville, MD, July 1990).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, Division of

Epidemiology and Prevention Research,

Annual Data 1988: Data jiom the Drug Abuse

Warning Network, Series I, No. 8, DHHS Pub.

No. (ADM) 89-1634 (Rockville, MD: 1989)

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, Division of

Epidemiology and Prevention Research, Drug

Abuse Warning Network data file, March

1989.

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, Division of

Epidemiology and Prevention Research,

National Household Survey on Drug Abuse:

1988 Population Estimates, DHHS Pub. No.

(ADM) 89-1636 (Rockville, MD: 1989).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse, Division of

Epidemiology and Statistical Analysis,

National Household Survey on Drug Abuse:

Main Findings 1985, DHHS Pub. No. (ADM)

88-1586 (Rockville, MD: 1988).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

National Institute on Drug Abuse and {

332a.

332b,

333.

334.

335.

336.

National Institute on Alcohol Abuse and

Alcoholism, National Drug and Alcoholism

Treatment Unit Survey (NDATUS) 1987 Final

Report, DHHS Pub. No. (ADM) 89-1626

(Rockville, MD: 1989).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Administration, National

Institute on Drug Abuse, Division of

Epidemiology and Prevention Research, and

National Institute on Alcohol Abuse and

Alcoholism, Division of Biometry and

Epidemiology, Highlights from the 1989

National Dmg and Alcoholism Treatment Unit

Survey (NDATUS) (Rockville, MD: July

1990).

U.S. Department of Health and Human Services, Public Health Service, Alcohol, Drug

Abuse, and Mental Health Administration,

Office for Treatment Improvement, “Office

for Treatment Improvement,” Rockville, MD.

U.S. Department of Health and Human Services, Public Health Service, Committee To

Reduce the Demand for Illicit Drugs, “State of

the Science Report on Current Status of Drug

Abuse Research,” prepared for the Assistant

Secretary for Health, Aug. 1,1989.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, “Revision of the CDC Surveillance

Case D efinit ion for Acquire d

Immunodeficiency Syndrome,” M.M. W.R.

(Supplement), 36(1S):3S-14S, Aug. 14,1987.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

C on t r 01, “ U p d at e : Acqu i red

Immunodeficiency Syndrome Associated with

Intravenous-Drug Use -- United States, 1988,”

M.M. W.R. 38(10):165-170, Mar. 17, 1989.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, “Urine Testing for Drug Use Among

Male Arrest ees-United States, 1989,”

M.M. W.R. 38(45):780-783, Nov. 17, 1989.
150- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIV Infection

337.

338.

339.

340.

341.

342.

343.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

C o n t r 01, “ U p d a t e : A c q u i r e d

Immunodeficiency Syndrome -- United States,

1989: M.M. W.R. 39(5):81-86, Feb. 9,1990.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, “Estimates of HIV Prevalence and

Projected AIDS Cases: Summary of a

Workshop, October 31-November 1, 1989,”

M.M. W.R. 39(7):110-119, Feb. 23,1990.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, “ Update : Acquire d

Immunodeflciency Syndrome--United States,

1989,” J.A.M.A. 263(9):1191-1192, Mar. 2,

1990.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, “Risk Behaviors for HIV Transmission Among IVDUS Not in TreatmentUnited States, 1987 -1989,” M.M. W.R.

39(16):273-276, Apr. 27,1990.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, “Update: Reducing HIV Transmission in Intravenous-Drug users Not in

Drug Treatment - United States,” M.M.WR.

39(31):529-538, Aug. 10,1990.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, “Publicly Funded HIV Counseling

and Testing: United States, 1985 -1989,”

AIDS/HWRecord 4(1):14, Apr. 30,1990.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, “HIV-Related Knowledge and

Behaviors Among High School Students --

Selected U.S. Sites, 1989,” M. M. W.R.

39(23):385-397, June 15, 1990.

344.

345.

346.

347.

348.

349.

350.

351.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, Center for Infectious Diseases, AZDS

Weekly Sumeillance Repoti, Dec. 29,1986.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, Center for Infectious Diseases,

Division of HIV/AIDS, H~/AIDS Surveillance Report, December 1989.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, Center for Infectious Diseases,

Division of HIV/AIDS, “Projected Numbers

of AIDS Cases by Risk Behavior Group, 1989-

1993,” unpublished data, Atlanta, GA, Mar.

12, 1990.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, Center for Infectious Diseases,

Division of HIV/AIDS, H~/AIDS Survei2-

iance Repoti, April 1990.

U.S. Department of Health and Human Services, Public Health Service, NationaI Center

for Health Statistics, Centers for Disease

Control, Center for Infectious Diseases,

Division of HIV/AIDS, HW/AIDS SurveiL

lance Report, May 1990.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, Center for Infectious Diseases,

Division of HIV/AIDS, HW/AZDS Surveillance Report, June 1990.

U.S. Department of Health and Human Services, Public Health Service, National Center

for Health Statistics, Centers for Disease

Control, Center for Prevention Services,

Atlanta, GA, unpublished data, July 20,1990.

U.S. Department of Justice, Bureau of

Prisons, Office of Research and Evaluatio~

Proposal for the Evaluation of the Federal

Bureau of Prisons Drug Abuse Treatment Programs (Washington, DC: March 1990).
References -151

352.

353.

354.

355.

356.

357.

358.

359.

360.

361.

362.

Vaillant, G.E., “The Natural History of Narcotic Drug Addiction,” Seminan in Psychiatry

2(4):486-498, November 1970.

Vanicheeni, S., Wright, N., Akarasavi, P., et

al., “Case Control Study of HIV Among Male

Intravenous Drug Abusers in Bangkok,”

abstract in the Fifth International Conference

on AIDS, Montreal, June 1989.

Van Den Hock, J.A.R., Van Haastrecht,

HJ.A., and Coutinho, RA., “Risk Reduction

Among Intravenous Users in Amsterdam

Under the Influence of AIDS,” Am. J. Public

Health 79(10):1355-1357, October 1989.

Waldorf, D., “Natural Recovery from Opiate

Addiction: Some Social-Psychological Processes of Untreated Recovery,” J. Drug Issues

13(2):237-280, spring 1983.

Waldorf, D., and Biernacki, P., “The Natural

Recovery From Opiate Addiction: Some

Preliminary Findings,” J. Dtug Issues pp. 61-

74, winter 1981.

Walker and Associates, Inc., “An Analysis of

Outcomes Achieved by a Sample of Primary

Inpatient Treatment Programs in Minnesota,w

(Minneapolis, MN: Chemical Dependency

Program Division, Minnesota Department of

Public Welfare, February 1981).

Wallace, B. C., Crack Cocaine: A Practical

Treatment Approach for the Chemically

Dependent (Brunner/Mazel, Inc., in press,

December 1990).

Wallack, S. S., Director, Bigel Institute for

Health Policy, Brandeis University, Waltham,

MA, “Cost of Drug Abuse Treatments,”

testimony before the Legislation and National

Security Subcommittee, Government Operations Committee, U.S. House of Representatives, U.S. Congress, Apr. 17, 1990.

Ward, J.W., Holmberg, S.D., Allen, J.R., et

al., “Transmission of HIV by Blood Transfusions Screened as Negative for HIV

Antibody,” N. Engl. J. Med. 318:473-478, 1988.

Watters, J.K., “’Bleach’ and ‘Teach’ Programs

Are Good Policy,” School of Medicine, University of California, San Francisco, 1989.

Watters, J.K., Cheng, Y.T., Segal, M., et al,

“Epidemiology and Prevention of HIV in

Heterosexual Intravenous Drug Users in San

Francisco,” presented at the Sixth International Conference on AIDS, San Francisco,

June 1990.

363.

364.

365.

366.

367.

368.

369.

Webb, A. Y., Director, New York State

Division of Substance Abuse Services,

testimony before the Select Committee on

Narcotics Abuse and Control, U.S. House of

Representatives, U.S. Congress, hearing on

Methadone Maintenance, New York March

23,1990.

Weber, R., “Immunologic Effects of Drugs of

Abuse,” Problems of Drug Dependimce 1988,

L.S. Harris (cd.), National Institute on Drug

Abuse, Alcohol, Drug Abuse, and Mental

Health Association, Public Health Service,

U.S. Department of Health and Human Services, NIDA Research Monograph 90, 1988,

DHHS Pub. No. (ADM) 89-1605 (Rockville,

MD: 1988).

Weber, R., Ledergerber, B., Opravil, M., et al,

“Cessation of Intravenous Drug Use Reduces

Progression of HIV Infection in HIV+ Drug

Users,” abstract in the Sixth International

Conference on AIDS San Francisco, June

1990.

Wesson, D. R., “Revival of Medical

Maintenance in the Treatment of Heroin

Dependence,” J.A.M.A. 259(22):3314-3315,

June 10, 1988.

Wesson, D. R., Havassy, B. E., and Smith,

D.E., “Theories of Relapse and Recovery and

their Implications for Drug Abuse

Treatment,” Relapse and Recove~ in Dmg

Abuse, F.M. Tires and C.G. Leukefeld (eds.),

National Institute on Drug Abuse, Alcoho~

Drug Abuse, and Mental Health Administration, Public Health Service, U.S.

Department of Health and Human Services,

NIDA Research Monograph Series 7% 1986,

DHHS Pub. No. (ADM) 86-1473 (Rockville,

MD: 1986).

Whitehead, P. C., “Acupuncture in the

Treatment of Addiction: A Review and

Analysis,” International Journal of Addictions

13(1):1-16, 1978.

Wiebel, W., Principal Investigator, AIDS Outreach Intervention Project, “Testimony,”

hearing before the Subcommittee on Health

and the Environment, Committee on Energy

and Commerce, House of Representatives,

U.S. Congress, April 1989, Serial No. 101-70

(Washington, DC: U.S. Government Printing

Office, 1989).
152- The Effectiveness of DrugAbuse Treatment: Implications for Controlling HIVInfection

370.

371.

372.

373.

374.

375.

376.

Wiebel, W., and Altman, N., “AIDS Prevention Outreach to IVDUS in Four U.S

Cities,” poster presentation at the Fourth

International Conference on AIDS,

Stockholm, June 1988.

Wiebel, W.W, Lampinen, D., Ward-Chene, et

al., “HIV-1 Seroconversion in a Cohort of

Street Intravenous Drug Users in Chieago~

abstract in the Sixth International Conference

on AIDS, San Francisco, June 1990.

Wiebel, W., (luellet. L., Guydam, C., et al.,

“Cocaine Injection as a Predictor of HIV Risk

Behaviors: abstract in the Sixth International

Conference on AIDS, San Francisco, June

1990.

Wilbur, R., “A Drug To Fight Cocaine,”

Science 7(5):42, March 1986, as cited in

“Pharmacotherapy.”

Williams, A., Vranizan, K., Gorter, P., et al.,

“Methadone Maintenance, HIV Serostatus

and Race in Injection Drug Users in San

Francisco, CAj” abstract in the Sixth International Conference on AIDS, San Francisco,

June 1990.

Wilson, B. K., Elms, R.R., and Thomson, C.P.,

“Outpatient vs. Hospital Methadone

Detoxification: An Experimental Comparison,” International J. of the Addictions

10(1):13-21, 1975.

Wohlfciler, D., “Summary of Presentations on

Drug Use and AIDS,” presented at the “Fifth

377.

378.

379.

380.

International Conference on AIDS, ”

Montreal, Canada, June 1989. me Nws2etteq

International Working Group on AIDS and IV

Drug Use 4(3)(Suppl):525 -527, September

1989.

Woody, G.E., McLellan, A.T., O’Brien, C.P.,

et al., “Addressing Psychiatric Co-morbidity,”

paper presented at “NIDA IUUS, Improving

Drug Abuse Treatment,” sponsored by

National Institute on Drug Abuse, Alcohol,

Drug Abuse, and Mental Health Administration, Public Health Service, U.S.

Department of Health and Human Services,

Bethesda, MD, August 1989.

Zackon, F., McAuliffe, W.E., and Ch’ien J.M.,

Addict Afte~are: Recoveq Training and SelfHe/p, National Institute on Drug Abuse,

Alcohol, Drug Abuse, and Mental Health

Administration, Public Health Service, U.S.

Department of Health and Human Services,

Treatment Research Monograph Series,

DHHS Pub. No. (ADM) 85-1341 (Rockville,

MD: 1985).

Zweben, J. E., and Sorensen, J.L., “Misunderstandings About Methadone,” Journal of

Psychoactive Drugs 20(3):275-281,

July/September 1988.

Zuckerman B., Frank, DA., Hingson, R., et

al., “Effects of Maternal Marijuana and

Cocaine Use on Fetal Growth,” N. Engl. J.

Med. 320(12):762-68, Mar. 23,1989.