ADDICTIONS

A COMPREHENSIVE GUIDEBOOK
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 ADDICTIONS
A COMPREHENSIVE GUIDEBOOK

EDITED BY

Barbara S. McCrady
Elizabeth E. Epstein

New York Oxford

Oxford University Press
1999
 Oxford University Press
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Copyright © 1999 by Oxford University Press, Inc.

Published by Oxford University Press, Inc.
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Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
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without the prior permission of Oxford University Press.

Library of Congress Cataloging-in-Publication Data

McCrady, Barbara S.
Addictions : a comprehensive guidebook / Barbara S. McCrady,
Elizabeth E. Epstein.
p. cm.
Includes index.
ISBN 0-19-511489-2
1. Substance abuse. 2. Alcoholism. 3. Drug abuse. I. Epstein,
Elizabeth E. II. Title.
RC564.M327 1999
616.86-dc21 98-51552

1 3 5 7 9 8 6 4 2
Printed in the United States of America
on acid-free paper
To Margaret Miller Sachs (1921-1994), my mother, my role model, my inspiration.—BSM

To my family—Joe, Jeremy, Eve, and Sam.—EEE

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 Foreword

Some years ago, before coming to the National Insti- titioners, unlike their predecessors, have access to an
tute on Alcohol Abuse and Alcoholism, I directed a impressive array of clinical resources to help them to
large alcoholism treatment program in New York understand, diagnose, and treat the problems of alco-
City. At that time, our major goal was a relatively hol and drug misuse. This textbook, Addictions: A
simple one: to get our patients sober and to help Comprehensive Guidebook, is a fine example of such
them remain so. The tools that we had available to a resource. It presents a wide range of subjects writ-
help accomplish this goal also were relatively sim- ten by experts from the many varied fields that im-
ple: the experience of those who had recovered pri- pact in one way or another on the treatment of alco-
marily through Alcoholics Anonymous (AA) and our hol and other drug abuse. Its breadth and scope, in
basic clinical "common sense" (i.e., approaches that fact, are a testament to how far we have come in
seemed plausible and made intuitive sense but had defining what we do and how we can do it effectively
not been validated with contemporary techniques of based not just on common sense, but on a growing
treatment outcome evaluation). The type of science- body of quality basic and behavioral research.
based information available to other health care This change from reliance solely on common
practitioners through textbooks, health professions sense to common sense and science, above all others,
training, and other sources of information sharing has led our fields to acceptance and respect by the
that we take for granted today was, with a few notable professional health care field at large. It has also led
exceptions, nonexistent just 15 years ago. to greater understanding by the public of alcohol and
Today, the simple goal of treatment that we share substance use disorders as bona fide medical condi-
as alcohol and other drug abuse scientists and prac- tions that can respond to treatment. This change is
titioners has not changed. However, today's prac- reflected in many different ways. For example, it is
viii FOREWORD

reflected in the growing recognition of the need for access to resources such as this book is a must. Here,
science-based information by policymakers and prac- in one source, is the information needed by alcohol
titioners, a need deriving in part from demands by and drug abuse specialists, primary-care providers,
managed-care organizations, other third-party insur- policymakers, and others who are involved in pro-
ers, and state and federal policymakers for the same grams which are geared to helping those who abuse
type of safety and efficacy evidence that is required or are dependent on alcohol and other drugs to be-
for all other illnesses. It is also reflected in the in- come informed about these problems, including the
creasing number of physicians' and other primary far-reaching effects of these substances on individuals
health care organizations that provide research-based and on society. I commend both Dr. McCrady and
findings about alcohol and other drug problems to Dr. Epstein for their efforts in presenting such a
their memberships. This change is also reflected in wealth of material in a clear and concise manner ap-
the extensive research effort underpinning new di- propriate for a variety of audiences, and for having
agnostic classification systems, both nationally and pulled together the talented group of subject-matter
internationally, and in the increasing attention to li- experts represented in this book.
censure and certification by professional organiza-
tions and by the states. Enoch Gordis, M.D.
Because of these and other changes in how we do Director
business, and the growing amount and complexity of National Institute on
information about alcohol and other drugs, having Alcohol Abuse and Alcoholism
 Acknowledgments

Several individuals were key to the completion of scholarship, being surrounded by colleagues con-
this book. First, we thank Larry Beutler, who recom- ducting research and clinical work related to sub-
mended both the topic and the editors to Oxford stance use and abuse, and the ready availability of
University Press. Second, we express our tremendous the outstanding alcohol studies library—all provided
appreciation to Joan Bossert at Oxford University the environment and resources necessary to com-
Press, who was patient and encouraging in our work plete this venture. Finally, our greatest appreciation
to conceptualize the book and bring it to fruition. goes to the authors and coauthors, a superb and re-
The third key individual is Karen Rhines, both a nowned group of clinicians and researchers who pro-
promising clinical psychology graduate student at duced wonderful chapters, and suffered patiently
Rutgers and an utterly organized human being who through our thorough and sometimes obsessive edit-
has served as our editorial assistant. Fourth, the work ing, to create this valuable resource for the field.
could not have been completed in a more congenial
and supportive setting than the Center of Alcohol April 1998 B.S.M.
Studies at Rutgers University. The enthusiasm for Piscataway, NJ E.E.E.
This page intentionally left blank
 Contents

Contributors xv 3. Theories of Etiology of Alcohol and Other

Drug Use Disorders 50
Introduction 3 MICHIE N. HESSELBROCK
BARBARA S. MCCRADY VICTOR M. HESSELBROCK
ELIZABETH E. EPSTEIN ELIZABETH E. EPSTEIN

I. Epidemiology, Etiology, and Course of II. Specific Drugs of Abuse: Pharmacological

Substance Use Disorders and Clinical Aspects

1. Alcohol and Drug Use, Abuse, and 4. Alcohol 75

Dependence: Classification, Prevalence, DARLENE H. MOAK
and Comorbidity 9 RAYMOND F. ANTON
BRIDGET F. GRANT
DEBORAH A. DAWSON 5. Sedative-Hypnotic and Anxiolytic Agents 95
KATHLEEN T. BRADY
2. The Course of Treated and Untreated HUGH MYRICK
Substance Use Disorders: Remission and ROBERT MALCOLM
Resolution, Relapse and Mortality 30
JOHN W. FINNEY 6. Stimulants: Amphetamines and Cocaine 105
RUDOLF H. MOOS MICHAEL F. WEAVER
CHRISTINE TIMKO SIDNEY H. SCHNOLL
xii CONTENTS

7. Cannabis and Hallucinogens 121 18. Self-Help Groups for Addictions 328
ROBERT S. STEPHENS JOSEPH NOWINSKI

8. Opioids 141 19. Pharmacotherapies 347

SUSAN M. STINE WAYNE S. BARBER
THOMAS R. KOSTEN CHARLES P. O'BRIEN

9. Nicotine 162 20. Relapse Prevention: Maintenance of Change

JOHN SLADE
After Initial Treatment 370
LORI A. QUIGLEY
10. Other Drugs of Abuse: Inhalants, Designer
G. ALAN MARLATT
Drugs, and Steroids 171
ROBERT PANDINA
21. Treatment of Drug and Alcohol Abuse:
ROBERT HENDREN
An Overview of Major Strategies and
Effectiveness 385
III. Case Identification, Assessment, and JOHN P. ALLEN
Treatment Planning RAYE Z. LITTEN

11. Assessment Strategies and Measures in

Addictive Behaviors 187 V. Practice Issues
DENNIS M. DONOVAN
22. Legal and Ethical Issues 399
12. Treatment Decision Making and FREDERICK B. GLASER
Goal Setting 216 DAVID G. WARREN
RONALD M. KADDEN
PAMELA M. SKERKER 23. Credentialing, Documentation, and
Evaluation 414
THERESA B. MOYERS
IV. Treatment
REID K. HESTER

13. Enhancing Motivation for Treatment and

Change 235 24. Interfaces between Substance Abuse Treatment
CAROLINA E. YAHNE
and Other Health and Social Systems 421
SUSAN J. ROSE
WILLIAM R. MILLER
ALLEN ZWEBEN
14. Behavioral and Cognitive Behavioral VIRGINIA STOFFEL
Treatments 250
KATHLEEN M. CARROLL
VI. Issues in Specific Populations
15. The Disease Model 268
TIMOTHY SHEEHAN
25. Treatment of Persons with Dual Diagnoses of
PATRICIA OWEN
Substance Use Disorder and Other
Psychological Problems 439
16. Treatment Models and Methods: Family
RICHARD N. ROSENTHAL
Models 287
LAURENCE WESTREICH
TIMOTHY J. O'FARRELL
WILLIAM FALS-STEWART
26. Age-Limited Populations: Youth, Adolescents,
17. The Therapeutic Community Treatment and Older Adults 477
Model 306 PILAR M. SANJUAN
GEORGE DE LEON JAMES W. LANGENBUCHER
 CONTENTS xiii

27. Ethnic and Cultural Minority Groups 499 VII. Prevention, Policy, and Economics of
FELIPE G. CASTRO Substance Use Disorders
RAE JEAN PROESCHOLDBELL
LYNN ABEITA 30. Prevention Aimed at Individuals: An Integrative
DOMINGO RODRIGUEZ Transactional Perspective 555
MARY ANN PENTZ

28. Women 527 31. Prevention Aimed at the Environment 573

EDITH S. LISANSKY GOMBERG
HAROLD D. HOLDER

29. Gay Men, Lesbians, and Bisexuals 524 32. Economic Issues and Substance Use 595
RODGER L. BEATTY JEFFREY MERRILL
MICHELLE O. GECKLE
JAMES HUGGINS Index 611
CAROLYN KAPNER
KAREN LEWIS
DOROTHY J. SANDSTROM
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 Contributors

Lynn Abeita, B.A., Graduate Research Assistant, De- Kathleen M. Carroll, Ph.D., Associate Professor,
partment of Psychology, Arizona State University, Department of Psychiatry School of Medicine, Yale
Tempe, AZ University School of Medicine, New Haven, CT
John P. Allen, Ph.D., Chief, Treatment Research Felipe G. Castro, M.S.W., Ph.D., Professor, De-
Branch, National Institute on Alcohol Abuse and Al- partment of Psychology, Arizona State University,
coholism, Bethesda, MD Tempe, AZ
Raymond F. Anton, M.D., Professor of Psychiatry,
Medical University of South Carolina, Institute of Deborah A. Dawson, Ph.D., Mathematical Statisti-
Psychiatry, Charleston, SC cian, Biometry Branch, Division of Biometry and
Epidemiology—National Institute on Alcohol Abuse
Wayne S. Barber, M.D., Director of Behavioral and Alcoholism, Bethesda, MD
Health Services, Rehoboth McKinley Christian Health
Care Services and Chairman of Psychiatry, Rehoboth George De Leon, Ph.D., Director, Center for Ther-
McKinley Christian Hospital, Gallup, NM apeutic Community Research at National Develop-
Rodger L. Beatty, Ph.D., Project Coordinator, Com- ment and Research Institutes, Inc., Research Profes-
munity AIDS Risk Reduction Project, Western Psy- sor of Psychiatry, New York University School of
chiatric Institute and Clinic, Pittsburgh, PA Medicine, New York, NY

Kathleen T. Brady, M.D., Ph.D., Associate Profes- Dennis M. Donovan, Ph.D., Director, Alcohol and
sor of Psychiatry, Department of Psychiatry and Be- Drug Abuse Institute, Professor, Department of Psy-
havioral Sciences, Medical University of South Caro- chiatry and Behavioral Sciences, University of Wash-
lina, Institute of Psychiatry, Charleston, SC ington, Seattle, WA
xvi CONTRIBUTORS

Elizabeth E. Epstein, Ph.D., Assistant Research Thomas R. Kosten, M.D., Professor of Psychiatry,
Professor, Center of Alcohol Studies, Rutgers, The Yale University School of Medicine, VA Connecti-
State University of New Jersey, Piscataway, NJ cut Healthcare System (Chief of Psychiatry Service),
West Haven, CT
William Fals-Stewart, Ph.D., Assistant Professor of
Psychology, Department of Psychology, Old Domin- James W. Langenbucher, Ph.D., Associate Profes-
ion University, Norfolk, VA sor, Research Diagnostic Project, Center of Alcohol
Studies, Rutgers, The State University of New Jersey,
John W. Finney, Ph.D., Health Science Specialist,
Piscataway, NJ
VA Palo Alto Health Care System, Center for Health
Care Evaluation, Palo Alto, CA Karen Lewis, M.A., M.H.A., C.A.C., N.C.A.C., Psy-
chologist, Private Practice, Pittsburgh, PA
Michelle O. Geckle, M.Ed., C.R.C., Senior Re-
search Associate, Western Psychiatric Institute and Raye Z. Litten, Ph.D., Program Officer, Treatment
Clinic, Pittsburgh, PA Research Branch, National Institute on Alcohol
Abuse and Alcoholism, Bethesda, MD
Frederick B. Glaser, M.D., F.R.C.P. (C), Professor
and Director, Division of Substance Abuse, Depart- Robert Malcolm, M.D., Professor of Psychiatry, De-
ment of Psychiatric Medicine, East Carolina Univer- partment of Psychiatry and Behavioral Science, Med-
sity School of Medicine, Greenville, NC ical University of South Carolina, Charleston, SC

Edith S. Lisansky Gomberg, Ph.D., Professor of G. Alan Marlatt, Ph.D., Professor of Psychology, Di-
Psychology, Department of Psychiatry, University of rector, Addictive Behaviors Research Center, Addic-
Michigan Alcohol Research Center, Ann Arbor, MI tive Behaviors Research Center, University of Wash-
ington, Seattle, WA
Bridget F. Grant, Ph.D., Chief, Biometry Branch,
Division of Biometry and Epidemiology—National Barbara S. McCrady, Ph.D., Professor, Graduate
Institute on Alcohol Abuse and Alcoholism, School of Applied and Professional Psychology and
Bethesda, MD Department of Psychology; Clinical Director, Center
of Alcohol Studies, Rutgers University, Piscataway,
Robert Hendren, D.O., Director, Division of Child
NJ
and Adolescent Psychiatry, University of Medicine
and Dentistry of New Jersey, Robert Wood Johnson Jeffrey Merrill, Ph.D., Director for Economic Policy
Medical School, Piscataway, NJ and Research, Treatment Research Institute, Univer-
sity of Pennsylvania School of Medicine, Philadel-
Michie N. Hesselbrock, Ph.D., Professor, School of
phia, PA
Social Work, University of Connecticut, West Hart-
ford, CT William R. Miller, Ph.D., Regents Professor of Psy-
chology and Psychiatry, Department of Psychology,
Victor M. Hesselbrock, Ph.D., Professor of Psychia-
University of New Mexico, Albuquerque, NM
try, School of Medicine, University of Connecticut
Health Center, Farmington, CT Darlene H. Moak, M.D., Assistant Professor of Psy-
chiatry, Medical University of South Carolina, Insti-
Reid K. Hester, Ph.D., Director, Research Division,
tute of Psychiatry, Charleston, SC
Behavior Therapy Associates, Albuquerque, NM
Rudolf H. Moos, Ph.D., Research Career Scientist,
Harold D. Holder, Ph.D., Director and Senior Sci-
VA Palo Alto Health Care System, Center for Health
entist, Prevention Research Center, Berkeley, CA
Care Evaluation, Palo Alto, CA
James Huggins, Ph.D., B.C.D., Associate Director,
Theresa B. Moyers, Ph.D., Clinical Director, Sub-
Persad, Pittsburgh, PA
stance Abuse Treatment Program, VAMC Albuquer-
Ronald M. Kadden, Ph.D., Professor, Department que, Albuquerque, NM
of Psychiatry, University of Connecticut Health Cen-
Hugh Myrick, M.D., Assistant Professor of Psychia-
ter, Farmington, CT
try, Department of Psychiatry and Behavioral Sci-
Carolyn Kapner, M.S.W., L.S.W., Therapist, Per- ence, Medical University of South Carolina,
sad, Pittsburgh, PA Charleston, SC
 CONTRIBUTORS xvii

Joseph Nowinski, Ph.D., Associate Adjunct Professor Sidney H. Schnoll, M.D., Ph.D., Professor, Depart-
of Psychology, University of Connecticut, Storrs, CT ments of Internal Medicine and Psychiatry, Chair-
man, Division of Substance Abuse Medicine, Medi-
Charles P. O'Brien, M.D., Ph.D., Professor and
cal College of Virginia, Virginia Commonwealth
Vice Chair, Department of Psychiatry, University of
University, Richmond, VA
Pennsylvania, Chief of Psychiatry, VA Medical Cen-
ter, University of Pennsylvania, Treatment Research Timothy Sheehan, Ph.D., Executive Director, Re-
Center, Philadelphia, PA covery Services, Hazelden Foundation, Center City,
MN
Timothy J. O'Farrell, Ph.D., Associate Professor of
Psychology, Harvard Families and Addiction Pro- Pamela M. Skerker, R.N., M.S., Psychiatric Nurse
gram, Harvard Medical School Department of Psy- Practitioner, Department of Psychiatry, University of
chiatry, Veterans Affairs Medical Center, Brockton Connecticut Health Center, Farmington, CT
and West Roxbury, MA John Slade, M.D., Professor of Clinical Medicine,
Patricia Owen, Ph.D., Director, Butler Center for University of Medicine and Dentistry of New Jersey,
Research and Learning, Hazelden Foundation, Cen- New Brunswick, NJ
ter City, MN Robert S. Stephens, Ph.D., Associate Professor, De-
Robert Pandina, Ph.D., Professor of Psychology, Di- partment of Psychology, Virginia Polytechnic Insti-
rector, Center of Alcohol Studies, Rutgers, The State tute and State University, Blacksburg, VA
University of New Jersey, Piscataway, NJ Susan M. Stine, M.D., Ph.D., Associate Professor,
Department of Psychiatry and Behavioral Neurosci-
Mary Ann Pentz, Ph.D., Associate Professor, De-
ences, Wayne State University School of Medicine,
partment of Preventive Medicine, Director, Center
Detroit, MI
for Prevention Policy Research, University of South-
ern California, Los Angeles, CA Virginia Stoffel, M.S., Associate Professor, Univer-
sity of Wisconsin—Milwaukee, School of Social Wel-
Rae Jean Proescholdbell, B.A., Graduate Research
fare, Milwaukee, WI
Assistant, Department of Psychology, Arizona State
University, Tempe, AZ Christine Timko, Ph.D., Health Science Specialist,
VA Palo Alto Health Care System, Center for Health
Lori A. Quigley, Ph.D., Research Manager, UCSF
Care Evaluation, Palo Alto, CA
Treatment Outcome Research Group, University of
California—San Francisco, San Francisco, CA David G. Warren, J.D., Executive Director, North
Carolina Governor's Institute on Alcohol and Sub-
Domingo Rodriguez, Vice President for Commu- stance Abuse, Professor, Department of Community
nity Health and Human Services, Chicanos por la and Family Medicine, Duke University Medical
Causa, Phoenix, AZ Center, Durham, NC
Susan J. Rose, Ph.D., Assistant Professor, University Michael F. Weaver, M.D., Assistant Professor of In-
of Wisconsin-Milwaukee, School of Social Welfare, ternal Medicine, Division of Substance Abuse Medi-
Milwaukee, WI cine, Virginia Commonwealth University/Medical
Richard N. Rosenthal, M.D., Associate Professor of College of Virginia, Richmond, VA
Psychiatry, Director, Division of Substance Abuse, Laurence Westreich, M.D., Assistant Clinical Pro-
Albert Einstein College of Medicine; Associate fessor of Psychiatry, New York University School of
Chairman, Department of Psychiatry, Beth Israel Medicine; Chief of Dual Diagnosis Program, Belle-
Medical Center, New York, NY vue Hospital, New York, NY
Dorothy J. Sandstrom, M.S., Project Coordinator, Carolina E. Yahne, Ph.D., Psychologist, Center on
Western Psychiatric Institute and Clinic, Pittsburgh, Alcoholism, Substance Abuse, and Addictions, Uni-
PA versity of New Mexico, Albuquerque, NM
Pilar M. Sanjuan, B.A., Graduate Fellow, Center of Allen Zweben, D.S.W., Associate Professor, Univer-
Alcohol Studies, Rutgers, The State University of sity of Wisconsin-Milwaukee, School of Social Wel-
New Jersey, Piscataway, NJ fare, Milwaukee, WI
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 ADDICTIONS

A COMPREHENSIVE GUIDEBOOK
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 Introduction

Barbara S. McCrady
Elizabeth E. Epstein

If we could sniff or swallow something that would, for five or six hours each day, abolish our
solitude as individuals, atone us with our fellows in a glowing exaltation of affection and make
life in all its aspects seem not only worth living, but divinely beautiful and significant, and if
this heavenly, world-transfiguring drug were of such a kind that we could wake up next morning
with a clear head and an undamaged constitution—then, it seems to me, all our problems (and
not merely the one small problem of discovering a novel pleasure) would be wholly solved and
earth would become paradise.
Aldous Huxley, 1949

Aldous Huxley's romantic vision of substance use cal model of the time. Many models of addiction
stands in stark contrast to the serious problems have held the view that abstinence is necessary to
caused by substance use in the late 20th century. successful control of the addiction:
Substance use in the United States claims close to
600,000 lives per year, including approximately If an addict who has been completely cured starts
440,000 attributable to nicotine use, 125,000 from smoking again he no longer experiences the dis-
alcohol use, and 10,000 from heroin and cocaine use comfort of his first addiction. There exists, there-
fore, outside alkaloids and habit, a sense for
(exclusive of deaths from HIV). Alcohol, tobacco,
opium, an intangible habit which lives on, de-
and other drug use and abuse are interwoven into spite the recasting of the organism. . . . The dead
many of the most pressing of our societal ills, includ- drug leaves a ghost behind. At certain hours it
ing chronic illness, crime, violence, and homeless- haunts the house. (Cocteau, 1929)
ness. Concerns about the adverse effects of alcohol,
tobacco, and other drugs date back to biblical times: Contemporary thought, however, has introduced
"He shall separate himself from wine and strong the possibility that moderation is an appropriate goal
drink, and shall drink no vinegar of wine, or vinegar for the substance abuser, either as an interim goal to
of strong drink, neither shall he drink any liquor of engage an individual in treatment, or as a long-term
grapes, nor eat moist grapes, or dried" (Bible Num- goal. Data on long-term use patterns of alcohol- and
bers 6:3). drug-abusing and -dependent individuals suggest that
Models of addiction have varied throughout his- lifelong abstinence is an uncommon outcome: Most
tory, and different treatment approaches have pre- individuals experience fluctuating periods of modera-
dominated, corresponding to the prevailing theoreti- tion, abstinence, and heavy or problem use. Conse-

3
4 INTRODUCTION

quently, many professionals in the public health and the authors have been successful in achieving this
clinical realm now embrace a harm reduction ap- difficult balance.
proach to minimize or decrease the adverse conse- The chapters are organized according to consis-
quences of use. tent themes within each section to facilitate compa-
Despite a rich and varied history of and literature rability of topics across chapters. Part I (chapters 1-3)
on alcohol, tobacco, and other drugs, science has provides a broad background about substance use:
come lately to the field. The National Institute on epidemiology, current models of and knowledge
Alcohol Abuse and Alcoholism (NIAAA) was estab- about etiology, and information about the course in
lished in 1971; the National Institute on Drug Abuse both treated and community samples. Part II (chap-
(NIDA), in 1973. Since the establishment of these ters 4-10) covers pharmacological and clinical infor-
two federal agencies, alcohol, tobacco, and other mation about major drug classes, including basic
drugs have become increasingly legitimate topics of knowledge about each drug class, its metabolism,
inquiry for scientists and targets for clinical care by and its neuropharmacology as well as clinical infor-
health care professionals. Today, we have an impres- mation such as preparations, street names, symptoms
sive body of knowledge of the epidemiology, etiology, of intoxication, dependence, and withdrawal.
neuropharmacology, assessment, treatment, and pre- Parts III, IV, and V provide core material for the
vention of substance use disorders. In all areas of practitioner. In part III (chapters 11-12), chapter 11
health care delivery, professionals are being required provides a comprehensive overview of approaches to
to acquire and demonstrate mastery of the core assessment and measures, while chapter 12 focuses
knowledge in this field. Many professions now offer on treatment planning and decision making. Part IV
specialty credentialing in the substance use field, and (chapters 13-21) provides descriptions of a range of
alcohol and drug counseling is becoming an increas- models of treatment that have empirical support for
ingly regulated field. their efficacy and includes detailed information on
Our goal in developing this volume was to create historical origins, theory, therapeutic change, and
a resource for several audiences. First, health care empirical support for each approach. Part IV con-
professionals and professionals in training in psychol- cludes with a summary chapter that highlights major
ogy, medicine, social work, nursing, and counseling psychological and pharmacological approaches to
will find the volume invaluable. As a training guide, treatment. Part V (chapters 22-24) focuses on addi-
for instance, the book covers material useful for cre- tional issues of direct concern to the practitioner: le-
dentialing exams, such as that required by the Ameri- gal and ethical matters, credentialing, and the com-
can Psychological Association College of Profes- plex interface between the treatment of substance
sional Psychology Certificate of Proficiency in the use and other social and health care systems.
Treatment of Alcohol and Other Psychoactive Sub- Part VI (chapters 25-29) shifts attention from
stance Use Disorders. The book is also suitable for models of care to target populations. Authors in this
scientists who would want easy access to a breadth of section contributed chapters that review the best cur-
knowledge in the field that would complement the rent knowledge about alcohol, tobacco, and other
specialized knowledge they have in their own area of drug abuse in a range of populations: those with con-
inquiry. comitant psychiatric disorders, age-limited popula-
The volume is intended to be comprehensive yet tions (youth and the elderly), racial and ethnic mi-
manageable, accessible yet scholarly. In outlining nority groups, women, and gay men and lesbians.
the sections of the book, we attempted to include Part VII (chapters 30-32) turns to the prevention
chapters on all aspects of substance abuse/depen- and economics of substance use. The prevention
dence that a typical practitioner might need to be chapters (30 and 31) describe strategies that target
familiar with to understand and treat addictive disor- both the individual and the environment; the eco-
ders. In outlining each chapter, we envisioned nei- nomics chapter (chapter 32) considers the larger
ther a case-study-based "how-to" approach nor an ar- context of the health economics of substance abuse
cane review of scientific knowledge. Rather, each treatment.
author strove to strike a balance, to write a chapter The reader may use the volume in three distinct
that provides the best scientific knowledge, but in a ways: (1) As a textbook, the volume provides an or-
format that is accessible and useful. We believe that derly and comprehensive survey, suitable for a gradu-
 INTRODUCTION 5

ate course on the assessment and treatment of the from experience. We hope that this volume will pro-
abuse of alcohol, tobacco, and other drugs. The text- vide you, the reader, with a firm grounding in cur-
book reader should begin at the beginning and read rent knowledge and clinical methods that will stimu-
through the entire volume. (2) When the book is late you to contribute to this exciting and evolving
used as a resource for treatment planning, the reader field.
should first look to specific chapters relevant to the
presenting drug(s) of abuse and the treatment popu- References
lation and should then use the index to identify as-
sessment devices and treatment models related to the Cocteau, Jean. Opium. (1929). Cited in Columbia Dic-
tionary of Quotations. New York: Columbia Univer-
specific drug(s) of interest. (3) To use the book as a
sity Press.
reference volume, the reader can find answers to spe-
Huxley, Aldous. (1949). Wanted, a new pleasure. In
cific questions in both the specific chapters and the Music at Night and Other Essays. Cited in Colum-
index. bia Dictionary of Quotations. New York: Columbia
Knowledge evolves, both from the laboratory and University Press.
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 I

Epidemiology, Etiology, and Course

of Substance Use Disorders
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 1

Alcohol and Drug Use, Abuse, and

Dependence: Classification,
Prevalence, and Comorbidity
Bridget F. Grant
Deborah A. Dawson

This chapter provides an epidemiological context for sion of various approaches to subtyping alcohol and
the remainder of this volume by describing the mag- drug use disorders. Attempts to classify alcohol and
nitude of the alcohol and drug problem in the drug use disorders have been problematic both con-
United States. It also presents the most recent na- temporarily and historically. Although the lack of
tional statistics on alcohol and drug use, abuse and consensus is not unique to the alcohol and drug
dependence, and comorbidity between alcohol, drug, fields, there currently exists no consensus on how to
and psychiatric disorders. Emphasis is placed on the classify alcohol and drug use disorders, and no such
summary of data from general population surveys, consensus is expected in the near future. Historical
because prevalence statistics derived from treated changes in these classification systems also adversely
samples are not representative and are subject to affect the collection and communication of accurate
unique selection biases. Moreover, individuals in public health statistics over time. This chapter's dis-
treatment are more likely to have multiple disor- cussion of changes in classification systems over time
ders than are individuals in the general population, and the differences and similarities among alterna-
thus spuriously inflating estimates of the prevalence tive systems is intended to help researchers and clini-
of comorbidity and distorting the relationships exist- cians gauge the degree to which current and future
ing between alcohol, drug, and other psychiatric dis- research findings can be integrated with one another
orders. and with results from earlier studies using historical
Preceding the prevalence and comorbidity statis- classification systems. Only in this way can scientific
tics is a historical overview of classification systems knowledge in the alcohol and drug fields be ad-
in the alcohol and drug fields that includes a discus- vanced.

9
10 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

CLASSIFICATION OF ALCOHOL jor category for intoxication psychosis but placed pri-
AND DRUG USE DISORDERS: mary emphasis on organic disorders associated with
HISTORICAL OVERVIEW chronic alcoholism.
It was not until the early 1960s that classification
Up until the early 1800s, the classification of alcohol systems began to give some consideration to alcohol
and drug use disorders received very little attention. and drug use problems that did not involve addiction
At the institutional level, early official efforts at classi- or dependence. The most well known of these classi-
fication can be seen in 19th-century asylum records ficatory systems was outlined by Jellinek (1960) in
in which terms such as delirium tremens, insanity his classical work, "The Disease Concept of Alcohol-
caused by intemperance, and dipsomania (drink seek- ism." In his classification, Jellinek clearly differenti-
ing) were used to describe conditions resulting from ated varieties of alcohol use disorders that involved a
alcohol use. In France, the statistical classification clear dependence process (gamma and delta types)
used throughout the 19th century to record morbid- from those that did not (alpha, beta, and epsilon
ity and mortality included alcohol-related rubrics types). It was not until the third edition of the Diag-
such as habitual drinking and socially induced heavy nostic and Statistical Manual of Mental Disorders
drinking (Babor, 1992). (DSM-III; American Psychiatric Association [APA],
Beginning in the early 19th century, a series of 1980) and the eighth revision of the International
medical writers began to lay the groundwork for what Classification of Diseases (ICD-8; World Health Or-
would eventually become the disease concept of al- ganization [WHO], 1968) that nondependent sub-
coholism. Among these early contributors was Bruhl- stance use disorders were introduced.
Cramer, who in 1819 introduced the concept of In the ICD-8, alcohol addiction was character-
drink seeking, or dipsomania. Esquirol (1845) was ized by a state of physical and emotional dependence
the first to give drunkenness or monomania a place on regular or periodic heavy and uncontrolled alco-
in psychiatric nomenclatures, and Huss (1849) was hol consumption during which a person experiences
first to use the term alcoholism. By the latter part of a compulsion to drink and withdrawal symptoms
the 19th century, Carpenter (1850), Crothers (1893), upon cessation of drinking.The categories of episodic
Kerr (1888), and McBride (1910) had promulgated and habitual excessive drinking, which were not ex-
the disease concept of inebriety as a concept very tended to other drugs, focused on pathological drink-
similar to what is referred to today as dependence. ing patterns and were differentiated from alcohol
In this formulation, inebriety and dipsomania were addiction by the absence of compulsion and with-
diseases, and their presumed origin was biological or drawal. The alcohol and drug abuse and dependence
possibly genetic. categories of the DSM-III were characterized by pat-
Although the early nosological history of drug use terns of pathological use, and by impairment in so-
disorders is more vague than that of alcohol use cial or occupational functioning due to use, with de-
disorders, it is likely that the first attempts at their pendence additionally requiring the presence of
classification occurred during the early drug epi- either tolerance or withdrawal.
demics of the late 19th century. At that time, addic- In 1976, Edwards and Gross developed the con-
tion to opiates and cocaine gave rise to terms such cept of the alcohol dependence syndrome (ADS).
as morphism and narcomania. These terms were The concept of the ADS was to become extremely
used in much the same way as inebriety and dipsoma- influential in the formation of all further revisions of
nia had been used to describe dependence on al- the /CD and DSM definitions of both alcohol and
cohol. drug use disorders. The syndrome was provisionally
With the disease concept firmly entrenched by endowed with the following seven elements: (1) nar-
the end of the 19th century, diagnostic classifications rowing of the drinking repertoire; (2) salience of
for the next 50 years would continue to emphasize drink-seeking behavior; (3) increased tolerance to al-
the concepts of addiction or dependence, giving very cohol; (4) repeated withdrawal symptoms; (5) relief
little attention to the social, psychological, and medi- or avoidance of withdrawal by further drinking; (6)
cal consequences of substance intoxication and subjective awareness of compulsion to drink; and (7)
chronic use. This trend began with Kraeplin (1909- rapid reinstatement of symptoms after a period of ab-
1915), whose Textbook of Psychiatry included a ma- stinence.
 CLASSIFICATION, PREVALENCE, AND COMORBIDITY 11

The ADS was described not as an all-or-none dis- ence how substance use relates to legal or social con-
ease state, but as a condition which existed in de- sequences, respectively.
grees of severity with the emphasis squarely placed Although the ICD-10 and DSM-IV classifications
on dimensionality of a learned phenomenon. Not all of alcohol and drug use disorders do mirror many of
components of the syndrome needed always to be the structural aspects of the ADS, they do not accept
present in the same intensity. More important, the the learning theory underlying it. The DSM-III,
unidimensional ADS was kept theoretically distinct DSM-II-R, and DSM-IV classifications were claimed
from other alcohol-related disabilities in what Ed- to be largely atheoretical, as were the corresponding
wards and his colleagues (Edwards, Gross, Keller, ICD classifications. (However, the DSMs have been
Moser, & Room, 1977) termed the biaxial concept. criticized by social and behavioral scientists for fail-
Alcohol- and drug-related physical, mental, and so- ing to explicate the underpinnings of their nomen-
cial problems were recognized as public health con- clature, even though it is clear that their classifica-
cerns that were significant in their own right, quite tions entail both ontological and epistemological
apart from dependence. assumptions arising from a medical model.) Rather,
The ADS concept's impact on the current ICD- the DSM authors' claims of an atheoretical classifica-
10 and DSM-IV is evident (table 1.1). In both these tion would seem to have been adopted to minimize
definitions, the syndromal and dimensional compo- opposition from other health professions concerned
nents of the ADS are present in addition to the differ- about the medicalization of the mental health field.
entiation of the dependence category from nonde- Over the past 30 years, behavioral scientists have
pendent categories of abuse and harmful use (table proposed an alternative approach to the disease con-
1.2). Both classifications also share much of the con- cept of alcohol and drug dependence that underlies
tent of their diagnostic criteria with those of the the DSM classifications (Adesso, 1995; Nathan, 1981;
ADS. Changes that occurred with the ninth revision Pattison, Sobell, & Sobell, 1977). In this approach,
of the ICD (ICD-9; WHO, 1978) and the third edi- alcohol and drug use disorders are viewed not as uni-
tion, revised, of the DSM (DSM-III-R; APA, 1987) tary disorders defined in terms of a single disease
and that were retained in the tenth revision of the label, but as acquired habits that emerge from bio-
ICD (ICD-10; WHO, 1992) and fourth edition of logical, pharmacological and conditioning factors.
the DSM (DSM-IV; APA, 1994) also included the Drinking behavior occurs on a continuum of sever-
adoption of the same criteria for abuse, harmful use, ity, and excessive drinking occurs on a continuum
and dependence across all psychoactive substances. with normal drinking. Emphasis is placed on envi-
More important, the earlier defining criteria of com- ronmental, affective, and cognitive antecedent condi-
pulsion, tolerance, and withdrawal were retained— tions and on reinforcing consequences of drinking.
but were no longer required—for a dependence di- The goal of this functional approach is a classifica-
agnosis in either the ICD-10, the DSM-IV, or their tion of pathological drinking that is governed by uni-
immediate predecessors. versal principles of human motivation and learning
Although many subtle differences exist between that guide us all (Wulfert, Greenway, & Dougher,
the current ICD and DSM formulations of alcohol 1996).
and drug use disorders, one important difference is
worth noting. In the ICD-10, the harmful use cate-
gory is characterized by actual physical or psycholog- SUBTYPES OF ALCOHOL AND
ical harm to the user, whereas the DSM-IV abuse DRUG USE DISORDERS
category additionally includes social, legal, and occu-
pational consequences of use. Because cultural con- From as early as the mid-19th century, clinicians and
text is an important determinant of substance use researchers recognized that individuals classified as
patterns and consequences, it can be expected that alcoholics or as alcohol-dependent were far from ho-
the inclusion of social and legal problems in the mogeneous. Babor and Lauerman (1986) cited the
DSM-IV will reduce the cross-cultural applicability development of 39 different classifications of alco-
of the abuse category. For example, changes in legal holic subtypes between 1850 and 1941. Although
definitions or controls and differences between cul- these early typologies were unsystematic and lacking
tural mores of various countries will markedly influ- in empirical foundation, they helped to identify de-
 TABLE 1.1 DSM-/V and ICD-10 Diagnostic Criteria for Alcohol and Drug Dependence

DSM-/V ICD-IO

Clustering criterion A. A maladaptive pattern of substance use, A. Three or more of the following have
leading to clinically significant impair- been experienced or exhibited at some
ment or distress as manifested by three time during the previous year:
or more of the following occurring at
any time in the same 12-month period:
Tolerance (1) Need for markedly increased (1) Evidence of tolerance, such that in-
amounts of a substance to achieve creased doses are required in order
intoxication or desired effect; or to achieve effects originally pro-
markedly diminished effect with duced by lower doses
continued use of the same amount
of the substance
Withdrawal (2) The characteristic withdrawal syn- (2) A physiological withdrawal state
drome for a substance or use of a when substance use has ceased or
substance (or a closely related sub- been reduced as evidenced by: the
stance) to relieve or avoid with- characteristic substance withdrawal
drawal symptoms syndrome, or use of substance (or a
closely related substance) to relieve
or avoid withdrawal symptoms
Impaired control (3) Persistent desire or one or more un- (3) Difficulties in controlling substance
successful efforts to cut down or use in terms of onset, termination,
control substance use or levels of use
(4) Substance use in larger amounts or
over a longer period than the per-
son intended
Neglect of activities (5) Important social, occupational, or (4) Progressive neglect of alternative
recreational activities given up or re- pleasures or interests in favor of sub-
duced because of substance use stance use; or
Time spent (6) A great deal of time spent in activi- A great deal of time spent in activi-
ties necessary to obtain, to use, or ties necessary to obtain, to use, or to
to recover from the effects of sub- recover from the effects of sub-
stance used stance use
Inability to fulfill roles None None
Hazardous use None None
Continued use despite (7) Continued substance use despite (5) Continued substance use despite
problems knowledge of having a persistent or clear evidence of overtly harmful
recurrent physical or psychological physical or psychological conse-
problem that is likely to be caused quences
or exacerbated by use
Compulsive use None (6) A strong desire or sense of compul-
sion to use substance
Duration criterion B. No duration criterion separately speci- B. No duration criterion separately speci-
fied. However, several dependence crite- fied
ria must occur repeatedly as specified
by duration qualifiers associated with
criteria (e.g., "often," "persistent," "con-
tinued")
Criterion for subtyping With physiological dependence: Evi- None
dependence dence of tolerance or withdrawal (i.e.,
any of items A(l) or A(2) above are
present)
Without physiological dependence: No
evidence of tolerance or withdrawal
(i.e., none of items A(l) or A(2) above
are present)
 CLASSIFICATION, PREVALENCE, AND COMORBIDITY 13

TABLE 1.2 DSM-IV and ICD-JO Diagnostic Criteria for Alcohol and Drug Abuse/Harmful Use

DSM-IV Alcohol and Drug Abuse

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one
(or more) of the following occurring within a 12-month period:
(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
(2) recurrent substance use in situations in which use is physically hazardous
(3) recurrent substance-related legal problems
(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacer-
bated by the effects of alcohol
B. The symptoms have never met the criteria for substance dependence for the same class of substance.
ICD-10 Harmful Use of Alcohol and Drugs
A. A pattern of substance use that is causing damage to health. The damage may be physical or mental. The diagnosis
requires that actual damage should have been caused to the mental or physical health of the user.
B. No concurrent diagnosis of the substance dependence syndrome for same class of substance.

fining characteristics, such as drinking patterns, fam- is characterized as occurring primarily among men
ily history of alcoholism, personality characteristics, and is associated with an early onset of alcoholism, a
and psychopathologies, that have served as the basis high level of familial alcoholism among male rela-
for subsequent alcoholism typologies (Babor, 1996). tives (i.e., a primarily endogenous etiology), high lev-
In 1941, Bowman and Jellinek synthesized a number els of antisocial activity and novelty seeking, and low
of earlier typologies into a classification scheme that levels of harm avoidance (Cloninger, 1987; Clon-
defined four types of alcoholics on the basis of their inger et al., 1981).
drinking patterns (continuous, periodic, or irregular) Babor and associates (1992) used the technique
and etiology (endogenous or exogenous). These cate- of cluster analysis to identify 17 defining characteris-
gories were later superseded by Jellinek's (1960) far tics that distinguished their proposed categories of
more widely recognized categories of alpha, beta, Type A and Type B alcoholism. They found that of
gamma, delta, and epsilon alcoholism. Of these, Jel- the two groups, Type B alcoholics had a greater ge-
linek regarded only the gamma and delta varieties as netic predisposition toward alcoholism, more child-
conforming to the disease concept of alcoholism and hood risk factors such as conduct disorder, an earlier
distinguished these by more endogenous influences, onset of alcoholism, more severe symptoms of depen-
more rapid progression, and greater loss of control dence, more polydrug use, more psychopathology
among gamma alcoholics, and more exogenous in- and life stress, and a more chronic treatment his-
fluences, slower progression, and greater inability to tory. Subsequent attempts to replicate this dichotomy
abstain among delta alcoholics. and extend it to substances other than alcohol have
More recent alcohol typologies have refined these yielded different results in terms of which of the de-
categories and added new defining characteristics, fining characteristics contribute most strongly to the
but the most well known of the current subtypes Type A-Type B distinction, but medical conditions,
have maintained the distinction between two broad dependence severity, and lifetime severity have been
categories of alcoholics. For example, Cloninger, repeatedly identified as among the most important
Bohman, and Sigvardsson (1981) proposed a Type dimensions (Ball, 1996; Schuckit et al., 1995).
1 versus Type 2 distinction. Type 1 (milieu-limited) Although each new classification scheme has been
alcoholism is hypothesized to affect both men and based on modifications of existing subtypes, the simi-
women, to have a relatively late onset, to be influ- larities among the typologies are more striking than
enced by both endogenous and exogenous factors, to their differences. Babor (1996) argued that the di-
involve relatively mild alcohol problems with little chotomy between what he terms the Apollonian and
antisocial activity, and to be associated with low lev- Dionysian types of alcoholism captures not only the
els of novelty seeking and high levels of harm avoid- delta-gamma, Type 1-Type 2, and Type A-Type B
ance. In contrast, Type 2 (male-limited) alcoholism distinctions but also many of the other typologies that
14 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

have been proposed during the last century, includ- Longitudinal Alcohol Epidemiologic Survey (NLAES),
ing the reactive versus essential and symptomatic a nationwide household survey sponsored by the Na-
subtypes (Knight, 1938), the family history negative tional Institute on Alcohol Abuse and Alcoholism
versus positive dichotomy (Frances, Timm, & Buckey, (Grant et al., 1994). The NLAES consisted of a rep-
1980), affiliative versus schizoid drinkers (Morey & resentative sample of the U.S. population involving
Skinner, 1986), developmentally cumulative versus direct face-to-face interviews with 42,862 respon-
antisocial and negative affect drinkers (Zucker, 1987), dents, 18 years of age and older. The sampling de-
and the late- versus early-onset dichotomy (Buydens- sign included clustering and stratification with the
Branchey, Branchey, & Noumair, 1989). Future re- provisions for oversampling blacks and young adults
search will undoubtedly continue to clarify the dis- (aged 18-29).
tinctions that characterize these two broad categories Data from the NLAES indicated that two thirds
of alcoholism, to test the applicability of these cate- (66.0%) of adults 18 years of age and over were life-
gories to different drugs and within different subpop- time drinkers who had consumed at least 12 alco-
ulations, and to extend their usefulness as predictors holic drinks during any 1 year of their lives, and
of response to different types of treatment. nearly half (44.4%) were past year drinkers who had
Some of the typologies of alcohol dependence de- consumed 12 or more drinks in the year preceding
scribed above have been tested for their applicability the interview (table 1.3). Drinking was more com-
to other substances. Wills, Vaccaro, and McNamara mon among men than women with the gender dif-
(1994) examined substance use and personality char- ferential strongest among blacks and was more com-
acteristics in a sample of 457 adolescents 12 to 15 mon among nonblacks (including whites and all
years of age. Cluster analysis resulted in five distinct other races) than blacks with the racial differential
groups. The two groups with the highest levels of strongest among women. The prevalence of lifetime
novelty seeking and lowest levels of harm avoidance drinking was highest (73.3%) for individuals in the
and reward dependence were also those with the age range of 30-44 years and lowest (47.8%) for
highest levels of cannabis use. Wills et al. interpreted those aged 65 years and older. The prevalence of
these results as consistent with the Typel-Type 2 dis- past-year drinking was marginally higher for persons
tinction, the adolescents in these two groups corre- aged 18-29 than for those aged 30-44 (53.4% versus
sponding to the Type 2 subtype. The construct, con- 50.2%) and declined sharply in the older age groups
current, and predictive validity of the Type A-Type to 40.5% for persons aged 45-64 and 24.5% for those
B distinction has been supported in a cluster analysis aged 65 years and older.
of 399 cocaine users that included both those seek- Heavy drinking may be defined in terms of drink-
ing and those not seeking treatment (Ball, Carroll, ing patterns (e.g., the frequency of drinking five or
Babor, & Rounsaville, 1995), and some but not all more, or some other number of, drinks) or in terms
of the characteristics distinguishing these two sub- of volume of ethanol intake. Among volume-based
types were replicated in samples of cannabis and opi- measures, an average daily intake of more than 1
ate users (Feingold, Ball, Kranzler, & Rounsaville, ounce of ethanol (the equivalent of more than two
1996). Other typologies that have been proposed for standard drinks) frequently has been used as a thresh-
drug abuse and dependence include Cancrini's old for heavy drinking (Williams & Debakey, 1992).
(1994) fourfold classification based on underlying By this measure, nearly one quarter (23.4%) of U.S.
psychopathology (adjustment disorders, neurotic dis- adults were lifetime heavy drinkers, that is, they
orders, psychosis/borderline disorders, and socio- drank an average of more than 1 ounce of ethanol
pathic personality disorders) and the distinction be- per day during their period of heaviest drinking (but
tween recreational users and self-medicators that is not necessarily throughout their entire lives). Thus,
based on underlying motivation (Carlin & Strauss, slightly more than one third of all lifetime drinkers
1978). could be defined as heavy drinkers at some point
during their drinking histories. In contrast, the preva-
PREVALENCE OF ALCOHOL lence of past-year heavy drinking was only 8.7%, less
AND DRUG USE than one fifth of past-year drinkers.
The prevalence of heavy drinking was higher
Prevalence figures on alcohol and drug use pre- among men than women and higher among non-
sented in this chapter are based on the 1992 National blacks than blacks. With respect to age, the preva-
TABLE 1.3 Prevalence (%) of Lifetime and Past-Year Alcohol Use3 and
Heavy Use, by Gender, Ethnicity, and Age

Alcohol use3 Heavy use"

Sociodemographic
characteristic Lifetime Past year Lifetime Past year

Total 66.0 44.4 23.4 8.7

18-29 68.0 53.4 25.3 11.2
30-44 73.3 50.2 27.2 8.4
45-64 66.1 40.5 23.0 8.9
65+ 47.8 24.5 13.0 5.2
Total men 78.3 55.8 35.6 13.7
18-29 75.7 64.2 34.8 17.1
30-44 82.8 60.8 39.7 13.1
45-64 80.3 51.0 36.8 13.5
65+ 68.2 36.4 25.0 9.1
Total women 54.7 33.9 12.1 4.1
18-29 60.4 42.6 15.7 5.3
30-44 63.9 39.8 15.0 3.8
45-64 52.8 30.7 10.3 4.5
65+ 33.4 16.1 4.8 2.4
Total nonblack 67.9 45.9 24.1 8.8
18-29 71.7 56.4 27.2 11.5
30-44 75.3 51.7 28.1 8.4
45-64 67.3 41.7 23.3 9.1
65+ 48.7 25.7 13.2 5.4
Nonblack men 79.6 56.9 36.5 13.7
18-29 77.9 66.1 36.4 17.2
30-44 84.2 62.0 40.8 13.0
45-64 80.9 51.8 37.0 13.7
65+ 68.9 37.6 25.0 9.4
Nonblack women 56.9 35.6 12.6 4.2
18-29 65.3 46.5 17.6 5.7
30-44 66.4 41.4 15.3 3.7
45-64 54.3 32.1 10.3 4.7
65+ 34.2 17.2 5.0 2.6
Total black 51.4 32.5 17.5 7.7
18-29 45.1 34.5 13.5 9.0
30-44 58.7 39.1 21.1 8.8
45-64 55.0 30.1 20.8 7.1
65+ 37.9 11.7 11.0 2.4
Black men 67.6 46.6 28.6 13.3
18-29 60.5 50.9 23.4 16.2
30-44 71.8 51.3 30.9 14.3
45-64 74.0 43.5 34.1 11.8
65+ 59.6 22.7 23.9 4.6
Black women 38.3 21.2 8.7 3.3
18-29 32.2 20.8 5.3 3.1
30-44 47.7 28.8 12.9 4.3
45-64 39.8 19.4 10.0 3.4
65+ 24.0 4.8 3.2 1.0
Note. Data compiled from Source and accuracy statement for the National Longitudinal Alcohol
Epidemiologic Survey. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
"Consumption of 12 or more drinks within a 12-month period.
b
Average daily consumption of more than 1.0 ounce of ethanol.
16 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

lence of lifetime heavy drinking generally was of commonly used drug (13.9%), followed by illicit use
about the same magnitude for all ages under 65 of prescription drugs (6.2% for all types combined,
years, with lower rates among persons 65 years and including 2.2% for sedatives, 2.4% each for opioids
older. Among nonblack women, though, the rates of and tranquilizers, and 4.1% for amphetamines) and
lifetime heavy drinking were lower for those aged cocaine or crack (3.7%). Lifetime use of hallucino-
45-64 than for those aged 18-29, and the opposite gens was reported by 2.0% of all adults. Considering
was true among black men and women. Past-year all types of drugs combined, the lifetime prevalence
heavy drinking was equally common among persons of use was higher for men than women (23.0% vs.
aged 45-64 and those aged 30-44, the highest preva- 13.2%), higher for individuals aged 18-29 than for
lence being found among those aged 18-29. those aged 30 and older (26.3% vs. 17.1%, with a
Table 1.4 shows the lifetime prevalence of illicit smaller age differential for blacks than for non-
drug use, that is, the use of drugs at least 12 times blacks), and slightly higher for nonblacks than blacks
without or beyond the limits of a doctor's prescrip- (16.0% vs. 12.4%, with most of the difference occur-
tion. Overall, 15.6% of U.S. adults reported a positive ring among individuals aged 18-29). These patterns
lifetime history of drug use. Cannabis was the most held true for most of the individual types of drugs

TABLE 1.4 Prevalence (%) of Lifetime Illicit Use of Selected Types of Drugs, by Gender,
Ethnicity, and Age

Prescription drugs

Sociodemographic Any Tranquil- Amphet- Hallu-

characteristic drug Total Sedatives Opioids izers amines Cannabis cinogens Cocaine

Total 15.6 6.2 2.2 2.4 2.4 4.1 13.9 2.0 3.7
18-29 23.0 8.4 2.6 3.6 3.2 5.8 21.1 3.4 5.6
30+ 13.2 5.4 2.1 2.0 2.2 3.6 11.5 1.5 3.1
Total men 19.5 7.5 3.0 3.2 3.2 5.4 18.0 3.0 5.0
18-29 26.3 8.7 3.1 4.2 3.6 6.4 25.0 4.7 6.5
30+ 17.1 7.1 2.9 2.8 3.0 5.0 15.5 2.5 4.5
Total women 12.0 4.9 1.6 1.7 1.8 3.0 10.1 1.0 2.6
18-29 19.8 8.1 2.1 2.9 2.7 5.3 17.2 2.1 4.7
30+ 9.6 4.0 1.4 1.3 1.4 2.3 7.9 0.7 1.9
Total nonblack 16.0 6.5 2.4 2.5 2.6 4.5 14.3 2.2 3.8
18-29 24.4 9.3 2.8 3.9 3.6 6.6 22.4 3.8 6.0
30+ 13.4 5.7 2.2 2.1 2.3 3.8 11.7 1.7 3.1
Nonblack men 19.8 7.9 3.1 3.3 3.4 5.7 18.2 3.3 5.1
18-29 27.2 9.5 3.3 4.5 4.0 7.1 25.8 5.2 6.9
30+ 17.2 7.4 3.0 2.9 3.2 5.3 15.6 2.6 4.5
Nonblack women 12.5 5.3 1.7 1.7 1.8 3.3 10.6 1.2 2.7
18-29 21.5 9.0 2.3 3.2 3.1 6.1 18.8 2.3 5.2
30+ 9.8 4.1 1.5 1.3 1.5 2.5 8.2 0.8 1.9
Total black 12.4 3.3 1.1 1.6 1.4 1.4 10.9 0.6 3.0
18-29 14.6 2.8 1.0 1.7 0.8 0.9 13.0 0.9 2.9
30+ 11.4 3.6 1.2 1.6 1.7 1.6 9.9 0.5 3.0
Black men 17.4 4.1 1.7 1.8 1.7 2.2 16.3 1.1 4.2
18-29 20.1 3.2 1.4 2.0 1.1 1.3 18.9 1.4 4.2
30+ 16.2 4.5 1.8 1.7 2.0 2.6 15.2 1.0 4.2
Black women 8.3 2.7 0.7 1.4 1.2 0.8 6.4 0.2 2.0
18-29 10.0 2.5 0.6 1.5 0.5 0.7 8.1 0.5 1.9
30+ 7.6 2.9 0.7 1.4 1.4 0.8 5.8 0.1 2.0
Note. Data compiled from Source and accuracy statement for the National Longitudinal Alcohol Epidemiologic Survey. Rockville, MD: Na-
tional Institute on Alcohol Abuse and Alcoholism.
 CLASSIFICATION, PREVALENCE, AND COMORBIDITY 17

TABLE 1.5 Prevalence (%) of Past-Year Illicit Use of Selected Types of Drugs, by Gender,
Ethnicity, and Age

Prescription drugs

Sociodemographic Any Tranquil- Amphet- Hallu-

characteristic drug Total Sedatives Opioids izers amines Cannabis cinogens Cocaine

Total 4.9 1.5 0.2 0.6 0.5 0.4 3.9 0.3 0.6
18-29 10.7 3.0 0.4 1.2 0.9 1.3 9.3 1.0 1.3
30+ 3.0 1.0 0.2 0.4 0.4 0.2 2.2 <0.1 0.4
Total men 6.4 1.5 0.2 0.6 0.6 0.5 5.5 0.4 0.9
18-29 13.2 2.9 0.4 1.2 0.9 1.5 12.1 1.4 1.7
30+ 4.0 1.0 0.1 0.5 0.5 0.2 3.1 0.1 0.5
Total women 3.6 1.4 0.3 0.6 0.5 0.4 2.5 0.1 0.4
18-29 8.2 3.0 0.4 1.3 0.9 1.2 6.4 0.6 0.8
30+ 2.1 0.9 0.2 0.4 0.5 0.1 1.3 <0.1 0.2
Total nonblack 4.9 1.5 0.2 0.6 0.5 0.5 4.0 0.3 0.5
18-29 11.2 3.2 0.5 1.3 1.0 1.5 9.7 1.1 1.3
30+ 2.9 1.0 0.2 0.4 0.4 0.2 2.1 0.1 0.3
Nonblack men 6.3 1.6 0.2 0.7 0.6 0.6 5.4 0.5 0.8
18-29 13.5 3.2 0.4 1.3 0.9 1.7 12.4 1.6 1.8
30+ 3.8 1.1 0.1 0.5 0.5 0.2 3.0 0.1 0.5
Nonblack women 3.6 1.5 0.3 0.6 0.5 0.4 2.6 0.2 0.3
18-29 8.8 3.3 0.5 1.4 1.0 1.4 7.0 0.7 0.8
30+ 2.0 0.9 0.2 0.4 0.4 0.2 1.3 <0.1 0.2
Total black 4.7 1.0 0.1 0.5 0.4 <0.1 3.8 0.1 1.0
18-29 7.3 1.3 0.1 0.6 0.5 <0.1 6.5 0.2 1.0
30+ 3.6 0.9 0.1 0.4 0.4 <0.1 2.7 0.0 1.0
Black men 6.9 0.9 0.1 0.4 0.4 <0.1 6.0 0.2 1.4
18-29 10.8 1.4 0.1 0.4 0.9 <0.1 10.4 0.5 1.4
30+ 5.1 0.7 0.1 0.4 0.3 <0.1 4.1 0.0 1.4
Black women 3.0 1.1 0.1 0.6 0.4 <0.1 2.1 0.0 0.7
18-29 4.4 1.2 0.1 0.9 0.2 <0.1 3.3 0.0 0.7
30+ 2.4 1.0 0.1 0.4 0.5 <0.1 1.6 0.0 0.7
Note. Data compiled from Source and accuracy statement for the National Longitudinal Alcohol Epidemiologic Survey. Rockville, MD: Na
tional Institute on Alcohol Abuse and Alcoholism.

except for illicitly used prescription drugs, especial- but among persons aged 18-29, the prevalence of
ly tranquilizers and amphetamines, whose lifetime use was higher for nonblacks than blacks (11.2% vs.
use was more common among older than younger 7.3%). These patterns varied somewhat for individual
blacks. drugs. For example, the age differential was particu-
The prevalence of past-year use of any type of larly strong for hallucinogens, there was no gender
drug was 4.9%: 3.9% for cannabis; 1.5% for illicit use differential in the illicit use of prescription drugs,
of prescription drugs, with opioids the most com- and blacks aged 30 and older were more likely than
monly used (0.6%) of these; 0.6% for cocaine or nonblacks in that age range to have used cocaine or
crack; and 0.3% for hallucinogens (table 1.5). As crack in the past year.
with lifetime use, past-year drug use for all types of The gender, ethnic, and age differentials that
drugs combined was more common among men were obtained from the NLAES data presented in
than women (6.4% vs. 3.6%) and far more prevalent tables 1.3-1.5 correspond closely to those based on
among individuals aged 18-29 (10.7%) than among the National Household Survey on Drug Abuse
those aged 30 and older (3.0%). For all ages com- (NHSDA), despite differences in the age groups
bined, there was no significant difference by race, surveyed and the definitions of substance use. The
18 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

NHSDA sample included individuals age 12 and the Future Survey collect information on the use of
over and classified respondents as drug users on the alcohol and various types of drugs, the descriptive
basis of a single incident of use. Prevalence estimates publications based on these surveys do not indicate
based on the NHSDA are accordingly higher (e.g., the prevalence of multiple drug use, that is, the use
37.2% lifetime use and 11.8% past-year use in in- of more than one type of psychoactive substance
dividuals aged 12 and over in 1993) (Substance within a given time frame. Data from the 1992
Abuse and Mental Health Services Administration NLAES revealed that one third (33.1%) of all U.S.
[SAMHSA], 1995a). adults had never used either alcohol or drugs at any
Data on adolescent substance use are also col- point during their lives. More than half (51.3%) re-
lected annually in the Monitoring the Future Study, ported lifetime use of alcohol but not drugs. The pro-
whose findings indicated that in 1995 the lifetime portions using alcohol and either a single type of
prevalence of any drug use was 28.5% for 8th-grad- drug or multiple drugs were 8.3% and 6.3%, respec-
ersr 40.9% for 1 Oth-graders, and 48.4% for 12th-grad- tively. Lifetime use of a single drug or multiple drugs
ers. The corresponding rates of past-year use were without alcohol use was rare, reported by 0.7% and
21.4%, 33.3%, and 39.0%, respectively. Among 12th- 0.2% of adults, respectively. Patterns of past-year use
graders, rates of lifetime drug use were highest for were similar, except that the proportion using neither
cannabis (41.7%), followed by inhalants (17.8%), alcohol nor drugs was higher (54.8%) and the pro-
stimulants (15.3%), hallucinogens (12.7%), barbitu- portion using alcohol only was lower (40.3%) than
rates (7.4%), tranquilizers (7.1%), and cocaine (6.0%). for the corresponding lifetime estimates.
The prevalence of lifetime alcohol use among 12th- In addition to these national population estimates,
graders was 80.7% (Johnston, O'Malley, & Bachman, studies of emergency room and clinical samples have
1996). revealed widespread multiple drug use. Of more
Data from the NHSDA (SAMHSA, 1995a) indi- than half a million drug-related emergency room ep-
cated that among individuals 12-17 and 18-25 years isodes reported to the Drug Abuse Warning Network
of age, the lifetime prevalence of alcohol use rose (DAWN) in 1994, nearly one third involved the use
throughout the late 1970s and declined between 1979 of alcohol in combination with drugs (SAMHSA,
and 1992, with a very slight upturn between 1992 1996). The annual National Drug and Alcoholism
and 1993. The same trend was observed for cannabis Treatment Unit Survey (NDATUS), which collects
use, whereas the lifetime prevalence of cocaine use data from all providers of alcohol and/or drug treat-
peaked in 1982 and declined between 1982 and ment services, revealed that 40% of all clients in
1993. The patterns for past-year use of alcohol and treatment in 1993 abused both alcohol and drugs,
drugs followed the same pattern. Among individuals 35% abusing alcohol only and 25% abusing drugs
26 years of age and older, the lifetime prevalence only (SAMHSA, 1995b). In a sample of 212 subjects
of alcohol consumption rose during the late 1970s, who provided full screening information for admis-
decreased between 1979 and 1982, and remained sion into an alcohol treatment program, the propor-
fairly stable between 1982 and 1993. Lifetime use of tions of men and women who reported concurrent
cannabis and cocaine increased steadily between use of other drugs were 44% and 41%, respectively,
1986 and 1993 within this age group, although the for cannabis, 32% and 33% for amphetamines, 22%
increases in cannabis use after 1988 were slight. Data each for sedatives, 17% and 10% for opiates, and 17%
from the Monitoring the Future Study indicated that and 13% for hallucinogens (Schmitz et al., 1993). In
the prevalence of past-year cannabis use among 8th-, another study of an inpatient treatment sample, 63%
10th-, and 12th-graders increased sharply between of the subjects reported concurrent use of alcohol
1991 and 1995, reversing a long-term trend toward and any other type of drug, and almost all of these
decreasing use that began in the early 1980s. These concurrent users reported at least one episode of si-
data also showed an increase during the 1990s in the multaneous use (i.e., use on the same day) of alcohol
prevalence of past-year use of other drugs (e.g., inhal- and other drugs (Martin et al., 1996a). In a mixed
ants and hallucinogens), but the statistical signifi- treatment/community sample of adolescents, the
cance of these increases cannot be assessed from the mean number of illicit drugs ever used was highest
published data (Johnston et al., 1996). (3.8) for adolescents meeting the DSM-/V criteria for
Although both the NHSDA and the Monitoring alcohol dependence, next highest (3.1) for those
 CLASSIFICATION, PREVALENCE, AND COMORBIDITY 19

meeting the criteria for alcohol abuse, and lowest epidemiological studies in the early 1980s. The sec-
(1.9) for those without either diagnosis (Martin, Kac- ond was the National Comorbidity Survey (NCS), a
zynski, Maisto, & Tarter, 1996b). national probability sample of 8,098 respondents
Data on multiple drug use have provided the aged 15-54, conducted in 1991 (Kessler, McGona-
foundation for research on the developmental stag- gle, & Shanyang, 1994). The most recent national
ing of substance use, which indicates a fairly consis- survey on the prevalence of alcohol and drug use
tent sequencing in the initiation of alcohol and other disorders is the National Longitudinal Alcohol Epi-
drug use, and for the gateway theory of substance demiologic Survey (NLAES), in which direct face-
use, which proposes that adolescent alcohol and/or to-face interviews were administered to 42,862 re-
cigarette use leads to (or increases the risk of) canna- spondents, aged 18 and older, residing in the nonin-
bis use and ultimately the use of hard drugs such stitutionalized population of the contiguous United
as cocaine (see, for example, Kandel &Logan, 1984; States (Grant, Peterson, Dawson, & Chou, 1994).
Kandel & Yamaguchi, 1993; Welte & Barnes, 1985). Although these three major national surveys all
Multiple drug use also has important implications for measured alcohol and drug use disorders, they are
treatment. Studies of treatment samples generally not comparable. Considerable differences between
have indicated that multiple drug users are younger, the surveys existed in terms of the diagnostic criteria
more likely to be male, more likely to be single, and represented, the survey instruments used, the amount
more likely to live alone than individuals with alco- and type of psychometric testing of the instruments,
hol problems only (Brown, Seraganian, & Tremblay, and definitions of lifetime diagnoses. The NLAES
1993, 1994; Schuckit & Bogard, 1986). Other studies was the first national survey to measure alcohol and
have shown that multiple drug users have more anti- drug use disorders according to the most recent psy-
social problems, a greater history of depression and chiatric classification, the DSM-IV. Most notably,
suicide attempt, higher levels of impulsivity, lower the NLAES survey instrument required alcohol and
levels of self-control, more severe interpersonal and drug symptoms to cluster together chronologically in
intrapsychic conflicts, and fewer personal coping re- order for a diagnosis of dependence to be made. In
sources than persons with alcohol use problems only the EGA and NCS surveys, dependence on alcohol
(Brown & Fayek, 1993; Schuckit & Bogard, 1986). or any drug was defined as the lifetime accumulation
Not surprisingly, multiple drug users often have a of the required number of dependence symptoms to
poorer treatment outcome than do individuals treat- achieve a diagnosis, even though their occurrence
ed for alcohol problems alone (Brown et al., 1993; may have been spread out over many years. Unlike
Schuckit & Bogard, 1986). Thus, multiple drug users the survey instruments used in the EGA and NCS,
may require forms of treatment that do not rely on the NLAES diagnostic instrument was also subjected
strong personal resources or a social network of sup- to a test-retest study that assessed its reliability in a
port, that do attend to comorbid psychiatric prob- general population sample similar to the samples for
lems, and that additionally deal with the complex is- which it was intended to be used (Grant, Harford,
sues surrounding the reinforcement of craving and Dawson, Chou, & Pickering, 1995).
the inappropriateness of using certain types of drugs The most recent prevalence estimates of lifetime
in treatment under the circumstances of multiple and past-year alcohol use disorders derived from the
drug use. NLAES appear in table 1.6, disaggregated by gender,
ethnicity, and age. The past-year prevalence of com-
bined alcohol abuse and dependence was 7.4%, rep-
PREVALENCE OF ALCOHOL AND resenting 13,760,000 Americans, while the lifetime
DRUG USE DISORDERS rate was much higher (18.2%). More respondents
were diagnosed with dependence during the past
The Epidemiologic Catchment Area (EGA) survey year (4.4%) and on a lifetime basis (13.3%) than
was the first of three national studies to assess alcohol were diagnosed with alcohol abuse for those two
and drug use disorders according to psychiatric diag- time periods (3.0% and 4.9%, respectively).
nostic criteria (Robins, Locke, & Regier, 1990). In Regardless of time frame, prevalence rates for al-
this survey, 18,571 respondents, aged 18 and older, cohol abuse and alcohol dependence were greater
were interviewed in a series of five community-based among men than women and greater among non-
TABLE 1.6 Prevalence (%) of Lifetime and Past-Year DSM-JV Alcohol Abuse and
Dependence by Gender, Ethnicity, and Age

Total alcohol
Alcohol abuse only Alcohol dependence abuse/dependence
Sociodemographic
characteristics Lifetime Past year Lifetime Past year Lifetime Past year

Total 4.9 3.0 13.3 4.4 18.2 7.4

18-24 6.7 6.5 19.9 9.4 26.6 15.9
25-44 6.2 3.0 15.7 4.3 21.9 7.3
45-64 3.7 1.4 9.9 2.1 13.7 3.5
65+ 1.3 0.3 3.4 0.4 4.7 0.7
Total men 7.0 4.7 18.6 6.3 25.5 11.0
18-24 8.6 9.3 25.0 12.8 33.7 22.1
25-44 8.2 4.6 21.2 6.1 29.4 10.7
45-64 6.1 2.4 15.1 3.2 21.2 5.6
65+ 2.5 0.6 6.4 0.6 8.9 1.2
Total women 2.9 1.5 8.4 2.6 11.4 4.1
18-24 4.8 3.8 14.8 6.0 19.5 9.8
25-44 4.2 1.5 10.3 2.5 14.5 3.9
45-64 1.4 0.4 5.2 1.1 6.6 1.5
65+ 0.4 <0.1 1.3 0.2 1.7 0.3
Total nonblack 5.2 3.2 13.9 4.5 19.1 7.7
18-24 7.3 7.2 21.7 10.1 29.0 17.3
25-44 6.7 3.2 16.5 4.2 23.2 7.4
45-64 3.9 1.4 9.9 2.0 13.8 3.5
65+ 1.3 0.3 3.5 0.4 4.8 0.7
Nonblack men 7.4 4.9 19.2 6.4 26.6 11.3
18-24 9.3 10.0 26.7 13.5 36.0 23.5
25-44 8.8 4.8 22.2 6.1 30.9 10.9
45-64 6.4 2.5 14.9 3.1 21.3 5.6
65+ 2.6 0.6 6.5 0.6 9.1 1.2
Nonblack women 3.2 1.6 8.9 2.6 12.1 4.3
18-24 5.3 4.3 16.6 6.7 21.9 10.9
25-44 4.6 1.6 10.9 2.4 15.5 3.9
45-64 1.5 0.4 5.2 1.0 6.7 1.5
65+ 0.4 <0.1 1.3 0.3 1.7 0.3
Total black 2.2 1.5 8.6 3.8 10.8 5.3
18-24 2.6 2.5 8.7 5.0 11.3 7.4
25-44 2.5 1.8 9.5 4.5 12.0 6.3
45-64 2.2 0.5 9.9 2.9 12.0 3.4
65+ 0.4 0.0 2.8 0.3 3.2 0.3
Black men 3.5 2.5 13.3 5.8 16.8 8.3
18-24 3.9 4.0 13.6 8.4 17.5 12.3
25-44 3.7 2.8 13.4 6.0 17.1 8.8
45-64 4.0 1.2 16.0 4.0 20.1 5.2
65+ 0.8 0.0 5.8 0.8 6.6 0.8
Black women 1.1 0.7 4.8 2.2 5.9 2.9
18-24 1.5 1.2 4.5 2.1 6.1 3.3
25-44 1.4 1.0 6.3 3.2 7.7 4.2
45-64 0.6 <0.1 4.9 1.9 5.5 1.9
65+ 0.1 0.0 0.8 0.0 1.0 0.0
Note. Data compiled from Source and accuracy statement for the National Longitudinal Alcohol Epidemiologic Survey.
Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
 CLASSIFICATION, PREVALENCE, AND COMORBIDITY 21

blacks than blacks. Rates for nonblack men and IV drug use disorders by gender, ethnicity, and age
women often exceeded the rates of their black coun- are shown in table 1.6. With the exception of canna-
terparts by over 30%. Prevalence rates of alcohol bis abuse and dependence, rates for past-year abuse
abuse and dependence, measured separately or com- and dependence for most drugs also were generally
bined, also decreased as a function of age, with the less than 1% for each gender, age, and ethnic sub-
highest rates among respondents 18-45 years old rel- group of the population. Similar to trends observed
ative to those 45 years and older, regardless of gender for alcohol use disorders, the rates of abuse and/or
or ethnicity. Possible explanations for the decline in dependence on all drugs taken singly were greater
both past-year and lifetime alcohol abuse and depen- for men than women, greater for nonblacks than
dence rates with age may include faulty recall ac- blacks, and greater among the younger age group
companying increasing age, lower survival rates (<30 years) than to the older age group (30 years and
among alcoholics, and various time-dependent re- older).
sponse styles. Alternatively, the age gradient may re-
flect a true cohort effect, that is, that alcohol abuse
and dependence are more prevalent among the COMORBIDITY BETWEEN
younger generation of Americans. ALCOHOL USE DISORDERS,
Although alcohol abuse and dependence were DRUG USE DISORDERS,
more common among men than among women, AND PSYCHIATRIC DISORDERS
there was evidence of convergence of the rates be-
tween the sexes in the youngest age groups. The Over the last two decades, there has been increasing
men-to-women ratios (i.e., the men's rate divided by interest in the relationship between alcohol and drug
the women's rate) were lowest in the 18- to 29-year- use disorders and various forms of other psychopath-
old age group. However, when the men-to-women ology. During this time, considerable controversy has
ratio was examined separately for each ethnic group, arisen surrounding several issues in comorbidity re-
it was clear that the rate converged among the youn- search. Opinions have varied widely on the reasons
gest age groups only among nonblacks, a finding sug- for comorbidity. There are several possible explana-
gesting that nonblack women may be catching up. tions for comorbidity, including the toxicity hypothe-
This phenomenon does not generalize to black sis, in which alcohol or drug use disorders are viewed
women because the men-to-women ratios in blacks as causing the comorbid disorder, and the self-medi-
were shown to decrease as a function of age. cation hypothesis, in which an individual drinks or
Prevalences of DSM-IV drug use disorders were uses drugs to self-medicate the comorbid disorder
much lower than the corresponding rates of alcohol (i.e., the comorbid disorder causes the alcohol or
use disorders (table 1.7). Rates for past-year abuse drug use disorder). It is also possible that both disor-
and dependence for most drugs were less than 1% in ders are caused by some common factor, or that the
this general population sample, with the exception disorders are etiologically distinct but that each mod-
of cannabis abuse and dependence combined ifies the risk and/or course of the other. In view of
(1.2%). The prevalence of past-year abuse and/or de- the number of comorbid relationships recognized in
pendence on any drug was 1.5%, with the rate of the literature, it is very likely that each of these
dependence (1.1%) exceeding the rate of abuse hypotheses pertains to various subsets of comor-
(0.5%) (data not shown). Overall, the lifetime rate of bidity.
any drug abuse and/or dependence was 6.1%. The Another controversy in the comorbidity field is
rate for lifetime cannabis abuse and dependence whether rules can be developed to reliably differenti-
(4.6%) was greater than the rates for all the other ate organic or substance-induced disorders or syn-
drugs, followed in order of magnitude by abuse and/ dromes that mimic psychiatric disorders but are actu-
or dependence on any prescription drug (2.0%; in- ally the toxic effects of alcohol or drug intoxication
cluding sedatives, tranquilizers, amphetamines, and or withdrawal from independent forms of the psychi-
opioids), cocaine (1.7%), amphetamines (1.5%), sed- atric disorder. A similar issue arises in the differential
atives (0.6%), tranquilizers (0.6%), and hallucino- diagnosis between pure forms of a psychiatric disor-
gens (0.6%) (data not shown). der and those that are induced by a preexisting medi-
The prevalences of lifetime and past-year DSM- cal condition.
 TABLE 1.7 Prevalence (%) of Lifetime and Past-Year DSM-JV Drug Use Disorders by Gender, Ethnicity, and Age

Lifetime Past Year

18-29 18-29
Drag Use Disorder Men Women Black Nonblack years 30+ years Men Women Black Nonblack years 30+ years

Any drug abuse or dependence 8.1 4.2 4.0 6.3 10.2 4.7 2.2 0.9 1.2 1.6 4.0 0.7
Any drug abuse only 4.4 2.0 1.7 3.3 5.2 2.5 1.6 0.5 0.7 1.1 3.0 0.5
Any drug dependence 3.7 2.2 2.2 3.0 5.1 2.2 0.6 0.4 0.6 0.5 1.2 0.2
Prescription drug abuse or dependence 2.5 1.6 0.6 2.2 2.8 1.8 0.3 0.3 0.3 0.3 0.7 0.2
Prescription drug abuse only 1.3 0.7 0.2 1.1 1.3 0.9 0.3 0.2 <0.1 0.2 0.5 0.1
Prescription drug dependence 1.2 0.9 0.4 1.1 1.5 0.9 0.1 0.1 <0.1 0.1 0.2 0.1
Sedative abuse or dependence 0.8 0.4 0.3 0.7 0.7 0.6 0.0 <0.1 0.0 <0.1 <0.1 <0.1
Sedative abuse only 0.4 0.2 0.2 0.3 0.3 0.3 0.0 0.0 0.0 0.0 0.0 0.0
Sedative dependence 0.4 0.2 0.1 0.4 0.4 0.3 <0.1 <0.1 0.0 <0.1 <0.1 <0.1
Tranquilizer abuse or dependence 0.8 0.4 0.4 0.6 0.9 0.6 <0.1 0.1 <0.1 0.1 0.1 <0.1
Tranquilizer abuse only 0.4 0.2 0.2 0.3 0.5 0.3 <0.1 <0.1 0.0 0.1 0.1 <0.1
Tranquilizer dependence 0.4 0.2 0.2 0.3 0.4 0.3 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1
Amphetamine abuse or dependence 2.0 1.0 0.4 1.6 2.1 1.3 0.2 0.1 0.0 0.1 0.4 <0.1
Amphetamine abuse only 1.0 0.3 0.2 0.8 1.0 0.7 0.1 0.1 0.0 0.1 0.3 <0.1
Amphetamine dependence 1.0 0.6 0.2 0.8 1.1 0.6 0.1 <0.1 0.0 0.1 0.1 <0.1
Cannabis abuse or dependence 6.6 2.9 2.9 4.9 8.2 3.5 1.9 0.5 0.8 1.3 3.4 0.5
Cannabis abuse only 4.1 1.7 1.6 3.0 4.9 2.2 1.5 0.4 0.6 1.0 2.6 0.4
Cannabis dependence 2.5 1.2 1.3 1.9 3.3 1.3 0.4 0.1 0.2 0.3 0.8 <0.1
Cocaine abuse or dependence 2.2 1.1 1.6 1.7 2.7 1.3 0.3 0.1 0.5 0.2 0.4 0.1
Cocaine abuse only 0.9 0.4 0.4 0.7 1.0 0.5 0.2 <0.1 0.1 0.1 0.2 <0.1
Cocaine dependence 1.3 0.7 1.2 1.0 1.7 0.8 0.1 0.1 0.4 0.1 0.2 0.1
Hallucinogen abuse or dependence 1.0 0.3 0.1 0.6 1.1 0.4 0.1 <0.1 <0.1 0.1 0.3 0.0
Hallucinogen abuse only 0.5 0.2 <0.1 0.3 0.6 0.2 0.1 <0.1 0.0 <0.1 0.2 0.0
Hallucinogen dependence 0.5 0.1 <0.1 0.3 0.5 0.1 <0.1 <0.1 <0.1 <0.1 0.1 0.0

Note. Data compiled from Source and accuracy statement for the National Longitudinal Alcohol Epidemiologic Survey. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
 CLASSIFICATION, PREVALENCE, AND CO-MORBIDITY 23

Disentangling independent from substance-in- flects a positive association between two comorbid
duced disorders can be difficult, because this deter- disorders. An odds ratio of 1.0 or indistinguishable
mination rests largely on a self-report clinical history from 1.0 is considered nonsignificant.
that may be unreliable, particularly when chronic, Despite major differences in interview schedules,
long-standing disorders may be involved. In view of diagnostic criteria, and algorithms, the relative mag-
this issue, it is not surprising that much of the think- nitudes of the rates are quite consistent across the
ing about comorbidity has been focused on the pri- EGA, NCS, and NLAES and between past-year and
mary-secondary distinction, or on which disorder ap- lifetime odds ratios, with the majority of associations
peared first chronologically. The assumption has being smaller for lifetime than past-year time frames.
been that a psychiatric disorder that is primary to an These results suggest that while self-medication of
alcohol or drug use disorder is more likely to be an depression with alcohol may be effective in the short
independent disease entity which will persist in absti- term, it may lead to increased dysphoria and exacer-
nence and require appropriate treatment. Converse- bation of depressive symptoms in the long term. If
ly, a chronologically secondary psychiatric disorder is self-medication were successful in the long term, we
thought to be more likely to result from the toxic would have expected the associations to be lower for
effects of alcohol and drugs and to remit with absti- past-year diagnoses relative to lifetime diagnoses.
nence. The level of association among alcohol and drug
Most of the research on comorbidity has been use disorders was greatest in the two most recent sur-
conducted in treated samples. Data from these clini- veys, the NCS and NLAES (OR > 20), but much
cal studies show wide variation in comorbidity rates lower in the older (EGA) survey. The magnitude of
between alcohol and drug use disorders and other this association and its consistency in the latest two
psychiatric disorders. The observed variation in the surveys, despite their methodological differences,
rates is very likely due to differences in the diagnostic strongly suggest that alcohol and drug use disorders
interviews and criteria used to arrive at diagnoses and are more likely to co-occur today than they were a
differences in the demographic composition of the decade ago on both a lifetime and a concurrent ba-
samples. Regardless of the reported variability, stud- sis. Alcohol and drug use disorders were also more
ies of medical, psychiatric, and substance-abusing pa- highly related to major depression and antisocial per-
tients are not well suited to the study of comorbidity. sonality disorder than to manic disorder or any of
Individuals in treatment are more likely to have mul- the anxiety disorders. This result is consistent with
tiple disorders than cases in the general population, evidence from the clinical literature, in which alco-
thereby spuriously inflating comorbidity rates and hol and drug use disorders, major depression, and
creating an environment ripe for what is referred to antisocial personality disorders sometimes aggregate
as Berkson's bias (Berkson, 1946). in the same family and in the same individuals, indi-
Because of these problems, it is necessary to turn cating that the three disorders may simply be alterna-
to general population samples for more accurate and tive manifestations of the same disorder (Winokur &
precise estimates of comorbidity. However, general Coryell, 1991; Winokur, Rimmer, & Reich, 1971).
population surveys designed to reliably study comor- However, from the limited number of data available
bidity are rare. As previously mentioned, only three from adoption and genetic marker studies, there is
major studies in the United States have considered no consistent evidence of genetic overlap among the
psychiatric comorbidity, including alcohol and drug disorders in this putative spectrum (Cloninger,
use disorders and other psychopathology. These stud- Reich, & Wetzel, 1979; Goodwin et al., 1974; Good-
ies were the EGA conducted in the early 1980s, the win, Schulsinger, Hermansen, Guze, & Winokur,
NCS conducted in 1991, and the NLAES conducted 1973). Further research will be required to deter-
in 1992. mine if these three disorders are heterogeneous clini-
The relationships between current and lifetime cally and etiologically or, alternatively, represent dif-
alcohol and drug use disorders and other psychiatric ferent expressions of the same underlying pathogenic
disorders from these three surveys are summarized in mechanism.
table 1.8. In this table, we present odds ratios as mea- Despite the findings from clinical studies that co-
sures of the strength of an association between disor- morbidity rates vary by gender and age, these specifi-
ders. An odds ratio significantly greater than 1.0 re- cations have been largely ignored in previous general
24 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

TABLE 1.8 Comorbidity Between Current and Lifetime Alcohol and Drug Use Disorders and
Other Major Psychiatric Disorders in the NLAES, NCS, and EGA: Odds Ratios

Current* Lifetime

Alcohol Alcohol
use Drug use use Drug use
Disorder Survey disorder disorder disorder disorder

Drug use disorder NLAES 25.1 _ 13.0 _

NCS 20.6 — 13.7 —
ECA 7.8 — 5.8 —
Major depression NLAES 3.7 7.2 3.6 5.2
NCS 2.6 3.0 1.9 2.4
ECA 2.7 3.4 1.9 3.5
Mania NCS 5.6 5.7 4.9 7.4
ECA 3.8 3.2 4.6
Obsessive-compulsive disorder ECA 3.4 3.4 2.1 3.3
Phobia NCS 2.3 3.9 1.7 2.2
ECA 1.7 1.7 1.4 1.8
Panic disorder NCS 1.4 3.9 1.6 3.0
ECA 4.6 1.0 2.6 3.1
Generalized anxiety disorder NCS 2.7 5.0 2.0 2.9
Posttraumatic stress disorder NCS 2.2 2.9 1.7 3.2
Antisocial personality disorder NCS 11.3 11.5
"EGA — — 14.6 8.9
"Current: ECA and NCS, 6 months; NLAES, 12 months.

population studies. In the NLAES, associations be- the use, giving up important activities to use) and
tween lifetime alcohol and drug use disorders and tolerance and withdrawal symptomatology were rele-
major depression were presented for abuse and de- gated to the dependence category. Unlike the indica-
pendence separately by gender and age (Grant, 1995; tors of DSM-IV dependence, the DSM-IV abuse cri-
Grant & Harford 1995) (see table 1.9). For alcohol teria may reflect societal reactions to substance use
and each drug, the dependence-depression associa- behavior. Women's drinking and drug-taking behav-
tion was greater than the corresponding abuse-de- ior may be more heavily sanctioned than that of men
pression association, and the odds ratios were greater (Makela, 1987; Park, 1983), thereby increasing their
for drug than for alcohol use disorders. vulnerability to societal reaction as reflected in the
Associations between alcohol and drug use disor- DSM-IV formulation of abuse. The increased risk of
ders for all drugs combined and between depen- major depression among women diagnosed as abus-
dence and major depression did not differ by gender. ers therefore may reflect the development of major
With the exception of cocaine and hallucinogens, depression as the result of a more adverse societal
the risk for alcohol and other drug abuse and major reaction to their drinking and drug use than that ex-
depression was consistently greater for women than perienced by men. The finding that women also do
men. One reason for this observed risk differential not demonstrate greater abuse-depression associa-
relates directly to the definition of abuse underlying tions than men for cocaine and hallucinogens impli-
the comorbidity rates. The DSM-IV defines alcohol cates the importance of the context in which drug
and drug abuse, separately from dependence, as so- taking occurs. Cocaine and hallucinogen use fre-
cial, occupational, legal, and interpersonal conse- quently takes place among subcultures of society
quences arising from substance use. Indicators of pat- within which women may be protected from societal
terns of compulsive use (e.g., impaired control over reactions through peer support and approval.
 CLASSIFICATION, PREVALENCE, AND COMORBIDITY 25

TABLE 1.9 Lifetime Comorbidity Between DSM-IV Alcohol and Drug Use Disorders and
DSM-IV Major Depression by Gender and Age: Odds Ratios

J8-29
Alcohol/drug use disorder Men Women years 30+ years Total

Alcohol abuse or dependence 4.2 4.0 2.8 3.8 3.6

Alcohol abuse only 1.5 2.1 1.4 1.7 1.7
Alcohol dependence 4.3 4.3 2.9 4.1 3.8
Any drug abuse or dependence 5.5 5.9 4.3 5.3 5.2
Any drug abuse only 3.2 4.0 2.6 3.4 3.3
Any drug dependence 7.2 7.3 5.5 7.1 6.9
Prescription drug abuse or dependence 6.5 6.7 5.3 6.6 6.3
Prescription drug abuse only 3.9 5.1 3.6 4.3 4.1
Prescription drug dependence 9.7 8.0 7.1 9.1 8.6
Sedative abuse or dependence 6.7 6.1 5.2 6.5 6.1
Sedative abuse only 3.8 4.9 3.4 4.2 3.9
Sedative dependence 10.1 7.3 7.3 9.1 8.5
Tranquilizer abuse or dependence 6.6 7.1 5.3 6.9 6.5
Tranquilizer abuse only 4.2 6.6 4.1 4.9 4.8
Tranquilizer dependence 9.6 7.4 7.5 8.8 8.3
Amphetamine abuse or dependence 6.4 6.6 4.4 7.1 6.2
Amphetamine abuse only 3.7 5.2 2.9 4.6 4.0
Amphetamine dependence 10.3 8.0 6.0 10.5 8.9
Cannabis abuse or dependence 4.8 5.8 3.8 4.7 4.7
Cannabis abuse only 3.0 4.2 2.5 3.2 3.1
Cannabis dependence 7.3 8.0 5.4 7.4 7.0
Cocaine abuse or dependence 5.3 5.2 3.6 5.5 5.0
Cocaine abuse only 5.1 4.3 2.6 5.9 4.5
Cocaine dependence 5.1 5.7 4.2 5.1 5.1
Hallucinogen abuse or dependence 7.4 5.4 4.4 7.1 6.3
Hallucinogen abuse only 6.9 4.5 4.6 5.7 5.7
Hallucinogen dependence 7.6 7.2 4.1 8.6 6.8
Note. Data compiled from Source and accuracy statement for the National Longitudinal Alcohol Epidemiologic Sur
vey. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

The association between alcohol and drug use use is frequently accompanied by dysphoria (Ellin-
disorders and major depression was consistently great- wood, 1979; Post, Kotlin, & Goodwin, 1974). Alter-
er in the older age group than in the younger age natively, these findings may merely reflect age differ-
group. This result is consistent with evidence from ences in the lifetime risk of both drug use disorders
clinical studies that suggest that a variety of drugs are and major depression. Although major depression
often used to self-medicate depression. Specifically, was strongly related to both cannabis and hallucino-
the mood effects of central nervous system depres- gen abuse and dependence, these two drug classes
sants, such as alcohol, tranquilizers, and sedatives, are not usually associated with the self-medication
have been shown to be variable, initially causing eu- paradigm as it relates to major depression. However,
phoria, but then producing dysphoria, particularly chronic high-dose use of cannabis and hallucinogens
with prolonged use among chronic users. The find- may be accompanied by the development of amo-
ing that risk of comorbidity increases with age ap- tivational syndrome, characterized by anhedonia,
pears to confirm that self-medication for depression chronic apathy, difficulty concentrating, and social
with alcohol, tranquilizers, and sedatives may be ef- withdrawal (Cohen, 1981), symptoms strikingly simi-
fective in the short term but that chronic high-dose lar to those of major depression. Alternatively, failure
26 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

to extract clear relations between specific drugs of gitudinal data would help elucidate the causes and
choice predicted by the self-medication hypothesis as the natural history of alcohol and drug use disorders
ameliorating major depression may be the result of and would provide the basis for understanding the
the common phenomena of polydrug abuse and de- pathophysiological processes underlying them. Since
pendence. adolescence is a high-risk period for the development
of alcohol and drug use disorders, the longitudinal
study of the chronology of alcohol and drug use dis-
FUTURE DIRECTIONS AND TRENDS: orders and other forms of psychopathology should
CLASSIFICATION, PREVALENCE, prove to be most informative. Longitudinal research
AND COMORBIDITY also has the potential to define important subtypes of
alcohol and drug use disorders defined by comorbid-
The future evolution of the classification of alcohol ity and to identify accompanying risk factors helpful
and drug use disorders is likely to entail a continua- in prevention, treatment, and rehabilitation.
tion of the trend toward differentiating dependence
disorders from other substance-related disabilities as
Key References
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ing factors. It is also expected that future changes in drug use disorders and major depression: Results of
classification systems will depend more and more on a national survey of adults. Journal of Substance
empirical data for their justification, a trend begun Abuse, 7, 481-497.
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Recent efforts by behaviorally oriented scientists should P., Dufour, M., & Pickering, R. (1994). Prevalence
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 2

The Course of Treated and

Untreated Substance Use Disorders:
Remission and Resolution,
Relapse and Mortality
John W. Finney
Rudolf H. Moos
Christine Timko

Each person's life has its unique course, and that Rounsaville & Kleber, 1985; Sobell, Cunningham, &
course can be understood in terms of multiple di- Sobell, 1996; Tucker & Gladsjo, 1993). Cohen and
mensions and behaviors. In this chapter, we focus on Cohen (1984) coined the term clinician's illusion to
the course of substance abuse/dependence (disorders refer to the selective, pessimistic perceptions of prac-
involving alcohol, nicotine, and other drugs—parti- titioners regarding the course of the disorders they
cularly, heroin) and describe the more common life treat.
trajectories and influences that alter the course of In contrast, some analysts have provided very opti-
these disorders. mistic views on the long-term outcome of psychoac-
Practitioners offering substance abuse services of- tive substance addiction. For example, based on a
ten see patients return for treatment repeatedly over records search, Winick (1962) argued that, over time,
a period of years. As a result, they are likely to con- about two thirds of persons treated for heroin addic-
clude that substance use disorders are chronic, pro- tion "mature out" of their dependence, typically in
gressive conditions. However, those beliefs are based their 30s. Similarly, Drew (1968) suggested that alco-
on observations of a restricted subset of individuals: holism is a "self-limiting" disease.
those with the most severe, chronic forms of sub- The research reviewed ' i this chapter, though not
stance use disorders. In this regard, substantial empir- without limitations, provides a more comprehensive
ical evidence indicates that persons who seek treat- and balanced perspective on the course of substance
ment for substance abuse are more impaired than use disorders. We address the following questions:
persons not seeking treatment (Finney & Moos, What is the course and long-term outcome of treated
1995; Fiore et al., 1990; Graeven & Graeven, 1983; and untreated substance use disorders? To what ex-

30
 THE COURSE OF TREATED AND UNTREATED SUBSTANCE USE DISORDERS 31

tent do persons with substance abuse/dependence ex-

Long-Term Functioning in
hibit progression in the severity of their symptoms?
Community Samples
Can persons who are stably remitted function as well
as individuals who never have had substance use dis- We located only two long-term follow-up studies that
orders? focused on alcohol use disorders in community sam-
After reviewing research on the course and long- ples. In one, Ojesjo (1981) reported outcomes for 96
term outcomes of substance use disorders, we focus alcoholic men who had been interviewed initially 15
on one end point for some addicted persons: prema- years earlier. The men, whose age at baseline aver-
ture death. We examine the link between active ad- aged 47 years, were categorized at that point as
diction and heightened mortality risk. Then, we fo- "abusers" (heavy drinkers with "medical and social
cus on course changes and the role of personal and disabilities"); "addicts," with generalized dependence
environmental factors in remission, resolution, lapse, symptoms; or "chronics," who had dependence
and relapse. Because of the intended practitioner au- symptoms and medical comorbidities. None received
dience, we focus more attention on findings for intensive treatment during the course of the study.
treated samples, and in the concluding section, we At the 15-year follow-up, 26% had died. Among the
consider implications for treatment. As will become survivors, 41% (2.7% per follow-up year) were in re-
apparent, there is a larger body of research on these mission. The surviving "abusers" had the best out-
issues with respect to alcohol use disorders than for comes, with 64% in remission, followed by "addicts"
smoking and other drug abuse. (18% in remission), and "chronics" (none in remis-
sion).
Vaillant (1995, 1996) presented long-term follow-
THE COURSE OF SUBSTANCE up data on two quite different community samples,
USE DISORDERS whose members had met DSM-III criteria for alco-
hol abuse (some also met criteria for dependence) at
It is inaccurate to speak of the course of any addic- some point in their lives. One group was made up of
tion, as the course for any individual is affected by 150 inner-city men (the "Core City" sample) who
numerous personal and environmental factors, in- had initially been control group members in a study
cluding any other addictions. Thus, in referring to of juvenile delinquency. The "College" sample con-
the course of a substance use disorder, one is refer- sisted of 55 men originally assessed as sophomores at
ring less to its "natural history" as it unfolds in some Harvard University for a study of "normal develop-
inexorable way (Edwards, 1984), than to the "ca- ment."
reers" of the disorder (Edwards, 1984) as they are Long-term follow-up data were secured on 112
shaped by varying personal and environmental fac- men in the Core City sample and 44 men in the
tors for different individuals. In this section, we focus College sample. By age 60, 28% of the men in the
on long-term outcomes and the typical course for al- Core City sample had died. Among the survivors,
cohol, other drug (primarily heroin), and nicotine 59% were in remission, with about three abstainers
addiction. for each controlled drinker (Vaillant, 1996). The
men in Vaillant's College sample exhibited a differ-
ent pattern of outcome when they were 60 years old.
Course of Alcohol Use Disorders
A smaller percentage had died (18%), and among the
Two types of findings from longitudinal studies pro- survivors, only 27% were in remission and about
vide evidence on the course of alcohol use disorders: equally divided between abstainers and controlled
data on individuals' functioning at a long-term fol- drinkers. By age 70, 40% of the College sample men
low-up point and a smaller body of results on the had died. Remission was slightly less prevalent (47%)
course of alcohol use disorders for groups of individ- among the survivors than continuing alcohol abuse
uals who have been studied repeatedly over time. We (53%) (the Core City sample has been followed only
examine separately the data for community (essen- to age 60 at this point).
tially untreated) and clinical samples that have been Overall, these two studies of community samples
tracked for 8 years or more. suggest that around 3% of individuals with alcohol
32 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

use disorders experience remission each year. How- thereafter. Age 40 also marks the point at which
ever, annual remission rates are difficult to calculate some men in the sample began dying; among those
for Vaillant's (1995, 1996) samples, where, unlike in who died, more were active alcohol abusers than ab-
Ojesjo's (1981) study, the follow-ups for some men stainers before their deaths. On a more optimistic
began before their alcohol use disorders had devel- note, many of the surviving men resolved their alco-
oped. hol abuse, as noted earlier, by either becoming ab-
stainers (the more prevalent form of resolution) or
controlled drinkers.
Course of Alcohol Use Disorders in
The onset of alcohol abuse occurred at a later age
Community Samples
for many College sample men than for the members
A more complete picture of the typical course of of the Core City sample, and a smaller percentage
alcohol use disorders requires data on individuals' (38%) of the College men ever met criteria for alco-
functioning at intervening points, in addition to func- hol dependence (all met criteria for abuse at some
tioning at a long-term follow-up. Using retrospective point). The prevalence of alcohol abuse/dependence
accounts from 286 essentially untreated persons (170 peaked at a later age (50) as well and continued later
men and 116 women), Schuckit, Anthenelli, Buc- in the lives of many of the College sample men.
holz, Hesselbrock, and Tipp (1995) outlined the Overall, Vaillant (1995) observed that "the reason
course of alcoholism in terms of the typical age at that alcoholism is relatively uncommon after the age
which 44 life events occurred. Study participants re- of 60 is that roughly 2 percent of alcohol-dependent
ported drinking more than intended at an average individuals become stably abstinent every year and
age of 21 and developing tolerance at 23 years of age. after age 40 roughly 2 percent die every year" (p.
Objections from family, friends, or physicians ensued 152).
at age 24, on average, and respondents first consid- Clearly, various alcohol addiction careers are sub-
ered themselves excessive drinkers at age 26. A first sumed in the data for Vaillant's two samples. Some
period of abstinence of 3 months or more was experi- persons reached criteria for alcohol abuse at an early
enced by 181 of these individuals at age 28, followed age and either became abstinent or engaged in con-
by a second period of 3 months or more at 30 (N = trolled drinking before other persons in the sample
98) and a third period of abstinence at 34 (N= 50). first met criteria for alcohol abuse. We discuss later
Although retrospective data, such as those of factors that may account for various courses and
Schuckit et al. (1995), are valuable, prospective stud- course changes when we focus on factors associated
ies provide a more accurate perspective of the vari- with remission, resolution, lapse, and relapse.
able courses that alcohol abuse/dependence takes in
individuals' lives. Vaillant's (1995, 1996) is the most
Progression of Alcohol Use Disorders
lengthy and in-depth prospective study of the course
of alcoholism. Participants in both of Vaillant's sam- One of the questions that longitudinal studies of
ples completed multiple interviews, so it was possible persons with alcohol use disorders can address is
to determine their status at various stages in their whether such conditions are progressive. Retrospec-
lives. Vaillant's (1995, 1996) analyses reveal a differ- tive studies of alcohol-dependent persons have sug-
ent pattern of functioning over time for his two sam- gested progression. In one of the earliest, Jellinek
ples. The relevant data for the Core City sample are (1952) interviewed members of Alcoholics Anony-
presented in figure 2.1 and those for the College mous (AA), who reported a sequence of the symp-
sample in figure 2.2. toms characterizing the "disease of gamma alcohol-
For many of the Core City men, alcohol abuse ism" that was similar to that described above in the
began relatively early in their lives (over 25% met study by Schuckit et al. (1995).
criteria for alcohol abuse by age 20). Although all of Thus, if one begins with a sample of persons who
the men met criteria for alcohol abuse at some point, meet criteria for abuse/dependence and asks them to
51% also met criteria for alcohol dependence. The reconstruct the sequence of events, the results are
prevalence of alcohol abuse/dependence in the Core likely to reveal progression. However, persons who
City sample was the highest at age 40 and decreased do not exhibit progression would not be included in
 THE COURSE OF TREATED AND UNTREATED SUBSTANCE USE DISORDERS 33

FIGURE 2.1 Quinquennial alcohol use status of the Core City men who met criteria for DSM-III alcohol
abuse. ALC indicates the proportion of deaths that occurred among alcohol abusers; ABS, the proportion
among stably abstinent men. Reprinted by permission from Vaillant (1996), Archives of General Psychiatry,
S3, 243-249. Copyright 1996, American Medical Association.

such studies. Thus, retrospective and prospective in cutting down; and symptoms of withdrawal and
studies of more representative samples that include restriction of activities. Among the individuals who
persons who do and do not meet criteria for a diag- indicated one or more symptoms, 44% of men and
nosis of alcohol dependence provide more accurate 50% of women exhibited symptoms in the first clus-
data on the issue of progression. ter; 31% of men and 28% of women, exhibited symp-
In a retrospective study with a general population toms in the first and second clusters; and 17% of
sample, Nelson, Little, Heath, and Kessler (1996) in- men and 13% of women exhibited symptoms in all
vestigated the lifetime prevalence and age of onset of three clusters. For 83% of the sample with symptoms
each of nine symptom criteria for DSM-III-R alcohol in more than one cluster, transitions from one cluster
dependence (roughly speaking, three criteria must to another, based on recalled age of onset of symp-
have been present for a diagnosis of alcohol depen- toms, reflected the expected progression from abuse
dence). Symptoms were broken down into three to tolerance to withdrawal symptoms. Thus, not all
clusters: symptoms of abuse; symptoms of tolerance, persons with symptoms of alcohol dependence ex-
increasing time spent with alcohol use, and difficulty hibited progression, but if they did, their symptoms
34 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

FIGURE 2.2 Quinquennial alcohol use status of the College men who met criteria for DSM-II1
alcohol abuse. ALC indicates the proportion of deaths that occurred among alcohol abusers; ABS,
the proportion among stably abstinent men. Reprinted by permission from Vaillant (1996), Archives
of General Psychiatry, 53, 243-249. Copyright 1996, American Medical Association.

followed a course similar to that identified in retro- sion. Overall, studies of (predominantly) untreated
spective studies of treated alcohol-dependent per- populations provide little support for the notion of an
sons. inevitable progression of symptoms for persons with
In his prospective study, Vaillant (1995) observed earlier stage alcohol-use disorders. Both a "clini-
that between the ages of 45 and 70, the majority of cian's" and a "clinical researcher's illusion" may
the men in the College sample did not change in have been at work in promulgating the notion of in-
terms of the severity of their alcohol abuse. Specifi- evitable progression.
cally, 20 of 22 men who met criteria for abuse did
not progress to dependence and continued to exhibit
Long-Term Outcome of Treated Alcoholism
abuse until their deaths or the final follow-up. Like-
wise, Hasin, Grant, and Endicott (1990) reported Of particular interest to providers of specialized alco-
that only 30% of 71 men in a general population hol treatment services is what happens to patients in
sample who initially reported only indicators of alco- the long run after a treatment episode, the first of
hol abuse exhibited symptoms of alcohol depen- which occurs for many persons with alcohol use dis-
dence 4 years later. In contrast, 46% were in remis- orders in their early 40s (Schuckit, Smith, Anthen-
 THE COURSE OF TREATED AND UNTREATED SUBSTANCE USE DISORDERS 35

elli, & Irwin, 1993). Table 2.1 summarizes findings ity rates than did Ojesjo's (1981) and Vaillant's
from 12 studies with long-term follow-ups that varied (1995, 1996) community samples. Thus, they may
from 8 to 20 years. Remission is defined as absti- not have included as many persons who were more
nence, nonproblem drinking, or substantially im- prone to relapse. On the other hand, the patients in
proved drinking. Remission rates among successfully the treated samples likely were more impaired ini-
followed survivors ranged from 21% (Westermeyer & tially, as we noted earlier.
Peake, 1983) to 83% (O'Connor & Daly, 1985). Re-
mission rates for survivors in samples followed over
Comparing Alcoholic Patients and
longer periods were generally higher, in part because
Community Controls
of the winnowing out of chronic relapsers through
premature death. Do patients experiencing remission at long-term fol-
Remission rates divided by duration of follow-up low-ups "fully recover"? Do they function in other
yield annual rates that range from 2.1% to 7.6% and life areas as well as similar persons who have not ex-
average 4.8%. This average remission rate is higher perienced alcohol use disorders? What are the costs
than the estimated 3% in studies of community sam- of continuing alcohol abuse? Three long-term fol-
ples, although caution should be exercised in attrib- low-up studies (Finney & Moos, 1991; Kurtines,
uting this difference to the effect of treatment. Broad Ball, & Wood, 1978; Vaillant & Milofsky, 1982) indi-
comparisons between community and treated sam- cate that persons who exhibit long-term remission or
ples do not comprehensively control for population resolution function as well as non-problem-drinking
differences in risk factors associated with outcome, controls, but that continued alcohol abuse is associ-
and the patient samples generally had higher mortal- ated with poorer functioning. However, full recovery

TABLE 2.1 Remission Rates in Long-term Follow-Ups of Treated Alcoholics

Mean age Percentage Percentage Percentage

at first Percentage Length of followed deceased remission Annual
contact married follow-up including of those for remission
Study (years) Time 1 (years) deceased followed survivors rate (%)

Cross et al. (1990) 48 — 10.0 84 32 76 7.6

Edwards et al. (1983)
Taylor et al. (1985) 41 100 11.3 87 20 40 3.5
Finney & Moos (1991) - a
100 10.0 82b 19 57 5.7
Langleetal. (1993) 38 72 10.0 94 22 65 6.5
Mackenzie et al. (1986) 41 29 8.0 94 31 44 5.6
McCabe (1986) 45 100 16.6 88 44 65 3.9
Miller etal. (1992)
Miller & Taylor (1980) 45 76 8.0 71 7 28 3.5
O'Connor & Daly (1985) 48 83C 20.0 70 56 83 4.1
Pendery et al. (1982)
Sobell & Sobell (1973) 40 30 10.0 95 21 47 4.7
Vaillant et al. (1983) 30-50 35d 8.0 94 28 48 6.0
Walker (1987) 41 36 8.0-12.5 80 8e 43 4.2
Westermeyer & Peake (1983) 39 7 10.0 93 22 21 2.1
J
74% were age 40 or older.
Of persons agreeing to a study extension at a six-month follow-up.
'Of those persons later followed.
Living with spouse.
e
Some known-to-be-deceased patients were excluded from the sample prior to a follow-up attempt.
36 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

takes time. De Soto, O'Donnell, and De Soto (1989) stead of all patients entering treatment. Thus, we
found a strong relationship in AA members between conclude that among survivors, about 3% experience
length of abstinence and improvement in psychiatric remission each year, on average. This remission rate
symptoms as assessed by the Brief Symptom Inven- is somewhat lower than the rate of almost 5% found
tory. Symptoms dropped substantially within a year in long-term studies of persons treated for alcohol
or two but continued to decline gradually for 10 use disorders.
years or more, at which point symptom levels were
comparable to those in a general population sample.
The Course of Treated Opiate Dependence
Several of the long-term follow-up studies listed in
Course of Drug Abuse
table 2.2 employed multiple follow-ups and thus pro-
With the exception of a few studies of small, nonrep- vide some insight into addiction careers, particularly
resentative samples of drug abusers in the commu- during the posttreatment period. In a follow-up of
nity (e.g., Murphy, Reinarman, & Waldorf, 1989), male heroin-addicted patients who had been treated
long-term prospective studies of the course of drug at a Public Health Service (PHS) hospital, Vaillant
abuse have focused on treated samples, primarily of (1966) observed that about 90% relapsed in the first
opiate/opioid dependent patients. 2 years. On the other hand, the percentage of men
who exhibited active narcotic addiction declined
from 53% at a 5-year follow-up to 25% at an 18-year
Long-Term Outcome of
follow-up (Vaillant, 1973).
Treated Opiate Dependence
Over the 12 years following an index treatment
We found 10 prospective studies (see table 2.2) of episode, around 75% of the patients tracked by Simp-
patients treated for drug abuse (usually opiate depen- son et al. (1986; Simpson & Sells, 1990) used opioids
dence) that included follow-ups of at least 8 years. daily for one or more periods. However, only 27% of
Criteria for "remission" varied across studies. For ex- these patients were actively addicted for more than 3
ample, some studies focused on complete absti- years at a time. The percentage of daily users in the
nence, whereas others described only abstinence entire sample declined from 47% in Year 1 to 24%
from opioids. The percentage of patients "in remis- in Year 12. Cessation of daily use was not invariably
sion" in table 2.2 refers to "remission" among survi- associated with cessation of criminal behavior, how-
vors as defined by the most stringent criterion avail- ever. About half the patients who were no longer us-
able in the study (e.g., abstinence from all illicit ing opioids daily continued to engage in criminal ac-
drugs). tivity.
As was the case in the long-term studies of treated The entire addiction careers (before and after the
alcohol abuse, early death was the unfortunate out- index treatment episode) for the opioid-addicted pa-
come experienced by substantial percentages of pa- tients studied by Simpson and his colleagues (1986;
tients, with long-term mortality rates varying from Simpson & Sells, 1990) averaged about 10 years,
10% to 54% across studies. For surviving patients, the with a range from 1 to 35 years. During their careers,
percentage "in remission" ranged from 30% to 65% these individuals had an average of six treatment epi-
across the 10 studies. When remission rates are di- sodes and, over time, tended to gravitate toward
vided by the number of years of follow-up, the result- methadone therapy.
ing annual remission rates varied from 1.7% (Hser, How stable are remissions among persons treated
Anglin, & Powers, 1993) to 5.1% (Cottrell, Childs- for narcotics dependence? For 78 patients who were
Clarke, & Ghodse, 1985) and averaged 3.7%. both stably abstinent and employed at a 7-year fol-
The remission rates in several of the studies are low-up by Haastrup and Jepsen (1988), 68% were
likely to have been inflated either because of reliance similarly classified 4 years later and another 17%
on record data rather than personal interviews or, in were in the next best outcome category. Not surpris-
the case of Simpson, Joe, Lehman, and Sells (1986), ingly, less stability in positive outcomes was found
because the 12-year follow-up sample was based on over a longer interval by Hser et al. (1993). Of the
persons successfully followed at 6 years (and more men testing negative for narcotics at a 10- to 12-year
likely to be doing well than those not followed), in- follow-up, 45% were in the same category at a 24-
 THE COURSE OF TREATED AND UNTREATED SUBSTANCE USE DISORDERS 37

TABLE 2.2 Remission Rates in Long-term Follow-Ups of Treated Drug Abuse/Dependence Patients

Mean
age at Percentage Percentage
first Primary deceased remission Annual
contact Type of drug of Length of of those for remission
Study (years) Country treatment abuse follow-up followed survivors rate (%)

Cottrell et al. 25 G.B. DDC Opiates 11.0 20 56 5.1

(1985)
Edwards & 21 G.B. DDC Opiates 10.0 15 50 5.0
Goldie
(1987)
Gordon (1983) 22 G.B. Drug clinic Mixed 10.0 18 41 4.1
Haastrup & 21 Den. City treatment IV opioid 11.0 29 37 3.4
Jepsen service or
(1988) hosp.
Hser et al. 25 USA CCAP Opiate 23.0 31 39 1.7
(1993)
Maddux & 26 USA PHS hosp. Opiate 9.5 13 30 3.2
Desmond
(1980)
O'Donnell 42 USA PHS hosp. Opiate 11.6 54 43 3.7
(1969)
Simpson et al. 22 USA Varied Opioid 12.0 10a 60 5.0
(1986)
Simpson et al.
(1982)
Tobutt et al. 25 G.B. DDC Opiate 22.0 36 65 3.0
(1996)
Stimson et al.
(1978)
Wille (1981)
Vaillant (1973) 25 USA PHS hosp. Opiate 18.0 23 45 2.5

Note. G.B. = Great Britain; Den. = Denmark; DDC = drug dependency clinics; PHS hosp. = Public Health Service hospital; MM = metha-
done maintenance; CCAP = California Civil Addict Program.
''Percentage who died between a 6-year and the 12-year follow-up; not from treatment entry.

year follow-up. Another 17% had died and 8% were not develop until at least early adulthood. Smoking
incarcerated; the remaining individuals who were typically begins in adolescence (Chen & Kandel,
tracked were active narcotics users. 1995) and is persistent. For example, Chassin, Pres-
son, Rose, and Sherman (1996) found that the per-
centage of regular (at least weekly) smokers increased
Course of Smoking
from 20% among llth- and 12th-graders to 27% in
We could find no longitudinal study of the course of young adulthood (age 23, on average) and remained
smoking comparable to those by Vaillant on the stable (26%) into later adulthood (average age of 29).
course of alcohol and drug abuse. However, a picture For adolescent smokers, 59% were smokers as adults
of a typical course, at least into middle adulthood, versus only 10% for adolescent nonsmokers. For
can be pieced together with information from vari- young adult smokers, 72% were adult smokers versus
ous sources. only 7% for young adult nonsmokers. Using data
Although drinking and drug use are frequently in- from various birth cohorts, Pierce and Gilpin (1996)
itiated in the teenage years, addiction typically does projected that an adolescent smoker, born 1975-
38 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

1979, would continue to smoke for 15 years, on aver- (see table 2.2). To the extent that (a) individuals
age, if a male and 20 years if a female. "mature out" of addictions and (b) death claims
Once initiated, nicotine addiction appears to many who do not (see the next section), the rates of
have a higher remission rate than that found in the remission can be expected to be higher among older
community samples of persons with alcohol use dis- than among younger persons.
orders. Among offspring of participants in the Fra- The studies we reviewed provide more good news
mingham Heart study, a high 52% of 397 men and for persons with alcohol use disorders. First, such dis-
49% of 497 women smoked when they were inter- orders are not inevitably progressive, and if persons
viewed initially in 1971-1975 at age 20-29. When do recover, their psychosocial functioning is eventu-
they were recontacted 8 years later, 32% of the men ally comparable to sociodemographically similar per-
smokers and 23% of the women smokers had quit, sons who never had alcohol use disorders. In addi-
4% and 3% annual remission rates, respectively (Hu- tion, as we describe in the next section, the mortality
bert et al., 1987). Presumably, most had quit on their risk for persons who successfully resolve substance
own. We were unable to locate long-term follow-up use disorders is lowered.
studies of treated smokers.
The course of smoking is likely to exhibit stronger
cohort effects than is the case for alcohol and other MORTALITY
drug abuse. Whereas the broad social context (aware-
ness of consequences, sanctions and controls, etc.) in Because the course of addictive disorders ends in
which alcohol and drug abuse occur has been rela- premature death for many individuals, it is worth
tively constant over the past 30 years, there has been considering this end point in greater depth. We focus
an increasing awareness of smoking's adverse health on two issues: first, the extent to which persons with
consequences, a declining number of locations in addictive disorders die prematurely, and second, the
which it is acceptable or legal to smoke, and increas- extent to which persons whose substance use disor-
ing social pressure against smoking. Thus, prior stud- ders are in remission, and whether patients who re-
ies may be less accurate indicators of future trends ceive more treatment have a reduced mortality risk
than is the case for long-term studies of alcohol and relative to those who continue as active substance
drug abuse. abusers or receive less treatment.

Summary Alcohol Use Disorders and Mortality

Vaillant (1995) observed that "if alcoholics can but We first examine mortality in extended follow-ups of
survive, they will often recover" (p. 148). The data community and treated samples of persons with alco-
reviewed here suggest that this somewhat optimistic hol use disorders; we then determine the relationship
conclusion can be extended to persons with other of posttreatment drinking status to mortality risk.
substance use disorders. Among survivors, about 3%
of alcohol abusers in community samples, 5% of
Mortality in Community Samples
treated persons with alcohol disorders, 3% of treated
opiate-dependent persons, and 3-4% of smokers ex- The paucity of long-term follow-ups of community
perience remission each year. samples means that few data are available on pre-
On the surface, the findings indicate that the an- dominantly untreated samples of persons with alco-
nual remission rate for persons treated for alcohol hol use disorders. However, in Ojesjo's (1981) sample
use disorders is about two thirds greater than that for of untreated alcoholics, 26% died over the 15-year
opiate-dependent patients (the single long-term fol- follow-up interval for an annual mortality rate of
low-up of smokers is not a sufficient base on which 1.7%. Among those individuals classified at baseline
to rest conclusions). However, that interpretation as "chronics," 44% had died, 24% of "addicts" had
does not take into account the fact that the persons died, and 20% of "abusers" had died. Thus, presum-
treated for alcohol use disorders in these studies (see ably because it is associated with a higher likelihood
table 2.1) tended to be older than persons treated for of continued severity, severity of alcohol use disorder
heroin dependence and other forms of drug abuse at baseline was a mortality risk factor. How these
 THE COURSE OF TREATED AND UNTREATED SUBSTANCE USE DISORDERS 39

mortality rates compared with general population fig- a problem (Marshall et al., 1994). Time to death was
ures was not reported. significantly shorter for men than for women patients
As noted earlier, 28% of the men in Vaillant's in a study by Lewis et al. (1995a).
(1995, 1996) Core City sample died by age 60, as
did 18% of the men in the University sample, rates
Posttreatment Drinking Status
two and three times as high, respectively, as estimates
and Mortality
for demographically similar genera] population
groups. Men who met criteria for alcohol depen- The relationship of posttreatment drinking status to
dence were more likely to die by age 60 in the Col- mortality risk may be of greater relevance to treat-
lege and Core City samples (62% and 32%, respec- ment providers than is patients' pretreatment func-
tively) than men who met criteria for only alcohol tioning. Because of the infrequency of data from in-
abuse (17% and 18% in the two samples, respec- tervening follow-ups, such information is relatively
tively). Accidents and other violent deaths accounted scarce. However, Smith, Cloninger, and Bradford
for more deaths in the earlier years of follow-up; in (1983) found that treated women who were abstain-
later years, heart disease and cancer accounted for ers at a 3-year follow-up had the lowest mortality rate
more deaths (see also Vaillant, Schnurr, Baron, & (8%) 8-9 years later, followed by sporadic/variable
Gerber, 1991). drinkers (17%), social drinkers (20%), and problem
drinkers (54%). At a 21-year follow-up, these percent-
ages were 31%, 40%, 31%, and 66%, respectively
Mortality in Treated Samples
(Smith, Lewis, Kercher, & Spitznagel, 1994). Like-
We have more extensive data on mortality for per- wise, in a study by Barr, Antes, Ottenbertg, and
sons with treated alcohol use disorders. For 11 of the Rosen (1984) of 410 alcohol patients still alive at a
12 long-term follow-up studies in table 2.1 (we ex- 2-year follow-up, 6% of those classified as "not misus-
cluded Walker, 1987, in which some known-to-be- ing" at that point died in the next 6 years, versus the
deceased persons were excluded from the sample significantly greater 15% of those classified as "misus-
prior to initiating the follow-up), annual mortality rates ing." In studies by Feuerlein, Kufner, and Flohr-
ranged from .9% to 3.9% and averaged 2.8%. In an schutz (1994) and Bullock, Reed, and Grant (1992),
earlier review (Finney & Moos, 1991), we found that the mortality risk for patients who had relapsed was
across seven long-term follow-ups, comparisons with three to five times as high as for those who were ab-
general population data (usually adjusted for age, gen- stainers (cf. Finney & Moos, 1991; Pell & D'Alonzo,
der, and, less often, race) indicated that mortality 1973). Overall, the bulk of the evidence suggests a
rates among alcohol patients were 1.6 to 4.7 times substantial reduction in mortality risk for persons
greater than expected, and that they averaged 3.1 with alcohol use disorders who are able to abstain or
times the mortality rate in the general population. to reduce their alcohol intake following treatment.
More recent studies (Hurt et al., 1996; Lewis et
al. 1995a, 1995b; Marshall, Edwards, & Taylor,
Mortality and Treated Drug
1994) have provided additional data on mortality
Abuse/Dependence
rates and rates for different patient subgroups. Their
results generally have been consistent with those we Some variation exists in reported mortality rates for
reviewed previously: 2.2-2.8% of patients died per treated drug abuse patients, as might be expected,
year, rates that were 2.6-3.6 times higher than ex- given the different countries in which the studies
pected. Functioning prior to treatment was related to were conducted, the different treatment systems
mortality risk. Patients classified as "moderately de- which were in place, and the variation in duration of
pendent" at baseline were 2.9 times as likely to die follow-up. For nine studies in table 2.2 (excluding
as community controls, whereas those who were "se- Simpson et al., 1986, in which only persons who
verely dependent" were 4.4 times as likely to die (this were alive at a 6-year follow-up were "eligible" to die
difference was not statistically significant, however; by a 12-year follow-up), annual mortality rates ranged
Marshall et al., 1994). Estimated years of life lost from 1.3% (Hser et al., 1993; Vaillant, 1973) to 4.7%
were related to more alcohol consumption at intake (O'Donnell, 1969), where the patients were older;
and younger age at which drinking was first seen as the average annual mortality rate was 2.0%.
40 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

Although the 2.0% annual mortality rate among coupled with criminal conviction was associated with
treated drug (primarily opiate) abusers is lower than a heightened mortality risk for drug abuse patients
the 2.8% rate for treated persons with alcohol use over a 10-year follow-up.
disorders, the mortality risk of drug abuse (primarily
opiate-dependent) patients relative to members of
Mortality and Smoking
the general population is much higher than that for
alcohol patients. Specifically, across three studies Although smoking does not cause the social and psy-
(Goldstein & Herrera, 1995; Oppenheimer, Tobutt, chological disruption in its active phase that alcohol
Taylor, & Andrew, 1994; Tunving, 1988), patients and drug abuse do, because of its prevalence it ends
being treated for narcotics addiction were from 4 more lives prematurely than alcohol and other drugs
times (Goldstein & Herrera, 1995—male patients combined. Estimates are that over 400,000 persons
only) to almost 12 times (Oppenheimer et al., 1994) in the United States (McGinnis & Foege, 1993) and
as likely to die as their general population counter- 3 million people worldwide (Peto et al., 1996) die
parts. The apparent inconsistency between the an- each year as a result of smoking. Heavy smoking
nual mortality rates and relative mortality risk for al- shortens an individual's life by 8 years, on average,
cohol- and opiate-dependent patients is explained, at and by 16 years for those who die of causes related
least partially, by the substantially greater age of the to smoking (Peto et al., 1996). Persons who are heavy
alcohol patients relative to the drug abuse patients smokers at age 25 can expect a 25% life reduction
(see tables 2.1 and 2.2). In this regard, the relative compared to nonsmokers (Rogers & Powell, 1991).
mortality risk was found to be higher in younger her- Phillips, Wannamethee, Walker, Thomson, and
oin-addicted patients (under 30) than in older pa- Smith (1996) estimated that only 42% of smokers
tients (Oppenheimer et al., 1994; see also the study alive at age 20 would live to age 73 versus 78% of
by O'Donnell, 1969). nonsmokers.
Opiate addiction appears to be a particularly le- In their 15-year follow-up of British men aged
thal form of drug abuse. Tunving (1988) attempted 40-59 at baseline, Phillips et al. (1996) found that
to track 524 patients receiving care at an inpatient 8% of the nonsmokers had died versus 23% of the
treatment and detoxification unit in Lund, Sweden, continuing smokers. Thus, middle-aged smokers ap-
between 1970 and 1978. The "dominating type of pear to have almost three times the mortality risk of
abuse" was determined for each patient: opiates, am- nonsmokers over a 15-year period.
phetamines, or mixed. Patients were traced via regis- Quitting smoking reduces an individual's mortal-
ters to 1984, at which point 62 had died at an average ity risk. Among former smokers included in a Coro-
age of 27.6 years. Overall, patients were 3.5 times as nary Artery Surgery Study Registry, there was an im-
likely to die as members of the general population. mediate decrease in mortality risk within 1 year of
However, opiate addicts had a greater relative mortal- quitting, but for at least 20 years after quitting, for-
ity risk (5.4 for men and 8.0 for women) than did mer smokers still had a somewhat higher risk of mor-
amphetamine users (2.5 for men; no women died) tality than nonsmokers (Omenn, Anderson, Kron-
or mixed drug users (3.0 for men and 2.0 for women) mal, & Vlietstra, 1990). Similar results emerged in a
(see also Engstrom, Adamsson, Allebeck, & Rydberg, study (Kawachi et al., 1993) of 117,000 registered
1991). nurses in the United States whose age range at base-
Finally, although few long-term follow-up studies line was 20-55. The relative risk of mortality for cur-
have examined the relationships between posttreat- rent smokers was 1.9 times greater than that for non-
ment substance use and mortality, the available evi- smokers, whereas the relative risk for former smokers
dence suggests that posttreatment drug abstinence is was 1.3. Nurses who started smoking before they
associated with a reduced mortality risk. Among ac- were 15 years old had the highest relative mortality
tive drug users at a 10- to 12-year follow-up by Hser risk (3.2). Within 2 years of quitting, former smokers
et al. (1993), 23% had died by a 24-year follow-up, had a 24% reduction in their risk of mortality due to
whereas 17% of persons not testing positive at the cardiovascular causes. However, it took 10-14 years
earlier point had died by the later follow-up. Another of abstinence for the mortality risk of former smokers
study (Gordon, 1983) found that active addiction to approximate that of nonsmokers.
 THE COURSE OF TREATED AND UNTREATED SUBSTANCE USE DISORDERS 41

dropped out of methadone maintenance were almost

Summary
three times more likely to die than were patients ac-
Clearly, substance use disorders place individuals at tively involved in treatment. For alcohol patients,
heightened risk of premature death. The relative le- longer periods of inpatient treatment have also been
thality of alcohol, drug, and nicotine addiction is linked to a lower risk of premature death (Bunn,
somewhat difficult to determine, as mentioned ear- Booth, Loveland Cook, Blow, & Fortney, 1994). Al-
lier, because of age and other differences in the sam- though it is impossible in such studies to completely
ples studied. The data we have presented, as well as disentangle the effects of patient characteristics and
a study by Barr et al. (1984), indicate that alcohol of treatment, these findings should bolster the resolve
patients are more likely to die over a given year than of treatment providers and the motivation of patients
are drug abuse patients. However, alcohol patients to remain in treatment.
tend to seek treatment at a substantially older age
than drug abuse patients (see tables 2.1 and 2.2). The
risk of death relative to that of general population CESSATION, REMISSION,
members is similar for alcoholic patients and RESOLUTION, AND RELAPSE
younger drug abuse patients.
Do drug and alcohol patients of the same age The studies we have reviewed here indicate that sub-
have similar mortality risks? We found only one stantial numbers of persons with alcohol, opiate, and
study that addressed this issue. Among middle-aged nicotine abuse/dependence successfully resolve their
and older patients in VA substance abuse treatment disorders. How are such positive outcomes achieved?
programs, the relative risk of mortality over a 4-year Stall and Biernacki (1986) concluded that the pro-
period was 2.42 for patients with only alcohol depen- cess of behavior change is influenced by multiple
dence diagnoses; patients with a drug dependence or physiological, psychological, and social factors and is
drug psychosis diagnosis were 2.93 times as likely to similar in many respects across different substance
die as demographically similar (age, gender, race) use disorders. The essence of current views on how
members of the general population (Moos, Bren- most addictive behaviors are resolved was captured
nan, & Mertens, 1994). Overall, we conclude that by Tuchfeld and Marcus (1984) in their two-stage
drug abuse (particularly opiate dependence; see model of (1) cessation and (2) maintenance.
Tunving, 1988) is a somewhat more lethal disorder
than alcohol abuse or dependence.
Cessation of Substance Use
In many cases, multiple addictions are inter-
woven as causes of early deaths. For example, Hurt The primary impetus in the cessation process is the
et al. (1996) reported that among deceased persons accumulation of substantial costs of substance use
who had received treatment primarily for alcoholism, and the realization by the affected person that those
51% had a tobacco-related and 34% an alcohol-re- negative experiences flow from his or her substance
lated cause of death. Concool, Smith, and Stimmel use. An individual may become aware of the costs of
(1979) concluded that comorbid alcoholism was substance use gradually, or through the occurrence
present in 60% of the deceased methadone patients of some significant event or crisis (Tuchfeld, 1981),
they studied. such as a life-threatening medical condition or a
On a hopeful note, our review indicates that re- spouse's threatening divorce.
mission is linked to reduced mortality risk. Also of An individual's perception of the rising toll of
relevance to treatment providers is evidence that substance use is influenced heavily by objective
treatment involvement is associated with lower mor- events that he or she has experienced with respect to
tality rates. Patients who receive more methadone health, psychological functioning, social relation-
treatment are less likely to die than those receiving ships, employment, and legal status. In addition,
less treatment (Gearing & Schweitzer, 1974; Gron- perception of the costs of substance use may be influ-
bladh, Ohlund, & Gunne, 1990; Segest, Mygind, & enced by anticipated future consequences. For ex-
Bay, 1990). For example, Caplehorn, Dalton, Cluff, ample, the potential health consequences of smoking
and Petrenas (1994) reported that patients who are a prominent impetus for many persons trying to
42 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

quit, particularly if those risks are weighed in per- men. Instead, 20 of 22 men in the College sample
sonal, rather than general, terms (Rose, Chassin, drifted along in a state of alcohol abuse that while
Presson, & Sherman, 1996). not optimal, apparently was tolerable.
In addition to the mounting costs of substance
use, the addicted person may experience diminish-
Maintenance of Change:
ing psychophysiological benefits (the "rush" or tran-
Remission and Resolution
quillity) from substance use, due to the development
of tolerance. At some point, perhaps after an ex- Although important, the decision to change one's
tended period of ambivalence, the decisional bal- substance use behavior or to quit entirely may be
ance of costs and benefits of substance use shifts to fleeting ("It's easy to quit; I've done it many times").
the negative side and the individual decides to quit In a widely cited analysis, Hunt, Barnett, and Branch
(Sobell, Sobell, Toneatto, & Leo, 1993). In a sense, (1971) charted time to relapse following treatment
then, substance use disorders contain the seeds of from 84 studies of smokers. The percentage of ab-
their own resolution (Mulford, 1977; Orford, 1985). stainers was about 35% at 3 months, 25% at 6
The influential role of perceived negative conse- months, and 20% at 12 months. A study they re-
quences in prompting behavior change among un- viewed of patients treated for alcohol abuse/depen-
aided substance abusers is mirrored by its role in trig- dence and one of heroin addiction patients showed
gering treatment entry. In this regard, Finney and similar relapse curves. Among unaided smokers mak-
Moos (1995) found that the "effects" of hardship fac- ing a quit attempt, rates of failure to maintain behav-
tors, which have been the most consistently identi- ior change have been even higher. One study found
fied precipitants of alcohol treatment entry in a num- that 62% of the individuals had returned to smoking
ber of studies, were mediated by individuals' within 15 days (Ward, Klesges, Zbikowski, Bliss, &
perceived severity of their drinking problem. Similar Garvey, 1997); another reported that only 22% of un-
findings emerged in a study of drug abuse patients aided smokers who quit maintained abstinence for
by Power, Hartnoll, and Chalmers (1992). 14 days and only 8% were abstinent for 6 months
What is perceived as a significant substance use (Hughes et al., 1992).
problem by one person may not be by another. Short-term (e.g., 3-6 months) maintenance of
Among problem drinkers, persons of higher socio- change may be referred to as remission. Longer term
economic status (SES) tend to recognize a drinking change can be labeled recovery or resolution. In
problem sooner than lower SES persons: They hit a Tuchfeld and Marcus's (1984) two-stage model, a va-
higher "bottom" (Humphreys, Moos, & Finney, riety of factors contribute to remission and resolu-
1995). Recognizing a substance use problem earlier, tion. These "maintenance factors" include both in-
before a high level of dependence symptoms has de- trapersonal and interpersonal determinants.
veloped, is associated with a greater likelihood of suc- With respect to cognitive intrapersonal factors, a
cessful resolution (Cohen et al., 1989; Dawson, greater commitment to abstinence (Hall, Havassy, &
1996; Rose et al., 1996). Also, the early realization of Wasserman, 1990, 1991) and a stronger sense of self-
a drinking problem may provide persons with more efficacy (Garvey, Bliss, Hitchcock, Heinold, &
options regarding attainable outcomes (e.g., non- Rosner, 1992; McKay, Maisto, & O'Farrell, 1993;
problem drinking). Rose et al., 1996; Stephens, Wertz, & Roffman,
Some persons may fall into an intermediate level 1993) are associated with a greater likelihood of
of addiction, being sufficiently dependent so that maintaining remission/resolution. Behaviorally, indi-
substance use is not somewhat readily discontinued viduals who possess skills to cope with relapse-induc-
(especially at an earlier age; e.g., Cohen et al., 1989; ing situations (Shiftman et al., 1996) and stressful sit-
Dawson, 1996; Rose et al., 1996), but not so depen- uations in general (Moos et al., 1990) are more likely
dent that the costs of substance use become exceed- to have successful resolutions of their substance use
ingly high. Recall that in Vaillant's (1995, 1996) disorders. Donovan (1996) suggests that individuals
study of the course of alcohol use disorders, fewer tend to cope initially by avoiding high-risk situations
men in the College sample ever met criteria for de- or, if they encounter such situations, by seeking so-
pendence, but also fewer resolved their alcohol use cial support. In later stages of resolution, individuals
disorders in comparison to the Core City sample tend to rely less on behavioral coping approaches
 THE COURSE OF TREATED AND UNTREATED SUBSTANCE USE DISORDERS 43

and more on cognitive coping responses, such as fo- Marlatt and Gordon's (1985) conceptualization of
cusing on the negative consequences of prior sub- the relapse process has been predominant and is de-
stance use and the benefits that have accrued as a scribed in more detail by Quigley and Marlatt (chap-
result of behavior change. ter 20, this volume). In brief, however, a lapse is seen
Abundant research indicates that factors outside as a result of a vulnerable person's confronting a
the individual—the controls and support provided by high-risk situation. Eight types of high-risk intraper-
others in his or her social environment—are also im- sonal or interpersonal situations have been reported
portant in maintaining behavior change (Garvey et by persons with alcohol, opiate, and nicotine depen-
al., 1992; Havassy, Hall, & Wasserman, 1991; Rose dence (Marlatt & Gordon, 1985). The most com-
et al., 1996; Sobell et al., 1993). In this regard, Vail- mon two are negative affect and social pressure to
lant (1988) identified three social conditions that, use substances. Not all persons succumb to relapse-
along with such substitute dependencies as medita- inducing situations, however. Vulnerability is caused
tion or exercise, were associated with long-term absti- by a breakdown in the maintenance factors described
nence among both heroin addicts and persons who earlier. For example, a person may have a reduced
had met criteria for alcohol abuse. The social envi- sense of confidence that he or she can maintain ab-
ronment conditions included (a) some form of com- stinence (lowered sense of self-efficacy) or may fail
pulsory supervision (e.g., parole); (b) new social sup- to apply appropriate coping responses.
ports (e.g., new marriage); and/or (c) membership in A lapse often leads to a full-blown relapse
an inspirational group, such as a self-help or religious (Hughes et al., 1992; Ward et al., 1997), but not al-
group that provided hope, inspiration, and self- ways (Gossop, Green, Phillips, & Bradley, 1989). In
esteem. Vaillant (1988) viewed these factors as im- Marlatt's model, a lapse is more likely to lead to re-
posing structure on addicted persons' lives that coun- lapse if the person experiences the abstinence viola-
teracts the conditioned, unconscious aspects of sub- tion effect (AVE). The AVE consists of cognitive dis-
stance use behavior. sonance, caused by the discrepancy between the
During the maintenance process, the former sub- lapse and a person's self-concept as a former sub-
stance abuser gradually assumes the identity and life- stance user, and by the person's attributing the lapse
style of a nonaddicted person. For a former smoker, to stable, internal causal factors. The magnitude of
this lifestyle change may be nothing more profound the AVE is determined by the person's commitment
than finding something else to do after eating or to abstinence, the effort she or he has expended in
drinking, or drinking a glass of juice after waking up maintaining abstinence prior to the lapse, and the
in the morning instead of having a cigarette. For a perceived benefits of renewed substance use. Overall,
person with chronic alcohol or drug dependence, there is less research support for the critical factors in
however, where sustained use has entailed involve- Marlatt's second stage of the relapse process than there
ment in a "deviant" subculture and perhaps criminal is for the first (Bradley, Phillips, Green, & Gossop,
activity, this latter stage of the maintenance process 1992; Brandon, Tiffany, Obremski, & Baker, 1990).
entails developing an entirely new self-concept and
way of life (Frykholm, 1985; Waldorf, 1983).
Summary

Persons with substance use disorders are both capa-

ble of cessation and resolution and vulnerable to
Relapse: The Failure to Maintain
lapse and relapse. Fortunately, substance use disor-
Remission or Resolution
ders provide the impetus for their own resolution in
Unfortunately, remitted substance abusers are often the form of accumulating negative consequences. In
unable to maintain their behavior change. The re- addition, the risk of lapse/relapse decreases as the du-
lapse process, like the resolution process, has been ration of remission/resolution increases (De Soto et
conceptualized as occurring in two stages. First, al., 1989; Loosen, Dew, & Prange, 1990; Vaillant,
there are factors that either make an individual vul- 1995). Both cessation/resolution and lapse/relapse
nerable to or precipitate a slip or lapse. Second, there are complicated processes in which a number of per-
are "maintenance" factors that determine whether or sonal and environmental factors may play a role.
not a lapse will lead to a full-blown relapse. Multiple change attempts, unaided or aided by other
44 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

helping resources, are often involved in successful Because individuals usually seek treatment at
resolutions (Simpson & Sells, 1990; Timko, Finney, times of crisis, it is a point that has significant poten-
Moos, & Moos, 1995). As we discuss below, treat- tial for change. However, because crises are transi-
ment providers can capitalize on "natural healing tory, it is important that treatment seekers be en-
processes" to enhance the likelihood of successful gaged quickly in the treatment process. Initial
resolutions of substance use disorders. therapeutic efforts should focus on strengthening the
individual's decision and commitment to change.
The findings reviewed in this chapter provide empir-
TREATMENT IMPLICATIONS ical data that can be brought to bear in helping pa-
tients to "take stock" (Sobell et al., 1993), that is, to
Researchers investigating the course of substance use weigh the costs and benefits of continued substance
disorders have typically been unimpressed with the abuse versus abstinence or behavior change. For ex-
role of treatment in the remission/resolution process ample, the findings on the heightened mortality risk
(but see Simpson et al., 1986). Their research indi- of continued abuse, along with the reduced mortality
cates that many persons resolve their substance use risk that flows from abstinence, are concrete evi-
disorders without treatment, and for those receiving dence of the severe consequences of continued
treatment, treatment episodes frequently are followed abuse and the benefits of abstinence. More impor-
by relapses, resolutions often occur at points consid- tant, empirical data indicating that persons can re-
erably after treatment has ended, and many treated solve serious substance use disorders, and that those
persons who are functioning well point to other fac- who do recover function as well as persons who were
tors (e.g., family support) as being critical in the reso- never addicted, can enhance patients' sense of self-
lution process (Dawson, 1996; Saunders & Kershaw, efficacy that recovery is possible and can reinforce
1979; Schachter, 1982; Vaillant, 1996; cf. Simpson their perhaps tenuous beliefs that the effort will be
et al., 1986). Orford (1985) spoke for many research- worthwhile.
ers when he argued that the personal and life context Findings on the course of substance use disorders
factors that impinge on the addicted person, al- also have implications for the role of treatment in the
though "'extraneous' when viewed from the treat- maintenance process. Edwards (1989) observed that
ment perspective, operate more intensively, for far a long-term perspective on substance abuse/depen-
longer, and hence seem likely to be by far the more dence forces one "to place the treatment experience
influential" (p. 268). within the enormously important totality of the ebb
Certainly, there are multiple pathways out of ad- and flow of what happens to that person's life—the
diction, and not all involve treatment. Although an job promotions and the redundancies, the broken
episode of treatment may have a modest impact in marriages and the new lovers, children grown up, the
many cases, it may be a critical factor in particular death of parents, brain damage or growth in personal
instances. Stall and Biernacki (1986) noted that in maturity, accidents and inheritances, boom and
the process of resolution of alcohol, heroin, and nic- slump" (pp. 19-20). From this perspective, it makes
otine addiction, "significant accidents," which might sense that treatment should be directed toward help-
have been "rather commonplace during the remit- ing patients improve their life circumstances and en-
ter's problem use career, served at that moment as a hancing their ability to cope with the situations they
powerful catalyst to irrevocably change and reorient confront in their everyday lives.
the remitter's self-concept and corresponding per- The protracted, fluctuating courses of many per-
spective" (p. 16). At times, treatment can play a simi- sons' substance use disorders, with periods of remis-
lar role. Especially for persons receiving treatment sion and relapse, suggest a temporal extension of
for the first time, having sought treatment is a public treatment—that treatment should be available, as
declaration of an intent to change and may be an needed, over a long period, much as treatment is
important "commitment mechanism" (Tuchfeld & available for diseases, such as diabetes, that are
Marcus, 1984). In addition, entering treatment may chronic (O'Brien & McLellan, 1996). In that regard,
remoralize persons who have failed in multiple at- mutual help groups, such as Alcoholics Anonymous,
tempts to change on their own. Cocaine Anonymous, Narcotics Anonymous, and
 THE COURSE OF TREATED AND UNTREATED SUBSTANCE USE DISORDERS 45

Nicotine Anonymous, can be a stable and consistent Affairs Mental Health Strategic Health Group and
source of support (Humphreys et al., 1995). Health Services Research and Development Service.
Although progression in the severity of substance
use disorders is not inevitable, it does occur. In addi- Key References
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experience successful resolutions than are more im- from the problematic use of substances: An inductive
paired individuals. These findings imply that inter- model derived from a comparative analysis of the al-
ventions should be available for persons with less se- cohol, opiate, tobacco, and food/obesity literatures.
vere disorders (Sobell & Sobell, 1993). With respect International Journal of the Addictions, 21, 1-23.
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revisited. Cambridge: Harvard University Press.
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 THE COURSE OF TREATED AND UNTREATED SUBSTANCE USE DISORDERS 47

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 3

Theories of Etiology of Alcohol and

Other Drug Use Disorders

Michie N. Hesselbrock
Victor M. Hesselbrock
Elizabeth E. Epstein

Research on the etiology of alcohol and drug use temporary bodies of literature in an attempt to eluci-
disorders is a complex, multidiscipline endeavor, and date the current state of research and knowledge on
the set of results reported in the literature is enor- the etiology and maintenance of alcohol and drug
mous. Etiology can be conceptualized on many use disorders. Of course, this task would better be
levels, by means of several different theoretical ap- accomplished in a multivolume book devoted solely
proaches. For instance, individuals who take a dis- to the topic of etiology, so by design, we hope to
ease model approach to addictions would be most provide a framework here for readers to understand
interested in learning about genetic and biological the basic issues in the study of etiology from several
contributions to the disorders. Researchers who different theoretical viewpoints. First, evidence is
adopt a behavioral approach might look for lawful presented for genetic contributions to alcohol and
systems of antecedent and consequent events that drug abuse/dependence. Mechanisms of heritability
initiate and maintain drinking. Personality or devel- are illustrated through a brief discussion of research
opmental theorists, or those interested in comorbid on antisocial personality as an etiological pathway to
psychopathology, might search for mediating path- substance abuse/dependence. Then, biological mod-
ways, such as certain psychiatric disorders or person- els of the risk for developing alcohol abuse/depen-
ality characteristics, to addictive disorders which are dence are reviewed. Clinical heterogeneity among
seen as end points of these other syndromes. Sociolo- substance abusers is then covered in some detail,
gists might examine factors on a more macro level, since a complication in the study of etiology of ad-
such as peer or societal influences that contribute to dictive disorders is the phenotypic and possibly geno-
development and maintenance of addiction. typic complexity of these disorders.
In this chapter, we summarize several major con- Mediating variables, or risk factors, are then dis-

50
 ETIOLOGY OF ALCOHOL AND OTHER DRUGS 51

cussed in a section reviewing the literature on psy- (1990) reported a sevenfold increase in the risk for
chopathology (conduct disorder and antisocial per- developing alcoholism among the first-degree rela-
sonality disorder), personality, and temperament as tives of alcoholics as compared to controls.
related to development of alcohol and drug misuse. The dramatic rate of risk for alcoholism reported
Then, various other models of etiology are presented, by these studies could be due to sampling bias (i.e.,
such as behavioral models, family models, peer influ- most studies reporting an increased risk of familial
ences, and sociocultural approaches. alcoholism have been conducted on men). However,
Note that in this chapter, the term alcoholism pedigree studies of the biological relatives of female
may be used interchangeably with and refers to alco- alcoholic patients have found similar high rates of
hol abuse/dependence, and alcoholic is used in this alcoholism among both male and female relatives
chapter to mean "an individual with alcohol abuse (Cloninger, Christiansen, Reich, & Gottesman, 1978;
or dependence." Hesselbrock et al., 1984). Further, a recent study of
female twins has found that both mothers and fathers
were equally likely to transmit the liability for devel-
GENETIC AND BIOLOGICAL MODELS oping alcoholism to their daughters, particularly in
its more severe forms (Kendler, Heath, Neale, Kes-
sler, & Eaves, 1992).
Genetic Factors and the Vulnerability to
While the reported prevalence of alcoholism
Developing Alcohol and Other Drug
among biological family members varies from one
Abuse/Dependence
study to the other, higher rates of alcoholism are con-
Many psychiatric disorders are familial in nature; sistently found among the family members of alco-
that is, the disorder is also often found among other holic persons than among those of nonalcoholic per-
family members. While this increased prevalence sons. Further, there seems to be a positive association
among family members is suggestive of a possible ge- between the rates of alcoholism and pedigree posi-
netic contribution to the development of a disorder, tion (i.e., the rate drops as the biological distance
it is not conclusive. Other types of evidence are also increases). However, it is difficult to separate biologi-
needed that examine the role of both environmental cal (genetic) factors from possible environmental in-
and genetic factors. There is a substantial literature, fluences in family history studies, since members of
based upon studies of monozygotic and dizygotic nuclear families typically share both genetic and en-
twins, half-siblings, adoptees, and extended-family vironmental factors. Adoption studies enable the sep-
pedigrees, suggesting that the mode of transmission aration of genetic and environmental factors. A series
of addiction problems and disorders from parent to of adoption studies have found a strong link between
child has both a genetic and an environmental com- paternal alcoholism and the son's development of al-
ponent. coholism. Using the Danish adoption registers, these
studies indicate that sons of an alcoholic parent have
a similar risk for alcoholism whether raised by the
Alcohol Abuse/Dependence
alcoholic parent or not. Further, the sons were four
The familial nature of alcoholism has long been rec- times more likely to develop alcoholism than sons
ognized and is well documented. A review of this of nonalcoholics, even when adopted away at birth
literature by Goodwin (1979) found that as many as (Goodwin et al., 1974). These findings have been
25% of fathers and brothers of alcoholic patients are replicated by adoption studies conducted in Sweden
themselves affected with alcoholism, while studies of (Bohman, Sigvardsson, & Cloninger, 1981; Clon-
hospitalized alcoholics indicate that as many as 80% inger, Bohman, & Sigvardsson, 1981), as well as in
may have a close biological relative with a lifetime Iowa (Cadoret, Cain, & Grove, 1980).
history of alcohol-related problems (Hesselbrock & Studies of twins also support the role of genetic
Hesselbrock, 1992). Cotton's (1979) review of 39 factors in the development of alcoholism (see review
family history studies estimated a four- to fivefold in- by Hesselbrock, 1995). The majority of twin studies
crease in the risk of developing alcoholism among report increased concordance rates of alcoholism
the first-degree relatives of alcoholics as compared to among monozygotic twins compared to dizygotic
the general population. More recently, Merikangas twins (Kendler et al., 1992; McGue, Pickens, &
52 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

Svikis, 1992; Pickens et al., 1991). Further, a similar- prevalence of drug dependence among the biological
ity in alcohol consumption among twins raised sep- relatives of inpatients with nonalcohol chemical de-
arately has also been reported (Hayakawa, 1987; pendence.
Kaprio et al., 1987; Pedersen, Friberg, Floderus- The preference for similar types of drugs may oc-
Myrhed, McClearn, & Plomin, 1984). These studies cur among family members of drug abusers. For ex-
provide additional support for the role of genetic fac- ample, monozygotic twins appear to display greater
tors (although unspecified) in the vulnerability to al- similarity than dizygotic twin pairs in their prefer-
coholism. ence for, and response to, certain types of drugs
Pickens et al. (1991) studied same-sex twin pairs (Schuckit, 1987). However, not all researchers agree
of subjects who were treated for alcohol or other on these findings. Mirin, Weiss, Sollogub, and Mi-
drug abuse and found a heterogeneous pattern of in- chael (1984) and Mirin, Weiss, and Michael (1986),
heritance. Approximately half of the twins' biological in a study of first-degree relatives of substance abus-
parent or parents were themselves alcoholic. Herita- ers in a treatment program, found differences in the
bility was much stronger for alcohol dependence prevalence of substance abuse in relation to the gen-
than for alcohol abuse; heritability was also typically der of the relative and the choice of substance.Their
much stronger for men than for women (NIAAA, findings indicate that substance abuse disorders (ex-
1993). Further analysis by McGue et al. (1992) cluding alcohol) were less frequent among both the
found that the rates of alcohol and drug dependence male and female relatives of depressant abusers than
and conduct disorder were much higher among among the relatives of opiate or stimulant abusers.
monozygotic male twin pairs than among dizygotic Further, the prevalence of substance abuse disorders
twins of males who were alcohol-dependent or abus- among the female relatives of stimulant and depres-
ing alcohol. Gender differences were apparent in sant abusers was higher than that among male rela-
that among female twins, similar rates of problem be- tives. The opposite was true of the relatives of opiate
haviors were reported by both female pairs. Further abusers, where more male relatives than female rela-
gender differences were found in terms of age of on- tives were found to be affected with substance abuse.
set of alcohol problems and heritability of the prob- More recently, Bierut et al. (1998) have examined
lems. An association between early onset and herita- the familial nature of substance abuse in the Collab-
bility was found among male subjects, but not orative Study on the Genetics of Alcoholism
females. A study of twins in Australia has also sug- (COGA) sample. While COGA was designed to de-
gested a genetic influence in their drinking patterns, termine the genetic basis of alcoholism by using an
with a higher heritability among men than among extended-family study method, many of the persons
women (.66 h 2 vs. .42, h2 respectively) (Heath, in the sample with alcohol dependence were also af-
Meyer, Jardine, & Martin, 1991). fected with another comorbid substance use disorder.
Data from this six-site study indicate some specificity
of the familial nature of substance dependence, in-
Drug Abuse and Dependence
cluding alcohol dependence. In this study, the life-
Family pedigree studies have the potential to help to time prevalence of alcohol, marijuana, and cocaine
identify risk factors for other drug dependence as dependence was found to be higher in the biological
well as alcohol dependence, since they attempt to siblings of alcohol-dependent persons than in those
identify patterns of other substance abuse among bio- of control subjects, but an increased risk for mari-
logical relatives. However, only a few studies have juana or cocaine dependence in siblings was found
sought to determine a familial influence in the de- only when marijuana or cocaine dependence was
velopment of substance use disorders other than present in the probands. The risk of developing alco-
ethanol. Among this small group of studies some pat- hol dependence in the siblings was not increased by
terns seem to be emerging. Croughan (1985) re- comorbid substance dependence in probands.
viewed several family history studies and found that Several investigators have examined the role of
antisocial personality and criminality cluster in drug parents' influence on the drug of choice of their off-
dependence families, just as in families with alco- spring. A high concordance rate of tranquilizer use
hol dependence. Meuller, Rinehart, Cadoret, and (56%) between parent and child was found by Smart
Trough ton (1988) found a significant increase in the and Fejer (1972), while Annis (1974) found a posi-
 ETIOLOGY OF ALCOHOL AND OTHER DRUGS 53

tive relationship between adolescents' and parents' ton, Woodworth, and Stewart (1995) examined mul-
use of alcohol and painkillers. Although several stud- tipathways of transmission of these disorders from
ies of intergenerational drug use agree on the overall parent to offspring. Etiological pathways related to
impact of parental substance abuse, no consistency alcoholism, antisocial personality disorder, and drug
of findings for parents' influence on the drug of dependence were examined in a sample 95 male
choice by their offspring has been reported. adoptees in Iowa. In terms of the association between
While investigators seem to agree on the role of alcohol abuse and antisocial personality disorder,
genetic influences on the development of both alco- three independent pathways representing genetic and
holism and other drug abuse/dependence, separate environmental factors were found. The first pathway
genetic risk factors may affect the transmission of al- demonstrated a direct genetic effect of one or both
cohol dependence versus other drug dependencies. biological parents with alcoholism on the increased
Hill, Cloninger, and Ayre (1977) found that the risk for alcoholism among the biological offspring.
transmission of opioid dependence was independent The second pathway, indicating environmental fac-
of the transmission of alcoholism among the first-de- tors, showed a direct effect of alcohol problems in
gree relatives of subjects who were dependent on opi- adoptive relatives contributing to the increased risk
ates only, on alcohol only, and on both. Rounsaville, for alcoholism in adoptees. The third pathway, rep-
Weissman, Kleber, and Wilber (1982) compared the resenting antisocial personality disorder in the bio-
rates of drug abuse among the siblings of opiate ad- logical parent, showed an increased risk of an in-
dicts with or without a concurrent diagnosis of alco- tervening variable, antisocial personality disorder in
holism. Although the differences in the rates were adoptees. The presence of antisocial personality dis-
small, higher rates of drug abuse were reported by order, in turn, increased the risk for alcohol abuse/
the siblings of opiate addicts without alcoholism. dependency in adoptees.
Similarly, Stabenau (1992) found evidence suggest- Similarly, alcohol abuse/dependence in the bio-
ing that the risk for alcohol dependence was inde- logical parent increased the risk for drug abuse/de-
pendent of the risk for drug dependence in a sample pendence in adoptees, while antisocial personality
of 219 nonhospitalized nontreated young male and disorder in the biological parent increased the likeli-
female subjects. Further, it was found that antisocial hood of aggressivity associated with antisocial person-
personality disorder predicted alcohol abuse and de- ality disorder in the adoptees. Aggressivity functioned
pendence, family history of drug abuse predicted as an intervening variable for the development of
drug abuse/dependence, and additively, they pre- drug abuse and/or dependency in adoptees. Environ-
dicted lifetime rates of alcohol and drug abuse/de- mental factors, characterized by parental divorce or
pendence. separation as well as the presence of behavior prob-
lems in the adoptive parent, were also associated with
an increased risk for drug abuse/dependence in
Mechanisms of Heritability
adoptees (Cadoret et al., 1995).
The importance of the interaction between an inher- The separate and independent role of antisocial
ited vulnerability and environmental risk factors has personality disorder in the development of alcohol
been stressed by Kendler (1995). He places an empha- and other drug abuse/dependence found in the Ca-
sis on gene-environment interaction (G x E) rather doret et al. (1995) study is consistent with other pub-
than an "additive model," which assumes that the lished studies. Other investigators have demonstrated
impact of a pathogenic environment is independent that alcohol abuse/dependence and antisocial per-
of genotype. There is evidence from epidemiological sonality disorders in biological parents appear to be
studies that indicates a genetic influence on the self- transmitted to their offspring as separate traits, while
selection of individuals into high-risk environments both traits contribute to the risk of developing alco-
as well as supporting the role of environmental fac- holism and drug dependence in the offspring (Clon-
tors affecting the development of psychiatric disor- inger et al., 1978; Reich, Cloninger, Lewis, & Rice,
ders (Kendler, 1995). 1981). Further, the heritability of aggressive behav-
In their attempt to clarify genetic and environ- iors has also been documented. (Eron & Huessman,
mental contributions to the development of alcohol 1990; Mattes & Fink, 1987; Plomin, Nitz, & Rowe,
and other drug dependence, Cadoret, Yates, Trough- 1990). Similarly, conduct problems also distin-
54 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

guished children whose parents had antisocial per- Several investigators have found central nervous
sonality disorder from those children whose parents system disturbances, including impaired cognitive
did not (August & Stewart, 1983; Stewart, deBlois, & functioning and electrophysiological disturbances,
Cummings, 1980). Thus, conduct disorder, aggressiv- among persons affected with a substance abuse dis-
ity, and antisocial personality contribute to the risk order. Impairment of brain functioning as well as
of alcohol/drug abuse independent of each other and structural abnormalities have been reported among
independent of the risk due to parental alcohol/drug chronic alcoholics (Deckel, Bauer, & Hesselbrock,
abuse (Cadoret & Wesner, 1990; Hesselbrock et al., 1995; Hesselbrock et al., 1991). The areas of im-
1984, 1992; Loney, 1980). paired cognitive functioning include memory, atten-
A twin study by Lyons et al. (1995) also investi- tion span, visuospatial skills, abstract thinking, and
gated different mechanisms responsible for the famil- verbal reasoning. DeObaldia, Parsons, and Yohman
ial transmission of alcoholism by separating possible (1983), among others, reported an association be-
genetic factors from environmental factors. Symp- tween severe symptoms of alcohol dependence and
toms of antisocial personality disorder were ex- poor cognitive test performance among alcoholics.
amined in 3,226 male twin pairs. It was found that Electroencephalographic (EEG) and event-related
shared family environment was more important in potential (ERP) disturbances among alcoholics have
predicting the concordance of individual juvenile also been reported. Using event-related potential
symptoms, whereas genetic influences were more methods, Porjesz and Begleiter (1985) found reduced
important for predicting adult symptoms. P3 ERP waveform amplitudes among alcoholics as
compared to nonalcoholics. However, originally it
was not clear whether these differences represented
an indicator of risk for the development of alcohol-
Biological Factors in the Etiology of
ism or were the result of chronic heavy drinking.
Substance Use Disorders
Several studies of alcoholics have observed at least
some level of recovery in cognitive functioning fol-
Central Nervous System:
lowing abstinence.
Neuropsychological Functioning and the
Recent studies have provided evidence that elec-
Risk for Developing Alcoholism
trophysiological factors as measured by the EEG and
A variety of studies implicate heritable physiological ERP may contribute to the vulnerability to alcohol
factors associated with central nervous system func- dependence, independent of chronic alcohol con-
tioning in relation to an increased vulnerability to sumption. Begleiter et al. (1984) reported reduced
developing drug and alcohol abuse. Although the rel- P3 ERP component amplitudes, particularly over the
ative contribution of these specific inherited factors parietal area, among prepubescent, alcohol-naive
to an increased risk has not yet been identified, po- sons of alcoholic fathers compared to sons of nonal-
tential neurophysiological indicators of this vulnera- coholic fathers. These findings have been replicated
bility suggested in the literature include differences by other investigators (cf. O'Connor, Hesselbrock, &
in body sway (static ataxia; Lipscomb, Carpenter, & Tasman, 1986; V. Hesselbrock, O'Connor, Tasman,
Nathan, 1979), subjective feelings of intoxication, & Weidenman, 1988). Further, the amplitude of the
and an increased physiological response to ethanol P3 waveform has been shown to be related to aspects
(Schuckit, 1980, 1985; Schuckit, Gold, & Risch, of both figural memory and cognitive flexibility
1987). among young men at high risk for alcoholism (V.
Neuropsychological functioning has also been ex- Hesselbrock, Bauer, O'Connor, & Gillen, 1993). De-
amined as a risk factor. Aspects of neuropsychologi- spite these findings indicating the possible contri-
cal functioning are heritable, and it has been postu- bution of both electrophysiological and neuropsy-
lated that certain cognitive deficits among children chological factors to the development of alcohol
of alcoholics may contribute to the risk for develop- dependence, the relationship between electrophysio-
ing alcoholism and other substance abuse disorders logical measures and behavioral (neuropsychologi-
(see review by Hesselbrock, Bauer, Hesselbrock, & cal) measures of cognitive functioning are not well
Gillen, 1991). understood.
 ETIOLOGY OF ALCOHOL AND OTHER DRUGS 55

Deckel et al. (1995) examined neuropsychologi- or severe alcohol abuse in the probands and no his-
cal and electrophysiological measures in relation to tory of criminality or alcohol abuse in their biologi-
alcohol-related variables in young men at risk for al- cal fathers. Type 2 alcoholism is thought to be highly
coholism because of a positive family history of pater- heritable, male-limited (father-to-son transmission),
nal alcoholism. Neuropsychological tests measuring and developed independent of environmental fac-
frontal and/or temporal neocortical functioning were tors. It is characterized by moderate alcohol abuse in
found to be predictive of the age of taking their first the probands and severe alcohol use and criminality
drink and the frequency of drinking to get intoxi- in the fathers.
cated. Left-frontal slow-alpha EEC activity was also Bohman et al. (1981) examined female adoptees
associated with these alcohol-related variables. These in the Swedish sample and found only Type 1 alco-
findings suggest that disturbances in the integrity of hol abuse. However, only 31 female adoptees were
the anterior neocortex may be a risk factor in the identified who met criteria for alcohol abuse. A repli-
development of alcohol-related behaviors. cation study derived from a sample in Gothenburg,
Branchey, Buydens-Branchey, and Lieber (1993) Sweden, was reported recently by this study team
suggest that a low P3 amplitude could antedate sub- (Sigvardsson, Bohman, & Cloninger, 1996). The rep-
stance abuse and may be a risk factor for the develop- lication study essentially confirms the original find-
ment of substance misuse. They found that a subtype ings for both male and female adoptees.
of alcoholics with lifelong aggressive behavior exhib- The phenotypic characteristics of persons with a
ited lower P3 voltages in the event-related potential. family history of alcohol abuse in the Cloninger et
These patients were also characterized by a high ge- al. study are different from those reported by Good-
netic loading for alcoholism (Branchey et al., 1988, win (1979, 1984), who found a severe form of alco-
1993). While the number of subjects examined was holism among adoptee probands with a paternal his-
small (n = 10), low P3 amplitude was also observed tory of alcoholism. The differences in findings
among former cocaine and/or heroin addicts who between the two studies could be due to sample dif-
had been abstinent for at least 6 months. ferences, where the studies were conducted, and the
source of the information upon which parental clas-
sifications were made. In the Swedish study, a sub-
CLINICAL HETEROGENEITY AMONG ject was defined as having alcoholism based upon
ALCOHOL AND SUBSTANCE ABUSERS: two or more contacts with local temperance boards
IMPLICATIONS FOR ETIOLOGY or having been treated for alcoholism, while the
Danish study defined a subject as having alcoholism
based upon national hospitalization records.
Type I/Type 2
Both Swedish adoption studies are limited by the
The independent contributions of genetic factors rather small number of female alcohol abusers in-
and environmental factors to the development of al- cluded in the study, the restricted sample selection
cohol and drug addiction are difficult to separate. A methods, and the use of indirect measures of alcohol
primary reason for this difficulty is that neither alco- abuse for both the subjects and their fathers (Van-
hol nor other drug dependence is a unitary clinical clay & Raphael, 1990). Efforts to replicate the Swed-
disorder (Hesselbrock, 1986a, 1995). Both patient ish adoption study in the United States have resulted
and general populations of persons so affected are in equivocal support.
heterogeneous in relation to their clinical presen- Investigations of Type 1 and Type 2 alcoholism
tation. An early, influential attempt to subclassify in U.S. samples have found that the principal distin-
alcoholism was conducted in Sweden by the use of guishing etiological factor is the age of onset of alco-
retrospective data obtained from adoption records. holism. Type 2 alcoholism is characterized by an
Cloninger et al. (1981) proposed two forms of alco- early age of onset, while Type 1 is more prevalent
holism found among male adoptees based upon their among later onset alcoholics. While many alcohol-
own alcohol use and their parents' characteristics. related symptoms did not distinguish the two types of
The first form, Type 1, influenced by both genetic alcoholism among men treated at a VA hospital, the
and environmental factors, is characterized by mild age of onset of alcoholism was an important factor in
56 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

characterizing the two types of alcoholism (Penick et to Type A subjects, Type B cocaine abusers reported
al., 1990). Similar findings were reported by Irwin, higher rates of premorbid risk factors, including a
Schuckit, and Smith (1990) and von Knorring et al. family history of drug abuse, childhood behavior
(1987). problems, and an early age of onset of cocaine abuse.
Buydens-Branchey, Branchey, and Noumair (1989a) The course and consequences of the disorder among
also divided a sample of recently detoxified male al- Type B cocaine abusers were also more severe (i.e.,
coholic patients admitted to a rehabilitation program more severe drug and alcohol abuse, more addiction-
according to their age at the onset of alcoholism. related psychosocial impairment, more antisocial be-
Early-onset alcoholism included those patients who havior, and more comorbid psychiatric problems)
began alcohol abuse before 20 years of age, while than among Type A cocaine abusers.
the late-onset group had an onset of alcohol abuse
sometime after 20 years of age. The early-onset group
Gender Differences in Clinical
reported a higher prevalence rate of paternal alcohol-
Heterogeneity
ism and were twice as likely as the late-onset alcohol-
ics to have been incarcerated for crimes involving While typologies developed on the Swedish sample
physical violence. Further, the early-onset subjects and an empirically derived typology in the United
were found to be suffering from depression and were States seem to have etiological significance for the
more likely to have attempted suicide than the late- development of alcoholism for men, they do not nec-
onset alcoholics. Buydens-Branchey et al. (1989b) essarily apply to the women in the United States with
also suggested that early-onset alcoholics may have alcohol or other substance abuse problems. Unlike
a preexisting serotonin deficit, manifesting itself by the female subjects in the Swedish adoptee study,
increased alcohol intake at an early age. who were found to be of only one type (Type 1), a
female sample in the United States was found to in-
clude both Type 1 and Type 2 alcoholism. The Type
Type A/Type B
2 female alcoholics were characterized by early age
A more recent methodology of classifying alcoholics of onset, high familial density, and paternal alcohol-
and drug abusers was proposed by Babor et al. ism (Glenn & Nixon, 1991).
(1992). Using a cluster analysis of variables derived In another study with a small sample, Hessel-
from 17 different areas of clinical data, Babor et al. brock (1991) found that antisocial personality (ASP)
(1992) derived two types of alcoholism from 321 alcoholic women had characteristics similar to those
male and female hospitalized alcoholics. Two "types" of male Type 2 alcoholism. In order to further con-
of alcoholism were identified (Type A and Type B), sider possible gender differences, DelBoca and Hes-
which closely resembled Cloninger's Type 1 and selbrock (1996) conducted a reanalysis of the original
Type 2. Type A was also characterized by a late onset Type A and B (Babor et al., 1992) data set by deriv-
of alcoholism, while a principal characteristic of ing a four-cluster solution (vs. the original two-group
Type B alcoholism was an early onset of alcohol solution). As in the original analysis, the clusters ap-
problems and alcoholism. Further, the Type 2-like peared to separate, in part, along "risk" and "severity"
cluster (Type B) alcoholics displayed severe and dimensions. The risk dimension included vulnerabil-
chronic consequences of alcoholism and had a ity factors such as a family history for alcoholism,
higher frequency of childhood risk factors, familial early onset of alcohol problems, and a history of
alcoholism, and a more chronic treatment history. childhood conduct problems. The severity dimen-
Ball and colleagues (Ball, Carroll, & Babor, 1995; sion included indicators of physiological dependence
Feingold, Ball, Kranzler, & Rounsaville, 1996), using (tolerance and withdrawal), alcohol-related prob-
cluster-analytic methods to subclassify a nonclinical lems, and comorbid or alcohol-induced psychiatric
sample of cocaine abusers, found support for the symptoms (e.g., anxiety, affective disturbance). The
Type A and B classification of alcoholism among co- proportions of men and women found in the low
caine abusers. Their findings suggest that a multidi- risk-low severity group (39% women and 28% men)
mensional subclassification system may also have an and the high risk-high severity group (22% women
impact on our understanding of etiology and course and 22% men) were similar. The two intermediate
of both alcohol and other substance abuse. Relative subgroups were more gender-specific. The "internal-
 ETIOLOGY OF ALCOHOL AND OTHER DRUGS 57

izing" subtype, characterized by moderate risk and adulthood. More recently, Boyle et al. (1992) exam-
high alcohol involvement, included more women ined prospectively the association between conduct
than men. This group displayed a high level of de- disorder in early adolescence and substance use. The
pression and anxiety symptoms, but a low prevalence children were first assessed at 12-16 years of age re-
of ASP. The gender composition of the "externaliz- garding their substance use (e.g., tobacco, alcohol,
ers," with moderate risk and high severity, included marijuana, and hard drugs) and the presence of psy-
more men than women. The rate of ASP among sub- chiatric disorders (conduct disorder, attention deficit
jects in this subtype was high, while the prevalence disorder) and emotional problems (feelings of anxiety
of depression and anxiety was lower than in the other and depression). A follow-up assessment was con-
groups. These findings indicate the importance of ducted 4 years later. Even after controlling for poten-
gender considerations in the examination of the eti- tial confounding factors measured at the first assess-
ology and the clinical presentation of alcohol depen- ment (including drug use, attention deficit, and
dence. emotional disorder), Boyle et al. found that the asso-
ciation between conduct disorder in early adoles-
cence and marijuana and hard drug use in late ado-
PSYCHOPATHOLOGY, PERSONALITY, lescence remained statistically significant.
AND TEMPERAMENT AS RISK FACTORS It is difficult to delineate clearly a specific etiolog-
FOR ALCOHOL AND DRUG USE ical mechanism that ties childhood problem behav-
DISORDERS iors to the development of alcoholism or substance
abuse in adulthood. First, the concept of "childhood
problem behavior" includes a broad range of behav-
Association of Conduct Disorder and
ior problems in children, including hyperactivity,
Antisocial Personality Disorder as Risk
MBD, emotional problems, and deviant behavior
Factors for Alcoholism
(including vandalism, aggression, and hostility). This
The association of childhood behavioral problems constellation of behaviors has often been found to
and the development of alcoholism has been docu- predict substance use in adolescents, substance use
mented repeatedly in longitudinal studies of both problems in young adults, and onset and severity of
clinical and nonclinical samples over the past 30 a substance use disorder in adult patients. Most in-
years. The classic study conducted by Robins (1966) vestigators typically have not examined a broad, com-
found that childhood conduct problems predicted prehensive range of behavior problems. Instead, only
the later development of alcoholism in men treated some of the selected behaviors mentioned above
initially at a child guidance clinic as children. In an have been examined, and none have studied a com-
earlier study, McCord and McCord (1960) found prehensive list of behaviors/problems. Consequently,
that aggression and sadistic behaviors in delinquent it is difficult to identify a specific behavior(s) that in-
boys were predictive of the development of alcohol- fluences the development of substance abuse. Sev-
ism in adulthood. These findings have been repli- eral attempts have been made to identify clusters or
cated in longitudinal studies of community samples groups of risk behaviors that are related to the devel-
as well as in retrospective studies of adults with drink- opment of substance abuse. Windle (1996) found a
ing problems (Cahalan & Room, 1974; Jones, 1968). high intercorrelation among measures of different ex-
Childhood hyperactivity, when combined with ternalizing behaviors, including conduct disorder,
childhood conduct disorder, has been linked to adult attention deficit/hyperactivity disorder, and opposi-
alcoholism through studies of hospitalized alcohol- tional disorder, among teenagers. Further, teenaged
ics. Using a retrospective assessment, Tarter, Mc- moderate drinkers reported a higher frequency of
Bride, Buopane, and Schneider (1977) reported a these behaviors than light drinkers, and problem
higher frequency of childhood hyperactivity and drinkers reported more problem behaviors than mod-
minimal brain dysfunction (MBD) behaviors among erate drinkers, demonstrating a direct positive rela-
primary or "essential" alcoholics than among "reac- tionship between childhood problem behaviors and
tive" alcoholics. DeObaldia et al. (1983) also found both the level of consumption and the severity of
an association between hyperactivity/MBD in child- drinking problems in adolescents. M. N. Hesselbrock
hood and severe symptoms of alcohol dependence in (1986b) divided Tarter et al.'s (1977) list of problem
58 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

behaviors into hyperactivity, attention deficit, impul- socialization and aggressiveness (see review by
sivity, and conduct problems to examine their inde- Loeber & Dishion, 1983). Children who continue to
pendent contribution to the prediction of alcohol- be inattentive and impulsive are often characterized
ism. Only childhood conduct problems were related as aggressive, noncompliant, and antisocial and use
to a certain type of alcoholism in adulthood, namely, alcohol in their teens.
alcoholism with antisocial personality disorder. Simi- Importantly, persons who continue to use alcohol
larly, other investigators have found that conduct and drugs in their teens continue to use substances
problems also distinguished children whose parents as young adults .These results are supported by Kan-
were diagnosed with antisocial personality disorders del, Simcha-Fagan, and Davies (1986), who found
from those whose parents were not (August & Stew- that illicit drug use by boys during adolescence (ages
art, 1983; Stewart et al., 1980). 15-16) was a strong predictor of continued drug use
It may be of importance to differentiate conduct as long as 9 years later. Early drug use also predicted
disorder from attention deficit disorder, although later delinquent behavior among women. The find-
they frequently co-occur (Murphy & Barkley, 1996). ings of Kandel et al. suggest that gender differences
Boyle et al. (1992) found a significant independent influence the role played by delinquency, early drug
contribution of conduct disorder in predicting mari- use, and other problems as risk factors for adult sub-
juana and hard drug use among adolescents, but lit- stance use and misuse. Adult role deviations (e.g.,
tle evidence of an independent contribution of atten- unstable employment, not being married) were also
tion deficit disorder apart from conduct disorder. A identified as risk factors for illicit drug use in young
similar finding was reported by August and Stewart adulthood.
(1983).
A review of longitudinal developmental studies of
Temperament as a Risk Factor for
alcoholism indicates that antisocial behavior and dif-
Alcohol and Other Drug Abuse
ficulty in achievement-related activities in childhood
and adolescence are consistently related to the de- A search of the developmental process of childhood
velopment of alcoholism in adulthood (Zucker & problem behavior suggests that aspects of tempera-
Gomberg, 1986). The antisocial behavior cited in ment may predict both behavior problems and later
these studies included aggression, sadistic behaviors, substance abuse, particularly in adolescence. Tem-
antisocial activity, and rebelliousness, while the perament traits are expressed at an early stage of
achievement-related problems included poor school child development and seem to differentially predict
achievement, truancy, and dropping out of high boys' and girls' later behaviors. For example, a longi-
school. While Zucker and Gomberg's (1986) review tudinal study of very young children found that girls
found a link between childhood problems and the who were low in ego resiliency and ego control in
development of alcoholism, these factors were also nursery school were using marijuana at age 14, while
found among high-risk subjects who did not develop marijuana use in boys was predicted by low ego con-
alcoholism. trol, but not by early ego resilience (Block, Block, &
As also indicated by Zucker and Gomberg's re- Keyes, 1988).
view, not all children with behavior problems are Temperament has been identified as an impor-
destined to develop substance use disorders or antiso- tant factor in several theoretical formulations related
cial personality disorders in adulthood. Longitudinal to the development of pathological alcohol involve-
studies of hyperactive children found that many chil- ment (Cloninger, 1987; Lerner & Vicary, 1984;
dren diagnosed as hyperactive improve as they ma- Sher, 1991; Tarter, 1988). While prior research has
ture, although others do not (August & Stewart, shown that a predisposition to the development of
1983). Further, longitudinal studies of children with alcoholism is due partially to the individual's genetic
conduct problems indicate that only about one third makeup, several studies suggest that this genetic pre-
become antisocial adults (Robins, 1966; Robins & disposition may be expressed, in part, through the
Price, 1991). Violent and aggressive behavior typi- individual's temperament. Temperament characteris-
cally does not appear in adulthood if it has been ab- tics and extreme deviations in temperament charac-
sent in childhood. The distinguishing features of teristics have been found to be highly heritable (cf.
those who do not improve is the presence of under- Cloninger, 1987) and to manifest early in a child's
 ETIOLOGY OF ALCOHOL AND OTHER DRUGS 59

development. Studies of adolescent problem drinkers As described above, harm avoidance, novelty
have identified tolerance of deviance and related per- seeking, and reward dependence they are thought to
sonality traits (e.g., distrust, aggressive sociality, cyni- be genetically based and to be transmitted indepen-
cism) as being associated with acute alcohol prob- dently from parent to offspring, and they are thought
lems in adolescence. to represent variations in the individual's neurologi-
Currently, two of the more prominent theoretical cal makeup and influence susceptibility to the devel-
models of the development of alcoholism include opment of alcoholism. Although Cloninger has repli-
temperament as a key feature (Cloninger, 1987; cated his own findings in a separate Swedish sample
Cloninger & Gottesman, 1987; Tarter, 1988). In (Sigvardsson et al., 1996), few investigators have been
both models, temperament and personality charac- able to identify these three specific personality traits
teristics are linked to alcoholism through clusters of as distinguishing features of either alcohol-depen-
temperament and personality attributes that may be dent persons or high-risk subjects among U.S. sam-
transmitted from parents to their offspring. Cloninger ples (Hesselbrock & Hesselbrock, 1992; Masse &
(1987) has hypothesized that biologically based per- Tremblay, 1997).
sonality differences distinguish between Type 1 and Tarter and colleagues have proposed a broader
Type 2 alcoholism. Type 1 alcoholism was theorized temperament model of alcoholism. This model in-
to be associated with three heritable dimensions of cludes six dimensions of temperament that may be
personality: low novelty seeking, high harm avoid- inherited: activity level, attention span persistence,
ance, and high reward dependence. Type 2 alcohol- soothability, emotionality, reaction to food, and so-
ism was thought to be associated with the opposite ciability. Indeed, low attentional capacity, high emo-
spectrum of these personality characteristics. Masse tionality, and low sociability have been found to be
and Tremblay (1997) found that two of the personal- associated with an increased risk for developing alco-
ity traits of the Type lAType 2 typology are predictors hol-related problems (Tarter, 1988; Tarter, Kabene,
of early onset of substance use. In a study of kinder- Escallier, Laird, & Jacob, 1990). In addition, Lerner
garten boys, they found that high novelty seeking and and Vicary (1984), as well as Ohannessian and Hes-
low harm avoidance measured at age 6 predicted selbrock (1995), found that certain clusters of tem-
early onset of cigarette smoking, getting drunk, and perament traits, which constitute a "difficult temper-
other drug use in adolescence. Further, there was ament" (high activity level, low flexibility and task
some stability of the three traits from age 6 to age 10, orientation, mood instability, and social withdrawal),
with novelty seeking r= .38; harm avoidance r = .24; are related to substance use/abuse.
and reward dependence r = . 18 in a sample of about Mezzich et al. (1993) identified adolescents with
900 boys. alcohol abuse/dependence that could be clustered
Irwin et al. (1990) examined the usefulness of into two groups according to an internalizing/exter-
novelty seeking, harm avoidance and reward depen- nalizing behavior dimension. The first group was
dence for predicting alcohol-related problems among characterized by negative affect, while the second
young men whose fathers had alcohol problems, but group was better characterized by behavioral disturb-
they found no significant relationship between the ances, reduced depression, and anxiety symptoms
personality traits proposed by Cloninger and Gottes- (i.e., behavioral dyscontrol and hypophoria). The
man (1987) and either a family history of alcoholism second group also had increased substance use, in-
or the young men's drinking pattern (Irwin et al., creased problems at school and with peers, and in-
1990; Schuckit, Irwin, & Mahler, 1990). Hesselbrock creased behavioral problems. These findings provide
and Hesselbrock (1990) examined a sample of nonal- some confirmatory evidence for an adolescent typol-
coholic young adult men at high risk for developing ogy of alcohol dependence based upon personality
alcoholism. In addition, antisocial personality disor- factors that is similar to the Type A/Type B dichot-
der, regardless of a family history of alcoholism, was omy developed by Babor et al. (1992).
found to be an important factor in the prediction of More recently, personality research has focused
the development of alcohol use. Antisocial personal- upon what has been termed the five-factor model of
ity disorder was also associated with the three person- personality. This work traces its origins to Gordon
ality characteristics among young men at high risk Allport (1937) and Cattell (1947) and over the years
for developing alcohol abuse. has led to the identification of five robust factors:
60 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

(a) neuroticism—a tendency to experience negative they were 12-14 years old (Blackson & Tarter, 1994).
affect; (b) extroversion—gregariousness, activity; (c) Martin, Kaczynski, Maisto, and Tarter (1996) found
openness to experience—intellectual curiosity, aware- that dispositional traits characterized by heightened
ness of inner feelings, need for variety in actions; (d) negative affect (depressed mood and anxiety) and be-
agreeableness—altruism, emotional support, helpful- havioral undercontrol reflecting impulsivity, aggres-
ness; and (e) conscientiousness—will to achieve, de- sivity, acting out, and sensation seeking were signifi-
pendability, responsibility. These factors, which com- cant predictors of the number of drugs used by
bine aspects of the temperament traits proposed by adolescents. Assuming that "difficult temperament"
Cloninger and by Tarter as having etiological signifi- is predictive of adult antisocial personality disorder,
cance, consider the effects of more "normal" traits the findings of Martin et al. are supported by a study
rather than deviations. A study of the risk for alcohol- of unaffected young men in their early 20s which
ism in relation to the five-factor model of personality found that a diagnosis of antisocial personality disor-
found that a family history of alcoholism was posi- der was a more powerful predictor of heavy drinking
tively associated with openness and negatively as- (Hesselbrock & Hesselbrock, 1992).
sociated with agreeableness and conscientiousness Individual differences in temperament can be
(Martin & Sher, 1994). Alcohol use was positively conceptualized in terms of the developmental pro-
correlated with neuroticism and negatively correlated cess, along with the personality development of chil-
with agreeableness and conscientiousness. No inter- dren and adolescents. Rothbart and Ahadi (1994)
action was found between a family history of alcohol- proposed temperament as being constitutionally based
ism and gender in relation to the five dimensions and including an individual's reactivity (responsive-
of personality, nor was antisocial personality disorder ness of emotional activation and arousal systems) and
related to any of the five dimensions in subjects with development of ability for self-regulation, interacting
alcohol use disorders. over time with heredity, maturation, and experience.
Conversely, temperament may influence the way
children interact with their environment. Barren and
Association of Temperament and Conduct
Earls (1984) found that temperamental inflexibility,
Problems as Precursors to Substance Abuse
negative parent-child interaction and high family
The association between other aspects of children's stress showed a strong association with problem be-
temperament and conduct problems as precursors to havior in 3-year-old children. Others suggest that
substance abuse has been studied. "Difficult temper- temperament deviation in children may promote
ament disposition" or "temperament deviation" was maladaptive behavior and a tendency to associate
found to be associated with conduct disorder in with deviant peers. Deviation in temperament is also
childhood/adolescence, progressing to antisocial per- associated with aggression and poor responsiveness to
sonality disorder in adulthood, while "normative parental discipline, both of which are predictive of
temperament" was associated with time-limited de- conduct disorders (Blackson, 1994).
linquent behavior (Moffit, 1993; Windle, 1996). In
another study, 10- to 12-year-old sons of fathers with
and without substance abuse were separated by PSYCHOLOGICAL MODELS OF
means of a cluster analysis. The resulting two-cluster ETIOLOGY AND MAINTENANCE OF
solution classified boys along the dimensions of diffi- ALCOHOL AND DRUG USE DISORDERS
cult and normative temperament. The sons' temper-
ament cluster membership was a more salient pre-
Psychoanalytic Models
dictor of deviancy than a family history of substance
abuse. The boys classified as having difficult temper- Leeds and Morgenstern (1995) reviewed several the-
ament were high on aggressivity, maladaptive disci- ories of substance use that relate to various aspects of
pline, family dysfunction, attributional errors in per- psychoanalytic theory. Wurmser (1984) viewed sub-
ception of self, and high peer affiliations associated stance abusers as having severe intrapsychic conflict
with unconventionality and delinquent behavior. in the form of overly harsh superegos, so that these
Furthermore, these characteristics were predictive of individuals use alcohol or drugs to escape intense
the boys' alcohol and drug use 2 years later, when feelings of rage and fear. Khantzian, Halliday, and
 ETIOLOGY OF ALCOHOL AND OTHER DRUGS 61

McAuliffe (1990) took a self-deficit approach, posit- and Siegel (1979) noticed are often the opposite of
ing that inadequacies of the ego underlie substance the initial drug effects. Siegel called these unex-
abuse. This theory takes into account the notion that pected CRs "conditioned compensatory responses"
an individual's drug of choice has particular "self- (CCRs). The CCRs were noted to increase in strength
medicating" properties for his or her particular type with repeated trials, thus decreasing the observed
of ego deficit. Krystal's (1984) theory focuses on dis- drug effect (see Sherman, Jorenby, & Baker, 1988).
turbed object relations as the basis of substance Wikler (1973) also noticed that heroin addicts ex-
abuse/dependence and disturbed affective regula- hibited withdrawal symptoms simply by looking at
tion. McDougall (1989) proposed that all addictive paraphernalia associated with heroin use. He called
disorders are psychosomatic defenses against psychic this "conditioned withdrawal" and carried out a se-
conflict. ries of studies using heroin as the US, resulting in
In general, psychoanalytic models have been less withdrawal symptoms as the UR. The CS was the
widely accepted as underlying substance abuse/de- heroin-related paraphernalia, and the CR was an ex-
pendence, though they are thought-provoking and in- perience of withdrawal after the injection of an inert
teresting. The reader is referred to Morgenstern and substance (see also Rotgers, 1996).
Leeds (1993) and Leeds and Morgenstern (1995) for
more detailed discussion of psychoanalytic theories
Operant Conditioning
of etiology of substance use disorders.
Operant conditioning principles apply to the positive
reinforcing effects of alcohol and drugs as social rein-
Behavioral, Cognitive Behavioral, and
forcers, and to the avoidance or cessation of with-
Social Learning Theory Models
drawal symptoms. That is, an individual drinks in re-
Historically, behavioral models of substance use dis- sponse to an antecedent stimulus, such as a glass of
orders postulated that substance use behavior is beer or an angry mood, and then associates the rein-
learned and maintained through either classical or forcing effects of alcohol (i.e., euphoria or elevated
operant conditioning (chapter 14, this volume). The mood) with the antecedent stimulus. Substance-us-
contemporary cognitive behavioral (CB) models ing behavior increases as a result of the positive or
such as social learning theory (SLT) incorporate negative reinforcing effects of the alcohol or drug.
thoughts and feelings as important determinants of For instance, the putative effects of alcohol on
behavior and responses to the environment. Behav- tension reduction have been well documented. The
ioral and cognitive behavioral models are described literature documents variable effects of alcohol and
in detail in chapter 14 of this book and elsewhere drugs across different settings, individual characteris-
(Rotgers, 1996). Here, we will briefly review the ba- tics of drinkers, and different sources of stress. Recent
sic tenets of each approach to the etiology of sub- studies have conceptualized a self-medicating theory
stance abuse/dependence disorder. in terms of conditioned behavioral responses result-
ing from positive reinforcement received through the
consumption of alcohol and other drugs. Kushner,
Classical Conditioning
Sher, Wood, and Wood (1994) examined the moder-
Classical conditioning is thought to facilitate devel- ating effects of alcohol expectancies on tension re-
opment of a drinking or drug problem or craving duction, level of anxiety symptoms, and drinking be-
through pairing of conditioned stimuli (CS) such as havior among college students. A strong association
particular sites of use or people and the uncondi- between anxiety symptoms and alcohol consumption
tioned stimulus (US; alcohol or drugs), the result be- was found among men with high tension-reduction
ing a conditioned response (CR), or conditioned outcome expectancies, but not among women. How-
craving. ever, recent investigations of both clinical and non-
Conditioned tolerance has been proposed as a clinical samples have found anxiety disorders, while
classical conditioning paradigm, in which the sub- highly comorbid with alcohol and substance use dis-
stance is the US and the physiological effects are the orders, typically follow the development of alcohol
unconditioned response (UR); substance-related cues and other drug abuse rather than precede their de-
become the US, eliciting a CR which Wikler (1973) velopment (Hesselbrock, Hesselbrock, & Stabenau,
62 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

1985; Schuckit & Hesselbrock, 1995; Schuckit et al., description of the CB model of the etiology of sub-
1995). stance use disorders).
An example of a specific SLT is that of Petraitis,
Flay, and Miller (1995), who proposed the cognitive
Cognitive Behavioral/SLT Models
affective approach to explain adolescents' experimen-
Cognitive behavioral (CB) models highlight the im- tation with alcohol and other drugs. Their conceptu-
portance of cognitions and feelings as preceding and alization is based on a social learning theory which
directing behavior. Social learning theory (SLT) fo- asserts that the decision to experiment with sub-
cuses on constructs such as expectancies, self-effi- stances is influenced, in part, by the adolescent's be-
cacy, and attributions, all types of cognitions that are lief regarding the cost-benefit ratio of substance use.
thought to mediate the pathway from stimuli to use The process of forming the belief to using substances
of substances as response. Expectancies of the posi- progresses through several stages. The first cognitive
tive effects of substance use develop from repeated process is the evaluation that the costs are smaller
classical and/or operant pairings of the alcohol or than the benefits of substance use; this is followed by
drug with its reinforcing effects. Expectancies can be the formation of positive attitudes toward substance
thought of as conditioned cognitions, which can use and the perception that substance use is en-
themselves be associated with positive experiences, dorsed by the people around the adolescent. The au-
or positive subjective responses, to alcohol or drug- thors also cited the lack of self-efficacy in being able
related cues. Positive expectancies, such as expectan- to refuse alcohol/drug use as an important reason for
cies of relief from withdrawal symptoms or of relax- forming the decision to use substances.
ation following a drink, can facilitate more frequent
alcohol or drug use and thus contribute to the devel-
opment of dependence (see Rotgers, 1996). SOCIOCULTURAL MODELS OF
Self-efficacy, according to SLT, is an individual's ETIOLOGY AND MAINTENANCE
expectation or confidence in his or her ability to per-
form particular coping behaviors in certain situations
Familial Factors
and the expectation that the coping behavior will be
reinforced (see Rotgers, 1996, for a more detailed dis- As noted, alcohol and drug use disorders are multiply
cussion). Since SLT views substance use disorders as determined by a complex association of genetic, en-
a failure of coping, it is assumed that self-efficacy for vironmental, personality, and other factors. Because
coping without alcohol or drugs is low among active of these factors, often more than one family member
users, and this type of cognition contributes to in- is substance-dependent, which further complicates
creased use and development of dependence on the the task of teasing apart the specific influences that
substance. family environment, rearing, and interspousal rela-
CB theory postulates that initial heavy use of sub- tionships have on the development of alcoholism.
stances is the result of several interacting factors, Three contemporary models of family influence on
such as an individual's biological makeup (genetic the development and maintenance of substance de-
risk, temperament), which determines if the sub- pendence each take a different approach (see chapter
stance use will be reinforcing or punishing; the so- 16, this volume; McCrady & Epstein, 1996; Mc-
cial environment, which may facilitate or condone Crady, Kahler, & Epstein, 1998). The family disease
use; and the basic principles of operant conditioning, model posits that all family members suffer from a
which reward and maintain use. As an individual "family disease" of either alcoholism or codepen-
uses more, he or she uses other coping skills less and dency, and that alcoholism and codependency are
develops reduced self-efficacy and increased positive interrelated in such a way as to "enable" (perpetuate)
expectancies of the effects of the substance, the result the alcohol problem. Thus, according to this model,
being more use. In later stages, classical conditioning the specific etiology of the alcoholism is biological,
principles such as conditioned craving, tolerance, but the alcoholism is then maintained by a family
and withdrawal play an important role in the devel- disease.
opment and maintenance of heavy problem use of Research by means of the family systems model
alcohol or drugs (see Rotgers, 1996, for an excellent on the role of the family of origin of the drinker and
 ETIOLOGY OF ALCOHOL AND OTHER DRUGS 63

the spouse in the etiology of the substance abuse has adolescents for using alcohol were to socialize with
focused on family behavior around drinking. Origi- friends; to alleviate tension and anxiety, especially in
nally developed by Steinglass and associates (Davis, mixed-gender situations; to get high; to "cheer up";
Berenson, Steinglass, & Davis, 1974; Steinglass, and to reduce boredom.
Weiner, & Mendelson, 1971), the family systems It is not clear whether association with a deviant
model assumes that alcohol serves to stabilize family peer group is a risk factor for, or a result of, maladap-
equilibrium, and that families organize their interac- tive behavior. It has been suggested that adolescents
tions and structure around the alcohol to continue who abuse alcohol and drugs tend to associate with
the "homeostasis" (i.e., to maintain the alcohol prob- peers who are positive toward the abuse of alcohol
lem despite the problems associated with such a sys- and other drugs, providing support and reinforce-
tem). The degree to which alcoholic families uphold ment for these risky behaviors (Freeman & Dyer,
"family rituals" (e.g., dinnertime, celebration of holi- 1993; Harford & Grant, 1987). Furthermore, adoles-
days) may protect against development of alcoholism cents' deviant peer-group involvement interacts with
in offspring or at least may serve as a marker of trans- other risk factors, including family problems, stress
mission (Bennett, Wolin, Reiss, & Teitelbaum, 1987; and other mental health problems, and low self-es-
Steinglass, Bennett, Wolin, & Reiss, 1987; Wolin, teem. Thus, it can be difficult to separate etiological
Bennett, Noonan, & Teitelbaum, 1980). More re- factors from the consequences of substance abuse
cently, Bennett and Wolin (1990) reported that con- and other behavior problems (Freeman & Dyer,
tinuing interaction between alcoholic parents and 1993). Gender differences are evident, as males re-
their adult offspring is associated with increased rates port a higher rate of deviant peer involvement, pro-
of alcoholism among the male offspring. viding explanatory support for a higher rate of alco-
The third contemporary model is the behavioral hol and drug use in adolescent boys (Wills et al.,
family approach, which examines the family's (espe- 1992). Further, cultural differences seem to affect
cially the spouse's) behaviors as antecedents to and the differential influence of parental support for alco-
reinforcing consequences of substance use. These hol and drug abuse in young adults. Gillmore (1990)
behaviors serve to help develop and maintain the found that the initiation of alcohol, tobacco, and
drinking problem. This model is outlined in detail marijuana use, as well as the intention to use sub-
in chapter 16 of this book. stances as an adult, was also related to substance
availability and perceived parental approval, which
varied among Caucasians, Asian-Americans, and Af-
Peer Influences
rican-Americans.
Peer group influences have been cited consistently
as risk factors for the initiation of alcohol and other
Social Environments That Support
drugs among adolescents (Kandel, Kessler, & Mar-
Substance Use
gulies, 1978; Wills, Vaccaro, & McNamara, 1992).
Peers influence adolescents' behavior, values, and at- The social learning theories have relevance only
titudes. The association with deviant friends has within the context of both the micro- and the macro-
been found to promote the acceptance of deviant be- community. Petraitis et al. (1995) proposed a social
haviors (Loeber, Stouthamer, Van Kammen, & Farr- control theory which asserts that acceptance by or
ington, 1991) and to increase the risk for alcohol and attachment to family, school, or community is a so-
drug use among adolescents (Robins & McEvoy, cial bond to the conventional society. These social
1990). Further, peer relationships can either pro- bonds prevent adolescents from expressing deviant
mote or reduce the student's motivation for school behavior. According to this theory, the use of alcohol
performance and can affect self-esteem and social re- and other drugs is caused by a lack of social bonds.
lationships in adolescents (O'Connell, 1989). Segal Petraitis et al.'s conceptualization of social control
and Stewart (1996) found adolescents citing their theory regarding adolescents' experimentation with
perception of the positive aspects of substance use drugs and alcohol is supported by the work of Segal
involving peers, along with the tension reduction ef- and Stewart.
fects of alcohol, as reasons for alcohol/substance use. Segal and Stewart (1996) found that recent
In this study, the most important reasons cited by changes in cultural factors interact with individual
64 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

factors in the development of substance abuse. They ues and attitudes (Azzi-Lessing & Olsen, 1996). Fur-
noted that a cultural vacuum, produced by the de- thermore, the role of a particular culture as well as
clining role of family values, leads to the glorification the value system of a neighborhood, has been chang-
of fun and violence, as well as the use of alcohol and ing in recent years and plays a significant role in
drugs associated with promiscuous sexual practice, as the development of complex postindustrial society.
a means of escape from identity problems, frustra- These apparent changes are characterized as a de-
tion, disappointments, boredom, and so on. They cline in the support and interaction among neigh-
also regard the imitation of adult behavior, curiosity, bors, a weakening of the neighborhood's ability to
and a rebellion against age-related restrictions and ta- exert social control, social disorganization, and the
boos as reasons for adolescent drug use. These factors loss of a sense of continuity and belonging among
seem to apply both to the first experimental use of a neighborhood members. These social factors may re-
substance and to the development of the abuse of sult in an individual's increase in feelings of alien-
alcohol and drugs. Segal and Stewart view the abuse ation, narcissistic escapism, and deviant behavior
of alcohol and other drugs as being associated with (Segal & Stewart, 1996). Hawkins et al. identified a
more serious psychological factors but do not provide deterioration in parental socialization and supervi-
specific empirical support for their thoughts. sion, consistent with this explanation of neighbor-
Certain characteristics of neighborhoods also hood disorganization, as a risk factor in adolescent
seem to contribute to the development of problems drug abuse.
related to drug and alcohol use among their inhabit-
ants. Hawkins, Catalano, and Miller (1992) reviewed
several studies supporting the notion of "neighbor-
Socioeconomic Status as a Risk Factor
hood disorganization" as a risk factor for adolescent
drug abuse. This general term encompasses a variety Studies of the relationship between socioeconomic
of factors, including high population density, physi- status and alcohol and other drug abuse have found
cal deterioration, high levels of adult crime, and ille- a bimodal distribution of risk factors. Hawkins et al.'s
gal drug trafficking. (1992) review confirmed a positive correlation be-
Hawkins and Weis (1985) proposed a develop- tween parental education level and marijuana use
mental approach that integrates social control theory and drinking among teens. However, the poverty as-
and social learning theory as an etiological explana- sociated with childhood behavior problems has been
tion of delinquency. According to this approach, the found to increase the risk for later alcoholism and
person interacts sequentially with the smallest to the drug problems (Robins & Ratcliff, 1979). The rela-
largest social system. Thus, "social development" is a tionship of poverty to the development of drug abuse
process in which the most important units of social- could be explained by the environmental conditions
ization—families, schools, and peers—influence be- that define poverty, including unemployment, wel-
havior sequentially, both directly and indirectly. So- fare dependency, single parenthood, and an abun-
cial bonding and attachments to family, school, and dance of illicit drugs in the neighborhood (Gitlin,
the community increase the level of commitment to 1990). In a study of alcohol abuse/dependence and
conventionality among youths. However, youths de- associated patterns of psychiatric comorbidity in an
velop attachment and commitment to conventional- Ontario, Canada, household sample, Ross (1995)
ity only when they have opportunity to interact with found that high income was associated with pure al-
conventional activities that provide positive experi- cohol abuse, but not with alcohol dependence. Low
ences for them. The bonding of youths to the social income was associated with alcohol dependence
norms occurs only when the youths' association with complicated by comorbid psychiatric disorders. To-
conventional units is more rewarding than their asso- gether, these findings suggest a complex role of so-
ciation with delinquent peers. Thus, the value and cioeconomic status for both the etiology and the con-
activities of conventionality must be viewed as re- sequences of alcohol/substance use and abuse.
warding. Poor parenting skills and high levels of fam- Further research is needed to clarify the role of socio-
ily stress (often associated with parental substance economic status in relation to the level of severity
abuse) fail to provide children with conventional val- of use and abuse of substances, the specific types of
 ETIOLOGY OF ALCOHOL AND OTHER DRUGS 65

substances abused, and other possible etiological fac- alcoholic beverages are associated with decreased
tors, including comorbid psychopathology. drinking. Manning et al. (1991) reported that both
light and heavier drinkers appear to be less respon-
sive to price than moderate drinkers. However, Ken-
Social Policy Considerations
kel (1996) noted that this effect may be due to a lack
Social policy considerations, discussed in more detail of information about the health consequences of
in chapter 31 of this volume, can be considered heavy drinking among both the light and heavy
more distal factors related to the etiology of sub- drinkers rather than to concern over cost. In Kenkel's
stance abuse/dependence. Social policy influences study, better informed consumers showed greater re-
the availability of substances to the population and ductions in drinking due to price increases than less
the punitive effects of consuming particular sub- informed consumers, including heavy drinkers. The
stances. To some extent, lack of exposure and access use of taxation to increase the cost of obtaining alco-
to alcohol and drugs would serve as a protecting fac- hol is not straightforward. Federal taxes on alcohol,
tor against use, abuse, and development of depen- for example, are applied uniformly on each unit of
dence on substances. alcoholic beverage produced. However, different
Over the years, society (through governmental ac- manufacturers and different retailers operating in a
tion) has employed a variety of measures to restrict competitive market may choose to differentially pass
the availability of alcoholic beverages. Prohibition this cost along to the consumer. Thus, the cost of
enacted through an amendment to the U.S. Consti- alcohol may rise in some locales, but not in others.
tution at the national level, local and federal taxation Further, the cost of any particular brand of an
policies, and the legislation of minimum legal drink- alcoholic beverage may vary considerably within a
ing ages have had both short- and long-term effects specified geographic region, depending upon the
on the availability of beverage alcohol. Legal restric- type of establishment where the beverage is pur-
tions (e.g., based upon a minimum age) on the pur- chased. The package outlet price of a can of beer is
chase of alcohol have had recent favor as a means of typically lower than its cost at a restaurant, even
controlling adolescent morbidity and mortality re- though the unit tax is the same for both. This effect
sulting from alcohol use, apparently with some suc- may be manifested through an "ability to pay" in re-
cess. Between 1970 and 1975, when 29 states low- lation to younger drinkers. Sloan, Reilly, and Schen-
ered their minimum legal drinking ages, increases in zler (1994) estimated that the price of alcohol had a
teen alcohol consumption, auto fatalities, and injur- significant effect on motor vehicle fatalities among
ies were recorded. As the legal drinking age was 18- to 20-year olds, but not older age groups.
raised over the following years, reductions in adoles-
cent alcohol consumption (particularly beer), injur-
ies, and auto fatalities were generally noted (Wagen- SUMMARY
aar, 1993).The effect of raising the minimum
drinking age on the prevalence of other alcohol-re- This chapter reviewed a variety of etiological factors
lated behaviors among adolescents, such as assaults, that are related to development of alcohol and other
teen pregnancy, drownings, and sexually transmitted drug abuse. While the biological factors, including
diseases, is less clear as is the effect on the incidence genetics, and the neuropsychological factors have be-
of alcohol abuse and dependence in subsequent come increasingly important as etiological factors in
years. Such changes are difficult to determine di- the development of alcohol and other drug abuse
rectly because minimum drinking laws vary across problems, specific mechanisms of heredity are not
states, and because of the rather ready availability of known.
alcohol from other sources. Further, each biological factor interacts with per-
Taxation has also been viewed as a means of con- sonality, behavior, and development within the con-
trolling the availability of alcohol. The typical view text of environment in which a person grows up and
is that higher taxes on alcohol (resulting in an in- resides. Several environmental factors appear to af-
crease in unit price) lead to reduced consumption. fect the expression of genetic factors. For example, a
In general, increased taxes on (i.e., increased cost of) variety of studies indicate that peer influences, stress-
66 EPIDEMIOLOGY, ETIOLOGY, AND COURSE OF SUBSTANCE USE DISORDERS

ful and negative life events, and family environment Annis, H. (1974). Patterns of inter-familial drug use.
(including poor parenting styles) seem to enhance British Journal of Addiction, 69, 361-369.
the likelihood of developing alcohol or addictive August, G. }., & Stewart, M. A. (1983). Familial sub-
drug use behavior among adolescents and young types of childhood hyperactivity. Journal of Nervous
adults at high risk for developing problems with alco- and Mental Disease, 170, 147-154.
Azzi-Lessing, L., & Olsen, L. J. (1996). Substance
hol and other addictive substances. On the other
abuse-affected families in the child welfare system:
hand, certain social and environmental factors ap-
New challenges, new alliances. Social Work, 41(1),
pear to attenuate the risk for developing alcohol and
15-23.
drug use problems conferred by a family history of
Babor, T. F., Dolinsky, Z. S., Meyer, R. E., Hesselbrock,
alcoholism or drug abuse. Good relations with non- M. N., Hofmann, M., & Tennen, H. (1992). Types
drug-using peers, family rituals that actively seek to of alcoholics: Concurrent and predictive validity of
prevent alcohol/drug use, and consistency of parental some common classification schemes. British Jour-
discipline appear to reduce exposure to alcohol and nal of Addiction, 87, 1415-1431.
drugs among youth. Reduced exposure reduces the Ball, S. A., Carroll, K. M., & Babor, T. F. (1995). Sub-
likelihood that genes responsible for developing alco- types of cocaine abusers: Support for a type A-type B
holism or other drug use disorders will become acti- distinction. Journal of Consulting and Clinical Psy-
vated (Hesselbrock & Hesselbrock, 1990). chology, 63(1), 115-124.
The interaction between biological and environ- Barren, A. P., & Earls, F. (1984). The relation of tem-
mental factors is constantly changing, and new mod- perament and social factors to behavior problems in
els of etiology are being introduced. Prevention and three-year-old children. Jounal of Child Psychology
treatment efforts should consider these new develop- and Psychiatry, 25(1), 23-33.
Begleiter, H., Porjesz, B., Bihari, B., et al. (1984). Event
ments and evaluate their validity and applicability to
related brain potentials in boys at risk for alcoholism.
work with those who are affected.
Science, 225, 1493-1495.
Bennett, L. A., & Wolin, S. J. (1990). Family culture
and alcoholism transmission. In R. L. Collins, K. E.
ACKNOWLEDGMENT This work was supported by Leonard, & J. S. Searles (Eds.), Alcohol and the
NIAAA grants P50-AA35010 and U10-AA08403. Family: Research and Clinical Perspectives. New
York: Guilford Press.
Key References Bennett, L. A., Wolin, S. }., Reiss, D., & Teitelbaum,
M. A. (1987). Marital conflict resolution of alcoholic
Cadoret, J. J., & Wesner, R. B. (1990). Use of the adop- and nonalcoholic couples during drinking and non
tion paradigm to elucidate the role of genes and en-
drinking sessions. Journal of Studies on Alcohol, 40,
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183-195.
coholism. In C. R. Cloninger & H. Begleiter (Eds.),
Bierut, L. J., Dinwiddie, S., Begleiter, H., Crowe, R. R.,
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 II

Specific Drugs of Abuse:

Pharmacological and
Clinical Aspects
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 4

Alcohol

Darlene H. Moak
Raymond F. Anton

Among substances commonly abused by humans, al- hol; its actions in the central nervous system; the
cohol has by far the simplest structure, consisting of physical symptoms of use, abuse, and dependence;
only two carbon atoms, six hydrogen atoms, and a the symptoms and course of alcohol withdrawal; and
single oxygen atom. It is also a relatively "weak" drug, the pathological effects of its use. The diagnosis and
since grams of alcohol must be consumed in order treatment of the alcohol use disorders will be ad-
to achieve any measurable effect in contrast to the dressed in a subsequent chapters.
milligram (1/1000 gram) dosages of other abused
substances. Alcohol, in contrast to other abused sub-
stances, is a legal or licit substance (at least for per- MAJOR PHARMACOLOGICAL ACTIONS
sons over a certain age). Yet the misuse and abuse of
alcohol result in a complex biological, psychological,
Metabolic Pathways
and social disorder of enormous impact on society.
In 1993, the last year for which complete statistics Metabolism is the process by which the human body
are available, alcohol was believed to be responsible converts an ingested substance to other compounds
for 19,557 deaths, with an age-adjusted death rate of which are either more or less toxic than the parent
6.7 per 100,000 (Gardner & Hudson, 1996), and to compound. The primary metabolic pathway by
cost American society close to $100 billion annually which alcohol is detoxified, shown in figure 4.1, is
in loss of life, property, and productivity. "oxidation," most of which takes place in the liver.
This chapter will address the basic biological A small amount, about 5-10% of alcohol consumed
properties of this drug and its impact on human under normal conditions, bypasses this pathway and
function, including the metabolic pathways for alco- is excreted unchanged from the lungs or in the

75
76 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

FIGURE 4.1 Metabolism of alcohol via the major pathway, oxidation.

urine. Oxidation of alcohol in the liver is accom- (Tylenol) is also metabolized by CYP2E1, and in
plished through the action of the enzyme alcohol de- chronic heavy drinkers, there is evidence that acet-
hydrogenase, which converts alcohol to acetalde- aminophen use results in liver damage due to the
hyde. Acetaldehyde, in turn, is converted to acetate accumulation of toxic metabolites (Seeff, Cuccher-
by aldehyde dehydrogenase. This metabolic pathway ini, Zimmerman, Adler, & Benjamin, 1986). The
has been known since the 1940s. CYP2E1 system is also responsible for the metabo-
Although alcohol dehydrogenase is contained lism of many other medications, and the increased
largely in the human liver, it is also found in the activity of this system in chronic heavy drinkers typ-
lining of the stomach. Alcohol dehydrogenase in the ically results in lower blood levels for many impor-
stomach may play a major role in alcohol metabo- tant medications (Kalant, Khanna, Lin, & Chung,
lism (Haber et al., 1996), although the exact contri- 1976).
bution of this gastric component remains somewhat
controversial. Women appear to have less alcohol de-
Actions in the Central Nervous System
hydrogenase in the stomach lining than men and,
consequently, less activity of this enzyme (Frezza et
Impact on Neurotransmitter Systems
al., 1990). Thus, women may develop liver damage
after less extensive drinking careers than men be- Unlike other substances of abuse, which typically af-
cause of exposure of the liver to higher alcohol con- fect a particular transmitter system more strongly
concentrations. It is now known that there are at least than others (e.g., dopamine in the case of cocaine
eight subtypes, or isozymes, of human alcohol dehy- and the opioid system in the case of heroin), alcohol
drogenase in the liver alone (Ehrig, Bosron, & Li, is believed to affect many different neurotransmitter
1990), and many of the genes responsible for their systems, with no single system predominating. The
expression have been identified. findings of animal research have been reviewed re-
The enzyme aldehyde dehydrogenase has also cently by De Witte (1996). Acute alcohol consump-
been studied extensively. The widely used medica- tion in animals enhances release of serotonin,
tion disulfiram (Antabuse) exerts its effect on alcohol gamma aminobutyric acid (GABA), and taurine.
metabolism by inhibiting the activity of aldehyde de- However, chronic alcohol consumption decreases se-
hydrogenase. This inhibitor causes a buildup of the rotonin release and increases concentrations of en-
toxic metabolite acetaldehyde, which is normally dogenous opioid peptides and glutamate binding
present in only very small amounts in individuals sites. Most likely the reward pathways mediated by
consuming alcohol. This buildup, in turn causes a dopamine are also involved (Koob, 1992). Subtypes
distressing clinical syndrome characterized by ex- of receptors in each transmitter system probably play
treme flushing, nausea, and decreased blood pressure an important role in the initiation and maintenance
(the "disulfiram reaction"). Only two genetic variants of drinking behaviors.
of this enzyme have been identified. Most indi- The possible interactions of neurotransmitter sys-
viduals of Asian background have a variant with low tems and alcohol in the human brain have been ex-
activity, which results in poor tolerance of alcohol plored by Kranzler and Anton (1994) and are out-
consumption and relatively low rates of alcohol de- lined in table 4.1. A key tenet of these relationships
pendence (Mizoi et al., 1983). is that the dysfunctions in transmitter systems proba-
Alcohol is also metabolized via an alternative bly vary among subtypes of individuals affected by
pathway involving the liver enzyme cytochrome alcohol use disorders. Naltrexone, an opioid receptor
P450IIE1 (CYP2E1). This pathway exhibits in- blocker, has been found to be efficacious in the treat-
creased activity in individuals who have ingested al- ment of alcohol-dependent subjects, a finding that
cohol chronically (Lieber, 1994). Acetaminophen suggests the direct or indirect involvement of the opi-
 ALCOHOL 77

TABLE 4.1 Relationships of Alcohol and Neurotransmitter Systems

Neurotransmitter system Relationship to alcohol Possible clinical manifestations

GABA-A Enhanced activity with acute exposure Sedation

Desensitization with chronic exposure Withdrawal symptoms, seizures
Dopamine Increased release of dopamine (may be Stimulation of motor system, reinforcing
mediated by opioidergic mechanism) properties of alcohol
during acute exposure
Opioid Decreased basal levels of beta-endorphins Increased craving
in abstinent alcoholics and in children
of alcoholics
Inhibition of opioid receptor binding by Decreased alcohol consumption, de-
opioid antagonists creased tendency to relapse
Serotonin Alcohol causes increased serotonergic ac- Low serotonin levels in central nervous
tivity in brain (may "normalize"' low system may be associated with impul-
baseline levels) sivity and tendency toward violence
Serotonin agonists decrease alcohol in-
take in animals; inconsistent results on
alcohol intake in human studies
N-methyl-D-aspartate Inhibition of transmission with acute ex- None identified at this time
(NMDA) and glutamate posure to alcohol
Possible upregulation of NMDA recep- Behavioral tolerance
tors with chronic exposure to alcohol Seizures
Alcoholic dementia due to loss of
long-term potentiation (needed for
memory)

Note. From Kranzler and Anton (1994).

oid system (O'Malley et al., 1992; Volpicelli, Alter- alcohol. Tolerance has been shown to develop rap-
man, Hayashida, & O'Brien, 1992). An important idly in both animals and humans. Mechanisms un-
role for the serotonergic system is supported by find- derlying the development of tolerance in humans in-
ings of decreased metabolites of serotonin in the clude increasing the activity (induction) of the
cerebrospinal fluid of alcohol-dependent individuals enzymes responsible for the metabolism of alcohol
(Ballenger, Goodwin, Major, & Brown, 1979). Treat- as outlined above (metabolic tolerance), the ability
ment studies utilizing medications that alter seroton- of an organism to function in spite of the presence
ergic function have shown varying results, depending of alcohol (behavioral tolerance), and adaptation of
on the population studied (Kranzler et al., 1995; Sell- central nervous system cells to the effects of alcohol
ers, Higgins, Tompkins, & Romach, 1992). A new (neuronal tolerance) (Harris & Buck, 1990).
medication, acamprosate, which is believed to mod- Behavioral tolerance has been shown to be envi-
ulate the action of the excitatory amino acid gluta- ronmentally dependent in animals (Tabakoff & Mel-
mate, has been shown to be helpful in improving out- chior, 1981), since mice who developed tolerance in
comes (Sass, Soyka, Mann, & Zieglgansberger, 1996). one environment showed less tolerance in a novel
Ultimately, combinations of pharmacotherapy that environment. The N-methyl-D-aspartate (NMDA)
impact on several different neurotransmitter systems receptor may be particularly important in this pro-
may be of help in treating individuals with alcohol cess (Szabo, Tabakoff, & Hoffman, 1994).
use disorders. This approach will be explored in As a finding of great theoretical and practical in-
greater detail in chapter 19. terest, sons of alcoholics who show less intoxication
(i.e., demonstrate greater tolerance) when given a
single dose of alcohol are at higher risk of subsequent
Mechanisms of Tolerance
development of alcohol use disorders. This finding
and Dependence
suggests that more rapid development of tolerance in
Tolerance is defined as a reduction over time in the individuals with a family history of alcoholism may
behavioral effects after ingestion of the same dose of be genetically mediated (Schuckit & Smith, 1997).
78 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

While tolerance and physical dependence may When alcohol is consumed, it is first absorbed
share some mechanisms, there appear to be signifi- through the stomach wall. The rate at which it is
cant differences between these two processes as well. absorbed, and at which it subsequently enters the
Not all individuals who exhibit tolerance to alcohol general circulation, depends upon the concentra-
are physically dependent, and conversely, some indi- tion. Therefore, the alcohol in a strong drink is ab-
viduals who are physically dependent on alcohol sorbed more quickly than that in a weaker drink
may not display tolerance. Physical dependence on (Goldstein, 1992). Because absorption of alcohol in
alcohol occurs when central nervous system cells re- the stomach is slower than in the small intestine, ab-
quire the presence of alcohol to function normally. sorption can also be slowed by the presence of food
When alcohol intake is discontinued, there are clear in the stomach, which delays the emptying of the
signs of withdrawal. Although withdrawal can be stomach contents into the small intestine. Whatever
demonstrated after smaller doses of alcohol in both alcohol is not metabolized through "first-pass" me-
animals and humans (the typical "hangover"), a tabolism (either by alcohol dehydrogenase in the
more severe syndrome is seen after prolonged, stomach lining or by the liver) enters the general cir-
chronic use of alcohol. This syndrome will be more culation and reaches the brain, where it results in
fully described later in this chapter. characteristic behavioral effects (see below).
The propensity to develop physical dependence In general, the same dose of alcohol will result in
may also be genetically mediated. Different strains of a higher BAG in females than in males (Frezza et
mice have been bred which are differentially sensi- al, 1990; Sutker, Tabakoff, Goist, & Randall, 1983).
tive to withdrawal seizures (Phillips, Feller, & This effect is felt to be due largely to the smaller
Crabbe, 1989). Although the exact mechanism by proportion of body water in women than in men,
which physical dependence develops is not known, which leads to a smaller volume of distribution (Ar-
there is evidence to support a role for several differ- thur, Lee, & Wright, 1984) and to the decreased ac-
ent central nervous system pathways. These include tivity of alcohol dehydrogenase in the stomachs of
changes in neuronal membranes (Hunt, 1985); women. There is no predictable effect of menstrual
changes in excitability and function of nerve cells phase on blood alcohol concentration (Lammers,
mediated through the transport of charged atoms Mainzer, & Breteler, 1995).
(ions) especially calcium (Daniell & Leslie, 1986) Although the concentration of alcohol in a drink
and the GABA receptor/chloride channel (Allan & may affect the rate at which it is absorbed, it does
Harris, 1987); changes in the activity of excitatory not affect the total amount of alcohol delivered. A
neurotransmitter systems such as the glutamate sys- standard drink contains approximately 13.6 g of abso-
tem (Tsai, Gastfriend, & Coyle, 1995); and changes lute alcohol. A standard drink may therefore be 12
in "second messenger" systems (Gordon, Collier, & oz of beer containing 5% alcohol by volume, 5 oz of
Diamond, 1992). wine at 12% alcohol by volume, or 1.5 oz of hard
liquor containing 40% alcohol by volume. Since
"one drink" can mean quite different amounts to dif-
CLINICAL ASPECTS ferent people, it is important to use standardized
methodology when determining how much alcohol
Blood alcohol concentration is most commonly ex- an individual is consuming. A widely used method
pressed as milligrams of alcohol per 100 milliliters of is the time-line follow back (Sobell, Sobell, Klanjner,
volume, or milligrams percent. The level at which a Pavan, & Basian, 1986). The utilization of surrogate
social drinker might display symptoms of intoxication fluids (i.e., water) and standard glasses, allowing di-
is 100 milligrams percent, or .100. Alternatively, rect estimation of consumed volume, results in in-
blood alcohol concentration can be expressed as mil- creased accuracy for this method (Miller & Del
limoles per liter, in which case the level of intoxica- Boca, 1994).
tion becomes 10 millimoles per liter. The rate at which alcohol is eliminated from the
The absorption of alcohol from the gastrointesti- human body has been of interest because of its medi-
nal tract largely determines the rate of increase of the colegal implications, particularly in regard to opera-
blood alcohol concentration (BAG), the peak BAG tion of motor vehicles while under the influence of
that occurs, and the time at which the peak occurs. alcohol. Jones and Andersson (1996) studied blood
 ALCOHOL 79

samples from a large sample of individuals who had warfarin, barbiturates, benzodiazepines, phenothi-
been charged with driving under the influence and azines, and opiates. Conversely, chronic exposure to
found significantly higher rates of elimination for wom- alcohol results in increased activity, or induction, of
en (0.214 ±0.053 mg/ml/hr) than for men (0.189 ± this enzyme system, resulting in decreased levels of
0.048 mg/ml/hr). Of individuals in this study, 95% these medications. A few medications, such as ci-
had an elimination rate between 0.09 and 0.29 metidine and ranitidine (histamine H2-receptor an-
mg/ml/hr. This rate suggests that, since ingestion of tagonists), appear to be able to increase alcohol
one standard drink typically results in a blood alco- concentrations through inhibition of gastric alcohol
hol concentration of approximately 20 mg%, one dehydrogenase (DiPadova et al, 1992). Table 4.3
standard drink is eliminated in approximately 1 hr. shows interactions of both acute and chronic alcohol
The approximate blood alcohol concentrations for use with commonly used medications.
men and women resulting from ingestion of various Many individuals who abuse alcohol also abuse
amounts of alcohol and the decrease over varying other substances. A common abuse pattern is the
amounts of time are shown in table 4.2. combination of cocaine and alcohol. Cocaethylene,
an active metabolite of cocaine, is formed by concur-
rent use of alcohol and cocaine and has been found
Drug Interactions
to be pharmacologically similar to cocaine but is
Acute alcohol exposure tends to inhibit the CYP2E1 eliminated more slowly than cocaine (McCance,
enzyme system in the liver and thus to increase Price, Kosten, & Jatlow, 1995). In animals, cocaethy-
blood levels of many common medications, such as lene has been reported to cause increased lethality

TABLE 4.2 Blood Alcohol Concentrations (Milligrams Percent) by Gender,

Weight, and Number of Drinks Over Time

Males Females

Weight (Ib) Weight (Ib)

J50 200 250 100 120 J50

1 SD*a
After 1 hour 12 5 1 34 26 18
2SD
After 1 hour 40 32 18 84 67 51
After 2 hours 25 17 3 69 52 36
3 SD
After 1 hour 67 47 34 133 108 84
After 2 hours 52 32 19 118 93 69
After 3 hours 37 17 4 103 78 54
4SD
After 1 hour 95 67 51 183 149 117
After 2 hours 80 52 36 168 134 102
After 3 hours 65 37 21 153 119 87
After 4 hours 50 22 6 137 104 72
5 SD
After 1 hour 122 88 67 232 191 150
After 2 hours 107 73 52 217 176 135
After 3 hours 92 58 37 202 161 120
After 4 hours 77 43 22 187 146 105
After 5 hours 62 28 7 172 131 90

Note. Adapted from Fisher, Simpson, and Kapur (1987).

J
SD = standard drink as defined.
80 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

TABLE 4.3 Interactions of Alcohol With Commonly Used Medications

Medication Acute alcohol use Chronic alcohol use

Acetaminophen (Tylenol) Unclear Liver damage (can be fatal)

Nonsteroidal antiinflammatories Aspirin may increase effect of alcohol Damage to gastrointestinal tract (bleed-
(aspirin, Advil, etc.) ing, ulceration)
Benzodiazepines (Valium, etc.) Increased sedation Same
Decreased motor coordination
Anticonvulsants (Dilantin, etc.) Increased blood level and increased Increased risk of seizures
side effects
Antidepressants
Tricyclics Increased blood level (increased side ef- Decreased effectiveness due to de-
Serotonin uptake inhibitors fects) creased blood levels
Monoamine oxidase inhibitors Hypertensive reaction
Antipsychotics (Thorazine, etc.) Increased sedation Increased risk of liver damage
Anticoagulants (warfarin) Increased risk of bleeding Increased risk of blood clotting

Note. From National Institute on Alcohol Abuse and Alcoholism: Alcohol Alert (1995).

over cocaine (Hearn, Rose, Wagner, Ciarleglio, & individuals who abuse alcohol are more likely to die
Mash, 1991), but in humans, concurrent cocaine use from nicotine-related diseases than from the direct
was associated with decreased alcohol withdrawal effects of alcohol (Hurt et al., 1996). Since humans
symptoms (Castaneda, Lifshutz, Westreich, & Ga- may also develop cross-tolerance to alcohol and nico-
lanter, 1995) and a decreased risk of seizures (Moak & tine, exposure to nicotine-related stimuli may affect
Anton, 1996). However, inpatients who abused both craving of and relapse to alcohol (Monti et al., 1995).
cocaine and alcohol were found to be more de- Marijuana is also commonly used with alcohol,
pressed and to have higher global severity scores than and the combined effects of these two substances
inpatients who abused only cocaine (Brady, Sonne, have not been studied extensively. When normal
Randall, Adinoff, & Malcolm, 1995). subjects were administered the two substances either
Nicotine abuse also commonly occurs with alco- alone or together (Chait & Perry, 1994), additive ef-
hol use and abuse. While approximately one quarter fects on performance impairment and subjective
of the population of the United States has a history mood ratings were noted.
of tobacco dependence and one seventh has a history
of alcohol dependence (Anthony, Warner, & Kessler,
Physical Symptoms of Use,
1994), prevalence rates of smoking among alcohol-
Abuse, and Dependence
dependent individuals range from 71% to 97%, and
in contrast to trends in the general population, there In normal drinkers, acute alcohol use results in char-
has been no decrease in smoking rates in alcoholics acteristic effects at different BAG levels. Typically,
in the last two decades (Monti, Rohsenow, Colby, & mild euphoria is detected at levels of 30 mg/dl
Abrams, 1995). Furthermore, alcohol-dependent in- (mg%); mild incoordination at 50 mg/dl; ataxia, or
dividuals tend to smoke more heavily than nonalco- difficulty walking, at 100 mg/dl; and at 200 mg/dl,
holic smokers (Kozlowski, Skinner, Kent, & Pope, confusion and a reduced level of mental activity. At
1989). Nicotine has been shown to cause tolerance 300 mg/dl, most individuals have become stuporous,
to several effects of alcohol in mice, including hypo- and above 400 mg/dl, there is deep anesthesia (Vic-
thermia, open-field activity, and sleep time (Collins, tor, 1992).
Wilkins, Slobe, Cao, & Bullock, 1996). These find- Frequently, intoxicated individuals exhibit an in-
ings suggest that concurrent use of nicotine may ability to recall events that occurred during their
allow increased amounts of alcohol to be consumed drinking, a phenomenon known as a blackout. The
with less immediate adverse effects but without pro- precise mechanism by which blackouts occur is not
tection against long-term negative sequelae. In fact, known, although inhibition of N-methyl-D-aspartate
 ALCOHOL 81

(NMDA) receptor-stimulated calcium flux has been monly within 6-8 hr, and typically last 48-72 hr in
implicated (Diamond & Messing, 1994). Blackouts uncomplicated cases. DTs usually manifest between
are felt to be associated with more severe degrees of 48 and 96 hr after cessation of drinking and, with
alcohol misuse and may be an early warning sign of adequate treatment, usually last for 48-72 hr. Al-
developing abuse and dependence. though seizures typically occur within the first 24 hr
As mentioned previously, alcohol-abusing and after drinking ceases, they can occur up to 5 days
-dependent individuals frequently show less effect at afterward. At least two of the following symptoms are
each BAG mentioned above, as they have developed required to meet the definition of AW found in the
tolerance to the acute effects of alcohol. fourth edition of the Diagnostic and Statistical Man-
ual of Mental Disorders (DSM-IV): nausea and vom-
iting, tremor, sweating, anxiety and irritability, motor
Symptoms and Course of Withdrawal
arousal (agitation), skin sensations, heightened sensi-
There appears to be considerable interindividual tivity to light and sound, headache, and problems
variability in the presentation of alcohol withdrawal with concentration and orientation (Sellers, Sullivan,
(AW) symptoms. Individuals with quite similar drink- Somer, & Sykora, 1991). Increased blood pressure
ing careers may exhibit quite different degrees of and increased heart rate (pulse) are often found.
withdrawal symptoms, a finding that again suggests Most individuals with AW also exhibit decreased ap-
the strong influence of individual genetic vulnerabil- petite and abnormal sleep architecture. A commonly
ity to the withdrawal syndrome. The typical hangover used rating instrument that measures the intensity of
is a mild form of AW. Severe, life-threatening with- AW symptoms reliably is the Clinical Institute With-
drawal accompanied by loss of orientation and hallu- drawal Assessment for Alcohol (revised) (CIWA-Ar;
cinations is known as delerium tremens (DTs). DTs Sullivan, Sykora, Schneiderman, Naranjo, & Sellers,
occur in less than 5% of individuals with AW, and 1989). Scores over 10 on this scale generally indicate
mortality resulting from this syndrome when un- withdrawal that should be managed with medication
treated is estimated to be 15% (Victor, 1992) but is and supportive care.
less than 2% when the syndrome is recognized and Although many clinicians and researchers believe
treated properly (Ozdemir, Bremner, & Naranjo, that there is a "protracted" AW syndrome, defined as
1993). AW symptoms that persist after the first several days
Delerium tremens is more likely to occur in med- of cessation of drinking, the nature of this syndrome
ical settings, a finding that suggests that other organ remains ill defined. Abnormalities in brain function,
pathology, such as pancreatitis, pneumonia, and hep- as demonstrated in electroencephalographic (EEC)
atitis, may predispose toward the development of sleep recordings and positron emission tomography
DTs (Thompson, 1975). Seizures may occur during (PET) scans, lasting at least several weeks after drink-
withdrawal from alcohol, most likely occurring in 5- ing has been discontinued, have been documented
15% of alcohol-dependent individuals (Victor & (Gillin, Smith, Irwin, Kripke, & Schuckit, 1990; Vol-
Brausch, 1967). Seizure risk increases as daily intake kow et al., 1994) and support the notion that more
of alcohol increases, with an approximately 3-fold in- subtle AW symptoms may continue to affect alcohol-
crease in risk at 51-100 g alcohol/day (4-8 standard ics. Distinguishing possible protracted AW symptoms
drinks/day), an 8-fold increase in risk at 101-200 g/ from the symptoms and signs of other psychiatric dis-
day (9-14 standard drinks/day), and an almost 20- orders, such as affective and anxiety disorders, re-
fold increased in risk at more than 200 g/day (more mains challenging.
than 14 standard drinks/day) (Ng, Hauser, Brust, & There are many effective pharmacological treat-
Susser, 1988). When seizures are due solely to alco- ments for AW that are discussed in chapter 19. There
hol withdrawal, ongoing treatment with standard an- is increasing evidence that repeated episodes of AW
ticonvulsant medication is usually not required, in lead to more serious AW symptoms in subsequent
contrast to requirements for seizures associated with episodes (Booth & Blow, 1993; Brown, Anton, Mal-
idiopathic or posttraumatic epilepsy (Rathlev et al., colm, & Ballenger, 1988; Moak & Anton, 1996)
1994). which may be due to a "kindling" or sensitization
AW symptoms usually begin within 24-48 hr of phenomenon as originally hypothesized by Ballenger
decreasing or discontinuing drinking, most com- and Post (1978). If the severity of AW episodes is
82 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

mediated by a kindling process, anticonvulsants such new information. Confabulation, which is character-
as carbamazepine and valproate might reduce the ized by verbal responses that are grossly inaccurate
progressive worsening of AW symptoms over re- and often bizarre and fantastic, is common as an at-
peated AW episodes better than benzodiazepines, tempt to partially compensate for the defect. Korsa-
which are the current standard treatment. Research koff s psychosis is permanent in 25% of individuals
to define the role of these medications in the treat- in which it develops. Both of these severe syndromes
ment of AW is ongoing. can largely be prevented by the prompt administra-
Not all episodes of AW may require pharmaco- tion of thiamine, either orally or by intramuscular
logical treatment. Concern has been expressed re- injection, in individuals entering alcohol withdrawal.
garding the use of medications which themselves Many alcoholics develop a cerebellar syndrome
possess addictive potential, such as the benzodiaze- with profound ataxia, more pronounced in the legs
pines, in the treatment of a substance use disorder. than in the arms. Chronic use of alcohol also appears
A small but well-designed study by Naranjo and col- to lead to a typical dementia, with clinical manifesta-
leagues (1983) of alcoholics with mild to moderate tions of cognitive deficits including memory impair-
AW symptoms showed similar outcomes for both ment and pathological findings of cortical atrophy,
pharmacological and nonpharmacological treatment. enlargement of the lateral ventricles, and a loss of
More research is needed to better define the optimal cortical neurons. Modern brain-imaging techniques
use of medications in the treatment of AW episodes. bear promise in better defining the changes that oc-
cur and their possible resolution with abstinence
from alcohol (Mann, Mundle, Strayle, & Wakat,
PATHOLOGICAL EFFECTS 1995).
Polyneuropathy is the most common neurological
complication in alcoholism. Affected individuals com-
Physiological Effects
plain of numbness (paresthesias), pain, and weakness,
Organ systems that are particularly vulnerable to the especially in the feet. This can be severe enough to
adverse effects of excessive alcohol use are the cen- interfere with walking. Finally, an acute and even
tral nervous system; the gastrointestinal system, in life-threatening myopathy can occur after binge
particular the liver, and the cardiovascular system. drinking, with muscle swelling, weakness, and pain;
Table 4.4 summarizes the clinical syndromes that elevated blood levels of creatine kinase; and myoglo-
are a result of the toxic effects of alcohol. binuria, which can result in kidney damage. A more
chronic, usually painless, and commonly undiag-
nosed myopathy can also develop.
Central Nervous System

The alcohol withdrawal syndromes, which are mani-

Gastrointestinal System and Liver
festations of alcohol's toxicity on the central nervous
system, have already been discussed. Additionally, Alcohol is detoxified primarily in the liver and affects
chronic exposure to alcohol can give rise to a num- this organ in a number of ways (French, 1996). Alco-
ber of more pervasive neurological syndromes. Some hol appears to induce a hypermetabolic state in liver
may be due to an interaction with nutrition, such cells (hepatocytes), which results in a relative oxygen
as Wernicke's encephalopathy, caused by thiamine deficiency. This may in turn promote the formation
deficiency. Other disorders are most likely due to the of "free radicals" which lead to fibrosis (Ishii et al.,
direct neurotoxicity of alcohol, such as alcoholic de- 1996). Liver damage is first manifested by fatty
mentia and disorders of the nerves (neuropathy) and change (steatosis) which is reversible and clinically
muscles (myopathy) (Diamond & Messing, 1994). silent. This is followed by the development of alco-
Wernicke's encephalopathy is characterized by a holic hepatitis, which can present with jaundice, fe-
triad of ataxia (difficulty with walking), oculomotor ver, anorexia, and right upper quadrant abdominal
abnormalities (difficulty with eye movement), and pain.
global confusion (Reuler, Giard, & Cooney, 1985). Cirrhosis, or irreversible liver damage, is the most
It usually occurs in combination with Korsakoff s psy- severe form of alcoholic liver disease. It was the llth
chosis, which consists of a complete inability to learn leading cause of death in the United States in 1993,
 ALCOHOL 83

TABLE 4.4 Medical Disorders Caused by Alcoholism

Organ system Disorder

Central nervous system Wernicke's encephalopathy

Korsakoffs psychosis
Cerebellar ataxia
Alcoholic dementia
Polyneuropathy
Myopathy
Gastrointestinal system and liver Steatosis (fatty change)
Alcoholic hepatitis
Cirrhosis
Pancreatitis
Gastritis
Cardiovascular system Cardiomyopathy
Arrhythmias
Hypertension
Increased cholesterol and blood lipids
Decreased platelet aggregation
Endocrine system Hypoglycemia with acute exposure
Hyperglycemia with chronic exposure
Osteoporosis
Menstrual cycle irregularity in women
Decreased testosterone levels in men

although it ranked as high as 7th among women be- characteristic "flapping" tremor), fluctuating neuro-
tween the ages of 45 and 64 (Gardner & Hudson, logical signs, and distinctive changes on electroen-
1996). Cirrhosis appears to develop more quickly in cephalogram and is associated with elevated blood
women (Morgan, 1994), perhaps partly because of levels of ammonia. The hepatorenal syndrome, in
early exposure to higher levels of alcohol due to the which blood flow to the kidneys is critically de-
lower activity of gastric alcohol dehydrogenase. Con- creased, manifests clinically as a decreased urine pro-
comitant physical findings can include an enlarged duction and a retention of sodium and fluid.
spleen, abdominal fluid (ascites), testicular atrophy, The interaction of alcohol and viruses causing
enlarged breasts in males (gynecomastia), enlarged acute and chronic hepatitis is of great interest. Evi-
superficial blood vessels (spider angiomata), and pal- dence of hepatitis C virus infection, in particular, has
mar erythema. Frequently, the liver enzyme abnor- been found to be more common among individuals
malities characteristic of earlier stages of damage with alcoholic liver disease than in either patients
may actually normalize in cirrhosis, although a de- without alcoholism or patients with alcoholism but
crease in serum albumin and increase in serum glob- without alcoholic liver disease (Mendenhall et al.,
ulin may persist. 1991) and appears to be associated with more severe
Because cirrhosis causes obstruction of blood flow liver disease (Pares et al., 1990). An increased preva-
through the liver and increased pressure in the circu- lence of hepatitis B virus antibodies has been found
lation proximal to the liver (portal hypertension), in some studies as well (Brechot, Nalpas, & Feitel-
veins in the esophagus frequently become enlarged son, 1996). In addition to contributing to an acceler-
and are termed varices. These varices can bleed ated course of progression to cirrhosis, infection with
spontaneously and lead to fatal gastrointestinal hem- hepatitis viruses appears also to play a role in the de-
orrhage. Late complications of cirrhosis include he- velopment of cancer of the liver (Brechot et al.,
patic encephalopathy and the hepatorenal syndrome. 1996).
Hepatic encephalopathy is a complex neuropsychiat- Other gastrointestinal complications of excessive
ric syndrome consisting of disturbances in concious- alcohol use are inflammation of the pancreas, or
ness and behavior, personality changes, asterixis (a pancreatitis, and injury to the stomach lining, or gas-
84 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

tritis. The symptoms of pancreatitis are abdominal believed to result in a protective cardiovascular effect
pain, usually of a boring and steady quality and origi- (Gaziano et al., 1993). It is important to note that
nating in the upper abdomen with radiation through any positive effects of alcohol that have been docu-
to the back, and vomiting. Although most attacks are mented have occurred in individuals who are moder-
limited and last 2-3 days, severe attacks may result ate drinkers (less than three drinks per day) and that
in hospitalization, and there is a mortality of up to these benefits are quickly offset when drinking ex-
30%. Gastritis typically presents as pain in the upper ceeds truly moderate levels, currently defined as two
abdomen and vomiting of blood. While bleeding standard drinks per day for men and one standard
from gastritis is usually self-limited, it is important to drink per day for women.
distinguish it from bleeding from esophageal varices, Alcohol use also impacts the cardiovascular sys-
as described above. tem through its effect on platelet function (Re-
naud & Ruf, 1996). Platelets play a critical role in
blood clotting through their ability to clump at sites
Cardiovascular System
of injury. Alcohol has been shown to inhibit platelet
Alcohol has been known for over a century to have aggregation in both humans and animals. This may
a direct toxic effect upon the heart, having been be an underlying cause of the increased incidence of
first described in 1884 as occurring in persons who cerebral hemorrhages observed in alcoholics. It has
consumed large amounts of beer in Germany (the also been shown that, after heavy alcohol use, plate-
Munich "beer heart") (Rubin & Thomas, 1992). Al- lets will "rebound" and exhibit enhanced aggre-
though initially felt to be a manifestation of con- gation. This rebound aggregation may lead to an
comitant thiamine deficiency, it is now known that increased occurrence of cardiovascular events, in-
chronic use of alcohol results in a condition of heart cluding myocardial infarction, or heart attack, and
muscle weakening known as cardiomyopathy. This stroke. Interestingly, this rebound aggregation is not
condition may lead to irregular rhythms that some- observed in animals given red wine (Ruf, Berger, &
times result in sudden death (Ettinger et al., 1978). Renaud, 1995), in humans drinking red wine (Re-
Acute alcohol abuse can also result in deleterious ef- naud, Dumont, Godsey, Suplisson, & Thevenon,
fects on the heart. Kelly and colleagues (1996) found 1979), or when grape tannins are added to alcohol
decreases in heart muscle contractile force in healthy (Rufetal, 1995).
adult subjects at alcohol concentrations common
among social drinkers.
Endocrine System
Hypertension, or elevated blood pressure, is more
common among alcohol-abusing and -dependent in- Alcohol influences the function of several important
dividuals than in nonalcoholic members of the gen- hormonal and metabolic systems. In particular, it
eral population (Klatsky, 1996). This has been found can affect the metabolism of glucose and calcium
to be true for both sexes, across various age groups, and the function of the reproductive system. Acute
among different racial groups, and for drinkers of li- alcohol use can result in low blood sugar (hypoglyce-
quor, wine, or beer. Even though this relationship mia) through exhaustion of glycogen stores and inhi-
was first identified early in this century, the exact bition of glucose metabolism (Gordon & Lieber,
mechanism by which alcohol causes hypertension is 1992). Chronic heavy drinking is more likely to re-
not known. Some researchers have felt that hyperten- sult in elevated blood glucose (hyperglycemia) and
sion is a manifestation of mild alcohol withdrawal, can be especially harmful in those individuals who
while others have focused on the use of salt in the are predisposed to the development of diabetes melli-
diets of alcoholics. tus (Crane & Sereny, 1988).
Of importance in relation to these direct effects Alcohol interferes with calcium metabolism at
on the cardiovascular system is the effect of alcohol several levels. Acute alcohol use may lead to a tran-
on lipids (Frohlich, 1996). This has been an area of sient insufficiency of the important calcium regula-
some interest and also of controversy in recent years, tory glands, the parathyroids (Laitinen et al., 1991).
with several studies supporting a beneficial effect of This results in increased loss of calcium from the
moderate alcohol use on lipid profiles through in- body. Chronic alcohol use frequently leads to dietary
crease in high-density lipoprotein (HDL), which is insufficiency of calcium and vitamin D, which can
 ALCOHOL 85

lead to softening of the bones (i.e., osteoporosis). been suggested that such infant characteristics be
Liver disease, through alteration of reproductive hor- called alcohol-related birth defects (ARBD; Hanni-
mone levels, can also affect bone and calcium me- gan, Welch, & Sokol, 1992).
tabolism (Laitinen & Valimaki, 1993). In individuals The mechanisms by which alcohol use results in
with osteoporosis, the increased risk of falls associ- fetal effects are most likely complex. Four pathways
ated with alcohol use can result in an increased inci- have been suggested by Pratt (1984). Early in preg-
dence of fractures (Hingson & Rowland, 1987). nancy, alcohol acts as a direct teratogen, causing ei-
Many studies have found evidence of dysfunction ther cell death or chromosomal aberrations. Later in
of the reproductive system in heavy drinkers and al- development, between 4 and 10 weeks after concep-
coholics (Mendelson & Mello, 1988). Amenorrhea, tion, alcohol may act as a toxin to cells. Subse-
or absence of menstrual cycles, has been observed in quently, from 8 to 10 weeks onward, alcohol causes
women who drink heavily. Low levels of alcohol use disorganization and delay of cell migration and de-
(three to six drinks per week) in postmenopausal velopment. Finally, alcohol interferes with the pro-
women have been shown to be associated with in- duction of important brain transmitters and thus
creased levels of estradiol, which may result in a de- probably leads to behavioral problems. Growth defi-
creased risk of cardiovascular disease (Stampfer, Col- ciency may be mediated in part by alcohol effects on
ditz, Willett, Speizer, & Hennekens, 1988) but may growth hormone in these infants. Additionally, it has
also increase risk of breast cancer (Singletary, Dor- been suggested that alcohol use causes perinatal hy-
gan, Gapstur, & Anderson, 1996). Testicular func- poxia and acidosis in the fetus due to impairment
tion is also profoundly affected by heavy alcohol use, of umbilical circulation (Randall, Ekblud, & Anton,
with findings of decreased testosterone levels (Gor- 1990). It is not clear whether alcohol itself or its me-
don, Altman, Southren, Rubin, & Lieber, 1976) and tabolite acetaldehyde causes this effect.
the appearance of female sexual characteristics, such Longitudinal follow-up of infants and children
as enlarged breasts (Bannister & Lowosky, 1987). with FAS into adulthood is still in its early stages. It
has been shown that many children with FAS are
able to "catch up" in adolescence in regard to growth
Fetal Alcohol Syndrome
and that some of the facial anomalies resolve, but
Fetal alcohol syndrome (FAS) is very likely the most that maladaptive behaviors, including poor judg-
common known cause of mental retardation and af- ment, distractibility, and difficulty perceiving social
fects from 1 to 3 of every 1,000 infants born in the cues, persist (Streissguth et al., 1991).
United States. The risk to fetal health from alcohol It has been shown that increased maternal age is
has been recognized since the writing of the Bible, associated with greater fetal risk from alcohol use
and in 1899, a publication by Sullivan documented (Jacobson, Jacobson, & Sokol, 1996). Currently, the
an increased rate of stillbirth and infant death in the safest approach to alcohol use during pregnancy is
children of alcoholic women. believed to be the recommendation of complete ab-
The full manifestation of FAS is characterized by stinence. The possibility that such a stringent recom-
the triad of characteristic facial malformations, pre- mendation might unnecessarily alarm women who
natal and postnatal growth deficiency, and central may have drunk at very low levels during early preg-
nervous system dysfunction. Facial malformations in- nancy is of some concern (Abel, 1996).
clude short palpebral fissures (eye openings), elon-
gated midface, long and flat philtrum (area between
Psychological Effects
the mouth and nose), thin upper vermilion (lip), flat-
tened maxilla (cheeks), and flattening of the nasal Alcohol profoundly affects both affective states and
bridge (Sokol & Clarren, 1989). Central nervous sys- cognitive functioning. These effects can be seen in
tem involvement is demonstrated by findings of IQs social drinkers, in chronic heavy drinkers, in alcohol-
between 60 and 65, although a wide range is fre- ics, and in dually diagnosed individuals (those indi-
quently seen (Streissguth, Herman, & Smith, 1978). viduals with both an alcohol use disorder and an-
Infants who display some features of FAS but do not other psychiatric disorder). Relationships between
meet the full diagnosis were once described as hav- psychiatric symptomatology and alcohol use are very
ing fetal alcohol effects (FAE). More recently, it has likely complex and bidirectional; that is, alcohol use
86 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

results in characteristic affective changes, but preex- some cognitive functions, with verbal skills returning
isting affective disorders and expectancy sets may most quickly, usually within a month of attaining ab-
strongly influence the effect and pattern of drinking. stinence. Difficulties with abstraction and problem
Alcohol use disorders are more common among in- solving appear to be more long-lasting. Younger age
dividuals who meet criteria for affective and anxiety and length of abstinence are predictive of better re-
disorders (Kessler et al., 1997) than in individuals covery of cognitive functioning, while pattern and
without these disorders, but it is often not clear if the duration of alcohol use appear to be relatively weak
alcohol use disorder preceded or followed the onset determinants of cognitive impairment (Fein, Bach-
of the affective or anxiety disorder. Structured inter- man, Fisher, & Davenport, 1990). With continued
views that attempt to distinguish between so-called abstinence, scores on tests tend to improve but ap-
primary disorders (disorders that predate the onset of pear to remain inferior to those in age-matched con-
alcohol and other substance use disorders) and those trols.
disorders that occur secondary to substance use are
useful (Hasin et al., 1996).
Effects of Affective and Anxiety States
It is also crucial, when reviewing experimental
data, to be aware of the population being studied, as Many individuals, particularly heavier social drink-
it is likely that social drinkers and alcohol-abusing ers, use alcohol as a means to ameliorate uncomfort-
and -dependent individuals differ in important ways able affective and anxiety states (Lex, Mello, Mendel-
in their reasons for drinking and their response to son, & Babor, 1989). Because of alcohol's propen-
alcohol. sity to cause anxiety and depression, both through its
direct action on the central nervous system and
through subsequent withdrawal states, this "self-med-
Cognitive Effects
ication" with alcohol is likely to worsen existing psy-
The effect of alcohol on cognitive functioning in chological symptoms. Kushner, Sher, and Beitman
abusing and dependent populations is clearly a nega- (1990) found that while agoraphobia and social pho-
tive one. In social drinkers, however, the situation is bia were more likely to precede the onset of an alco-
not as clear. Individuals under the influence of alco- hol use disorder, panic disorder and generalized anx-
hol perform poorly on cognitive tests (Lex, Green- iety disorder were more likely to follow onset of
wald, Lukas, Slater, & Mendelson, 1988) but proba- alcohol abuse and dependence.
bly of greater interest is the long-term effect of Although depressive symptoms are common in
alcohol on cognitive performance of social drinkers. individuals with alcohol use disorders, these symp-
Important early studies (Hannon, Day, Butler, Lar- toms frequently remit with even short periods of
son, & Casey, 1983; Jones & Jones, 1980; Parker & abstinence (Brown & Schuckit, 1988). In some indi-
Noble, 1977) showed an association between de- viduals, particularly in women and in those experi-
creased performance on cognitive tasks and higher encing a disruption of social support, depressive dis-
levels of alcohol consumption among social drink- orders can occur independent of alcohol use and
ers. Other studies have been less supportive of a sig- persist after sobriety is achieved (Beck, Steer, &
nificant role of chronic alcohol use in decreased cog- McElroy, 1982; Overall, Reilly, Kelley, & Hollister,
nitive functioning, although recent heavy alcohol 1985). Suicide is a serious consequence of both alco-
intake was associated with mild cognitive defects hol use disorders and depression (Winokur & Black,
(Bergman, 1985). 1987), and suicide attempts by depressed alcoholics
Longitudinal studies have substantiated persis- are typically impulsive in nature, involving little if any
tently poorer performance on cognitive testing premeditation (Cornelius, Salloum, Day, Thase, &
among heavy drinkers than among social drinkers Mann, 1996). Suicide attempts are common among
and nondrinkers (Arbuckle, Chaikelson, & Gold, alcoholics, with 21% of men and 41% of women re-
1994). In abusing and dependent populations, defi- porting at least one lifetime attempt in one study
cits are observed in perceptual-motor skills, visual- (Hesselbrock, Hesselbrock, Syzmanski, & Weiden-
spatial performance, abstraction and problem solv- man, 1988). This report underscores the importance
ing, and learning and memory processes (Parsons & of assessing suicidality in individuals with alcohol use
Nixon, 1993). Abstinence does lead to recovery of disorders.
 ALCOHOL 87

It would also appear that personality attributes ics have been found to have interpersonal problem-
that are considered persistent and enduring may in solving deficits (Nixon, Tivis, & Parsons, 1992), and
fact change after the cessation of drinking, since the more improvement on a social skills task battery has
Minnesota Multiphasic Personality Inventory, as well been found to be associated with better adjustment
as the diagnostic criteria for personality disorders in alcoholics who were followed up 1 year after treat-
(SCID-P), shows change when repeated after a pe- ment (Jones & Lanyon, 1981). Since alcoholics have
riod of abstinence (Pettinati, 1990; Pettinati, Suger- been shown to have decreased functioning of the
man, & Maurer, 1982). prefrontal lobes of the brain (Volkow et al., 1992),
where social judgment and behavior or restraint are
mediated, it is possible that the impaired social func-
Expectancies of Alcohol Use
tioning, judgment, impulsivity, and lack of insight
In a study of a social drinking population interviewed manifested by actively drinking alcoholics are attrib-
by telephone, the typical reasons for alcohol use were utable to a direct toxic effect on the brain.
drinking to cope, drinking to be sociable, drinking to
enhance social confidence, and drinking for enjoy-
Family Function and Domestic Violence
ment (Smith, Abbey, & Scott, 1993). More positive
expectancies of alcohol use were found to predict Alcohol use and misuse are frequently associated
current drinking patterns and symptoms of alcohol with family dysfunction and domestic violence. Alco-
dependence in young adults (Williams & Ricciar- hol and other drug use by parents has been found to
delli, 1996). However, among "highly sexually inse- contribute to sexual and physical abuse of children,
cure" male and female college students, the expecta- although it is difficult at this time to estimate the
tion that alcohol would enhance sexuality did not extent of increased risk given the methodological
predict drinking patterns (Mooney, 1995). limitations of the studies that have been done, and
there is also evidence to support a link between the
experience of childhood violence and later alcohol
Social and Interpersonal Effects
and other drug abuse (Miller, Maguin, & Downs,
This section will discuss the relationship of alcohol 1997). Although homicides caused by domestic vio-
use and the following aspects of social functioning: lence were less likely to involve alcohol and drugs
impulsivity and lack of social restraint, family func- than homicides resulting from causes other than do-
tion and domestic violence, other forms of violence, mestic violence, the proportion of domestic violence
motor vehicle trauma and other trauma, work perfor- homicides in which substance use was involved
mance, and legal consequences. The important ef- (54%) was still high (Arbuckle et al., 1996). It is im-
fects of gender and age on the impact of alcohol use portant to assess substance use in the victim as well
on social functioning are considered in other sec- as in the perpetrator of domestic violence, since ex-
tions of this book. posure to trauma has been shown to be both a pre-
dictor and a consequence of alcohol use disorders
(Stewart, 1996).
Impulsivity and Lack of Social Restraint

Similar to the relationship of cognition and affect to

Motor Vehicle and Other Trauma
alcohol use as discussed above, the relationship of
social functioning to alcohol use appears to be bidi- Alcohol use also frequently plays a role in motor ve-
rectional. It is important, but sometimes difficult, to hicle accidents, burn injuries, and other trauma. Al-
distinguish the pathological effects of alcohol use on cohol intoxication, defined as a blood alcohol con-
social functioning from those deficiencies in social centration of 100 mg%, is associated with 40-50% of
functioning that can lead to problem drinking. In a traffic fatalaties, 25-35% of nonfatal motor vehicle
sample of young adult drinkers, low self-restraint, a injuries, and up to 64% of fires and burns (National
measure of social functioning, was a strong predictor Institute on Alcohol Abuse and Alcoholism [NIAAA],
of alcohol-related problems, especially when com- 1989). Burn victims who tested positively for alcohol
bined with a high level of distress (Weinberger & and other substances had significantly greater total
Bartholomew, 1996). Both male and female alcohol- body surface area involvement (McGill, Kowal-Vern,
88 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

Fisher, Kahn, & Gamelli, 1995) and overall mortal- a crime (66% of the former group vs. 38% of the
ity (Haum et al., 1995; McGill et al. 1995). Interest- latter group) (Roslund & Larson, 1979). Based on
ingly, a stronger association was found between these statistics, rehabilitation of imprisoned individu-
drinking variables and injuries that resulted from vio- als that includes attention to treatment of substance
lence in a study of individuals requiring an emer- use disorders would seem to be appropriate, but stud-
gency room visit than for other frequent sequelae of ies of the effectiveness of such treatment programs
alcohol use, including motor vehicle accidents, pen- are lacking at the present time (Roesch, Ogloff, &
etrating traumas not caused by violence, and fires Eaves, 1995).
(Cherpitel, 1996).

SUMMARY
Occupational Performance

Alcohol use has long been believed to cause de- The consumption of alcoholic beverages can be a
creased work performance (Berry & Boland, 1977; pleasant aspect of many family and social activities,
U.S. General Accounting Office, 1970). However, and there is evidence that truly moderate alcohol use
many studies in this area have methdological flaws may offer some health benefits. However, the mis-
that have resulted in contradictory findings, suggest- use of alcohol, leading to the development of alcohol
ing a more complicated relationship between levels use disorders, has a negative impact on society at
of alcohol use and occupational performance (Webb many different levels. The medical disorders that re-
et al., 1994). Problem drinkers were found to be sult from excessive alcohol use are significant causes
more likely to sustain occupational injuries and to of morbidity and mortality. Psychological disturb-
have more absences due to these injuries (Hing- ances and social and interpersonal dysfunction
son & Rowland, 1987). Hangovers and drinking caused by or worsened by alcohol use result in im-
while at work were better predictors of work-related mense economic loss for society as well as human
problems than overall levels of drinking in a study of suffering that cannot be measured in dollars. Expo-
workers at a manufacturing facility (Ames, Grube, & sure of a fetus to alcohol extends the impact of alco-
Moore, 1997). Additionally, level of job satisfaction hol use disorders to future generations.
and belief in drinking as a coping mechanism were Research, both animal and human, which seeks
found to be important mediators of the effect of to improve our understanding of the action of alco-
drinking on work performance (Greenberg & Grun- hol at the molecular and biochemical level of the
berg, 1995; Webb et al., 1994). A study of the inter- central nervous system, as well as the development of
action of ethnicity and socioeconomic status on so- new psychotherapies and pharmacotherapies, offers
cial consequences of drinking found that less affluent hope to the millions of human beings affected by
black men had more drinking-related problems than these disorders.
less affluent white men, while affluent black men re-
ported fewer problems related to drinking than afflu-
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 5

Sedative-Hypnotic and
Anxiolytic Agents

Kathleen T. Brady
Hugh Myrick
Robert Malcolm

Sedative and anxiolytic agents have long been used use is probably, in part, attributable to an increase in
for the reduction of anxiety and the induction of negative attitudes toward the use of these com-
sleep. Most of these drugs have a similar spectrum of pounds. Of medical specialists, family physicians and
activity along a continuum of central nervous system internists are the major prescribers of benzodiaze-
(CNS) depression, producing a calming, anxiolytic pines, followed by psychiatrists. With the increased
effect at low doses (sedation) and drowsiness and use of benzodiazepines, the use of nonbenzodiaze-
sleep at higher doses (hypnosis). Barbiturates were pine sedative-hypnotics has decreased to the point
introduced into clinical practice in the early 1900s where trends in the prescription of benzodiazepines
and were the most commonly used drugs in the treat- accurately reflect the prescription of sedative-hypnot-
ment of anxiety, insomnia, and seizure disorders un- ics generally.
til the introduction of the benzodiazepines in the Despite a trend toward the decreasing use of seda-
early 1960s. The benzodiazepines offered substantial tive-hypnotics, they remain commonly prescribed
advantages over the barbiturates in terms of safety agents. Data from the National Prescription Audit
and selectivity of activity. and the National Disease and Therapeutic Index in-
After the benzodiazepines became available in dicated that retail pharmacies dispensed 20.8 million
the 1960s, prescriptions for sedative-hypnotics stead- prescriptions in 1989 (Wysowski & Baum, 1991).
ily increased to a peak level of approximately 100 Nevertheless, only 0.9% of the general adult popula-
million prescriptions per year in 1975. Prescriptions tion endorsed nonmedical use of sedatives in 1992
then decreased to 65 million in 1981 and have lev- (U.S. Department of Health and Human Services,
eled off since then (Griffiths & Sannerud, 1987). 1992). Furthermore, data seem to indicate that these
The tendency toward more conservative anxiolytic are valuable therapeutic agents and, for the most

95
96 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

part, are being prescribed appropriately within the higher doses, they produce drowsiness and facilitate
context of health care provision (Griffiths & San- the onset and maintenance of sleep. Some sedative-
nerud, 1987). hypnotics (i.e., barbiturates) have the capacity to in-
It is important to note that many antidepressant duce general anesthesia. However, it is important to
agents (tricyclic antidepressants, selective serotonin note that the benzodiazepines do not induce general
reuptake inhibitors) are effective in the treatment of anesthesia. While there are variations in the specific-
anxiety disorders. These agents, however, are not ity and spectrum of clinical activity among sedative-
marketed primarily as anxiolytic agents, and discus- hypnotic agents, many of these drugs have anticon-
sion of their use is beyond the scope of this chapter. vulsant, anxiolytic, and muscle-relaxant properties. In
These agents do have a clear role in the treatment of clinical practice today, the most common uses of the
anxiety disorders and little abuse potential. Thus, sedative-hypnotics include sleep induction, anxiety
they are clearly agents that warrant serious consider- reduction, anticonvulsant activity, and muscle relax-
ation in the treatment of anxiety disorders in the sub- ation. Buspirone, an anxiolytic agent which is not a
stance-abusing population. sedative-hypnotic agent, does not produce wide-
Two newer agents have been introduced that spread CNS depression or sleep induction.
have unique spectrums of clinical activity. Buspirone Sedative-hypnotic and anxiolytic agents have
(Buspar) is an anxiolytic drug, shown to be effective other important pharmacological differences. These
in the treatment of generalized anxiety disorder, but include variation in onset of clinical activity, varia-
not in the treatment of other anxiety disorders. tion in half-life, the presence or absence of active
Buspirone is of particular interest because, unlike the metabolites, and differences in the specificity of the
benzodiazepines, it has no abuse potential. A recent various sedative-hypnotics in producing various clini-
study of the use of buspirone in anxious alcoholics cal effects. For instance, it appears that the benzodi-
indicated that this drug could be useful both in de- azepines are more specific in their anxiolytic proper-
creasing anxiety in an alcoholic population and in ties than the barbiturates. Thus, the benzodiazepines
improving some alcohol-related outcomes (Kranzler have an anxiolytic effect at nonsedating doses, where-
et al., 1994). Thus, this agent may be of particular as barbiturates do not. Benzodiazepines are also far
interest as an anxiolytic in substance abusers but ap- safer to use than barbiturates. Barbiturates suppress
pears to have a limited spectrum of clinical efficacy. the respiratory drive at doses only three times greater
Zolpidem (Ambien) was introduced in 1993 in than those used to induce sleep and hence are very
the United States as a short-acting nonbenzodiaze- dangerous in overdose.
pine hypnotic agent. This agent does, however, work
through the GABA-ergic neurotransmitter system,
Metabolic Pathways
has metabolites which are active at benzodiazepine
receptor sites, and shares many properties with the The chemical and pharmacokinetic properties of the
benzodiazepines. In addition, there has been at least sedative-hypnotics affect their clinical utility. They
one case of dose escalation and withdrawal in indi- are all lipophilic and essentially completely ab-
viduals with a history of a substance use disorder sorbed. As can be seen in tables 5.1 and 5.2, they
(Bruun, 1993). Other newer agents, such as abecar- have very different elimination half-lives, however,
nil, gepirone, and alpidem, are not currently avail- and may thus be divided into four categories: (a) ul-
able in the United States and there are few data con- tra-short-acting (midazolam); (b) short-acting (T'/i <
cerning their usefulness as hypnotic agents or their 6 hr; triazolam, zolpedim); (c) intermediate-acting
abuse potential. (Tl/i = 6-24 hr. temazepam, lorazepam, oxazepam);
and (d) long-acting (T1A > 24 hr.; flurazepam, diaze-
pam). The benzodiazepines and their active metabo-
MAJOR PHARMACOLOGICAL ACTIONS lites bind to plasma proteins. The concentration in
the cerebrospinal fluid (CSF) is approximately equal
All of the sedative-hypnotic and anxiolytic agents to that of free drug in plasma. The benzodiazepines
have the ability to produce widespread CNS depres- are extensively metabolized in the liver (Hobbs,
sion. In lower doses, most decrease activity, moderate Rail, & Verdoorn, 1996). Many have active metabo-
excitement, and have a calming, anxiolytic effect. In lites that are biotransformed more slowly than the
TABLE 5.1 Names, Routes of Administration, Dosage, and Half-Life of Commonly Used Benzodiazepines

Routes of Half-life
Generic/trade name (street name) administration (hours) Usual therapeutic use Usual dosage (mg)

Alprazolam/Xanax (blue haze) Oral 6-16 Anxiety disorder 0. 125-3.0 bid-qid

Chlordiazepoxide/Librium (libs, Oral, IM, IV 5-15 Anxiety/alcohol withdrawal 50-100 qd-qid
tranqs)
Clonazepam/Klonopin Oral 30-60 Seizure disorders/agitation/ 1-5 qd-bid
anxiety
Diazepam/Valium (CVs, vals, Oral 20-70 Anxiety/withdrawal/seizures 5-10 tid-qid
yellow-and-blues)
Flurazepam/Dalmane Oral 47-100 Insomnia 15-30qhs
Lorazepam/Ativan Oral 12-18 Anxiety/agitation/withdrawal 1-5 bid-qid
Midazolam/Versed IV or IM 1.2-12.3 Preanesthetic 5.0 mg
Oxazepam/Serax Oral 5.7-10.9 Anxiety /withdrawal 15-30, tid-qid
Temazepam/Restoril Oral 3.5-18.4 Insomnia 7.5-30.0 qhs
Triazolam/Halcion Oral 1.5-5.5 Insomnia 0.125-0.25 qhs

TABLE 5.2 Other Sedative-Hypnotics/Anxiolytics

Routes of Half-life Usual sedative/

Generic/trade name (street name) administration (hours) Usual therapeutic use anxiolytic dosage

Barbiturates
Amobarbital/Amytal (blue Oral, IM, IV 10-40 Insomnia/preoperative/ 40-50 bid-tid
devil/blue doll) seizures
Butabarbital/Butisol Oral 35-88 Insomnia in combination 15_30, tid-qid
with analgesics for
headache
Methohexital/Brevital IV 3-5 Preoperative -
Pentobarbital/Nembutal Oral, IM, IV, 15-50 Insomnia/seizures/ 100 qhs
(yellow jackets/yellows) rectal preoperative
Phenobarbital/Luminal Oral, IM, IV 80-120 Seizures 30-120 bid-tid
(phennies)
Secobarbital/Seconal (red Oral, IM, IV, 15-40 Insomnia/seizures 100 qhs
devils/reds) rectal
Others
Buspirone/Buspar Oral 10-16 Anxiety 10-60 bid-tid
Chloral Hydrate/Noctec Oral, rectal 5-10 Insomnia 500 @ hs
(miki's/mickey Finn)
Ethchlorvynol/Placidyl Oral 10-20 Insomnia 500 @ hs
Glutethemide/Doriden Oral 7-15 Insomnia 250-500 @ hs
Meprobamate/Miltown Oral 6-7 Anxiety 1200-1600
(goof balls) bid-tid
Zolpidem/Ambien Oral 2-4 Insomnia 5-20 qhs
98 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

parent compounds, explaining the long duration of

Mechanisms of Tolerance and Dependence
effects. Metabolism occurs in three major stages. For
those compounds that have a substituent on the dia- Tolerance is defined as a reduction in response to a
zepine ring, the initial phase of metabolism is the drug after repeated administrations (Hobbs et al.,
removal of the substituent producing an N-desalky- 1996). Pharmacokinetic tolerance occurs with the
lated compound which is biologically active. One barbiturates, but not the benzodiazepines, and refers
such compound, nordiazepam, is an active metabo- to changes in the distribution or metabolism of a
lite common to the metabolic pathway of diazepam, drug after repeated administration so that reduced
clorazepate, prazepam, and halazepam. The second concentrations are present in the blood. Barbiturates
phase of metabolism involves hydroxylation and also stimulate the activity of the hepatic microsomal en-
usually yields an active metabolite. The third major zymes and therefore cause more rapid metabolism of
stage of metabolism is conjugation, principally with the barbiturates themselves as well as of many other
glucuronic acid to an inactive metabolite. drugs. Hence, barbiturate administration can cause a
decreased plasma level and therefore therapeutic ef-
fects of a number of other agents. Benzodiazepines
do not stimulate activity of the hepatic microsomal
Actions in the Central Nervous System
system.
Pharmacodynamic tolerance occurs with chronic
Impact on Neurotransmitter Systems
benzodiazepine administration and is most likely
Since the 1970s, much attention has been focused caused by drug-induced changes in receptor density
on the neurobiology of sedative-hypnotic and anxio- or function. Tolerance to the various effects of drugs
lytic agents. While most of the work has focused on develops at differing rates. For the benzodiazepines,
the benzodiazepines, it is likely that most sedative- although tolerance develops fairly rapidly to the
hypnotics have important similarities in the mech- sleep-inducing properties, tolerance to anxiolytic ac-
anism of action. Most of the actions of sedative- tivity and memory impairment is generally not seen.
hypnotic agents are a result of potentiation of neural Physical dependence is the state that develops as
inhibition mediated through the gamma-aminobu- a result of the resetting of physiological responses as a
tyric acid (GABA) neurotransmitter system. Ninety consequence of repeated drug use. The GABA-ergic
percent of all inhibitory neurons are believed to be system adjusts to the chronic presence of benzodiaz-
GABA-mediated. Animal and clinical studies have epines, so that when the agents are stopped abruptly,
demonstrated that drugs with an intrinsic positive ef- physical signs and symptoms occur (table 5.3) that
fect at the GABA-benzodiazepine-chloride channel are manifestations of central nervous system hyper-
complex (e.g., GABA agonists, benzodiazepine ago- arousal due to readaptation to the absence of the
nists, barbiturates, and alcohol) facilitate GABA-me- drug. As will be discussed in a later section, with-
diated chloride conductance and possess anxiolytic drawal from sedative-hypnotic agents can be life-
and anticonvulsant activity (Aaronson, Hinman, & threatening.
Okamoto, 1984; Frye, McGown, & Breese, 1983).
The mechanism of inhibitory activity appears to be CLINICAL ASPECTS
activation of the central benzodiazepine receptor or
the GABA-A receptor, which increases chloride con-
Abuse Potential and Toxicity
ductance through the ionophore, thereby hyperpo-
larizing the cell membrane and stabilizing the cell In tables 5.1 and 5.2, the names, route of administra-
(Potter, Rudorfer, & Manji, 1990). Specific benzodi- tion, usual dosages, and half-lives of benzodiazepines
azepine receptors associated with the GABA recep- (table 5.1) and other sedative-hypnotics and anxiolyt-
tor/chloride ion channel have been identified, and ics (table 5.2) are displayed.Generally, these drugs
benzodiazepine antagonists have been developed. are taken orally. The benzodiazepines have low tox-
GABA receptors are present at all levels within the icity and few drug interactions but can produce addi-
central nervous system. The many different pharma- tive sedation in combination with alcohol. The bar-
cological activities of the benzodiazepines are due to biturates have complex drug interactions. These
activities in varying, specific brain regions. drugs inhibit the metabolism of many other drugs
 SEDATIVE-HYPNOTIC AND ANXIOLYTIC AGENTS 99

TABLE 5.3 Sedative-Hypnotic Withdrawal Symptoms

Mild Moderate Severe

Anxiety Panic Hypothermia

Insomnia Decreased concentration Vital sign instability
Dizziness Tremor Muscle fasciculations
Headache Sweating Seizures
Anorexia Palpitations Delirium
Perceptual hyperacusis Perceptual distortions Psychosis
Irritability Muscle aches
Agitation GI upset
Insomnia
Elevated vital signs
Depression

and can cause life-threatening CNS depression in shown to produce less preference and euphoria than
combination with alcohol and other CNS depres- pentobarbital and secobarbital, both of which have a
sants. rapid onset of action.
The potential for sedative-hypnotic and anxiolytic
abuse and dependence is apparent from laboratory
Physical Symptoms of Abuse
as well as clinical settings. Drug self-administration
and Dependence
procedures in laboratory animals provide valuable in-
formation concerning the potential for the abuse of An area of major concern if a decision is made to
pharmacological agents in humans. Multiple experi- discontinue a sedative-hypnotic agent is the physical
mental studies with rats and nonhuman primates dependence and withdrawal that can occur with
have indicated that a variety of sedative-hypnotic and nearly all of these agents. It is important to note that
anxiolytic agents are self-administered. These studies withdrawal has not been reported for buspirone,
indicated that benzodiazepines are less efficacious which is an anxiolytic but not a sedative-hypnotic
reinforcers than barbiturates and psychomotor stimu- agent. Studies have confirmed that withdrawal symp-
lants (Griffiths & Sannerud, 1987). Of interest, in self- toms can occur both with high-dose use and after
administration paradigms, buspirone has not been prolonged treatment at therapeutic doses (Griffiths
shown to be self-administered by animals or humans & Sannerud, 1987). Withdrawal manifestations are
or to produce physical dependence. In this regard, quite variable (table 5.3) and are related to the seda-
buspirone clearly has a different pharmacological tive-hypnotic used, the half-life and dosage of the
profile from the sedative-hypnotic agents. However, agent, and patient characteristics such as personality
self-administration in animal laboratory paradigms, factors, age, and general health. Rickels, Schweizer,
as well as dependence and tolerance, has been estab- Case, and Garcia-Espana (1988) found that personal-
lished with zolpidem (Griffiths, Sannerud, Ator, & ity factors, such as neuroticism and dependence,
Brady, 1992). made significant contributions to the severity of with-
Studies comparing the abuse liability of various drawal from sedative-hypnotics and were good pre-
benzodiazepines have found that there are meaning- dictors of difficulty with sedative-hypnotic discon-
ful differences among these compounds. Oxazepam, tinuation. Older age and male sex were favorable
halazepam, and chlordiazepoxide all appear to have demographic features for sedative-hypnotic-depen-
less abuse potential than lorazepam, diazepam, and dent patients wishing to discontinue intake.
alprazolam (Griffiths & Sannerud, 1987). It may be Withdrawal following cessation of short-half-life
that a rapid onset of effect is an important determi- drugs (e.g., alprazolam and oxazepam) generally be-
nant of differential abuse liability among drugs in the gins within 1-3 days, while withdrawal from longer-
same class. This finding is paralleled in the studies half-life drugs (e.g., diazepam, chlordiazepoxide)
of barbiturates in which phenobarbital has been usually begins after 4-7 days. The time course for
100 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

such symptoms may be only a few days or, less com- may present special problems during withdrawal.
monly, 1-4 weeks. For short-half-life agents, with- Brown and Hauge (1986) noted that the triazolo
drawal is likely to begin and peak within a few days group may lead to greater binding affinity for a sub-
and be over within a week. For agents with a longer population of benzodiazepine receptors that are not
half-life, the symptoms may last for several days to influenced by other benzodiazepines. They believe
weeks. that other benzodiazepines are therefore not totally
Minor withdrawal is often described by patients effective in producing cross-tolerance for triazoloben-
as involving increased acuity to sound or smell and zodiazepines and therefore are less effective in treat-
sometimes vision, with colors often being "too vivid"; ing their withdrawal symptoms. Other case reports
anxiety that may exceed the pretreatment level, at substituting clonazepam for triazolobenzodiazepines
least temporarily; and irritability, insomnia, agitation, would seem to contradict this belief (Herman, Ro-
dizziness, and anorexia. Moderate withdrawal may senbaum, & Brotman, 1987).
be characterized by some vital sign elevations, panic- It is important to distinguish withdrawal symp-
like symptoms, decreased concentration, tremor, toms from the reemergence of symptoms, as well as
sweating, headache, palpitations, insomnia, percep- symptom rebound, in individuals with anxiety disor-
tual distortions, muscle aches, GI symptoms, and de- der. For the most part, this can be done by careful
pression. Severe withdrawal is generally not seen in assessment of the profile and time course of symp-
individuals with therapeutic dose dependence. Se- toms that emerge upon drug termination. Symptom
vere withdrawal has been characterized as similar to reemergence involves a gradual return of the original
that of delirium tremens following alcohol cessation symptoms. Rebound anxiety is anxiety symptoms
and can include hypothermia, vital sign fluctuations, more severe than the original symptoms, which sub-
muscle fasciculations, delirium, seizures, and psy- sequently return to original levels. Withdrawal symp-
chotic symptoms including depersonalization, dere- toms appear during drug taper and disappear in a
alization, and paranoid ideation. Debate continues matter of days to weeks. It is necessary for patients
over the existence of a protracted abstinence syn- to remain medication-free for at least 2-3 weeks to
drome lasting months to years. Smith and Wesson distinguish fully among these three phenomena, but
(1995) postulate that low-dose sedative-hypnotic certain symptoms experienced for the first time after
withdrawal is receptor-mediated. This theory posits a benzodiazepine has been discontinued should
that because of this receptor mediation, symptoms probably be considered withdrawal symptoms.
worsen when patients are tapered from the last few
milligrams of drug and may last for 6 months to 1
Treatment of Sedative-Hypnotic Withdrawal
year.
Despite the total number of doses of benzodiaze- Patient education is one of the most important as-
pines prescribed per year, the number of withdrawal pects of managing sedative-hypnotic withdrawal, par-
reactions reported is relatively small. However, esti- ticularly with therapeutic dose dependence. Patients
mates are that 40% of benzodiazepine users will ex- should be informed of the need for withdrawal and
perience clinically distressing signs of withdrawal educated about potential signs and symptoms, and
with abrupt cessation and constitute a significant the approach to discontinuation should be discussed
population of patients (Tyrer & Seivewright, 1984). with the patient. Several strategies may be used in
The duration of sedative-hypnotic treatment that can the management of sedative-hypnotic withdrawal.
produce physical dependence is not well character- The first two approaches, which involve drug taper-
ized. Some estimate it to be as short as 4-6 weeks ing, are the most commonly used in situations of
(Fontaine, Chouinard, & Annable, 1984). If rebound therapeutic drug dependence in which a slow dis-
insomnia is considered a measure of withdrawal, this continuation of drug can be tolerated and the with-
has been demonstrated after only 2 weeks of daily drawal can be managed on an outpatient basis. The
drug administration (Bixler, Kales, Kales, Jacoby, & third approach, phenobarbital substitution, is more
Soldatos, 1985). appropriate in situations where sedative-hypnotic
There is suggestion from recent reports that the abuse is clearly established and detoxification needs
triazolobenzodiazepines, alprazolam and triazolam, to be done rapidly. This strategy is designed to be
 SEDATIVE-HYPNOTIC AND ANXIOLYTIC AGENTS 101

used where close observation is possible, such as in possible. Because of the preliminary nature of the
an inpatient setting. It is important to note that with- controlled evidence supporting the use of carbamaz-
drawal from high-dose sedative-hypnotic use can be epine and the potential for serious adverse conse-
life-threatening and often requires an inpatient setting. quences with inadequately managed sedative-hyp-
In the approach of drug tapering, perhaps the notic withdrawal, a benzodiazepine backup for
most common approach is to taper the therapeutic elevated vital signs or other signs of withdrawal in
agent over a 6- to 12-week period, using small reduc- individuals being detoxified with carbamazepine
tion increments. It is appropriate to reduce by one should always be used.
fourth the prescribed dosage per week for the first
several weeks, but as lower doses of medication are
Pathological Effects
approached, even smaller decrements should be
used. This is particularly true if the half-life of the Sedative-hypnotic abuse appears to be predominant
drug is short. With shorter half-life drugs, this may in certain populations clinically. In the majority of
mean dosing three to four times per day or more to- cases, sedative-hypnotic abuse occurs in the context
ward the end of the taper. For individuals who expe- of polysubstance abuse. In these cases, the sedative-
rience withdrawal symptoms using this regimen, a hypnotics are often taken to ameliorate adverse ef-
switch to a longer acting agent, such as clonazepam fects of psychostimulants, to self-medicate heroin or
(Herman et al., 1987), which can then be tapered alcohol withdrawal, or to produce intoxication when
over several weeks, may be indicated. Clonazepam is other drugs are not available. Sedative-hypnotics are
a particularly good agent to use when a decision has rarely the drug of choice in these individuals. In one
been made to switch to a long-half-life agent. It has study of individuals in an inpatient substance-abuse
a slower onset of activity and relatively less abuse po- treatment setting, 96% of individuals presenting with
tential than other agents with long half-lives (e.g., di- sedative-hypnotic abuse or dependence also had an-
azepam). other substance-use disorder (Malcolm, Brady, John-
A protocol for switching patients to phenobarbital ston, & Cunningham, 1993).
has been described by Smith and Wesson (1995). Another population at risk for the development of
Their article provides conversion dosages between sedative-hypnotic abuse or dependence is individuals
phenobarbital and most sedative-hypnotics. For indi- seeking treatment for anxiety or depression who also
viduals for whom the daily administered dose of sed- have a history of, or current, substance use disorder.
ative-hypnotic is unclear, a protocol for using a pen- A history of a substance use disorder or a strong fam-
tobarbital challenge to determine the phenobarbital ily history of a substance use disorder should alert
dosing strategy for detoxification has been described the physician that the risk-benefit ratio for sedative-
by Jackson and Shader (1973). hypnotic use must be assessed carefully. Covert alco-
A carbamazepine substitution protocol has been holism presents a great challenge to the clinician in
shown preliminarily to be an effective treatment for prescribing sedative-hypnotics because it often pre-
benzodiazepine withdrawal. Carbamazepine has sents as an anxiety disorder. However, Ciraulo,
been shown to be as effective in the treatment of Sands, and Shader (1988) challenged the assertion
alcohol withdrawal as oxazepam (Malcolm, Bal- that alcoholics have a greater liability for sedative-
lenger, Sturgis, & Anton, 1989). In two preliminary hypnotic abuse. In their review, they asserted that the
open-label studies, carbamazepine in dosages of 200 liability for abuse may be greater for alcoholics, but
mg tid for 7-10 days was effective in managing pa- there are such methodological deficiencies in the
tients with difficult benzodiazepine withdrawal present studies that such a conclusion cannot auto-
(Klein, Uhde, & Post, 1986; Ries, Roy-Byrne, Ward, matically be reached. In light of the potential for se-
Nepper, & Cullison, 1989). In a multisite, placebo- rious interactions and the clinical experience that al-
controlled study of the use of carbamazepine in al- coholics abuse both alcohol and sedative-hypnotics,
prazolam withdrawal (Ballenger, Lydiard, Laraia, it seems that the use of sedative-hypnotics by alcohol-
Fossey, & Zealberg, 1991), carbamazepine showed ics, whether drinking or in recovery, should be un-
some promise in the management of withdrawal, but dertaken with great caution even on a short-term ba-
the high dropout rates made definite conclusions im- sis and probably should not be prescribed long term.
102 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

accurate diagnosis, knowledge of indications and side

Physiological Effects
effects, and the willingness to monitor outcome re-
Benzodiazepines and other sedative hypnotics can peatedly and frequently. The vast majority of seda-
cause varying degrees of light-headedness, lassitude, tive-hypnotic and anxiolytic users use them appropri-
increased reaction time and motor incoordination, ately and as prescribed by their physicians.
impairment of mental and motor function, confu- Guidelines regarding benzodiazepine prescribing
sion, and anterograde amnesia. All of these effects have been published by the American Psychiatric As-
can impair driving and other psychomotor skills. As sociation in a task force report (1990). In the report,
previously mentioned, interaction with ethanol may therapeutic dose dependence is clearly acknowl-
be particularly dangerous. These agents may also edged and discussed. The importance of informing
cause paradoxical effects. There have been reports of patients concerning this potential before initiating
increased nightmares, anxiety, and irritability and the long-term treatment is made clear, and strategies for
release of bizarre, uninhibited behavior with the use managing withdrawal are discussed. This task force
of benzodiazepines, referred to as disinhibition or report recommends that benzodiazepines be used for
dyscontrol reactions (Rashi, Patrissi, & Cook, 1988). the short-term treatment of anxiety or insomnia that
The most serious physiological consequence of interferes with daily functioning. Long-term use is
chronic use of these agents is the risk of physical de- recommended for only two groups of patients: the
pendence and life-threatening physical withdrawal medically ill with persistent anxiety as a component
with discontinuation of use. of the medical illness that cannot be treated in other
ways and individuals with chronic panic or agora-
phobia for which benzodiazepines are decided to be
Psychological Effects
the agent of choice by the treating physician. The
As mentioned above, benzodiazepines have pro- task force report discourages the long-term use of
found effects on cognition and memory. Paranoia, benzodiazepines by patients with chronic sleep disor-
depression, and suicidal ideation have also been re- ders. It is recommended that the lowest dose possible
ported in several small case series associated with be used and that patients be treated for the briefest
chronic use of benzodiazepines. These effects have period of time indicated for their clinical condition.
not been investigated in any well-controlled studies. The task force urges particular caution in prescribing
benzodiazepines to the elderly and to individuals
with substance use disorders. Clear and more limited
Social/Interpersonal Effects
guidelines for sedative-hypnotic prescribing practices
Like all addictive disorders, sedative hypnotic abuse will probably greatly reduce the risk of sedative-hyp-
and dependence generally have profound effects on notic abuse.
social and interpersonal functioning. Because of While withdrawal reactions are likely with long-
effects on cognition, memory, and psychomotor per- term sedative-hypnotic use, these can be clinically
formance, work and/or school performance is im- managed and should not militate against appropriate
paired. Like any addiction, sedative-hypnotic abuse use. Withdrawal symptoms are generally mild in rou-
and dependence impair consistent performance in tine clinical use of sedative-hypnotics and controlled
social roles (wife/husband/parent) and interfere with by sensible drug tapering. The potential for with-
the development of healthy interpersonal relation- drawal phenomena should be discussed with all pa-
ships. tients at the initiation of therapy. Current or past sub-
stance abuse appears to be the most prominent risk
factor for sedative-hypnotic abuse and should be
SUMMARY carefully assessed in all patients. Clinicians must be
mindful of the risks of prescribing sedative-hypnotics.
Sedative-hypnotics and anxiolytics remain one of the With both physicians and patients fully informed
most useful classes of medication for the manage- concerning the risks and benefits of these drugs, their
ment of numerous disorders, particularly the anxiety use can be safe, appropriate, and important in the
disorders. As with all medications, treatment requires care of many patients.
 SEDATIVE-HYPNOTIC AND ANXIOLYTIC AGENTS 103

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 6

Stimulants:
Amphetamines and Cocaine

Michael F. Weaver
Sidney H. Schnoll

Stimulants are drugs that stimulate the central ner- This has been the case with amphetamine in the
vous system (CNS) to produce increased psychomo- 1960s and methylenedioxymethamphetamine (MDMA)
tor activity. Stimulants are widely used throughout in the 1980s. The United States is currently experi-
the world, and nearly every society has some form of encing a cocaine epidemic and the rise of a new cy-
stimulant, whether it is caffeine in the West, khat in cle of smokable methamphetamine abuse. Under-
the Middle East, or methamphetamine throughout standing the effects of stimulants on the individual
the world. Amphetamines and cocaine are the most as well as on society is essential to the effective treat-
prevalent stimulants of abuse. Smokable metham- ment of stimulant addiction.
phetamine has been growing in popularity since the
early 1980s, and over 4 million people in the United
States have tried it (Substance Abuse and Mental
Health Services Administration, 1995). MAJOR PHARMACOLOGICAL ACTIONS
Stimulant abuse is cyclic in nature. A new drug
will become popular on the illicit market and reach
Metabolic Pathways
a peak of abuse among addicts, often generating
panic in the general population. However, rates of Amphetamine is metabolized extensively in the liver
abuse will gradually decline over time through death into several biologically active metabolites (see figure
or disinterest until another new drug comes along to 6.1), and nearly half is excreted unchanged in the
start the cycle again. Stimulant epidemics, like stim- urine while the rest is eliminated by biotransforma-
ulant problem users, have a natural tendency to burn tion. The biological half-life of most amphetamines
themselves out (Kaplan, Husch, & Bieleman, 1994). is 6-12 hr (Lader, 1983).

105
106 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

FIGURE 6.1 Structures and metabolism of some amphetamines.

Cocaine is also rapidly and extensively metabo- lum, 1988; Weiss & Gawin, 1988). Cocaine under-
lized (see figure 6.2), then excreted in the urine. Its goes oxidative metabolism by cytochrome P-450
chemical name is benzoylmethylecgonine and it is monooxygenases in the liver to a potentially toxic ac-
broken down into both active and inactive metabo- tive metabolite, norcocaine, but less than 10% is me-
lites by cholinesterases found in serum and the liver. tabolized by this pathway (Roberts, Harbison, &
The vast majority is hydrolyzed to two inactive me- James, 1991). Another active metabolite is ethylco-
tabolites (benzoylecgonine and ecgonine methyl-es- caine (cocaethylene), which is formed by the liver
ter) with half-lives of 4-6 hr. Both are detectable on only in the presence of alcohol. Ethylcocaine has a
a urine drug screen within 4 hours of inhalation and potency equal to cocaine, which heightens the risk
up to 48 hours after cocaine use or even longer in of toxicity from cocaine when it is taken with alcohol
chronic users (Quandt, Sommi, Pipkin, & McCal- (Benowitz, 1993).
 STIMULANTS: AMPHETAMINES AND COCAINE 107

FIGURE 6.2 Metabolism of cocaine.

Certain types of patients are at higher risk for de- ciated with expression of behavior and emotions, a
veloping cocaine toxicity. Those who have deficient heightened state of arousal, and pleasure. The simul-
plasma cholinesterase, about 3% of the U.S. popula- taneous interaction between these different NT path-
tion (Becker, 1972), will metabolize it more slowly, ways is fundamental to stimulant euphoria and re-
so that they are at higher risk for adverse effects ward behavior (Gawin, 1991).
(Hoffman et al., 1992). Cholinesterase activity is Amphetamine binds to the DA transporter (reup-
lower in the elderly, patients with liver disease, preg- take pump) on the presynaptic neuron in the synap-
nant women, and infants. Agents that induce cyto- tic cleft, then causes reversal of the pump mecha-
chrome P-450 enzymes, such as alcohol or pheno- nism, which allows DA to be released back into the
barbital, can increase the percentage of cocaine that synaptic cleft to stimulate postsynaptic receptors
is converted to norcocaine and other active metabo- (Raiteri, Bertollini, Angelini, & Levi, 1975). Amphet-
lites which are toxic. Care should be taken to prevent amine also enhances release of excitatory NT from
cocaine use in those populations that are more vul- intracellular vesicles (Knepper, Grunewald, & Rut-
nerable to its toxic effects. ledge, 1988) and inhibits monoamine oxidase from
breaking down NT in the synaptic cleft (Miller,
Shore, & Clarke, 1980), an action that accounts for
Actions in the Central Nervous System
its long duration of effect. The primary mechanism
of cocaine's effects is blockade of the DA transporter
Impacts on Neurotransmitter Systems
(Ritz, Lamb, Goldberg, & Kuhar, 1987), but without
Despite structural and neuropharmacological differ- reversal of DA reuptake or inhibition of monoamine
ences, all stimulants are indirect sympathomimetic oxidase. Therefore, the acute effects of cocaine are
drugs. By blocking neurotransmitter (NT) reuptake transient and soon result in rapid depletion of NT.
at the synaptic junction, which raises the concentra- Cocaine acts very rapidly and can increase NE levels
tion of NT in the synapse, they produce activation of in the brain within 10 min of administration, but
dopamine (DA), norepinephrine (NE), and seroto- there is a subsequent decrease to subnormal levels
nin (5-HT) systems. These pathways are closely asso- within 20 min (Pradhan, Roy, & Pradhan, 1978).
108 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

Thus, there is a rapid onset of euphoria, but once on pharmacologically based euphoria despite a pro-
the available NT is depleted, the euphoric effects di- gressive inability to attain this state (tolerance) and
minish rapidly, to be replaced by feelings of depres- adverse consequences. Controlled use shifts to com-
sion and craving for a repeat of the euphoria. pulsive use when users attain increased access to
Chronic use of stimulants results in NT deple- these drugs and escalate dosage or when they switch
tion. Synapses operate using a negative feedback sys- to a more rapid route of administration, such as from
tem, so compensatory changes occur that allow the chewing leaves to insufflation to smoking or intrave-
neurons to adapt to alterations in the NT milieu nous injection. The absence of a daily use pattern
caused by stimulants. Brain reward regions affected does not indicate less impairment, since stimulant
by stimulants are down-regulated and become sub- dependence is characterized by binges, or "runs," of
sensitive, the reaction responsible for the protracted intense use alternating with periods of decreased use
anhedonia experienced when chronic stimulant us- or short periods of abstinence without an intention
ers become abstinent (Gawin, 1991). High-dose use to quit permanently. Subjective experiences or symp-
of stimulants over long periods of time causes neuro- toms other than physiological discomfort are crucial
physiological changes in brain systems, which can in addiction to stimulants. Numerous periods of ex-
take months to resolve after cessation of stimulant treme euphoria are experienced during a binge,
use. forming vivid memories that are later contrasted with
the depression resulting after the stimulant effects
have worn off, so and craving results (Gawin &
Mechanisms of Tolerance and Dependence
Kleber, 1986). Addicts continue to use stimulants to
Tolerance is the need to take larger doses of a drug avoid the depressed mood when the effects wear off;
to get the same initial effect. Tolerance to stimulant the result is hinging, with acute tolerance causing
effects develops rapidly, especially to some properties rapid dose escalation until drug supplies are ex-
such as anorexic effects, some cardiovascular effects, hausted. Neurochemical changes cause long-term
euphoria, and many CNS actions. Acute tolerance mood alteration and create psychological depen-
may be due to enhanced synaptic clearance and/or dence that leads to recurrent binges. Stimulants
decreased release of DA, which may explain the dose cause physiological dependence at the NT level,
escalation that occurs when people use increasingly which is clinically expressed as psychological depen-
larger doses at frequent intervals during a binge. dence. According to estimates by the National Insti-
Only partial tolerance develops to arrhythmias or sei- tute on Drug Abuse (NIDA), only 10-15% of those
zures (Ambre et al., 1988), which raises the risk for who initially try stimulants (specifically cocaine) in-
development of toxicity during a binge. Develop- tranasally become abusers. No set of characteristics
ment of tolerance indicates that a user is at risk for has been identified predicting whether a recreational
developing dependence on stimulants. user will become chemically dependent.
Psychological dependence is the feeling that a
drug is essential to normal functioning. Stimulants
were previously believed not to have a withdrawal CLINICAL ASPECTS
syndrome or to produce dependence, but this mis-
conception may have arisen because most early stud- Clinical Pharmacological Aspects
ies were done on subjects who used relatively low
Preparations
doses for short periods of time. Cocaine and amphet-
amines are the most potent reinforcing agents Amphetamines come in a variety of commercial and
known, and they produce intense classical and op- illicit preparations and can be used orally or intrana-
erant conditioning. Animals trained to acquire co- sally, smoked, or injected intravenously (IV) (see ta-
caine will continue to take the drug, disregarding ble 6.1). They are most commonly taken as tablets
food and sex. In similar fashion, addicts report that when used for therapeutic purposes such as treat-
during binges, virtually all thoughts are focused on ment of attention deficit disorder (ADD), narcolepsy,
stimulants: sleep, nourishment, money, loved ones, or exogenous obesity. One of the earliest amphet-
responsibility, and survival lose all significance amines available for commercial use was benzathine
(Gawin & Kleber, 1986). A stimulant addict focuses nasal spray used to treat asthma and rhinitis. Meth-
 STIMULANTS: AMPHETAMINES AND COCAINE 109

TABLE 6.1 Names of Common Stimulant Preparations

Generic name Trade name Street names

Amphetamines
Amphetamine sulfate Benzedrine Bennies, peaches
Dextroamphetamine Dexedrine Dexies, footballs
Amphetamine + dextroamphetamine Adderall
Biphetamine
Phenmetrazine Preludin
Methylphenidate Ritalin Kits
Methamphetamine Methedrine Uppers, white crosses, black beauties, pep
Desoxyn pills, speed, meth, crystal, crank
Freebase methamphetamine Ice, crystal

Designer drugs
DOM (dimethoxymethylamphetamine) STP (serenity, tranquility, and peace),
sweet tart, wedge
MDA (methylenedioxyamphetamine) The love drug
MDMA (methylenedioxymethamphetamine) Ecstacy, XTC, Adam, M & M
MDEA (methylenedioxyethamphetamine) Eve

Cocaine
Coca paste Pasta, bazooka
Cocaine HC1 Blow, snow, nose candy, white lady, flake,
paradise, girl, coke
Alkaloid (freebase) Freebase crack, rock, supercoke, gravel,
Roxanne

amphetamine is a more potent form of amphetamine used by multiple routes (see table 6.1). It is found
used for therapeutic and illicit purposes. The free- naturally in the leaves of the Erythroxylon coca plant
based form of methamphetamine hydrochloride indigenous to South America, which contain about
(HC1) is highly pure and smokable and is known on 1% cocaine by weight. South American natives chew
the street as ice. coca leaves to reduce hunger and fatigue as well as
"Designer drugs" are synthetic derivatives of fed- to increase their sense of well-being. The leaves can
erally controlled substances, created by a slight alter- be steeped in tea or incorporated into beverages such
ation in the molecular structure of existing drugs and as wine or the original formulation of Coca-Cola.
produced illegally in clandestine laboratories for il- Coca paste is a crude extract of coca leaves con-
licit use. The most popular of these is methylenedi- taining 40-85% cocaine sulfate, which is smoked
oxymethamphetamine (MDMA), known on the street (Karan, Haller, & Schnoll, 1991). This is used pri-
as ecstasy. Initially, it was used legally as an adjunct marily in South America, while more potent prepara-
to psychotherapy, but it became popular on the illicit tions are used throughout the rest of the world.
market for its intoxicating effects. There are at least Cocaine HC1 is the most common form of co-
half a dozen amphetamine designer drugs available caine used for illicit or therapeutic purposes. It is
on the illicit market today (see table 6.1). Most have processed from the leaves of the coca plant. Since it
some psychoactive properties and cause visual dis- is easily absorbed through any mucous membrane, it
turbances but are not true hallucinogens like lysergic can be ingested orally or used topically as a local
acid diethylamide (LSD) (Beebe & Walley, 1991). anesthetic. Commercial generic cocaine HC1 is
Cocaine comes in a variety of commercial and available for therapeutic use in the form of crystals,
illicit preparations and, like amphetamines, can be flakes, or tablets that can be dissolved, or in a pre-
110 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

packaged solution. It is also available for pediatric euphoria, or the "rush," leads to immediate gratifica-
local anesthesia in fixed combination with tetracaine tion and provides a powerful stimulus for readminis-
and adrenaline as TAG solution (Pryor, Kilpatrick, & tration of the drug to maintain the euphoria, or
Opp, 1980). Alkaloid forms of cocaine can be made "high." Most often, the more rapid the onset of ac-
by different techniques to produce either "freebase" tion, the shorter the duration, so that more frequent
or "crack." Unlike cocaine HC1, which decomposes administration is required. The routes of administra-
at high temperatures, alkaloid cocaine vaporizes at tion having the most rapid onset of action are IV and
a much lower temperature, so that it is suitable for smoking. When injected IV, stimulants reach cere-
smoking. bral circulation in 10-15 sec. When smoked, they
reach the brain in 6-8 sec, but this route is less
potent than IV since smoked stimulants have only
Routes and Dosages
50-60% of the bioavailability of IV stimulants. Smok-
Routes of Administration (See Table 6.2) As with ing can achieve blood levels comparable to those
other classes of abused drugs, certain routes of ad- reached through IV injection (Cook & Jeffcoat, 1990)
ministration of stimulants carry higher risk for acute despite lower bioavailability because the lungs pro-
toxicity as well as potential for the development of vide a very large surface for rapid absorption of drug
addiction. Stimulants can be taken by several differ- and the smoker can rapidly titrate the amount ad-
ent methods, and some formulations are more suit- ministered to provide the desired blood level based
able for certain routes. In general, the faster a drug on effect. These routes also have the most potential
has its euphoric effect on the brain, the higher the for toxicity due to rapid dose escalation. They are
potential for addiction and toxicity. Rapid onset of more dangerous than other routes because of the

TABLE 6.2 Common Stimulant Dosages

Administration Common Dosage

Street
Drug Route terminology Usual dose Street terminology

Amphetamine Oral 5—20 mg/day (Therapeutic)

Amphetamine + Oral 10-mg tablets
dexrroamphet- 20-mg tablets
amine
Methamphetamine Intravenous Run average 1/10 g Hit
Coca leaves Oral (chew) 1% cocaine by weight Cocada
Coca paste Smoke Bazooka 40-85% cocaine sulfate
Cocaine HC1 Oral 135-me soluble tablets
Topical 40-100 mg/ml solution (Therapeutic)
5-2 5-g powder
(200-400 mg in adults)
Intranasal in- Snort, sniff, 10-30 mg powder per line, 30 lines Line, rail
sufflation toot from 1 g
Intravenous Shoot, main- 3g Eight-ball
line 6-8 g or 1/4 oz/week binge, run,
spree
Alkaloid cocaine Smoke Bong 2-3 inhalations/rock, 2-3 rocks/vial Rock, vial
(crack) (pipe)
TAG (tetracaine, Topical 11.8% cocaine HC1 (Therapeutic)
adrenaline, co-
caine) solution
 STIMULANTS: AMPHETAMINES AND COCAINE 111

need for specialized equipment ("works") such as sy- tions of the Andes Mountains, and the distance a per-
ringes or pipes, which pose additional risks, such as son can travel in the time it takes to chew a wad of
spread of infection or injury by fire. Intranasal insuf- coca leaves is known as a cocada (Karan et al., 1991).
flation ("snorting") is the most common route of ad- Because it is illegal in the United States to use
ministration for stimulants (Cregler & Mark, 1986) cocaine except as a topical anesthetic, any other use
since it requires no specialized equipment. Euphoria may be considered misuse. Out of the millions of
is achieved in 3-5 min, but bioavailability is only people in the United States who have tried cocaine,
20-60% (Jatlow, 1987). The amount absorbed is lim- 80% have not become regular users and 95% have
ited by vasoconstriction of the nasal mucosa, espe- not developed compulsive use or addiction (Ga-
cially for cocaine. About 90% of cocaine users have win & Ellinwood, 1988). In one study, the average
snorted, around 33% have smoked, and less than user seeking treatment for cocaine abuse reported us-
10% have injected (National Institute on Drug ing 6-8 g or one-quarter ounce per week (Schnoll,
Abuse [NIDA], 1991). Smoked and IV stimulants ap- Daghestani, & Hansen, 1985). Those who smoked
pear to be more behaviorally reinforcing than or injected cocaine consumed larger quantities than
snorted stimulants, due to binging. those who snorted it. Like amphetamines, cocaine is
A stimulant is absorbed orally with a bioavailabil- cut with varying amounts of other drugs, so the ac-
ity of 30-40%; the remainder is eliminated by first- tual dose is difficult to determine. Crack has grown
pass hepatic metabolism. Absorption occurs more in popularity in recent years and may have more
slowly from the intestines, with peak plasma levels abuse potential because of its rapid onset of action,
being reached 30-120 min after dosing. In South short duration, and widespread availability. Individu-
America, the chewing of coca leaves is very com- als who use stimulants in escalating doses over a pe-
mon, but because the amount of cocaine in the riod as short as several days are vulnerable to devel-
leaves is so low, there is no evidence that this prac- oping problems of dependence. Users may average 1
tice causes chronic toxicity or dependence. to 7 binges per week, each binge lasting 4-24 hr.
Addicts may readminister the drug as often as every
Dosages (See Table 6.2) Amphetamines are avail- 10-30 min. The duration of action of methamphet-
able by prescription for treatment of exogenous obe- amine is much longer than that of cocaine, and the
sity, narcolepsy, and ADD; the dosage is titrated by effects of methamphetamine may last 10 times as
the treating physician. Prior to the introduction of long as the effects of cocaine (Derlet & Heischober,
tricyclic antidepressants, amphetamines were used as 1990), so readministration of the drug is not as fre-
symptomatic treatment of depression in doses of quent.
5-20 mg/day (Lader, 1983). Dosage varies between
amphetamines and methamphetamines, since the ef-
Drug Interactions
fect of methamphetamines on the CNS is twice that
of amphetamines because of higher penetration
across the blood-brain barrier. Illicit amphetamines Adulterants In order to increase profits, street deal-
do not come in standardized doses. Most illegally ers adulterate the drugs with other compounds, in-
produced amphetamine is adulterated, or "cut," with cluding inert and active substances. Most stimulants
virtually any amount of another compound—which are in the form of white powder, so dealers cut them
varies widely among dealers and batches of drug—so with other white powders. These may be inert sub-
the actual dose of amphetamine taken is difficult to stances that provide bulk, such as talc, flour, corn-
determine and varies with each use. starch, or sugars. These can lead to problems by trav-
Generic cocaine is available commercially for use eling through the circulation as emboli to the lungs
as a topical anesthetic. In children it is used in TAG or by causing infection since they are usually not
solution for anesthesia during repair of minor lacera- sterile. Other adulterants may be active drugs that
tions, but there is a risk of toxicity if the solution potentiate some aspect of cocaine or amphetamines,
is accidentally swallowed (Dailey, 1988). In South such as local anesthetics or cheaper stimulants.
America, chewing coca leaves to relieve fatigue is These additives may raise the risk of toxicity by in-
widely prevalent among natives in the higher eleva- creasing the sympathetic effects or chances of car-
112 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

TABLE 6.3 Primary Drug Interactions with Stimulants

Drugs causing effect when taken with a stimulant

Effect (amphetamines or cocaine)

Increase in blood pressure and/or heart MAOIs,a alcohol, marijuana, carbamazepine, caffeine,
rate beta-blockers, NSAIDsb
Decrease in blood pressure Haloperidol, calcium channel blockers
Increase in coronary vasoconstriction Beta-adrenergic blockers (propranolol)
Reduction in vasoconstriction Tricyclic antidepressants (TCAs)
Arrhythmias Anticholinergics, bromocriptine, digoxin, anesthetics
(enflurane, halothane)
Enhancement of euphoria Heroin, buprenorphine, naloxone
Lessening of craving Flupenthixol, amantadine, TCAs
Addictive toxic metabolite Alcohol (only with cocaine)
a
MAOIs: monoamine oxidase inhibitor medications.
b
NSAIDs: nonsteroidal anti-inflammatory drugs.

diac arrhythmias. Stimulants may be cut with nearly alcohol, 20% used another depressant such as metha-
any compound, so if a patient presents with acute qualone or benzodiazepines, and 11% also used her-
intoxication or overdose, a general laboratory screen oin (Chitwood, 1985).
of urine or serum for unknown drugs is indicated Stimulants can be mixed with marijuana or to-
in addition to a screening test for common drugs of bacco and smoked in a cigarette. Marijuana potenti-
abuse. ates some sympathetic effects of stimulants, and the
combination can elevate heart rate by up to 50 beats
Common Illicit Drug Combinations (See Tables per minute, an effect that is maintained longer than
6.3 and 6.4) Polysubstance abuse is common, and with either drug alone (Foltin, Fischman, Pe-
any drug combination is possible. Users coadminister droso, & Pearlson, 1987). Heroin is used with stimu-
other drugs to reduce unpleasant components of the lants to enhance euphoria and offset overstimulation.
stimulant experience, such as anxiety. However, the Phencyclidine and hallucinogens have also been
consequences of combining stimulants with other used with stimulants but less commonly. Metham-
drugs are poorly understood. The regular use of other phetamine and crack have been used together in a
addictive drugs is prevalent: In one survey, 53% of combination sometimes known on the street as ice,
stimulant users also used marijuana, 35% also used which has the potential to cause dangerous sympa-

TABLE 6.4 Street Names for Common Illicit Drug Combinations

Drug combination Street name

Methamphetamine + alkaloid cocaine (crack) Ice

Methamphetamine + heroin Poor man's speedball
Methylphenidate + heroin Pineapple
Cocaine + heroin Speedball, girls and boys, whiz bang
Cocaine + alcohol Liquid lady
Cocaine + marijuana C &M
Cocaine + strychnine (adulterant) Death hit
Cocaine + phencyclidine Ghostbuster, space blaster
 STIMULANTS: AMPHETAMINES AND COCAINE 113

thetic overstimulation. Alcohol is used to lessen anxi- placebo for stimulant-dependent men and women
ety during the high, to induce sleep during the crash, (Schuckit, 1994).
or to help the addict cope with mood disturbances.
The combination of alcohol and cocaine produces
Physical Symptoms of
ethylcocaine, previously described. Alcohol also po-
Use, Abuse, and Dependence
tentiates stimulant-induced increases in resting heart
rate (Foltin & Fischman, 1989). Small initial doses of stimulants cause acute dopa-
minergic stimulation of the brain's endogenous plea-
Potential Therapeutic Agents (See Table 6.5) sure center. Users experience euphoria, heightened
Many different medications have been tried in at- energy and libido, decreased appetite, hyperalertness,
tempts to lessen craving for stimulants or to attenuate and increased self-confidence. Objective signs of
their euphoric effects. Stimulant abusers are a het- small doses are acute NE effects such as mild eleva-
erogeneous population, so that controlled trials are tion of pulse and blood pressure or reduction in skin
difficult to carry out and much of the evidence for temperature, which reflects cutaneous vasoconstric-
efficacy is anecdotal or based on limited open trials. tion.
The literature reveals no pharmacological agent that Higher doses cause intensification of euphoria,
has been demonstrated in large double-blind con- accompanied by heightened CNS stimulation shown
trolled clinical trials to be significantly better than as increased alertness, talkativeness, repetitive be-

TABLE 6.5 Potential Therapeutic Agents

Agent Action

Tricyclic antidepressants Block catecholamine uptake to stabilize DA and NE

Desipramine receptors
Imipramine
Monoamine oxidase inhibitors Block NT metabolism at synaptic cleft and counter-
act intraneuronal NT depletion of stimulant with-
drawal
Other antidepressants
Fluoxetine Selective serotonin reuptake inhibition to prevent 5-
Trazodone HT depletion by stimulants
Neuroleptics Block DA receptor
Haloperidol
Flupenthixol Selective blockade of D2 autoreceptors
Antiparkinsonian medications
Levodopa DA precursor
Bromocriptine DA receptor agonist
Amantidine Raises brain DA levels
Antiepileptics Prevent subclinical seizures, which may be related to
Carbamazepine craving
Valproate
Opioid agonists and antagonists
Methadone Opioid agonist
Buprenorphine Partial agonist
Naloxone Opioid antagonist
Stimulants Replacement therapy
Methylphenidate
Mazindol
Lithium Mood stabilizer
114 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

havior, and altered sexual behavior. Users have in- rapid depletion of NT at the synaptic level. Addicts
creased sympathomimetic effects such as dizziness, experience craving, depression, anxiety, and para-
tremor, hyperreflexia (rapid reflexes), hyperpyrexia noia. The craving for stimulants decreases over 1-4
(fever), mydriasis (dilated pupils), diaphoresis (sweat- hr, to be replaced by craving for sleep and rejection
ing), tachypnea (rapid breathing), tachycardia (rapid of further stimulant use. The late part of Phase 1
heartbeat), and hypertension (high blood pressure). consists of hypersomnolence lasting 8 hr to 4 days
If at least two of these signs are present within 1 hr and is accompanied by electroencephalographic
of use, criteria are met for stimulant intoxication changes (Kowatch, Schnoll, Knisely, Green, & Els-
(American Psychiatric Association, 1994). Behavioral wick, 1992). Sleep is punctuated by brief awakenings
changes are also part of the criteria for stimulant during which the addict experiences hyperphagia
intoxication; these include fighting, grandiosity, hy- ("the munchies"). Phase 1 parallels the hangover
pervigilance, psychomotor agitation, impaired judg- after an alcohol binge.
ment, and impaired social or occupational function- Phase 2 begins 12-96 hr after the crash and lasts
ing. Intravenous users are unable to tell apart the 2-12 weeks. The first 1-4 days consist of euthymia,
effects of different stimulants and cannot distinguish sleep, and little craving. Then starts a protracted dys-
cocaine from amphetamines (Fischman & Schuster, phoric syndrome in which the addict experiences
1982). Acute intoxication usually resolves within anhedonia, boredom, anxiety, generalized malaise,
6-24 hr, especially for short-acting stimulants like co- problems with memory and concentration, and occa-
caine. sional suicidal ideation. This syndrome induces se-
Repeated phasic use of low-dose stimulants leads vere craving, which may lead to resumption of stimu-
to enhanced sensitivity and potentiation of motor ac- lant use and a vicious circle of recurrent binges. The
tivity, such as exaggerated "startle" reactions, dyskine- delayed effects of withdrawal are due to neuroadap-
sia (disturbances of movement), and postural abnor- tations caused by stimulants, such as higher density
malities. The clinical features of chronic use are of receptors and supersensitivity to NT, which may
depression, fatigue, poor concentration, and mild normalize over about a month after cessation of use.
Parkinsonian features such as myoclonus (inappro- Phase 2 parallels the syndrome of withdrawal from
priate, spontaneous muscle contractions), tremor, or other abused drugs, except for the absence of gross
bradykinesia (slowing of movements). Patients pres- physiological changes.
enting with these signs should be suspected of stimu- Phase 3 is the extinction phase. There is no anhe-
lant abuse and screened carefully. donia, but there is intermittent conditioned craving
lasting months to years after the last stimulant use;
this craving is gradually extinguished over time.
Symptoms and Course of Withdrawal
Craving is the most prominent and disturbing symp-
Abrupt cessation of stimulants has no gross physiolog- tom of stimulant withdrawal. There are two types of
ical changes, so for many years it was assumed that craving: anhedonic and conditioned. Anhedonic
there was no discrete withdrawal syndrome. How- craving arises from boredom and a general desire to
ever, more recent research has revealed an absti- get high. Conditioned craving, also known as evoked
nence syndrome with symptoms more subtle and or cue craving, arises from stimuli in the environ-
complex than those previously associated with drug ment that remind the addict of the pleasures associ-
withdrawal. Biological measures suggest derange- ated with using stimulants. Conditioned craving is
ment of neurochemical activity, which appears to be more intense for stimulants than in other addictive
linked to a reduction in dopaminergic tone following disorders because stimulants are such powerful rein-
abrupt cessation of stimulant use (Lago & Kosten, forcers.
1994). The stimulant withdrawal syndrome has a tri- The severity and duration of withdrawal depends
phasic pattern of symptoms which begins immedi- on the intensity of the preceding months of chronic
ately after the last use and may last for many months abuse and the presence of predisposing psychiatric
(Gawin & Kleber, 1986). disorders, which amplify withdrawal symptoms. Neu-
Phase 1 begins with the "crash," or drastic reduc- roadaptation from high-intensity binge use may be
tion in mood and energy, starting 15-30 min after required before withdrawal occurs, and infrequent
cessation of a stimulant binge. This is caused by the users without psychiatric comorbidity may not ex-
 STIMULANTS: AMPHETAMINES AND COCAINE 115

perience withdrawal (Gawin, 1991). Since abrupt in the frontal and temporal lobes (Pascual-Leone,
discontinuation of stimulants does not cause gross Dhuna, & Anderson, 1991).
physiological sequelae, they are not tapered off or re- Pulmonary complications occur mainly when
placed with a cross-tolerant drug during medically stimulants are smoked. The most common com-
supervised withdrawal. plaint is a chronic cough with black sputum (War-
ner, 1995). Pulmonary edema (accumulation of fluid
in lung tissue) develops rapidly and may be due to
capillary membrane disruption with altered perme-
Pathological Effects
ability; fortunately, it usually resolves with supportive
therapy without specific treatment (Cucco, Yoo,
Physiological
Cregler, & Chang, 1987). Granulomatous pneumo-
Stimulants are widely distributed throughout the nitis with pulmonary hypertension may develop as
body, the highest concentrations appearing in the a result of talc in the lungs from IV injection
brain, spleen, kidney, and lungs (Prakash & Das, (Estroff & Gold, 1986). "Crack lung" is a syndrome
1993). They activate the sympathetic nervous system of chest pain, hemoptysis (coughing up blood), and
(SNS), which causes a fight-or-flight response, affect- diffuse alveolar infiltrates that may be due to lung
ing the heart, lungs, vasculature (including the brain hypersensitivity to cocaine (Forrester, Steele, Wal-
and intestinal arteries), and even sexual performance. dron, & Parsons, 1990). Long-term use results in an
The acute effects of large doses of stimulants or cu- abnormal reduction in alveolar membrane diffusing
mulative effects of long-term use can result in serious capacity (Itkonen, Schnoll, & Glassroth, 1984).
medical sequelae (see table 6.6). Repeated intranasal insufflation results in inflam-
Tachycardia and hypertension are classic sympa- mation and atrophy of nasal mucosa, chronic sinus-
thetic responses even at low doses. Activation of NE- itis, or even necrosis with perforation of the nasal
mediated systems in the heart causes coronary artery septum. Smoking stimulants in a pipe may result in
vasoconstriction so that coronary blood flow is de- singed eyebrows, facial burns, or laryngeal edema
creased during a period of high oxygen demand. due to hot smoke. Gingival ulceration may occur at
There is a high incidence of silent ischemia (lack of the site of application of oral cocaine (Quart,
blood flow to cardiac tissue) during withdrawal Small, & Klein, 1991). Stimulants may cause intesti-
(Nademanee et al., 1989), or a susceptible individual nal ischemia as a result of vasoconstriction (Texter,
may have a myocardial infarction during a binge. Chou, Merrill, Laureton, & Frohlich, 1964). Acute
Stimulants potentiate the effects of NE in cardiac renal failure may occur as a result of rhabdomyolysis
cells, an effect that leads to arrhythmias (Wilkerson, (muscle tissue breakdown) from stimulant use, but
1988). Long-term use can lead to myocarditis or cate- the mechanism for rhabdomyolysis is unclear.
cholamine-related cardiomyopathy (Virmani, Robin- Stimulants have variable effects on sexual func-
owitz, Smialek, & Smyth, 1988). tion: It may be enhanced or inhibited. Sexual arousal
The CNS has many affected areas in addition to may be heightened along with a delay in orgasm.
the pleasure centers: Direct effects on the thermoreg- Priapism (continuous painful penile erection) may
ulatory center may result in hyperpyrexia or even ma- also result. High doses for prolonged periods can re-
lignant hyperthermia (Roberts, Quattrocchi, & How- sult in aberrant sexual behavior (Smith, Wesson, &
land, 1984); depression of medullary centers can Apter-Marsh, 1984).
cause respiratory paralysis (Gay, 1982); stimulants Use of stimulants during pregnancy can cause ob-
also lower the seizure threshold. Cerebral vascula- stetric complications including preterm labor, spon-
ture is particularly affected: Vasoconstriction with is- taneous abortion, or fetal distress (Oro & Dixon,
chemia may lead to a transient ischemic attack or a 1987). From 10% to 20% of inner-city pregnant
cerebral infarct (stroke), which is more common women in the United States use cocaine (Zucker-
with crack; cocaine HC1 is associated with hemor- man et al., 1989), so effects on the fetus have been
rhagic strokes (Levine et al., 1991); migrainelike vas- well studied. The consequences of prenatal exposure
cular headaches during withdrawal have been linked to methamphetamine are believed to be similar to
to serotonin dysregulation (Satel & Gawin, 1989). those of cocaine. Higher rates of congenital malfor-
Long-term users develop cerebral atrophy, especially mations and intrauterine growth retardation may be
116 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

TABLE 6.6 Consequences of Stimulant Abuse

Physical
Cardiovascular Head and neck Other
Hypertension Erosion of dental enamel Hyperthermia
Arrhythmias Gingival ulceration Rhabdomyolysis
Myocarditis Keratitis Sudden death
Cardiomyopathy Mydriasis Sexual dysfunction
Myocardial ischemia Altered olfaction
Myocardial infarction Chronic rhinitis Reproductive
Nasal septal perforation Obstetric
Central nervous system Spontaneous abortion
Headache Renal Placental abruption
Seizures Acute renal failure Placenta previa
Transient focal neurological Premature rupture of membranes
deficits Endocrine Fetal
Cerebral hemorrhage Hyperprolactinemia Intrauterine growth retardation
Cerebral infarction Elevated thyroxin level Congenital malformations
Cerebral edema Neonatal
Cerebral atrophy Pulmonary Cerebral infarction
Cerebral vasculitis Chronic productive cough Delayed neurobehavioral development
Toxic encephalopathy/coma Pneumothorax Sudden infant death syndrome
Pneumomediastinum
Gastrointestinal Pneumopericardium
Nausea/vomiting/diarrhea Asthma exacerbation Infectious (from sharing needles)
Anorexia Pulmonary edema Human immunodeficiency virus (HIV)
Malnutrition Pulmonary hemorrhage Infectious endocarditis
Intestinal ischemia Bronchiolitis obliterans Hepatitis B and/or C
Gastroduodenal perforation "Crack lung" Tetanus

Psychological
Emotional lability Anxiety Delerium
Insomnia Depression Toxic psychosis
Altered self-esteem Aggressive behavior Suicide
Aberrant sexual behavior Paranoia
Irritability Hallucinations

Social
Less social participation Lost job productivity Violent behavior
Loss of judgment Criminal activity Higher incidence of trauma
Loss of family structure Prostitution Homicide
Child neglect or abuse Spread of infection Accidental death

due to fetal hypoxia from placental vasoconstriction trol needed to disentangle the effects of complex
and altered circulating levels of DA and NE. Stimu- interactions of drug use, lifestyle, and subject history
lants cross the placenta freely and accumulate in fe- is difficult to achieve (Ellis et al., 1993). Neurobe-
tal tissue (Ellis, Byrd, Sexson, & Patterson-Barnett, havioral abnormalities include irritability, abnormal
1993). Babies born to stimulant-using mothers often sleep-wake cycles, tremulousness, poor feeding, and
have alterations in birth weight or length, and con- hypo- or hypertonia (Oro & Dixon, 1987). In neo-
genital abnormalities include malformations of the nates, cerebral infarction can result from maternal
skull, limbs, CNS, intestines, and genitourinary sys- stimulant use near term. These children are also at
tem. However, many of the abnormalities attributed high risk for sudden infant death syndrome (Riley,
to cocaine are occasionally observed in premature in- Brodsky, & Porat, 1988). Longitudinal studies of
fants independent of any drug involvement (Rosen- these children have not been completed, so little is
krantz, 1987). In most studies, the experimental con- known about potential long-term adverse effects, but
 STIMULANTS: AMPHETAMINES AND COCAINE 117

abnormalities suggesting frontal lobe dysfunction chosis, further stimulant use may induce another
may manifest at school age (Dixon, 1989). Even after psychotic episode within a shorter time than initially.
birth, children are at risk from maternal stimulant Chronic stimulant users may develop anxiety or
use because it passes into breast milk (Chasnoff, paranoia, and chronic use is associated with weight
Lewis, & Squires, 1987). loss, insomnia, and depression. Chronic use of
MDMA in particular can lead to a paranoid psycho-
sis that is clinically indistinguishable from schizo-
Psychological
phrenia; fortunately, it is usually reversible after a
Small doses of stimulants cause euphoria with a prolonged drug-free state (Buchanan & Brown,
sense of heightened alertness and energy. Moderate 1988).
doses cause the classical high in which the user feels
intensely euphoric but becomes hyperexcitable and
Social/Interpersonal
exhibits grandiose behavior. Larger doses cause se-
vere alterations of behavior with impairment of judg- In the 1960s and 1970s, stimulants were thought to
ment, memory, and control on thought processes, so promote conviviality and good spirits and were used
the user appears confused. Users may experience ex- as "party drugs." People initially use stimulants to re-
treme fear or paranoia and frequently resort to vio- duce social inhibitions and promote interpersonal
lence. There may also be psychotic manifestations communication, but as usage goes up, social partici-
such as hallucinations or paranoid delusions, which pation drops precipitously. Continued use causes
may lead to suicide. Anxiety, delusions, and depres- paranoia, so addicts withdraw from their friends to
sion become more pronounced with increasing use. avoid other people who might disrupt the high.
Between episodes of drug use, abusers are irritable, Active stimulant use causes progressive loss of
suspicious, and dysphoric. Visual hallucinations are judgment concerning "safe" drug use habits. The
not uncommon with cocaine use and are known as risk of accidents is increased in users owing to poor
snow lights. Formication is the sensation of insects judgment and psychomotor hyperactivity when high.
crawling on or under the skin, compelling the addict Substantial personal and societal injury may result
to pick at the skin, causing excoriations. This phe- from infection due to IV drug use, trauma, criminal
nomenon is known as having crank bugs or coke activities, child neglect, and lost job productivity.
bugs. Violent behavior is the leading cause of death
Known psychiatric disorders may be exacerbated among stimulant users. The most common forms of
by stimulant use. Schizophrenia is more susceptible death are accidents, suicide, and homicide (Warner,
to relapse, and panic disorder may have an increase 1993). In fact, cocaine has been associated with
in the intensity and frequency of attacks. Drug use more deaths than any other illicit drug (NIDA,
frequently represents an attempt to manage preexist- 1990).
ing psychiatric symptoms; this is known as the self- Use of stimulants increases the risk and spread of
medication hypothesis. Crack smokers have a higher sexually transmitted diseases (STDs), including hu-
incidence of psychiatric problems, psychosis, and as- man immunodeficiency virus (HIV). Some women
sociated violence than users of other forms of co- use prostitution as a means of securing stimulants to
caine (Honer, Gewirtz, & Turey, 1987). maintain an addiction, men may exchange drugs for
Stimulant use can cause a full-blown toxic psy- sex with a prostitute, or multiple users may have sex
chosis (Karan et al., 1991) with extreme paranoia, in a "crack house," all of which are high-risk behav-
panic, and hypervigilance as well as insomnia and iors.
visual hallucinations. Patients may exhibit unusual Stimulant abuse can have adverse health conse-
aggressiveness, which can lead to property damage quences for children, such as child neglect and
and suicidal or homicidal behavior. Unlike cocaine- abuse or loss of family structure. Society also faces
induced toxic psychosis, methamphetamine psycho- the economic burden of prolonged hospitalization of
sis lasts much longer than a few hours. It usually re- newborns or foster care for children of addicts. The
solves within 10 days of cessation of drug use, but in often chaotic environment of an addicted mother,
about 10% of patients, it persists for up to 6 months combined with lack of appropriate stimulation and
(Beebe & Walley, 1995). After resolution of toxic psy- an inappropriate role model, may cause substantial
118 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

impairment of intellectual capability as well as of so- about stimulants in order to decrease stimulant abuse
cial and ethical behavior among children growing up and prevent its spread.
in that environment (Chasnoff, 1988). This situation
sets the stage for another generation of drug users. Key References
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American Family Physician, 51(2), 449-453.
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activate the SNS and the brain's pleasure centers. References
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long-term neurochemical changes and the powerful American Psychiatric Association. (1994). Diagnostic
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Becker, C. E. (1972). Screening of 563 students for cho-
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linesterase variants. Clinical Chemistry, 18, 75-76.
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istered by almost any route. Smoking and IV are the the designer drugs. American Family Physician,
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icity but insufflation is the most common route of Beebe, D. K., & Walley, E. (1995). Smokable metham-
abuse. Illicit stimulants are adulterated with many phetamine ("ice"): An old drug in a different form.
compounds at the whim of the dealer, so actual dos- American Family Physician, 51(2), 449-453.
ages are unpredictable. During binges, addicts ad- Benowitz, N. L. (1993). Clinical pharmacology and tox-
minister as much drug as possible until supplies are icology of cocaine. Pharmacology and Toxicology,
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Small doses cause mild sympathetic signs, while Chasnoff, I. J. (1988). Drug use in pregnancy: Parame-
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logical changes which begins immediately, and crav- caine intoxication in a breast-fed infant. Pediatrics,
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possibly birth defects. Psychological effects include
tion of heroin, phencyclidine, and cocaine: Identifi-
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 7

Cannabis and Hallucinogens

Robert S. Stephens

Cannabis, hallucinogens, and phencyclidine (PCP) students indicates that cannabis use is increasing
are molecularly distinct drugs that share an ability to again (Johnston, Bachman, & O'Malley, 1994). Al-
alter perception and produce euphoria. As a group, most one third of high school seniors used cannabis
they represent some of the least toxic psychoactive in 1994, and daily use of cannabis climbed to 3.6%
substances, but there are important exceptions. They among high school seniors—up by 50% from 1993
are also linked by strong associations with the alter- levels. The increases in cannabis use occurred con-
native culture that emerged during the 1960s in the currently with a steady and accelerating decline in
United States that had as its motto, "Turn on, tune perceived risk of use and an increase in peer ap-
in, and drop out." They continue to be used recre- proval.
ationally today, and much information has accumu- On the other hand, hallucinogens are among the
lated on the patterns of use, pharmacology, and bio- illicit substances least frequently used in the Western
behavioral consequences of use and abuse. world. In a representative survey of the U.S. adult
Cannabis is the illicit substance most frequently population conducted between 1990 and 1992, only
used in the United States. According to the National 11% had ever used hallucinogens, ranking them
Household Survey on Drug Abuse in 1994 (NHSDA; lower than all other drugs except heroin, extramedi-
Substance Abuse and Mental Health Administration, cal use of analgesics, and inhalants (Anthony, War-
1995), 8.5% of the population (approximately 17.8 ner, & Kessler, 1994). Use of hallucinogens peaked
million people) used cannabis, and over one quarter in the 1970s, declined through much of the 1980s,
of users (approximately 5.1 million people) reported and remained stable at a low rate throughout the late
using it one or more times each week. A press release 1980s (e.g., Johnston, O'Malley, & Bachman, 1989).
from the 1994 annual national survey of high school However, there are indications that use of hallucino-

121
122 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

gens is increasing again (e.g., Cuomo, Dyment, & 10% of the initial blood level may remain. Absorp-
Gammino, 1994; Johnston, O'Malley, & Bachman, tion is much slower if THC is taken orally, and the
1994; Millman & Beeder, 1994). onset of effects may be delayed for 1 hr or more and
may last as long as 5 hr. Rapid metabolism and redis-
tribution to the brain and other fatty tissues accounts
CANNABIS for the rapidly falling blood levels of THC (Hall, So-
lowij, & Lemon, 1994; McKim, 1997).
Cannabis is derived from the plant of the same Metabolism of THC begins immediately in the
name. Actually, there is still debate on whether there lungs (if smoked) or the intestine (if ingested orally),
is only one species of Cannabis with two subtypes or but the majority is absorbed into the bloodstream
several species of Cannabis with differing psychoac- and carried to the liver, where it is converted primar-
tive potencies (McKim, 1997; Stafford, 1992). Large ily into 9-carboxy-THC and 1 l-hydroxy-delta-9-THC
variations in the size and shape of different varieties (Hall et al., 1994; McKim, 1997). Although 9-car-
of the plant fuel this debate. One variety matures rap- boxy-THC is not psychoactive, 1 l-hydroxy-delta-9-
idly and grows as a lanky plant up to 20 feet in height THC may actually be more potent than THC and
and is cultivated for the fiber known as hemp (Can- may account for much of the psychoactive effect of
nabis sativa). It is used to make rope and has a rela- cannabis, particularly when it is consumed orally
tively low psychoactive potency in comparison with (Hawks, 1982). THC is highly lipid-soluble and is
other varieties that are more compact, grow more readily stored in fatty tissue. The gradual release of
slowly, and are cultivated for their psychoactive prop- THC from storage in fat cells explains the relatively
erties (Cannabis indica). long time it takes to eliminate a single dose from the
Regardless of the correct botanical classification, body. The half-life of THC in the body may be from
the potency of the plant varies primarily as a function 3 to 5 days (Johansson, Agurell, Hollister, & Halldin,
of the concentration of delta-9-tetrahydrocannabinol 1988; Seth & Sinha, 1991), and traces may be detect-
(THC), the main psychoactive ingredient in canna- able for weeks or even months after chronic use (El-
bis. However, there are more than 60 molecular lis, Mann, Judson, Schramm, & Taschian, 1985).
compounds unique to cannabis. While most of these Blood levels of THC do not show strong corre-
other cannabinoids appear to be relatively inactive in spondence to the subjective intoxication or "high"
regard to psychological and behavioral effects, it is reported by users. A peak high typically occurs some-
possible that some are weakly psychoactive or that time after blood levels of THC start falling, a phe-
they alter the potency of the preparation by interact- nomenon suggesting either that other metabolites
ing with THC (Abood & Martin, 1992). Still other contribute to the subjective high or that levels of
cannabinoids may affect other cells or organs but THC in the brain increase even after blood levels
may not have effects on the mental state (Mechou- begin to fall (e.g., Bronson, Latour, & Nahas, 1984).
lam, Hanus, & Martin, 1994). It is known that new Large interindividual differences, the development
cannabinoids may be created in the process of burn- of tolerance, and the gradual release of THC stored
ing (smoking) or through the digestion process when in fat cells also hamper efforts to estimate impair-
cannabis is taken orally. Thus, the combination of ment from blood or urine specimens (Hall et al.,
cannabinoids responsible for the psychoactive effects 1994).
is complex and not completely understood. THC iso-
lated from the plant may not produce exactly the
Neuropharmacology
same effects as cannabis consumed intact.
The neuropharmacological processes through which
THC exerts its psychoactive effects were poorly un-
Absorption and Metabolism
derstood until recently. In 1990, several investigators
THC is absorbed rapidly from the lungs into the converged on the finding of a specific neuronal re-
bloodstream with peak blood levels occurring within ceptor for cannabinoids (Bidaut-Russell, Devane, &
10 min of smoking. However, the decline of THC in Hewlett, 1990; Herkenham et al., 1990; Matsuda,
the blood is equally rapid, so that after 1 hr only 5- Lolait, Brownstein, Young, & Bonner 1990). High
 CANNABIS AND HALLUCINOGENS 123

densities of the receptor have been identified in the THC in marijuana may vary from 0.5% to 14%, or
cerebral cortex, hippocampus, cerebellum, and basal even higher, depending upon the parts of the plant
ganglia. It is noteworthy that the functions served by used, the growing conditions, and the genetic char-
those portions of the brain with the highest con- acteristics of the plant (Hall et al, 1994; McKim,
centration of cannabinoid receptors correspond to 1997; Ray & Ksir, 1996). Sinsemilla is a particularly
long-established effects of marijuana on fragmented potent variety of marijuana that consists largely of the
thought (cortex), memory (hippocampus), and motor flowering tops of female plants. Sinsemilla (Spanish
coordination (cerebellum). Further, the euphoria for "without seeds") is produced by removal of the
produced by marijuana appears to be related to the male plants from the growing area, which prevents
cannabinoid receptor's modulation of the mesolim- fertilization of the female plant. The female plant's
bic dopaminergic pathways in the brain (Gardner, energy, then, is not wasted producing seeds, and the
1992). This dopaminergic pathway mediates the ex- result is THC concentrations in the range of 7-14%
perience of reward or reinforcement produced by or higher.
nearly all drugs that are typically abused. At least Hashish is a potent cannabis preparation created
some of THC's effect occurs through modulation of by squeezing or otherwise extracting the yellowish
the endogenous opioid system, which then interacts resin from the flowering tops of the plant. It turns
with the dopaminergic system (Gardner, 1992; Tanda, dark brown or black as it dries and is shaped into
Pontieri, & DiChiara, 1997). Recent research in ani- small rocks that may be smoked in a pipe or baked
mals indicates that chronic cannabis exposure pro- in cookies or other confections for oral consumption
duces neuroadaptive changes in the limbic system (e.g., "hash brownies"). The concentration of THC
similar to the changes produced by other drugs of in hashish varies widely and is typically in the range
abuse, an effect that may explain the withdrawal and of 2-8% but may be as high as 10-20% (Hall et al.,
craving phenomena associated with abstinence (De- 1994; McKim, 1997; Ray & Ksir, 1996). Hash oil is
Fonseca, Carrera, Navarro, Koob, & Weiss, 1997). a purified variation of hashish in which THC and
Devane and colleagues (1992) identified a natu- other cannabinoids have been extracted and concen-
rally occurring brain molecule that binds to the re- trated through the use of an organic solvent. The oily
ceptor. Named anandamide, a term derived from the substance is typically black or red and may be added
Sanskrit word ananda and meaning "internal bliss," to tobacco and smoked or heated on a piece of foil
it appears to mimic the action of cannabinoids. Al- or in a pipe and inhaled. The concentration of THC
though the role of anandamide in human physiology in hash oil may be as high as 60% but is generally
is not yet understood, these findings have led to an between 15% and 50%.
explosion of research that promises to better expli- The large variability in the concentration of THC
cate the mechanisms of action of cannabis. A likely in marijuana and related preparations makes it diffi-
outcome will be the development of new medicines cult to establish the dose typically consumed by the
that make use of the cannabinoid receptor family average user. Only 2 mg to 3 mg of intravenous THC
(McKim, 1997). is needed to produce the desired effects (Perez-
Reyes, Timmons, & Wall, 1974). A single marijuana
cigarette or "joint," may have between 5 mg and 150
Preparations, Dosage, and
mg of THC, but anywhere between 30% and 80% of
Routes of Administration
the THC may be lost in the combustion process or
Common street names, preparations, dosages, and through sidestream smoke that is never inhaled. Fur-
routes of administration of marijuana are summa- ther, the fraction of inhaled THC that actually
rized in table 7.1. Marijuana is the most common reaches the bloodstream may be as low as 5-24%
form of cannabis used in the United States. Mari- (Hall et al., 1994). It is estimated that the average
juana consists of a mixture of the flowering tops, daily user in the United States may consume 50 mg
leaves, and stems of the dried cannabis plant. THC of THC per day in comparison to heavy users in Ja-
is concentrated most highly in the flowering tops, maica or Asia, who may consume 200-400 mg per
then the upper leaves, then the lower leaves, and fi- day (Hall et al., 1994; McKim, 1997). There is some
nally the stems and seeds. The concentration of evidence that marijuana users titrate or adjust the
 TABLE 7.1 Cannabis and Hallucinogens: Common Names, Dosages, Routes of Administration, and Preparations

Routes of
Drug Common names Dosage administration Preparations

Cannabis Aunt Mary, boom, bud, chronic, dope, gangster, ganja, 5-150mgofTHC Smoked Marijuana—Mixture of dried flowering tops,
grass, herb, kif, Mary Jane, pot, reefer, scooby snack, Oral leaves, and stems
skunk, smoke, weed Hashish—Brown or black resin from flowering
tops shaped into small rocks
Hash oil—Black or red oily substance derived
from resin
Lysergic acid diethylamide Acid, Bart Simpson, Bartman, blue heaven, blotter, 30-300 meg Oral Absorbed on paper ("blotter") or in sugar
(LSD) doses, hits, gelatin chips, microdots, sugar cubes, tabs, cubes; capsules
trips, windowpane
Psilocybin Caps, liberty caps, magic or Mexican mushrooms, 4-60 mg; 4-60 Oral Dried mushrooms eaten whole, boiled to
'shrooms mushrooms make tea, or mixed with other foods
Dimethyltryptamine Businessman's lunch, businessman's LSD 15-40mg Smoked Crystals or oil mixed with marijuana, tobacco,
(DMT) Intranasal or other herbs and smoked or inhaled; dis-
Injected solved and injected
Mescaline Mesc, mescal buttons, peyote 200-500 mg Oral Fresh or dried peyote buttons chewed, boiled
into tea, or mixed with other foods; crystals
in capsules
Dimethoxymethyl amphet- STP 1-5 mg Oral Powder, crystals, tablets, or capsules
amine (DOM)
Methylenedioxyphenyliso- Love drug 75-100 mg Oral Powder, crystals, tablets, or capsules
propylamine (MDA)
and methylenedioxy-
methamphetamine
(MDMA)
Phencyclidine (PGP) Angel dust, dust, elephant or horse tranquilizer, hog, 5 mg-15 mg Smoked Crystals mixed with tobacco, marijuana
ozone, peace pill, rocket fuel, tranq, wack Intranasal ("sherms"), or other herbs and smoked; crys-
Injected tals snuffed or dissolved in water and in-
Oral jected; tablets and capsules
Ketamine K, ket, psychedelic heroin, special K, vitamin K 50-375 mg Oral Tablets or capsules; crystals snuffed
Intranasal
Injected
Amanita muscaria Fly agaric 1-10 mushrooms Oral Dried mushrooms eaten whole or chopped
and mixed with other foods
 CANNABIS AND HALLUCINOGENS 125

amount they smoke to compensate for the varying

Acute Effects
concentrations of THC (Perez-Reyes, DiGuiseppi,
Davis, Shindler, & Cook, 1982), but the data are Cannabis is known to produce a wide variety of cog-
mixed and learned smoking habits may play a larger nitive, emotional, physiological, and behavioral ef-
role (Wu, Tashkin, Rose, & Djahed, 1988). fects that vary as a function of the dose, the setting,
Smoking is by far the most common route of ad- the current state of the user, the user's prior experi-
ministration of cannabis in the United States. Mari- ence with the drug, and the user's expectations and
juana is typically rolled in cigarette papers to make attitudes. For most users, cannabis produces a mild
"joints" or "nails." It may also be smoked in pipes, as state of euphoria or relaxation referred to as being
are hashish and hash oil. Recently, it has become high or stoned. It is often perceived to enhance other
popular to roll marijuana in cigar wrappers, which experiences such as listening to music, the taste of
are called blunts. Water pipes ("bongs") force the food, or the enjoyment of sexual interactions. Distor-
smoke through a chamber of water prior to inhala- tions in the sense of time may make experiences
tion and are used by some individuals to cool the seem to last longer. Increased talkativeness and
smoke and filter unwanted constituents. Oral con- laughter are common in social situations, but there
sumption of marijuana and hashish is less common may be swings in mood, with increased sociability
and is accomplished by baking the substance in replaced by an introspective dreaminess. Lethargy
cookies, brownies, or cakes. When consumed orally, and sleepiness are common as the effects of a dose
the effects are delayed by about 1 hr and are typically wear off.
not as intense (Agurell, Lindgren, Ohlsson, Gilles- Cannabis intoxication can cause increased anxi-
pie, & Hollister, 1984). On the other hand, oral con- ety, paranoia, and even panic, particularly in naive
sumption prolongs the effects, which are experi- users (Thomas, 1993). Even experienced users may
enced for several hours or more depending upon the experience these feelings occasionally after consum-
amount consumed. The inability to titrate the dose ing larger doses than usual or after oral doses with
when consumed orally and the prolonged duration slower onset but longer duration. Increased heart rate
of effects may increase the likelihood of anxiety and may augment the experience of panic in naive users
panic reactions. who misinterpret the sensation as indicative of a dan-
Marijuana is used in combination with many gerous reaction. Blood pressure fluctuates unpredict-
other drugs, and particular combinations vary in pop- ably, and light-headedness or fainting upon rising to
ularity by geographic region or as trends over time. a standing position sometimes occurs. Although
Alcohol is the drug most commonly used in conjunc- these symptoms may be experienced as uncomfort-
tion with marijuana and appears to augment the de- able, tolerance to most of these effects develops in
gree of intoxication and behavioral impairment in an regular users, and the actual health risk from an
approximately additive fashion (Chait & Perry; 1994; acute dose is minimal. Individuals with known car-
Hall et al., 1994). Smoking cannabis has also been diovascular disease or defects should be cautioned,
shown to increase the subjective high from intranasal but from information based on animal studies, the
cocaine use, perhaps by increasing the availability of dose that would cause death in otherwise healthy hu-
cocaine in the plasma (Lukas, Sholar, Kouri, Fuku- mans is 1,000 times the dose that produces the de-
zako, & Mendelson, 1994). Marijuana and amphet- sired feelings of being high (Hall et al., 1994). There
amines increase autonomic nervous system activity are no reports of death from acute administration of
through different means, so that their combined ef- cannabis.
fects on arousal may be perceived as aversive. On the Cannabis intoxication impairs short-term memory
other hand, stimulants may antagonize the sedative and attention and thus frequently results in dis-
effects of cannabis and offset the decreases in behav- jointed thought patterns and speech, so that individu-
ior that are typically observed (Hall et al., 1994). als lose track of what they were thinking or saying in
Marijuana may also be laced with PCP or other hal- midstream. For occasional users, this disruption in
lucinogens whose effects tend to overpower the thought may be little more than an amusing side ef-
effects of THC. Substantial increases in toxicity are fect or even a desired outcome that allows the user's
not seen when cannabis is used in combination with mind to wander easily from thought to thought. Can-
other drugs. nabis has been shown repeatedly to affect perfor-
126 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

mance on a variety of laboratory tasks requiring heart rate associated with cannabis use declined with
attention, concentration, eye-hand motor coordina- repeated dosing, and observations of initial negative
tion, and memory, although mixed findings and effects on subjects' social interactions were almost
large interindividual differences suggest that the ef- entirely gone by the end of the daily dosing period.
fects may not be very robust (Chait & Pierri, 1992; Similar recovery of cognitive and psychomotor per-
Hall et al., 1994). The debilitating effects are seen formance with repeated dosing was witnessed as well.
more reliably when complex tasks are used that re- Evidence of tolerance to the subjective high also
quire attention to multiple stimuli simultaneously or emerged in a study in which subjects smoked an av-
when attentional demands have been prolonged erage of 10 marijuana cigarettes per day (Georgo-
(e.g., to more than an hour). There do not seem to tas & Zeidenberg, 1979), but another study that re-
be substantial effects on mood or performance the quired subjects to smoke only a single marijuana
day after marijuana use (e.g., Chait & Perry, 1994). cigarette per day for 28 days did not find any evi-
dence of tolerance (Frank, Lessin, Tyrrell, Hahn, &
Szara, 1976). These findings suggest that casual use
Tolerance, Withdrawal, and Dependence
of cannabis is unlikely to produce significant toler-
Despite the prevalence of use there is a surprisingly ance, but that large daily doses result in tolerance for
small literature on problematic use of cannabis. The many of the physiological, cognitive, and social ef-
lack of research on clinical issues probably stemmed fects of THC.
from controversy over the addictive potential of can- These same studies have generally found evi-
nabis and the perception that it was clinically rele- dence of withdrawal upon sudden cessation of large
vant only as a secondary drug of abuse among more daily doses (Georgotas & Zeidenberg, 1979; Jones &
seriously impaired polydrug abusers (see Roffman, Benowitz, 1976). Subjects reported "inner unrest"
Stephens, Simpson, & Whitaker, 1988). However, re- within hours of the last dose of THC. Irritability, hot
cent data show that a subgroup of marijuana users flashes, insomnia, sweating, restlessness, runny nose,
develops a dependence syndrome and may experi- loose stools, hiccups, and loss of appetite were com-
ence increased risks of negative health, safety, and monly reported 12 hr after the last dose (Jones &
social consequences. Benowitz, 1976). Uncooperative and even resistant
The relative absence of tolerance and withdrawal behavior was noted in some cases (Georgotas &
effects in humans fueled debate on the addictive po- Zeidenberg, 1979). Although the doses used to pro-
tential of cannabis throughout much of the 1960s duce these effects were large (e.g., 210 mg/day),
and 1970s. In fact, many users report the phenome- there is some evidence that under conditions of
non of reverse tolerance or sensitization to the effects chronic administration, doses as low as 10 mg/day
of cannabis upon early repeated use. Reverse toler- for 10 days can produce tolerance and withdrawal
ance has never been demonstrated in the laboratory symptoms (Jones et al., 1981). Yet, withdrawal symp-
and is probably related more to experienced users' toms are not always apparent even with moderately
learning to smoke more efficiently and learning to high daily doses (e.g., Mendelson, Kuehnle, Green-
better identify and label the effects of cannabis rather berg, & Mello, 1976).
than to its neuropharmacology. Although laboratory studies have demonstrated
On the other hand, tolerance to many of the ef- that tolerance and withdrawal develop under specific
fects of cannabis has been demonstrated in both ani- conditions, there are fewer data on the occurrence of
mal (Abel, McMillan, & Harris, 1974; Kosersky, Mc- tolerance and withdrawal among users in the natural
Millan, & Harris, 1974) and human studies (Babor, environment. Case studies and the uncontrolled ob-
Mendelson, Greenberg, & Kuehnle, 1975); Georgo- servations of treatment professionals have reported
tas & Zeidenberg, 1979; Jones & Benowitz, 1976; withdrawal phenomena but have not ruled out the
Jones, Benowitz, & Herning, 1981). Jones and Ben- possibility that the symptoms reflected preexisting
owitz (1976) administered high doses of THC orally psychopathology or withdrawal from other substances.
every 4 hr to healthy male marijuana users over a In one study, about 15% of moderate to heavy users
period of 30 days. Their results showed that subjects' reported a withdrawal syndrome that primarily in-
ratings of subjective "highs" decreased as the dura- cluded nervousness, sleep disturbance, and appetite
tion of the daily dosing increased. The increase in change (Wiesbeck et al., 1996). Symptoms appeared
 CANNABIS AND HALLUCINOGENS 127

to be related to the duration of daily use and were 1994). As with other drugs of abuse, the risk of de-
not totally accounted for by a history of other drug pendence appears to be higher in men than in
dependence or personality characteristics. It is im- women. Given the difficulty of quantifying the dose
portant to remember, however, that the withdrawal of cannabis that reaches the bloodstream, there are
symptoms reported by cannabis users are mild and no clear guidelines on the amount of THC that must
generally cease within 1-3 days. Further, nearly half be consumed to produce dependence. It is clear that
of the daily users seeking treatment do not report the risk of dependence increases as the frequency of
withdrawal symptoms (Stephens, Roffman, & Simp- use increases. Yet, even daily use is not synonymous
son, 1993). Thus, the role of physical dependence in with dependence, and many daily users do not report
determining chronic, problem use is far from cer- significant negative consequences or a desire to quit
tain. (Haas & Hendin, 1987; Rainone, Deren, Klein-
The diagnosis of drug dependence today relies man, & Wish, 1987). Thus, the vast majority of mari-
less on the occurrence of signs of physical depen- juana users do not become dependent, while a small
dence and more on a drug-dependence syndrome minority develop a syndrome of compulsive use that
defined behaviorally by the high salience of drug use is similar to the dependence syndromes described for
in the user's life, difficulty quitting or controlling most other drugs.
use, a narrowing of the drug-using repertoire, and
rapid reinstatement of dependence after abstinence
(Edwards, Arif, & Hodgson, 1981; Edwards & Gross,
Adverse Effects on Health,
1976). Withdrawal and tolerance are seen as co-oc-
Safety, and Adjustment
curring aspects of the dependence syndrome but are
neither necessary nor sufficient. Several psychomet- A primary area of concern for cannabis users is re-
ric studies of these dependence criteria indicate that lated more to the mode of use than to the psychoac-
they provide an accurate description of dependence tive ingredient, THC. Cannabis smoke is similar to
on cannabis, as well as on most other drugs of abuse tobacco smoke in many of its constituents and may
(Kosten, Rounsaville, Babor, Spitzer, & Williams, pose similar health risks. Currently, there are no
1987; Newcombe, 1992; Rounsaville, Bryant, Babor, studies clearly linking marijuana use with cancers of
Kranzler, & Kadden, 1993). Daily marijuana users the aerodigestive tract or lungs in humans, but mari-
who sought treatment showed evidence of this syn- juana smoking, independent of tobacco smoking, has
drome (Stephens & Roffman, 1993). They averaged been shown to increase chronic and acute bronchi-
over 10 years of near-daily use and over six serious tis, to cause functional alterations in the respiratory
attempts at quitting. Their use had persisted in the tract, and to produce morphological changes in the
face of multiple forms of impairment (i.e., social, airways that may precede malignant change (see for
psychological, physical), and most perceived them- reviews Hall et al., 1994; Tashkin et al., 1990). The
selves as unable to stop (Stephens et al., 1993; Ste- adverse effects appear to occur with fewer marijuana
phens, Roffman, & Simpson, 1994). cigarettes per day and at earlier ages than for tobacco
Epidemiological studies using DSM diagnostic smokers. In addition, concurrent tobacco smoking
criteria converge on the relative risk for a lifetime augments many of the effects of marijuana smoking
diagnosis of cannabis dependence. Both the Epide- in an additive fashion. Notably, 50% of the chronic,
miological Catchment Area (EGA; Anthony & heavy marijuana users seeking treatment also smoke
Helzer, 1991) and the National Comorbidity Study tobacco (Stephens et al., 1993). A study of the medi-
(NCS; Anthony et al., 1994) estimate that slightly cal records of daily "cannabis-only" smokers receiv-
more than 4% of the population develops a depen- ing care in a large health maintenance organization
dency on marijuana—the highest prevalence rate of found a slight increase in outpatient visits related to
any illicit drug. Approximately 9% of those who had respiratory complaints over the visit frequency of
ever used marijuana qualified for this diagnosis, a nonsmokers (Polen, Sidney, Tekawa, Sadler, &
rate comparable to that for sedatives, antianxiety Friedman, 1993). The full effects of chronic mari-
medications, and stimulants but somewhat less than juana use on the respiratory system may not yet be
that for alcohol (15%) and substantially less than that known given the relatively short period of widespread
for tobacco (32%) and heroin (23%) (Anthony et al., use in the Western world.
128 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

The majority of studies and reviews have con- marijuana use during pregnancy with an increased
cluded that there is little evidence of any substantial risk of a rare form of childhood cancer (Robinson et
permanent damage to the brain even from chronic al., 1989), but the unexpected nature of the finding
cannabis use (Hollister, 1986; Wert & Raulin, 1986a, suggests the need for replication. The Ottawa Prena-
1986b). Methodological problems in many studies tal Prospective Study followed a group of children
and the failure to replicate occasional adverse find- born to mothers who used marijuana during preg-
ings make definitive statements impossible, but it nancy and matched controls through 9 years of age
seems clear that major impairments are unlikely. (Fried, 1995; Fried, O'Connell, & Watkinson, 1992;
However, some studies using recordings of event-re- Fried & Watkinson, 1990). Early findings of differ-
lated potentials that are indicative of the ability to ences between groups were largely negative on mea-
focus attention and to filter irrelevant distracting sures of global scores of intelligence. Specific deficits
stimuli have found evidence of impairment related related to prenatal marijuana use were found at ages
to duration and frequency of marijuana use (Solowij, 4-9 on several neurobehavioral tasks. Fried (1995)
Michie, & Fox, 1991, 1995). The relationship of the speculated that the late emergence of differences in
findings to daily intellectual functioning is not sustained attention, language comprehension, and vi-
known, and there are null findings with the use of sual perceptual tasks indicated more general impair-
similar tasks (Patrick et al, 1995). More sensitive neu- ment in the executive functions of the prefrontal
ropsychological tests have also revealed small but sig- lobe, which becomes fully active only at later stages
nificant impairments in the attentional and executive of development. There are other findings consistent
functioning of heavy-marijuana-using college stu- with this interpretation, but the absolute differences
dents that does not show up in more global estimates in intellectual functioning appear to be very small
of intelligence (Pope & Yurgelun-Todd, 1996). They (Day et al., 1994; Richardson, Day, & Goldschmidt,
may be due to a drug residue effect that will dimin- 1995). The clinical significance of these findings
ish with longer abstinence, rather than a more per- await further follow-ups of this cohort and replication
manent alteration of the central nervous system in other prospective studies.
(Pope, Gruber, & Yurgelun-Todd, 1995). However, Research on experimental driving simulators and
several investigators have warned that the signifi- on-road research found mixed evidence of impair-
cance of marijuana's effect on cognitive functioning ment after cannabis use, lane control errors being
may be underestimated by these studies of more the most frequent type of error found (Smiley, 1986).
highly functioning individuals and that the effects The most reliable finding has been a reduction in
could be much greater on those whose intellectual risk taking (e.g., by driving slower or maintaining a
abilities are compromised (e.g., by learning disabili- greater distance from other cars) after smoking mari-
ties or lower intelligence). juana that may partially explain the relative lack of
Animal research suggests that cannabis may re- impairment on driving tasks. More driving errors
duce the immune response and leave the organism were seen under unexpected emergency conditions
susceptible to infection by bacteria and viruses, but when drivers were not able to compensate for the
the clinical relevance of these findings is question- effects of intoxication (Smiley, 1986). Reviews of
able in humans (Hall et al., 1994; Hollister, 1986). studies examining the presence of cannabinoids in
When small adverse effects on the human immune relation to automobile accident mortality are incon-
system have been found, they have typically not been clusive (McBay, 1986; Simpson, 1986). Although
replicated (Hall et al., 1994; Hollister, 1986). cannabis has been found to be present in the bodies
Smoking marijuana during pregnancy may be as- of accident victims at rates of 4-37%, it is not known
sociated with a shorter period of gestation and lower whether this prevalence exceeded the base rate of
birth weight (Hatch & Bracken, 1986; Zuckerman et cannabis use in the population under consideration
al., 1989), but a large multicenter study failed to find (e.g., young male drivers; Terhune, 1986). In addi-
these effects (Shiono et al., 1995). Prenatal mari- tion, most victims who are positive for cannabinoids
juana use does not seem to cause major birth defects are also positive for alcohol, which has a known asso-
(Zuckerman et al., 1989) and does not impair gross ciation with increases driving accidents (McBay,
motor development (Chandler, Richardson, Galla- 1986).
gher, & Day, 1996). One study implicates maternal A major question about the use of marijuana is
 CANNABIS AND HALLUCINOGENS 129

its role in promoting the use of harder drugs. The pations. Field studies of heavy users in comparison
"gateway" hypothesis holds that marijuana is a "step- with nonusers in other cultures (Carter, Coggins, &
ping-stone" to the use of harder drugs. Although nu- Doughty, 1980; Rubin & Comitas, 1975) have gener-
merous studies confirm a progression of drug use in ally not yielded findings of decreased productivity.
the United States, starting with alcohol and tobacco Laboratory studies provide mixed evidence that mari-
use and proceeding to marijuana and then harder juana decreases motivation, but these studies rely on
drugs (e.g., Ellickson, Hays, & Bell, 1992; Huba, relatively short periods of use under artificial circum-
Wingard, & Bentler, 1981; Kandel & Faust, 1975), stances (Hall et al., 1994). It seems unlikely that mar-
the causal role of marijuana in this progression is ijuana directly causes motivational problems; rather,
doubtful (e.g., Kandel 1988). More likely, it reflects it may interact with predisposing personality charac-
a societal phenomenon of the use of legal drugs fol- teristics in some individuals to produce this clinical
lowed by marijuana, the mildest and most available phenomenon. Surveys of self-identified marijuana
of the illicit drugs (Miller, 1994). A subset of mari- users in three separate communities in the United
juana users go on to experiment with harder drugs, States indicate that a majority of regular, heavy users
perhaps because of the association with drug users report impairment of memory, concentration, moti-
(e.g., Kandel, 1984), other risk factors (see New- vation, self-esteem, interpersonal relationships, health,
combe, 1992), or preexisting differences in personal- employment, or finances related to their marijuana
ity characteristics (Baumrind, 1983; Perry & Man- use (Haas & Hendin, 1987; Rainone et al., 1987;
dell, 1995), but the progression is far from inevitable Roffman & Barnhart, 1987), indicating that at least
and is not likely to be directly linked to the pharma- a subset of users may be adversely affected. Some of
cology of cannabis. these users seek treatment and appear to profit from
Regardless of whether it leads to harder drug use, it (Stephens et al., 1993, 1994).
regular cannabis use by adolescents raises concerns Although there is some evidence that cannabis
about negative educational, occupational, social, and use rarely produces an acute psychosis consisting of
psychological consequences. Longitudinal studies confusion, agitation, anxiety, delusions, and halluci-
have generally confirmed that heavier marijuana and nations, it does not appear to persist beyond the pe-
other drug involvement in adolescence is predictive riod of intoxication (Gruber & Pope, 1994; Thomas,
of less stability in a variety of adult roles, including 1993). Verbal support, a quiet place, and, perhaps,
college involvement, occupational stability, and mar- small doses of tranquilizers are typically sufficient to
riage (Kandel, Davies, Karus, & Yamaguchi, 1986; reassure the individual until the acute effects wear
Newcombe & Bentler, 1988). These outcomes may off. One of the difficulties of research in this area is
be explained by preexisting differences in the adjust- distinguishing between psychotic symptoms caused
ment of those who choose to use cannabis (e.g., by cannabis use and the emergence of preexisting psy-
Brook, Cohen, Whiteman, & Gordon, 1992; Kan- chotic conditions such as schizophrenia and manic-
del & Davies, 1992; Newcombe & Bentler, 1988; depressive psychoses following cannabis use. Cannabis
Shedler & Block, 1990) or by the combined use of may precipitate the expression of latent schizophre-
cannabis, alcohol, and other drugs (see Newcombe & nia or exacerbate the course of the disorder (e.g.,
Bentler, 1988). Nevertheless, the acute effects of can- Linszen, Dingemans, & Lenior, 1994), but there is
nabis on cognition and behavior recommend against little systematic evidence that it causes any form of
its use when attending school, performing complex chronic mental disorder in psychiatrically normal in-
tasks, or mastering new social skills. dividuals (Taylor & Warner, 1994; Thomas, 1993).
Related to concerns about impaired educational There is ongoing debate on whether the potency
and occupational performance is the notion that of marijuana available in the United States today is
marijuana produces an "amotivational syndrome" significantly greater than that available during the
characterized by low motivation, apathy, lethargy, early 1970s, when much of the research on the ad-
mental dulling, and social withdrawal. While there dictive potential and harmful effects of cannabis was
are many clinical observations and case reports of conducted (Cohen, 1986; Mikuriya & Aldrich, 1988).
chronic marijuana users who fit this picture, it is also If so, it is possible that the older research underesti-
clear that many other equally heavy users perform mates the adverse effects of cannabis. Analyses of
well in school and in complex and demanding occu- marijuana seized by the Drug Enforcement Agency
130 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

(DEA) in the 1970s showed lower concentrations of HALLUCINOGENS

THC than those found in samples seized in the
1980s, but there was no systematic increase in the Hallucinogens constitute a broad group of substances
potency of confiscated samples throughout the 1980s that share an ability to produce sensory distortions
and early 1990s. It is probable that samples from the and hallucinations at doses that are not otherwise
1970s showed lower amounts of THC because they toxic to the body. In contrast to cannabis, these drugs
were stored improperly and degraded (Mikuriya & produce more intense perceptual-emotional experi-
Aldrich, 1988). It is also not clear that these confis- ences and stronger physiological effects. Hallucino-
cated samples were representative of what was gener- gens have been used throughout history as part of a
ally available to users. Further, if users titrate their variety of religious and spiritual rituals and are still
dose, or if the effects of THC on long-term function- used in this manner by some. Other names given to
ing are not dose-dependent, any change in average these drugs include psychedelics, phantasticants, and
potency would not necessarily translate into greater psychotomimetics. The former two terms derive from
adverse consequences. These issues remain to be re- the use of these drugs to achieve enlightening visual
solved. and emotional experiences or to create fantasylike ex-
periences, respectively. Psychotomimetics refers to the
similarity between the drug effects and the symptoms
Cannabis Summary
of psychosis.
Cannabis is a complex psychoactive substance with There are over 100 different hallucinogens with
a variety of acute effects on mood, cognition, and substantially different molecular structures. They are
physiology that appear to be mediated largely through commonly grouped by their similarity to particular
specific cannabinoid receptors in the brain. Most us- neurotransmitters (e.g., McKim, 1997; Ray & Ksir,
ers find these effects reinforcing, and acute toxicity is 1996). For instance, d-lysergic acid diethylamide (LSD),
minimal, anxiety and panic reactions being the most psilocybin, and dimethyltryptamine (DMT) share
commonly reported adverse effects. Death from can- the indole nucleus that provides the basic structure
nabis intoxication does not occur in humans. Toler- of the neurotransmitter serotonin. Mescaline and
ance and withdrawal have been demonstrated in the numerous amphetamine derivatives (e.g., dimethoxy-
laboratory after large chronic doses and have been methylamphetamine [DOM], methylenedioxyphenyl-
reported by heavy users, but the withdrawal syndrome isopropylamine [MDA], methylenedioxymethamphet-
appears to be mild and is not likely to account for amine [MDMA]) are based on the catechol nucleus
the behavioral dependence documented in a subset of and are more similar to the catecholamine neuro-
frequent users. The largest concern related to chronic transimitters, norepinephrine and dopamine. A group
use is the deleterious effects of smoking on the lungs. of hallucinogens less frequently used in the United
There are also recent data suggesting subtle residual States block the receptors for the neurotransmitter
cognitive impairment in chronic heavy users and de- acetylcholine but do not activate it. These anticho-
layed effects on the cognitive development of children linergic hallucinogens include belladonna, man-
born to mothers who used marijuana. These findings drake, henbane, datura, and several synthetic drugs
require replication before great weight is placed on used to treat parkinsonian symptoms (e.g., benzotro-
them because of mixed results and the more fre- pine and trihexyphenidyl). Phencyclidine, ketamine,
quently reported failure to find significant adverse ef- and Amanita muscaria (fly agaric) constitute a mis-
fects on intellectual abilities. On the whole, cannabis cellaneous group that share some effects with the
use does not seem to cause mental disorders or to hallucinogens but also produce distinct effects.
grossly affect psychosocial functioning, although it
may exacerbate preexisting psychotic conditions or
Acute Effects
subclinical personality dysfunction. A subset of heavy
users develop dependence and report adverse effects Despite their chemical diversity, the subjective expe-
on their social, occupational, and personal lives. riences or "trips" these substances produce have many
Such users who present for treatment appear to re- common features (Abraham, Aldridge, & Gogia, 1996;
spond to psychosocial interventions similarly to other Grinspoon & Bakalar, 1983; Stafford, 1992; Strass-
drug-dependent individuals. man, Quails, Uhlenhuth, & Kellner, 1994; Weiss &
 CANNABIS AND HALLUCINOGENS 131

Millman, 1991). Hallucinogens typically have their crease creativity, and in fact, studies suggest that they
most immediate effects on the autonomic nervous impair performance on laboratory creativity tasks
system and produce an increase in heart rate and (McKim, 1997; Ray & Ksir, 1996).
body temperature and slightly elevate blood pressure. "Bad trips" are one of the undesirable acute ef-
The individual may experience a dry mouth, dizzi- fects of hallucinogen use. These are characteristically
ness, and subjective feelings of being hot or cold. panic reactions that develop when individuals feel
Gradually, the focus on physiological changes fades that the hallucinogenic experience will never end or
into the background and perceptual distortions and when have difficulty distinguishing drug effects from
hallucinations become prominent. reality. In most cases, users can be "talked down" by
Although hallucinations occur in all sensory sys- being reassured that their experiences are drug-in-
tems, visual effects are the most common and audi- duced and will end soon. Most of these bad trips are
tory effects the least common (Abraham & Aldridge, thought to be related to an interaction of a negative
1993; Grinspoon & Bakalar, 1983). Aesthetic expe- mood state or adverse environmental circumstances
rience is altered so that colors seem more intense, with the drug effects. Adverse reactions are extremely
objects and events look sharper and take on new sig- rare in controlled studies of LSD use, where individ-
nificance, and music may seem richer and more uals are carefully screened for psychological adjust-
meaningful. Synesthesia, the crossing of senses so ment and consume the drug in safe and secure situa-
that sounds are seen or objects heard, has been re- tions (Levine & Ludwig, 1964), but they may be
ported. The sense of time slows or even comes to a somewhat more common under street conditions in
complete stop. Geometric patterns often appear with less psychologically stable users. It is also important
or without the eyes open early in the experience and to note that the true content of hallucinogenic drugs
give way later to visions of landscapes, people, or purchased on the street is always in doubt and has
symbolic objects. Anxiety and increased energy coex- often been misidentified or adulterated with other
ist with euphoria and even relaxation, and there is drugs.
often rapid alteration between emotional states. Set
(the user's expectations and cognitive/emotional state
Neuropharmacology, Dosage, Preparations,
prior to use) and setting (the physical surroundings
Absorption, and Metabolism
and circumstances) profoundly affect the experience.
There may be intense feelings of closeness to others There is little systematic research on many of the
whereas, later in the experience or on a different oc- hallucinogens, and detailed information on neuro-
casion, the user may feel distant and isolated. Short- pharmacology, typical dosages, and metabolic path-
term memory is impaired, but memories from the ways is lacking (Abraham et al., 1996). It is clear that
past may emerge and feel more vivid and real. The LSD and other hallucinogens block serotonin recep-
number and intensity of effects are dose-dependent, tors or otherwise alter serotonergic activity, but so do
and some of the more extreme perceptual distor- other drugs that do not produce hallucinations.
tions are probably not experienced by many recre- Some evidence exists that LSD and other hallucino-
ational users who consume low to moderate doses. gens (e.g., psilocybin and mescaline) produce effects
At very low doses, the effects of hallucinogens may by stimulating a specific subtype of serotonin recep-
be more somatic and less perceptual/cognitive, the tor known as 5-HT2(see Abraham & Aldridge, 1993;
result being uncomfortable feelings of physical ten- McKim, 1997).
sion (Strassman et al., 1994). Table 7.1 presents the common street names, typ-
LSD impairs functioning on a variety of cognitive ical dosages, routes of administration, and common
tasks (Hollister, 1978), and animal research suggests preparations of the hallucinogens most frequently
that PGP disrupts short-term memory. However, con- used in the United States. It is important to note that
trolled research on the effects of hallucinogens on many of the hallucinogens are derived from plants
performance is difficult to interpret because of the and are often consumed in this organic form. As in
difficulty in maintaining the subject's motivation for cannabis, the active ingredients in these plants vary
the tasks in the midst of the hallucinogenic experi- widely. Typical users are often not aware of the dose
ence (McKim, 1997). There is no systematic evi- they are taking. The ranges of dosages given in table
dence to support the claims that hallucinogens in- 7.1 are derived both from scientific studies that iso-
132 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

late the active ingredients and from anecdotal or doses (e.g., 40,000 meg; see Stafford, 1992) and sur-
case reports (see Gable, 1993; Stafford, 1992). The vived.
wide range in dosages reflects, in part, the fact that
users have different preferences for the intensity of
the hallucinogenic experience. Values at the lower Psilocybin
end of the ranges typically reflect the minimal effec- Psilocybin is found in mushrooms native to North
tive dose and are associated with autonomic effects America and has been used in religious rituals by
and mild feelings of euphoria, while values at the Mexican and Central American Indians for thou-
higher end constitute dosages that produce more in- sands of years (McKim, 1997; Stafford, 1992). Psilo-
tense hallucinogenic experiences. These ranges also cybin is much less potent than LSD but produces
represent differences in dosages related to routes of similar effects if the dose is adjusted. Lethality is ef-
administration. Smaller doses are typically used in fectively nil; a dose likely to produce death is about
injecting or smoking the drug than in oral consump- 3,500 times the effective dose (Gable, 1993). Psilocy-
tion. bin is converted in the body to psilocin, which appar-
ently is more psychoactive and accounts for most of
LSD the effects (McKim 1997; Ray & Ksir, 1996).

LSD is the classic hallucinogen and its discovery by

Albert Hoffman in 1943 is credited with introducing DMT
hallucinogen use to the Western world. It is pro-
duced synthetically and is the most potent of the hal- Dimethyltriptamine is the active ingredient found in
lucinogens. After its accidental discovery, LSD was a variety of plants around the world. It is extracted
produced legally for research and used briefly as an and snuffed by South American Indians (McKim,
adjunct to psychotherapy before becoming illegal. 1997; Stafford, 1992). It is typically produced syn-
The lack of carefully controlled studies and its un- thetically when available in the United States. Al-
predictable effects made LSD's utility as an aid to though never widely used in the United States,
exploring the mind highly debatable (see Abraham DMT was named the businessman's lunch or busi-
et al., 1996). It was adopted as a drug of choice by nessman's LSD because of the rapid onset of its ef-
the hippie movement of the 1960s and was actively fects and its relatively short duration of action. Onset
promoted by psychologist Timothy Leary as a mind- is very rapid, and effects are completely resolved
expanding drug (see Grinspoon & Bakalar, 1979; within 30 min to 1 hr (Ray & Ksir, 1996; Stafford,
Stafford, 1992). Use peaked in the late 1960s and 1992; Strassman et al., 1994).
early 1970s. It has been suggested that today's users
are more interested in it for pleasure than for the
Mescaline
self-enlightenment sought by the flower children of
that era (Baumeister & Placidi, 1983). Consequently, Mescaline is derived from the small, carrot-shaped
it is probably taken in smaller doses today and thus peyote cactus which is indigenous to the deserts of
produces more of a euphoric effect than the in- Mexico and the Southwestern United States. It is
tensely hallucinogenic trips of the 1960s (McKim, used legally in some states as part of religious cere-
1997). monies by members of the Native American Church
LSD is metabolized in the liver, and the half-life (McKim, 1997). Typically, the cactus is cut into
of the drug in the body is approximately 2 hr. The thick slices and dried, producing "mescal buttons"
metabolites do not appear to be psychoactive. Effects that are chewed and eventually swallowed. Nausea is
begin within 30-90 min and last from 6-12 hr (Abra- common after eating the burtons. Mescaline appears
ham & Aldridge, 1993; McKim, 1997). The lethal to be the ingredient responsible for visual hallucina-
toxicity of LSD is very low, as the dose that is likely tions, but other psychoactive alkaloids have been
to be lethal to humans is probably 200-300 times the identified in peyote. Mescaline is also produced syn-
effective dose of 30 -100 meg (Gable, 1993). Reports thetically as a saltlike crystal but may not produce
of death by overdose are very rare, and there are nu- effects identical to peyote in this form (Ray & Ksir,
merous cases of individuals who have taken massive 1996; Stafford, 1992).
 CANNABIS AND HALLUCINOGENS 133

Mescaline is absorbed into the bloodstream from are taken orally, but most often, it is found in a salt-
the digestive tract and reaches maximum concentra- like crystal form that is sprinkled on plant material
tions in the brain within 30 to 120 min. Most of the (e.g., tobacco, marijuana, various herbs) and smoked.
drug is excreted unchanged. It has a half-life of ap- It can also be snuffed or absorbed through any moist
proximately 2 hr and effects may last up to 8 or 9 hr. membrane (eyes, rectum, vagina) or dissolved in wa-
The lethal dose of mescaline is estimated to be only ter and injected (McKim, 1997). There is evidence
10-30 times the effective dose, so the risk of toxicity that PGP's reinforcing properties result from stimula-
relative to LSD and other indole hallucinogens is in- tion of the mesolimbic dopaminergic system. There
creased (Gable, 1993; Ray & Ksir, 1996). is also evidence that PCP may have its own recep-
tor, and it is known to affect receptors for excitatory
amino acids in the cortex and other parts of the brain
MDA, DOM, and Other Designer Drugs
(Johnson, 1987).
MDA (3,4-methylenedioxyphenylisopropylamine) and At lower doses (5-10 mg), PCP produces a sense
DOM (2,5-dimethoxy-4-methyl-amphetamine) were of relaxation, tingling sensations, and numbness. It
two of the earliest hallucinogens created synthetically does not produce true hallucinations like LSD, but
by alteration of the amphetamine molecule. How- there are distortions of body image, floating sensa-
ever, they have psychoactive properties more similar tions, and euphoria that last 4-6 hr (McKim, 1997).
to mescaline (McKim, 1997; Stafford, 1992). The Depression sometimes follows the acute dose and
oils from a variety of plants, including nutmeg, con- may last 24 hr. At higher doses, some individuals de-
tain precursors of the MDA molecule and are some- velop a psychoticlike state including confusion, de-
times ingested to produce psychoactive effect (Staff- personalization, persecution, depression, and intense
ord, 1992). In the 1970s, MDA was known as the anxiety that may last several days (Brecher, Wang,
love drug because of its ability to produce a profound Wong, & Morgan, 1988; Ray & Ksir, 1996). Individ-
sense of closeness to others along with some milder uals in this acute psychotic state are known to be
stimulant effects. DOM was introduced to the streets difficult to manage, and there is popular lore that
as STP (serenity, tranquility, peace) during this same PCP induces violence. However, careful examina-
period. It produces effects very similar to those of tion of the literature suggests that PCP does not di-
mescaline and LSD that last 6-8 hr. Although not rectly induce violence in individuals who are other-
widely available today, these drugs were the forerun- wise not prone to violence (Brecher et al., 1988).
ners of numerous designer drugs, the best known of Rather, it appears that injuries occur in the context
which is ecstasy, or 3,4-methylenedioxymethamphet- of trying to subdue the agitated and irrational user
amine (MDMA; Steele, McCann, & Ricaurte, who, by virtue of being relatively anesthetized to
1994). These drugs are discussed in more detail in pain, will not respond to typical means of subjuga-
chapter 10 and are not considered further here. tion and may seem to have "superhuman" strength.
The lethal dose in humans is estimated to be 40
times the effective dose (Gable, 1993) although some
PCP
reviewers have estimated the toxic dose to be sub-
PGP was developed as an analgesic and anesthetic stantially lower (McKim, 1997).
and has the desirable effect of reducing the percep-
tion of pain by inducing a dissociative or trancelike
Ketamine
state without the irregularities of heart rate, blood
pressure, or respiration associated with many general Ketamine has recently gained notoriety as a "club
anesthetics (McKim, 1997; Ray & Ksir, 1996). How- drug" because of its frequent use at dance clubs and
ever, it had other unpredictable psychoactive effects all night "raves." It is closely related to PCP and pro-
on some individuals that made it unsuitable for use duces similar dissociative effects. It was developed as
as a human anesthetic, although it is still used with an anesthetic for children and is also used in veteri-
animals. PCP is easily synthesized and began appear- nary medicine (McKim, 1997). Some users report
ing on the streets in the 1960s and 1970s. It was often spiritual experiences and entry into alternate reali-
misrepresented as THC, LSD, or other hallucino- ties, while others note unpleasant excitability, confu-
gens. It can be produced as tablets or capsules that sion, and irrational behavior. More negative effects
134 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

appear to occur at the upper end of the range of dos- tion is available on street names and typical dosages.
ages (see table 7.1). The effects typically last from 1 Hence, these drugs are not included in table 7.1.
to 4 hr, depending upon dose and route of adminis-
tration.
Tolerance, Withdrawal, and Dependence
Tolerance builds rapidly to LSD, psilocybin, and
Amanita muscaria
mescaline, and it becomes impossible to achieve the
The Amanita muscaria mushroom typically grows in desired effects with any dose after several successive
forests and can be found on most of the world's con- days of use. Tolerance is lost equally rapidly, how-
tinents, including North America. It is commonly re- ever, and the same dose may again be used after a
ferred to as fly agaric because of its ability to sedate few days. There is cross-tolerance between LSD, psil-
flies for several hours without causing death. The ocybin, and mescaline (McKim, 1997). The rapidly
mushroom has a toadstool shape and ranges in color developing tolerance dictates that hallucinogens be
from creamy white to pinkish orange to scarlet. The used only occasionally, and even the heaviest users
active ingredient is thought to be ibotinic acid or its may trip only a few times per month. True with-
metabolite, muscamole (McKim, 1997; Stafford, drawal syndromes do not occur for these hallucino-
1992). It is suggested that from 1 to 10 of the dried gens (Abraham & Aldridge, 1993; McKim, 1997).
mushrooms consumed orally produce the desired ef- Hallucinogens also have one of the lowest potentials
fects (Ray & Ksir, 1996; Stafford, 1992). At lower for the development of dependence (Gable, 1993).
doses, there is twitching and trembling of the limbs Only about 5% of users ever meet diagnostic criteria
and a euphoric feeling, followed by colorful hallu- for dependence (Anthony et al., 1994), and very few
cinations. At higher doses, it has been noted to users report not being able to stop or cut down their
produce hyperactivity and violence on occasion use (Morgenstern, Langenbucher, & Labouvie, 1994).
(McKim, 1997). The user eventually falls into a pro- An exception to the lack of tolerance and with-
longed deep sleep with partial paralysis. The high drawal among hallucinogens is PCP, which has been
toxicity and potential for death of these mushrooms shown to produce tolerance in both animals and hu-
are well known. mans (Balster, 1987). Withdrawal symptoms have
also been demonstrated in animals and may be re-
lated to depletion of norepinephrine, dopamine, and
Anticholinergic Hallucinogens
serotonin neurotransmitters with chronic use (Gian-
The anticholinergic hallucinogens are rarely used nini, Loiselle, Graham, & Folts, 1993). No system-
recreationally in the United States. Atropine, scopol- atic human studies of withdrawal and dependence
amine, and hyoscyamine are the naturally occurring have been conducted, but based on animal research,
active ingredients in a variety of plants that grow PCP is considered to have moderate to high poten-
around the world (e.g., belladonna, mandrake, hen- tial to produce dependence (Gable, 1993). Similarly,
bane, datura). They block the acetylcholine receptor there are anecdotal reports of compulsive use pat-
in both the central and the peripheral nervous sys- terns with ketamine, but it is not clear to what extent
tems, but they do not activate it. Their acute effects this is related to tolerance and withdrawal (Stafford,
are different from those of other hallucinogens and 1992). The finding that animals will self-administer
resemble a toxic psychosis with delirium, confusion, PCP, but not other hallucinogens, suggests that it
and loss of memory for recent events (Ray & Ksir, possesses rewarding properties not shared by other
1996). There are no visual hallucinations. In addi- hallucinogens (Balster, 1987).
tion to this clouding of consciousness, these drugs
produce a number of undesirable peripheral effects,
Adverse Effects on Health,
including dry mouth, blurred vision, and increased
Safety, and Adjustment
body temperature. Toxicity is generally high, and ac-
cidental death from overdose is not uncommon There is little evidence that LSD and other halluci-
(McKim, 1997). Although there are some recent re- nogens produce genetic damage or cause birth de-
ports of abuse of synthetic varieties that were created fects in the children of users (Abraham & Aldridge,
for medical reasons (Dilsaver, 1988), little informa- 1993; Grinspoon & Bakalar, 1979). No chronic dis-
 CANNABIS AND HALLUCINOGENS 135

eases or medical conditions are known to be associ- ly, they consist of trails of moving objects, flashes of
ated with hallucinogen use. However, it is important color, lights in the peripheral fields, afterimages, and
to remember that hallucinogen use is rare in the stroboscopic-like effects. These visual phenomena of-
population. Thus, it is difficult to obtain adequate ten occur when the person enters a dark room or
samples to study these potential outcomes, particu- when other psychoactive drugs are used. They may
larly if they result only from years of cumulative use. also be self-induced by an intentional remember-
Further, hallucinogen users frequently use multiple ing of the experience. There is some evidence that
drugs, so it is difficult to identify their independent the phenomena may be related to relatively per-
effects. manent changes in the central nervous system's
The primary area of concern for hallucinogen use processing of visual stimuli (Abraham & Aldridge,
is the production of enduring psychoses. Cases of 1993).
prolonged psychoses following hallucinogen use are
well documented, but the extent to which these dis-
orders were caused by the drug is not known (Abra-
Hallucinogen Summary
ham & Aldridge, 1993; Abraham et al., 1996; Steele
et al., 1994). Many cases clearly occur in individuals Hallucinogens are a molecularly diverse set of drugs
with schizophrenia or in those who showed poor pre- with surprisingly similar psychoactive effects. Auto-
morbid adjustment indicative of a latent psychosis. nomic effects predominate shortly after use and are
However, other cases appear to have developed in later overshadowed by powerful hallucinogenic ef-
psychologically stable individuals. The low inci- fects on perception and emotion. The most common
dence of these reactions in controlled administration adverse reaction is panic, although more psychotic-
studies suggests that unidentified predisposing char- like confusion and disorientation occur occasionally,
acteristics interact with the hallucinogenic experi- particularly with PCP, which is generally more dis-
ence to produce chronic psychoses. ruptive to behavior when taken in high doses. The
Other concerns center on the accidental injuries rapid acquisition of tolerance prevents daily or near-
or deaths that occur during the acute hallucinogenic daily use of many hallucinogens, and there is no
state. The frequency of these events is probably exag- withdrawal syndrome. Dependence on these drugs is
gerated by sensationalized media reports, but it is rare. PCP is an exception and does produce toler-
clear that judgment is sometimes impaired during ance, withdrawal, and behavioral indications of de-
hallucinogen use and can lead to injury. This is par- pendence in some users. There are few indications
ticularly likely in the case of high doses of PCP, of longer term adverse consequences, but infrequent
where the hallucinogenic state is associated more use in the population makes it difficult to detect such
with confusion, disorientation, paranoia, and resis- outcomes if they do exist. Chronic psychoses may be
tance to intervention. precipitated by hallucinogen use, but they are rare
Flashbacks, or the recurrence of acute effects of and appear to be more likely in psychiatrically pre-
the drug, weeks or months after use are sometimes disposed individuals. Impaired judgment and rare
reported even after a single use of LSD. They are acute psychoticlike states may increase injuries and
unpredictable in timing and frequency, and some accidental deaths.
may be nothing more than intense memories of the
previous trip (Ray & Ksir, 1996). They vary widely in
content (e.g., perceptual, somatic, emotional) and in Key References
duration (from fractions of a second to 5 years; Abra-
ham & Aldridge, 1993). They typically diminish with Hall, W., Solowij, N., & Lemon, J. (1994). The health
and psychological consequences of cannabis use. Na-
time if the person stops using psychoactive drugs.
tional Drug Strategy Monograph Series No. 25. Can-
Flashbacks involving the reexperiencing of visual
berra: Australian Government Publishing Service.
hallucinations and distortions have been termed McKim, W. A. (1997). Drugs and behavior: An introduc-
posthallucinogen perception disorder and hallucino- tion to behavioral pharmacology (3rd ed.). Upper
gen persisting perception disorder in the two most re- Saddle River, NJ: Prentice Hall.
cent editions of the DSM, respectively (American Stafford, P. (1992). Psychedelics encyclopedia (3rd ed.).
Psychiatric Association, 1987, 1994). Most common- Berkeley, CA: Ronin.
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 8

Opioids

Susan M. Stine
Thomas R. Kosten

The term opioids includes all known agents with three families: the enkephalins, the dynorphins, and
morphinelike and morphine-blocking activity as well the beta-endorphins. Each family is derived from a
as naturally occurring and synthetic opioid peptides. distinct precursor polypeptide and has a characteris-
Opiates constitute that subclass of opioids that are tic anatomical distribution. These precursors are des-
alkaloids extracted from opium, including morphine ignated as proopiomelanocortin (POMC), proen-
and codeine, and a wide variety of semisynthetic de- kephalin, and prodynorphin. A detailed description
rivative compounds from them and from thebaine, of the processing of these peptides is provided by
another component of opium. Opium contains more Hollt (1986). The distribution of peptides from
than 20 distinct alkaloids, the first of which (mor- POMC is relatively limited (compared to the distri-
phine) was isolated in 1806. Many semisynthetic de- bution of other families). In the human brain, the
rivatives are made by relatively simple modifications distribution of POMC corresponds to areas where
of the major opium alkaloids, morphine or thebaine. electrical stimulation can produce pain relief (Pil-
Thebaine has little analgesic action but is a precursor cher, Joseph, & MacDonald, 1988), such as the arcu-
of several important compounds, such as oxycodone ate nucleus, which projects its fibers widely to limbic
and naloxone. In addition to morphine, codeine, and and brain stem areas. Some POMC-containing fibers
the semisynthetic derivatives of the natural opium al- descend to the spinal cord (Lewis, Mansour, Khacha-
kaloids, a number of other structurally distinct chem- turian, Watson, & Akil, 1987). POMC peptides are
ical classes of drugs have pharmacological actions also found in endocrine organs such as the pituitary
similar to those of morphine. (See table 8.1.) and pancreas. The peptides from prodynorphin and
Endorphin is a term referring to the opioid sub- proenkephalin are distributed more widely through-
class of endogenous opioid peptides that consists of out the CNS, and the pattern is more complex. Pro-

141
 TABLE 8.1 Commonly Abused and Prescribed Opiates

Duration
Generic name Trade name Street name* Dose and route of administrationb'c (hr)k Comments

Illegal
Heroin (diacetyl- None Smack, horse; many IM, IV, SC (5 mg); IN, O (60 mg) 4-5 Illegal in US. Not available by prescrip-
morphine) and varied brand (street supply, bags, 0.1-0.2 g for tion.
markings (e.g., $5, $10, $15; variable purity 15-
DOA, Silence of 90%)d
the Lamb, Preda-
tor, Brain Dam-
age)d
Legally available by
prescription
Morphine Astramorph/PF Morpho, morph, IM, SC (10 mg) 4-5 Oral dose only 1/6 as effective as paren-
Duramorph, Infumorph stuff, monkey, M, O (60 mg) 4-7 teral, wide variability in first-pass me-
MS Contin, Oramorph, Rox- tab. tabolism.
anol
Codeine (Many brands of combina- School boy IM (130 mg); O (200 mg) (10-20 4-6
tion meds for cough) for antitussive effect).
Hydromorphone Dilaudid Dilliese IM, SC (1-2 mg); O (2 mg) 4-5
Hydrocodone Hycodan, others Little D, lords O (5-10 mg) 4-5
Oxycodene Percodan; Percocet Peres O (5-10 mg) 4-5 Used with other ingredients (aspirin,
acetaminophen).
Propoxyphene Darvon Unknown 0 (65 mg) 4-6 Related structurally to methadone, can
cause positive urine toxicology for
methadone. Very irritating, damages
veins and tissues if used IV or SC.
Pentazocine Talwin Unknown IM, SC (30-60 mg) O(180 mg) 4-6 Can cause withdrawal in physically de-
4-7 pendent persons (due to partial ago-
nist properties at [l receptors). Irritat-
ing if given IV.
 Meperidine Demerol Cubes6 IM, SC (75 mg) O (300 mg) 3-5 Complicated metabolism, notably nor-
4-6 meperidine (long-lasting active com-
pound with stimulant properties, risk
of seizure with accumulation).
Fentanyl Sublimaze Pdope IM, IV (0.1 mg) 1-2 When abused often not measured in
urine toxicology due to potency,
short action. Often abused by profes-
sionals with access. Reported to be
active compound in "P dope."
Maintenance agents
Methadone Dolophine Dollies, Dolls, ami- IM (10 mg) O (20 mg) 4-5 Other nonanalgesic effects have longer
done duration. Oral dose longer acting.
Maintenance dose usually 40-100
mg effective 24 hr.
LAAM ORLAAM Unknown 4-6 Duration of parent drug and long-last-
(Levo-alpha- ing active metabolites 48-72 hr.
acetymethadol) Street availability unlikely due to fed-
eral regulations prohibiting take-
home doses.
Buprenorphine Buprenex Unknown IM (0.4 mg) 4-5 Current investigational use as mainte-
SL (0.8 mg) 5—6 nance agent for opiate dependence,
usual dose 8-20 mg SL, duration
24-72 hr (dose-dependent).

'Witters (1992).
b
Dose producing equivalent analgesic effect to 10 mg morphine: IH —inhalation; IM —intramuscular; IN —intranasal; IV—intravenous; O—oral; SC—subcutaneous; SL—sublingual.
c
Reisine and Pasternak (1996).
d
Office of National Drug Control Policy (1994).
c
johnson (1990).
f
"P dope" often contains heroin as active agent.
144 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

enkephalin peptides are present in areas of the CNS similarity in the way most opioid drugs are metabo-
that are presumed to be related to the perception of lized, there are also some specific unique issues with
pain (e.g., laminae I and II of the spinal cord, the individual compounds and the action of their metab-
spinal trigeminal nucleus, and the periaqueductal olites. Only a few important examples can be men-
gray); to the modulation of affective behavior (e.g., tioned here. Heroin (diacetylmorphine) has a plasma
amygdala, hippocampus, locus ceruleus, and cere- half-life of only 0.5 hr but has a 4- to 5-hr duration
bral cortex) and motor control (caudate nucleus and of action due to its active metabolites (Reisine & Pas-
globus pallidus); and to the regulation of the auto- ternak, 1996). Heroin is mainly excreted in the
nomic nervous system (medulla oblongata) and neu- urine, largely as free and conjugated morphine. The
roendocrinological functions (median eminence). major pathway for the metabolism of morphine in
Similar to the POMC-derived peptides, the peptides turn is conjugation with glucuronic acid to form
derived from proenkephalin and prodynorphins are both active and inactive products. One product, mor-
also not confined to the CNS. phine-6-glucuronide, is excreted by the kidney, and
in renal failure, the levels of morphine-6-glucuronide
can accumulate. The absorption, fate, and distribu-
MAJOR PHARMACOLOGICAL ACTIONS tion of morphinelike drugs have been reviewed by
Misra (1978) and by Chan and Matzke (1987), and
opioid pharmacology is also comprehensively sum-
Metabolic Pathways
marized in Reisine and Pasternak (1996).
Morphine and most opioids act most rapidly when One specific example of opiate metabolism de-
they are given intravenously. Most opioids are also serves mention because of its clinical significance.
absorbed from the gastrointestinal tract and through Meperidine (Demerol), a commonly used opioid
the rectal mucosa (e.g., morphine and hydromor- medication, is hydrolyzed to normeperidinic acid,
phone are available in suppositories). The more lipo- which, in turn, is partially conjugated. Meperidine is
philic opioids are also readily absorbed through the also N-demethylated to normeperidine, which may
nasal or buccal mucosa, and the latter route of ad- lead to tremors, muscle twitches, dilated pupils, hy-
ministration is under investigation (Weinberg 1988), peractive reflexes, and convulsions due to the accu-
notably with the new maintenance medication bu- mulation of this metabolite, which has a half-life of
prenorphine. Opioids are also absorbed after subcu- 15-20 hr compared with 3 hr for meperidine. Since
taneous or intramuscular injection and also pene- normeperidine is eliminated by both the kidney and
trate the spinal cord following epidural or intrathecal the liver, decreased renal or hepatic function in-
administration. Transdermal absorption is related to creases the likelihood of such toxicity (Kaiko et al.,
lipid solubility. More lipid-soluble opioids also act 1983). Only a small amount of meperidine is ex-
even more rapidly than morphine after subcutaneous creted unchanged.
administration. Opioids have many pharmacological
actions, and the specific effects differ in time course
Actions in the Central Nervous System
and in relation to drug absorption and metabolic
rates. For example, when opioids such as morphine
Effects on Neurotransmitter Systems
are given initially, their durations of euphoria or an-
algesic action show relatively little variation regard- Although the endogenous opioid peptides appear to
less of rate of metabolism, while other effects may function as neurotransmitters, modulators of neuro-
persist longer and some metabolites may accumulate transmission, or neurohormones, their role in physio-
with repeated administration, increasing this com- logical processes is not completely understood and is
plexity. made more difficult by their frequent coexistence
Opiates are metabolized by the liver, and in pa- with other peptides or biogenic amines within a
tients with hepatic disease, increased bioavailability given neuron.
after oral administration or cumulative effects may In vivo studies in animal models initially demon-
occur (Sawe, Dahlstrom, Paalzow, & Rane, 1981). strated the importance of many neurotransmitters in
Renal disease can also significantly alter the pharma- the action of opioid drugs. Since the discovery of the
cokinetics of some opioids. Although there is overall endorphins, the interactions of other neurotransmit-
 OPIOIDS 145

ters with opioid pathways have continued to be im- the locus coeruleus (LC), the mesolimbic dopamine
portant in the understanding of the function of these system, and the dorsal root ganglion-spinal cord. The
systems. For example, the involvement of glutamater- first two systems are the most relevant to addictive
gic and the noradrenergic systems in opioid with- actions. The LC is located on the floor of the fourth
drawal is discussed below in the next section and has ventricle in the anterior pons and is the major norad-
led to important pharmacotherapeutic approaches. renergic nucleus in the brain, with widespread pro-
Dopamine effects, especially in the mesolimbic jections to both the brain and spinal cord. An impor-
dopamine system, have been similarly implicated in tant role for the LC in opiate physical dependence
opiate reinforcement. Virtually any drug abused by and withdrawal has been established at both the be-
humans, including opiates and cocaine, causes in- havioral and the electrophysiological levels: Overact-
creased dopamine release after acute administration ivation of LC neurons and decreased release of nor-
(Chen, Mestek, Liu, Hurley, & Yu, 1993). Acute sys- epinephrine (NE) are both necessary and sufficient
temic administration of opiates to rats excites do- for producing many of the behavioral signs of with-
paminergic neurons of the ventral tegmental area drawal (Aghajanian, 1978; Maldonado & Koob, 1988;
(VTA). However, studies in brain slices in vitro have Nestler, 1992; Nestler, Hope, & Widnell, 1993; Ras-
shown that such activation also represents an indirect mussen & Aghajanian, 1989). Chronically, LC neu-
effect of the opiates: Opiates, apparently via activa- rons develop tolerance to acute inhibitory actions of
tion of mu receptors, directly inhibit GABA-ergic opiates, as neuronal activity recovers toward preexpo-
neurons within the VTA and thereby reduce the in- sure levels (Aghajanian, 1978; Christie, Williams, &
hibitory influence of these cells on the dopaminergic North, 1987). Abrupt cessation of opiate treatment—
neurons (Johnson & North, 1992) and increase dopa- for example, via administration of an opioid receptor
minergic transmission to the nucleus accumbens antagonist—causes a marked increase in neuronal
(NAc). This dopaminergic input is inhibitory to most firing rates above preexposure levels (Aghajanian,
cells in that brain region. There are also numerous 1978; Kogan, Nestler, & Aghajanian, 1992; Rasmus-
reports that chronic opiate exposure can alter extra- sen, Beitner-Johnson, Krystal, Aghajanian, & Nestler,
cellular levels of dopamine in the VTA-NAc pathway 1990). Overactivation of LC neurons during with-
as determined by in vivo microdialysis (e.g., Acquas, drawal arises from both extrinsic and intrinsic
Carboni, & DiChiara, 1990). Such changes in dopa- sources. The extrinsic source involves a hyperactive
mine levels are proposed to be involved in chronic excitatory glutamatergic input to the LC (Akaoka &
opiate-induced alterations in drug reward mecha- Aston-Jones, 1991; Rasmussen & Aghajanian, 1989).
nisms. There are also nondopaminergic mechanisms The intrinsic source involves intracellular adapta-
of opiate reward (Koob, 1992). tions in signal transduction pathways coupled to opi-
oid receptors in the LC neurons (see below for sub-
cellular mechanism).
Mechanisms of Tolerance and Dependence
Increasing evidence indicates that the mesolim-
The mechanisms by which opiates induce addiction bic dopamine system —consisting of dopaminergic
have long been a subject of great interest. Model sys- neurons in the VTA and their projection regions,
tems to explain tolerance and dependence exist on most notably the nucleus accumbens —plays an im-
three levels: the neuroanatomical level, the cellu- portant role in mediating the reinforcing actions of
lar (neurotransmitter release and receptor-binding) opiates on brain function. Animals will self-adminis-
level, and the subcellular ("second-message") level. ter opiates directly into the VTA and NAc and will
develop conditioned place preference after such lo-
Neuroanatomical Systems Neuroanatomically, many cal drug administration (Koob, 1992; Self & Nestler,
regions of the central nervous system are opiate-re- 1995; Wise, 1990).
sponsive, but certain well-characterized regions have
provided particularly useful model systems in which Cellular (Synaptic) Mechanisms The discovery of
to study the mechanisms underlying the acute and opioid receptors raised the possibility that aspects of
chronic actions of opiates on the nervous system. opiate addiction might involve these endogenous re-
Three neuroanatomical systems are most impor- ceptors. However, over 15 years of research have
tant: pathways originating from and impinging upon failed to identify consistent changes in the number
146 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

of opiate receptors, or changes in their affinity for in mediating their aversive actions (Koob, 1992;
opiate ligands, under conditions of opiate addiction, Self & Nestler, 1995). However, opioids that are rela-
which has led to a focus on subcellular mechanisms tively selective at standard doses will interact with ad-
(see below). Nevertheless, the receptor and cellular ditional receptor classes when given at sufficiently
mechanisms of addiction remain important, and the high doses. This is especially true as doses are esca-
identification of opioid receptors in the 1970s repre- lated to overcome tolerance. Some drugs, particu-
sented a major advance in our understanding of the larly mixed agonist/antagonist agents, interact with
mechanisms of addiction. There are three major more than one receptor class at usual clinical doses,
classes of opioid receptors in the CNS, designated and they may act as an agonist at one receptor and
mu, delta, and kappa, as well as subtypes within each an antagonist at another.
class. Members of each class of opioid receptor have Numerous receptor-binding studies have been
been cloned from human cDNA and their predicted carried out to investigate changes induced by
amino acid sequences obtained. Their amino acid chronic opiate exposure. Long-term incubation of
sequences are approximately 65% identical, and they cultured cell lines with receptor ligands results in
have little sequence similarity to other G-protein- downregulation of opioid receptors as evidenced by
coupled receptors, except receptors for somatostatin a decrease in maximal specific binding, but many
(Reisine & Bell, 1993). other studies have failed to detect changes in opiate
There have been numerous claims over the years binding after chronic opiate exposure (Harris &
that multiple subtypes of the mu, delta, and kappa Nestler, 1993). The involvement of other transmitter
receptors exist in the brain (e.g., Pasternak, 1993). systems, as described above at the beginning of this
However, the molecular basis of some of these vari- section, has perhaps been more useful in the elucida-
ants remains uncertain, since molecular cloning tion of tolerance and dependence than of the opiate
studies have, so far, failed to confirm them, notably, mechanisms themselves. For example, blockade of
mui and mu2 (Reisine & Pasternak, 1996). The pri- glutamate actions by noncompetitive and competi-
mary approach used to define the unique pharmaco- tive NMDA (N-methyl-D-aspartate) antagonists blocks
logical profiles of the receptor classes has been the morphine tolerance (Elliott et al., 1994; Trujillo &
design of functional studies (as opposed to receptor Akil, 1991). Since these NMDA antagonists have no
chemistry and binding studies). Although biochemi- effect on the potency of morphine in naive animals,
cal and pharmacological evidence indicates that mu, their effect cannot be attributed to a simple potentia-
delta, and kappa receptors are distinct molecular tion of opioid actions. Blockade of the glycine regu-
entities, they share a number of pharmacological latory site on NMDA receptors also has the ability to
characteristics. First, they all appear to function pri- block tolerance (Kolesnikov, Maccehini, & Paster-
marily by exerting inhibitory modulation of synaptic nak, 1994). Inhibition of nitric oxide synthase also
transmission in both the CNS and the myenteric blocks morphine tolerance (Kolesnikov, Pick, Cis-
plexus. Although their location varies, they are often zewska, & Pasternak, 1993) and reverses tolerance in
found on presynaptic nerve terminals, where their morphine-tolerant animals, despite continued opioid
action results in decreased release of excitatory neu- administration. Although the NMDA antagonists and
rotransmitters. Second, they all appear to be coupled nitric oxide synthase inhibitors are effective against
to the guanidine nucleotide, which is involved in the tolerance to morphine and other mu agonists, they
subcellular mechanisms of addiction. have little effect against tolerance to the kappa ago-
Of the endogenous opioid peptides, beta-endor- nists.
phin has the greatest affinity for mu receptors, en- Pharmacological dependence (abstinence symp-
kephalins for delta receptors, and dynorphin for toms or naloxone-precipitated symptoms) seems to
kappa receptors. Morphinelike opiates, such as her- be closely related to tolerance (decreased effect with
oin, preferentially bind to the mu opiate receptor, long-term exposure), since the same treatments that
whereas the benzomorphan opiates, such as pentazo- block tolerance to morphine also often block depen-
cine, preferentially bind to the kappa receptor. With dence. Coadministration of the alpha2-adrenergic an-
respect to psychological addiction to opiates, mu and tagonist yohimbine, however, has been reported to
delta receptors are primarily implicated in mediating prevent naloxone-precipitated withdrawal (depen-
the reinforcing actions of opiates and kappa receptors dence) in animals without diminishing the analgesic
 OPIOIDS 147

effect (tolerance) (Taylor et al., 1991), so it may be cluding endogenous opioid systems, as well as other
possible to differentially affect these phenomena. neurotransmitters such as dopamine, GABA, and
glutamate. Opioid acute effects as well as mecha-
Subcellular Mechanisms In contrast to the diffi- nisms of tolerance and dependence also occur on
culty in establishing consistent effects of chronic opi- multiple levels: the neuroanatomical level (locus
ate exposure on opioid receptors, studies of the coeruleus, mesolimbic dopamine system, dorsal root
chronic effects of opiates on postreceptor signal ganglia, spinal cord), the cellular or synaptic level,
transduction pathways have been more fruitful (Nest- and the subcellular level. Opiate pharmacology con-
ler et al., 1993). Opiates regulate adenyl cyclase, Ca + tinues to be an area of extremely active research with
channels, and phosphatidylinositol turnover, suggest- increasing numbers of pharmacological agents avail-
ing that opiates may also produce changes in cyclic able exhibiting complex and diverse mechanisms of
AMP-dependent and calcium-dependent protein action. Nevertheless, despite the excitement and
phosphorylation in specific target neurons. However, therapeutic potential of these developments, many
a definitive demonstration of opioid receptor phos- questions remain to be answered before the neurosci-
phorylation has yet to appear. These studies are re- ence of opiate dependence and tolerance is com-
viewed elsewhere (Harris & Nestler, 1993; John- pletely understood.
son & Fleming, 1989; Loh & Smith, 1990).
Acutely, opiates were found to decrease cellular
levels of cyclic AMP in neuroblastoma x glioma cells MAJOR CLINICAL ASPECTS
(Sharma, Klee, & Nirenberg, 1975), and chronic ex-
posure was found to result in substantial increases in Clinical aspects of opioid use include physiological
adenyl cyclase activity in this system. More recently, and psychological phenomena, therapeutic and toxic
similar types of mechanisms have been identified in effects, and the specific direct and indirect conse-
specific regions of the central nervous system. quences of abuse and dependence.
Chronic exposure to opiates produces long-term
changes in levels of specific G protein subunits and
General Physical Symptoms
in the individual proteins that comprise the cyclic
of Opioid Action
AMP system. While there are very likely other mech-
anisms of opiate dependence in the locus coeruleus In addition to other subdivisions among opioids (e.g.,
and elsewhere, upregulation of the cyclic AMP path- families of opium alkaloids and derivatives, endoge-
way after chronic opiate exposure represents one ex- nous vs. pharmacological agents discussed previous-
ample of a specific behavioral manifestation of opiate ly), opioids have also been divided into three func-
dependence that can be attributed directly to molec- tional groups with respect to pharmacological action
ular and cellular adaptations in specific neurons. on receptors: opioid agonists (or agents which act
The subject of subcellular mechanisms of addiction similarly to morphine); opioids with mixed actions,
has been extensively reviewed by Nestler (1997). such as nalorphine and pentazocine, which are ago-
nists on some receptors and antagonists or very weak
partial agonists at others; and opioid antagonists (or
Summary of Opioid Pharmacology
agents which block morphinelike actions of other
In summary the understanding of opiate pharmacol- drugs), such as naloxone. This classification, as well
ogy has increased exponentially in recent years and as which receptors are affected, determines the physi-
has occurred on multiple levels. The effects of natu- cal symptoms produced by the opioid drug.
ral, synthetic, and endogenous opioids are deter- Although analgesia occurs without loss of con-
mined initially by the unique and varied aspects of sciousness, there may be feelings of drowsiness, diffi-
their metabolism. The examples in this chapter are culty in mentation, apathy, and lessened physical ac-
far from a comprehensive description but serve as il- tivity. The effect of opioids on pain is complex. All
lustrations of the fundamental importance of this types of painful experiences include both the original
process. In addition to metabolic properties, the ac- sensation and the reaction to that sensation and can
tivity of opioids is determined by effects on central be affected by both mu and kappa agonist mecha-
nervous system neurotransmitters and receptors, in- nisms in the brain and spinal cord. Analgesic re-
148 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

sponses of an individual patient may also vary dra- esophageal reflux (Duthie & Nimmo, 1987). Mor-
matically with different morphinelike drugs. For phine also diminishes biliary, pancreatic, and intesti-
example, some patients unable to tolerate morphine nal secretions (Dooley, Saad, & Valenzuela, 1988)
may have no problems with an equianalgesic dose of and delays digestion of food in the small intestine.
methadone, whereas others can take morphine and Propulsive peristaltic waves in the colon are dimin-
not methadone. The complexity of these effects is ished or abolished after morphine administration,
reviewed by Pasternak (1993). and tone is increased to the point of spasm. The re-
Respiratory depression is of paramount clinical sulting delay in the passage of the contents causes
importance and is produced at least in part by virtue considerable desiccation of the feces. Constipation is
of a direct effect of morphinelike opioids on the an exceedingly common problem when opioids are
brain stem respiratory centers. The depression of res- used and can lead to life-threatening complications,
piratory rate is discernible even with doses too small and the use of stool softeners and laxatives should be
to disturb consciousness, and it increases progres- initiated early.
sively as the dose is increased. The combination of Although some opioid peptides can affect the im-
opiates with other medications may present a greater mune system by producing a number of naloxone-
risk of respiratory depression. The primary mecha- sensitive effects on the function of macrophages and
nism of respiratory depression by opioids involves a leukocytes, morphine itself is rarely active. The most
reduction in the responsiveness of brain stem respira- firmly established effect of morphine on the immune
tory centers to carbon dioxide, but opioids also de- system is its ability to inhibit the formation of rosettes
press the pontine and medullary centers regulating by human lymphocytes. The administration of mor-
respiratory rhythmicity and the responsiveness of phine to animals causes suppression of the cytotoxic
medullary respiratory centers to electrical stimulation activity of natural killer cells and enhances the
(Martin, 1983). Partial agonist opiods (e.g., bupren- growth of implanted tumors. Of interest, these effects
orphine and pentazocine) are less likely to cause se- are mediated by actions within the CNS. By contrast,
vere respiratory depression and are far less commonly beta-endorphin enhances the cytotoxic activity of
associated with death caused by overdose. human monocytes in vitro and increases the recruit-
The cardiovascular system is not affected as signif- ment of precursor cells into the killer cell popula-
icantly by direct action of morphinelike opioids. In tion: This peptide can also exert a potent chemotac-
the supine patient, therapeutic doses of these drugs tic effect on these cells. The immune system effects
have no major effect on blood pressure or cardiac of these drugs has become an intensified focus of in-
rate and rhythm, although such doses do produce terest due to the comorbidity of HIV infection in the
peripheral vasodilatation. Morphine and some other opioid-dependent population.
opioids also provoke release of histamine, which can Other miscellaneous effects of opioids merit brief
play a large role in hypotension. Although effects on mention. Opioids have action on various aspects of
the myocardium are not significant in normal hu- neuroendocrine function which have been reviewed
mans, morphine and other opiates should be used by Hewlett and Rees (1986) and by Grossman (1988).
with great care in patients with cor pulmonale and Opioids also affect the uterus, and therapeutic doses
chronic pulmonary disease, since deaths following of morphine may prolong labor. Neonatal mortality
ordinary therapeutic doses have been reported (Rei- may thus be increased by the injudicious use of mor-
sine & Pasternak, 1996). phinelike opioids. Skin effects also occur, and thera-
Effects of opioids on the gastrointestinal system peutic doses of morphine commonly cause urticaria,
are also of great clinical significance. Nausea and probably by dilatation of cutaneous blood vessels due
vomiting are commonly produced and are caused by to the release of histamine.
direct stimulation of the chemoreceptor trigger zone
for emesis, in the area postrema of the medulla. Mor-
Acute Opioid Effects:
phine and other mu agonists usually decrease the se-
Intoxication and Overdose
cretion of hydrochloric acid, although stimulation is
sometimes evident. Relatively low doses of morphine While mild opioid intoxication and opioid with-
decrease gastric motility, thereby prolonging gastric drawal are not usually life-threatening, severe intoxi-
emptying time; this can increase the likelihood of cation or overdose is a medical emergency that re-
 OPIOIDS 149

quires immediate attention. Of primary concern in countered by positive-pressure respiration. Tonic-clo-

the management of overdose are interactions with nic seizures, occasionally seen as part of the toxic
mu receptors in the central nervous system, which syndrome with meperidine and propoxyphene, are
can lead to signs of intoxication such as sedation and ameliorated by treatment with naloxone. Overdose
respiratory depression. These signs are perhaps less with more potent (e.g., fentanyl) or longer acting
specific than miosis ("pinpoint pupils"), which is an (methadone) opioids may require higher doses of
important pharmacological effect that can be used naloxone given over longer periods of time, thus ne-
to identify possible opioid intoxication. Symptoms of cessitating the use of ongoing naloxone infusion.
opioid intoxication are distinct. Euphoria occurs im-
mediately after initial ingestion, and the individual
Chronic Opioid Effects: Symptoms of
experiences a dramatic decrease in anxiety or ten-
Dependence and Withdrawal
sion; the individual also often experiences an initial
burst of energy within a few minutes after ingestion. Two prominent pharmacological features of chronic
Apathy follows the initial euphoria, and "nodding," a opiate administration have been described: toler-
state between alertness and sleep, occurs. Physically, ance, characterized by a diminishing drug effect after
the individual exhibits miosis (constricted pupils), repeated administration, and dependence, revealed
slow and regular respirations, slurred speech, and hy- by a withdrawal syndrome after abrupt discontinua-
poactive bowel sounds. Judgment, attention, concen- tion of opiate exposure. It should be noted that this
tration, and memory are impaired (Thomason & use of the word dependence has a pharmacological
Dilts, 1991). meaning, as contrasted with behavioral and psycho-
The triad of coma, pinpoint pupils, and depressed logical dependence as defined in DSM-IV (discussed
respiration strongly suggests opioid poisoning. Be- elsewhere in this volume).
cause this often occurs in combination with other Withdrawal from opioids results in a specific con-
drugs, pharmacological therapy for opioid depen- stellation of symptoms as well as some relatively non-
dence should be instituted immediately as well as specific symptoms. Although some opioid withdrawal
screening for the presence of other drugs and metab- symptoms overlap with withdrawal from sedative-
olites. The finding of needle marks suggestive of ad- hypnotics, opioid withdrawal is generally considered
diction further supports the diagnosis. Examination less likely to produce severe morbidity or mortality.
of the urine and gastric contents for drugs may aid Clinical phenomena associated with opioid with-
in diagnosis, but the results usually become available drawal generally consist of symptoms related to neu-
too late to influence treatment. Naloxone hydrochlo- rophysiological rebound in the organ systems on
ride, a pure opioid antagonist, can effectively reverse which opioids have their primary actions (Jaffe &
the central nervous system effects of opioid intoxica- Martin, 1990), and the severity of opioid withdrawal
tion and overdose. An initial intravenous dose of 0.4- varies with the dose and duration of drug use. The
0.8 mg will dramatically reverse neurological and time to onset of opioid withdrawal symptoms de-
cardiorespiratory depression, in approximately 2 min, pends on the half-life of the drug being used. For
but care should be taken to avoid precipitating with- example, withdrawal may begin 4-6 hr after last use
drawal in dependent patients who may be extremely of heroin, but up to 36 hr after last use of methadone
sensitive to antagonists. The safest approach is to di- (Gold, Pottash, Sweeney, & Kleber, 1980; Gunne,
lute the standard naloxone dose (0.4 mg) and slowly 1959).
administer it intravenously, monitoring arousal and Early withdrawal symptoms may include abnor-
respiratory function. With care, it is usually possible malities in vital signs, including tachycardia and hy-
to reverse the respiratory depression without precipi- pertension. Pupillary dilation can be marked. CNS
tating a major withdrawal syndrome. If no response symptoms include restlessness, irritability, and in-
is seen with the first dose, additional doses can be somnia. Opioid craving also occurs in proportion to
given. Patients should be observed for rebound in- the severity of physiological withdrawal symptoms.
creases in sympathetic nervous system activity, which Patients frequently note yawning and sneezing, gas-
may result in cardiac arrhythmia and pulmonary trointestinal symptoms (which may initially be sim-
edema (Duthie & Nimmo, 1987). Pulmonary edema ply anorexia but can progress to include nausea,
sometimes associated with opioid overdosage may be vomiting, and diarrhea), and a variety of cutaneous
150 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

and mucocutaneous symptoms (including lacrima- presynaptic receptors to reduce noradrenergic re-
tion, or eye watering; rhinorrhea, or runny nose; and lease, is generally used, but this method is less effec-
piloerection, also known as gooseflesh). This combi- tive against many of the more subjective complaints
nation of symptomatology and intense craving fre- during withdrawal, such as lethargy, restlessness, and
quently leads to relapse to drug use. dysphoria (Jasinski, Johnson, & Kocher, 1985). How-
As with the onset of withdrawal, the duration also ever, the method is safe and effective against most
varies with the drug used. In patients hospitalized for symptoms and is also faster than methadone detoxifi-
medical illnesses, the severity of the underlying clini- cation (Stine & Kosten, 1992). In outpatients, cloni-
cal conditions can alter the selection of withdrawal dine's efficacy in the treatment of opiate withdrawal is
therapy (O'Connor, Samet, & Stein, 1994). The de- controversial (Gold et al., 1980; Jasinski et al., 1985).
cision as to whether to perform opioid detoxification One very interesting pharmacological discovery is
on an outpatient or inpatient basis depends on the the ability of opiate antagonists to reverse opiate de-
presence of comorbid medical and psychiatric prob- pendence and accelerate detoxification. Administra-
lems, the availability of social support (e.g., family tion of naloxone in dependent monkeys causes a de-
members to provide monitoring and transportation), sensitization to subsequent naloxone doses (Krystal,
and the presence of polydrug abuse. The available Walker, & Heninger, 1989). The use of an antago-
methods of detoxification also may affect this deci- nist along with another medication like clonidine to
sion; for example, methadone detoxification is legally relieve the discomfort also seems to accelerate treat-
restricted by federal legislation to inpatient settings ment in humans. Administering an antagonist such
or specialized, licensed outpatient drug treatment as naltrexone precipitates withdrawal within minutes
programs (Federal Register, 1989). for both methadone-maintained and ordinary heroin
A variety of pharmacological therapies have been addicts, and this process of precipitation appears to
developed to assist patients through a safer, more decrease the duration of subsequent withdrawal
comfortable opioid withdrawal. These therapies in- symptoms. The amount of clonidine needed to ame-
volve the use of opioid agonists (e.g., methadone) liorate these symptoms when naltrexone and cloni-
and alpha-2 adrenergic agonists such as clonidine; an dine are used together is also lessened by using larger
opioid antagonist, naltrexone, in combination with initial doses of naltrexone (Brewer, Rezae, & Bailey,
clonidine; and a mixed opioid agonist/antagonist, bu- 1988; Charney et al., 1982; Vining, Kosten, & Kle-
prenorphine. ber, 1988). Recently, very rapid inpatient detoxifica-
The simplest approach to detoxification is to sub- tion from opiates using sedatives and anesthetics in
stitute a prescribed opioid for the heroin the addict combination with opiate antagonists has been re-
is dependent on, and then to gradually lower the ported (Loimer, Lenz, Schmid, & Presslich, 1991;
dose of the prescribed opioid. The prescribed opioid Loimer, Schmid, Lenz, Presslich, & Grunberger,
commonly is methadone (Senay, Dorus, & Sho- 1990) but these procedures require intensive medical
walter, 1981; Silsby & Tennant, 1974; Wilson, treatment (intubation, artificial ventilation) as well as
Elms, & Thomson, 1974), but levo-alpha acetyl the risk of anesthesia and are therefore controversial.
methadol (LAAM) can also be used, and the with- In addition to acute withdrawal and detoxifica-
drawal from LAAM has a delayed onset, relative to tion, another issue is that of "protracted withdrawal,"
methadone discontinuation, but a similar time course which has been implicated in such clinically crucial
(Fraser & Isbell, 1952; Sorensen, Hargreaves, & phenomena as the difficulty of maintaining absti-
Weinberg, 1982). Buprenorphine is a partial mu ago- nence after detoxification from methadone mainte-
nist with an extremely high receptor affinity (Gal, nance (Senay, Dorus, Goldberg, & Thorton, 1977),
1989; Lewis, 1985; Neil, 1984) and can also be used. high rates of relapse after abstinence (Dole, 1972),
The noradrenergic approach to detoxification and drug craving (Mirin, Meyer, & McNamee,
avoids the difficulties of prescribing an opioid to an 1976). Chronic use of opioids is followed by neu-
addict. This approach is based on the established robiological alterations that persist for months after
role of increased central nervous system noradrener- discontinuation of the opiates. Up to 9 months after
gic hyperactivity in opiate withdrawal symptoms detoxification, opiate addicts manifest abstinence
described earlier in this chapter (see Redmond & symptoms of weight gain, increased basal metabolic
Huang, 1982, for review). Clonidine, which acts on rate, decreased temperature, increased respiration,
 OPIOIDS 151

increased blood pressure, and decreased erythrocyte ten persists for decades. The consequent pervasive
sedimentation rate (Himmelsbach, 1942). However, and devastating deterioration leads to the need for
because these symptoms are nonspecific and are not long-term treatments and intense psychosocial inter-
clearly opposite in nature to opiate agonist effects, as ventions.
acute withdrawal symptoms are, the protracted with- During the last 5 years, a substantial new epi-
drawal phenomenon is controversial (Satel, Kosten, demic of heroin abuse has been developing in the
Schuckit, & Fischman, 1993). United States and spreading to middle-class users,
who were formerly more likely to abuse only co-
caine. Pulse Check, a publication by the Office of
Patterns of Abuse and
National Drug Control Policy (ONDCP), reported
Psychological Dependence
in December 1991 four key trends in heroin use:
Heroin use existed among whites and other ethnic More teenagers and young adults, more middle- and
groups prior to the 1950s but began to spread among upper-middle-class people were using purer heroin,
black males in Harlem during the 1950s. Among and the proportion of people inhaling or smoking
young men in Manhattan, heroin use increased from heroin, as well as the number of people seeking treat-
3% in 1963 to a peak of 20% in 1972 (13% used ment, continued to increase. At a September 1997
heroin in 1974) (Hunt, 1965; Malcolm X & Haley, NIDA conference, Donna Shalala, Health and Hu-
1965). The proportion using heroin then declined man Services Secretary, stated that in 1995, more
some and remained relatively low in the late 1970s. than 140,000 people tried heroin for the first time,
In the late 1970s and the 1980s in New York's hard most of them under the age of 26 ("Shalala Joins,"
drug scene, low proportions of youths reaching adult- 1997). The National Drug Control Strategy (1995)
hood in Harlem and the inner city initiated use of reported that the strongest sign of an epidemic is the
heroin or became regular users, but sizable propor- entry of a large number of new users (new initiates),
tions of those who did initiate heroin injection be- and this new influx of heroin users defines such an
came addicted within 2 years, and half of these per- epidemic. New users, because they have had less ex-
sisted in their addiction. Thus, the heroin era cohort posure and fewer chronic health (at least with re-
constitutes a large proportion of the heroin addicts spect to infectious disease) and legal adverse conse-
who continue to need treatment today (Frank, 1986). quences, are more likely to recruit other new users.
In addition to the traditional association of heroin Many drug abusers mistakenly believe that inhaling
addiction with a lower socioeconomic group, use it- heroin, rather than injecting it, reduces the risks of
self leads to further social and interpersonal deterio- addiction or overdose. In some areas, "shabang-
ration. Since opioids are severely regulated, espe- ing"—picking up cooked heroin with a syringe and
cially in the United States, demand by addicts results squirting it up the nose — has increased in popularity
in the existence of a black market characterized by (Addiction Treatment Forum, 1997). Commonly
crime, disease, poverty, and loss of personal and so- known as smack or horse for years, the new pure her-
cial productivity. Prostitution is closely linked with oin is more life-threatening, which is reflected in the
drug abuse in general and opioid use in particular new street terminology (DOA, body bag, instant
and contributes to the spread of HIV, as well as other death, and silence of the lamb), and the implied
venereal and infectious diseases. High overall death danger seems to actually increase the drug's allure
rates are associated with opioid abuse: approximately (Addiction Treatment Forum, 1997). In general, in-
10-15 per 1,000 users in the United States (Jaffe, haling predominates in cities where there is high
1989). Statistics indicate a dramatic increase in her- heroin purity, and IV use predominates where purity
oin-related deaths between 1993 and 1994 (National is lower (e.g., California and Colorado), but Pulse
Drug Control Strategy, 1997). This same source re- Check (1994) also reports that many young users in
ports that the annual number of heroin-related emer- "high-purity" cities such as Chicago and New York
gency room mentions increased from 34,000 in 1990 City have switched to injection.
to 76,023 in 1995. Opioids have the capacity to ab- This expanding market for heroin fortunately co-
sorb all of an individual's attention, resources, and incides with a variety of new treatments that have
energy, which become devoted exclusively to obtain- become available, for example, developments in the
ing the next dose at any cost. This vicious circle of- treatment of acute withdrawal and the treatment of
152 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

chronic dependence by antagonist and agonist phar-

Summary of Clinical Aspects
macotherapy, including ways to optimize the deliv-
ery of methadone maintenance and newly available Clinical effects of opioids as described above include
breakthrough pharmocotherapies. These treatments general beneficial effects of the medications such as
as discussed in detail elsewhere in this volume. analgesia as well as life-threatening effects such as
In addition to heroin, many other opioid drugs, respiratory depression. Opiates act on multiple sys-
including oral prescription analgesics, can also be tems to produce effects on almost all aspects of hu-
abused and lead to opiate dependence. When given man physiological functioning, such as the gastroin-
for clinical need—for example, in the treatment of testinal, cardiovascular, immune, and endocrine
pain associated with acute surgical procedures — functions. Acute clinical phenomena such as intoxi-
these medications can generally be used without re- cation and overdose have been described and are
sulting in opioid abuse or dependence. Even when contrasted with chronic effects such as symptoms of
longer term use of an opioid analgesic is necessary dependence and withdrawal. Both tolerance and de-
and some physiological tolerance results, this does pendence and intensity of withdrawal symptoms are
not usually constitute opioid dependence as defined functions of the potency of and length of exposure to
by DSM-/V. Chronic pain, however, can present a an opiate, while the time course of such symptoms
problem. Of all patients with chronic pain, 50% take is related to the duration of action of the opiate. De-
between one and five medications per day, and 25% toxification is an area of active clinical research, and
of these become addicted (Maruta, Swanson, & Fin- new, efficient treatments are continually being devel-
layson, 1979). These patients also frequently use al- oped. Currently, opioid agents such as antagonists
cohol, and this combination can result in accidental (naloxone and naltrexone) and partial agonists (bu-
overdose and death. One study at the Seattle VA prenorphine), as well as adrenergic agents, have been
(Chabal, Erjavec, Jacobson, Mariano, & Chancy, studied for use in detoxification and have shortened
1997) reported that a total of 19% (76 out of 403) of the time needed for this treatment.
all pain patients seen were using chronic opiates and Opiate dependence (in a behavioral or DSM-IV-
that 34% of these met one and 27.6% met three or defined as opposed to pharmacological sense) has
more DSM-III-R abuse criteria. It was further noted been an important public health concern throughout
in that study that prior opiate and alcohol abuse did the 20th century and is now a growing epidemic on
not predict who would become an opiate abuser. the eve of the 21st century. The many and varied
The use of increased amounts by these patients may, available opioid medications all have some degree
in turn, enhance the risk of toxic effects and may of abuse potential and can present special problems.
lead to other problems, such as seeking multiple phy- Some of the most common of these are summarized
sicians and pharmacies and obtaining the opioid il- in table 8.1. Of the available opiates, heroin, and the
licitly (Jaffe & Martin, 1990). These medications are current epidemic of its increased abuse and depen-
also available illegally on the street and are also dence, is the most significant threat to individual and
abused by individuals who have opiate dependence public health well-being. Health problems associated
without a history of treatment for chronic pain. Most with opioid and especially heroin abuse are discussed
are essentially similar to heroin and morphine but below.
some have some differences and associated special
problems (see table 8.1). Of the orally prescribed
medications, propoxyphene (Darvon) is commonly ASSOCIATED PATHOLOGY
quoted as being related to frequent emergency- AND PROBLEMS
room overdose visits and medical examiner statistics
(Soumerai, Avorn, Gortmaker, & Hawley, 1987). Hy-
Opioid Dependence and the HIV Infection
drocodone is also gaining recognition. The available
maintenance pharmacotherapy drugs may also be
Public Health Issues
abused if access is available on the street. The com-
monly abused illegal and prescription opioids are As of June 30, 1991, 58,879 or 32.2% of all AIDS
listed in table 8.1, along with some of their special cases reported to the Centers for Disease Control
properties. (CDC) were associated with illicit drug use (Nwany-
 OPIOIDS 153

anwu, Chu, Green, Buehler, & Berkelman, 1993). medical and social services. Studies have consistently
From 1989 to 1991, the geographic regions with shown that needle exchange, in addition to improv-
highest increase in AIDS were the South and the ing access to and engagement with needed services,
North-central compared with the Northeast, which is also independently associated with decreased nee-
was the lowest. Although there is some stabilization dle sharing and related high-risk behavior (Stimson,
of reported infection rates, the HIV seroprevalence 1989; Stryker & Smith, 1993; Waiters, Estilo,
in New York City IV drug users remains close to Clark, & Lorvick, 1994). Thus, the available research
50%, a prevalence which is maintained by new cases, suggests that a stabilization in HIV infection rates is
since some individuals have died. As is apparent associated with needle and syringe exchange pro-
from the above statistics, HIV infection rates among grams (Desjarlais et al., 1994; Stryker & Smith,
intravenous drug abusers in New York remain signifi- 1993). Although this has not been directly demon-
cant and are on the increase nationally. The infec- strated, additional interesting data supporting that
tion rate in the group of IV drug users in methadone conclusion have been reported by an innovative nee-
treatment, however, is low (Ball & Ross, 1991; Hartel dle exchange and research program in New Haven,
et al., 1995), making treatment of opioid dependence Connecticut. The prevalence of HIV infection and
a clear public health need (O'Connor et al., 1994). used syringes in that city has steadily declined since
In addition to treating and preventing opioid de- the program was introduced. Using these data, re-
pendence, harm reduction among actively using opi- searchers have determined that the likelihood of HIV
ate addicts has also become an important goal. One transmission via contaminated needles may have
highly publicized new intervention which has re- been reduced by as much as one third in this envi-
cently been developed to reduce risks of transmission ronment as a result of the increased availability of
of HIV and other blood-borne disease is the syringe sterile needles through the needle exchange program
exchange program (SEP). These programs have been (Kaplan, Khoshnood, & Heimer, 1994). Even though
controversial since their introduction due to concern early data support the effectiveness of SEPs, they re-
that providing easy access to needles would lead to main controversial, and continued research is neces-
increased intravenous drug use. There is, however, sary to establish their efficacy.
no evidence for this according to Ellie Schoenbaum,
M.D., Director of the AIDS Research Program, De-
Treatment Needs of Comorbid Opiate
partment of Epidemiology and Social Medicine at
Dependent and HIV Infected Patients
Montefiore Medical Center in the Bronx, New York,
speaking at a September 1997 NIDA conference In addition to risk reduction or prevention of infec-
("Shalala Joins," 1997). Needle exchange programs tion, there is also need for treatment of an increasing
now exist in many locations in North America, Eu- number of existing HIV-positive opiate-dependent
rope, and Australia (Lurie et al., 1993; Stimson, patients both in and out of opiate treatment. Inner-
1989; Stryker & Smith, 1993). In an April 1995 sur- city HIV-positive drug abusers have need of extensive
vey by the North American Syringe Exchange Net- medical and social services (London et al., 1995),
work, 60 SEPs reported operating in 46 cities in 21 which are most effectively delivered at a central site
states. The legality and acceptance of these programs (Selwyn, Budner, Wasserman, & Arno, 1993). Where
vary from state to state and range from "legal" (states this is feasible, the psychosocial intervention should
with no law requiring prescriptions for needles), to include mechanisms for ensuring that on-site ser-
"illegal but tolerated" (by local authorities) in spite vices are used appropriately. Where on-site delivery
of laws requiring needle prescription, to "illegal/un- of medical and social services is not possible, inter-
derground" (Titus, 1996). In addition to exchanging ventions for improving patients' compliance with
needles and providing condoms and related educa- medical regimens (e.g., keeping appointments, taking
tion, most SEPs also counsel injection drug users to antiretroviral medications and prophylaxes against
follow medical hygiene standards (e.g., use a new Pneumocystis carinii pneumonia and tuberculosis)
sterile needle and syringe for each injection, use and for connecting patients to community social ser-
clean water to prepare drugs; "Syringe Exchange," vice resources is essential. Compliance with medical
1995). These programs have also often served as an regimens has the potential to improve the quality
important link between active drug injectors and and quantity of life and thus impacts on motivation
154 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

for changing high-risk behaviors regardless of wheth- (didanosine, zalcitabine, and stavudine, to varying
er opiate dependence treatment is accepted. degrees), and less commonly, hepatitis (zidovudine,
For those individuals who are in treatment for didanosine, zalcitabine), and diarrhea (lamivudine).
opiate dependence, special issues in the concurrent Some of these toxicities may be particularly impor-
management of methadone and medications for HIV tant in populations of HIV-infected drug users, in
necessitate integration of medical services and opiate whom underlying rates of peripheral nerve disease,
treatment. Risk reduction education by staff and spe- pancreatitis (due to coexisting alcohol abuse), and
cial training in HIV spectrum disease, distribution of hepatitis due to underlying alcoholic, drug-induced,
condoms, and assistance with referrals to infectious or viral hepatitis may be very high compared to the
disease clinics are further examples of such inte- rates in other HIV-infected populations (Cherubin &
grated services. Primary medical care, including T Sapira, 1993; Kreek, 1973).
cell monitoring and prescriptions for zidovudine (az- The principal toxicity of the nonnucleoside re-
idothymidine, or AZT) and other HIV medications, verse transcriptase inhibitors (nevirapine, delavir-
is provided along with prophylaxis for Pneumocystis dine) is rash. The protease inhibitors, in contrast,
carinii (PCP) pneumonia and other opportunistic in- while very potent antiretroviral agents, can have sig-
fections. TB case management projects and the pro- nificant side effects: gastrointestinal distress (saqui-
vision of medications for prevention and treatment navir, indivanir, ritonavir) and liver function and
have developed in response to an increase in tuber- lipid abnormalities (ritonavir). Of the three available
culosis, especially treatment-resistant tuberculosis, by prescription in mid-1995 (saquinavir, ritonavir, in-
within this group (Albert Einstein College of Medi- dinavir), saquinavir and indinavir are generally better
cine, 1989; Joseph & Springer, 1990). tolerated than ritonavir, but ritonavir may be one of
the most potent of the three.
With the increasing number of HIV-infected pa-
Medication Interaction Concerns
tients in treatment programs for opiate dependence,
The assessment of antiretroviral drug efficacy, as well potential interactions between methadone and other
as the determination of patients' prognosis and rate opiate pharmacotherapies and antiviral agents used
of disease progression, was revolutionized in 1996 in the treatment of HIV are particularly important to
with the introduction of commercial assays that define. The ability of opioid-maintained patients to
quantitate the amount of HIV RNA in plasma. These tolerate most of these medications has not been spe-
blood tests, also called viral load tests, are performed cifically studied. Therefore, clinicians are hesitant to
by commercial laboratories and are now routinely use these powerful new agents in the opioid-depen-
available. HIV viral load measures have been shown dent and agonist-maintained patient for fear of en-
in several studies to provide powerful new tools to hanced drug toxicity. A study of possible interactions
estimate the risk of disease and long-term morbidity between methadone and zidovudine (azidothymi-
and mortality (Carpenter et al., 1996; Mellors et al., dine, or AZT) has shown that serum levels of meth-
1995; Mellors et al., 1996; O'Brien et al., 1996). Vi- adone are not affected by this drug, but that some
ral load assays should be performed as part of all patients who receive methadone maintenance treat-
HIV-infected patients' baseline evaluations and, in ment may show a potentially toxic increase in serum
addition, should be used to assess prognosis, to deter- levels of AZT (Friedland et al., 1992; McCance-
mine the appropriateness of initiating antiretroviral Katz, Jatlow, Rainey, & Friedland, in press; Schwartz
therapy, and to evaluate responses to therapy. et al., 1992;). However, these authors caution against
The introduction of new antiretroviral agents has making changes in the dosage of AZT and suggest
raised justifiable hope of a new therapeutic era for instead careful clinical monitoring for signs of dose-
HIV-infected patients. However, these agents have related AZT toxicity in such patients. In the case of
also introduced new complexities in patient manage- protease inhibitors, there is even less information
ment, particularly for injection drug users, due in concerning interaction with methadone. All the pro-
large part to potential drug toxicities and drug inter- tease inhibitors are metabolized by the hepatic cyto-
actions. The principal toxicities of the nucleoside an- chrome P450 microsomal enzyme system and, to var-
alogues consist mostly of bone marrow suppression ying degrees, may inhibit the metabolism of other
(zidovudine), peripheral neuropathy and pancreatitis drugs that are handled by this system. These drugs
 OPIOIDS 155

include methadone, other opioids, barbiturates, ben- hepatotoxic drugs in such patients (Cherubin &
zodiazepines, anticonvulsants, and a variety of other Sapira, 1993; O'Connor et al., 1994).
medications. Thus, dosing adjustments may be re- Chronic liver disease in all its forms has major
quired, and in some cases, certain medications may implications concerning medication use. For exam-
be contraindicated. Clinical and pharmaceutical ple, opioid medications for treatment of dependence
studies are urgently needed to evaluate the possibly on drugs such as methadone, LAAM, and buprenor-
wide range of drug interactions for which HlV-in- phine, medications commonly prescribed to treat dis-
fected drug users may be at risk through the use of eases that are prevalent in drug users such as tuber-
this important new group of antiretroviral medica- culosis (e.g., isoniazid, rifampin), and drugs used to
tions. treat or prevent opportunistic infections (e.g., tri-
methoprim-sulfamethoxazole) and some antiretrovi-
ral agents (e.g., didanosine) may have hepatotoxic in-
Other Medical Problems
fluence (Kreek, Garfield, Gutjahr, & Giusti, 1976;
O'Connor et al., 1994; Sawyer, Brown, Narong, &
Liver Disease
Li, 1993; Schwartz et al., 1990).
In addition to the direct physiological effects de- The bulk of severe chronic opioid addicts in treat-
scribed above with opioid use and abstinence, there ment receive methadone, and the liver may play a
are multiple indirectly associated medical problems. central role in several aspects of methadone disposi-
Chronic liver disease is the most common medical tion, including not only methadone metabolism and
problem. Fifty to sixty percent of all heroin addicts clearance but also storage and subsequent release of
entering methadone maintenance have biochemical unchanged methadone. However, clinically metha-
evidence of chronic liver disease primarily of two eti- done use has been well described in milder liver dis-
ological types: (a) sequelae of earlier acute infection ease and used successfully in these patients. Very se-
with hepatitis B or hepatitis C virus; (b) alcohol-in- vere liver disease or abrupt changes in hepatic status
duced liver disease, including fatty liver, alcoholic may cause significant alterations in methadone dis-
hepatitis, and alcohol cirrhosis. Each of the major position with concomitant clinical symptoms (Kreek,
forms of viral hepatitis has been associated with in- Oratz, & Rothchild, 1978).
jection-drug use, with hepatitis B and C being the
most important.
Other Infectious Diseases
A variety of studies have shown that over half of
injection-drug users are likely to show serological evi- A variety of bacterial infections have been well docu-
dence of past hepatitis B infection (positive serologi- mented to be associated with drug use in general,
cal test for hepatitis B surface antibody and/or hepati- and with injection-drug use in particular. For exam-
tis B core antibody), and a substantial proportion of ple, individuals with IV drug use (especially if they
this population also show evidence of active hepatitis also have HIV disease) are at further risk for impor-
B (hepatitis surface antigen positive) infection (Chu & tant bacterial infections, including skin and soft tis-
Wortley, 1995). These chronic carriers are at risk for sue infection, pneumonia, and endocarditis and sep-
transmitting hepatitis B infection and are more likely sis. Tuberculosis is an especially significant problem
to experience chronic liver disease. in this population. As with bacterial infections, tuber-
Hepatitis C is an important cause of posttransfu- culosis has long been known to be prevalent in drug
sion hepatitis, as well as hepatitis infection among users (Cherubin, 1967), but the AIDS epidemic has
injection-drug users (Cherubin & Sapira, 1993; resulted in a major increase in the number of cases
O'Connor, Selwyn, & Schottenfeld, 1994). A variety of tuberculosis, particularly among drug users (Sel-
of serological studies of hepatitis C virus infection wyn et al., 1992). Generally tuberculosis in HIV-
has found that the majority (over two thirds) of injec- infected individuals may represent reactivation of la-
tion-drug users examined have shown evidence of tent disease in the setting of immunosuppression, but
hepatitis C like hepatitis B, infection (Esteban et al., it is also brought on in other addicts by environmen-
1989; Simmonds et al., 1990). Hepatitis C is also as- tal and "social" factors related to drug use (O'Con-
sociated with chronic liver disease, and there are sim- nor, Selwyn, & Schottenfeld, 1994). HIV-infected in-
ilar implications concerning the use of potentially dividuals within the opiate-dependent population are
156 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

at particularly high risk for "extrapulmonary" mani- transient feelings of anger, anxiety, or depression;
festations of tuberculosis (Barnes, Bloch, David- psychiatric disorders complicated by medical condi-
son, & Snider, 1991; Braun et al., 1990), including tions such as hepatitis; and illnesses or injuries that
infection of the gastrointestinal system or central ner- produce chronic pain such as pancreatitis, sickle cell
vous system. anemia, or trauma resulting in nerve root irritation.
Rounsaville, Weissman, Crits-Christoph, Wilber,
and Kleber (1982) also found that untreated addicts
Complications of Pregnancy
had similar types of psychiatric illnesses in relatively
The potential medical and social costs of opiate de- similar proportions to patients who were in treat-
pendence during pregnancy are great. Pregnant opi- ment. However, treated addicts were less likely to
ate-dependent women experience a sixfold increase have a current psychiatric illness.
in maternal obstetric complications and significant
increases in neonatal complications (Dattel, 1990).
Pregnancy complications associated with opiate de- Summary of Associated Pathology
pendence include low birth weight, toxemia, third- and Problems
trimester bleeding, malpresentation, postchildbirth In summary, opiate dependence presents a diverse
morbidity, fetal distress, and meconium in the amni- array of associated medical, psychosocial, and psychi-
otic fluid. Neonatal complications include narcotic atric problems with a large public health impact.
withdrawal, postnatal growth deficiency, microceph- Treatment and prevention of HIV infection in partic-
aly, neurobehavioral problems, and a 74-fold increase ular requires an active approach using active psycho-
in sudden infant death syndrome (SIDS) (Dattel, social services such as education and support of med-
1990). ication compliance. Controversial approaches such
as syringe exchange programs require ongoing inves-
Psychiatric Problems tigation. Pharmacokinetic interaction of important
medications for the opiate-dependent/HIV-comorbid
There is a large subgroup of opioid-dependent pa- population is also an area of urgently needed re-
tients with psychiatric comorbidity, and inability to search.
treat the psychiatric disorders of the opiate-depen-
dent patient contributes to poor treatment response
and increased severity of all medical, addictive, and Key References
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can have almost every psychiatric illness that occurs treatment and matching treatments to patient. In S.
in nonaddicts. A comprehensive evaluation of psy- M. Stine & T. R. Kosten (Eds.), New treatments for
chiatric disorders in addicts was completed by Roun- opiate dependence (Vol. 3, pp. 121-172). New York:
saville, Weissman, Kleber, and Wilber (1982) in a Guilford Press.
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sion was the most frequently diagnosed illness, with and antagonists. In J. G. Hardman & L. E. Limbird
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depression at least once. Alcoholism was the next pp. 521-557).
Kreek, M. J. (1994). Pharmacology and medical aspects
most common problem (34.5%), followed by antiso-
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 9

Nicotine

John Slade

But for nicotine and addiction to it, tobacco products on the pH of the medium in which it is dissolved.
would very likely not be the public health menace The two are precisely equal in concentration at the
they are. While other components of tobacco prod- somewhat alkaline pH of 8.0. Although dissolved
ucts and tobacco smoke are in the main responsible salts of nicotine are not readily absorbed because
for the direct toxicity of tobacco, it is nicotine that they are ionized, the neutral free base freely crosses
keeps consumers interested in using. But for the biological membranes. Available nicotine delivery
enormous burden of illness and death that tobacco devices present nicotine to the skin (patches), the na-
causes, nicotine dependence would very likely not sal mucosa (nasal snuff and nasal spray), the oropha-
be an important clinical entity. ryngeal mucosa (cigars, pipe tobacco, spit tobacco,
As it is, though, the cigarette is the leading cause gum, inhaler), and the lower respiratory tract (ciga-
of preventable death, and nicotine is largely responsi- rettes and cigars).
ble for the high prevalence of its use. The high rate Nicotine is rapidly metabolized, mostly to coti-
of tobacco use among people who use other depen- nine and nicotine oxide (Henningfield, Cohen, &
dence-producing drugs presents special concerns and Pickworth, 1993). Most (85-90%) of the biotransfor-
challenges. mation occurs in the liver. (When nicotine is in-
gested orally, it is absorbed in the small intestine, but
MAJOR PHARMACOLOGICAL ACTIONS little reaches the systemic circulation because of first-
pass metabolism in the liver.) Cotinine formation de-
pends on the cytochrome P450 system (described in
Metabolic Pathways
chapter 4). Most cotinine is further metabolized to
The nicotine molecule may exist as a salt or as a free other products.
base; the relative proportion of each species depends Overall, only 5-10% of ingested nicotine is ex-
162
 NICOTINE 163

creted unchanged. Total clearance of nicotine aver- prominent in the cortex, thalamus, ventral tegmental
ages 1,300 ml/min of which only 200 ml/min is ac- area, interpeduncular nucleus, amygdala, septum,
complished by the kidney. The balance (1,100 ml/ brain stem motor nuclei, and locus coeruleus. Neu-
min) is equal to about 70% of hepatic blood flow; ronal nicotinic acetylcholine receptors have protein
since the liver is responsible for most of the disap- subunits designated a and P. Eight different varieties
pearance of nicotine from the blood, this indicates of a and three different varieties of (3 subunits are
that the liver takes up nicotine from the blood with found in the brain, but the predominant combina-
about a 70% efficiency. tion in rat brain is CL$I. Different receptors have var-
Nicotine has a half-life in the circulation of about ying affinities for nicotine and varying conductances
2 hr. This contributes to the peaks and valleys of nic- for sodium and calcium. These differences may ex-
otine levels seen in persons using tobacco products. plain some of the diversity of action of nicotine.
For instance, with cigarettes, after an overnight absti- Nicotinic receptors are present both on cell bod-
nence, the venous level might be about 5 ng/ml. ies and at nerve terminals and thus provide the po-
Over 6-8 hr of regular smoking, the level rises to tential for modulation of neural activity in a number
between 20 and 40 ng/ml, a level punctuated by of different ways. Stimulation of these receptors leads
surges associated with the smoking of each cigarette to release of a wide variety of neurotransmitters, in-
(and, indeed, each puff). Overnight, the level falls cluding acetylcholine, norepinephrine, dopamine,
again. While nicotine levels vary greatly over the serotonin, and p-endorphin. The hormones prolac-
course of a day, a regular smoker always has nicotine tin, growth hormone, and ACTH are also released
on board. by nicotine. Of note outside the CNS, nicotine stim-
The half-life of cotinine is about 18-20 hr. This ulates the release of epinephrine and p-endorphin
compound does not, then, show the acute cigarette- from the adrenal gland.
to-cigarette or puff-to-puff variation in level that nico-
tine does. However, the longer half-life of cotinine
Mechanisms of Tolerance and Dependence
has made this compound useful as a marker for re-
cent nicotine ingestion. Blood levels of cotinine in a Nicotine both activates and desensitizes nicotinic
smoker are on the order of 250 ng/ml. There is a cholinergic receptors (Benowitz, 1996). Desensitiza-
useful relationship between the random level of coti- tion may explain the rapid acquisition of tolerance
nine in the blood and total daily nicotine dose (Be- (tachyphylaxis) seen with nicotine exposure and the
nowitz, 1988). Multiplying the blood cotinine level upregulation of nicotinic cholinergic receptors char-
by 0.12 provides an estimate of the amount of nico- acteristic of sustained exposure to nicotine.
tine ingested over the previous 24 hr. Depending on Nicotine stimulates the release of dopamine from
how they are smoked, single cigarettes, across a wide the mesolimbic system in the ventral tegmental area,
range of FTC-rated, machine-measured nicotine de- projecting into the nucleus accumbens. This action
liveries, deliver between 1 and 3 mg of nicotine to is regarded as central to its reinforcing and depen-
the consumer (U.S. Department of Health and Hu- dence-producing effects and is similar to the action
man Services [USDHHS], 1988; NCI Expert Com- by which other addicting drugs such as cocaine and
mittee, 1996). heroin affect this brain region.

Actions in the Central Nervous System

CLINICAL ASPECTS
Impacts on Neurotransmitter Systems
Preparations and Dosing
Two cholinergic agonists, nicotine from tobacco and
muscarine from a species of Amanita mushroom, The nicotine market should be considered broadly
have long defined two basic types of biological recep- (Warner, Slade, & Sweanor, 1997). While nicotine
tor for acetylcholine. Receptors for nicotine are is usually consumed in the form of conventional to-
widely distributed in the body (Benowitz, 1996). bacco products, other dosage forms are increasingly
They are found at the neuromuscular junction, in available, and novel tobacco products are under de-
autonomic ganglia, and in the central nervous sys- velopment and beginning to appear (table 9.1).1 Nic-
tem. In the brain, nicotinic receptors are especially otine delivery devices include conventional tobacco
164 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

TABLE 9.1 Nicotine Delivery Devices

Relative
Route of addictive Relative
Product nicotine absorption potential toxicity

Traditional tobacco products

Cigarette Lung 4 4
Cigar Mouth and lung 3 3
Pipe Mouth and lung 3 3
Chewing tobacco and moist snuff Mouth 3 3
Nicotine replacement products
Gum Mouth 1 1
Patch Skin 0 1
Nasal spray Nose 2 1
Inhaler Mouth and throat 1 1
Novel tobacco products
Eclipse Lung 3 2
Tobacco gum Mouth 1 1
Tobacco lozenge Mouth 1 1

Note. The likely relative addictive potential and potential toxicity have been estimated for illustrative purposes
by the author on a scale of 0 to 4. Eclipse is the brand name for a novel nicotine delivery device undergoing
test marketing by the R. J. Reynolds Tobacco Company. The tobacco gum and tobacco lozenge referred to in
the table are products under development by the Star Tobacco and Pharmaceutical Company.

products, medicinal forms of nicotine from pharma- Cigars are engineered to produce a more alkaline
ceutical companies, and novel tobacco products. smoke than cigarettes, making oral absorption of ci-
There are hundreds of different brands of nicotine gar smoke possible. Testimony from cigar executives
delivery device on the market. Street names include before Congress has indicated that the oral absorp-
fag, cig, smoke, chew, dip, spit tobacco, and stogie. tion of nicotine from cigar smoke is intended by the
Tobacco products are, at root, devices for the de- manufacturers (American Society of Addiction Med-
livery of nicotine (U.S. Food and Drug Administra- icine, 1995). However, many smokers of cigars also
tion [USFDA], 1996). There is now a wealth of evi- inhale the smoke; inhalation leads to rapid absorp-
dence from previously secret files of tobacco product tion of nicotine and widespread dissemination of nu-
manufacturers that this has long been the view merous toxins and thus to adverse health effects
within the companies (Glantz, Slade, Bero, Ha- which are similar to those from smoking cigarettes.
nauer, & Barnes, 1996). Pipe tobaccos, while usually designed to produce al-
Cigarette smoke is usually inhaled, and nicotine kaline smoke, may have a lower pH as well, which
is absorbed in the lungs following inhalation. The would require inhalation for nicotine delivery. Puff-
acidity of cigarette smoke precludes absorption from ing, rather than inhaling, though, seems the more
the mouth, so inhalation is necessary for nicotine ab- usual way of using pipes.
sorption (Slade, 1993). Inhalation has two important Oral tobaccos (such as chewing tobacco and
effects: With pulmonary absorption, the arterial level moist snuff) are manufactured to facilitate nicotine
of nicotine rises very rapidly to levels of 80 ng/ml or absorption in the mouth. The manufacturers of
more (Henningfield, London, & Benowitz, 1990), moist snuff manipulate the pH of their products so
and inhalation exposes the lungs to all the other that products that are widely used by novices have
components of cigarette smoke, leading to more lower nicotine deliveries than products used by expe-
widespread distribution of these toxic materials than rienced dippers (Djordjevic, Hoffman, Glynn, &
occurs with other forms of nicotine ingestion. The Connolly, 1995; Henningfield, Radzius, & Cone,
surges of nicotine reaching the brain following inha- 1995).
lation are thought to make the inhalation route more Nicotine replacement products are marketed as
reinforcing than other routes of administration (Hen- adjuncts for the management of nicotine depen-
ningfield & Keenan, 1993). dence. However, it is not uncommon for people to
 NICOTINE 165

use some of these products for prolonged periods of The nicotine deliveries expected from cigars and
time (Warner et al., 1997). The use of those products moist snuff products vary considerably. Cigars exhibit
that deliver nicotine in discrete doses (gum, nasal a wide range of nicotine contents, in large part re-
spray, inhaler) can become paired with internal or lated to the great variety of sizes and weights of cigars
external cues. Thus, these nicotine delivery devices (USDHHS, 1998). Moist snuff brands seem engi-
may be at least mildly reinforcing in and of them- neered to deliver nicotine at varying rates depending
selves. There are no reports, however, of anything on the market niche for which particular brands are
resembling a dependence syndrome associated with designed (Connolly, 1995; Slade, 1995; Tomar, Gio-
use of the nicotine patch, as would be expected, vino, & Eriksen, 1995). While nicotine content is
since there is no way for the consumer to modulate similar from brand to brand, the pH of the products
the slowly absorbed dose from the patch apart from varies enormously, which affects the rate at which
applying or removing the product. nicotine can be absorbed in the mouth of a con-
A variety of novel products is emerging that defy sumer. Starter products (e.g., Skoal Long Cut) de-
conventional categories. Eclipse is a device manufac- liver nicotine more slowly than products that are
tured by R. J. Reynolds that resembles a cigarette but more often used by experienced, tolerant users (e.g.,
generates heat from a carbon fuel element and pro- Copenhagen) (Djordjevic et al., 1995; Henningfield
duces a nicotine-laden aerosol from papers made et al., 1995).
from tobacco and other materials. In use, the con- Unlike cigarettes, which are rated by supposed
sumer inhales an aerosol that contains a substantial nicotine yield, nicotine gum is rated by nicotine con-
dose of nicotine but lower doses of the other materi- tent. The available dosage strengths, 2 mg and 4 mg,
als than are found in most cigarettes (Slade, in press). actually deliver less than half of these doses to the
Star Tobacco and Pharmaceuticals is developing a consumer. Unlike nicotine gum, nicotine patches
tobacco-containing gum and lozenge using leaf to- are categorized by the delivered dose of nicotine over
bacco that has been treated to eliminate tobacco-spe- either 16 or 24 hr, depending on the brand (e.g., one
cific nitrosamines. The company is testing its prod- brand offers patches in three sizes which deliver 7,
ucts and plans to submit them to the FDA for 14, and 21 mg of nicotine over 24 hr, while another
approval as therapeutic agents (Sears, 1997). brand provides one size which delivers 15 mg over
Both confusion and gaps in knowledge exist about 16 hr). Nicotine nasal spray is labeled by the deliv-
the dose of nicotine that consumers of these various ered dose of nicotine, 0.5 mg per activation of the
products actually ingest. The nicotine yield of ciga- spray device.
rettes as measured on a machine has been the pri-
mary source of information available to consumers
Physical Symptoms of Use,
about nicotine dosing since the mid-1960s. These re-
Abuse, and Dependence
sults, though, bear little relationship to the actual
amounts of nicotine that consumers ingest (NCI Ex- Initial ingestion of nicotine is often an aversive expe-
pert Committee, 1996) because, simply, people don't rience. Nausea, headache, and a generalized feeling
smoke like machines. They often take larger and of being unwell are common initial impressions. Tol-
more frequent puffs, and they often block the tiny erance develops rapidly to these symptoms. With the
ventilation holes that surround the filter of most ciga- regular use of tobacco products, nicotine ingestion is
rettes on the market, a behavior that results in more reinforced and often becomes compulsive. Nicotine
concentrated smoke being inhaled. The way smokers ingestion becomes paired with an enormous range of
actually smoke increases the yields of their cigarettes internal and external cues, so that these cues become
from two- to fourfold (Djordjevic, Fan, Ferguson, & additional stimuli for more nicotine ingestion. Symp-
Hoffman, 1995). Moreover, there is little difference toms of dependence commonly occur prior to the
in the dose of nicotine people actually absorb across onset of daily smoking (McNeill, West, Jarvis, Jack-
a broad range of brands having different FTC-rated son, & Bryant, 1986).
nicotine yields (NCI Expert Committee, 1996). A Many find in the course of regular use that nico-
relatively constant phenomenon, however, is the nic- tine ingestion in the form of tobacco products facili-
otine content of a cigarette. On average, each ciga- tates relaxation and helps focus attention. Nicotine
rette, regardless of brand or brand style, contains delivered in the form of the cigarette has effects on
about 8-10 mg of nicotine (USDHHS, 1988). appetite and on metabolism. Regular use of ciga-
166 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

rettes is associated with a modestly lower weight (6-8 (Doll, Peto, Wheatley, Gray, & Sutherland, 1994).
Ib) than that seen in an appropriate comparison About half of deaths from smoking occur in the mid-
group of never smokers. Adolescent females who dle years of life and half in the later years. Stopping
smoke know this and often explain their smoking as smoking at any age reduces both morbidity and mor-
part of their keeping on a diet. Nicotine gum has a tality from smoking.
tendency to suppress appetite as well. Tobacco use In the United States, more than 400,000 persons
may suppress depressed mood. Cigarette smoking is die each year because of cigarettes; the risk of illness
more common among people who have a history of and death is strongly related to the amount and dura-
depression. Such people often have great difficulty tion of use (USDHHS, 1989). Cigar use is a cause
quirting, and symptoms of depression may emerge of cancers in the mouth and throat, and if cigar
during nicotine withdrawal. There are suggestions in smoke is inhaled, the risks of lung cancer, emphy-
the literature both that depression leads to smoking sema, and fatal heart disease rise steeply (USDHHS,
and that smoking leads to depression (Breslau, Pe- 1998). Smokeless tobacco causes a wide range of oral
terson, Schultz, Chilcoat, & Andreski, 1998; Choi, lesions, including cancer (USDHHS, 1986).
Patten, Gillin, Kaplan, & Pierce, 1997). While most attention has been paid to lung can-
In the doses usually ingested, nicotine does not cer, heart disease, and chronic obstructive pulmo-
cause intoxication. Thus, it can be used in many nary disease (chronic bronchitis and emphysema),
more settings than would be possible if it produced cigarettes cause many additional serious problems.
intoxication. Stroke and peripheral vascular disease, including
aortic aneurysm, are caused by cigarettes. The occur-
rence of cancers of the mouth, throat, larynx, esopha-
Symptoms and Course of Withdrawal
gus, pancreas, uterine cervix, and bladder are related
The symptoms of nicotine withdrawal that an indi- to the cigarette. Poor wound healing, reduced fertil-
vidual manifests vary from person to person. The fol- ity, impotence, earlier age at menopause, increased
lowing phenomena are listed as having diagnostic risk of osteoporosis, cataracts, and peptic ulcer dis-
importance in recognizing nicotine withdrawal in ease are some of the other robust associations with
the DSM-IV (American Psychiatric Association, 1994): cigarette use (London et al., 1996).
(a) dysphoric or depressed mood; (b) insomnia; (c) Adverse pregnancy outcomes have long been
irritability; frustration, or anger; (d) anxiety; (e) diffi- known to be caused by maternal cigarette use. Pla-
culty concentrating; (f) restlessness; (g) decreased centa previa and placental abruption are both related
heart rate; and (h) increased appetite or weight gain. to maternal smoking. Low birth weight, with its at-
In addition to these, craving or urges to use tobacco tendant increased risk of illness and death, is more
are also symptoms of nicotine withdrawal. common in this group of infants. The risk of SIDS
Nicotine withdrawal begins with a few hours of is high among infants exposed to tobacco smoke both
the last dose of nicotine. It has a variable course, with in utero and postnatally (California Environmental
clinical symptoms varying from days to weeks. One Protection Agency, 1997).
laboratory study found persistent abnormalities for the The precise role that nicotine itself plays in pro-
entire 10-day duration of the experiment (USDHHS, ducing these effects is not known. Nicotine is not a
1988). Patients often do not feel comfortable for carcinogen, but it has cardiovascular effects, includ-
weeks or even months after stopping. Like other ing effects on heart rate and blood pressure. How-
withdrawal syndromes, nicotine withdrawal is a com- ever, nicotine does not appear to be responsible for
plex function of dose, set, and setting. many of the phenomena associated with atherogene-
sis from smoking (Benowitz & Gourlay, 1997), and
the ingestion of nicotine in forms other than the cig-
Pathological Effects
arette and the cigar are, by and large, not associated
The adverse pathological effects of tobacco use are with cardiac complications.
legion (London, Whelan, & Case, 1996). No other Nicotine itself is suspected of being causally re-
psychoactive substance causes as much illness and lated to adverse pregnancy outcomes (Oncken, in
death. Overall, half of those who continue to smoke press) and to the occurrence of SIDS (Slotkin,
cigarettes will die prematurely as a direct result Lappi, McCook, Lorber, & Seidler, 1995).
 NICOTINE 167

caine users, however, relapse rates were the same re-

Psychological, Including Affective
gardless of tobacco use. Since nicotine is, primarily,
and Cognitive Effects
a stimulant, it may be that nicotine facilitates the
While nicotine is usually regarded as a drug with few abuse of depressant drugs such as alcohol and heroin
or no negative psychological effects, a number of while having no effect on the abuse of another stimu-
phenomena suggest that nicotine may not be free of lant, cocaine.
negative effects. A large literature exists on perfor-
mance effects related to tobacco use. Unfortunately,
Social and Interpersonal Effects
much of this literature compares deprived with unde-
prived smokers (Heishman, Taylor, & Henningfield, Tobacco smoke is a cause of illness and death in
1994). Moreover, the tasks employed have tended nonsmokers (California Environmental Protection
not to be as complex as tasks in daily life. Overall, Agency, 1997; Hackshaw, Law, & Wald, 1997; How-
the data are clear that smoking reverses decrements ard et al., 1998; Law, Morris, & Wald, 1997; U.S.
in performance associated with withdrawal. How- Environmental Protection Agency, 1992). In adults,
ever, there is as yet no clear indication that smoking environmental tobacco smoke (ETS) is a cause of
actually enhances performance. Using appropriate lung cancer and heart disease, leading to as many as
controls, Spilich, June, and Renner (1992) have 50,000 deaths in the United States each year
shown that smoking is associated with impaired per- (Glantz & Parmley, 1995). ETS makes asthma and
formance on several cognitive tests, including a read- other respiratory conditions worse. Among children,
ing comprehension test and a driving simulation. ETS is a cause of otitis media, bronchitis, and pneu-
These results are congruent with epidemiological monia.
data indicating that people who smoke are at in- The evidence that ETS is harmful to nonsmokers
creased risk of experiencing automobile crashes com- is compelling. Unlike pollution problems such as
pared to appropriate controls, a result which is not those of asbestos and radon, for which most of the
explained by distractions caused by manipulating evidence of serious environmental hazard involves
cigarettes (DiFranza, Winters, Goldberg, Cirillo, & extrapolations from high dose exposures, ETS is
Biliouris, 1986). known to be harmful both from studies of high dose
Many who use tobacco explain their use as a way exposures (among smokers) and from a wealth of
of coping with stress. Indeed, an increase in stressful studies at the actual levels of exposure of non-
feelings accompanies many attempts to withdraw smokers. Moreover, the problem is enormous be-
from tobacco use. However, people who smoke are, cause of the widespread exposure nonsmokers have
at baseline, under a higher level of self-perceived to ETS. Although only about 25% of adults smoke
stress than those who do not smoke. After quitting, in the United States, nearly 40% of children live in
people feel under less stress (Parrott, 1998). Thus, it a household in which at least one person smokes.
may be that, as with alcohol, smoking induces some Smoking by others is a factor in taking up smok-
of the adverse affective symptoms which users be- ing (USDHHS, 1994), and smoking by others is a
lieve their use of tobacco relieves. common precipitant of relapse for those who have
People addicted to other drugs, including alco- recently stopped (USDHHS, 1990).
hol, are about three times more likely than those
without other drug problems to smoke cigarettes:
The prevalence of smoking in this population is in SUMMARY
the range of 60-80% (Hurt, Eberman, Slade, &
Karan, 1993). In animal studies, cross-tolerance has Nicotine stimulates nicotinic cholinergic receptors
been demonstrated between alcohol and nicotine in the body. Within the brain, responsive receptors
(Dar, Li, & Bowman, 1993). Stuyt has suggested a are found in many locations, including in the ventral
possible mechanism for the interaction (Stuyt, 1997). tegmental area. Tolerance and dependence result
In a follow-up study of people treated for drug depen- from repeated ingestion of nicotine from tobacco
dence, relapse rates were substantially lower among products. Tobacco product use regularly leads to se-
persons who did not use tobacco if the other drug rious health problems for both users and nonsmokers
problem was either alcohol or heroin. Among co- exposed to tobacco smoke. While nicotine itself is
168 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

addicting and has a variety of other pharmacological Choi, W. S., Patten, C. A., Gillin, J. C., Kaplan, R.
properties, it is probably not directly responsible for M., & Pierce, J. P. (1997). Cigarette smoking pre-
most of the harm tobacco products cause. This fact dicts development of depressive symptoms among
makes it possible to use nicotine in medicinal forms U.S. adolescents. Annals of Behavioral Medicine, 19,
42-50.
in the treatment of nicotine dependence.
Connolly, G. N. (1995). The marketing of nicotine ad-
diction by one oral snuff manufacturer. Tobacco
Note Control, 4, 73-79.
Dar, M. S., Li, C., & Bowman, E. R. (1993). Central
1. The designations of relative addictive potential behavioral interactions between ethanol, (-)-nicotine,
and relative toxicity presented in table 9.1 are estimates and (-)-cotinine in mice. Brain Research Bulletin, 32,
by the author. 23-28.
DiFranza, J. R., Winters, T. H., Goldberg, R. J., Cirillo,
Key References L., & Biliouris, T. (1986). The relationship of smok-
ing to motor vehicle accidents and traffic violations.
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diction and therapeutics. Annual Review of Pharma- Djordjevic, M. V., Fan, J., Ferguson, S., & Hoffman, D.
cology and Toxicology, 36, 597-613. (1995). Self-regulation of smoking intensity: Smoke
Slade, }. (1993). Nicotine delivery devices. In C. T. Or- yields of the low-nicotine, low-"tar" cigarettes. Carci-
leans & J. Slade (Eds.), Nicotine addiction: Principles nogenesis, 16, 2015-2021.
and management (pp. 3-23). New York: Oxford Uni- Djordjevic, M. V., Hoffman, D., Glynn, T., & Con-
versity Press. nolly, G. N. (1995). US commercial brands of moist
Warner, K. E., Slade, J., & Sweanor, D. T. (1997). The snuff, 1994: 1. Assessment of nicotine, moisture, and
emerging market for long-term nicotine mainte- PH. Tobacco Control, 4, 62-65.
nance. JAMA, 278, 1087-1092. Doll, R., Peto, R., Wheatley, K., Gray, R., & Sutherland,
I. (1994). Mortality in relation to smoking: 40 years'
observations on male British doctors. British Medical
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and statistical manual of mental disorders (4th ed.). ing and heart disease mechanisms and risk. JAMA,
Washington, DC: Author. 273, 1047-1053.
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mission to the Food and Drug Administration: Com- Barnes, D. E. (1996). The cigarette papers. Berkeley:
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Chevy Chase, MD: American Society of Addiction Hackshaw, A. K., Law, M. R., & Wald, N. }. (1997).
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diction and therapeutics. Annual Review of Pharma- fects on human performance. Experimental and
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of Cardiology, 29, 1422-1431. ples and management (pp. 24-45). New York: Oxford
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Henningfield, J. E., Radzius, A., & Cone, E. J. (1995). tolerance after prenatal nicotine exposure: Implica-
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 10

Other Drugs of Abuse:

Inhalants, Designer Drugs, and Steroids
Robert Pandina
Robert Hendren

Typically, substances included in a general drug Of the classes to be discussed in this chapter,
class are comparable on many, if not all, basic pa- anabolic-androgenic steroids are the most traditional
rameters, including chemical structure, mechanisms in terms of commonalities. This chapter limits dis-
of action, and metabolic pathways, as well as physio- cussion to the general characteristics of those dozen
logical, psychological, and behavioral effects. In fact, or so anabolic-androgenic steroids (AASs) that are
commonalities along such parametric dimensions taken illicitly for their equivocal anabolic utilitarian
are clearly evident among the classes of drug of effects, that is, their purported ability to enhance
abuse discussed in the preceding chapters of this vol- muscle mass. Even so, discussion of this drug class is
ume (e.g., opiates, stimulants, hallucinogens, seda- somewhat problematic. Significantly, several authori-
tives). ties (e.g., Cicero & O'Connor, 1990) have ques-
This chapter focuses upon three broad and some- tioned the notion that AASs adequately meet the
what anomalous drug "classes." Each of these "other" standard criteria (e.g., use intentions, evidence of
drug classes is anomalous for different reasons. Even psychological or physiological dependence) for clas-
the characterization and nomenclature of inhalants, sification as abused drugs. Others suggest such a role
designer drugs, and steroids are derived from different can be demonstrated (e.g., Brower, 1993a).
roots. For example, inhalant (IH) commonalities in- Designer drugs (DDs) have as a common prop-
clude their volatile nature and gaseous properties— erty the fact that, typically, they are created purpose-
hence, a common route of administration. The sub- fully in the laboratory for specific effects, capitalizing
stances often subsumed under the rubric of inhalants on the same general technology and strategy em-
are widely disparate on many other basic parameters, ployed in crafting psychotropic medications. Often,
including chemical structure. such drugs are derivations of existing drugs. Designer

171
172 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

drugs are often touted as "new and improved" ver- these substance categories. Where possible, we will
sions of parent compounds, claiming elimination of identify references that provide more complete cov-
unwanted "side effects" (e.g., bad "trips") or en- erage of certain topics.
hanced main effects (e.g., effect duration). They are
often employed by the "recreational" user for pur-
poses never intended by their creators. This chapter INHALANT ABUSE
will present an overview of the prototype designer
drug MDMA (3,4-methylenedioxymethamphetamine),
Clinical Aspects and Epidemiology
known on the street as ecstasy, and will comment on
others often referred to as designer drugs. Inhalants (also called solvents and volatile substances)
These three anomalous drug classes are often sub- are a chemically diverse group of abused psychoac-
sumed along with other low-use-frequency sub- tive substances found in volatile solvents. Inhalant
stances under the dreaded "other drug" use category abuse involves a wide variety of substances, including
or are aggregated within global classes in summary gasoline, glue, solvents, spray paints, aerosols, and
reports. Furthermore, a given aggregated class (e.g., thinners, which contain a wide spectrum of chemi-
inhalants, hallucinogens) often subsumes drugs cals (hydrocarbons, nitrites, ketones, toluene esters).
widely disparate in terms of use profiles, conse- (See table 10.1.) Vasodilators such as amyl or butyl
quences, and other important parameters. Use pat- nitrate and general anesthetics are also abused inhal-
terns for such drug classes may be reported as aggre- ants but are considered as separate substances of
gated data and are treated as low-frequency events, abuse (Dinwiddie, 1994; Johnston, O'Malley, &
receiving relatively sparse analytic treatment even Bachman, 1996). Inhalation of commercial contact
when more detailed information is gathered. The re- cement containing n-hexanes and spray paints con-
sult is that sometimes it is difficult to conduct finer taining toluene and gasoline is popular, particularly
grained analyses of use patterns, consequences, and because of the euphoric effect, availability, and rela-
risk factor profiles for these drugs. Other circum- tively low cost.
stances hamper our understanding of salient dimen- Availability and ease of procurement appear to be
sions associated with other drugs of abuse. For exam- the primary reasons inhalants are abused and ac-
ple, use of these other drugs tends to fluctuate
somewhat rapidly (e.g., ecstasy). Use prevalence is
relatively low and often confined to certain difficult- TABLE 10.1 Common Inhalants
to-access, "hidden" subpopulations (e.g., steroid use
among athletes, inhalant use among Hispanic and Aerosols
Native American youth in rural areas or on reserva- Spray paint
Hair spray
tions), and use, when it occurs, may be erratic.
Deodorant, air freshener
In spite of the relatively low prevalence, idiosyn- Analgesic spray, asthma spray
cratic use patterns, and difficulties associated with Solvents and Gases
studying these substances, the consequences of inhal- Paint thinner and remover
ant, designer drug, and anabolic steroid use for the Typing correction fluid "white-out"
individual user and for society at large represent seri- Gasoline
ous public health problems that warrant the atten- Cigarette lighter fluid
Nail polish remover
tion of the clinical and scientific communities. What Bottled fuel gas
does unite these three classes is the fact that they Felt-tipped markers
tend to be substances of choice among adolescents Adhesives
and young adults. Further, use of these drugs is ac- Airplane glue
companied by serious health consequences. Contact cement
Given the limitations of space and the range of Cleaning agents
information available, coverage of each substance Dry-cleaning fluid
Spot remover
category is far from encyclopedic. This chapter at-
Degreaser "STP"
tempts to summarize basic information regarding
 OTHERS: INHALANTS, DESIGNER DRUGS, AND STEROIDS 173

count for the greater prevalence among disadvan- availability, ease of access, and local custom are fac-
taged youth (Fornazzari, Wilkinson, Kapur, & Car- tors as important as ethnicity in determining user
len, 1983). Particularly vulnerable are those who live profiles.
in areas where other substances of abuse are not
readily available (e.g., rural areas, reservations).
Metabolic Pathways and
The annual High School Senior Drug Use Sur-
Mechanisms of Action
vey (Johnston et al., 1996) indicates that while the
overall use of inhalants peaked in 1979, solvent Inhalants are "sniffed" from an open container or
abuse per se has actually been increasing. In 1995, plastic bag or "huffed" from a rag soaked in the sub-
inhalant use in the past year had been reported by stance ("toques") and placed near or on the nose and
about 13% of 8th-graders, 10% of lOth-graders, and mouth. Abusers may prefer one inhalant to another
8% of 12th-graders. Estimates may be conservative but commonly use a variety of agents depending on
due to underreporting and the probability that sol- availability and potency. For instance, gold and silver
vent-abusing youth have dropped out of school by spray paint are preferred over other colors because
the 12th grade. The lifetime prevalence rate was the greater weight of gold and silver molecules re-
about 22%, 19%, and 17% respectively for 8th, 10th, quires a larger amount of toluene propellant.
and 12th graders. Inhalant use tends to occur at rela- Inhalants are absorbed rapidly into the blood sup-
tively young ages and decreases in late adolescence. ply through the rich capillary surface of the lungs.
However, amyl and butyl nitrates ("poppers" or Peak concentrations are reached within minutes, and
"whippettes") are used as purported sexual enhancers effects last about 5-15 min. Hydrocarbons are the
by some adults (particularly those in the gay commu- chief chemicals of inhalants. They are rapidly taken
nity). Nitrous oxide ("laughing gas") is difficult to ob- into fat stores, including lipids in the central nervous
tain. Much of the reported use of this anesthetic system, making accurate measurement of blood lev-
agent can be attributed to the mislabeling of amyl or els difficult. The mechanism of action may involve
butyl nitrates. Inhalant users may sample a wide vari- the fluidization of cell membranes. The GABA-A re-
ety of these products (Rosenberg & Sharp, 1992) and ceptor complex appears to be the primary target of
use other drugs and alcohol (Beauvais, 1992; Get- most inhalants. Effects are mediated through control
ting & Webb, 1992). of ion channels. Metabolism and excretion are vari-
Studies of selected populations suggest that preva- able for different compounds. Inhalant degradation
lence may be higher among Mexican-Americans and and elimination are accomplished by the lungs, kid-
Native Americans, especially those living in impov- neys, and liver.
erished environments (characterized by economic Inhalant intoxication resembles alcohol intoxica-
disadvantages, disorganized family structures, high tion, with initial stimulation and euphoria followed
levels of crime, social isolation, etc.). However, con- by depression. Onset of effects is rapid and intense.
siderable variability among Hispanic and Native Visual, auditory, and tactile distortions may develop
American ethnic groups has been noted (Beauvais, into hallucinations with higher dosage. Giddiness,
1992; May, 1988; Getting & Beauvais, 1990; Tapia- staggering gait, disinhibition, nausea, vomiting, head-
Conyer, Cravioto, De La Rosa, & Velez, 1995). ache, double vision, ringing in the ears, and palpita-
A relationship between inhalant abuse and delin- tions may occur with flushing, coughing, and exces-
quency has been suggested. The relationship may be sive salivation. Users may have an odor of paint or
strongest among Hispanics from large, poor, and dis- solvents, discolored hands and nose from paint, and a
rupted families with siblings who are also inhalant rash around the nose and mouth (Dinwiddie, 1994).
abusers (Reed & May, 1984). Among delinquents, Tolerance appears to develop, as does withdrawal.
inhalant abusers tend to be more criminally involved The withdrawal period lasts from 2 to 5 days; it is
as measured by the number and violent nature of unclear what is the intensity of exposure (either dura-
their offenses. tion or dosage) that results in withdrawal. Symptoms
The hidden and highly variable nature of inhal- include sleep disturbance, tremors, irritability, rapid
ant-using groups makes definitive characterization respiration, nausea, and discomfort in the abdomen
most difficult. It is likely that low cost, universal and chest.
174 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

thews, Li, & Jinkins, 1993). Severe and prolonged

Biological, Psychological, and Behavioral
abuse may be related to frequency of anomalies in
Consequences of Inhalant Use
some sites (e.g., cerebellum) (Ron, 1986). Not all
The consequences of inhalant abuse are thought to subjects studied exhibited MRI abnormalities. When
be grim, but there are few studies of long-term se- anomalies are detected, some recovery occurs, al-
quelae or of the relationship of the duration and ex- though signs may persist for some time (e.g., up to 18
tent of abuse to the extent and duration of the months) (King, Day, Oliver, Lush, & Watson, 1981).
damage. One important reason is the difficulty in de- Myelin is thought to be severely affected by sol-
signing a study that can control for the majority of vents and inhalants in developing brains (Escobar &
significant and potentially confounding variables. Aruffo, 1980; Wiggins, 1986). White matter hyperin-
While it is generally accepted that emotional prob- tensities in the cerebrum, brain stem, and cerebel-
lems and social deprivation precede inhalant abuse, lum are reported in chronic toluene abusers (Yama-
the long-term effects of solvent abuse on the emo- nouchi et al., 1995). Myelin changes have also been
tional and cognitive functioning of solvent-abusing found to persist for up to 18 months after abstinence
youth are not known. (Rosenberg et al., 1988). The degree of white matter
Inhalant abuse has been linked to sudden death, abnormality found in chronic toluene abusers is
usually due to heart failure, referred to as sudden snif- found to correlate with neuropsychological impair-
fing death syndrome. In addition, there is chronic ment (Filley, Heaton, & Rosenberg, 1990).
damage to the heart, lungs, kidneys, liver, and pe- Poor performance on neuropsychological tests
ripheral nerves related to the specific chemicals measuring concentration, attention, visual percep-
found in the inhalant. There also are risks from han- tual abilities, learning skills, and memory is found
dling volatile substances. Between 1981 and 1990, in chronic toluene abusers (Fornazzari, 1990; Zur &
605 children reportedly died from the misuse of vola- Yule, 1990a). The extent of cognitive decline appears
tile substances. The largest single cause of death was to be related to the severity of cerebral white matter
misuse of butane gas lighter refills (Esmail, Meyer, involvement (Filley et al., 1990; Katzelnick, Da-
Pottier, & Wright, 1993). Suffocation can occur when var, & Scanlon, 1991). However, differences between
a plastic bag is used for delivery of the inhalant. inhalant abusers and well-matched controls are often
Neurological abnormalities include pyramidal, not found to be significant (Jansen, Richter, & Grie-
cerebellar, and brain stem dysfunctions including sel, 1992), especially when young abusers are tested
functional and, to a lesser extent, structural changes after several weeks of abstinence, and when socioeco-
(Fornazzari et al., 1983; Rosenberg, Sptiz, Filley, nomic status is taken into account (Chadwick & An-
Davis, & Schaumburg, 1988). Cerebellar abnormali- derson, 1989).
ties are likely to be seen with severe and prolonged Numerous limitations in the available studies
abuse and therefore are more likely to occur in make it difficult to judge whether consistent neuro-
young adults than in children (Ron, 1986). psychological deficits are present in solvent abusers
Neuroimaging studies clearly suggest that solvent and whether the deficits are transient or permanent
abuse may affect brain function. Methodological dif- (Ron, 1986). In a thorough review, Chadwick and
ficulties, discussed below, preclude firm conclusions. Anderson (1989) noted problems consequent to
CT scans have demonstrated cerebral cortical or cer- small sample sizes, absence of data on prior perfor-
ebellar atrophy, including widening of sulci and en- mance, lack of evidence for abstinence, and insuffi-
largement of the ventricular system (Shickler, Seitz, cient control for group differences that could be due
Rice, & Strader, 1982). Further, these structural to effects other than substance abuse (e.g., SES and
anomalies were significantly related to neuropsycho- delinquency). Other shortcomings include lack of
logical deficits in concentration, attention, memory, differentiation between acute and chronic effects,
and motor coordination (Fornazzari et al., 1983). questionable validity of measures of the dysfunction,
Chronic toluene abuse has been demonstrated to and sociocultural confounds (Tenenbein, 1992). It is
result in MRI-documented anomalies (atrophy and also uncertain whether the deficits are best explained
loss of differentiation) in cerebral, cerebellar, brain as the direct effect of solvent abuse or by factors such
stem, periventricular, and thalamic sites (Escobar & as background, social disadvantages, or history of de-
Aruffo, 1980; Rosenberg et al., 1988; Xiong, Mat- linquency.
 OTHERS: INHALANTS, DESIGNER DRUGS, AND STEROIDS 175

Evidence for preexisting personality traits that ment), and associated characteristics (e.g., differenti-
predispose to inhalant abuse is not clear from the ation and growth of genitalia, stimulation of hair
literature to date. One study suggests that the initia- growth, enhancement of libido and sexual potency),
tion of inhalant use is associated with a sensation- that is, so-called virilizing or masculinizing actions.
seeking trait (Morita et al., 1994). This is consistent Anabolic effects contribute to linear body growth and
with the finding that inhalant abusers are over five the development of body mass.
times more likely than nonabusers to have injected A broader role for androgens in central nervous
drugs even after statistical adjustments for sex, age, system (CNS) functioning and behavioral and psy-
socioeconomic status, and the use of marijuana chological processes under CNS regulation has been
(Schutz, Chilcoat, & Anthony, 1994). claimed, including modulation of aggression and
Solvent abuse is found to occur more frequently mood. AASs have several valid though limited medi-
in emotionally disturbed and depressed youth than cal uses, including limited treatment of asthma and
in the general population (Skuse & Burrell, 1982). specific 'anemias, control of metastatic breast cancer,
Other studies find depression to be more common and augmentation of sexual development in hypogo-
in toluene abusers than in young delinquents used nadal males (see also American Medical Association,
as controls (Zur & Yule, 1990b). In populations of 1990; Kochakian, 1993). However, it is the latter
drug and alcohol abusers, those who abuse solvents anabolic effects that have apparently resulted in the
appear to have more severely disturbed personalities, current patterns of illicit use, prompting continuing
but there is little evidence that specific or persistent concern in clinical, scientific, and sporting commu-
psychiatric disability either causes or results directly nities. Particularly important is the view that lean
from solvent abuse (Ron, 1986). body mass and strength can be significantly en-
As mentioned previously, a strong relationship hanced. There is additionally some credence to re-
exists between inhalant abuse and juvenile delin- ports that increased intensity in training and in-
quency, with more criminal and violent offenses creased aggressivity in competitive sports venues
among solvent-abusing delinquents (Reed & May, (e.g., football, track and field) are not unwanted side
1984). Solvent abuse in young adulthood is strongly benefits of AAS use. In the user community, the
associated with antisocial personality disorder and most popular "roids" are touted for their anabolic ac-
polysubstance abuse (Crites & Schuckit, 1979; Din- tivity, hence the emphasis on the terminology ana-
widdie, 1994; Dinwiddie, Reich, & Cloninger, bolic steroids. Nevertheless, all AASs appear to retain
1991). However, there are no conclusive findings re- some androgenic actions, most of which are viewed
garding whether psychiatric symptoms precede or re- negatively by illicit roid users. In fact, a substantial
sult from solvent abuse in youth. Identification of aspect of the marketplace attempts to capitalize on
particular patterns of psychiatric disorders and the purported "pure" anabolic actions of new deriva-
whether they precede, are exacerbated by, or are the tives as they become available.
result of solvent abuse will be helpful in prevention There are estimated to be over 100 different com-
and intervention planning. pounds claimed to have anabolic actions (Nuwer,
1990). Table 10.2 (after Strauss & Yesalis, 1991) lists
a sample of the more commonly used AASs; trade
ANABOLIC-ANDROGENIC STEROIDS and generic names are listed. Steroid preparations
come in two forms for administration: oral and par-
enteral (typically by intramuscular injection). Oral
Clinical Aspects and Epidemiology
preparations are derived principally from 17-alpha-
Anabolic-androgenic steroids (hereafter referenced as methyl, 17-alpha-ethyl, and 1-methyl testosterone de-
AASs, steroids, or "roids") are derivatives of, or syn- rivatives; intramuscular preparations are typically es-
thetically modeled after, testosterone, a prototypical ters of testosterone or esters of 19-nortestosterone
androgen that is produced naturally in the testes by (Haupt & Rovere, 1984; Kochakian, 1993).
males. This androgen has two primary effects. Andro- Popular attention began to focus upon steroid use
genic effects account for the development of the during the early 1960s, when the success of Soviet
male reproductive tract, other aspects of sexual differ- strength athletes was attributed, in part, to the use
entiation (including central nervous system develop- of AASs. Haupt and Rovere (1984) and Kochakian
176 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

TABLE 10.2 Trade Names and Dosages of Commonly Used Anabolic Steroids

Oral anabolic steroids Dosages Injectable anabolic steroids Dosages

Anadrol 1-5 mg/kg daily Anatrofin (stenobolone) -

(oxymetholone)
Anavar 5-10 mg daily Bolfortan (testosterone nicotinate) 200-400 mg weekly
(oxandrolone)
Dianabol 1 5-45 mg daily Deca-Durabolin (nandrolone decanoate) 50-100 mg 3-4x weekly
(methandrostenolone)
Maxibolin 4-8 mg daily Delatestryl (testosterone enanthate) 50-400 mg 2-3x weekly
(ethylestrenol)
Android 10-40 mg daily Depo-Testosterone (testosterone cypionate) 50-400 mg 2-4x weekly
(methyltestosterone)
Primobolan 1-5 mg/kg daily Dianabol (methandrostenolone) 200 mg weekly
(methenolone)
Proviron 75-100 mg daily Durabolin (nandrolone phenpropionate) 25-50 mg weekly
(mesterolone)
Winstrol 6-8 mg daily Enoltestovis (hexoxymestrolum) —
(stanozolol) Equipoise (boldenone— veterinary)
Finajet (trenbolone) 200-400 mg weekly
Primobolan (methenolone enanthate) —
Sustanon 250 (a mixture of testosterone esters) —
Therobolin 200 mg weekly
Trophobolene —
Winstrol V (stanozolol—veterinary) —

Note. After Strauss and Yesalis (1991). Dosages are highly variable among users. Missing values indicate that "typical" doses in humans have
not been established.

(1990, 1993) provide interesting historical perspec- Not surprisingly, reliable prevalence data are
tives on the use and development of testosterone and sparse, particularly for the decades of the 1960s,
its offspring, the AASs. Attention in the United States 1970s, and 1980s, for both the general public and
was catalyzed by the acknowledgment of American for high-risk segments such as professional and elite
athletes that AASs played an important role in their athletes. Ethnographic and anecdotal reports suggest
successes. Hence, by the 1960s, a substantial com- that use among professionals such as football players,
munity of elite and professional athletes as well as serious weight lifters, elite track-and-field contenders,
serious amateurs, particularly those interested in and other serious competitive athletes (including
strength conditioning and body building, had begun body builders) was endemic during this period (Ye-
using AASs. By the 1970s, serious concerns about the salis, Courson, & Wright, 1993). In fact, in some
impact of such substances on the "level playing quarters, it was considered necessary in order to
field" had generated the present attempts to regulate maintain a competitive equilibrium, let alone an ad-
the use of these substances among competitive ath- vantage! Whether accurate or not, these perceptions
letes. By the 1980s, several authorities considered probably contributed substantially to the view of the
AAS use among elite athletes to be epidemic in pro- general public that in spite of the risks, AAS use
portion (Haupt & Rovere, 1984) in spite of evidence could yield substantial rewards for those valuing
of negative consequences. The technological ad- strength, endurance, lean muscle mass, and a com-
vances that permitted derivation of AASs with pur- petitive advantage. From this perspective, it is easier
portedly relatively high anabolic and low androgenic to understand the attraction that AAS use has had
properties very likely contributed to their rise in pop- to segments of the youth- and performance-oriented
ularity. These substrata, then, formed the platform American culture of the 1980s and 1990s. A clear
for current concerns. barrier to obtaining reliable data resulted from efforts
 OTHERS: INHALANTS, DESIGNER DRUGS, AND STEROIDS 177

of professional (e.g., National Football League) and of between 6% and 10% for female athletes in vari-
elite amateur sports regulatory bodies (e.g., Interna- ous sports.
tional Olympic Committee) to control steroid use
among competitors. Though these bodies acted ap-
Metabolic Pathways and
propriately to prevent, or at least limit, such abuses,
Mechanisms of Action
the net effect was to drive AAS use underground and
to stimulate relatively creative means on the part of AASs have the capacity to increase protein synthesis
athletes to mask AAS use detection. by acting at specific receptor sites that are distributed
During the 1980s and 1990s, however, a number across a wide range of body tissues, including skeletal
of serious attempts were made to obtain estimates of and cardiac muscle, a range of receptor systems and
AAS use among a number of target populations, in- locations with the CNS, and a number of other body
cluding high-school- and college-aged students in the organs, including the skin, testes, and prostate gland.
general population. These efforts have yielded useful AASs probably act by increasing protein synthesis
prevalence data. Johnston et al.'s (1996) annual sur- through inhibiting the catabolic effects of glucocorti-
vey of high school students, arguably the most repre- coids (especially under conditions of extreme stress,
sentative sample (N = approximately 15,400) of stu- including that resulting from physically induced fa-
dents in school, added questions about steroid use in tigue) and interactions with receptors at neuromus-
the mid-1990s. Their data indicate a lifetime preva- cular junctions, and possibly by modulating complex
lence rate of about 2%, the overwhelming proportion CNS functions in a variety of neurotransmitter
of users being males; monthly rates are about 0.6%. systems (Haupt & Rovere, 1984; Lombardo, 1993;
Results from a more limited study focusing spe- Rubinow & Schmidt, 1996). Hence, precise identi-
cifically on AAS use that surveyed a selected sample fication of the mechanisms of action of AASs is com-
(N= 3,403) of male 12th-graders (Buckley et al., plicated by the range of target tissues affected, the
1988) yielded higher prevalence rates of 6.6%. In variety of AASs, and the general complexity of hor-
Buckley, Yesalis, and Bennell's (1993) more focused monally regulated processes (Kochakian, 1990). In a
study, students who participated in sports (particu- similar vein, specification of metabolic pathways is
larly football and wrestling) were likely to use ste- difficult, though metabolism is accomplished through
roids; however, a substantial proportion of users pathways generally reserved for naturally occurring
(about a third) were not involved in school-sponsored testosterone and related androgens. Testosterone is
programs. Pope, Katz, and Champoux (1988) re- metabolized by the liver to 5-alpha-androsterone and
ported results of an exploratory study of college men 5-beta-etiocholanolone (both 17 ketosteroids) and ex-
that yielded prevalence rates of about 2% consistent creted in urine. Small amounts are secreted un-
with the results of the Johnston et al. (1996) ongoing changed in urine. Testosterone is converted to other
study of high school seniors. Again, the larger propor- active compounds in some target organs (e.g., the
tion of users were likely to be varsity athletes. An- prostate) (Wadler & Hainline, 1989; Winters, 1990).
other, more comprehensive population-based study Given the wide range of potential targets, the vari-
(Yesalis, Kennedy, Kopstein, & Bahrke, 1993) yield- ety of action mechanisms, and the number of CNS
ed results more in agreement with Johnston and col- systems susceptible to AAS influences, it is not sur-
leagues. While much of the focus has been on prising that a role for AAS use in the abuse of other
males, particularly competitive athletes and body- substances, particularly alcohol and morphine, has
builders, some attempts have been made to study fe- been proposed. Cicero and O'Connor (1990), for ex-
males, especially athletes who should be at greater ample, citing literature examining testosterone-medi-
risk. What sparse data are available indicate an in- ated alcohol tolerance, suggest a possible indirect
creasing trend toward AAS use among these athletes role in key dependence processes. This suggestion is
(e.g., Buckley et al., 1993). The paucity of data about intriguing, especially in light of limited case reports
women probably gives an unrealistically benign view regarding behavioral anomalies of reported AAS us-
of AAS use, particularly among competitive athletes. ers coincident with ingestion of alcohol and other sub-
For example, Strauss and Yesalis (1993) (see also stances (e.g., Conacher & Workman, 1989). Other
Tricker, O'Neill, & Cook, 1989) reported use rates anecdotal evidence involving professional athletes
178 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

who have been AAS users and users of other sub- under some circumstances (e.g., combined with ap-
stances, particularly alcohol and cocaine, is also sug- propriate training and dieting programs), in some in-
gestive of possible interactive effects. Documentation dividuals (e.g., mature competitive athletes with sub-
of such interactions remains speculative. stantial pretreatment histories of training), and for
In spite of the controversy about the risk of depen- limited periods of time, some physical gains may be
dence (Cicero & O'Connor, 1990), ample case ma- appreciated. However, even relatively comprehensive
terial and recent survey data appear (e.g., Brower, assessments of the available literature (e.g., Haupt &
1993a) to document the dependence liability of AAS Rovere, 1984; Lombardo, 1993) point out that the
users. The mechanisms that lead to and sustain de- number of positive and negative reports in the litera-
pendence are far from clear. Issues regarding the fre- ture are close to equal. Reports appear to be clear
quency, duration, and dosages required to produce that for many individuals, the subjective value of
dependence are not easy to ascertain for a variety of AAS use is substantial even when physical gains or
reasons, particularly because of the manner in which advantages are not clearly demonstrable. This obser-
AASs are used. Typically, AAS users take them on an vation suggests a strong role for psychologically medi-
intermittent schedule, a practice termed cycling. The ated processes in use initiation and maintenance as
period of use may vary, but use often occurs over well as other aspects of dependence. Hence, AAS-
several weeks or months during training and is then induced changes in affect modulation and affective
interrupted for several weeks. Another practice, experience may serve to sustain use.
termed stacking, involves the use of several different The costs or negative effects of use are also diffi-
AASs. The purposes for which they are employed cult to ascertain. Part of the difficulty results from
also cause difficulties in assessing dependence liabil- the hidden nature of use and the clustering of users
ity. As indicated above, a primary motivation for AAS among specific risk groups, as well as the use prac-
use is performance enhancement. Other effects, tices of cycling and stacking described above. Given
such as increased training intensity, aggressivity, and the wide range of target organs potentially affected
other mood alterations, may be considered secondary by AASs, it is not surprising that a broad range of
and, to some extent, unwanted. Hence, AASs are negative consequences have been reported.
somewhat atypical compared to other psychotropics Pathological outcomes have been reported for al-
in terms of their primary expected and sought-after most all body tissues that are AAS targets (Friedl,
effects. Nonetheless, users do report subjective expe- 1990; Haupt & Rovere, 1984; Lombardo, 1993).
riences of well-being and other affective changes, an Hence, cancers and other abnormalities of the liver
inability and unwillingness to cut back on use, and (including peliosis hepatis and tumors), colon, kid-
other effects consistent with those reported for other neys, and prostate have been identified among users.
drugs of abuse. Case reports of cerebrovascular disease include oc-
Tolerance and withdrawal have been reported by currences of myocardial infarction and thrombosis.
AAS users (Brower, 1993b). Withdrawal symptom- Increases in blood pressure and cholesterol have
atology, when reported, appears more similar to a de- been documented and may be, in part, mechanisms
pressive profile (than to agitation); however, anxiety related to cerebrovascular outcomes. However, car-
and increased aggression have been noted in limited diovascular risks are viewed as equivocal by some au-
case reports. thorities. Cosmetic consequences include induction
of baldness and increase or alteration in growth pat-
terns of other body hair (including facial hair in
Biological, Psychological, and Behavioral
women) and occurrences of acne in many body re-
Consequences of AAS Use
gions. Changes in reproductive system organs and
As with other aspects of AAS use, a clear and concise their functions have been observed. These include
picture of consequences is difficult to paint. By this testicular atrophy, enlargement of the clitoris, gyne-
point, readers have probably asked themselves, "Does comastia (in males), sterility, impotence, and loss of
AAS use meet its advertized claims?" that is, are menses.
AASs effective in providing enhanced performance, In spite of attempts to document adverse medical
however measured? The answer to this question is outcomes of AAs use, the knowledge base remains
far from resolved. The consensus appears to be that somewhat sparse. Such issues as dose and use dura-
 OTHERS: INHALANTS, DESIGNER DRUGS, AND STEROIDS 179

tion, linkage of effects to specific AASs, and differen- team of investigators (Pope & Katz, 1990) have at-
tiation of drug-related outcomes from other risk fac- tempted to link steroid use to episodes of violence,
tors (e.g., training protocols, diet, lifestyle) remain to including homicide. Note that few female AAS users
be addressed more fully. Perhaps, one of the most have been systematically studied. These studies have
disconcerting conclusions reached regarding medi- provided no systematic information regarding alter-
cal consequences is that AASs have the potential to ations in perceived aggression and mood changes.
alter functioning in such a variety of vital bodily tis- Limited ethnographic observations suggest subjective
sues that it would be foolish to conclude that they effects similar to those for males.
could be safely used by athletes or, we would add, Hence, a pattern is beginning to emerge from the
any other individual expecting to enhance perfor- limited studies available. Some, though not all, AAS
mance markedly through their use (Friedl, 1993). users appear to experience a variety of changes in
Further, inasmuch as an important route of adminis- mood and affective states. Two dominant clusters of
tration is needle injection, the risk of HIV infection symptoms appear common. One cluster appears to
is potentially significant. comprise feelings of irritability, aggression, and hos-
A firm grasp of the undesirable psychological and tility. A second appears to be characterized by feel-
behavioral consequences of AAS use is even more ings of anxiety and depression. The "irritable" cluster
difficult to achieve than the rudimentary consensus may be accompanied by episodes of acting out, while
view of medical sequelae summarized above. Aggres- the other, more internally focused cluster may be ac-
sion, anger, anxiety, depression, euphoria, hostility, companied by withdrawal and isolation. It also ap-
irritability, and libidinal alterations (both increases pears that the majority of central questions remain
and decreases) have been reported. Much of the evi- not only unresolved but also minimally addressed.
dence is based on anecdotal reports, case histories,
and ethnographic studies (several of professional ath-
letes). Few controlled studies or studies using stan- DESIGNER DRUGS
dard psychological inventories or other assessment
tools have been reported. One such study (Bahrke,
Clinical Aspects and Epidemiology
Wright, Strauss, & Catlin, 1992) failed to find reli-
able differences among users, former users, and non- The designation of a substance as a designer drug is
users in scores on two standardized psychometric more a term of convention than one of accurate
tools (Profile of Mood States and Buss-Durkee Hos- pharmacological classification. This terminology be-
tility Inventory), even though steroid users reported came popular during the 1960s and 1970s, when the
subjective effects of aggression and hostility. Subjects legitimate pharmaceutical industry was actively en-
were all weight lifters, and the sample size was small, gaged in developing a variety of new compounds to
although within the range for other such investiga- treat psychiatric disorders. Many of the newly devel-
tions. In contrast, investigations relying on standard- oped drugs were variants of prototype substances
ized assessments of more severe symptomatology ap- (e.g., diazepam as a variant of chlordiazepoxide). Of-
pear to obtain more positive results. For example, ten, these new substances were viewed as possessing
Pope and Katz (1994) reported increased occur- considerable advantages over the prototypes, such as
rences of "major mood disturbances," such as major greater potency, longer or shorter durations of action,
depression, dysthymia, generalized anxiety, and fewer side effects, or more specific action. Given the
panic disorder (though not other psychiatric dysfunc- technical advancements in pharmacology, hundreds
tions), among steroid-using athletes as determined by of new compounds could be and were synthesized
the Structured Clinical Interview for DSM-III-R and tested (at least in animal models).
(SCID). Interview information also suggested in- These concepts soon caught the attention of indi-
creased aggressive behavior among those experienc- viduals interested in applying these technologically
ing mood disturbances. The study attempted to ad- sophisticated methods in the development of drugs
dress several key methodological issues, including for the illicit marketplace. Indeed, the era of "better
dose effects and use patterns. Analyses also suggested living through chemistry," a slogan of one of the le-
the importance of high doses in the emergence of gitimate pharmaceutical giants, had come to the
symptomatology. Several case reports by the same world of drug abuse. Ironically, some of the drugs
180 SPECIFIC DRUGS OF ABUSE: PHARMACOLOGICAL AND CLINICAL ASPECTS

that set the pattern for the illicit use of designer drugs set by amphetamines, the liability could be much
had been available for some time prior to their intro- higher.
duction into the illicit marketplace. For example, it
was during this same time that LSD use began a
sharp rise in popularity. In a sense, LSD was the pre-
Metabolic Pathways and
cursor of what was to come in the line of designer
Mechanisms of Action
drugs, a step in the evolution from experiences de-
rived from plants to those derived from the labora- MDMA, commonly referred to as ecstacy (also love
tory. boat) is a methamphetamine derivative that was syn-
The historic patterns of use of MDMA and re- thesized in 1914. MDMA is considered a prototype
lated designer drugs (e.g., 3,4 methelenedioxyetham- of designer drugs. It is likely that much of what is
phetamine, MDEA, "Eve") have been somewhat er- sold on the street under various names is, in fact,
ratic and hence difficult to trace. Even with the MDMA, inasmuch as it is relatively easy to synthe-
closer tracking of drug use patterns beginning in the size. Further, other related compounds have severe
1970s, documentation is at best sparse. MDMA use neurotoxicity. MDMA was first introduced as an ap-
appears to be most popular among 16- to 25-year- petite suppressant and was thought to be relatively
olds (both male and female). Surveys of adolescents safe (Green, Cross, & Goodwin, 1995; Steele, Mc-
indicate a lifetime prevalence of about 2% (Johnston Cann, & Ricaurte, 1994). It was viewed subsequently
et al., 1996). In the late 1970s and early 1980s, the as a nontoxic drug that could induce feelings of
drug was touted as the "love drug," reportedly en- "warm, loving relaxation." MDMA is believed to act
hancing the intensity of sexual encounters. It was on reward systems of the brain through stimulation
also billed as the "businessman's LSD," given its hal- of dopamine and serotonin pathways, probably by in-
lucinogenic and stimulant properties and its shorter creasing extracellular concentrations of both neuro-
duration of action in comparison to LSD. In the transmitters (White, Obradovic, Imel, & Wheaton,
1990s, the drug is most often used by adolescents and 1996). Recent studies in animals have documented
young adults. Its use is particularly popular at "raves" significant neurotoxicity, particularly in serotonin
(intensive all-night dance parties) and is generally neurons, that may be relatively permanent (Fischer
considered safe by users. The majority of users seem et al., 1995). However, such neurotoxicity has not
to experience few immediate toxic effects beyond been demonstrated conclusively in humans even
those viewed as part of the intoxication that occurs. though clinical reports of toxic effects, including fa-
However, based on the animal literature and the talities, document the serious harm potential of the
growing number of clinical case reports on humans, substance (Dar & McBrien, 1996; Demirkiran, Jan-
there is no question that MDMA and related de- kovic, & Dean, 1996; Green et al., 1995).
signer drugs carry significant physical and psycholog- MDMA effects are experienced as a combination
ical health risks even for otherwise symptom-free us- of those induced by hallucinogens and amphet-
ers or MDMA-experienced users. The risks appear to amines. The MDMA "trip" may last for several
be related to acute episodes of intoxication; however, hours, although its duration is shorter and intensity
there are few long-term studies, including case stud- less than that occurring with LSD; however, users
ies that track users longitudinally. However, animal frequently take additional doses as the effects dissi-
studies document the potential of long-term irrevers- pate. Users experience a dreamy state sometimes ac-
ible neurotoxicity (Fischer, Hatzidimitriou, Wlos, companied by hallucinations and delusions, along
Katz, & Ricaurte, 1995). There is little evidence of with an amphetamine-like increase in motor activa-
dependence development among MDMA users. tion, stimulation, and general arousal. A variety of
Here again, the literature is marked by the absence signs and symptoms may occur that indicate acute
of suitable data that would allow a firm conclusion toxic reactions: dilated pupils, agitation, excitement,
to be drawn. If on the one hand designer drugs hallucinations, tachycardia, palpitations, CNS de-
follow the pattern set by hallucinogens (e.g., LSD), pression, incontinence (occasionally), and signs of
dependence liability would seem relatively small. cognitive disorganization and distortion (Watson,
On the other hand, were they to follow the pattern Ferguson, Hinds, Skinner, & Coakley, 1993). The
 OTHERS: INHALANTS, DESIGNER DRUGS, AND STEROIDS 181

drug also induces hyperthermia, which can seriously FINAL COMMENT

compromise a variety of bodily functions.
The use of inhalants, anabolic-androgenic steroids,
and designer drugs represents a wide range of serious
Biological, Psychological, and
health risks even though prevalence rates are rela-
Behavioral Consequences
tively low in comparison to the use of many other
On those occasions when toxic reactions occur, a va- substances (e.g., alcohol, marijuana) and the magni-
riety of functions of several organ systems appear ad- tude of consequences may not seem as large. Fur-
versely affected. Cardiovascular effects include in- thermore, the fact that key information is somewhat
creased heart rate and blood pressure that may be sketchy provides both challenges for basic research-
accompanied by tachycardia. Blood coagulation dis- ers seeking to fill the voids and problems for clini-
orders (e.g., coagulopathy) have been noted in cases cians confronted with treating users of these sub-
of fatalities. Also, liver toxicity and kidney failure stances. Hopefully, this chapter not only provides a
have been observed in fatalities. Rhabdomyolysis useful summary of relevant facts but will also stimu-
(disease of the skeletal muscle characterized by tissue late much-needed basic and clinical research.
disintegration) and general muscle rigidity may also
occur. At least one case of cerebral infarction in an Key References
otherwise healthy male has been attributed to
MDMA intoxication. Hyperthermia is a common Brower, K. J. (1993a). Anabolic steroids: Potential for
physical and psychological dependence. In C. E. Ye-
consequence; this condition may be exacerbated in
salis (Ed.), Anabolic steroids in sport and exercise (pp.
cases where individuals are engaged in prolonged or
193-213). Champaign, IL: Human Kinetics Pub-
intensive motor activity such as dancing, especially
lishers.
when dehydration occurs. Given the range of affec- Steele, T. D., McCann, U. D., & Ricaurte, G. A. (1994).
tive and cognitive changes that occur and in light 3,4-Methylenedioxymethamphetamine (MDMA, "ec-
of the animal literature regarding neurotoxicity, it is stasy"): Pharmacology and toxicology in animals and
probable that significant alterations occur in dopa- humans. [Review]. Addiction, 89(5), 539-551.
minergic and serotonergic neural networks. How- Tenenbein, M. (1992). Clinical/biophysiologic aspects
ever, the duration and extent of neural toxicity in of inhalant abuse. In C. W. Sharp, F. Beauvais, &
humans remain to be resolved (Fischer et al., 1995; R. Spence (Eds.), Inhalant abuse: A volatile research
Steele et al., 1994). The degree to which these con- agenda (pp. 173-180). Rockville, MD: National In-
stitute on Drug Abuse (Research Monograph 129).
sequences occur in cases that do not result in the
full-blown toxic reaction is unknown.
Psychological and behavioral consequences that References
extend beyond the period of acute intoxication or are American Medical Association, Council on Scientific
not concomitant with acute toxic reactions have not Affairs. (1990). Medical and nonmedical use of ana-
been well documented. The most commonly, though bolic-androgenic steroids. Journal of the American
not frequently, reported outcomes are protracted Medical Association, 264, 2923-2927.
changes in mood, manifesting as depression and anx- Bahrke, M. S., Wright, J. E., Strauss, R. H., & Catlin,
iety. Cognitive disorganization resulting in decreased D. H. (1992). Psychological moods and subjectively
capacity has also been observed (Steele et al., 1994). perceived behavioral and somatic changes accompa-
Documentation has occurred primarily through clin- nying anabolic-androgenic steroid use. American
ical case reports; few ethnographic or observational Journal of Sports Medicine, 20(6), 717-723.
Beauvais, F. (1992). Volatile substance abuse: Trends
studies have been reported. Hence, one might con-
and patterns. In C. W. Sharp, F. Beauvais, & R.
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Spence (Eds.), Inhalant abuse: A volatile research
intoxication and toxic reactions or to the brief post- agenda (pp. 13-42). Rockville, MD: National Insti-
intoxication periods possibly coincident with detoxifi- tute on Drug Abuse (Research Monograph 129).
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ture, especially given the high potency and dramatic physical and psychological dependence. In C. E. Ye-
effects of designer drugs. salis (Ed.), Anabolic steroids in sport and exercise (pp.
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Case Identification, Assessment,

and Treatment Planning
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 11

Assessment Strategies and Measures

in Addictive Behaviors

Dennis M. Donovan

Given the high prevalence of alcohol and drug use 1991; Sobell, Sobell, & Nirenberg, 1988). Clinicians
disorders in the general population and, even higher, are often ill prepared for such an undertaking due to
among those with psychological problems (Regier et a lack of formal training in the areas of alcohol and
al., 1990; Ross, Glaser, & Germanson, 1988), it is drug abuse (e.g., Sobell et al., 1988). For example,
quite likely that all mental health practitioners will graduate training programs in both clinical and
be faced with the task of assessing and treating indi- counseling psychology have been found to provide
viduals with a substance use disorder, regardless of only minimal training in alcohol and drug problems
the clinical setting in which they work. However, (Lubin, Brady, Woodward, & Thomas, 1986); this
while clinicians are likely to agree that assessment is deficiency is often not rectified during clinical in-
a cornerstone of the therapeutic process with sub- ternship (Bacorn & Connors, 1989).
stance abusers and to endorse the ideal of providing The purpose of this chapter is to provide a brief
a comprehensive assessment of those seeking treat- overview of issues involved in the assessment process
ment for addictive disorders, this agreement will not in addictive behaviors with the hope of both increas-
necessarily lead to the actual practice of such an as- ing clinicians' familiarity with this area and enhanc-
sessment process in clinical settings (Institute of ing its clinical application. A number of more thor-
Medicine, 1990). A number of practical considera- ough reviews of these issues and of specific
tions contribute to this discrepancy between the ideal instruments for the assessment of alcohol and drug
and the actual in clinical practice, some of which problems are available to the interested reader (e.g.,
appear to be inherent in the complexity of substance Addiction Research Foundation, 1994; Allen & Co-
abuse and others that are more attributable to mental lumbus, 1995; Carey & Teitelbaum, 1996; Carroll,
health practitioners' attitudes and skill level (Allen, 1995; Donovan, 1988, 1992, 1995; Donovan & Mar-

187
188 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

latt, 1988; Litten & Allen, 1992; Nirenberg & Mai- identify those who have alcohol or drug abuse prob-
sto, 1987; Rounsaville, Tims, Horton, & Sowder, lems while minimizing false negatives) and specific-
1993; Sobell, Toneatto, & Sobell, 1994). ity (the ability to accurately identify those who do not
have a problem while minimizing false positives).
However, in most screening applications, an attempt
WHY ASSESS: PURPOSES OF is made to identify as large a group of potential cases
ASSESSMENT as possible, so that the sensitivity of the screening
instrument may be more important than its speci-
Assessment serves multiple functions (e.g., Allen & ficity, with more thorough assessments being used
Columbus, 1995; Allen & Mattson, 1993; Carey & subsequently to increase the accuracy of the initial
Teitelbaum, 1996; Institute of Medicine, 1990; Ja- screening (Carey & Teitelbaum, 1996; Connors,
cobson, 1989a, 1989b; Shaffer & Kauffman, 1985): 1995).
screening and case finding, motivating clients to en- The Institute of Medicine (1990) has suggested
ter treatment, problem description, diagnosis, treat- that the screening and case-finding function should
ment planning, and evaluation of treatment process be expanded beyond traditional substance abuse
and outcome. Some of these functions are related to treatment settings to other areas and populations that
information acquisition and integration, while others have a relatively high probability of alcohol or drug
are more directly related to motivating the individual use problems. Such populations, which include
and inducing him or her into the role of a client many individuals who may have problems but who
in a help-seeking relationship. In this chapter, the are not actively seeking treatment, might include
outcome evaluation function will not be reviewed. pregnant women (Russell, 1994), the mothers of
Information about this function can be found else- small children (Kemper, Greteman, Bennett, & Ba-
where (e.g., Allen & Columbus, 1995; Longa- bonis, 1993), and individuals brought to the atten-
baugh & Clifford, 1992). tion of child welfare authorities (Dore, Doris, &
Wright, 1995); patients seen in community health
clinics (Kipke, Montgomery, & McKenzie, 1993),
Screening: Identifying Individuals with
family practice settings (Nilssen & Cone, 1994),
Potential Substance Use Disorders
emergency rooms (Cherpitel, 1995), trauma centers
An initial function of assessment is identifying indi- (Gentilello, Donovan, Dunn, & Rivara, 1995), and
viduals who may have a substance abuse problem or psychiatric settings (Teitelbaum & Carey, 1996); in-
who are at increased risk of developing one. Such dividuals arrested for driving while intoxicated (La-
screening and case-finding approaches are typically pham et al., 1995) and other individuals involved in
relatively brief and inexpensive and are applied to the criminal justice system (Peters & Schonfeld,
relatively large groups of individuals. An attempt is 1993); high-risk youth (Dembo, Turner, Borden,
made, through questionnaires or interviews, to accu- Schmeidler, & Manning, 1994; Leccese & Wal-
rately classify an individual either as having a prob- dron, 1994) and older adults (DeHart & Hoffman,
lem (a true positive) or as not having a problem (a 1995).
true negative). A concern that must be taken into A number of instruments have been developed
account in this process is the probability of incor- for use in screening for substance abuse problems,
rectly identifying someone as having a problem more of these focusing on alcohol use than on drug
when he or she does not (a false positive) or as not use. Connors (1995) has identified and provides de-
having a problem when in fact he or she does (a false tailed information on 25 different measures for use
negative). The accuracy of the identification process in screening for alcohol problems in both adoles-
is somewhat relative, in that it will vary according to cents and adults. The comparative utility of a num-
the base rate of the substance abuse problem in the ber of these alcohol screening tests has been evalu-
population being screened. Also, the relative degree ated (Maisto, Connors, & Allen, 1995). Screening
of inaccuracy that is tolerable depends on the pur- tests range from as few as two questions (e.g., Brown,
pose of the screening procedure. An attempt is made Leonard, Saunders, & Papasouliotis, 1997; Cyr &
to use assessment instruments or procedures that Wartman, 1988) to much longer and' more struc-
maximize both sensitivity (the ability to accurately tured procedures (e.g., Tarter & Hegedus, 1991).
 ASSESSMENT STRATEGIES AND MEASURES IN ADDICTIVE BEHAVIORS 189

The Drug Abuse Screening Test (DAST; Gavin, positive steps to initiate change. Many have gone for
Ross & Skinner, 1989; Skinner, 1982) was developed years without perceiving that they have a problem,
specifically for and has been used frequently for seemingly oblivious of the negative consequences
screening for drug abuse. The usefulness of any of that others are able to observe. This behavior has of-
the available screening measures varies with the ten been described as being in denial. Other individ-
characteristics of the population being studied. Thus, uals have contemplated the need for changing their
there may be differences in the likelihood of a per- drinking or drug use for some time but have not
son's being identified as having a substance abuse been sufficiently committed to take any action. Oth-
problem at an individual level, as well as in the esti- ers may have attempted action in the past but have
mates of prevalence and incidence at the larger epi- since resumed use, raising questions in their minds
demiological level, based on the instrument when about the efficacy of treatment and their ability to
used with men versus women, different ethnic groups, reach their goals. Others, acknowledging the need to
and different age groups (e.g., Cherpitel & Clark, change, may still be influenced more by their per-
1995; Connors, 1995; Lapham et al, 1995; Russell, ceptions of the positive and more proximal benefits
1994). Therefore, either specialized screening meth- derived from using than by the anticipated but more
ods have been derived for some of these subgroups distal benefits of stopping use and thus are unable to
(e.g., Leccese & Waldron, 1994; Russell, 1994) or make a firm commitment to take action.
normative information has been developed for stan- Given the somewhat tenuous nature of the indi-
dard instruments when used with such subgroups. vidual's commitment in light of such ambivalence,
Table 11.1 presents a listing of a number of fre- the clinician may have a unique therapeutic oppor-
quently employed screening measures as well as tunity to facilitate a transition between an individu-
measures appropriate for each of the different stages al's contemplating the need for change, making a
and domains of the assessment process. commitment to change, and actually taking steps to
modify behavior patterns (Prochaska & DiClemente,
1986). The task of the clinician in such circum-
Motivating the Help Seeker
stances is to help reinforce the individual's commit-
A set of interrelated goals of screening for substance ment to seek help and to change his or her behavior.
abuse problems includes identifying an individual This task may require "hooking" the positive side of
with a present or potential problem, increasing the the person's ambivalence by focusing on her or his
individual's problem awareness, suggesting the need commitment and motivation to change, by making
for a more thorough assessment, and increasing the the new behavior pattern and lifestyle associated with
individual's interest in and readiness for treatment if giving up alcohol or drugs appear as rewarding as
recommended from the assessment (Connors, 1995). continuing to use, and by helping reduce fears and
Assessment is often one of the first steps in the pro- concerns about change (Donovan, 1988; Kanfer,
cess of treatment for those seeking help for an addic- 1986; Miller, 1983).
tive disorder. Choosing to give up alcohol or drugs is The approach that the clinician takes in attempt-
not a decision arrived at easily, and there are many ing to accomplish this task will differ depending on
barriers to doing so (e.g., Marlatt, Tucker, Dono- the client's readiness to change (Prochaska & Di-
van, & Vuchinich, 1997). Thus, the decision to seek Clemente, 1986; Prochaska, DiClemente, & Nor-
treatment is one that may have taken much time and cross, 1992). A client who is in the early stages of
determination to make. There is often a sense of un- the behavior change process, in which he or she is
certainty and ambivalence in the individual who may contemplating change and moving toward making a
be aware that change is needed yet unsure that it will commitment and taking action, appears to benefit
be possible to change or whether she or he wants most by approaches that increase his or her informa-
to give up the positive features associated with the tion and awareness about himself or herself and the
addictive behavior (Kanfer, 1986). nature of the problem, that lead to an assessment of
Prochaska and DiClemente (1986) suggested that how he or she feels and thinks about himself or her-
individuals go through a series of stages in this deci- self in light of a problem, that increase his or her
sion-making process, ranging from precontemplation belief in the ability to change, and that reaffirm his
(e.g., not feeling as if one has a problem) to taking or her commitment to take active steps to change
TABLE 11.1 Examples of Instruments and Interviews Appropriate for Use in Multidimensional Assessments
of Substance Use Disorders Across Different Stages of the Assessment Process

Stage of
assessment Assessment domain Examples of instruments Reference

Screening Alcohol use CAGE Questions Mayfield et al., 1974

Two Item Alcohol Screening Questions Cyr & Wartman, 1988
NET Russell, 1994
T-ACE Sokol et al., 1989
TWEAK Russell et al., 1991
Alcohol Use Disorders Identification Test Saunders et al., 1993
(AUDIT)
Michigan Alcoholism Screening Test (MAST) Selzer, 1971
Brief Michigan Alcoholism Screening Test Pokorny et al., 1972
(bMAST)
Short Michigan Alcoholism Screening Test Zung, 1984
(sMAST)
Drug use Two Item Alcohol and Drug Screening Ques- Brown et al., 1997
tions
Drug Abuse Screening Test (DAST) Skinner, 1982
Problem Alcohol use patterns Time-Line Follow Back Sobell & Sobell, 1992
assessment Form-90 Miller, 1996
Comprehensive Drinker Profile (CDP) Miller & Marlatt, 1984
Alcohol Use Inventory (AUI) Wanberg et al., 1977
Drug use patterns Addiction Severity Index (ASI) McLellan et al., 1992
Drug History Questionnaire (DHQ) Sobell et al., 1995
Individual Assessment Profile (IAP) Flynn et al., 1995
Diagnoses Psychiatric Research Interview for Substance Hasin et al., 1996
and Mental Disorders (PRISM)3
Diagnostic Interview Schedule (DIS) Robins et al., 1981
Schedules for Clinical Assessment in Neuro- Wing et al., 1990
psychiatry (SCAN)
Composite International Diagnostic Interview Robins et al., 1988
(CIDI)
Alcohol Use Disorders and Associated Disabili- Grant & Hasin, 1990
ties Interview Schedule (AUDASIS)
Outcome Negative Alcohol Expectancy Questionnaire Jones & McMahon, 1993
expectancies— (NAEQ)
Alcohol Alcohol Expectancy Questionnaire (AEQ) Brown et al., 1987
Drinking Expectancy Questionnaire (DEQ) Young & Knight, 1989
Alcohol Beliefs Scale (ABS) Connors & Maisto, 1988
Effects of Drinking Alcohol (EDA) Leigh, 1987
Comprehensive Effects of Alcohol Scale Fromme et al., 1993
(CEOA)
Outcome Cocaine Expectancy Questionnaire (CEQ) Jaffe & Kilbey, 1994
expectancies— Cocaine Effect Expectancy Questionnaire— Schafer & Fals-Stewart,
Drugs Likert (CEEF-L) 1993
Cocaine Effect Expectancy Questionnaire Schafer & Brown, 1991
(CEEQ)
Marijuana Effects Expectancy Questionnaire Schafer & Brown, 1991
(MEEQ)

(continued)

190
TABLE 11.1 (continued)

Stage of
assessment Assessment domain Examples of instruments Reference

Problem Relapse risk Substance Abuse Relapse Assessment (SARA) Schonfeld et al., 1993
assessment Cocaine Relapse Interview (CRI) McKay et al., 1996
(continued) Cocaine High-Risk Situations Questionnaire Michalec et al., 1992
(CHRSQ)
Situational Competency Test (SCT) Chancy et al., 1978
Reasons for Drinking Questionnaire (RFDQ) Zywiak et al., 1996
Reasons for Heroin Use Questionnaire Heather et al., 1991
(RFHUQ)
Relapse Situation Appraisal Questionnaire Myers et al., 1996
(RSAQ)
Coping: substance- Coping Behaviors Inventory (CBI) Litman et al., 1983
related Problem Skills Inventory (PSI) Hawkins et al., 1986
Alcohol Specific Role Play Test (ASRPT) Monti et al., 1993
Coping: general Ways of Coping Checklist (WOC) Folkman & Lazarus, 1980
COPE Carver et al., 1989
Coping Responses Inventory (CRI) Moos, 1995
Self-efficacy— Alcohol Abstinence Self-Efficacy Scale DiClemente et al., 1994
Alcohol (AASE)
Drinking Refusal Self-Efficacy Questionnaire Young et al., 1991
(DRSEQ)
Individualized Self-Efficacy Survey (ISS) Miller et al., 1994
Inventory of Drinking Situations (IDS) Annis et al., 1987
Situational Confidence Questionnaire (SCQ) Annis & Graham, 1988
Self-efficacy—Drugs Inventory of Drug-Taking Situations (IDTS) Annis & Graham, 1991
Drug Abuse Self-Efficacy Scale (DASES) Martin et al., 1995
Situational Confidence Questionnaire—Her- Barber et al., 1991
oin (SCQ-Heroin)
Personal Personality California Psychological Inventory (CPI) Gough, 1975
assessment
NEO Personality Inventory Costa & McCrae, 1992
Personality Research Form (PRF) Jackson, 1994
Psychopathology Minnesota Multiphasic Personality Inventory Hathaway et al., 1989
(MMPI-2)
Millon Clinical Multiaxial Inventory (MCMI- Millon, 1992
II)
Psychological Screening Inventory (PSI) Lanyon, 1970
Emotional state Symptom Checklist-90 (SCL-90) Derogatis, 1977
Anger State-Trait Anger Inventory Spielberger et al., 1983
Multidimensional Anger Inventory Siegel, 1986
Anxiety State-Trait Anxiety Inventory Spielberger et al., 1970
Beck Anxiety Inventory Beck et al., 1988
Depression Beck Depression Inventory (BDI) Beck et al., 1961
Center for Epidemiologic Studies Depression Radloff, 1977
Scale (CES-D)
Inventory to Diagnose Depression (IDD) Zimmerman & Coryell,
1987
General life/social Addiction Severity Index (ASI) McLellan et al., 1992
function Psychosocial Functioning Inventory (PFI) Feragne et al., 1983

(continued)

191
192 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

TABLE 11.1 (continued)

Stage of
assessment Assessment domain Examples of instruments Reference

Treatment- Readiness to change Stages of Change Readiness and Treatment Miller & Tonigan, 1996
related factors Eagerness Scale (SOCRATES)
Readiness to Change Questionnaire (RTCQ) Rollnick et al., 1992
University of Rhode Island Readiness to McConnaughy et al., 1983
Change Assessment (URICA)
Desire for Help Scale (DHS) Simpson & Joe, 1993
Intrinsic/Extrinsic Motivation to Quit Ques- Curry et al., 1990
tionnaire (IEMQ) McBride et al., 1994
Barriers to treatment Barriers to Treatment Instrument (BTI) Allen, 1994
Reasons for Delaying Seeking Treatment Cunningham et al., 1993
(RDST)
Fears About Treatment Questionnaire (FTQ) Oppenheimer et al., 1988
Reasons for seeking Treatment Seeking Scale (TSS) Cunningham et al., 1994
treatment Treatment Motivation Questionnaire (TMQ) Ryan et al., 1995
Readiness for Treatment Scale (RTS) Simpson & Joe, 1993
Reasons for Giving Up Drugs and Alcohol Murphy & Bentall, 1992
Reasons for Coming to Treatment Question- Oppenheimer et al., 1988
naire (RCTQ)
Circumstances, Motivation, Readiness, and DeLeon et al., 1994
Suitability Scales (CMRS)
Treatment goals Treatment Goals Inventory (TGI) Glaser & Skinner, 1981
Treatment services Treatment Services Review (TSR) McLellan et al., 1992
utilization
Collateral Collateral reports Form-90 Miller, 1996
information Comprehensive Drinker Profile (GDP) Miller & Marlatt, 1984,
1987

TRISM was formerly known as the SCID-A.

(Prochaska et al., 1992). In addition to being consis- when combined with detailed feedback about the na-
tent with "practice wisdom" and theoretical ap- ture of the addictive behavior and advice about possi-
proaches to change, the proposed focus on such ble alternative coping strategies, may enhance moti-
awareness-raising factors for those in the precontem- vation to change and may serve as an effective form
plation and contemplation phases is also consistent of intervention which either may preclude the need
with recent evidence from individuals who resolved for more extensive treatment or may increase the
an alcohol problem on their own without the aid of likelihood of accepting treatment referrals (e.g., Bien,
formal treatment. Sobell, Sobell, Toneatto, and Leo Miller, & Tonigan, 1993; Heather, 1989; Miller,
(1993) found that over half of the recoveries of such 1989).
individuals could be characterized by their cogni-
tive evaluation of the pros and cons of continued
Problem Assessment
drinking.
For a subset of individuals, the reasons that led to The task of screening is to determine whether a prob-
contemplating the need for change or seeking help lem exists; the task of problem assessment is to deter-
may be sufficient to lead to long-term change in the mine the extent of the identified problem. If an indi-
absence of more formal treatment (Mariezcurrena, vidual has been identified during the screening
1994; Marlatt et al., 1997; Sobell, Cunningham, & process as potentially having a problem, he or she
Sobell, 1996; Stall & Biernacki, 1986; Tucker & should be referred for a more thorough evaluation.
Gladsjo, 1993). For others, the assessment process, This action is consistent with the view that assess-
 ASSESSMENT STRATEGIES AND MEASURES IN ADDICTIVE BEHAVIORS 193

ment is a sequential process (Donovan, 1988; Insti- tive of addictive behaviors suggests that multiple sys-
tute of Medicine, 1990; Sobell et al., 1994). This tems are involved in the development and mainte-
next level of assessment involves problem assessment, nance of these behavior patterns (Donovan, 1988;
which involves a characterization of the nature, Institute of Medicine, 1990; Skinner, 1988). There-
scope, and severity of the potential substance use dis- fore, it is necessary for assessment to be multidimen-
order identified in the screening stage (Institute of sional, focusing on the physiological, behavioral, psy-
Medicine, 1990). This stage of assessment requires chological, and social factors that define or are
more time and resources to conduct and thus is related to the disorder. Consistent with this view,
more costly than screening, but it is important in or- Harrell, Honaker, and Davis (1991) factor-analyzed
der to determine whether specialized treatment is assessment information collected from alcohol abus-
needed and, if so, which available type or intensity ers and polydrug abusers. The assessment included
of treatment is appropriate. Figure 11.1 depicts an measures of quantity/frequency of alcohol or drug
assessment "funnel" that suggests that each step of use, physiological symptoms, situational stressors, an-
the assessment process becomes more intensive and tisocial behaviors, interpersonal problems, affective
focused, with an attendant increase in expense and dysfunction, attitude toward treatment, degree of im-
sensitivity. It also suggests that assessment is an ongo- pact of problems on one's life, and expectancies
ing and sequential process that interacts with the about the substance's perceived ability to reduce ten-
stage of treatment (Donovan, 1988). sion, facilitate social interactions, and enhance mood.
Three broad dimensions were found: behavioral/
physiological, social, and cognitive. Alcohol and
Defining the Parameters
polydrug abusers, although demonstrating some dif-
of the Target Behavior
ferences, had relatively similar and parallel patterns
The most notable aspect of assessment is that it in- of dysfunction across these three domains.
volves the collection, integration, and interpretation Within this context, the Institute of Medicine
of information from and about the individual to (1990) suggested that the assessment of alcohol prob-
allow a clear picture of the problem for which treat- lems should minimally include an evaluation of the
ment is sought. While on the surface this appears to parameters of alcohol use (e.g., quantity, frequency,
be a straightforward task, a biopsychosocial perspec- pattern), the signs and symptoms of alcohol use, and

FIGURE 11.1 The assessment funnel.

194 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

the consequences of alcohol use. The same general Kauffman, 1985). In addition to having practical re-
dimensions should also be included in the assess- imbursement value for the clinician, the clinical di-
ment of the use of drugs other than (or in addition agnosis is meant to convey an understanding of the
to) alcohol. However, it has been suggested that a etiology, development, and manifestation of the
greater focus be placed on the frequency of drug use substance use disorder; to aid in the development of
rather than the quantity of substance consumed, due appropriate treatment plans; and to provide some in-
to difficulties in quantifying "doses" of a given drug, dication of the likely prognosis of the disorder (Jacob-
the amount of the active ingredients, and uncertainty son, 1989a).
about the actual drug(s) being used (Addiction Re-
search Foundation, 1994). Additionally, other infor-
Substance-Related Diagnoses
mation about drug use should be collected, such as
route of administration and pattern of use. The de- The two diagnostic systems that are currently most
gree of consistency across these assessment domains commonly employed in substance abuse treatment
is less than one might assume, with a wide degree settings include the ICD-10 (World Health Organi-
of variability in the manifestations of substance use zation, 1990) and the DSMJV (American Psychiat-
problems both within and across individuals. Sobell ric Association, 1994; Grant & Towle, 1991; Hasin,
et al. (1988, 1994) provided detailed descriptions of Li, McCloud, & Endicott, 1997). The set of core
the types of information that should be included in symptoms and related diagnostic criteria that define
a comprehensive behavioral analysis and assessment a substance use disorder in these systems, and the
of alcohol and drug problems that address multiple interrelationship among them, have been influenced
systems and dimensions of the target behavior. Sim- greatly by the conceptualization of a substance de-
ilarly, Sobell and Sobell (1995) provide a detailed pendence syndrome. This syndrome consists of a
description, comparison, and recommendations of constellation of related features, the most prominent
measures useful in assessing alcohol consumption. of which include a narrowing of the drinking or drug
Maisto and McKay (1995) also provided information use repertoire, a salience of drink- or drug-seeking
on measures appropriate for assessing the degree of behavior, increased tolerance, repeated withdrawal
alcohol dependence and the negative consequences symptoms, relief or avoidance of withdrawal symp-
associated with problem drinking. toms, a subjective awareness of a compulsion to
drink or use drugs, and a reinstatement of use pat-
terns after an initial relapse following a period of ab-
Determining a Diagnosis
stinence. Not all of these features need to be present
Beyond facilitating client motivation and treatment at all times or with the same degree of intensity
entry, assessment serves a number of other important across time for an individual or across individuals.
functions in the management of substance abuse dis- The dependence construct, which had its origins in
orders (Allen & Mattson, 1993). One of these is the describing alcohol problems, appears to have been
development of a diagnostic formulation, which is generalized successfully to other drugs of abuse (Ba-
typically developed through the integration of infor- bor, Cooney, & Lauerman, 1987; Elaine, Horton, &
mation derived from the client's history of substance Towle, 1995; Edwards, 1986; Feingold & Rounsa-
use, clinical interviews based on the specific criteria ville, 1995; Hasin, Grant, Harford, & Endicott, 1988;
of the diagnostic system being employed, psychomet- Morgenstern, Langenbucher, & Labouvie, 1994).
ric tests, and laboratory data. Kranzler, Tennen, Ba- An important contribution made by the syndrome
bor, Kadden, and Rounsaville (1997) suggested that, concept is that dependence can be rated along a con-
where possible, a longitudinal procedure in which tinuum of the degree or severity of dependence
an experienced, expert clinician uses all available rather than being viewed only as a dichotomous diag-
data collected from multiple sources across time is a nostic classification (e.g., Hasin & Click, 1992). An-
helpful method to arrive at valid diagnoses among other important feature of the dependence syndrome
substance abusers. The diagnostic system employed is the distinction made between "dependence" and
by the clinician is determined in part by one's theo- alcohol- or drug-related "disabilities," or the negative
retical perspective and provides a method of orga- physical, mental, and psychosocial consequences in
nizing the range of information gathered from a which alcohol or drug use is implicated. These disa-
comprehensive assessment (Jacquot, 1992; Shaffer & bilities are considered to be related to, but conceptu-
 ASSESSMENT STRATEGIES AND MEASURES IN ADDICTIVE BEHAVIORS 195

ally distinct from, the dependence syndrome. That and/or dependence, may be secondary to other psy-
is, it is possible to be dependent either with or with- chiatric conditions, or may coexist concurrently and
out experiencing negative psychosocial conse- independently with other psychiatric disorders
quences; similarly, it is possible to experience such (Craig, 1988; N. S. Miller, 1993). The presence of
negative consequences without necessarily meeting additional substance use and psychiatric problems
the criteria for dependence. increases both the complexity of the diagnostic and
Many concerns exist about the adequacy of the assessment processes (e.g., Dawes, Frank, & Rost,
currently available diagnostic systems and the gen- 1993; Teitelbaum & Carey, 1996; Woolf-Reeve,
eral conceptual framework on which they rest (e.g., 1990) and the clinical determination of the most ap-
Beutler & Clarkin, 1990; Nathan, 1991; Sellman, propriate therapeutic approach (e.g., Rubenstein,
1994; Tarter, Moss, Arria, Mezzich, & Vanyukov, Campbell, & Daley, 1990). This is true for major
1992; Widiger & Smith, 1994), as well as about diffi- psychiatric disorders (e.g., Axis I) such as affective
culties in the practical translation of diagnostic con- disorders and concurrent drug dependence. The
cepts to clinical decision making and treatment plan- presence of additional Axis I disorders, as well as the
ning (Babor, Orrok, Liebowitz, Salomon, & Brown, relative severity of more generalized psychiatric prob-
1990). Also, despite the widespread adoption of the lems, is prognostic of poorer treatment outcome
dependence syndrome in current diagnostic systems, (McLellan, 1986; Rounsaville, Dolinsky, Babor, &
concerns have been raised about a number of the Meyer, 1987) and most often requires the provision
elements of the syndrome, such as the need for toler- of more intensive treatment services (Alterman,
ance and withdrawal (e.g., Carroll, Rounsaville, & McLellan, & Shifman, 1993). Axis II diagnoses are
Bryant, 1994) and the narrowing of the drinking or also relevant, given the strong relationship between
drug use repertoire (Cottier, Phelps, & Compton, certain addictive behaviors and personality disorders,
1995). A number of authors have also questioned the particularly antisocial personality (e.g., Blume, 1989;
conceptual distinction between dependence and dis- Nace, Davis, & Gaspari, 1991). Again, the presence
abilities. Empirical evidence suggests that the con- of a concurrent personality disorder may lead to
stellation of core elements of the dependence syn- poorer outcomes around substance use (Rounsaville,
drome are highly related to measures of health, et al., 1987) or with respect to other areas of life
social, and emotional problems attributable to alco- function such as emotional health, social life, rela-
hol or drug use and that they appear to represent a tionship with friends, or overall life satisfaction
single factor, rather than two distinct dimensions (Nace & Davis, 1993).
(e.g., Hasin et al., 1988; Hasin, Muthuen, & Grant, A number of structured, semistructured, and un-
1994). However, from a practical clinical perspec- structured clinical interviews are available to assist
tive, to be complete, a diagnostic assessment of sub- the clinician with determining a diagnosis both of
stance use disorder should include an assessment of substance use disorders and other psychiatric dis-
both the dependence syndrome, graded along a con- orders (see table 11.1). Hasin (1991), Grant and
tinuum of severity, and the types of negative con- Towle (1990), and Maisto and McKay (1995) have
sequences that have been experienced by the in- provided extensive information on measures used in
dividual. Also, most diagnostic systems allow the clinical and research settings to assess the alcohol de-
determination of both "lifetime" occurrence of the pendence syndrome, provide a diagnostic classifica-
diagnosis and whether the individual meets the diag- tion of alcohol dependence or abuse, and measure
nostic criteria based on symptom manifestation over aspects of problems and negative consequences re-
a more recent time frame (e.g., the last 6 months). lated to alcohol use. Similarly, Rounsaville et al.
(1993) provided a similar review of diagnostic mea-
sures used with drug abuse clients.
Other Psychiatric Diagnoses

While the primary focus of the diagnostic interview

Other Substance-Related Domains
is on the client's stated drug of choice, it must be
more broadly based than this. Substance use or de- In order to gain a more thorough understanding of
pendence does not usually exist in isolation. Depen- the individual's substance use disorder and to help
dence on a substance may represent a primary disor- develop appropriate plans for intervention, a number
der, may occur in conjunction with other drug use of additional features related to substance use need
196 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

to be assessed. To a large extent, the domains to as- in drinking or drug use and to mediate subse-
sess derive from cognitive behavioral models of quent drinking behavior (Rather & Goldman, 1994;
substance abuse problems and factors that may be Stacy, Leigh, & Weingardt, 1994). It is typically pre-
involved in relapse once the individual has reduced sumed that individuals drink or use drugs in order
or stopped alcohol or drug use (e.g., Connors, to achieve or enhance the emotional or behavioral
Maisto, & Donovan, 1996; Donovan, 1996; Dono- outcomes that they expect; thus, expectancies are
van & Chancy, 1985; Marlatt & Gordon, 1985; Raw- viewed as reflective of possible reasons for using.
son, Obert, McCann, & Marinelli, 1993). Such There is considerably more information available
models suggest that individuals may develop sub- about alcohol-related expectancies than about expec-
stance abuse or dependence in part based upon the tancies of the effects of other drugs (Brown, 1993).
perception that substance use is functionally useful Donovan (1995) provides a review of a number of
in dealing with interpersonal and intrapersonal situa- the measures assessing alcohol-related expectancies.
tions that are stressful, are associated with prior use, There has been a recent increase in the development
or involve social pressures to use, for which the indi- of assessment instruments focusing on expectancies
vidual may not have adequate coping skills. In such related to use of other substances such as cocaine
situations the anticipated effects of the substance are and marijuana (e.g., Jaffe & Kilbey, 1994; Schafer &
seen as being able to bring about positive effects by Brown, 1991). Initial efforts at assessing alcohol-re-
its influence on moods and social behavior. Thus, lated expectancies focused primarily on anticipated
assessment of these domains should include mea- positive outcomes (e.g., Goldman, Brown, & Chris-
sures of the individual's beliefs about the anticipated tiansen, 1987). It was assumed that these positive ex-
effects of the substance on mood and behavior (out- pectancies created a "pull" toward alcohol by devel-
come expectancies), the nature of those situations oping a positively valenced incentive to drink. More
that may pose the greatest risk of relapse, the relative recently, increasing attention has been paid to the
availability of or deficits in the individual's sub- role of expectancies about the negative effects of al-
stance-specific and general coping abilities, and the cohol or other drugs which may serve as a deterrent
person's belief about the relative availability of appro- or disincentive to use (e.g., Jones & McMahon,
priate coping skills and the ability to use them suc- 1994). It appears, then, that there are different moti-
cessfully to deal effectively with potential risks of re- vational factors represented by positive and negative
lapse (self-efficacy expectancies). expectancies in relationship to drinking behavior
(McMahon & Jones, 1993), and that each may con-
tribute to the prediction of relapse and treatment out-
Outcome Expectancies
come (Jones & McMahon, 1994). Therefore, it is
There has been an increased focus on the role important to assess both positive and negative expec-
played by the individual's expectancies concerning tancies.
the anticipated effects of alcohol or drugs on mood
and behavior in the development and maintenance
Relapse Risk
of substance use problems, as well as their potential
contribution to relapse following behavior change Marlatt and Gordon (1985) suggested that a number
(e.g., Brown, 1993; Oei & Baldwin, 1994). In gen- of different types of situations may increase the likeli-
eral, substance-related expectancies typically refer to hood of relapse. The three primary categories in-
the beliefs or cognitive representations held by the clude negative emotional states such as anger and
individual concerning the anticipated effects or out- resentment associated with interpersonal encounters,
comes expected to occur after consuming alcohol. negative emotions such as depression and boredom
These expectancies are shaped by an individual's which are more intrapersonal, and either direct or
past direct or indirect experiences with substances indirect social pressure to use. Cognitive behavioral
and the behaviors associated with their use (Con- relapse models suggest that if individuals encounter
nors & Maisto, 1988). To the extent that these repre- such high-risk situations and do not have available
sentations are activated and accessible to the indi- adequate or appropriate coping skills to deal with the
vidual in situations associated with using, they are situational demands, they experience a decrease in
hypothesized to determine the anticipated outcomes self-efficacy, the salience of the anticipated positive
 ASSESSMENT STRATEGIES AND MEASURES IN ADDICTIVE BEHAVIORS 197

outcomes of substance use increase, and relapse is the availability and accessibility of the emotional and
more likely to occur. behavioral skills necessary to cope with situations
A number of measures have been developed to that are appraised as a challenge to one's perception
assess each of these domains. Annis and colleagues, of control and that therefore may precipitate a re-
for example, have developed parallel measures to as- lapse. It is assumed that the greater the individual's
sess drinking and drug use situations (Annis, Gra- available repertoire of coping skills, the greater the
ham, & Davis, 1987; Annis & Graham, 1991). The strength of self-efficacy, and the lower the probability
situations presented in these scales are based on those of relapse or drinking in a given situation.
found in Marlatt and Gordon's (1980) taxonomy of A number of measures have been developed that
high-risk relapse situations. Individuals are asked to in- assess coping skills, specifically targeting alcohol or
dicate how frequently they have consumed alcohol or drug use. These include both self-report measures
used drugs either in these situations or in response to (e.g., Litman, Stapleton, Oppenheim, & Peleg, 1983)
them. The assumption underlying the assessment and behavioral analogue or role play methods (e.g.,
model is that the more frequently one has drunk or Chancy, Marlatt, & O'Leary, 1978; Hawkins, Cata-
used drugs in these settings, the greater the associative lano, & Wells, 1986; Monti et al., 1993). The self-
strength between the situation and drinking or using, report measures assess the behavioral and emotional
and the greater the likelihood of drinking and using coping strategies that the individual uses to avoid re-
in such settings in the future. From the client's re- lapse and the perceived effectiveness of these strate-
sponses, a "problem index" score is calculated for each gies. Individuals more likely to maintain posttreat-
of the categories of drinking situations, allowing the ment abstinence tended, when assessed at treatment
construction of a client profile showing the individu- entry, to perceive themselves as having more effec-
al's areas of greatest risk for heavy drinking and help- tive coping strategies overall and as rating the positive
ing to target and guide interventions. It should be thinking and avoidance approaches as more effective
noted that the presumed high-risk situations identified than those who would relapse during follow-up (Lit-
by such measures have been associated only with man, Stapleton, Oppenheim, Peleg, & Jackson, 1984).
heavy drinking or drug use; therefore, it may be inap- The role play methods present individuals with hypo-
propriate to presume a causal link between the types thetical high-risk relapse situations and ask them to
of situations endorsed, drinking or drug use behavior, respond as they would if actually in those situations.
and the likelihood of relapse (Sobell et al., 1994). Microelements of the responses (e.g., latency to re-
Sobell et al. (1994) suggested that other factors, such spond, length of response), observer-rated skillfulness
as coping skills deficits, may represent a common or adequacy of the response to resolve the situation
third factor that may moderate the relationship be- without drinking or using drugs, and self-reported
tween a given situation and relapse risk. Similarly, anxiety and craving in the situations have been as-
the categories assessed by such inventories provide sessed (e.g., Schmitz, Oswald, Damin, & Mattis, 1995).
information only about general categories of situa- Latency to respond, observer-rated anxiety and ob-
tions or general problem areas and may be lacking server-rated estimates of skill deficits, and self-report-
in detail about more personalized risk situations. So- ed urges to drink have been found to predict poor-
bell et al. (1994) indicated that it is important to ex- er drinking-related posttreatment outcomes among
plore in more depth the unique and personally rele- alcoholics (Chancy et al., 1978; Kadden, Litt,
vant high-risk situations or areas where the client Cooney, & Busher, 1992). Also, Kadden et al. (1992)
lacks self-confidence for resisting drinking or drug found that those individuals who had more difficulty
use. Other methods, primarily interviews, attempt to in the role play benefited more from a coping-skills
gain a more individualized assessment of the ante- training program of aftercare than from a supportive
cedents to and consequences of previous relapse epi- interactional therapy.
sodes (e.g., Schonfeld, Peters, & Dolente, 1993). While it appears that substance abusers' coping
ability is dependent in part on situational parameters
in high-risk situations (Schmitz et al., 1995), it is also
Coping
important to assess their more general coping and
Cognitive behavioral models of relapse assume that problem-solving skills (Beutler & Clarkin, 1990). De-
the strength of self-efficacy expectancies depends on Nelsky and Boat (1986) provided a model of psycho-
198 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

logical assessment and treatment that is based on do so. Again, more individualized assessments of self-
the assessment of the individual's coping skills and efficacy and prioritization of high-risk situations may
deficits in dealing with interpersonal relationships, provide the more specific information needed to tai-
thoughts and feelings, approaches to herself or him- lor interventions than is possible with measures of
self and life, and the ability to sustain goal-directed confidence and temptation in more general catego-
effort. The availability of such skills is seen as impor- ries of risk situations (Miller, McCrady, Abrams, &
tant in dealing with problems that can be anticipated Labouvie, 1994).
during the course of the treatment and maintenance
phases and therefore should have an effect on the
Personal Assessment:
probability of relapse. A number of measures of cop-
Domains of Assessment
ing ability are available and are consistent with this
general model (e.g., Folkman & Lazarus, 1980; Moos, The role of assessment goes well beyond classifying
1995). the individual's problem diagnostically to providing
a more extensive picture of other areas of life func-
tioning. Individuals who seek treatment usually have
Self-Efficacy
multiple problems in a number of life areas, such as
A second major cognitive factor to be incorporated employment, legal status, emotional function, social
into the assessment of substance abusers is self-effi- role function, medical status, and family relations
cacy (DiClemente, 1986; Rollnick & Heather, 1982; (e.g., Siegal et al., 1995; Wallace, 1986). The assess-
Wilson, 1987). While this construct plays a promi- ment of functioning in these life areas, following
nent role in cognitive behavioral models of problem screening and problem assessment, has been de-
drinking, considerably less research attention has scribed by the Institute of Medicine (1990) as per-
been focused on its assessment and its relationship sonal assessment. It is in this stage that a comprehen-
to drinking behavior than has been given to alcohol- sive assessment of the individual and his or her life
related outcome expectancies (Young, Oei, & Crook, problems is conducted. The nature, scope, and sever-
1991). Also, as is true of outcome expectancies, con- ity of such problems contribute to the treatment-
siderably more work appears to have been done to planning process as well as to subsequent treatment
date in the assessment of self-efficacy associated with outcome. The severity of problems in these life areas
alcohol than with other drugs. This self-efficacy con- at the point of initial assessment and entry into treat-
struct has been defined in terms of the beliefs that ment has also been found to predict poorer outcomes
individuals hold or their level of confidence concern- among alcohol-, opiate-, and cocaine-dependent
ing their ability to resist engaging in drinking or drug clients in both publicly and privately funded treat-
use behavior (Oei & Baldwin, 1994; Young et al., ment programs (McLellan et al. 1994). However, the
1991). In addition to attempting to infer an individu- more treatment services individuals receive specifi-
al's relative degree of self-efficacy from an assessment cally targeting these problem areas, the better the
of coping skills, a number of measures have been outcome compared to the outcome of those with
developed to assess this domain more directly. For similar problem severity who do not receive as much
example, Annis and colleagues have developed a set specifically targeted clinical service (McLellan et al.,
of measures, paralleling those that assess high-risk sit- 1994).
uations, that ask the individual's level of confidence In addition to an assessment of problem areas in
that he or she would not drink or not drink heavily psychosocial and role functioning, a number of other
or use drugs in each of these situations (Annis & domains need to be considered. One is personality
Graham, 1988; Martin, Wilkinson, & Poulos, 1995). and psychopathology. The role of personality vari-
Similarly, DiClemente, Carbonari, Montgomery, ables has been investigated with respect to the devel-
and Hughes (1994) assessed the degree of confidence opment of substance use disorders, their correlates
and the degree of temptation the individual might with substance use patterns, and their prognostic util-
experience in a number of high-risk situations. Each ity in predicting treatment outcome (Craig, 1995;
of these approaches allows the clinician to evaluate Sutker & Allain, 1988). Also, personality factors ap-
the strength of the "pull" to drink or use drugs rela- pear to represent one of several categories of inter-
tive to the degree of confidence that one will not acting variables that may contribute to the "reasons"
 ASSESSMENT STRATEGIES AND MEASURES IN ADDICTIVE BEHAVIORS 199

or motivation for using alcohol and drugs (Cox & greater severity of psychological and psychosocial
Klinger, 1987). A number of authors have made the problems than those who do not seek treatment
distinction between personality factors that antedate (Marlatt et al., 1997).
the onset of substance abuse problems and may con- It is also relevant to consider a more thorough
tribute to their development (e.g., the "preaddict per- assessment of individuals' general emotional state.
sonality") and "clinical personality" variables, repre- This can be done by use of measures that attempt to
senting the characteristics of substance abusers who provide an overview of a number of dimensions of
have sought out and are involved in treatment emotional function, such as the SCL-90 (Derogatis,
(Barnes, 1983; Craig, 1995). Craig (1995) described 1977), or by use of scales that are specific to a partic-
the "clinical personality" of substance abusers as fre- ular emotion. If one chooses the latter approach, it
quently including the following traits: passivity and would seem appropriate that the assessment mini-
dependence, an external locus of control, low self- mally include assessment of depression, anger, and
esteem, cognitions that are self-derogatory, depres- anxiety, each of which has been associated with alco-
sion, anxiety, immaturity, impulsivity, anger, low hol and drug use as either possible contributors to or
self-esteem, and psychopathic traits. While not all consequences of use.
substance abusers present such characteristics and
different combinations of these traits may be seen in
Determining Readiness to Change and
others, these are traits that the clinician has to work
Readiness for Treatment
with regardless of their origin.
To some extent, this area is related to some ap- As noted previously, individuals may be in different
proaches that might be used in determining diagno- stages of readiness to change their alcohol and drug
ses, in that one would be looking for other forms of use behaviors. The assessment process can assist in
psychological/psychiatric problems (Axis I) and per- determining where they fall with respect to this di-
sonality disorders (Axis II) as part of the diagnostic mension. Three measures are available to assist; each
process. Other measures can provide continuous is based on Prochaska and DiClemente's model of
measures of personality traits that may be useful. stages of behavior change (Prochaska et al., 1992).
Measures such as the MMPI-2 (Hathaway et al, Two of these scales, the University of Rhode Island
1989) and MCMI-II (Millon, 1992) have been found Change Assessment Instrument (URICA; McCon-
useful in assessing and determining treatment ap- naughy, Prochaska, & Velicer, 1983) and the Stages
proaches for alcohol- and drug-dependent popula- of Change Readiness and Treatment Eagerness
tions (e.g., Craig & Olson, 1992; Craig & Weinberg, Scale (SOCRATES; Miller & Tonigan, 1996) have
1992a, 1992b). Similarly, there is a high prevalence been used primarily with substance abusers who
of sociopathy and antisocial behavior among alcohol- have sought treatment. The other, the Readiness to
ics and substance abusers. Cooney, Kadden, and Litt Change Questionnaire (Rollnick, Heather, Gold, &
(1990) found that the Socialization scale on the Cali- Hall, 1992), was designed not for those seeking treat-
fornia Psychological Inventory (CPI; Cough, 1975) is ment but for use as part of a screening of medical
a particularly good index of this measure and that it patients who might have alcohol abuse problems.
might have merit in matching clients to appropriate Each of these measures provides a determination of
treatments (Kadden, Cooney, Getter, & Litt, 1989). the stage of change (e.g., precontemplation, contem-
Two issues should be noted in regard to the utility plation, preparation, action) that best categorizes the
of measures of personality and psychopathology. individual's readiness to change.
First, it is often difficult to determine whether the Even if a person evidences a willingness to
features seen in substance abusers in treatment con- change his or her addictive behavior, this does not
tributed etiologically to the development of their sub- mean that he or she is necessarily interested in treat-
stance use disorders or whether these are features ment (Marlatt et al., 1997). There may be a number
that have developed secondary to their abuse of the of reasons why individuals might choose not to seek
substances (Craig, 1995). Second, those substance or to delay seeking treatment, ranging from fear of
abusers who enter treatment are not representative of stigmatization, to concerns about whether treatment
the broader population of substance abusers; those will be effective or not, to wanting to try to quit with-
entering treatment often have a broader range and out formal treatment, as well as a number of more
200 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

practical logistical barriers, such as the lack of child the client and the clinician in developing and priori-
care. Similarly, there are many reasons why an indi- tizing short- and long-term goals for treatment, in se-
vidual seeks treatment at a given time. The factors lecting the most appropriate interventions to address
influencing this decision may be external pressure, the identified problems, in determining and address-
such as from the legal system, family, or employer; ing perceived barriers to treatment engagement and
internal sources of motivation, such as concerns compliance, and in monitoring progress toward the
about one's health or the result of weighing the costs specified goals, improved psychosocial functioning,
of continued use against the benefits of stopping, and harm reduction (Bois & Graham, 1993; Mill-
might also be involved. Ryan, Plant, and O'Malley er & Mastria, 1977; Sobell et al., 1988). The assess-
(1995) found that a group of cocaine-dependent cli- ment and treatment-planning processes should lead
ents who had high levels of both external and in- to the individualization of treatment, appropriate cli-
ternal motivation for seeking treatment were more ent-treatment matching, and the monitoring of goal
compliant with outpatient treatment and had better attainment (Allen & Mattson, 1993), based on the
short-term outcomes than those having other combi- assumption that more appropriate matches between
nations of these two sources of motivation. Thus, it client and therapy will lead to both a better outcome
is important to know what barriers individuals may and a more cost-effective delivery of services. While
have overcome in their pursuit of treatment, as well assessment at intake is instrumental attempts to
as to determine the nature, degree, and sources of match clients to the most appropriate available treat-
motivation for seeking treatment at this particular ment options, it should also be viewed as a continu-
time. Additionally, it is helpful to know the individu- ous process that allows monitoring of treatment prog-
al's perception of the type of treatment that he or she ress, refocusing and reprioritizing of treatment goals
feels is most appropriate for the particular substance and interventions across time, and determination of
use disorder and problems in other life areas that has outcome (Donovan, 1988; Institute of Medicine,
led to seeking help. A number of scales have been 1990; Sobell et al, 1994).
developed to assist the clinician to systematically as-
sess potential barriers to and motivation for treatment
entry as well as the individual's goals and the types HOW AND WHEN TO ASSESS:
of treatment being sought (e.g., Allen 1994; Cun- PRACTICAL ASPECTS OF THE
ningham, Sobell, Sobell, & Gaskin, 1994; Curry, ASSESSMENT PROCESS
Wagner, & Grothaus, 1990; DeLeon, Melnick, Kres-
sel, & Jainchill, 1994; Glaser & Skinner, 1981; Mc-
How Much Is Enough? Balancing Scope of
Bride et al., 1994; Murphy & Bentall, 1992; Oppen-
Assessment with Cost and Utility
heimer, Sheehan, & Taylor, 1988; Ryan, et al., 1995;
Simpson & Joe, 1993). There is a tendency for those working in the mental
health field generally and in substance abuse more
specifically to want to know as much about the client
Treatment Planning: Matching
as we can. This information is important in our at-
Clients to Treatments
tempt to understand the individual, the issues that
Within the clinical context, the primary goal of as- historically contributed to his or her personal devel-
sessment is to determine those characteristics of the opment and the etiology of a substance use disorder,
client and his or her current life situation that may and the client's current life circumstances. However,
influence decisions about treatment and that may there is the risk that we may be collecting more in-
contribute to the success of treatment (Allen, 1991). formation than is necessary to adequately plan appro-
Assessment procedures are crucial to and provide in- priate treatments for the individual. The assessment
formation necessary for the treatment-planning pro- process should be comprehensive; however, from a
cess. Treatment planning involves the integration practical perspective, it should also be relatively par-
of assessment information concerning the person's simonious, given the array of areas that can be as-
drinking behavior, alcohol-related problems (prob- sessed (Donovan, 1988; Institute of Medicine, 1990).
lem assessment), and other areas of psychological As Geller (1991) pointed out, for assessment proce-
and social functioning (personal assessment) to assist dures and instruments to be useful in clinical set-
 ASSESSMENT STRATEGIES AND MEASURES IN ADDICTIVE BEHAVIORS 201

tings, they must provide a sufficient breadth of cover- of different types of measures within it is the amount
age of those client symptoms (problem assessment) of time that has passed since the last drink or use
and other areas of concern (personal assessment) that of drugs. To be maximally useful to the clinician,
are relevant to clinical decision making, their use assessments need to be conducted as soon as possible
must be economically feasible, and the information after the client is admitted to treatment in order to
obtained must be specific to those treatment options allow the integration of the obtained information
that are realistically available to the client. Similarly, into a treatment plan; however, it must not be so
Sobell et al. (1994) suggested that there is no stan- soon after the last use of alcohol or drugs that the
dard formula for determining the length, breadth, or information is distorted by the residual effects of
depth of a clinical assessment. Rather, the ultimate acute intoxication, withdrawal, or emotional distress.
parameters of an assessment should be individually The issue of timing becomes more complex since
determined by both clinical judgment and common the length of stay in inpatient treatment settings is
sense. A number of different strategies can be used to being reduced markedly and more treatment func-
provide a framework and direction for the assessment tions are being moved to outpatient settings.
process in each of the systems and domains noted It appears that a determination of the timing
above. Skinner (1988) and the Institute of Medicine should take into account both the nature of the mea-
(1990) have distinguished between two types of con- sures being used and the type of substance the client
tent in the personal assessment stage. The first is has been using. Allen et al. (1995) suggested that
noncontingent content, which involves information those tests requiring a high level of cognitive func-
that should be routinely and always collected on the tion should be delayed longer and be sequenced
individual (e.g., demographics, family history of sub- later in the assessment process than measures that
stance abuse, prior treatment history). The contin- focus on traitlike personality characteristics. How-
gent problem assessment employs a sequential ap- ever, there is no standard recommended length of
proach, in which a less intensive screening of a broad time before such tests should be administered.
range of life areas is conducted; those areas noted as Sherer, Haygood, and Alfano (1984) examined differ-
being potentially problematic can be pursued further ent time frames for administering both personality
with more intensive and specialized assessments. A and cognitive function measures to newly admitted
second strategy is the use of clinical hypothesis test- alcoholics who were toxic upon admission. Test re-
ing, in which the clinician formulates hypotheses sults were quite unstable at the earliest testing point
about the individual's behavior based on his or her (4 days after admission) but appeared to be relatively
theoretical perspective and collects information stable on most measurers at 10 days or later. Gold-
through the assessment process to test the apparent man (1987) found that alcoholics evidence a very
validity of the hypotheses (Shaffer & Kauffman, marked recovery of neuropsychological functioning
1985; Shaffer & Neuhaus, 1985). Each of these ap- in the first month after they stop drinking; evaluation
proaches is meant to provide information about the of cognitive functions before at least 2-3 weeks fol-
most critical factors in determining the assignment lowing cessation thus are likely to be quite unstable
of the client to treatment. and to underestimate the individual's level of abili-
ties. Also, the rate of recovery in this early period of
recovery was often slower for older alcoholics and
Timing and Sequence of Assessments
those with a more chronic history of alcoholism.
Few guidelines have been developed to assist clini- Brown and colleagues (Brown et al., 1995; Brown,
cians in determining the appropriate timing and Irwin, & Schuckit, 1991; Brown & Schuckit, 1988)
sequencing of assessments of substance abusers (Al- have also examined the time course of changes in
len, Columbus, & Fertig, 1995; Rounsaville, 1993; both anxiety and depression during the early phases
Schottenfeld, 1994). While the assessment process of treatment and recovery. Alcoholics evidenced an
may include the collection of information from col- initially high level of state anxiety immediately fol-
lateral sources, such as significant others and labora- lowing admission to inpatient treatment, but their
tory findings, most will rely heavily on the client's scores typically returned to the normal range by the
self-report. A major consideration in trying to deter- second week of treatment. Similarly, the symptoms
mine the timing of the assessment and the ordering of depression appeared to abate fairly quickly after
202 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

the initiation of treatment. At admission, nearly half volved in an assessment may be in one of four gen-
the patients had clinically significant depression, but eral phases related to their substance use: (a) acute
only 6% remained clinically depressed at the end of intoxication (usually less that 24 hours since inges-
4 weeks of treatment. The greatest reduction in de- tion); (b) steady state use of the drug (having taken
pression appeared to occur during the second week. sufficient quantities in a time frame to avoid with-
It further appears that at least 3 weeks of abstinence drawal); (c) withdrawal—both acute and prolonged;
from alcohol are needed to differentiate consistently and (d) extended abstinence. Rounsaville (1993) sug-
between primary alcoholics who are depressed from gested that the rate of absorption and the half-life of
alcoholics with primary affective disorder on the ba- the drugs being used do affect the assessment pro-
sis of their depressive symptomatology. cess. In general, the more rapid the absorption and
Based on these results, it appears that minimally the shorter the half-life, the more intense and briefer
10 days to 3 weeks should pass from last drink or use the duration of the "high" or intoxicated state, and
before the resultant variables being assessed can be the more intense and briefer the withdrawal syn-
considered somewhat more stable and no longer be- drome. Given the four states that must be considered
ing distorted by acute alcohol or drug effects or with- for each class of drugs, the variability in absorption
drawal distress. This time frame may represent an and half-life of each class, and the likelihood that an
"ideal," given that managed-care programs often individual may be using multiple drugs from the
mandate inpatient stays of less than 10 days. Given same or different classes of drugs, the determination
the need for information useful for treatment plan- of timing of assessments is extremely complex. Roun-
ning purposes within this "real" time frame, mea- saville (1993) provided a number of useful steps that
sures that are less likely to be affected by alcohol or could make this determination somewhat more man-
drug effects or withdrawal (e.g., demographic charac- ageable. Before the evaluation, the clinician should
teristics, legal history, trait-based client attributes) get detailed information about the types of sub-
should be given earlier in the assessment sequence; stances used, the amount and frequency of use, and
measures that are more likely to be affected by alco- the amounts used in the past day, week, and 30 days
hol or drug effects (e.g., cognitive function, current and should perform a cursory evaluation of the indi-
mood states) should occur later in the sequence, vidual's current subjective state vis-a-vis the drugs he
when the individual is more likely to have had a or she is taking. Those who report themselves as be-
more extended period of abstinence (Allen et al., ing either acutely intoxicated or in acute withdrawal
1995; Rounsaville, 1993). A number of client charac- should be rescheduled for assessment. In those cases
teristics such as age, length of heavy use, time since where more than one assessment session is necessary,
last use, and the presence of other comorbid psychi- it may be appropriate to group together those mea-
atric or physical conditions may moderate the rate of sures that are likely to be unaffected by the influence
recovery of a number of functions; thus, interpreta- of substances and to administer them separately from
tions of the assessment results need to take these fac- those likely to be affected by drugs. Also, given that
tors into account. Given that individuals often con- a number of drug-induced effects may mimic symp-
tinue to evidence improvements in cognitive and toms of psychiatric disorders, it is important to con-
psychological functioning beyond these time frames, duct psychiatric interviews only after a history of re-
the process of assessment should be viewed as an on- cent drug use has been completed and the individual
going process rather than one taking place only at a is not currently intoxicated or in withdrawal.
single point (Donovan, 1988).

Methods to Enhance Validity and

Variability Based on Substance Reliability of Assessments
of Use and Abuse
A common clinical concern is that substance abusers
In addition to the influence of client characteristics may not provide an accurate picture of their alcohol
on the reliability and validity of information derived or drug use or of other aspects of their life potentially
from assessment, the types of substances and a num- relevant to treatment planning. Substance abusers
ber of their characteristics must also be taken into are often described as having a predisposition to min-
account (Rounsaville, 1993). Substance abusers in- imize their drug use and related problems (e.g., Ful-
 ASSESSMENT STRATEGIES AND MEASURES IN ADDICTIVE BEHAVIORS 203

ler, 1988; Schottenfeld, 1994; Watson, Tilleskjor, the scope of the assessment process and verifying the
Hoodecheck-Schow, Pucel, & Jacobs, 1984), thus client's self-report (Maisto & Connors, 1990). Such
potentially adding another source of variability to the verification is strongly recommended, since the va-
accuracy of self reports. While many substance abus- lidity of self-reports appears to be enhanced (Wil-
ers tend to underreport their use, others, particularly son & Grube, 1994), and involvement of a signifi-
in treatment-seeking settings, may exaggerate their cant other in the assessment and treatment process
use. Regardless of the direction, the fear among clini- appears to improve treatment outcome (Waltman,
cians is that the resulting self-reports are of question- 1995). When differences are found between the re-
able reliability and/or validity. ports of clients and those of collaterals, the percent-
Despite this clinical concern, research suggests age of collaterals who overestimate clients' substance
that the possible distortion in the self-report process use is about equal to the percentage of clients who
is less problematic than it is feared to be. Babor and underestimate self-reported substance use (Miller et
colleagues (Babor, Brown, & DelBoca, 1990; Ba- al., 1979). Cordingley et al. (1990) found that poly-
bor & DelBoca, 1992; Babor, Stephens, & Marlatt, drug users reported more drug use than collateral in-
1987), as well as the Institute of Medicine (1990), formants but were less likely to report negative drug-
have noted that self-reports provided by alcoholic related consequences. Investigators have found that
subjects are by and large reliable and valid. There the likelihood and degree of discrepancies between
is, however, a fairly large degree of variability across client and collateral vary as a function of the relative
individuals. This appears to be related to the sensitiv- ability of the collateral to observe the drinking and
ity of the information being gathered, the nature and drug use behaviors of the client, the degree of cer-
specificity of the information against which the self- tainty concerning the accuracy of her or his reports,
reports are being validated, the level of sobriety at the degree to which the clients are concerned about
the time of the assessment, the time window to be issues of confidentiality, and the relative familiari-
covered by the information being collected, and the ty and frequency of contact the collateral has had
demand characteristics of the assessment setting and with the client (e.g., Gladsjo et al., 1992; Wilson &
purpose. Grube, 1994). It is also felt that the validity of self-
While a large body of evidence suggests that self- reports increases when clients expect independent
reports of substance use, negative consequences, and corroboration of their reports. This is the assumption
life events of alcohol- and drug-dependent clients are underlying the "bogus pipeline procedure," in which
valid and reliable (e.g., Cordingley, Wilkinson, & individuals are led to believe that the clinical staff
Martin, 1990; Gladsjo, Tucker, Hawkins, & Vuchi- has an independent and objective measure of sub-
nich, 1992; Miller, Crawford, & Taylor, 1979; So- stance use and severity of consequences. A number
bell & Sobell, 1986; Stasiewicz, Bradizza, & Con- of standardized measures, such as the Form-90 (Mill-
nors, 1997; Wilson & Grube, 1994), Fuller (1988) er, 1996) and the Comprehensive Drinker Profile
and Watson et al. (1984) have suggested that self- (Miller & Marlatt, 1984, 1987), include interview
reports alone are insufficient. The use of multiple protocols for use in collecting information from col-
sources (e.g., collateral informants), the assessment laterals.
of multiple systems (e.g., biochemical markers as
well as self-report), the use of "bogus pipeline tech-
Biological Measures
niques," and the establishment of an interpersonal
context that enhances rapport and motivation all ap- A second area of assessment that provides useful in-
pear to be important in maximizing the honesty of formation about the client's alcohol and drug use is
reports (Rankin, 1990). biological markers that can be derived from blood
and urine samples. A number of markers have been
used to identify those individuals who may be vulner-
Collateral Informants
able to the development of alcohol problems (e.g.,
A collateral informant, typically a spouse, parent, "trait measures"; Helander & Tabakoff, 1997) and
child, significant other, and/or friend of the client, is both chronic and more recent (e.g., "state") alcohol
often asked to provide information about the client's consumption (Allen, Fertig, Litten, Sillanaukee, &
alcohol and drug use as a way of both broadening Anton, 1997; Anton, Litten, & Allen, 1995; Coni-
204 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

grave, Saunders, & Whitfield, 1995). Anton et al. gencies involved in treatment for positive urine re-
(1995) suggested that biological measures are best sults, the frequency and nature of the urine collec-
seen as markers of alcohol consumption rather than tion protocol (e.g., random vs. fixed), and the
as markers of alcoholism. This view is also more con- method employed in collecting the urine samples
sistent with the application of such measures in clini- (e.g., supervised vs. unsupervised) (Harrison, 1995;
cal settings. Measures that have been evaluated have Maisto et al., 1990; Moran, Mayberry, Kinniburgh, &
included gamma-glutamyltransferase (GGT), aspar- James, 1995; Sherman & Bigelow, 1992).
tate aminotransferase (AST), carbohydrate-deficient The radioimmunoassay of hair (RIAH) is a more
transferrin (CDT), and mean corpuscular volume recent development in the screening process for
(MCV). Anton et al. (1995) provided a thorough re- identifying drug use. As blood circulates, it supplies
view of biological measures appropriate to assessing hair follicles; when drugs are present in the blood,
recent alcohol intake, acute intake, subacute intake, elements of the drugs are incorporated into and re-
and chronic intake, including information about sen- main in the hair as it grows. Thus, a strand of hair
sitivity and specificity, detection limits, ease of use, can provide a history of drug use and abstinence for
availability of assays, and the relative costs of each up to approximately a year; it may be possible to de-
measure. Given that each test has limitations around tect drug use for months after 2 or 3 days' use (Ver-
its specificity and sensitivity, it is typically recom- eby, 1992). To a large extent, the results of hair anal-
mended that multiple biological measures be used yses have been found to be positively related to the
together and in conjunction with self-report. results of both self-reports of drug use and urinalysis
Measures used to screen for drug use are derived in detecting cocaine, marijuana, and heroin use
from both urinalysis and hair analysis. These two ap- among substance-dependent clients (Hindin et al.,
proaches to assessment have different but comple- 1994; Magura, Freeman, Siddiqi, & Lipton, 1992).
mentary functions (Vereby, 1992): Urinalysis pro- The apparent agreement among hair analysis, urinal-
vides an index of more recent or concurrent drug ysis, and self-report measures of drug use suggests a
use, while hair analysis provides a long-term drug use high degree of convergence among these three indi-
history. Different laboratory methods used in assay- cators. It appears that use of the combination of self-
ing urine samples for drugs are available (e.g., thin- report, urinalysis, and hair analysis provides the most
layer chromatography [TLC], radioimmunoassay [RIA], accurate account of the client's recent drug use pat-
and enzyme immunoassay [EIA], including enzyme terns and history (Cook, Bernstein, Arrington, An-
multiplied immunoassay technique [EMIT]; Saxon, drews, & Marshall, 1995).
Calsyn, Haver, & DeLaney, 1988). There are typi- Within the context of clinical assessment, a par-
cally two types of tests conducted (Saxon et al., ticular biochemical marker or set of markers can be
1988). Screening laboratory tests are typically simple, used to corroborate self-reports of alcohol and/or
efficient, and inexpensive and are used as a first step drug use or may provide valuable independent infor-
in assaying large numbers of urine samples. The sec- mation when an individual is unable or unwilling to
ond test is confirmatory and is employed when the offer valid data about alcohol or drug use. Such
initial screening test is positive for drug use; these markers can also serve as methods to screen for prob-
confirmatory tests are usually more time-intensive lem alcohol or drug use, to determine whether a
and expensive. The preponderance of research on health problem is likely to be substance-related, and
the validity of self-report use by drug abusers has to monitor alcoholics and drug addicts for continued
been found to be positively correlated with the re- use or relapse during and after treatment (Allen et
sults of urinalysis (e.g., Harrison, 1995; Maisto, al., 1997). It is often difficult to decide which of the
McKay, & Connors, 1990; Zanis, McLellan, & Ran- measures should serve as the "gold standard." It is
dall, 1994). The variability in the validity of self-re- clear that self-report, collateral information, and bio-
port appears to be related to the recency of the drug logical measures have limitations. As noted above, it
use (e.g., a discrepancy may exist because the win- is recommended, where possible, to get measures
dow of measurement for certain drugs in urinalysis from all three of these sources. A common practice
is relatively short, whereas self-report may cover a is to assume a conservative stance and to use that
longer period of time), the social desirability of the source having the most negative outcome for the cli-
drug being used (e.g., marijuana vs. heroin), contin- ent as an index of alcohol or drug use. This approach
 ASSESSMENT STRATEGIES AND MEASURES IN ADDICTIVE BEHAVIORS 205

is similar to using the "lead" standard, which suggests pectation that the person will assume the label of
that clinicians use a "longitudinal, expert, all-data" alcoholic or addict as a prerequisite to change will
procedure in determining the client's clinical status lead to a negative reaction in the client. The negative
(Kranzler et al, 1997). feelings that may be engendered by such a confront-
Babor et al. (1990) and the Institute of Medicine ive intervention, in conjunction with a variety of
(1990) have provided a number of additional, more other potential barriers to treatment, may lead the
specific approaches to the clinical assessment process ambivalent client to pull away from rather than to
that are meant to enhance the validity of self-report. approach treatment.
A number of these are presented in table 11.2. The more traditional view has been challenged
recently by Miller and colleagues (Miller, 1983,
1989; Miller, Benefield, & Tonigan, 1993; Miller &
Interviewing Techniques and Style
Rollnick, 1991). A view more consistent with the cli-
Traditional views within the substance abuse field nician's task and the goal of increasing commitment
have suggested that the alcoholic and the drug to change has begun to emerge. In addition to a
abuser are to a large extent unmotivated, may be in number of more specific clinical approaches helpful
denial, and are resistant to looking at their behavior in minimizing therapist-generated barriers and en-
or to make changes. In order to deal with this con- hancing clients' commitment during the initial
stellation of traits, a confrontive stance has often been phases of the assessment process (e.g., viewing "de-
suggested to facilitate clients' acceptance of their prob- nial" or "resistance" not as stable personality traits
lem and their maximum benefit from treatment. A but as states that can be modified within the context
concern about this more traditional approach to cli- of the working alliance developed between the client
ents, especially as they are seeking treatment, is that and the clinician; reducing the emphasis on the indi-
a confrontive therapist style, the attribution of denial vidual's accepting the label addict or alcoholic; elicit-
and resistance to the alcoholic or addict, and the ex- ing client self-motivational statements which reflect
an increased level of cognitive awareness of the prob-
lems associated with the addiction, express an affec-
TABLE 11.2 Factors Enhancing the Reliability and tive concern about the problem, and evidence a
Validity of Self-Reports Among Substance Abusers need to make behavioral changes), the clinician's in-
terpersonal and therapeutic style is quite important.
The client is alcohol- and drug-free when interviewed.
A therapist style based on the principles of motiva-
Sufficient time has passed since last drink/drug use to tional interviewing and a nondirective, supportive ap-
allow clear responses.
proach has been found to generate less "resistance"
Confidentiality is assured.
from clients, to be more successful in engaging indi-
The setting is nonthreatening and nonjudgmental and en- viduals with alcohol problems in the therapeutic pro-
courages honest reporting.
cess, and to predict better outcomes than a more di-
The client does not feel pressure to respond in a particu- rective, confrontive style (Miller et al., 1993). In this
lar way.
regard, it has been found that alcoholic clients' per-
The client has no reason to distort reports (e.g., absti-
ception of the quality of the therapeutic relationship
nence being a condition of parole).
with the staff member conducting an initial assess-
The client is aware that corroborating information is avail-
ment is highly related to subsequent engagement in
able and will be collected (e.g., breath test, report of
spouse), and that this information from other sources treatment (Hyams, Cartwright, & Spratley, 1996).
will be used to confirm what he or she reports. Clients were more willing to engage if they felt they
Care is taken to ensure that questions are clearly worded liked the staff member, felt understood, felt at ease
and valid measurement approaches are used. with the worker, and felt very satisfied with the way
The assessment worker or therapist has a good rapport they were treated; if the worker was warm and
with the client. friendly with the client and expressed a high degree
The person administering the measures should be able to of understanding; and if the client had both a sense
communicate clearly with the client. of catharsis in the assessment session and an opportu-
Note. Adapted from National Institute on Alcohol Abuse and Alcohol- nity to ask questions. Clients were less likely to en-
ism (1990) and the Addiction Research Foundation (1994). gage if they felt criticized by the worker, if they felt
206 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

the worker treated them as "stupid," if they perceived problems: A guide for clinicians and researchers (pp.
the worker not as being warm and genuine, but as 1-9). Treatment Handbook Series, Number 4.
merely acting a professional role, and if they per- Bethesda, MD: National Institute on Alcohol Abuse
ceived the worker as withholding information. and Alcoholism.
Allen, J. P., Fertig, J. B., Litten, R. Z., Sillanaukee, P., &
Anton, R. F. (1997). Proposed recommendations for
research on biochemical markers for problematic
SUMMARY
drinking. Alcoholism: Clinical and Experimental Re-
search, 21, 244-247.
Assessment is the initial step in the longer term pro- Allen, J. P., & Mattson, M. E. (1993). Psychometric in-
cess of therapy and behavior change. Its functions struments to assist in alcoholism treatment planning.
extend well beyond information gathering. The hope Journal of Substance Abuse Treatment, 10, 289-296.
is that the clinician, through the assessment process, Allen, K. (1994). Development of an instrument to iden-
will motivate the individual, helping him or her tify barriers to treatment for addicted women, from
move from the point of contemplating the need to their perspective. International Journal of the Addic-
change, through the action phase of change, and tions, 29, 429-444.
into a productive maintenance of the desired new Alterman, A. I., McLellan, A. T., & Shifman, R. B.
behavior pattern. It is also hoped that the clinician (1993). Do substance abuse patients with more psy-
can use the results of the assessment to facilitate the chopathology receive more treatment? Journal of
Nervous and Mental Disease, 181, 576-582.
selection of the most appropriate treatment and in so
American Psychiatric Association. (1994). Diagnostic
doing maximize the chances of success for the client.
and statistical manual of mental disorders (4th ed.).
Washington, DC: Author.
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 12

Treatment Decision Making

and Goal Setting

Ronald M. Kadden
Pamela M. Skerker

For years, many substance abuse programs offered all thinking about the assignment of clients to treatment
comers a single type of treatment, in a kind of "one- is the burgeoning interest in health care cost contain-
size-fits-air' approach. Even though a variety of ap- ment. This has led to the rise of "managed care" and
proaches were available to the field, in many cases an essentially cost-driven determination to provide
all clients at a particular facility or clinic received the the least intensive care that will get the job done.
same treatment content, and for a standard length of Like practitioners in most other areas of health care,
time. substance abuse treaters were ill prepared for this de-
Several factors have been responsible for a shift velopment. They have been struggling to deal with
away from that approach. One is the interest in im- the conflicts that often arise between their judgment
proving treatment outcomes for substance abusers. of what seems clinically necessary and the desires (of-
This has led to research on typologies, to character- ten stated as requirements) of third-party payers for
ize subgroups of clients and develop guidelines for less treatment.
assigning them to the treatment modalities that would This chapter views treatment decision making
be the most beneficial for their particular needs. A and goal setting from the perspective of clinicians
related factor is the availability of treatments that can who see a steady stream of new clients, must deter-
be targeted to specific problems. A variety of cogni- mine their unique needs, and make rational deci-
tive behavioral techniques now exist that can be used sions so as to provide them with the most appropriate
to modify particular problem behaviors, and an in- treatment at the lowest possible cost. Clinicians are
creasing number of medications have been devel- now required to justify every clinical recommenda-
oped to treat various aspects of substance abuse (e.g., tion in terms of both level of care (e.g., inpatient vs.
craving). A third factor that has caused a shift in outpatient) and specific components of treatment. In

216
 TREATMENT DECISION MAKING AND GOAL SETTING 217

this chapter, we describe the elements of the deci- through in-house consultants. The full range of sub-
sion-making process. stance abuse care levels should be kept in mind dur-
We first deal with clinical considerations involved ing the process of assessment, and regardless of initial
in selecting the level of care, and then with the more placement, clients may move among the levels as
detailed considerations involved in determining the needs change or various goals are met.
specific aspects of care that constitute the treatment The assessment process may range from a brief
plan. Next, there is a brief review of research that screening in a primary-care office or at a workplace
has sought to provide an empirical basis for client- to a detailed evaluation in a specialty clinic, ideally
treatment matching and a description of a systematic by a clinician experienced in dual diagnosis. The lit-
plan that has been proposed for making decisions erature describes a number of different assessment
about levels of care. Having considered levels of care methods, some of which may be brief or self-admin-
and treatment planning, we then discuss the setting istered. When screening identifies a possible prob-
of goals for treatment and various means of actively lem, further assessment is indicated. This typically
engaging the client in the treatment process. We also involves a personal interview (structured or unstruc-
touch upon the issue of clients who present for treat- tured) by a clinician, laboratory toxicology screens,
ment of some other problem but are found to also and perhaps also self-administered questionnaires to
have a substance use disorder. The final sections are further identify the unique problems and needs of
concerned with monitoring clients' responses to the client (Miller, Westerberg, & Waldron, 1995).
treatment and utilizing that information to make The areas covered should include the types of sub-
midcourse modifications of the treatment plan. stances used, patterns of use, amounts consumed,
need for detoxification, triggers for use, prior treat-
ment, and methods used to achieve abstinence in the
UTILIZING ASSESSMENT DATA TO past. The assessment also covers other functional
SELECT APPROPRIATE LEVEL OF CARE problem areas such as family and/or employer pres-
sures, current legal problems, medical problems (in-
The Institute of Medicine (1990) identified four lev- cluding pregnancy and physical limitations such as
els of care —outpatient, intermediate, residential, and vision or hearing impairment), psychiatric diagnosis,
inpatient—all offering detoxification and rehabilita- perceptual or cognitive limitations, and demographic
tion services that may vary in length, intensity, set- information. The client's own perceptions and atti-
ting, and treatment modality. Outpatient treatment tudes toward his or her problems and limitations are
may offer individual, couples, family, or group ther- also elicited. For more comprehensive information
apy sessions ranging from weekly (or even less often) about assessment, please refer to chapter 11.
to a few hours several times a week. At the intermedi- An accepting, nonjudgmental attitude on the part
ate level, partial hospital treatment offers a structured of the clinician when gathering the data is vital for
program that meets from twice a week up to daily. It identifying problems and motivating the client to ac-
can be the first level of care for some clients, avoid- cept treatment recommendations. Upon completion
ing the need for hospitalization, or may serve as a of the initial assessment, the triage clinician typically
transition from more intensive residential or inpa- recommends the level of care and may offer sugges-
tient care to less intensive outpatient treatment. Eve- tions regarding the initial treatment plan, in consul-
ning partial hospital programs allow a person to meet tation with other program staff as necessary.
job, school, family, and other daytime commitments There are a number of variables to be considered
while in treatment. At the next level, residential pro- when deciding on the most appropriate level of care.
grams become the client's home for a week or so, Some of the considerations in decision making in-
providing a substance-free environment, rehabilita- clude the client's medical or psychiatric problems,
tion services, and a tightly knit, supportive commu- past relapses and treatment failures, severity of de-
nity in a nonmedical setting. Finally, inpatient treat- pendence, available support system, motivation or
ment programs are hospital-based (in general or resistance, and need for structure. Generally, the
psychiatric hospitals) and may provide intensive greater the severity of the problems, and the more
medical and psychiatric services through clinicians limited the client's personal and social resources, the
assigned to the substance abuse program, as well as greater the need for more intensive treatment (Alter-
218 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

man, O'Brien, & McLellan, 1991; Sobell, Sobell, & and transportation. The fear of going to a "bad part of
Nirenberg, 1988). town" may discourage some clients from accepting
Unstable major mental illness generally requires optimal treatment recommendations.
inpatient treatment, ideally in a dual-diagnosis unit. Often, what is recommended is beyond what the
Acute or severe medical conditions are also reasons client is prepared to undertake. The clinician must
to recommend inpatient treatment. Pregnancy, while understand that well-intended recommendations are
not automatically considered a problem, requires not always accepted right away. When meeting resis-
special attention not only to the mother's needs, but tance to recommendations, an alternative may be to
to the implications her substance use has on fetal compromise if the client is agreeable to a lower level
development, possibly indicating the need for more of care. This is usually preferable to completely los-
intensive treatment. Another possible concern relates ing the client to treatment. If a compromise cannot
to the client's ability to remain substance-free in an be negotiated, it is important to indicate to the client
unstructured, unsupervised setting. If not, or if the that the "door will be open in the future if you
assessment reveals repeated outpatient treatment fail- change your mind." Sometimes, the client will ac-
ures or lack of significant abstinent periods, then in- cept the treatment at a later date, after further relapse
patient treatment is indicated, with possible consider- or consequences have occurred.
ation of long-term residential follow-up if there are A substance abuse assessment may identify sui-
many severe and chronic problems. If the assessment cidal thoughts, which are not uncommon in this
indicates that a client lives among substance users in population. These should never be discounted or dis-
an area where alcohol and drugs are readily available missed as manipulative or insignificant. A thorough
and openly used, is impulsive, or is mentally re- mental status assessment must be completed, with at-
tarded, more intensive treatment is indicated because tention to the existence of suicidal intent, plan, le-
of its greater degree of structure and supervision. thality, and available supports. There may be a
When 24-hour care is indicated, a residential pro- dilemma in arranging for care if the available pro-
gram may be satisfactory for a week or so, if the acute gram^) cannot assure client safety as well as provide
care medical or psychiatric services of a hospital set- substance abuse treatment. Admission to an inpatient
ting are not required. However, if there is uncer- psychiatry unit may be necessary. At other times, the
tainty as to whether the intensity of residential ser- assurance that treatment will be provided, combined
vices is necessary (e.g., the client has a reasonably with a strong social support network, is enough for
strong support system), then a trial in a partial hospi- the client to contract for safety. This often requires
talization program may be initiated. In this setting, much time and energy by the clinician but is well
considerable structure, frequent monitoring, and worth the effort when it ensures both safety and ap-
fairly intensive treatment can be offered for sub- propriate treatment.
stance use and comorbid disorders that do not re- If a client meets the legal criteria for an emer-
quire 24-hour care. Clients who can make do with gency commitment (gravely disabled or a danger to
even less structure and less intensive monitoring can self or others), refuses treatment recommendations,
often be served well in an outpatient setting where and is unable or unwilling to contract for safety, then
they are seen for group, family, or individual treat- he or she must be admitted to inpatient psychiatric
ment one or more times a week. In these settings, treatment. When the legal criteria for involuntary
more reliance is placed on the client's ability to func- commitment are no longer met, the client will be
tion independently and on his or her support net- given the option of continuing voluntary treatment.
work.
Sometimes, treatment programs (or tracks within
programs) are geared toward specific populations UTILIZING ASSESSMENT DATA TO
(e.g., geriatrics, adolescents, monolingual). The DEVELOP INITIAL TREATMENT PLAN
availability of specialized treatment programs for
some populations may override other level-of-care Treatment planning is what individualizes a pro-
considerations. Additional factors not to be over- gram. The initial treatment plan may be viewed as a
looked are accessibility, the location of the program, prioritization of problems that need immediate atten-
 TREATMENT DECISION MAKING AND GOAL SETTING 219

tion, as opposed to longer term treatment needs. Im- cess should also identify behavioral deficits that
mediate needs include (a) detoxification, (b) stabili- would make it difficult to implement alternative
zation of acute medical problems, (c) stabilization of behaviors instead of substance use in high-risk situa-
acute psychiatric problems, and (d) elimination of tions (Sobell, Sobell, & Nirenberg, 1982). Informa-
hazardous substance use. If a client is physically de- tion obtained in the assessments regarding antece-
pendent on either alcohol, a benzodiazepine, or an dents, consequences, and behavioral deficits forms
opioid and is at risk of severe withdrawal symptoms the basis for the initial treatment plan. In their func-
(seizure, vital sign fluctuation, confusion, agitation), tional model, Miller and Mastria (1977) organized
he or she is admitted to a detoxification program. precipitants to use and consequences of use into five
Here, the substance (or a safe and legal substitute life problem areas comprising social, situational,
such as methadone or a benzodiazepine) is tapered emotional, cognitive, and physiological categories,
over the course of several days. Medical and/or psy- for purposes of treatment planning. Marlatt (1985)
chiatric problems are stabilized by means of ongoing classified relapse episodes as being intrapersonal, in-
consultations and treatment as necessary. In the ab- terpersonal, or environmental in nature and identi-
sence of complicating factors, detoxification can be fied subcategories of each of them. Regardless of the
done on an outpatient basis in close collaboration model that is used, it is imperative that all major ar-
with an experienced medical provider. This is appro- eas be assessed to ensure that clients recognize what
priate if a client is highly motivated, has a strong sup- triggers their substance use and what consequences
port system, and does not have known medical prob- are likely to follow it.
lems or a history of withdrawal complications such Annis and Davis (1989) described use of the In-
as seizures. When ambulatory detoxification is possi- ventory of Drinking Situations to assess a client's
ble, it may provide a means of extending limited fi- high-risk situations for drinking, and to establish a
nancial resources or insurance benefits. hierarchy of them from highest to lowest risk. In col-
After the initial, acute needs have been addressed, laboration with the client, detailed descriptions of
further treatment planning involves input from a typical high-risk situations and the client's usual re-
multidisciplinary team. As soon after admission as sponses to them are formulated. These detailed anal-
practicable, the client is assessed by various disci- yses suggest intervention strategies, provide a basis for
plines. The resulting multidisciplinary database will selecting treatment goals, and suggest benchmarks
follow the client throughout his or her treatment in for assessing treatment progress. In addition to high-
the facility and provides the basis for formulating the risk situations, treatment planning must also take into
initial treatment plan. Each discipline adds to the account client strengths, coping abilities, and envi-
database as ongoing assessments are done and re- ronmental resources, to ascertain which are adequate
sponses to treatment are observed. Disciplines rou- and which need development or enhancement to
tinely involved in this process are nursing, occupa- support changes in response to the high-risk situa-
tional therapy, psychology, counseling, social work, tions.
and medicine. Also included as appropriate are psy- It is well accepted that involving the client in
chiatry, various medical specialties, dietary, dentistry, treatment planning is essential so that it is truly indi-
and clergy. vidualized. The plan is then more likely to be realis-
A clinician in solo outpatient practice, without tic and attainable, will provide the client with a sense
access to a multidisciplinary team, should assess each of control over his or her treatment (Sobell et al.7
major area and develop an appropriate treatment 1988), and is likely to engender greater commitment
plan. Consultation or referral may be needed for ar- to and involvement in the treatment process (Mill-
eas beyond the practitioner's scope of practice. er & Mastria, 1977). Client involvement can also fos-
The initial assessments should attempt to identify ter identification of the needs that were being met
precipitating events ("triggers") that are likely to lead by the use of substances; then, the client and the
the client back to substance use, as well as the usual therapist together can usually come up with a num-
supporting consequences that would reinforce sub- ber of alternative ways to meet those needs without
stance use once it occurred and make repeated use having to resort to substance use (Miller & Pecha-
in similar situations more likely. The assessment pro- cek, 1987).
220 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

CLIENT-TREATMENT MATCHING most consistent effect. Outpatients with greater anger

pretreatment reported more abstinent days and fewer
Research drinks per drinking day following motivational en-
hancement treatment (MET) than after cognitive be-
Although it is now commonplace to recommend the havioral treatment (CBT) and 12-step facilitation
tailoring of treatment to each client's specific needs, (TSF); those low in anger fared least well if treated
there is in fact little empirical support for doing so. in MET. This effect was observed at 1 year posttreat-
This section reviews the status of efforts to validate ment and again at 3 years (Project MATCH Re-
this idea and then considers the American Society of search Group, 1998). Two additional effects were ob-
Addiction Medicine (ASAM) plan for systematizing served at 1 year only. Outpatients with few or no
decision making about level of care. concomitant psychiatric problems had better out-
In recent years, there has been growing interest comes if treated in TSF than in CBT (Project
in aptitude-treatment interactions and examining the MATCH Research Group, 1997a). Aftercare clients
degree to which various treatments may have differ- with high levels of dependence on alcohol had better
ential effectiveness for certain individuals as a func- outcomes after TSF, while those with low depen-
tion of their personal characteristics (Snow, 1991). dence fared better if assigned to CBT (Project
In the alcoholism field particularly, there has been MATCH Research Group, 1997b). One effect was
interest in identifying patient characteristics that pre- evident only at the 3-year assessment: Outpatients
dict better (or worse) outcomes with various treat- whose social network provided greater support for
ment approaches. A number of the empirical patient- drinking had better outcomes after treatment in TSF,
treatment-matching studies that have appeared from while those with low network support for drinking
the early 1970s were reviewed in depth by Lindstrom fared better after treatment in MET (Project
(1992) and summarized by Mattson et al. (1994). MATCH Research Group, 1998).
Successful matching to cognitive behavioral inter- At present, all positive matching findings that
ventions has been found among clients with high have been reported in the literature must be re-
psychiatric severity or sociopathy (Kadden, Cooney, garded as promising hypotheses, rather than as practi-
Getter, & Litt, 1989); clients with less education, cal treatment assignment strategies. Before they can
strong urges to drink, and high anxiety (Rohsenow et be recommended for widespread clinical use, they
al., 1991); and clients who are able to identify their must be replicated under conditions of actual clini-
high-risk situations (Annis & Davis, 1989). Interac- cal practice. Furthermore, greater attention must be
tional group therapy (Brown & Yalom, 1977) is more paid to the "causal chains" which account for the
beneficial for clients low in psychiatric severity or relationships between patient variables and treatment
sociopathy (Kadden et al., 1989), and for clients with types (Longabaugh, Wirtz, DiClemente, & Litt,
low urges to drink, low anxiety, or good interperson- 1994), both to advance understanding of the match-
al skills (Kadden, Litt, Cooney, & Busher, 1992). ing process and to enable refinement of the treat-
Greater intensity of treatment appears to differen- ments provided, to maximize their effectiveness for
tially benefit those who are socially unstable (Petti- the clients who benefit from them.
nati, Meyers, Jenson, Kaplan, & Evans, 1993; Welte,
Hynes, Sokolow, & Lyons, 1981), high in psychiatric
ASAM Model
severity (Pettinati et al., 1993), likely to perceive an
external locus of control over what happens to them Given the more-or-less preliminary state of research
(Hartman, Krywonis, & Morrison, 1988), or behav- on matching, empirically based patient placement
iorally impaired due to drinking (Lyons, Welte, criteria do not yet exist. Nevertheless, the rapidly
Brown, Sokolow, & Hynes, 1982), although in some evolving health-care-financing situation demands
of these studies intensity and treatment modality that rational client placement criteria be developed,
were confounded. so that clients can be assigned to levels of care that
Project MATCH, a major multisite trial of match- will be effective for them but will not be more inten-
ing hypotheses, has recently begun to report its find- sive (read "expensive") than they require. As a result,
ings. Although data analyses are still ongoing, at pres- some efforts have been made to delineate systematic
ent it appears that matching to client anger is the patient placement criteria, although largely without
 TREATMENT DECISION MAKING AND GOAL SETTING 221

the benefit of empirical research findings that sup- by Glaser et al. (1984) for a "core-shell" model of
port their efficacy. treatment, in which clients are assigned to specific
The most widely known and utilized patient treatment modalities as well as to levels of care. Un-
placement criteria are those developed by the Ameri- der this model, a "core" assessment unit would evalu-
can Society of Addiction Medicine (ASAM; Hoff- ate all incoming clients and refer them to an appro-
man, Halikas, Mee-Lee, & Weedman, 1991). They priate level of care, selecting from among the
include six dimensions for specifying the severity of treatment programs, providers, and modalities that
clients' alcohol-related problems and four recom- constitute the "shell." Following their treatment, cli-
mended levels of care. The care levels include outpa- ents would return to the core for a follow-up assess-
tient treatment (fewer than 9 hours per week), inten- ment that would be used to construct success profiles
sive outpatient or partial hospitalization treatment for each treatment in the shell, thereby providing an
involving a structured treatment program of at least empirical basis for making future referrals to them.
9 hours per week, medically monitored residential Gartner and Mee-Lee (1995) advocated the de-
addiction treatment without the full resources of an velopment of universally applicable patient place-
acute care hospital, and medically managed inpa- ment criteria, perhaps based on the ASAM model, to
tient treatment in a hospital setting. The six client promote the use of individualized and cost-effective
dimensions that serve as the basis for making assign- treatment. They believe that broadly accepted place-
ments to one of the four levels of care are: (1) cur- ment criteria would provide a degree of standardiza-
rent state of intoxication and the potential for life- tion throughout the field that would make it easier
threatening withdrawal symptoms; (2) biomedical to identify active treatment ingredients, identify gaps
complications that may require monitoring and/or in the continuum of care, evaluate treatment out-
care; (3) emotional or behavioral conditions that may comes, and assess the cost-effectiveness of treatment.
affect level of care; (4) degree of treatment accep-
tance/resistance; (5) relapse potential; and (6) and the
extent to which a client's daily environment may pro- SETTING GOALS FOR TREATMENT
mote relapse or facilitate recovery. These dimensions
are used to determine the initial assignment to a level
Treatment Goals for Substance Use
of treatment, and to guide reassignment as a client's
status changes during the course of treatment. The primary goal of treatment is to achieve absti-
The ASAM criteria have been criticized on a nence or at least to reduce the level of substance use
number of grounds (Book et al., 1995), and an at- (considerations regarding this choice of goals are
tempt to validate the psychosocial criteria (Dimen- discussed in the next section). If uncontrolled use
sions 3—6) did not find superior treatment outcomes continues, the client will be unable to benefit from
for alcohol- or cocaine-dependent clients who had treatment of either the substance use disorder or co-
been assigned to treatment on that basis (McKay, existing problems (Vuchinich, Tucker & Harllee,
Cacciola, McLellan, Alterman, & Wirtz, 1997). 1988). The first goals of treatment include identifica-
McKay et al. concluded that the criteria could bene- tion of the antecedents and consequences of sub-
fit from better definition of the client dimensions stance use, followed by acquisition of the coping and
and from the establishment of standardized methods social skills needed to establish sobriety. However, in
of assessment. They also suggested that the criteria some instances, it may be necessary to focus concom-
for inpatient treatment are too broad and recom- itantly on other pressing problems, for if these are
mended that the inpatient level of care be used only not resolved, then it may be unlikely that the sub-
to provide stabilization for poor prognosis clients stance use will ever change. This issue is considered
prior to their being entered into an intensive outpa- in more detail in a later section.
tient program. Treatment goals should be partitioned into a se-
In their overviews of the ASAM criteria, Gartner ries of short-term objectives that will provide the
and Mee-Lee (1995) and Morey (1996) suggested building blocks for developing necessary behaviors
that matching be done not only to levels of care, but and skills (e.g., identifying high-risk situations, refus-
also to specific treatment modalities within each ing offers to use drugs or to drink, managing crav-
level. This suggestion appears similar to a proposal ings, handling anger). The goals should be clearly
222 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

operationalized so that therapist and client will be appropriate for early-stage problem drinkers who
able to agree as to whether or not they have been have concerns about the difficulties being caused by
met, and they should be in small enough steps to their drinking (but not major life crises), have experi-
allow for both early and ongoing success experiences enced these problems for less than 10 years, do not
(Sobell et al., 1982). consider themselves alcoholic (but worry that alco-
The process of setting treatment goals was de- holism may develop), have no alcoholic close rela-
scribed by McCrady, Dean, DuBreuil, and Swanson tives, and have not been physically addicted. Miller
(1985), who provided guidelines and a structure for and Munoz recommended that a controlled-drinking
getting clients and clinicians working together to set goal not be pursued in the presence of medical con-
goals and monitor progress toward fulfilling them. traindications, such as liver disease, gastrointestinal
Their guidelines for goal development specify four problems, heart disease, other physical problems that
key elements: (a) Goals should be stated in terms of could be worsened by even moderate drinking, or
the client's own behavior, so that the responsibility pregnancy. A controlled-drinking goal is also not rec-
clearly lies with him or her, and the sense of accom- ommended for those who experience a loss of con-
plishment for successful fulfillment of them will be trol whenever they consume alcohol, have a history
the client's alone; (b) goals should be measurable, so of physical addiction to alcohol, take prescribed
that success, or degrees of partial success, can be medications that could interact with alcohol, or are
gauged unequivocally by the client, the treater, and currently abstaining successfully. Some of those who
significant others in the client's daily life; (c) good are candidates for a moderate-drinking goal might
goals entail a certain degree of challenge and risk, nevertheless benefit from an initial period of absti-
which will enhance the sense of accomplishment nence to repair their physical health, for psychiatric
upon fulfillment, although not so much risk that fail- reasons (e.g., severe depression, especially with sui-
ure is likely, since that would tend to undermine the cidality), or to achieve a period of stability before at-
treatment process; and (d) setting time limits for tempting moderate use.
completion of goals puts some pressure on clients to On the other hand, some clients for whom absti-
work toward fulfilling them and provides a frame- nence is recommended may nevertheless insist upon
work for projecting the accomplishment of long-term a moderate-drinking goal. For such people it may be
goals based upon a series of short-term successes that useful to agree upon a trial in which a mutually ac-
are designed to build upon one another in an escalat- ceptable amount of alcohol (e.g., two drinks) is con-
ing sequence. sumed every day without exception for a period of
several weeks. Many alcohol-dependent drinkers can-
not limit themselves in this way, but if the client is
Controlled/Moderate Use Versus
able to, then he or she may indeed be a candidate
Abstinence Treatment Goals
for a more extended trial of controlled drinking.
The issue of selecting an appropriate drinking goal Some clients who initially refuse a recommended
can be a difficult one. Although some clients will goal of abstinence may revert to it on their own at a
have come to the conclusion, prior to seeking treat- later time. For example, Hodgins, Leigh, Milne, and
ment, that they must not drink any longer, many Gerrish (1997) provided treatment-seeking chronic
others will harbor hopes that they can continue to alcoholics a choice of goals: either abstinence or re-
consume alcohol at some level (Pattison, 1985). Cer- duced drinking. They found that initially, the partici-
tainly, clients who are severely dependent should be pants were equally likely to choose abstinence or
dissuaded from hoping that they can ever drink safely moderation, but by the end of 4 weeks of treatment,
again, whereas heavy drinkers without evidence of two thirds of them chose abstinence (especially those
problems are likely candidates for a trial of moderate who were older or had more severe drinking histo-
or controlled drinking. But what about the large ries). Initial goal choice was not related to treatment
number of people who fall between these two poles? outcome, but those whose final choice was absti-
Miller and Munoz (1982) began their controlled- nence had better drinking outcomes in the year fol-
drinking self-help guide with criteria specifying those lowing treatment.
who may or may not be appropriate for a goal of Sanchez-Craig, Wilkinson, and Davila (1995) in-
moderate drinking. They indicated that this goal is vestigated safe limits for moderate drinking among
 TREATMENT DECISION MAKING AND GOAL SETTING 223

problem drinkers for whom moderation was a clini- order is substance-induced, it may remit with contin-
cally justifiable treatment goal. They found cutoffs of ued abstinence (Schuckit & Monteiro, 1988), but if
4 drinks per day and 16 drinks per week for men, it is an independent disorder it will require ongoing
and 3 drinks per day and 12 per week for women. attention.
Exceeding the per day limits was associated with Some clients lack the basic coping skills to han-
continuing problems. Sanchez-Craig et al. note that dle certain situations or thoughts which could in-
the specified cutoffs apply to the social problems as- crease their risk of relapse. These deficiencies may
sociated with excessive drinking, and not to the necessitate setting goals to enhance their ability to
health risks of long-term use. communicate with others, deal with criticism, refuse
Clients who wish to engage in moderate use of offers to drink or use drugs, or function better in
illegal drugs should be reminded of their illegal sta- close relationships. Clients may also need training to
tus and encouraged to consider lifestyle changes that combat negative thinking, cope with angry feelings,
would eliminate all illegal activities, as part of an make decisions, solve problems, and manage thoughts
overall recovery plan. Here again, a client may insist about drinking or using drugs (Monti, Abrams, Kad-
upon a period of experimentation before an absti- den, & Cooney, 1989).
nence goal is accepted. Some collateral problems may require attention
Since the late 1980s, a new approach has been early in the treatment process, along with efforts to
developed that focuses less on the level of drinking curb substance use, because the needs are so press-
or drug use than on reducing the harm caused by ing that sobriety cannot be maintained, even in the
them. This "harm reduction" approach originated in short run, without their being addressed. Others may
Europe as part of the effort to reduce the spread of be less intense or may require a lengthy period of
HIV and has since spread to the United States. It time to resolve and may therefore be regarded as
involves a public health perspective and thus tends long-term goals. The resolution of still other prob-
to focus on broad strategies rather than on specific lems may entail the uncovering of painful affect,
interventions for individual cases. Its goal is to mini- which in itself could pose a considerable relapse risk.
mize the harmful consequences of drug and alcohol It is usually better, if at all possible, to postpone the
use and, if possible, to reduce heavy use. Some of treatment of such problems until stable sobriety has
the steps fostered by this approach include needle been achieved, although in some cases a problem
exchange programs, designated-driver programs, pric- may be so intertwined with the substance use that
ing structures that provide incentives to consume they both must be tackled together, despite the atten-
low-alcohol beverages, and so on (Single, 1996). The dant risks.
harm reduction approach does not take a position
regarding the alternative goals of reduced use versus
Treatment Process Goals
total abstinence, although one assumption of the ap-
proach is that moderate drinking is an acceptable Certain fundamental assumptions are basic to the
outcome. very process of treatment and must be met to at least
some degree if anything useful is to be accom-
plished. These may best be viewed as therapist goals
Goal Setting in Other Areas
related to the viability and integrity of the treatment
of Life Functioning
process.
In addition to treatment goals related to substance Client motivation and cooperation with the treat-
use, there are often other problems (sometimes a ment, already referred to above, must be present to
considerable number of them) that require attention. at least some degree if the client is even to remain
Some of these problems may be associated with sub- in treatment, and if anything is to be accomplished.
stance use and may therefore put a client at risk for Beyond that bare minimum, several initial therapist
relapse. It is thus important to identify and attend to goals must be met if the treatment process is to be
such collateral problems in conjunction with sub- viable (McAuliffe & Albert, 1992). The therapist
stance abuse treatment. must recognize and acknowledge the client's discom-
Concomitant medical or psychiatric problems re- fort associated with being in treatment and must help
quire independent evaluation and treatment. If a dis- him or her to recognize that a certain amount of dis-
224 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

comfort is an integral part of the process of change. perhaps focusing attention on an issue peripheral to
Another short-term therapist goal involves efforts to substance use, to maintain a client's interest and en-
resolve client denial or minimization of problems, gagement in treatment.
ambivalence about change, and outright resistance Miller and Rollnick (1991) described motivation
to change. These are present in varying forms and as "a state of readiness or eagerness to change, which
degrees in most substance abuse clients. Further- may fluctuate from one time or situation to another.
more, some clients enter treatment with the notion This state is one that can be influenced" (p. 14).
that they have come to "get the cure," which seems Their "motivational interviewing" techniques are
to mean that they expect treatment will be a rela- particularly recommended for dealing with poorly
tively short-term process in which they can assume a motivated clients but can be helpful regardless of a
passive role. They must be helped to understand the client's motivation. Expression of empathy, rather
difficulty of the process (without at the same time than confrontation, is more likely to foster trust. Ex-
being discouraged from continuing) and must be pressing support for the client, indicating under-
prepared for active participation over the long term. standing of what he or she has gone through, and
Finally, treatment is predicated on the existence of expressing confidence in his or her ability to change
trust and an effective working alliance with the thera- will strengthen the therapeutic alliance and enhance
pist, the development of which must be among the client motivation. Resistance and ambivalence are
therapist's goals in any therapeutic encounter. In the common, and are best explored objectively and mat-
case of group therapy, additional treatment process ter-of-factly, to avoid arousing client defensiveness
goals involve socialization into the group (learning (Miller & Rollnick, 1991).
its norms) and developing sufficient trust among If the assessment indicates that there are external
group members so that significant issues can be obstacles such as lack of transportation, child care, or
broached openly in the group setting. finances to cover the cost of treatment, the clinician
should be familiar with and willing to suggest local
resources. If a person seeking treatment has no insur-
UTILIZING ASSESSMENT DATA TO ance and no entitlements, referral to the local social
ENGAGE THE CLIENT IN TREATMENT services department or to a government-funded treat-
ment program can eliminate the cost barrier. If a per-
It is important early in the assessment process to be- son has no transportation, some programs offer van
gin to clarify the relationship between troubling life service or bus tokens. There may also be marital or
problems and the use of substances. Schottenfeld family problems. Many of these problems can be ad-
(1994) suggested that the clinician help the client dressed through the use of a case management ap-
map out a "parallel chronology" that compares the proach, which involves arranging and coordinating
development of substance use and the course of the provision of needed clinical and supportive ser-
other life problems. Clients' dissatisfaction with their vices (Willenbring, 1996).
current situation, as well as discrepancies between Withdrawal presents another potential barrier to
their hopes or goals and current reality, is often the treatment. The discomfort of withdrawal symptoms
most effective driving force for change. It is therefore such as nausea, abdominal cramps, and muscle
essential to identify areas of dissatisfaction and disap- aches can lead to a resumption of substance use if
pointment, and to explore them and their relation- they go unmedicated, and therefore, an attempt
ship to substance use in some detail. The intent of should be made to reduce the discomfort as much
this review of problems is to heighten clients' aware- as possible.
ness of them and of the role of substance use as a A lengthy waiting period is a deterrent to engage-
causative and/or maintaining factor (Miller & Roll- ment in treatment. Ideally, admission should be
nick, 1991). available immediately after initial contact, to main-
It is necessary to accurately assess motivation and tain motivation. Frequently, a crisis motivates a per-
accept clients in their present motivational state, son to seek help, and once the problem subsides,
whatever that may be (Annis, Schober, & Kelly, some clients may no longer be interested in treat-
1996). This may mean settling for less ambitious ini- ment. If there is a waiting period, encourage the use
tial goals than the therapist believes are indicated, or of available supports (e.g., staying with family, daily
 TREATMENT DECISION MAKING AND GOAL SETTING 225

fellowship meetings) and consider referral to another cluded in all medical and psychiatric assessments,
program in the area. Some programs use clinician many cases will go undetected, and proper treatment
letters or phone calls to follow up initial appoint- will be delayed or not provided at all (Galanter &
ments, but care must be taken to not inadvertently Kleber, 1994; Schottenfeld, 1994). A study of Boston
breach confidentiality by leaving a message or an ob- area residents who actually believed they had alco-
vious return address. hol-related problems revealed that many of those
Other methods for decreasing client resistance in- seen by physicians had not even been asked about
clude encouraging family, friends, and case manag- alcohol use (Hingson, Mangione, Meyers, & Scotch,
ers to become involved in and understand treatment. 1982). A hospital study in Seattle determined that
This is especially beneficial when the presenting almost half of nontrauma patients who abused sub-
problem is a crisis, since significant others are often stances had not been identified as substance abusers
affected or already involved (Barr, 1990). Of course, (Dunn & Ries, 1997). Babor (1990) advised that pri-
clinical judgment must be used when considering mary-practice health care professionals actively seek
the involvement of others, since a client may feel to identify substance use problems in those whom
pressured by family or may perceive that the clini- they are treating by including a routine screening
cian is taking sides with family members. Cultural among their assessments. There are several brief
differences regarding family involvement should also screening tools, some of which can be self-adminis-
be considered. tered. Beyond primary care, other settings where de-
For those who have had no prior treatment, tection may take place include emergency depart-
McAuliffe and Albert (1992) encourage clients al- ments, intensive care units, medical specialties, and
ready in treatment to share experiences with new- mental health settings.
comers, to help them see that treatment is relevant Members of psychiatric consultation/liaison teams
and that their goals are attainable. Attending 12-step frequently encounter patients who are not seeking
programs in addition to treatment can also help substance abuse treatment and are unaware of a
maintain motivation for abstinence and for remain- problem with alcohol or drugs. This is an ideal set-
ing in treatment. ting for use of a screening procedure, and provides
an opportunity to educate the patient about sub-
stance abuse as a means of engaging him or her in
IDENTIFYING SUBSTANCE ABUSE treatment (Heather, 1995).
WHEN THE PRESENTING PROBLEM When there have been life-threatening conse-
IS SOMETHING ELSE quences, facing one's mortality can be a prime moti-
vating factor in seeking or accepting treatment. How-
Health care professionals must take the initiative to ever, motivation can decrease when the crisis has
address substance use, regardless of what may have been resolved. Therefore, in an acute hospital set-
brought a client to their attention. Caregivers cannot ting, substance use consultation should be available
assume that a person's appearance, age, or socioeco- as soon as a person's acute medical problems have
nomic status exempts her or him from substance been stabilized.
abuse. If no one asks a client about substance use, it At times, people self-medicate with prescription
may seem irrelevant. Some clients may be too narcotics or anxiolytics, rationalizing that it is not
ashamed, embarrassed, or fearful of the implications abuse if the medication is prescribed. Over time,
to raise the issue themselves. they may use more than one pharmacy or health
Substance abuse can be a major factor even when care provider to maintain an adequate supply. Re-
the reason for seeking treatment appears unrelated. peatedly seeking pain medication, especially from
Serious medical or psychiatric consequences which different sources, can be a warning sign of substance
result from substance abuse are often the reasons abuse. Requesting information from other care pro-
people seek treatment from health care professionals. viders may help to confirm what medications are be-
Cardiac, respiratory, and gastrointestinal problems ing obtained and for what reasons. However, confi-
and recurring infection, trauma, depression, and psy- dentiality laws prohibit a clinician from access to
choses are presenting problems that may be sub- vital information that may be in the hands of others,
stance-related. If a substance use screening is not in- unless the client authorizes the release of informa-
226 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

tion. At the time of initial screening, the clinician their antecedents (for specific examples and sample
must explain the importance of, and encourage the recording forms, see chapter 14 in this volume;
client to authorize, communication with other pro- Miller & Mastria, 1977). Clients' progress can also
fessionals that he or she has seen recently. be monitored through assignments to practice new
Substance abuse is a potentially serious problem coping skills or problem solving in their natural envi-
with numerous consequences that can impact vari- ronment. Careful monitoring of these assignments
ous areas of functioning. Therefore, health care pro- can provide considerable information regarding de-
viders should maintain a high index of suspicion of veloping competencies and remaining deficiencies,
substance use in the presence of warning signs and which may lead to changes in emphasis, or even to
indications from screening tools. changes in the overall focus of treatment. These eval-
uations are typically woven into the fabric of ongoing
therapeutic contacts, so that there is no clear delinea-
MONITORING RESPONSE tion between ongoing assessment and treatment.
TO TREATMENT Despite the obvious value of making treatment re-
sponsive to therapeutic process, little has been writ-
Treatment planning may be viewed as a continuous ten about specific techniques for monitoring client
process in which client successes and failures provide progress, and there are few measures particularly de-
the basis for course corrections (Sobell et al., 1982). signed for this purpose (Finney, 1995). One measure
Where there is little progress, the reasons are ex- that has been adapted to meet this need is the Situa-
plored, and the treatment plan is modified accord- tional Confidence Questionnaire. During the course
ingly. In areas of success, once new responses have of treatment, clients may be requested to complete
been adequately practiced in a number of different this structured assessment, in which they are asked
situations, therapeutic attention can be shifted away to indicate their confidence in their ability to resist
from them, and more effort can be focused on re- urges to drink in a variety of situations (Annis &
maining problems. Davis, 1989). This questionnaire provides a means of
There are several domains in which positive re- assessing changes in self-efficacy during treatment
sponses to treatment are desired. Certainly, reduc- and areas of continuing low confidence that will re-
tion or elimination of drinking and drug use is pri- quire additional work.
mary. Closely related to these are identifying and The validity of self-reports can be enhanced if cli-
controlling the antecedents that may precede alcohol ents know that the information they provide will be
and drug use and increasing the client's perceived verified. It is recommended that self-reports regard-
self-efficacy (i.e., his or her belief that he or she can ing alcohol and drug use be corroborated through
achieve and maintain recovery). In addition, there the use of a breathalyzer (to estimate blood alcohol
are often problems in other areas of functioning that content) and urine toxicology screens. Additional in-
could increase the likelihood of a relapse (Vuchi- formation may be obtained from significant others
nich & Tucker, 1996). Finally, improvements in in a client's life, such as spouse, roommate, close
overall level of client functioning and sense of well- friend, case manager, or probation officer. Participa-
being (physical, psychological, social activities, and tion in recommended activities can be verified by
social support) may play a significant role in main- having the client bring in physical evidence, such as
taining recovery (Longabaugh et al., 1994). There- a receipt, or a signature to verify attendance at AA or
fore, assessments of client progress must include the NA fellowship meetings.
presenting problems identified at intake as well as
maintain a broader focus on various aspects of overall
functioning. UTILIZING ONGOING
The monitoring of clients' responses to treatment ASSESSMENT DATA TO MODIFY
may take several forms. The most detailed informa- THE TREATMENT PLAN
tion usually comes from client self-reports to the
therapist during the course of treatment. Additional Information obtained through various forms of ongo-
information may come from daily recordings of urges ing assessment may cast new light on client prob-
to drink, actual drinking, ongoing problems, and lems, perhaps indicating the need for modification
 TREATMENT DECISION MAKING AND GOAL SETTING 227

of treatment strategies and goals. In their review of latt, 1985). Early in treatment, clients should be pro-
assessment and treatment planning for substance vided with guidelines for coping with the immediate
abuse, Sobell et al. (1988) presented a plan for moni- consequences of a relapse and for minimizing its du-
toring progress over the course of treatment, focusing ration and severity by getting rid of the alcohol/drug
on reasons for lack of progress and problems with the at once, removing themselves from the situation, get-
treatment plan. We believe that this assessment ting help (from a sponsor, a family member, or a
could also include evidence of progress as well as friend), and trying not to allow the feelings of guilt
lack of it, allowing a better evaluation of the overall that often follow a relapse (Marlatt, 1985) provide an
effectiveness of the treatment plan. The following list excuse for further substance use. After a relapse oc-
is an abbreviated version of the Sobell et al. evalua- curs, the therapist should assist the client to examine
tion questions: events prior to the relapse, to consider ways of avoid-
ing a recurrence in similar circumstances, and to
• Is the client engaging in/refraining from the be- identify more effective coping behaviors that could
haviors that are the focus of clinical attention? be utilized in the future (McCrady et al. 1985). This
• Were the antecedents/consequences of the process is likely to lead to a modification of the treat-
problem behaviors correctly identified? ment plan that will strengthen coping abilities in ar-
• Were client strengths and resources correctly
eas of deficiency. The exact changes in the plan will
identified?
• Does the client have adequate support in his or depend upon the nature of the relapse situation and
her environment? upon the therapist's and client's joint assessment of
• Are the treatment goals appropriate? Were sub- the weaknesses the relapse revealed. Similar princi-
goals identified in sufficiently small steps and ples also apply to managing continued recurrences
of gradually increasing difficulty? of other problem behaviors addressed by the treat-
• Are the treatment strategies working? Does it ment plan.
appear that some treatment techniques are
more appropriate than others with this client?
Are they being properly applied by the therapist
and by the client? SUMMARY
• Does the client understand the reasons why he
or she is doing well or experiencing continued
problems? In this chapter, we have provided an overview of con-
• Are the client's problems, or their conse- siderations typically involved in initial decision mak-
quences, serious enough to motivate the client ing about level of care, goal setting, and treatment
to change? planning, as well as monitoring the course of treat-
ment and making midcourse adjustments. These are
Questions of this sort could be incorporated into summarized in figure 12.1. After assessment of sev-
scheduled periodic reviews of each case to identify eral key areas, a decision is made regarding the most
areas of strength and weakness in the treatment plan. appropriate level of care. This decision may also
Perhaps the most common reason for modifying have to take into account the availability of needed
treatment plans is the occurrence of persistent re- clinical resources in the geographic area as well as
lapses. It has been recommended that relapse epi- limitations that may be imposed by third-party pay-
sodes be viewed as learning experiences, and that the ers. After the level of care has been determined, the
events preceding and following the relapse be care- specific therapeutic interventions within that level of
fully analyzed to provide a basis for strengthening be- care must be selected. This selection will involve rec-
haviors that would reduce the likelihood of a re- ommendations by the treatment provider and should
currence under similar circumstances (Miller & include negotiations with the client based on his or
Mastria, 1977). her goals and expectations about treatment. Once
It is important to help the client understand that the treatment plan has been initiated, ongoing assess-
relapses are a common occurrence that can be ment of progress and the occurrence of problems
viewed as an error made in the natural course of the may necessitate changes in the interventions or, in
learning process, rather than as a sign of failure or a some cases, perhaps a different level of care. Adjust-
reason to give up treatment and abandon hope (Mar- ments in the treatment plan are likely to occur sev-
228 CASE IDENTIFICATION, ASSESSMENT, AND TREATMENT PLANNING

Assessments

Substances of choice
Quantity/frequency of use
Pattern of use
Triggers for use
Client motivation
Client limitations
Social supports
Treatment history
Comorbid psych problems

Constraints imposed
by managed care,
Triage
insurance, or public
assistance, and by
Decision about level of care
availability of
treatment programs

Treatment Planning
Client expectations
Specific treatment needs of and golas
particular client

Treatment

Implementation of treatment
plan

Ongoing Monitoring

Ongoing assessment and

adjustments to plan during the
course of treatment

FIGURE 12.1 Key elements of treatment decision making.

eral times over the course of treatment, regardless of for practitioners to provide outcome data for their cli-
its success. entele, it is anticipated that a body of knowledge will
Many of these aspects of clinical decision making gradually be amassed that will provide better infor-
are based on clinical experience, often without the mation on the efficacy of current treatment-planning
benefit of empirical validation. As the demands grow practices and an empirical basis for improving upon
for treatments that have demonstrated efficacy, and them.
 TREATMENT DECISION MAKING AND GOAL SETTING 229

A C K N O W L E D G M E N T S The writing of this chapter Finney, J. W. (1995). Assessing treatment and treatment
was supported in part by NIAAA grant R01-AA09648, to processes. In J. P. Allen & M. Columbus (Eds.), As-
Ronald Kadden, Principal Investigator. The authors sessing alcohol problems. A guide for clinicians and
wish to thank Jaime Skerker for her helpful comments researchers (pp. 123-142). Bethesda, MD: National
on an earlier draft of this- chapter. Institute on Alcohol Abuse and Alcoholism.
Galanter, M., & Kleber, H. (1994). Preface. In M. Ga-
lanter & H. D. Kleber (Eds.), The American psychiat-
Key References
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Marlatt, G. A., & Gordon, J. R. (Eds.). (1985). Relapse status of patient placement criteria in the treatment
prevention: Maintenance strategies in the treatment of substance use disorders: Treatment Improvement
of addictive behaviors. New York: Guilford Press. Protocol Series 13. Rockville, MD: Center for Sub-
Miller, P. M., & Mastria, M. A. (1977). Alternatives to stance Abuse Treatment.
alcohol abuse: A social learning model. Champaign, Glaser, F. B., Annis, H. M., Skinner, H. A., Pearlman,
IL: Research Press. S., Segal, R. L., Sisson, B., Ogborne, A. C., Bohnen,
E., Gazda, P, & Zimmerman, T. (1984). A system of
health care delivery (Vols. 1-3). Toronto: Addiction
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treatment matching hypotheses. In D. M. Dono- Monti, P. M., Abrams, D. B., Kadden, R. M., &
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Hynes, G. (1982). Variation in alcoholism treatment search World, 20, 36-44.
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(pp. 201-279). New York: Guilford Press. F., & Evans, B. D. (1993). Inpatient versus outpa-
Mattson, M. E., Allen, J. P., Longabaugh, R., Nickless, tient treatment for substance dependence revisited.
C. J., Connors, G. J., & Kadden, R. M. (1994). A Psychiatric Quarterly, 64, 173-182.
chronological review of empirical studies matching Project MATCH Research Group. (1997a). Matching
alcoholic clients to treatment. In D. M. Donovan & alcoholism treatments to client heterogeneity: Proj-
M. E. Mattson (Eds.), Alcoholism treatment match- ect MATCH posttreatment drinking outcomes. Jour-
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proaches. Journal of Studies on Alcohol Monograph Project MATCH Research Group. (1997b). Project
(Suppl. 12), 16-29. MATCH secondary a priori hypotheses. Addiction,
McAuliffe, W. E., & Albert, J. (1992). Clean start: An 92, 1671-1698.
outpatient program for initiating cocaine recovery. Project MATCH Research Group. (1998). Matching al-
New York: Guilford Press. coholism treatments to client heterogeneity: Project
McCrady, B. S., Dean, L., DuBreuil, E., & Swanson, S. MATCH three-year drinking outcomes. Alcoholism:
(1985). The problem drinkers' project: A program- Clinical and Experimental Research, 22, 1300-1311.
matic application of social-learning-based treatment. Rohsenow, D. }., Monti, P. M., Binkoff, J. A., Leipman,
In G. A. Marlatt & J. R. Gordon (Eds.), Relapse pre- M. R., Nirenberg, T. D., & Abrams, D. B. (1991).
vention (pp. 417-471). New York: Guilford Press. Patient-treatment matching for alcoholic men in com-
McKay, J. R., Cacciola, J. S., McLellan, A. T., Alter- munication skills versus cognitive-behavioral mood
man, A. I., & Wirtz, P. W. (1997). An initial evalua- management training. Addictive Behaviors, 16, 63-69.
tion of the psychosocial dimensions of the American Sanchez-Craig, M., Wilkinson, A., & Davila, R. (1995).
Society of Addiction Medicine criteria for inpatient Empirically based guidelines for moderate drinking:
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Assessing and treating psychological dependence. ism, anxiety and depression. British Journal of Addic-
Journal of Substance Abuse Treatment, 4, 73-77. tion, 83, 1373-1380.
Miller, W. R., & Rollnick, S. (1991). Motivational inter- Single, E. (1996). Harm reduction as an alcohol-preven-
viewing: Preparing people to change addictive behav- tion strategy. Alcohol Health and Research World,
ior. New York: Guilford Press. 20(4), 239-243.
Miller, W. R., Westerberg, V. S., & Waldron, H. B. Snow, R. E. (1991). Aptitude-treatment interaction as a
(1995). Evaluating alcohol problems in adults and framework for research on individual differences in
adolescents. In R. K. Hester & W. R. Miller (Eds.), psychotherapy. Journal of Consulting and Clinical
Handbook of alcoholism treatment approaches: Effec- Psychology, 59, 205-216.
tive alternatives (2nd ed., pp. 61-88). Boston: Al- Sobell, L. C., Sobell, M. B., & Nirenberg, T. D. (1982).
lyn & Bacon. Differential treatment planning for alcohol abusers.
 TREATMENT DECISION MAKING AND GOAL SETTING 231

In E. Mansell Pattison & Edward Kaufman (Eds.), Vuchinich, R. E., Tucker, J. A., & Harllee, L. M.
Encyclopedic handbook of alcoholism (pp. 1140- (1988). Behavioral assessment. In D. M. Donovan &
1151). New York: Gardner Press. G. A. Marlatt (Eds.), Assessment of addictive behav-
Sobell, L. C., Sobell, M. B., & Nirenberg, T. D. (1988). iors (pp. 51-83). New York: Guilford Press.
Behavioral assessment and treatment planning with Welte, J. W., Hynes, G., Sokolow, L., & Lyons, J. P.
alcohol and drug abusers: A review with an emphasis (1981). Effect of length of stay in inpatient alcohol-
on clinical application. Clinical Psychology Review, ism treatment on outcome. Journal of Studies on Al-
8, 19-54. cohol, 42, 483-491.
Vuchinich, R. E., & Tucker, J. A. (1996). Alcoholic re- Willenbring, M. L. (1996). Case management applica-
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A prospective analysis. Experimental and Clinical R. C. Rapp (Eds.), Case management and substance
Psychopharmacology, 4, 19-28. abuse treatment (pp. 51-75). New York: Springer.
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 IV

Treatment
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 13

Enhancing Motivation for

Treatment and Change

Carolina E. Yahne
William R. Miller

Imagine that a 15-year-old boy, Tommy, is sitting in working right, and that it's usually caused by drink-
your office with you. He says, "My parents are always ing. It kind of took me by surprise. I'm pretty healthy,
on my back. I can't even go out with my friends with- and I feel fine. But the doc thought I should talk to
out their wanting to know where I'm going, who I'm you." How would you proceed?
with, and when I'll be back. Now they find one joint An important issue here is what you believe about
in my drawer and they're off the wall. It's not like Tommy, Dr. Thompson, and Mr. Cervantes, how
nobody else my age does it. Most kids do booze or you think about the problems they bring. What do
weed. I wish they'd just leave me alone." How would your first reactions to these three people reveal about
you respond to Tommy? your underlying beliefs about motivation? There are,
In a second encounter, you listen to a 53-year-old after all, many different ways of thinking about
physician, Dr. Thompson, say, "I feel like I've been human motivation (see table 13.1), and how you
railroaded. My husband's been after me about my conceptualize motivation directly affects how you ap-
drinking at home, and now this self-righteous 'Im- proach change. Consider the following ways of think-
paired Physician Committee' tells me I have to come ing about motivation.
here and see you or lose my license. Well, who are you
to tell me about drugs and alcohol? Just what exactly
WHAT DO YOU BELIEVE
are your qualifications?" What would you say to her?
ABOUT MOTIVATION?
A third conversation is with a 24-year-old man, Mr.
Cervantes: "My doctor said I should come to see you.
Do you agree or disagree:
I had a routine physical because I'm in the Reserves,
and there was some problem with my blood test. The • Until a person is motivated to change, there is
doc said something about a warning that my liver isn't not much a practitioner can do.

235
236 TREATMENT

TABLE 13.1 Modifiability of Client Motivation

A client's motivation is not modifiable. Client motivation is modifiable.

The practitioner's behavior is irrelevant to a client's readi- The therapist's behavior in part determines a client's
ness to change. readiness to change.
Motivation is a characteristic or personality trait within Motivation is a process that happens between the client
the client. and the therapist.
Denial is the standard defense mechanism for people Readiness to change addictive behavior arises from inter-
with addiction problems. personal interaction.
Resistance is the client's problem. Resistance is a therapist skill challenge.
A practitioner with this view may think: "You're not A practitioner with this view may think: "I'm evoking
ready. You haven't bottomed out yet. Until you are mo- some resistance. I need to try a different approach.
tivated, there's nothing I can do to help you." What could I do to help increase this person's open-
ness to change?"
If the client is arguing with me, it is evidence of denial If the client is arguing with me, it is a sign I need to
and lack of motivation to change. shift strategies.
Contradictory beliefs about drinking are pathological and Ambivalence is a normal part of change.
reflect denial.
Motivation is a stubbornly stable pattern, consistent Motivation is a malleable process which can change
across situations. across situations.
Motivation is an individual characteristic. Motivation changes with the environment.

• The most significant aspects of human motiva- WHAT RESEARCH REVEALS

tion are unconscious. ABOUT MOTIVATION
• It usually takes a significant shock or crisis to
motivate a person to change. Studies from the past two decades have pointed to
• A person's readiness for change fluctuates over
new ways of thinking about clients' motivation for
time, sometimes rapidly.
change. Persons with substance use disorders often
• Motivation is an interpersonal interaction.
• Resistance to change arises from deep-seated terminate treatment early, continue to use substances
defense mechanisms. during treatment, or are noncompliant with the
• People choose whether or not they will change. stated requirements of the therapy, so that prac-
• Motivation for change requires hitting bottom. titioners are led to label such clients as resistant, de-
• Readiness for change involves a balancing of nying, and unmotivated. Provocative findings have
the pros and cons. challenged traditional notions that "denial" is a char-
• A person's motivation depends a lot on the situ- acteristic trait of people with substance use disorders,
ation. that it is the amount or intensity of treatment that
• Once a person is motivated to change, it is im- determines how much change will occur, that moti-
portant to act quickly.
vation is a trait that individuals bring or do not bring
• Creating motivation for change usually re-
to treatment, and that noncompliance is a function
quires confrontation.
• Denial is not a client problem, it is a therapist of the individual's character. Research has contrib-
skill problem. uted some fascinating pieces of the puzzle, and it is
a challenge to decide how to put them together.

What is it, in your opinion, that motivates people to

Natural Change
change? What do you think are the main motiva-
tional obstacles in treating addictions? What are your The work of James Prochaska, Carlo DiClemente,
greatest frustrations in trying to help clients to and their colleagues across three decades (e.g., Pro-
change? How do you currently go about trying to chaska & DiClemente, 1986) has highlighted a
motivate your clients? phenomenon once described as "spontaneous remis-
 ENHANCING MOTIVATION FOR TREATMENT AND CHANGE 237

sion"—that many, perhaps most, people who change six components frequently present in brief interven-
addictive behaviors do so on their own, with no for- tions that were found to be effective in altering drink-
mal treatment at all. Most smokers who have quit ing behavior. FRAMES is an acronym for the six key
did so unaided by health professionals. At any given components:
time, about 1 in 10 American adults show significant
problems related to their own drinking. When inter- Feedback. Effective brief interventions provide
viewed some years later, most people who had drink- clients with personal feedback regarding their in-
ing problems have resolved or at least substantially dividual status.
reduced them, and only a small minority have re- Responsibility. Effective brief interventions have
ceived formal treatment (Sobell, Sobell, & Toneatto, emphasized personal responsibility for change
1991). and the individual's freedom of choice.
What is going on here? Such "natural" change is Advice. Effective brief counseling has included a
common and appears by no means to be a spontane- clear recommendation or advice on the need for
ous accident. Rather, research suggests, change can change, typically in a supportive rather than an
be described as proceeding through the sequence of authoritarian manner.
predictable stages (Prochaska, DiClemente, & Nor- Menu. Often, a menu of different strategies for
cross, 1992). Furthermore, change that happens in change is offered, providing options from which
the context of psychotherapy appears to follow the clients may choose what seems suitable to them.
same course. This finding suggests that therapy may Empathy. Emphasis is placed on an empathic, re-
be facilitating what is fundamentally a natural pro- flective, warm, and supportive practitioner style,
cess of change (Sobell & Sobell, 1993). which is linked with more positive treatment out-
comes.

Brief Interventions Self-efficacy. Effective brief interventions rein-

force self-efficacy, the client's expectation that she
It has been known for some time that it is possible or he can change.
to enhance motivation for treatment (Chafetz, 1968)
and induce significant change in risky or problem
The Drinker's Check-Up
drinkers with just a session or two of counseling.
With impressive consistency, controlled trials of brief How would FRAMES look in practice? A Drinker's
interventions with problem drinkers have shown a Check-Up (DCU) was designed as an intervention to
significant reduction in alcohol use, compared with manifest the FRAMES elements (Miller & Sover-
the use by control groups receiving no intervention eign, 1989). It consists of an assessment followed by
(Bien, Miller, & Tonigan, 1993). Even as little as a single counseling session in which the client is
5-15 minutes of counseling has been found in a given feedback of findings in a empathic manner
multinational study to suppress heavy drinking (Miller & Rollnick, 1991). Evaluations of the DCU
(WHO Brief Intervention Study Group, 1996). have shown that it yields rapid reduction in drinking
Still more perplexing is a reasonably consistent behavior relative to the drinking behavior of control
finding from studies comparing brief intervention groups waiting 6-10 weeks for counseling (Miller,
with various intensities of treatment for alcohol prob- Benefield, & Tonigan, 1993; Miller, Sovereign, &
lems. Most such studies have found substantial re- Krege, 1988). Subsequent studies evaluated the out-
ductions in drinking in both groups, with little or no comes of alcoholism treatment with or without a
difference in efficacy between brief and more ex- single-session DCU upon admission, showing that
tended treatment. One interpretation of this finding drinking and related problems were substantially
is that certain critical conditions that trigger change suppressed by the DCU when added to inpatient
may be contained within both briefer and longer (Brown & Miller, 1993) or outpatient programs
treatment approaches. (Bien, Miller, & Boroughs, 1993). More recent clini-
cal trials have supported the effectiveness of a DCU
approach in counseling pregnant heavy drinkers
FRAMES
(Handmaker, 1993), treating heroin addicts (Saun-
Searching for such common elements, Miller and ders, Wilkinson, & Phillips, 1995), and providing
Sanchez (1994; Miller & Rollnick, 1991) identified secondary prevention with heavy-drinking college
238 TREATMENT

students (Baer et. al., 1992). The Project MATCH various dimensions, including their degree of thera-
Research Group (1993) selected the DCU as one of peutic empathy as defined by Carl Rogers—the
three treatments to be tested in a multisite random- ability to reflect accurately a client's meaning and
ized clinical trial which included extensive pretreat- emotion through nonintrusive "active listening"
ment and follow-up assessment. To provide some (Gordon, 1970). When client outcomes were subse-
comparability to the other two treatments—12-step quently revealed by follow-up interviews, it was dis-
facilitation (TSF) and cognitive behavior therapy covered that the degree of therapist empathy accu-
(CBT)—which were designed for 12 sessions over 12 rately predicted clients' drinking at 6 months (r =
weeks, the DCU was extended to 4 sessions offered .83) and 12 months (r= .67) after treatment. Even 2
at Weeks 1, 2, 6, and 12. The result was a manual- years later, therapist empathy still predicted clients'
guided motivational enhancement therapy (MET; drinking levels (r=.50). The more empathic the
Miller, Zweben, DiClemente, & Rychtarik, 1992) counselor, the more the client changed. Valle (1981)
developed specifically for Project MATCH. During similarly found that clients' relapse rates could be
the course of 12 weeks of treatment, clients randomly predicted from the extent to which their randomly
assigned to MET reported slightly (and significantly, assigned therapists manifested the interpersonal ther-
in this large sample) more drinking than TSF- and apeutic conditions defined by Rogers. Therapist be-
CBT-treated clients. From the end of treatment (3 havior was a better predictor of outcome than any
months) through follow-ups at 6, 9, 12, 15, and 39 client characteristic.
months, however, outcomes of the three treatments Further evidence on the impact of therapist skill
were virtually identical. Only when outcome was de- emerged from a study in which a single counseling
fined by continuous abstinence measures (e.g., time session was tape-recorded, and all therapist and client
to first drink) was there a significant difference, responses were classified by a therapy-coding system.
slightly favoring TSF over MET and CBT, which Patterson and Forgatch (1985) had previously shown,
did not differ from each other (Project MATCH Re- using this coding system, that the "resistance" level
search Group, 1997). of clients could be driven up and down within the
same session as counselors intentionally switched
back and forth between supportive/empathic and di-
Therapist Effects
rective/confrontive styles. In the subsequent study,
Another piece of the puzzle is found in the fact that problem drinkers' levels of all four resistance re-
clients' outcomes often differ substantially depending sponses were related to a single therapist response:
upon the therapist with whom they work (Najavits & confronting. Furthermore, the level of clients' drink-
Weiss, 1994). When one counselor resigned in a ing a year later was again predictable (r=.56, p<
drug abuse treatment program, the caseload was ran- .001) from the randomly assigned therapist's level
domly distributed among four other counselors. This of confrontation. The more the therapist had con-
situation offered an opportunity to study whether out- fronted, the more the client drank (Miller et al.,
comes are affected by the particular therapist a client 1993).
received by the luck of the draw. In fact, clients of
two counselors showed substantial improvement,
Client Compliance
those of a third counselor showed more modest
gains, and clients of the fourth counselor showed, on One more piece of the puzzle is found in what is
average, no change or deterioration on various out- often referred to as client compliance—the extent to
come measures (Luborsky, McLellan, Woody, which a client does what the therapist asks. It is a
O'Brien, & Auerbach, 1985). very common finding that in general, the longer cli-
A study of problem drinkers in outpatient treat- ents continue in treatment, the better they do. In
ment found similar wide variability in nine thera- these studies, however, the length of treatment is not
pists' success rates, ranging from 20% to 100% randomly assigned. Clients who stay longer are a self-
(Miller, Taylor, & West, 1980). This study also pro- selected minority who may differ in many ways (such
vided a clue as to at least one possible reason for the as motivation) from those who leave early. Those
variation. Via one-way mirror, the nine therapists who take their medication faithfully (even if it is a
were observed while counseling and were rated on placebo) also tend to have better outcomes (Fuller et
 ENHANCING MOTIVATION FOR TREATMENT AND CHANGE 239

al., 1986). Voluntary involvement in Alcoholics Anon- prophecies (Leake & King, 1977). Various approaches
ymous is also associated with better outcomes (e.g., have been developed for measuring client motiva-
Emrick, Tonigan, Montgomery, & Little, 1993). It tion, which may help the practitioner to decide
appears, in fact, that recovery from alcohol problems where to begin in treatment. Four measurement ap-
may be associated with the extent to which an indi- proaches are briefly described here.
vidual faithfully does something to get better (Miller,
Westerberg, Harris, & Tonigan, 1996). Successful
outcomes have also been linked to both the client's Decisional Balance
(DiClemente, Prochaska, & Gilbertini, 1985) and Benjamin Franklin had his own method for making
the therapist's (Leake & King, 1977) belief that the complex decisions, which involved competing moti-
client will succeed. vations. He drew a line down the middle of a page
and then spent time, sometimes several days, listing
Putting the Pieces Together the pros and cons and estimating their relative im-
portance or weights as a means of reaching a conclu-
Here, then, are some intriguing findings. Many peo- sion. He recommended this "moral or prudential al-
ple change addictive behaviors on their own without gebra" as an aid in decision making (Janis & Mann,
professional help, and the process of natural change 1977, p. 149). Two centuries later, Janis and Mann
appears to be similar whether it occurs in therapy or (1977) found that people who were asked four key
in the natural environment. Relatively brief interven- questions felt more secure later about decisions they
tions with FRAMES elements are significantly more had made:
effective than no intervention in reducing problem
drinking and appear to substantially improve the out-
1. What are the potential gains and losses for me
comes of subsequent treatment. What a therapist
in this choice?
does interpersonally, even within the context of a sin-
2. What are the gains and losses for others in this
gle counseling session, seems to exert a substantial choice?
and long-lasting influence on whether a client will 3. What are aspects of my self-approval or -disap-
get better or worse. The extent of improvement proval in this choice?
seems to be linked to a client's believing in and ac- 4. What are aspects of approval or disapproval by
tively trying a method of change. others in this choice (including criticism or ex-
One synthesis of these findings is that positive clusion from a group as well as being praised
change is a natural process that the therapist does or obtaining prestige, admiration, and re-
not own or originate but can facilitate. Enduring spect)?
change can be triggered by a combination of an
awareness that there is a problem and a belief that Participants in this research who completed such a
there is a way out, facilitated by a supportive and balance sheet procedure were less likely than con-
empathic therapeutic relationship. This can occur trols to experience postdecisional distress or regret.
even in a single session, which is good news because They were also better able to implement their deci-
the modal length of stay in substance abuse treat- sion. Helping a client to construct a decisional bal-
ment is short (Ellis, McCan, Price, & Sewell, 1992). ance sheet by simply drawing a line down the center
Change is usually engendered not by the therapist of a piece of paper and labeling one side "Pros of
pushing, confronting, or directing, but by her or his Drug Use For Me" and the other side "Cons of Drug
listening reflectively to the client and evoking the cli- Use For Me" is a simple way to begin exploring am-
ent's own motivation for change. bivalence and measuring motivation. (Note that this
balance sheet might be quite different from one drug
to another.) A slightly more complicated balance
MEASURING MOTIVATION sheet contains four columns. Such a decisional bal-
ance sheet might look like the one in table 13.2. The
Practitioners develop hunches about a client's level decisional balance sheet for Dr. Thompson, the phy-
of motivation or readiness to change, but these can sician at the opening of this chapter, might take the
be inaccurate and can easily become self-fulfilling form of the one found in table 13.3.
240 TREATMENT

TABLE 13.2 Sample Decisional Balance Sheet

Continue to smoke marijuana as before Quit smoking pot and hashish

Benefits Costs Benefits Costs

Relax. Smell bad at work. No strange odor. Feel nervous.

Forget about rape. Can't think clearly. Focus on tasks. Remember being hurt.
Go with the flow. Bad example for kids. Make my kids proud. Feel out of it.

Not surprisingly, the very act of constructing such or considering what to do; (d) the action stage, dur-
a decisional balance sheet can begin to influence ing which the person has settled on one or more
motivation, which is a dynamic state or process steps to take and begins implementation; and (e)
rather than a fixed trait. The balance sheet is also maintenance, which involves sustaining change. Re-
useful for the practitioner because it clarifies what lapse is also included as a normal part of the change
positive and negative expectations the client has process, in that most people do not maintain change
about drug use and change. It opens the door for on their first try and cycle through the stages sev-
discussion of alternative ways to achieve benefits that eral times before achieving stable change. The Uni-
the client is seeking from drug use. The decisional versity of Rhode Island Change Assessment (URICA)
balance sheet is a way to measure and explore ambiv- is a 32-item self-administered questionnaire for mea-
alence and motivation, to clarify the competing moti- suring these stages of change, with strong psycho-
vational factors, and to encourage the client to con- metric characteristics (McConnaughy, Prochaska, &
sider the possibility of change. Velicer, 1983). It can be used to ask about any prob-
lem area, including problems with alcohol or other
drugs.
Stages of Change
Other instruments have been designed to identify
Prochaska and DiClemente (1986) developed a and measure readiness for change by using the trans-
transtheoretical model positing progressive stages of theoretical model. A one-page, 12-item Readiness to
change (figure 13.1), with the idea that therapeutic Change Questionnaire (RCQ; Rollnick, Heather,
interventions should be matched to the client's level Gold, & Hall, 1992) taps three stages: precontempla-
of readiness. In simplest form, the stages are (a) pre- tion, contemplation, and action. It was developed for
contemplation, in which a person is not considering a medical population not seeking help with addic-
change, often because he or she does not perceive a tion, and therefore, the instrument avoids using prob-
problem or a need to change; (b) contemplation, in lem-oriented terminology. It can therefore be used
which a person may seesaw ambivalently between for quick administration in a busy health care setting.
changing and remaining the same, perhaps weighing Heather (1995) selected patients "not ready to
the costs and benefits as in the decisional balance change" as measured by the RCQ and found that
above; (c) preparation, where it is clearer that a brief motivational interviewing (designed to enhance
change is needed, and the person is getting ready motivation for change) resulted in a significantly

TABLE 13.3 Dr. Thompson's Sample Decisional Balance Sheet

Continue to drink as before Change my drinking

Benefits Costs Benefits Costs

Relax after work. Husband still bugging me. Husband more trusting. Feel tense.
Control own time. Risk losing license. Keep medical license. Lose autonomy.
Not care so much. Have to deceive. Not have to hide. Feel overwhelmed.
 ENHANCING MOTIVATION FOR TREATMENT AND CHANGE 241

FIGURE 13.1 Stages of change. From Prochaska and DiCli-

mente (1986).

greater reduction in drinking than did action-ori- test reliability and internal consistency for these
ented skills-based counseling. The author recom- scales. Other potentially important motivational vec-
mended that problem drinkers (or at least male tors include self-efficacy (DiClemente et al., 1985),
heavy drinkers on hospital wards) should be assessed outcome expectancies (Brown, 1985), specific pros
for their stage of change readiness. The question- and cons of change, and social support for use or
naire provides a short and convenient measure of abstinence (Longabaugh, Wirtz, & Clifford, 1995).
readiness to change which may be used in conjunc-
tion with brief, opportunistic interventions with ex-
Readiness
cessive drinkers who are not presenting primarily
with substance use concerns (Rollnick et al., 1992). Still simpler measures have been used to sample the
single construct of readiness for change. The Readi-
ness Ruler (see figure 13.2) is a simple scale that can
Motivational Vectors
be used to ask clients how ready they are for change
A third approach is to sample various dimensions of in a particular health behavior. The scale might be
motivation for change. The Stages of Change Readi- used, for example, to ask about the client's motiva-
ness and Treatment Eagerness Scale (SOCRATES) tion to change her or his use of each of several drugs.
is a 19-item paper-and-pencil measure designed spe- Such a visual analogue scale may range from 1 (not
cifically to assess motivation for change in problem ready to change) to 4 (unsure) to 7 (ready to change)
drinking or drug use. Whereas the URIC A asks to 10 (trying to change). The client indicates how
questions about "my problem," SOCRATES poses ready he or she is to quit or cut down on each of the
questions specifically about alcohol or other drug drugs simply by pointing to or circling a number on
use. Items of the SOCRATES were originally written the ruler.
to correspond with the stages of Prochaska and
DiClemente's transtheoretical model. A series of fac-
tor analyses, however, pointed to three underlying di- ENHANCING MOTIVATION
mensions rather than discrete stages: recognition
of problem, ambivalence, and taking steps toward Once motivation has been measured, what is the
change. Miller and Tonigan (1996) reported test-re- next step? Clients who are further along on readiness
242 TREATMENT

Using the ruler shown below, indicate how ready you are to make a change (quit or cut down) in your
use of each of the drugs shown. If you are not at all ready to make a change, you would circle the 1.
If you are already trying hard to make a change, you would circle the 10. If you are unsure whether
you want to make a change, you would circle 3, 4, or 5. If you don't use a type of drug, circle "don't
use" in the box at the right.

Circle one answer for each type of drug

Not Ready 1 Unsure 1 Ready to 1 Trying to or:

Types of Drugs to Change 1 1 Change 1 Change I don't use this
1 type of drug
1 2 3 4 5 6 7 8 9 10
Alcohol 1 2 3 4 5 6 7 8 9 10 Don't
Use
Tobacco 1 2 3 4 5 6 7 8 9 10 Don't
Use
Marijuana/ Cannabis 1 2 3 4 5 6 7 8 9 10 Don't
Use
Tranquilizers 1 2 3 4 5 6 7 8 9 10 Don't
Use
Sedatives/ Downers 1 2 3 4 5 6 7 8 9 10 Don't
Use
Steroids 1 2 3 4 5 6 7 8 9 10 Don't
Use
Stimulants/ Uppers 1 2 3 4 5 6 7 8 9 10 Don't
Use
Cocaine 1 2 3 4 5 6 7 8 9 10 Don't
Use
Hallucinogens 1 2 3 4 5 6 7 8 9 10 Don't
Use
Opiates 1 2 3 4 5 6 7 8 9 10
Don't
Use
Inhalants 1 2 3 4 5 6 7 8 9 10 Don't
Use
Other Drugs 1 2 3 4 5 6 7 8 9 10 Don't
Use
Not Ready 1 Unsure 1 Ready to 1 Trying to
to Change 1 1 Change 1 Change
1 1 1
1 2 3 4 5 6 7 8 9 10

FIGURE 13.2 Readiness Ruler.

for change (in the preparation, action, or mainte- FRAMES: Six Components of Effective
nance stage) may benefit from action-oriented ap- Brief Intervention
proaches focusing on skills and strategies for behavior
Here there are useful guidelines from research on
change. Taking this approach with clients who are
effective brief counseling, and from the acronym
less ready for change (in the precontemplation or
FRAMES discussed earlier. These six elements will
contemplation stage), however, is likely to elicit un-
now be expanded upon with regard to therapeutic
cooperative responses. When confronted with the
strategies.
need for change, for example, an ambivalent person
naturally responds with the other side of the deci-
sional balance. This response may be misinterpreted
Feedback
as "denial" or "resistance," but in fact, such responses
can practically be turned on and off by changes in The F in FRAMES is personalized feedback or
therapist behavior (Patterson & Forgatch, 1985). health-relevant information based on careful assess-
How can a therapist best respond when working with ment. Personalized feedback should not be confused
less ready clients? with educational information about the effects of al-
 ENHANCING MOTIVATION FOR TREATMENT AND CHANGE 243

cohol and other drugs on people in general, which hance outcome. Many studies of effective brief inter-
has been found to have little or no impact on sub- vention included, as an element of research, system-
stance abuse once it is established. Instead, clients atic follow-up interviews that may have contributed
are provided with personally relevant information to the achievement and maintenance of gains (cf.
based on an individual assessment. Such objective Bien et al., 1993; Miller & Rollnick, 1991).
personal feedback may include the results of labora-
tory tests, or a calendar on which are recorded days
Responsibility
of use, or measures of motivation as described above,
or the more comprehensive Personal Feedback Re- Conveying individual responsibility with a tone of
port (Miller, Zweben, DiClemente, & Rychtarik, trust and respect is another common element in ef-
1992) showing how an individual's scores compare fective brief intervention. This involves respectfully
with those of other people. Some practitioners teach reminding the client (and yourself) that she or he is
their clients how to calculate standard drinks and ultimately in charge, choosing whether and how to
how to use that calculation to calculate blood alco- make changes, and that no one else can take this
hol level. Other practitioners use carbon monoxide responsibility. This tone is very different from "You
readings with clients who smoke. Mr. Cervantes, the are to blame and you'd better shape up." Rather, a
client described in an opening vignette, had received responsibility message should convey "I respect you
feedback (liver function test values) which surprised as a capable adult who can and will make decisions
him. about your own future." It is up to the individual to
A key element of effective feedback is the client's decide what, if anything, to do with feedback. Fur-
readiness to hear it. How one presents feedback ap- thermore, whatever responsibility the client has al-
pears to have a potent effect on a client's ability to ready taken can be reinforced here: "I appreciate that
accept it. It can be helpful to ask a client's permis- you followed through on your doctor's suggestion to
sion to give feedback, which can help to pave the come back in."
way for taking it in, especially if it contains unex- Issues of informed consent also relate to client re-
pected aspects. Of course, the information should be sponsibility. Informed consent is also a key part of
explained clearly, but then it is helpful to listen re- rapport building. The informed-consent process in
flectively to the client's response to the feedback. A research and in treatment helps to remind both par-
practitioner might respond to a client's balking at ties that the client is the one responsible for choosing
feedback by reflecting, "It sounds like these test re- about her or his own life (Edwards & Yahne, 1987;
sults surprise you; they aren't what you expected." Yahne & Edwards, 1986). Clarifying the limits of
Feedback can trigger a kind of client self-reflection. confidentiality is also an essential part of informed
Sometimes practitioners confuse such feedback consent. By clarifying the ground rules and structur-
with giving the client their own opinions and impres- ing the interaction, the practitioner empowers the
sions of the situation. Provider impressions are not client to decide how much to disclose.
what is meant by objective feedback here. Feedback
should be unambiguous for learning to occur (Gold-
Advice
stein, Heller, & Sechrest, 1966). It should take the
form of information that the client can identify as Advice, particularly if offered quickly, can be a road-
accurate, unbiased, and clear. Initial evaluation is block to listening by stopping the client's momen-
one source of feedback, and another is systematic fol- tum in discussion (Gordon & Edwards, 1995). Yet
low-up over time. This can be particularly useful in there is also a time for offering a concise expert opin-
health care settings where people are seen periodi- ion, based on objective data and presented in a man-
cally for various concerns. A chart note to follow up ner that conveys respect for the client's ability to de-
by asking about a particular topic (such as smoking cide how or if to implement such advice. Clear and
or drinking) allows continued attention to a concern. respectful professional advice appears to be an impor-
Whereas a patient may not be ready to consider tant component in enhancing motivation to change
change at one time, readiness may be higher at a harmful lifestyles. The World Health Organization
later time. A client's knowledge that you will check Brief Intervention Study Group (1996) found that
back with her or him in a few months seems to en- after careful assessment, even relatively brief advice
244 TREATMENT

resulted in heavy-drinking men reducing their daily frontational strategies such as disagreeing, emphasiz-
alcohol consumption by 17% more than an unad- ing negative evidence, arguing, and persuading.
vised group. Confrontation elicits client resistance, which in turn
is a predictor of poor outcome, whereas accurate em-
pathy in the form of listening, reflecting, and refram-
Menu of Options
ing is associated with low levels of client resistance
Advice to change may be more likely to be carried (Miller et al., 1993; Patterson & Forgatch, 1985).
out if the client is offered a variety of change options, Thus, "resistance" from the client should be a signal
rather than a solitary solution. A menu of alternatives to the therapist to take a different approach (Gold-
also increases the client's perception of personal stein et al., 1966). In the opening vignette of Dr.
choice and control, which promotes intrinsic motiva- Thompson, an empathic practitioner might respond,
tion and can also foster optimism. One option is eas- "You feel somewhat insulted at being sent in to see
ily rejected, but presenting multiple options engages me, and you're wondering about my qualifications."
a client in the process of choosing among them. Fur- Similarly, an empathic practitioner might respond to
thermore, it can be helpful to consider a menu not Tommy by saying, "Sounds as if you feel kind of frus-
only of change methods, but also of change goals. trated by your parents' reactions."
For example, women in recovery, when interviewed Establishing empathy builds trust and rapport and
about types of services considered most helpful, provides a doorway through which to introduce more
ranked transportation assistance first, followed by difficult addiction issues (Rollnick & Bell, 1991). A
help obtaining food, housing, clothing, recreational less emotionally charged topic may be an easier start-
activities, on-site health care, and 12-step meetings ing point than the threatening topic of addictive be-
(Nelson-Zlupko, Dore, Kauffman, & Kaltenback, havior. It may also help to clarify the client's values
1996). and sources of self-efficacy, such as any recent suc-
cesses (e.g., losing weight, a child's good grades at
school, qualifying for financial assistance). When a
Empathy
practitioner readily celebrates small victories (a cli-
Therapeutic empathy creates an environment con- ent's showing a photograph of his child), the client
ducive to change, instills a safe sense of being under- may be more willing to explore ways to increase the
stood and accepted, and reduces defensiveness. We likelihood of further victories, including changing
believe that empathy may be the most crucial of the addictive behavior.
FRAMES components. It sets the tone within which Asking clients about the positive aspects of their
the entire communication occurs, and without it, the substance use is another way to develop understand-
other components may sound like mechanical tech- ing and put a client at ease (Saunders, Wilkinson, &
niques. Therapist empathy has reliably predicted cli- Allsop, 1991). Clients often come expecting to be
ents' change (or lack thereof) in drinking for as long judged, and asking, "I'd like to hear about some of
as 2 years after treatment (Miller & Baca, 1983). The the good things about your drinking" is an opener
nature of the practitioner-client relationship in early that may communicate to the client genuine interest
sessions, even in a single session, has predicted treat- in seeing the whole picture.
ment retention and outcome (Luborsky et al., 1985;
Tomlinson, 1967). Carl Rogers (1959) defined accu-
Self-Efficacy
rate empathy as skillful reflective listening that clari-
fies and amplifies the client's own experience and Self-efficacy is a specific form of optimism, a "can-
meaning, without imposing the practitioner's mate- do" belief in one's ability to accomplish a particular
rial (cf. Gordon, 1970). Such reflective listening is task or change. Helping a client to see his or her own
not the only component of effective brief interven- ability to make positive changes is crucial. To Mr.
tions, but it is a key component. Cervantes, a practitioner who wants to affirm self-effi-
Confrontational responses from a therapist, on cacy may say, "The abnormal liver test that your doc-
the other hand, tend to increase defensiveness and tor noted is almost certainly reversible. You can bring
diminish the client's readiness to consider change. it back to normal by changing your alcohol intake."
Empathy represents a conceptual opposite of con- Reminding a client of strengths and successes al-
 ENHANCING MOTIVATION FOR TREATMENT AND CHANGE 245

ready demonstrated—even small ones—can be use- size the unacceptability of one's current state ("Tear
ful in boosting a sense of personal efficacy: "You them down to build them up") have a rather dreadful
made it to this meeting with me today, despite many track record in fostering positive change.
obstacles, which tells me you can get things done Skillful reflective listening is fundamental in ex-
when you decide to." Asked to speak about the char- pressing empathy. When the therapist can accurately
acteristics of "good" counselors, clients said that their summarize the client's meaning from verbal and
counselors believed in them (Nelson-Zlupko et al., nonverbal communication, the client is more likely
1996). As one Albuquerque client expressed it to the to feel understood and, indeed, to develop self-under-
first author, "Thank you for believing in me until I standing. Within this context, there is nothing un-
was ready to believe in myself." usual or pathological about a person's experiencing,
simultaneously, both positive and negative aspects of
his or her own addictive behavior. Ambivalence is a
Motivational Interviewing
normal experience to be explored, rather than op-
Motivational interviewing (Miller, 1983) was origi- posed. Left unresolved, ambivalence can be immobi-
nally intended to be a prelude to treatment, to en- lizing.
hance client acceptance of and compliance with
professional help. Indeed, as shown by research re-
Develop Discrepancy
viewed earlier, there is good evidence that outcomes
of substance abuse treatment are substantially im- The second principle of motivational interviewing
proved by adding an initial motivational interview emphasizes the importance of developing within the
(Bien et al., 1993; Brown & Miller, 1993; Saunders client's awareness a growing discrepancy between the
et al., 1995). An unexpected but consistent finding, addictive behavior and more deeply held goals and
however, is that motivational interviewing is also as- values. This involves, in part, helping the client to
sociated with behavior change when used as a stand- become more aware of and to verbalize the negative
alone intervention. Even a relatively brief contact of consequences of his or her present course. We be-
a session or two often instigates change in addictive lieve that this is most effectively done by having the
behaviors. In fact, the less motivated a client is to client (rather than the therapist) make the argument
begin with, the greater may be the advantage in this for change. Through a variety of strategies, clients
approach (Heather, Rollnick, Bell, & Richmond, are encouraged to talk about what their current (ad-
1996). dictive) behavior is costing them and how it is harm-
Fundamental principles and practical procedures ing or inconveniencing them. This process can be-
for motivational interviewing have been described in gin with exploring the client's most central values or
detail elsewhere (Miller & Rollnick, 1991; Miller life goals and then asking the client to reflect on how
et al., 1992). The five basic principles of motivation- the addictive behavior fits into these hopes and
al interviewing outlined by Miller and Rollnick dreams.
(1991) overlap somewhat with the components of
FRAMES, the common ingredients of effective brief
Avoid Argumentation
interventions. Motivational interviewing is not so
much a set of techniques as it is a style or way of A third principle is that in general, it is unhelpful to
being with people, helping them to resolve ambiva- argue with clients. Confrontation elicits defensive-
lence and find within themselves the resources for ness, which in turn predicts a lack of change. It is
change. The principles of motivational interviewing particularly countertherapeutic for the therapist to be
are defined here briefly. arguing that there is a problem in need of change,
while the client argues that there is no real problem
or need for change. Though tempting, this is a sce-
Express Empathy
nario to be avoided. It is also worth observing that
Paradoxically, acceptance facilitates change. The discrepancy can be developed effectively without the
more a therapist can create an atmosphere of accep- client's ever accepting a diagnostic label. Arguing
tance, the more the client may be freed to change. about labels like alcoholic or drug addict or even
Conversely, confrontational approaches that empha- "you have a problem" tends to get in the way of
246 TREATMENT

change rather than to facilitate it. Some clients enter CONCLUSION

treatment apparently ready to change, and the prac-
titioner may begin to implement action-oriented ap- Coming full circle back to.Tommy, Dr. Thompson,
proaches. However, practitioners should also antici- and Mr. Cervantes, we have discussed many ways
pate that motivation may fluctuate during treatment. that a practitioner might enhance their motivation
Assessment of motivation can be done at regular, re- for treatment and change. After reading this chapter,
peated intervals during treatment. If motivation ap- have your responses to the three clients in the initial
pears to be decreasing, therapeutic strategies should vignettes shifted or expanded in any way? How might
shift from action-oriented to motivation-enhancing you respond to them now? Consider creatively com-
techniques. The therapist needs to shift rather than bining components of FRAMES and principles of
argue. A client's defensiveness or "resistance" is a sig- motivational interviewing to craft your own affirming
nal for the therapist to change strategies rather than responses such as:
to engage in combat.

"Tommy, you seem to be a young man who val-

ues independence and making your own deci-
Roll -with Resistance
sions. I'd like to hear more about what matters to
The fourth principle of motivational interviewing, you."
rolling with resistance, encourages the practitioner to
use momentum to good advantage, flexibly and cre- "Dr. Thompson, your marriage and practicing
atively. Consonant with the idea of avoiding argu- medicine are things you really care about, and it
mentation, seemingly resistant responses from the sounds like right now you are concerned that
client are met not with opposition but with accep- both are in jeopardy."
tance and an invitation to new perspectives. It may
be, in fact, that "resistance" is a misleading concep- "Mr. Cervantes, I admire you for taking your
tion here. It is less than surprising that an ambivalent health seriously. Not everyone does, you know.
person would express reluctance to change or doubts Maybe we should talk a little more about what
about abandoning present ways. This is nothing out the surprising news about the blood test means
of the ordinary and simply reflects part of the process for you. Would that be all right with you?"
of exploration as the client moves toward change.
There is a sense of turning responsibility for change
Enhancing motivation for treatment and change is
back to the client, who is viewed as a valuable re-
a constant challenge in health care and is perhaps
source in finding solutions to problems.
one of the most important parts of effective treat-
ment. We wish you creativity, patience, and enjoy-
ment in meeting that challenge with your own cli-
Support Self-Efficacy
ents.
A fifth and final principle of motivational interview-
ing encourages the therapist to support clients' self-
efficacy, the belief that one is capable of changing. Key References
A realistically optimistic belief in the possibility of
change can be a powerful instigator and motivator Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993).
for change. "She believed in me," clients often say Brief interventions for alcohol problems: A review.
Addiction, 88, 315-336.
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Heather, N. (1995). Brief intervention strategies. In R.
could do it, even when I didn't think I could." Ulti-
K. Hester & W. R. Miller (Eds.) Handbook of alco-
mately, it is the client who is responsible for choos- holism treatment approaches: Effective alternatives
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very real role for hope in this process. Given the Miller, W. R., & Rollnick, S. (1991). Motivational inter-
range of effective approaches available for changing viewing: Preparing people to change addictive behav-
addictive behaviors, such hope is warranted. ior. New York: Guilford Press.
 ENHANCING MOTIVATION FOR TREATMENT AND CHANGE 247

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Miller, W. R., Zweben, A., DiClemente, C. C., &
tions, 87, 743-754.
Rychtarik, R. G. (1992). Motivational enhancement
Saunders, B., Wilkinson, C., & Allsop, S. (1991). Moti-
therapy manual: A clinical tool for therapists treating
vational intervention with heroin users attending a
individuals with alcohol abuse and dependence. Proj-
ect MATCH Monograph Series, Vol. 2. Rockville, methadone clinic. In W. R. Miller & S. Rollnick
MD: U.S. Department of Health and Human Ser- (Eds.), Motivational interviewing: Preparing people to
vices and National Institute on Alcohol Abuse and change addictive behavior (pp. 279-291). New York:
Alcoholism. Guilford Press.
Najavits, L. M., & Weiss, R. D. (1994). Variations in Saunders, B., Wilkinson, C., & Phillips, M. (1995). The
therapist effectiveness in the treatment of patients impact of a brief motivational intervention with opi-
with substance use disorders: An empirical review. ate users attending a methadone programme. AcWz'c-
Addiction, 89, 679-688. rion, 90, 415-424.
Nelson-Zlupko, L., Dore, M. M., Kauffman, E., & Kal- Sobell, L. C., Sobell, M. C., & Toneatto, T. (1991).
tenback, K. (1996). Women in recovery: Their per- Recovery from alcohol problems without treatment.
ceptions of treatment effectiveness. Journal of Sub- In N. Heather, W. R. Miller, & J. Greeley (Eds.),
stance Abuse Treatment, 13(1), 51-59. Self-control and the addictive behaviours (pp. 198-
Patterson, G. A., & Forgatch, M. S. (1985). Therapist 242). Sydney: Pergamon Press.
behavior as a determinant for client noncompliance: Sobell, M. B., & Sobell, L. C. (1993). Problem drinkers:
A paradox for the behavior modifier. Journal of Con- Guided self-change treatment. New York: Guilford
sulting and Clinical Psychology, 53, 846-851. Press.
Prochaska, }. O., & DiClemente, C. C. (1986). Toward Tomlinson, T. M. (1967). The therapeutic process as
a comprehensive model of change. In W. R. related to outcome. In C. R. Rogers (Ed.), The thera-
 ENHANCING MOTIVATION FOR TREATMENT AND CHANGE 249

peutic relationship and its impact, (pp. 315-335). ers. American Journal of Public Health, 86, 948-
Madison: University of Wisconsin Press. 955.
Valle, S. K. (1981). Interpersonal functioning of alco- Yahne, C. E., & Edwards, W. S. (1986). Learning and
holism counselors and treatment outcome. Journal teaching the process of informed consent. Research
of Studies on Alcohol, 42, 783-790. In Medical Education: Proceedings of the 25th An-
WHO Brief Intervention Study Group. (1996). A cross- nual Conference (pp. 29-35). Washington, DC: As-
national trial of brief interventions with heavy drink- sociation of American Medical Colleges.
 14

Behavioral and Cognitive

Behavioral Treatments

Kathleen M. Carroll

Behavioral and cognitive behavioral treatments have "strict" behavioral interventions, where clients may
been among the most well defined and rigorously be provided incentives for desired behaviors such ab-
studied of the psychosocial treatments for substance stinence (e.g., Higgins, Budney, Bickel, & Hughes,
abuse and dependence, and they have a compara- 1993); to approaches where behavioral principles are
tively high level of empirical support across the ad- used in extinction paradigms for conditioned crav-
dictions. This chapter will review their origins, their ings for drugs (Childress et al., 1993); to cognitive
theoretical basis and application to substance use dis- behavioral approaches such as relapse prevention
orders, the major techniques associated with several (e.g., Marlatt & Gordon, 1985); coping-skills training
of these approaches, and their level of empirical sup- (e.g., Monti, Abrams, Kadden, & Cooney, 1989),
port. and other broad-spectrum approaches, such as the
community reinforcement approach (Hunt & Azrin,
1973), which combine behavioral principles with
THE BREADTH OF BEHAVIORAL cognitive medication; to purely cognitive approaches
AND COGNITIVE (e.g., Beck, Wright, Newman, & Liese, 1991), which
BEHAVIORAL TREATMENTS attempt to modify dysfunctional cognitions that may
underlie substance use.
It should be noted that behavioral and cognitive be- What these models have in common is a theoreti-
havioral treatments do not represent a single ap- cal basis in learning principles: Human behavior is
proach to treatment. Instead, these terms encompass largely learned, and basic learning principles can be
an extremely broad range of interventions, from applied to change human behavior. The fundamen-

250
 BEHAVIORAL AND COGNITIVE BEHAVIORAL TREATMENTS 251

tal assumptions of these approaches include the fol- would eventually lead to extinction of the condi-
lowing (Rotgers, 1996, p. 175): tioned response. The power of classical conditioning
was demonstrated in drug abuse by Wikler (1971,
1. Human behavior is largely learned rather than 1973), who confirmed that opioid addicts exhibited
being determined by genetic factors (although conditioned withdrawal symptoms upon exposure to
etiology does not necessarily dictate treat- drug paraphernalia. Today, classical conditioning
ment). theory is the basis of several behavioral approaches
2. The same learning processes that create prob-
to substance use treatment, such as cue exposure
lem behaviors can be used to change them.
(Childress, Ehrman, Rohsenow, Robbins, & O'Brien,
3. Behavior is largely determined by contextual
and environmental factors. 1992; Childress et al., 1993), described in more de-
4. Covert behaviors such as thoughts and feelings tail below.
are subject to change through the application Second, Skinner's work on operant conditioning
of learning principles. demonstrated that behaviors that are positively rein-
5. Actually engaging in new behaviors in the forced are likely to be exhibited more frequently.
contexts in which they are to be performed is The field of behavioral pharmacology, which has
a critical part of behavior change. convincingly demonstrated the reinforcing properties
6. Each client is unique and must be assessed as of abused substances in both humans and animals
an individual in a particular context. (Aigner & Balster, 1978; Bigelow, Stitzer & Liebson,
7. The cornerstone of adequate treatment is a
1984; Schuster & Johanson, 1974; Thompson &
thorough behavioral assessment.
Pickens, 1971); is grounded in operant conditioning
theory and principles. A wide range of behavioral in-
HISTORICAL ORIGINS terventions, including those which seek to provide al-
ternate reinforcers to drugs and alcohol or to reduce
reinforcing aspects of abused substances, are also
Early Development of Behavioral and
based on operant conditioning theory. Examples in-
Cognitive Behavioral Treatments
clude the Community Reinforcement Approach (CRA)
A distinction of behavioral and cognitive behavioral of Azrin and colleagues (1976); the work of Stitzer
treatments as applied to substance use disorders is and colleagues, which has demonstrated that metha-
that these approaches are solidly rooted in well-estab- done-maintained opioid addicts will reduce illicit drug
lished theories and principles of human behavior use when incentives such as take-home methadone
and are closely linked to other behavioral and cogni- are offered for abstinence (Stitzer, Iguchi, Kidorf &
tive behavioral treatments for a range of problems Bigelow, 1993); and the very effective incentive sys-
and disorders other than substance abuse. Thus, they tems developed by Steve Higgins and colleagues
contrast with treatments such as disease model ap- (Higgins, Budney, Bickel, Foerg, et al., 1994)—all of
proaches, which have developed solely within the which are described in more detail below.
field of substance abuse. Finally, Bandura's (1977) work on modeling,
which postulates that new behaviors can be acquired
through observational learning and performance, is
Behavioral Treatments
another cornerstone of behavioral approaches to sub-
Behavioral treatments have their roots in classical be- stance abuse and dependence. In particular, research
havioral theory and the pioneering work of Pavlov, on the acquisition of substance use during adoles-
Watson, Skinner, and Bandura (for excellent reviews cence consistently points to peer group modeling
and history, see Craighead, Craighead, & Ilardi, and influence (Kandel & Faust, 1975; see Kaplan &
1995; Rotgers, 1996). First, Pavlov's work on classical Johnson, 1992) as important factors. Many behav-
conditioning demonstrated that a previously neutral ioral and cognitive behavioral approaches include
stimulus could elicit a conditioned response after be- treatment modeling and rehearsal of more effective
ing paired repeatedly with an unconditioned stimu- coping strategies and behavioral alternatives to sub-
lus. Furthermore, repeated exposure to the condi- stance use. An example of the use of modeling in
tioned stimulus without the unconditioned stimulus cognitive behavioral treatment is the group coping-
252 TREATMENT

skills training approach developed by Monti and col- and mastery of skills through rehearsal, role playing,
leagues (1989). and extrasession homework tasks (Carroll, 1996).

Cognitive Behavioral Treatments

ETIOLOGY AND MAINTENANCE OF
Cognitive behavioral treatment (CBT), which is SUBSTANCE USE DISORDERS
closely related to and grounded in behavioral theory,
emphasizes the importance of the person's thoughts Behavioral and cognitive behavioral therapies con-
and feelings as determinants of behavior and reflects ceive of substance abuse as a complex, multideter-
the pioneering work of Ellis and Beck. CBT evolved mined behavior, with a number of etiological influ-
in part from dissatisfaction with strictly behavioral ences playing a role in the development of substance
theory and treatment and from observations that how use disorders. These may include family history and
the individual perceived and reacted to the relation- genetic factors (particularly for substance depen-
ships between his or her behavior and critical events dence as opposed to abuse) (Cadoret, 1992; see
was also an important determinant of behavior (i.e., Merikangas, Rounsaville, & Prusoff, 1992; Pickens et
the ABC model of emotion) (Meichenbaum, 1995). al., 1991); the presence of comorbid psychopathol-
In other words, the person's thoughts, feelings, and ogy (see Weiss, 1992); personality traits such as sensa-
expectancies are thought to mediate her or his re- tion seeking or sociopathy (see Clayton, 1992); and
sponse to the environment. A key concept in CBT is a host of environmental factors, including substance
reciprocal determinism, which emphasizes the inter- availability and lack of countervailing influences and
dependence of cognitive, affective, and behavioral rewards (see Brook, Cohen, Whitman & Gordon,
processes. 1992; Kandel & Logan, 1984). Overall, however, be-
In general, cognitive behavioral treatments are havioral and cognitive behavioral therapies em-
among the most widely used for the treatment of psy- phasize the reinforcing properties of substances as
chiatric disorders other than substance abuse. This central to the acquisition of substance abuse and de-
group of treatments have in common strategies pendence. Moreover, these risk factors are seen as
which help patients become aware of maladaptive consistent with behavioral theories of the acquisition
cognitions and "teach them how to notice, catch, and maintenance of substance use. That is, sub-
monitor, and interrupt the cognitive-affective-behav- stances may be abused because they are particularly
ioral chains and to produce more adaptive coping rewarding to particular individuals. Examples might
responses" (Meichenbaum, 1995, p. 147). include individuals with a family history of alcohol-
This strategy is also the basis of the wide variety ism, those with comorbid depression, those with a
of cognitive behavioral approaches to substance use high need for sensation seeking, those who watch
disorders. In particular, the work of Alan Marlatt and model family and friends use substances, and
and colleagues on relapse prevention (Chancy, those who live in environments devoid of alternative
O'Leary, & Marlatt, 1978; Marlatt, 1979; Marlatt & reinforcers.
Gordon, 1985) stands out in the development and Behavioral factors are also seen as central to the
application of cognitive behavioral theory to the maintenance of substance abuse and dependence
treatment of substance use disorders. Techniques once initiated. Operant conditioning factors are seen
which characterize this approach include the identi- as continuing to have an important role in the main-
fication of high-risk situations for relapse, instruction tenance of substance dependence, not only through
and rehearsal of strategies for coping with those situa- the positive reinforcing aspects of the abused sub-
tions, self-monitoring and behavioral analysis of sub- stance, but also through avoidance of withdrawal
stance use, strategies for recognizing and coping with symptoms for substances with significant tolerance
craving and thoughts about substance use, planning and withdrawal syndromes. Classical conditioning
for emergencies and coping with lapses, instruction may begin to play an important role in the develop-
in problem-solving strategies, and focus on lifestyle ment of conditioned craving and withdrawal, as well
balance (Carroll, 1996). Consistent with cognitive as in the environmental regulation of drug-taking be-
behavioral approaches for other psychiatric disorders, havior (Rotgers, 1996). Cognitive processes, particu-
this approach emphasizes exposure to, practice of, larly expectancies of substance effects (Goldman,
 BEHAVIORAL AND COGNITIVE BEHAVIORAL TREATMENTS 253

Brown, & Christiansen, 1987), are also seen as im- ditioned craving is reduced and eliminated over time
portant in maintaining substance abuse and depen- (Carroll, 1998).
dence (e.g., "I need cocaine to get through the day"). Similarly, one of the earliest approaches to the
Moreover, as the individual responds to a host of en- treatment of alcohol dependence, aversive counter-
vironmental, interpersonal, and intrapersonal con- conditioning therapies, was also based on principles
texts with substance use, continued substance abuse of classical conditioning. The underlying principle
and dependence are seen as becoming an overused, of these approaches was to pair an aversive experi-
overgeneralized, and maladaptive coping strategy. ence (electric shock, induced nausea, negative im-
Hence, by the time treatment is sought (usually ages) with drinking or drinking-related stimuli, thus
when the negative consequences of substance use seeking to make drinking a negative, rather than a
have achieved primacy over positive effects and con- positive, experience (see Wilson, 1978). Although
sequences), the individual may have few other cop- aversive counterconditioning therapies have been
ing responses remaining in his or her repertoire, and used for many years and with large numbers of sub-
his or her reference group is likely to be limited to stance users, well-controlled trials of their effective-
other substance-dependent individuals. ness have been infrequent (Childress et al. 1992).
Operant conditioning concepts are applied several
ways in behavioral and cognitive behavioral treat-
ments. A commonly used approach in behavioral
THERAPEUTIC CHANGE IN treatments is the application of positive incentives for
BEHAVIORAL AND COGNITIVE desired behaviors (such as abstinence) or negative in-
BEHAVIORAL TREATMENTS centives for undesired behaviors (such as continued
substance use or noncompliance). Examples of nega-
tive contingencies include detoxification and termi-
Assumptions About How People Change
nation from methadone maintenance treatment for
As noted above, behavioral and cognitive behavioral patients who continue to use illicit drugs (e.g., Mc-
approaches posit that the same principles that may Carthy & Borders, 1985) and contracts involving no-
be involved in the inception or maintenance of sub- tification of employers of the patient's cocaine abuse
stance abuse and dependence can be applied to for individuals who continue to use cocaine (e.g.,
change these behaviors. Anker & Crowley, 1982). Examples of positive con-
For example, principles of classical conditioning tingencies include the incentive system developed by
are a cornerstone of cue exposure approaches (Hodg- Higgins and colleagues to promote retention and ab-
son & Rankin, 1978). Several investigators have dem- stinence among cocaine abusers (Higgins et al., 1991;
onstrated that repeated exposure to stimuli previously Higgins, Budney, Bickel, Foerg, et al., 1994) and the
paired with substance use (e.g., handling drug para- use of available reinforcers within methadone main-
phernalia, watching videotapes of individuals prepar- tenance programs (e.g., methadone take-home privi-
ing and using the substance) in controlled laboratory leges, reduced frequency of clinic attendance, dose
settings has been associated with extinction of some changes) to reduce illicit drug use within methadone
conditioned responses to those cues, including de- maintenance programs (Stitzer et al., 1993).
creases in subjective craving (Childress, Ehrman, Operant conditioning principles are also are used
McLellan, & O'Brien, 1988; McLellan, Childress, several ways in cognitive behavioral treatments. First,
O'Brien, & Ehrman, 1986; Rankin, Hodgson, & through a detailed examination of the antecedents
Stockwell, 1983). Cognitive behavioral treatments and consequences of substance use, therapists at-
also invoke principles of classical conditioning as tempt to develop an understanding of why the pa-
they seek to decrease craving through helping the tient may be more likely to use in a given situation
patient to understand and recognize conditioned and to understand the role that the substance plays
craving, to identify his or her own idiosyncratic array in his or her life. This functional analysis of sub-
of conditioned cues, or triggers, for craving, to iden- stance use is thus used to identify the high-risk situa-
tify means of avoiding exposure to those cues, and to tions in which the patient is likely to use drugs and
learn strategies to cope effectively with craving when thus to provide the basis for learning more effective
it does occur, without using substances, so that con- coping behaviors in those situations. Second, the
254 TREATMENT

therapist attempts to help the patient develop mean- ment, to prioritize problems, to select the type and
ingful reinforcers alternate to drug use, that is, other sequence of interventions to be used, and to monitor
activities and involvements (relationships, work, hob- progress in meeting treatment goals.
bies) that serve as viable alternatives to substance use Thus, applying behavioral treatments effectively
and help the patient remain abstinent. Finally, a de- requires that the patient and therapist have a thor-
tailed examination of the consequences, both long- ough understanding of the following areas:
and short-term, of substance use is used as a strategy 1. What are the particular determinants of this
to build or reinforce the patients' resolve to reduce person's substance use? What is the severity of this
or eliminate their substance use (Carroll, 1998). person's substance use (intensity, quantity/frequency)?
Principles of modeling are also used in both be- What are his or her individual patterns of use (week-
havioral and cognitive behavioral treatments to help ends only, every day, binge use)? What are his or her
the patient learn and apply new behaviors, such as conditioned cues, or "triggers," for substance use?
how to refuse an offer of drugs by having the patient Does this person use the substance by herself or him-
participate in role plays with the therapist or other self or with other people? Where does this person
group members. That is, the patient learns to re- buy and use substances? Where does she or he ac-
spond in unfamiliar, but more adaptive, ways by first quire the money to buy drugs? What has happened
watching the therapist model those new strategies to (or within) this person before the most recent epi-
and then practicing those strategies within the sup- sodes of use? What circumstances were at play when
portive context of the therapy hour as well as outside the substance use began or became a problem? How
sessions. does this person describe the substance and its effects
Finally, principles of cognitive change (Beck, on him or her? What roles, both positive and nega-
Rush, Shaw, & Emery, 1979) are used in many ways. tive, does substance use play in this individual's life?
An assumption of the cognitive behavioral ap- In evaluating the environmental context of the in-
proaches is that recognizing, monitoring, and chang- dividual's substance use, therapists typically cover at
ing maladaptive or dysfunctional beliefs that play a least the following general domains:
role in maintaining substance use can also help re- a. Social. With whom does the individual spend
duce and eliminate substance use. Examples of this most of her or his time? With whom does she or he
approach include the work of Beck and colleagues use drugs? Does she or he have relationships with
(1991), which includes techniques such as conduct- those individual outside substance use? Does the
ing an analysis of the advantages and disadvantages individual live with someone who is a substance
of continued substance use versus discontinuation, abuser? How has the patient's social network
identifying and modifying drug-related beliefs, reat- changed since drug use began or escalated?
tribution of responsibility, thought stopping, and b. Environmental. What are the particular envi-
modifying black-and-white or catastrophic thinking. ronmental "cues" for this patient's drug use (e.g.,
money, alcohol use, particular times of day, particu-
lar neighborhoods)? What is the level of this person's
day-to-day exposure to these cues? Can some of these
Key Interventions in Behavioral and
cues be easily avoided? Which are "fixed" in the in-
Cognitive Behavioral Treatments
dividual's environment?
c. Emotional. Affect states commonly precede
Assessment Procedures
substance use or craving. These include both nega-
A thorough behavioral assessment is at the heart of tive (depression, anxiety, boredom, anger) and posi-
behavioral and cognitive behavioral treatments. As- tive (excitement, joy) affect states. Because many pa-
sessment is organized around a functional analysis of tients initially have difficulty linking particular states
the individual's substance use, which is simply an to their substance use (or do so, but only at a surface
exploration of substance use with respect to its ante- level), affective antecedents of substance use are typi-
cedents and consequences. Early in treatment, the cally more difficult to identify in the initial stages of
functional analysis plays a critical role in helping the treatment.
patient and the therapist to assess the determinants d. Cognitive. Particular sets of thought or cogni-
of the individual's substance use, to set goals for treat- tions also frequently precede substance use ("I need
 BEHAVIORAL AND COGNITIVE BEHAVIORAL TREATMENTS 255

to escape," "I can't deal with this unless I'm high," 3. What skills and strengths does the individual
"The hell with it," "I deserve to get high"). These have? What skills or strengths has the patient demon-
cognitions often have a sense of urgency. strated during any previous periods of abstinence?
e. Physical. Desire for relief from uncomfortable What is his or her coping style? Has he or she been
physical states such as withdrawal has been impli- able to maintain a job or positive relationships dur-
cated as a frequent antecedent of substance use. As- ing substance use? What family/social supports and
sessing the level of the individual's tolerance or with- resources may be available to bolster the patient's ef-
drawal symptoms is an essential step in planning forts to become abstinent? How does he or she spend
treatment, as it also indicates the need for medical time when not using drugs or recovering from their
evaluation and treatment (Carroll, 1998). effects? What was this person's highest level of func-
Standardized diagnostic and assessment instru- tioning before using drugs? What brought this person
ments that are useful in evaluating severity of sub- to treatment now? How motivated is this individual?
stance dependence in treatment settings include the Again, there are a variety of standardized instru-
Structured Clinical Interview for DSM-IV (SCID; ments available for assessing these areas, including,
Spitzer, Williams, Gibbon, & First, 1996), the Addic- for the assessment of motivation, the University of
tion Severity Index (ASI; McLellan et al., 1992), the Rhode Island Change Assessment (URICA; DiClem-
Form 90 (Miller & DelBoca, 1994), the TimeLine ente & Hughes, 1990) and the Stages of Change
Follow-Back (Sobell & Sobell, 1992), the Drinker Readiness and Treatment Eagerness Scale (SOCRA-
Inventory of Consequences (DrlnC; Miller, 1992), TES; Miller, 1992); for current level of substance-
the Cocaine Craving Questionnaire (Tiffany, Single- related coping skills, the Situational Competency
ton, Haertzen, & Henningfield, 1993), the Cocaine Test (Chancy et al., 1978), a role-playing instrument
Relapse Interview (McKay, Rutherford, Alterman, & intended to assess skill acquisition among alcoholics,
Cacciola, 1996), and biological measures including which has been modified for use with other popula-
the urine toxicology screen, breathalyzers, liver func- tions and settings (Abrams et al., 1991, Carroll, Nich,
tion tests. Frankforter, & Bisighini, in press); for self-efficacy
2. What skills or resources does the individual and confidence in high-risk situations (e.g., Condi-
lack, and what concurrent problems may be obstacles otte & Lichtenstein, 1981); and for level of social
to becoming abstinent? Has this person been able to and family support, the Important People and Activi-
recognize the need to reduce the availability of sub- ties Scale (IPA; Clifford & Longabaugh, 1991).
stances? Has the patient been able to recognize im-
portant conditioned cues? Has he or she been able
to achieve even brief periods of abstinence? Has he
Treatment Goals
or she recognized events which have led to relapse?
Has he or she been able to tolerate periods of craving Treatment goals in behavioral and cognitive behav-
or emotional distress without resorting to drug use? ioral treatments are highly individualized and typi-
Does he or she recognize the relationship of his or cally reflect a collaborative process between patient
her other substance use (especially alcohol) in main- and therapist (Morgan, 1996). Moreover, a marked
taining drug dependence? Are there people in the contrast between these treatments and traditional dis-
patient's social network who do not use or supply ease model approaches has been the nature of treat-
drugs? Does he or she have a concurrent psychiatric ment goals vis-a-vis substance use. Whereas tradi-
disorder or other problems (e.g., medical, legal, fa- tional models have stressed complete abstinence,
milial, employment) that might confound his or her behavioral treatments have encompassed risk reduc-
efforts to change behavior? tion goals as well as abstinence (Carey & Maisto,
Standardized diagnostic and assessment instru- 1985; Morgan, 1996; Rosenberg, 1993). However,
ments that evaluate clinically significant comorbid goals of moderation or risk reduction have been
problems among substance abusers include the more typical of behavioral treatments for alcohol use
SCID (Spitzer et al., 1996), the ASI (McLellan et disorders than among treatments for drug use and
al., 1992), the California Psychological Inventory So- dependence disorders, in part because of the illicit
cialization Scale (CPI-So; Megargee, 1972), and the nature of drug use, as well as the comparative risks
Beck Depression Inventory (BDI; Beck et al., 1961). and serious morbidities associated with HIV, tuber-
256 TREATMENT

culosis, and other medical complications of many tored closely and frequently, and the therapist takes
classes of drug use. an active stance throughout treatment.
In behavioral approaches, treatment goals are The "typical" structure of a given session varies
highly focused and depend on the nature of the spe- widely, depending on what type of behavioral ap-
cific treatment approach. For example, cue exposure proach is used. For example, in a "pure" contingency
and extinction approaches are intended primarily to management approach, the therapist and the patient
reduce reactivity to specific cues (e.g., cocaine para- might meet infrequently, or not at all, while the con-
phernalia) and may not generalize to other cues tingency is in place. Alternatively, the behavioral
(e.g., affect states) nor affect other substance-related contingency may be added to a full-spectrum treat-
problems (Childress et al., 1992). Similarly, in con- ment approach, encompassing supportive counsel-
tingency management approaches, researchers have ing, monitoring and feedback of urine toxicology or
generally demonstrated specificity of response to the breathalyzer screen results, pharmacotherapies, and
behavior that is reinforced or punished. For example, a wide array of other supportive services. More typi-
if abstinence is reinforced, substance use generally is cally, behavioral and cognitive behavioral sessions
eliminated or reduced; conversely, if group atten- take place within a regular, usually weekly, therapy
dance is reinforced, attendance is likely to increase, "hour." In broad-spectrum cognitive behavioral ap-
but changes in substance use may not be seen proaches, sessions are often organized roughly in
(Iguchi et al., 1996). In addition, behavioral treat- thirds (the 20/20/20 rule), with the first third of the
ments typically target a single behavior or group of session devoted to assessment of substance use and
behaviors; that is, contingency management proto- general functioning in the past week, as well as op-
cols would be expected to reduce substance use, but portunity for the patient to report current concerns
have little influence on other concurrent problems. and problems; the second third is more didactic and
However, abstinence associated with focused behav- devoted to skills training and practice; and the final
ioral treatments may lead to improvements in a num- third allows time for therapist and patient to plan for
ber of areas, such as reductions in psychiatric symp- the week ahead and discuss how new skills will be
tomatology and improved social functioning. implemented (Carroll, 1998). Practice of new skills
The goals of cognitive behavioral treatments tend outside sessions is generally seen as an integral part
to be somewhat broader than those of "strict" behav- of treatment in cognitive behavioral therapy.
ioral approaches, and the choice of treatment goals
will dictate the specific interventions implemented.
Major Techniques of the Treatments
For example, in broad-spectrum cognitive behavioral
treatments (e.g., Azrin, 1976; Monti et al., 1989), the Specific techniques vary widely with the type of be-
patient and therapist may select a wide range of tar- havioral or cognitive behavioral treatment used, and
get behaviors in addition to a treatment goal of absti- there are a variety of manuals and protocols available
nence or harm reduction, including improved social which describe the techniques associated with each
skills or social functioning, reduced psychiatric approach. A brief summary of the techniques and
symptoms, reduced social isolation, and entry into procedures typifying the major types of behavioral
the workforce. and cognitive behavioral approaches referred to
throughout this chapter follows.
Cue exposure approaches typically begin with a
Structure of Therapy Sessions
thorough assessment of cues, or stimuli, associated
Behavioral and cognitive behavioral treatments are with conditioned craving, and with the development
typically highly structured in comparison to other ap- of a hierarchy of cues. This is followed by repeated
proaches for substance use disorders. That is, these exposure to those cues (through actual exposure to
treatment approaches are typically comparatively or handling of a conditioned cue, videotapes, or im-
brief (12-24 weeks) and are organized closely around agery) in a laboratory or other controlled setting
well-specified treatment goals. There is typically an which prevents the patient from having access to the
articulated agenda for each session, and discussion substance. The patient's physiological and subjective
remains focused around issues directly related to sub- responses to the stimuli are typically assessed both
stance use. Progress toward treatment goals is moni- before and after each exposure session. Extinction of
 BEHAVIORAL AND COGNITIVE BEHAVIORAL TREATMENTS 257

craving associated with a specific stimulus typically abstinence, the value of the points earned by the pa-
takes place in 20 sessions or fewer (Childress et al., tient increases with each successive clean urine spec-
1993). imen, and the value of the points is reset back to its
An example of the techniques used in contingency original level when the patient produces a drug-posi-
management approaches would be those described by tive urine screen or does not come in for treatment.
Higgins and colleagues for their program (Budney & Cognitive behavioral approaches include a range
Higgins, 1998; Higgins & Budney, 1993; Higgins et of skills that foster or maintain abstinence. These typ-
al., 1991), which incorporates positive incentives for ically include strategies for (a) reducing availability
abstinence, reciprocal relationship counseling, and and exposure to the substance and related cues; (b)
disulfiram into a Community Reinforcement Ap- fostering resolution to stop substance use through ex-
proach (CRA; Sisson & Azrin, 1989) approach. The ploring positive and negative consequences of con-
Higgins strategy has four organizing features, which tinued use; (c) self-monitoring to identify high-risk
are grounded in principles of behavioral pharmacol- situations and to conduct functional analyses of sub-
ogy: (a) drug use and abstinence must be swiftly and stance use (see figures 14.1 and 14.2); (d) recogni-
accurately detected; (b) abstinence is positively rein- tion of conditioned craving and development of strat-
forced; (c) drug use results in loss of reinforcement; egies for coping with craving; (e) identification of
and (d) emphasis is on the development of rein- seemingly irrelevant decisions which can culminate
forcers that compete with reinforcers of drug use in high-risk situations; (f) preparation for emergen-
(Higgins & Budney, 1993). In this program, urine cies and coping with a relapse to substance use; (g)
specimens are required three times weekly. Absti- substance refusal skills; and (h) identifying and con-
nence, assessed through drug-free urine screens, is fronting thoughts about the substance. Material dis-
reinforced through a voucher system, where patients cussed during sessions is typically supplemented with
receive points redeemable for items consistent with extrasession tasks (i.e., homework) intended to foster
a drug-free lifestyle, such as movie tickets, sporting practice and mastery of coping skills.
goods, and the like, but patients never receive money Broad-spectrum cognitive behavioral approaches
directly. To encourage longer periods of consecutive such as that described by Monti and colleagues

Intensity
of Craving
Date Situation (Include Your Thoughts and Feelings) (1-100) Coping Behaviors Used

FIGURE 14.1 Self-monitoring form. Reproduced from Kadden et al., 1992.

258 TREATMENT

Trigger Thoughts and Behavior Positive Negative

Feelings Consequences Consequences

(What sets me (What was 1 thinking? (What did 1 (What positive (What negative
up to use?) What was 1 feeling?) do then?) thing happened?) thing happened?)

FIGURE 14.2 Functional analysis worksheet (from Kadden et al., 1992).

(1989), and adapted for use in Project MATCH (Kad- note that these factors may not be a necessary condi-
den et al., 1992), expand to include interventions di- tion for success in all behavioral approaches.
rected to other problems in the individual's life that Unique "active ingredients" of this group of ap-
are seen as functionally related to substance use, for proaches depends, of course, on the specific treat-
example, general problem-solving skills, assertiveness ment approach in question. For example, for cogni-
training, strategies for coping with negative affect, tive behavioral coping-skills approaches, the active
awareness of anger and anger management, coping ingredients are thought to be skill acquisition and
with criticism, increasing pleasant activities, enhanc- implementation; for cognitive therapies, the active
ing social support networks, and job-seeking skills. ingredient is thought to be identification and modifi-
cation of dysfunctional cognitions; and for cue expo-
sure approaches, the active ingredient for extinction
Active Ingredients
is repeated exposure to the conditioned stimulus un-
Behavioral and cognitive behavioral treatments, like der conditions incompatible with use.
most psychosocial therapies, realize their effects The relative role and contribution of common
through a complex combination of common factors versus specific factors to treatment outcome has in
(treatment elements that are shared by most thera- fact rarely been studied among behavioral and cogni-
pies) and unique factors. As with most therapies, out- tive behavioral treatments for the addictions (DiCle-
comes for behavioral and cognitive behavioral treat- mente, Carroll, Connors, & Kadden, 1994). Simi-
ments are generally thought to depend to a large larly, few investigators have explicitly identified or
extent on the effective use of common factors, in- evaluated the active ingredients of their approaches;
cluding education about the nature of the disorder, that is, few have demonstrated that the presence of
a persuasive therapeutic rationale, expectations of the hypothesized active ingredient is actually respon-
improvement, the skill of the therapist, and the qual- sible for therapeutic change. One exception has
ity of the therapeutic relationship (Castonguay, 1993; been the elegant series of studies by Higgins and col-
Rozenzweig, 1936). However, it is also important to leagues, which has demonstrated (a) that of the ele-
 BEHAVIORAL AND COGNITIVE BEHAVIORAL TREATMENTS 259

ments provided in their multimodal CRA approach, ioral and cognitive behavioral treatments for the addic-
it was the incentive system itself that was associated tions have not been widely studied. However, in their
with abstinence (Higgins, Budney, Bickel, Foerg, et classic study of psychotherapy in the context of meth-
al., 1994), and (b) that vouchers contingent on absti- adone maintenance, Luborsky, McLellan, Woody,
nence were more effective than noncontingent O'Brien, and Auerbach (1985) found that personal
vouchers (Silverman et al., 1996). Similarly, prelimi- adjustment, interest in helping the patient, ability to
nary evidence from work with cognitive behavioral foster a positive working alliance, and high empathy
coping-skills treatments for cocaine abusers has dem- and warmth were associated with better patient out-
onstrated that treatment-specific acquisition of skills come across therapies. In an evaluation of therapist
and posttreatment skill levels were associated with characteristics from the large cohort of Project
better cocaine outcomes during follow-up (Carroll et MATCH therapists, none of the therapist characteris-
al., in press). tics assessed (including gender, age, race, and various
personality attributes) were associated with variability
in outcome among patients treated by the CBT ther-
Role of the Therapist
apists (Project MATCH Research Group, in press).
In behavioral and cognitive behavioral therapies, the
therapeutic relationship is seen as principally collab-
Use of Relationship Elements
orative. Thus, the role of the therapist is typically
seen as that of a consultant, educator, and guide who The quality of the therapeutic alliance has emerged
can lead the patient through a functional analysis of as a consistent and comparatively robust predictor of
his or her substance use, aid in identifying and priori- positive outcome across psychotherapies of different
tizing target behaviors, and consult in selecting and types and with diverse clinical samples (Horvath &
implementing strategies to foster the desired behav- Luborsky, 1993; Horvath & Symonds, 1991). How-
ior changes. ever, detailed studies of the relationship of the thera-
peutic alliance to outcome for behavioral and cogni-
tive behavioral treatments for substance use disorders
Typical Training
have been rare. Luborsky and colleagues (1985)
A broad range of therapists can, with appropriate found that while the purity of technique had a strong
training and supervision, implement behavioral and relationship to outcome for methadone-maintained
cognitive behavioral treatments effectively. Typical opioid addicts, therapeutic alliance ratings had a far
education and training requirements for therapists stronger correlation with outcome (across cognitive
implementing these treatments in controlled clinical therapy, supportive-expressive therapy, and drug
trials have included a master's degree or higher in counseling). More recently, using the Working Alli-
psychology, counseling, social work or a closely re- ance Inventory (Horvath & Greenberg, 1986), Con-
lated field; several years' experience in working with nors, Carroll, DiClemente, Longabaugh, and Dono-
a substance abuse population; familiarity with and van (1997) found that the better working alliance
commitment to the specific behavioral treatment scores were associated with improved alcohol out-
they will deliver; and satisfactory completion of for- comes across the Project MATCH therapies, one of
mal training in the approach. Therapist training in which was CBT.
behavioral and cognitive behavioral treatments has The complexity of the relationship between the
been greatly facilitated through the wide availability therapeutic alliance and the delivery of active ingre-
of manuals for this group of approaches. Training dients in CBT was demonstrated by data which sug-
usually involves (a) a didactic seminar which in- gested not only that the therapeutic alliance was
cludes review of the treatment manual, viewing vid- rated as more positive for CBT than for clinical man-
eotaped examples of the treatment technique, and agement (a nonspecific supportive condition that of-
practice exercises and (b) successful completion of fered empathy and clinical monitoring but none of
several closely supervised training cases (see Carroll the active ingredients of CBT), but that sessions in
et al., 1994). which more of the active ingredients of CBT were
Personal characteristics of therapists that are asso- delivered were also rated as having a more positive
ciated with improved outcome specifically in behav- therapeutic alliance (Carroll, Nich, & Rounsaville,
260 TREATMENT

1997). This finding suggests, for example, that an ad- found for alcohol patients low in psychiatric severity
equate therapeutic alliance may be necessary to pro- (as measured by the ASI) when treated with 12-step
vide the conditions under which specific behavioral facilitation as compared with CBT, although this ef-
interventions can be productively implemented. fect tended to diminish across time (Project MATCH
Similarly, a positive alliance may also foster greater Research Group, 1997). Patient characteristics such
treatment retention and thus permit more exposure as higher motivation for change were associated with
by patients to active ingredients of treatment. better drinking outcomes across the three treatments,
while higher social support for drinking and, to some
extent, higher sociopathy, were associated with poor-
er drinking outcomes across the three treatments
PATIENT CHARACTERISTICS (Project MATCH Research Group, 1997).
ASSOCIATED WITH VARIABILITY IN Smaller, single-site studies of CBT have suggest-
RESPONSE TO BEHAVIORAL AND ed a range of patient characteristics associated with
COGNITIVE BEHAVIORAL improved outcome with respect to comparison ap-
TREATMENTS proaches. Kadden, Cooney, Getter, and Litt (1989),
in a prospective matching study, found that patients
Behavioral and cognitive behavioral treatments have higher in sociopathy had better drinking outcomes
been designed and implemented as approaches that when treated with CBT than when treated with a
are highly individualized and that recognize the het- group interactional approach, and patients lower in
erogeneity of persons with substance use disorders. sociopathy had better outcome when treated with the
Thus, they've been used successfully with a wide interactional approach. For patients higher in psy-
range of individuals. chopathology, CBT was superior. For patients higher
However, comparatively few studies of behavioral in neuropsychological impairment, the interactional
and cognitive behavioral treatments have conducted therapy was superior. A 2-year follow-up indicated
detailed analyses of patient characteristics associated that these matching effects were durable (Cooney,
with variability in outcome (e.g., success profiling) Kadden, Litt, & Getter, 1991).
or have prospectively evaluated hypothesized patient- Among cocaine abusers, exploratory analyses of
treatment interactions. Even fewer of these studies patient characteristics associated with treatment re-
have been replicated. Thus, it is important to note sponse have suggested better cocaine outcomes for
that there are few empirical data on types of individ- patients higher in severity of cocaine use or higher
uals who are particularly well, or poorly, suited to in depressive symptoms when treated with CBT than
these approaches, although variability in outcome is when treated with supportive clinical management
commonly seen. (Carroll, Nich, & Rounsaville, 1995; Carroll, Roun-
However, some recent studies pointing to indica- saville, Gordon, et al., 1994), as well as poorer out-
tors of better response to behavioral interventions comes for alexithymic cocaine abusers (those who
have emerged. Among contingency management ap- had difficulty articulating affect) when treated with
proaches, Higgins and colleagues reported markedly CBT than when treated with clinical management
improved outcomes for patients who had a signifi- (Keller, Carroll, Nich, & Rounsaville, 1995).
cant other willing to participate in treatment com-
pared with those who did not (Higgins, Budney,
Bickel, & Badger, 1994). EMPIRICAL DATA ON THE
For cognitive behavioral treatments, recent data EFFECTIVENESS OF THE MODELS
from Project MATCH (Project MATCH Research
Group, 1993), a multicenter trial of patient-treat- Overall, behavioral and cognitive behavioral treat-
ment matching for alcoholics, revealed few indica- ments have been among the most well defined and
tions of clinically significant patient-characteristic-by- rigorously studied of the psychosocial treatments for
treatment interactions for CBT or the other treatments substance abuse and dependence, and have a com-
evaluated (12-step facilitation and motivational en- paratively high level of empirical support across the
hancement therapy). However, better outcomes were addictions. For example, in their review of cost and
 BEHAVIORAL AND COGNITIVE BEHAVIORAL TREATMENTS 261

effectiveness data for treatments for alcohol use dis- dures with cocaine patients (Childress et al., 1988),
orders, Holder, Longabaugh, Miller, and Rubonis where extinction of craving to some cocaine cues has
(1991) included social skills training, self-control been demonstrated, but it is not yet clear whether
training, stress management training, and the com- extinction generalizes to other cues more difficult to
munity reinforcement approach—all broad-spectrum control in laboratory/treatment settings, or whether
CBT approaches—as having good empirical evidence extinction of craving has an appreciable difference
of effectiveness. Recent reviews of the effectiveness on drug use (Childress et al., 1993).
of treatments for drug abuse (APA Workgroup on
Substance Use Disorders; Crits-Christoph & Sique-
Contingency Management Approaches
land, 1996; DeRubeis & Crits-Christoph, 1998; Gen-
eral Accounting Office, 1996) identified contingency Because of a recognition that methadone mainte-
management and cognitive behavioral therapy as nance may curtail opioid use but often has little ef-
having among the highest levels of empirical support fect on other illicit substance use, particularly co-
for the treatment of opioid and cocaine dependence caine use (Kosten, Rounsaville, & Kleber, 1987), a
disorders. variety of contingency management approaches have
been evaluated for their reduction of illicit substance
use among methadone-maintained opiate addicts.
Cue Exposure Approaches
Several features of standard methadone maintenance
While cue exposure approaches have generally been treatment (daily attendance, frequent urine monitor-
associated with reductions in some conditioned re- ing, and reinforcing properties of methadone) have
sponses, the value of these procedures in producing offered behavioral researchers the opportunity to
clinically meaningful reductions in substance use control the reinforcers available to patients and
has been met with only modest success to date hence to evaluate the effects of both positive and
(Childress et al., 1992; Monti et al., 1993). For exam- negative contingencies on outcome in methadone
ple, to evaluate the utility of extinction procedures as maintenance programs.
an adjunct to drug treatment, 56 methadone-main- Several studies have evaluated negative contin-
tained addicts were randomly assigned to one of gency contracting, which requires specific improve-
three groups: a combination group which received ments in behavior (typically submission of drug-free
cognitive behavioral therapy, extinction, and relax- urines) for continued methadone treatment, with
ation training (CE); a group which received cogni- failure to improve or comply resulting in dose reduc-
tive behavioral therapy and relaxation training with- tion, detoxification, or termination of treatment.
out extinction (CT); and a group which received Liebson, Tommasello, and Bigelow (1978) found
drug counseling alone (McLellan et al., 1986). The that this procedure increased compliance with disul-
group which received extinction (CE) evidenced a firam treatment for alcoholic methadone-maintained
reduction in subjective craving for opiates with re- opiate addicts. Several studies, including Dolan,
peated extinction sections. However, although both Black, Penk, Rabinowitz, and DeFord (1985), Mc-
groups which received psychotherapy (CE and CT) Carthy and Borders (1985), Saxon, Calsyn, Kivla-
had significantly better 6-month outcomes than the han, and Roszell (1993), and Nolimal and Crowley
group which received drug counseling alone, the two (1990), have demonstrated that approximately 40-
psychotherapy groups were not significantly different 60% of subjects are able to reduce or stop illicit sub-
from each other, a finding suggesting that the extinc- stance use under threat of dose reduction or treat-
tion procedure added no great relative benefit over ment termination. However, fully half the subjects in
the cognitive therapy plus relaxation training. The these studies did not reduce their substance use un-
authors suggested several factors which may have der these conditions and were forced to leave treat-
undercut the power of the outpatient extinction pro- ment. Often, patients who do not comply with be-
cedure, including (a) the need for use of individual- havioral requirements and are terminated are those
ized stimuli and (b) the need to consider modifying with more frequent or severe polysubstance use (Do-
variables such as affect or cognitive set. Similar find- lan et al., 1985; Saxon et al., 1993). Thus, these stud-
ings have also been reported for extinction proce- ies demonstrate that while negative contingencies
262 TREATMENT

may reduce or stop illicit substance use in some proach has also recently been replicated among co-
methadone maintenance patients, these somewhat caine-abusing methadone-maintained opioid addicts
draconian procedures may also have the undesirable (Silverman et al., 1996).
effect of terminating treatment for those more se-
verely impaired patients who have difficulty comply-
Cognitive Behavioral Coping-Skills
ing and who may need treatment most (Stitzer,
Approaches
Bickel, Bigelow, & Liebson, 1986).
The methadone take-home privilege contingent Coping-skills approaches have also been widely stud-
on reduced drug use is an attractive approach, as it ied and have a comparatively high level of empirical
capitalizes on an inexpensive reinforcer which is po- support. To date, over 25 randomized controlled tri-
tentially available in all methadone maintenance als have evaluated the effect of cognitive behavioral
programs. Stitzer and colleagues (1993) did extensive coping-skills treatment on substance use outcomes
work in evaluating methadone take-home privileges among adult smokers and abusers of alcohol, co-
as a reward for decreased illicit drug use. In a series caine, marijuana, and other types of substances. Re-
of well-controlled trials, this group of researchers view of this body of literature suggests that across sub-
demonstrated (a) the relative benefits of positive over stances of abuse but most strongly for smoking
negative contingencies (Stitzer et al., 1986); (b) the cessation, there is evidence of the effectiveness of
attractiveness of take-home privileges over other in- CBT compared with no-treatment control condi-
centives available in methadone maintenance clinics tions. However, evidence regarding its superiority rel-
(Stitzer & Bigelow, 1978); (c) the effectiveness of tar- ative to discussion control conditions or other active
geting and rewarding drug-free urines over other, treatments has been less consistent (Carroll, 1996).
more distal, behaviors such as group attendance Outcomes in which CBT may hold particular prom-
(Iguchi et al., 1996); and (d) the benefits of using ise include reducing severity of relapses when they
take-home privileges contingent on drug-free urines occur (e.g.., Davis & Glaros, 1986; O'Malley et al.,
over noncontingent take-home privileges (Stitzer, 1992; Supnick & Colletti, 1984); enhanced durabil-
Iguchi, & Felch, 1992). ity of effects (Azrin et al., 1996; Carroll, Rounsaville,
One of the most innovative and exciting findings Nich et al., 1994; O'Malley et al., 1996); and patient-
pertaining to the effectiveness of behavioral treat- treatment matching, particularly for patients at high-
ments for cocaine abuse is the recent reports of Hig- er levels of impairment along dimensions such as
gins and colleagues (Budney & Higgins, 1998; Hig- psychopathology or dependence severity (e.g., Car-
gins, 1991, 1993; Higgins, Budney, Bickel, Foerg, et roll, Rounsaville, Gordon et al., 1994; Kadden et al.,
al., 1994) evaluating the combination of incentives 1989).
in the form of vouchers and CRA. In a series of well-
controlled clinical trials, Higgins et al. (1991, 1993)
demonstrated (a) high acceptance, retention, and STRENGTHS AND WEAKNESSES
rates of abstinence for patients randomized to this
approach (85% completing a 12-week course of treat- Strengths of behavioral and cognitive behavioral ap-
ment; 65% achieving 6 or more weeks of abstinence) proaches were summarized by Rotgers (1996) and in-
relative to standard 12-step-oriented substance abuse clude (a) flexibility in meeting individual needs, (b)
counseling (Higgins et al., 1991, 1993); (b) no de- acceptability to a wide range of substance-abusing in-
cline in rates of abstinence when less valuable incen- dividuals seen in clinical settings, (c) solid grounding
tives, such as lottery tickets, were substituted for the in established principles of behavior theory and be-
voucher system (Higgins & Budney, 1993); (c) the havior change, (d) an emphasis on linking science to
value of the voucher system itself (as opposed to treatment, (e) well-specified treatment goals and
other program elements) in producing good out- clear guidelines for assessing treatment progress, (f)
comes by comparing the behavioral system with and emphasis on building self-efficacy, and (g) a compar-
without the vouchers (Higgins, Budney, Bickel, atively strong level of empirical support. These ap-
Foerg, et al., 1994); and (d) the durability of treat- proaches are highly flexible and can be used in a
ment effects after cessation of the contingencies number of treatment modalities and settings, can be
(Higgins et al., 1995). The effectiveness of this ap- applied across different types of substance use with
 BEHAVIORAL AND COGNITIVE BEHAVIORAL TREATMENTS 263

minor modifications, and are compatible with a wide F. Rotgers, D. Keller, & J. Morgenstern (Eds.), Treat-
range of other treatment approaches, including fam- ing substance abusers: Theory and Technique (pp.
ily therapy and pharmacotherapy. Another advantage 174-201). NewYork: Guilford Press.
is that these approaches have emphasized clear speci-
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 15

The Disease Model

Timothy Sheehan
Patricia Owen

Few would dispute the extent and severity of alcohol ior (Pernanen, 1990; Wieczorek, Welte, & Abel, 1990).
and drug dependence in today's society. The prob- In fact, nearly one fourth of all persons admitted to
lem is widespread. For example, the psychiatric Epi- general hospitals have alcohol problems or are undi-
demiological Catchment Program (Robins et al., agnosed alcoholics being treated for alcohol-related
1984) reported an estimated 13.7% base rate of alco- consequences (Lee, 1993).
hol abuse and dependence in the general popula- Alcohol and drug dependence furthermore poses
tion. In 1992, the National Institute on Alcohol a public safety threat associated with serious automo-
Abuse and Alcoholism (NIAAA, 1994) reported that bile crashes and fatalities (Johnston, 1982). The Na-
13.8 million Americans had problems with drinking, tional Institute on Alcohol Abuse and Alcoholism
and in a major population survey (Reiger et al., (1993) reported that approximately 50% of automo-
1990), substance abuse was identified as the largest bile crashes in 1989 were alcohol-related.
category of mental health disorder. How do we explain the ravages of this problem?
The consequences of alcohol and drug depen- Can it be a simple matter of willful behavior or the
dence are serious public health problems resulting in results of a bad habit? How do we explain the preva-
medical conditions involving high rates of medical- lence of this problem even in the face of repeated
surgical complications (Loveland-Cook, Booth, Blow, serious personal and social consequences?
Gogineni, & Bunn, 1992), terminal illness, trau- The disease model contends that alcoholism and
matic injury (Merrill, Fox, & Chang, 1993), emer- drug dependence are not a matter of willpower nor
gency room visits (Cherpitel, 1989a, 1989b), suicide the result of a deeply ingrained habit of recurrent
(Gomberg, 1989), and violent and homicidal behav- excessive consumption. At the heart of the disease

268
 THE DISEASE MODEL 269

model is the fundamental tenet that alcohol and HISTORY AND ORIGIN:
drug dependence is a physical illness. The disease is DISEASE MODEL
neither the end result nor the symptom of another
disorder but a primary, progressive, chronic illness. As early as the 18th century, Benjamin Rush,
Rather than a singular personality disorder or mal- founder of modern psychiatry, described alcoholism
adaptive learned behavior, alcohol and drug depen- as an illness that "resembles certain hereditary, fam-
dence involves the biological fabric of the individual ily, and contagious diseases" (Keller, 1986, p. 27).
and eventually impacts every phase of the afflicted The concept of disease is broadly defined as disregu-
person's life. As a result, the disease model represents lation of homeostasis resulting in a predictable con-
a comprehensive explanatory concept that encom- stellation of disabling symptoms. Since causes of dis-
passes the social, psychological, spiritual, and biolog- ease are often speculative or unknown, a disease can
ical dimensions of alcohol and drug dependence. be best understood in terms of its biological basis and
Born from the clinical efforts of those who treated symptomatic manifestations. Engels (1977) expanded
alcoholism and those who suffered from it, the dis- the biomedical concept of disease to include psycho-
ease model represents a combination of grassroots logical, cultural, and social implications affecting the
practicality and scientific endeavor. individual's susceptibility and treatment response.
This chapter provides a comprehensive overview Referring to disease as a biopsychosocial phenome-
of the basic tenets of the disease model, including non, Engels advocated a comprehensive conceptual-
definitions and terms, etiological hypotheses, and ization of disease both to explain the multifaceted
theoretical constructs. Treatment approaches and components of illness and to expand the scope of
processes are also addressed, with careful consider- treatment to multimodel approaches.
ation of the conceptual underpinnings of the 12 steps Lewis (1994) compared alcoholism to other dis-
of Alcoholics Anonymous (1955) as a behavior eases such as essential hypertension and cardiac dis-
change model. Historically, a form of treatment ease, that are not solely biological in nature and that
called the Minnesota model was developed to address interface with environmental risks for onset and pro-
the disease of alcohol and drug dependence, incor- gression. Like alcoholism, both of these medical con-
porating some of the major components of Alcohol- ditions are affected by personality and lifestyle and
ics Anonymous (Spicer, 1993). This model was ini- also have genetic contributions in terms of etiology.
tially conceptualized at a small state hospital in The exact biological etiology for most chronic dis-
Willmar, Minnesota, and was transported and fully eases, like alcoholism, are unknown. A biopsychoso-
developed at a private nonprofit residential program cial model of disease has greater potential for ex-
in Minnesota called Hazelden. From there, this plaining and understanding disease entities while
model became prevalent in treatment programs providing a broader base for effective intervention,
across the United States, and in other countries (Ful- often including behavioral or lifestyle changes.
ler, 1989; Spicer, 1993). Project MATCH (Project
MATCH Research Group, 1997) worked with staff
Early Development of the Disease Model
at Hazelden to develop a manualized version of the
Minnesota model and called it the 12-step facilita- Pioneers of the disease model (Jellinek, 1946; Silk-
tion model (Nowinski, Baker, & Carroll, 1992). The worth, 1939); provided a theory based on traditional
overarching feature of this model, however termed, biological concepts of disease while stressing the psy-
is that it provides the vehicle by which individuals chological, spiritual, and social ramifications of both
initiate pervasive, ongoing lifestyle changes that sup- the illness and the process of recovery. Silkworth
port continuous abstinence. Several recent studies (1939) described alcohol dependence as an illness
have been done to define the main curative factors characterized by an atypical physiological reaction to
of the disease model in more depth (e.g., Miller & alcohol that triggers a mental obsession. The mental
Kurtz, 1994; Morgenstern & McCrady, 1992). The obsession fuels a physical demand for alcohol con-
purpose of this chapter is to examine the nature of sumption in spite of problematic consequences or
alcohol and drug dependence, and its treatment, strong intentions to cut back or quit altogether. Silk-
from a disease model perspective. worth purported that alcoholics could not resume
270 TREATMENT

normal drinking since the root cause of the disease rapid consumption for relief, and lingering feelings
involved a physical allergy to alcohol. of guilt.
Silkworth's early work was not limited solely to In the crucial phase, the involuntary loss of con-
the biology of alcohol dependence. He also de- trol over drinking behavior becomes overt, as drink-
scribed the psychological aspects of craving: restless- ing sets off a chain reaction involving a physical
ness, irritability, and tension. Furthermore, he de- demand for continued alcohol consumption. It be-
scribed the mental anguish of the alcoholic faced comes increasingly difficult to predict periods of ab-
with an inability to reduce or stop drinking. Silk- stinence or intoxication. The crucial phase involves
worth contended that only a pervasive personality hypervigilance, rationalization, and periods of re-
change would alleviate the emotional turmoil and morse. There are likely to be concerted efforts to
spiritual bankruptcy of the alcoholic. This transfor- control drinking behavior by abstaining from alcohol
mation, described by William James as quoted in Al- for periods of time, changing patterns and times of
coholics Anonymous (1955), involved a gradual yet drinking, or switching brands or types of alcohol con-
significant change in consciousness, or a spiritual sumed. The alcoholic develops a lifestyle centered
awakening. on alcohol.
Jellinek (1946, 1960) elaborated on the disease The chronic phase is characterized by the presen-
model by addressing its physiological dimensions, tation of symptoms of the first four stages, in addition
the progression of the disease, and a classification of to prolonged periods of intoxication that result in
disease typologies. Like Silkworth (1939), Jellinek ethical deterioration, severe memory dysfunction,
(1946) contended that the alcoholic experienced an physical traumas, and irrational fears. The chronic
atypical response to alcohol involving an internal phase is associated with deterioration in both occupa-
tension and craving that eventually led to an involun- tional and social functioning. During the chronic
tary loss of control over drinking behavior. Jellinek phase, the alcoholic may no longer be able to main-
hypothesized an X factor that predisposed the af- tain interpersonal relationships or vocational produc-
flicted individual to uncontrolled drinking, in com- tivity. Unless the alcoholic is treated, the chronic
parison to the heavy drinker. Using a survey of ap- stage results in severe irreversible disability or death.
proximately 2,000 alcoholics, Jellinek differentiated Jellinek's description of the progressive nature of
heavy drinkers from alcoholics based on a predict- the disease provides both a rationale for clinical in-
able progression of symptoms. tervention and an impetus for further research and
Stages of alcoholism described by Jellinek (1946) theoretical elaboration. Jellinek (1960) was not dog-
included the symptomatic phase, the prodromal matic but contended that definitions and theories
phase, the crucial phase, and the chronic phase. The of alcoholism were likely to change as additional
prealcoholic symptomatic phase is characterized by knowledge was gained.
the initial rewarding qualities of drinking behavior.
The alcoholic perceives a reduction in tension as the
Current Status of the Model
result of drinking. Subsequently, the alcoholic's
drinking progresses from occasional to more continu- Advances in explaining the pathophysiology of alco-
ous relief drinking. During the symptomatic phase, holism have addressed the correlation between bio-
there is an increase in tolerance as more alcohol is logical dysfunction and drinking or using behavior.
needed for its sedative effect. In particular, neurobiological and neurobehavioral
As the individual engages in more continuous re- explanations of addiction have been proposed in ac-
lief drinking, excessive quantities of alcohol are con- cordance with the disease model. Several researchers
sumed, yet there may be few overt signs of intoxica- have continued the exploration of the progression
tion. Periodically, the individual is unable to recall of symptoms, as first delineated by Jellinek (1946,
or account for selected intervals of time. There is no 1960). For example, Schuckit, Smith, Anthenelli,
memory regarding certain behavior patterns or and Irwin (1993) studied 636 male alcoholic in-
events. These blackouts or circumscribed periods of patients in a Veterans Administration hospital to
amnesia are symptomatic of the prodromal phase. determine the course of the development of their al-
Other concurrent progressive symptoms include coholism. These researchers found a common con-
drinking to feel normal, preoccupation with alcohol, stellation of symptoms, unfolding in a fairly consis-
 THE DISEASE MODEL 271

tent pattern, and concluded, "The evidence of a that any individual who uses a particular chemical with
general progression of alcohol-related life problems is enough regularity will develop the necessary cellular
consistent with the prior research by Jellinek as well as adaptation to acquire the disease. However, it may be
the several additional attempts to replicate his earlier that some people are particularly prone to (a) seeking
findings" (p. 790). The authors, however, were unset- out and ingesting chemicals and/or (b) acquiring cel-
tled as to whether the predictable progression of symp- lular adaptation resulting from use. Research in this
toms actually signaled a disease and instead referred area has been focused on the question "If alcohol/drug
to it as a "diagnosable clinical syndrome" (p. 791). dependence is genetic, what exactly is transmitted to
More recent studies in the field of neurology have offspring through genetic material?" Note that because
been able to demonstrate that alcohol and drug de- alcohol is a legal and rather ubiquitous substance,
pendence is best characterized as a disease. In his most research in this area pertains to alcohol depen-
study of molecular and cellular changes in neural dence (alcoholism) rather than drug dependence.
function produced by chronic drug use, Hyman It has been hypothesized that alcoholism is the
(1996) found that brain cells adapt to the introduc- end product of a genetically linked process affecting
tion of chemicals. He suggested that the disease of disregulation of arousal, resulting in behavioral cor-
addiction involves the excessive bombardment of the relates of overactivity, anxiety, and tension (Tarter,
brain by drugs causing long-line molecular adapta- Alterman, & Edwards, 1988). Early-stage relief drink-
tions that usurp the functioning of critical pathways ing (Jellinek, 1960) lessens anxiety by its pharmaco-
in the brain that control motivated behavior. Hyman logical effects on the noradrenergic system (Sam-
(1995) concluded that "alcoholism is a brain disease son & Hoffman, 1995). Individuals with a genetic
that markedly impairs a person's ability to control his dysregulation of stress and emotionality may experi-
or her drug-seeking behavior" (p. 841). ence alcohol differently from nonalcoholics and are
Leshner, building on Hyrnan's and others' bio- thus predisposed to risk (Anton, Kranzler, & Meyer,
chemical discoveries, wrote a seminal article titled, 1995).
"Addiction Is a Brain Disease and It Matters" (1997). Neurobiological theories are based on research
In this article, he proposed that at some point during examining the dynamics of reinforcement, tolerance,
drug use, because of drug-induced cellular adapta- and physical dependence. In a review of the litera-
tion, a metaphorical molecular "switch" signals a ture, Meyer (1995) cited a relationship between ge-
change from use or abuse to addiction. At this point, netically determined neuronal sensitivity to the aver-
the brain becomes fundamentally altered, producing sive and reinforcing effects of alcohol and the
drug effects and behavior that are quite different progression of alcohol dependence. Typical brain pa-
from the "predisease" state. Leshner's article is partic- thology associated with the reinforcing effects of al-
ularly important because he stressed the importance cohol intensifies the rewarding results. Tolerance to
of removing the stigma and moral overtones from the alcohol develops as the altered physiology filters the
conceptualization of addiction. aversive qualities of excessive consumption. The re-
In treatment, the disease model is used to teach inforcing qualities of alcohol predominate as more
the alcohol- or drug-dependent person that she or he alcohol is consumed. Neuronal dysregulation pro-
has a treatable illness. While, because it is a disease, vides unreliable cues to modulate drinking behavior
there is no blame placed on the individual, it is (Tabakoff & Hoffmann, 1988).
made clear that the patient has a responsibility for Since the Victorian era, alcoholism has been
recovery—just as a person does with any other dis- thought to run in families. However, these observa-
ease. The concept of alcohol and drug dependence tions were rarely more than speculation, since shared
as a disease is a foundation of the Minnesota model environment could also explain the familial pattern
of treatment. (Petrakis, 1985). In 1944, Jellinek, using a review of
the literature, speculated that alcoholism was not ge-
netically transmitted but socially transmitted to vul-
ETIOLOGY OF THE DISEASE nerable individuals. Jellinek theorized that the alco-
holic inherited a physical constitution that left him
If addiction results from cellular adaptation, a ques- or her susceptible to the social risk of alcohol depen-
tion remains about variable predisposition. It may be dence.
272 TREATMENT

While neurobehavioral and neurobiological pro- cross-culturally and across different time intervals ex-
cesses involving stress reduction or exaggerated re- tending from twins born in the 1920s to twins born
warding effects may interact to create risk, additional as late as 1967. The degree of genetic influence was
factors are likely to play a role in the onset and main- also consistent in spite of different sampling methods
tenance of the disease (Anton et al., 1995). For in- and variability in the progression and severity of alco-
stance, impulsivity is a key characteristic of many holism among study subjects.
alcoholics (Babor et al., 1992; Cloninger, 1987). Ser- Research supporting genetic contributions to al-
otonergic defects may result in increased impulsivity coholism risk provides an important dimension to
and may contribute to early onset of alcoholism in the disease model. Evidence of genetic influence im-
at-risk populations (Coccaro & Murphy, 1990). Like- plies a predetermined biological vulnerability that
wise, alcohol craving may resemble obsessive-com- suggests a causal link between heredity and the
pulsive phenomena, where preoccupation with alco- pathophysiology of alcohol and drug dependence.
hol exists even in the absence of alcohol or related Proponents of the disease model believe that the re-
drinking cues. Thus, neurotransmitter dysregulation sults of such research place alcohol and drug depen-
may play a multifaceted role in the onset, develop- dence outside the realm of purely a learned behavior
ment, and progression of alcoholism (Anton et al., and instead substantiate its disease status.
1995).
While the etiology of alcoholism is multifactorial,
involving culture, heredity, economics, and environ- MAINTENANCE OF THE DISEASE
mental influence, gene contribution may weigh
heavily in the equation (Valliant, 1995). Since In addition to the reinforcing qualities of alcohol that
World War II, there has been mounting evidence perpetuate its use (Koob & Bloom, 1988), the disease
supporting a genetic predisposition as a causal factor is maintained by the emergence of an elaborate de-
(Bleuler, 1955; Cotton, 1979). Researchers have re- fense system that essentially denies the severity of
lied on twin, family pedigree, and adoption studies drinking or using behavior and its consequences.
to differentiate the effects of similar family environ- The defense system is characterized by attempts to
ment and the proportional contributions of genes. minimize the amounts of alcohol or drugs con-
For example, Cotton (1979) reviewed 39 studies on sumed, rationalize problems it has engendered, and
the heredity of alcoholism involving 6,251 alcoholic blame others for the use behavior. Intimidation,
and 4,083 nonalcoholic families. Data from these angry defensiveness, manipulation, and oppositional
studies indicated that alcoholics were more likely behavior may be used as methods to stave off inter-
than nonalcoholics to have an alcoholic father, vention that disrupts access to and continued use of
mother, sibling, or distant relative. Approximately alcohol or other drugs (Levy, 1993; Metzger, 1988).
one third from any of the samples studied showed The defense system of denial shelters the afflicted
that alcoholics had at least one parent who was also individual from reality, thereby masking harmful
alcoholic. consequences of substance abuse and dependence.
Cadoret (1990) found a greater concordance for As a result, change is rarely self-initiated and is more
alcoholism among identical twins than among frater- often the result of situational stresses that provide the
nal twins in a reevaluation of 13 published twin stud- necessary motivation to seek assistance (FitzGerald,
ies. These studies pointed to a trend suggesting that 1988).
genes play a role in determining vulnerability for al- One might assume that the progression of the dis-
coholism and influence the frequency and quantity ease into greater severity and chronicity would natu-
of drinking behavior. rally propel an individual away from denial into re-
In a review of adoption and twin studies from ality. In fact, there are three main factors that
Scandinavia and the United States, Heath (1995) re- contribute to the maintenance of the disease and the
evaluated the relative contributions of genes and defense system: physiological changes in the individ-
shared environment to the development of alcohol- ual; behavioral conditioning; and homeostatic social
ism. Consistent evidence was found to support an systems. From a physiological point of view, an indi-
important genetic influence on alcoholism risk in- vidual may continue his or her use, at least in the
volving men and women. Trends were identified short term, in order to avoid withdrawal symptoms
 THE DISEASE MODEL 273

and to quell craving (Beck, Wright, Newman, & An important aspect of Minnesota model treat-
Liese, 1993). However, some drugs of abuse (e.g., ment is teaching the individual to recognize internal
marijuana) do not produce extreme craving and and external factors that actively maintain the dis-
withdrawal symptoms immediately upon discontinu- ease, and to make personal and lifestyle changes to
ation. Or for drugs that do produce immediate with- address these factors. An important component of the
drawal symptoms, the symptoms are often short-lived disease model is that a patient is never fully cured;
and can be dealt with by medications. Rarely, how- that is, because of the brain's fundamental change in
ever, does simple detoxification end the cycle of ad- how alcohol or other drugs are processed, the indi-
diction. What may be more important—is if indeed vidual may never safely use again. This can be un-
the brain is fundamentally altered, as proposed by cur- derstood as the maintenance phase in stages-of-
rent neuroscientists (Hyman, 1996; Leshner, 1997) — change theory (Prochaska, DiClementi, & Norcross,
the individual may no longer be able to experience 1992), during which time the individual actively
normal reward states without chemicals. It may be practices certain behaviors to decrease the likelihood
that the altered brain state leads to what is termed of relapse into active addiction.
loss of control (i.e., the inability to accurately predict
when ingestion of a chemical will stop, once begun).
In the disease model, this is a hallmark symptom. RATIONALE FOR HOW THE
Behavioral theorists describe alcohol and drug de- DISEASE MODEL OF TREATMENT
pendence as being maintained by reinforcement, ei- FOLLOWS FROM THE THEORY
ther by the chemical itself or by stimuli in the envi-
ronment prompting alcohol/drug use (Froelich & Li, From the above discussion on the origin and mainte-
1991; Miller & Brown, 1997). Sometimes, the cues nance of the disease, it is clear that alcohol and drug
for use may be a combination of external stimuli and dependence is complex and multifaceted. It follows,
internal (cognitive) stimuli. For example, it is well then, that the treatment of it must also be compre-
known that addicts who return to their using environ- hensive. By the time an individual presents with a
ment after a long period of abstinence will experi- full-blown dependency disorder, there are likely to
ence strong feelings of craving, which make relapse be consequences and complications in all spheres of
more likely than if that environment is avoided. In his or her life: biological, intrapersonal, psychosocial,
this case, the familiar environment associated with and mental health.
using pairs with self-statements about desire to use or Biologically, the person may experience with-
ability to cope (Beck et al, 1993). In the conceptual- drawal symptoms for varying lengths of time and of
ization of the 12-step model, this is known as the varying intensity. Withdrawal medications may be in-
danger of "people, places, and things" associated dicated. During this time, the person may still be
with using in propelling a person into relapse (No- physically uncomfortable and find it difficult to con-
winski, Baker, & Carroll, 1995). centrate on standard treatment components. Craving
Another factor that often maintains the disease is may also be present, even after the withdrawal, again
the behavior of family and friends. Families often de- distracting the person from a focus on learning and
velop defense systems around the disease, normaliz- practicing lifestyle changes. Finally, serious biomedi-
ing the alcohol- or drug-dependent's behavior. Part- cal complications may be present stemming from the
ners, other family members, and friends develop deleterious effects of the alcohol or drug use, ranging
their own behaviors that may inadvertently act as trig- from relatively acute states (e.g., fractures or lesions
gers for use or make it more likely that the using from falls, fights, or accidents, out-of-control secon-
patterns will continue (Noel, McCrady, Stout, & dary diseases such as diabetes or hypertension due to
Nelson, 1987; Wegscheider Cruse, 1989). Part of the alcohol/drug use) or chronic states (e.g., liver impair-
treatment process includes helping significant others ment, compromised cognitive functioning, acquired
identify their own issues and behaviors surrounding disease such as HIV).
the alcoholic and addict, and to make changes. From an intrapersonal standpoint there are likely
Some disease model programs conceptualize or de- to be problems with (a) treatment resistance based
scribe this as codependency (Morgenstern & Mc- on denial, (b) understanding the extent and severity
Crady, 1992). of the problem, and (c) initiating attitudinal and life-
274 TREATMENT

style changes consistent with continuous abstinence

Physical Health Care
(Levy, 1993; Metzger, 1988). In fact, denial may be
maintained to forestall the impact of the realization Physicians and nurses must ensure a safe transition
of how extensive the problem is and the magnitude from toxicity to abstinence. Symptoms are medically
of the changes that must be made. These intraper- monitored and withdrawal protocols established to
sonal issues are not generally viewed as an insur- reduce seizure risk, promote physical comfort, and
mountable barrier to treatment and instead often be- prevent related complications (Sheehan & Garret-
come the starting point for treatment. son, 1994). Medical conditions that have been ig-
From a psychosocial perspective, there are likely nored, masked, or exacerbated by excessive, recur-
to be problems with (a) remorse and shame; (b) rent consumption are diagnosed and treated. In the
hopelessness; (c) daily coping skills involving self-as- disease model of treatment, the goal is to stabilize
sertion and stress-management, and expressing nega- the individual's physical state so that she or he can
tive emotion; (d) negotiating healthy interpersonal be more available for the treatment process. Stabili-
relationships; (e) loss and unresolved grief from zation is not the sole end product of treatment itself.
drinking-related issues; (f) spiritual conflict involving
basic human values; and (g) vocational discord (Fitz-
Mental Health Care
Gerald, 1988).
Comorbid mental health complications are rela- Psychologists identify individual differences relevant
tively common (Valliant, 1995). For example, there to treatment planning and continued treatment. Psy-
appears to be a strong association between major de- chological assessment is used to measure and identify
pression and alcoholism. Both tend to run in families (a) intellectual functioning, (b) personality character-
and can co-occur in the same person (Merikangas & istics, and (c) mental disorder. Intelligence tests and
Gelernter, 1990). In fact, the prevalence of comorbid neuropsychological measures are employed to evalu-
mental health complications may be as high as one ate cognitive skills and impairment, while objective
third of the substance dependence population over personality tests are routinely used to identify individ-
the life span (Robins et al., 1984). Diagnostic scru- ual traits and characteristics relevant to treatment
tiny is warranted to avoid (a) premature diagnosis response. Psychiatrists and psychologists work as a
and unnecessary treatment and (b) failure to identify team in assessing, diagnosing, and treating concur-
and treat mental disorders that will impede treatment rent mental health complications. Comorbid condi-
response and contribute to relapse (Anton et al., tions are treated concurrently. Psychotherapy and
1995; Liskow, Powell, Nickel, & Penick, 1990). nonaddictive psychotropic medications may be used.
The sum total of biological, intrapersonal, and In the disease model, mental health issues are identi-
psychosocial and mental health implications de- fied and addressed with the goal of helping the per-
mands a comprehensive approach. Failure to con- son understand what aspects of his or her personality
sider social and environmental support for recovery, (or actual disorders) may leave him or her vulnerable
interpersonal conflict, comorbid conditions, and psy- to relapse, as well as to identify and build on personal
chosocial stressors results in an incomplete approach strengths.
to the complexity of the disease process. Treatment
methods are planned based on the individual's ca-
Spiritual Care
pacity to integrate new learning and practice newly
learned behavior. Neither a singular approach nor Spirituality is facilitated by chaplains specially
discipline is adequate; rather, multidisciplinary team trained in clinical pastoral chemical dependence
is warranted composed of counselors, physicians, counseling. Spiritual care fosters the development of
nurses, psychologists, and chaplains. The Minnesota a synergistic personal belief system by aiding individ-
model is characterized by a holistic approach that uals in examining their values and standards for be-
relies on a multidisciplinary team for the assessment, havior. Spirituality provides the basis for ethical liv-
planning, and delivery of treatment services. Aspects ing and behavior change while addressing life's
of the treatment, related to aspects of the theory, are difficult questions that are not easily answered by sci-
listed below. ence and reason alone. Chaplains facilitate individ-
 THE DISEASE MODEL 275

ual pastoral counseling and group sessions and fre- sota model was initially developed for use in a resi-
quently provide intensive grief work for those individ- dential setting, it can be easily implemented in a hos-
uals coping with losses often related to the conse- pital or outpatient setting. For outpatients, resources
quences of alcohol and drug dependence. From the in the community or an adjoining residential/hospi-
perspective of the disease model, people who have tal treatment center may be used to augment outpa-
struggled with alcohol/drug dependency for years tient resources.
have often abandoned values and connections they
once felt important. Finding meaning and strength
beyond willpower—the power of fellowship of the KEY INTERVENTIONS IN THE MODEL
group or the power of peace in a meditative state, for
example—helps the person learn new ways of living The multidisciplinary team works cooperatively to
without chemicals. develop an individualized plan of care that is coordi-
nated by the primary therapist (chemical depen-
dence counselor). Counseling services use the meth-
Chemical Dependency Counseling
odology of the 12 steps of Alcoholics Anonymous to
Chemical dependence counselors function as pri- facilitate attitudinal, affective, and behavior change.
mary therapists by providing the core of treatment Personal application of each step is measured by the
services through a continuum of assessment, treat- parameters established in the treatment plan and is
ment planning, and individual and group counsel- evaluated based on overt observations of anticipated
ing. Assessment and treatment entail data collec- changes in affect, attitude, and behavior. Treatment
tion and diagnosis and include the development of strategies are modified according to individual clini-
treatment strategies that promote behavior change cal needs and treatment response.
through individual and group counseling methods. Cross-discipline key clinical processes are the ave-
The counselor coaches, mentors, and teaches by tak- nues by which services are delivered. Each clinical
ing an active role as a change agent. Because the process correlates with a stage of developmental
disease model holds that alcohol and drug depen- change (Prochaska et al., 1992). At Hazelden, the
dence is a primary disorder (not a symptom of an- Minnesota model is conceptualized as involving five
other disorder), it follows that the chemical depen- key clinical processes: preentry, intake, assessment
dency counselor is the primary caregiver on the and care planning, care, and continuing care.
team. Preentry services help prepare individuals con-
templating change or involvement in clinical ser-
vices through educational information, emotional
THERAPEUTIC CHANGE: support, and referral.
ASSUMPTIONS ABOUT HOW Intake addresses the initial stage of problem rec-
PEOPLE CHANGE ognition and transition from contemplation to taking
action by identifying initial motivating factors. Intake
Therapeutic change is based on three modes of inter- typically (a) prioritizes presenting problems, (b) pro-
vention that build on the methodology of the 12 vides intervention for urgent clinical needs, and (c)
steps of Alcoholics Anonymous: education, therapy, facilitates transition to treatment.
and fellowship. Education provides the informational Assessment and care planning entail a compre-
basis for self-understanding, skill training, and attitu- hensive evaluation of the biopsychosocial elements
dinal changes. Individual and group therapy address of the disease through an alcohol and drug assess-
the emotional conflicts that impede behavior change ment, a social history, a psychological evaluation, a
and promote the development of adaptive skills in spiritual care consultation, and a physical examina-
coping with negative emotion. Fellowship is the in- tion. An outcome of the assessment process is a clini-
terpersonal value of self-help that builds a common cal formulation that provides a comprehensive de-
motivational effort to modify self-defeating behavior, scription of the clinical issues that will serve as a
gain support for ongoing change, and establish re- basis for ongoing treatment planning. Treatment
sources for continuous learning. While the Minne- planning is a highly individualized process based on
276 TREATMENT

the supposition that the disease is superimposed over ing episode. Next, the self-report history is reviewed
a widely varying population. Individual differences with the primary therapist to aid in evaluating indica-
among substance abusers include cultural influences, tors of loss of control, continued use in spite of nega-
personality characteristics, socioeconomic backgrounds, tive consequences, social and/or vocational dysfunc-
learning styles, cognitive impairment, and psychiatric tion, and evidence of change in tolerance. Criteria
complications. As a result, treatment approaches are from the fourth edition of the Diagnostic and Statis-
tailored to match the presenting clinical needs of the tical Manual of Mental Disorders (DSM-JV; Ameri-
individual. can Psychiatric Association, 1994) are formated to
Care processes promote active engagement in at- provide a semistructured interview allowing the clini-
titude and behavior change by implementing the cian to assess diagnostically significant data. Fre-
treatment plan. The treatment plan is a blueprint for quently, the Jellinek chart, a self-administered inven-
intervention, based on a developmental approach of tory, is used to map the progression of symptoms,
gradual increments of self-awareness, new learning, providing a counseling vehicle for further assessment
emotional stability, and behavior change. and patient education.
Continuing care involves both ongoing care plan- Biological markers involving acute effects of alco-
ning and specific services. A continuing-care plan hol toxicity (elevated liver enzymes) and/or longer
entails those services necessary to facilitate adjust- term alcohol- and drug-related complications (pe-
ment to sober living posttreatment. Less intensive in- ripheral neuropathy, secondary hypertension) are
tervention continues, involving referral to AA, indi- used as objective measures to help substantiate the
vidual counseling, and in some cases, halfway house extent and severity of alcohol and drug use.
placement. Several research studies have found that Psychological data are employed to evaluate and
AA attendance following treatment is predictive of describe alcohol- or drug-related symptoms. For ex-
better outcomes (Montgomery, Miller, & Tonigan, ample, neuropsychological screening results may be
1995; Morgenstern, LaBouvie, McCrady, Kahler, & used to assess cognitive impairment. Other measures
Frey, 1997; Tonigan, Toscova, & Miller, 1996). are used to evaluate the likelihood and nature of al-
cohol and drug dependence, such as the Alcohol Se-
verity Index (ASI; McLellan, Luborsky, Woody,
Assessment Procedures
O'Brien, & Druley, 1983).
Assessment of alcohol and drug abuse and depen-
dence is an integrated process involving patient self-
Treatment Ingredients, Structure, Goals,
report, input from significant others and related
and Approaches
sources, objective measures, and clinical observation.
An important aspect of the disease model is the un- The clinical process of care intensively addresses
derstanding that the patient is the primary source of the application of the 12 steps through a carefully
information about his or her alcohol/drug history. In planned treatment strategy to promote therapeutic
the disease model, the patient is treated as an intelli- change. Each step encompasses specific milestones
gent, capable person in the process who is—or soon that help individuals interpret and operationalize the
will be—responsible for choices about his or her step as a guide for living. Individual and group coun-
care. There is a decided preference for believing the seling techniques such as person-centered, cognitive
patient, recognizing that time and education are behavioral, or existential approaches are employed to
likely to facilitate better recall and more thorough (a) heighten individual understanding of each step
self-report. As a result, a number of assessment meth- and its ramification for change; (b) reduce obstacles
ods are employed, including collateral information to continued progress; (c) resolve risk factors for re-
and, at times, drug testing, but the patient is in most lapse; and (d) mobilize potential strengths. Progress
cases the best source of information (Room, 1991). is measured by observations of attitudinal, affective,
A systematic clinical interview is the basis for patient and/or behavioral change consistent with anticipated
self-report. First, an alcohol and drug use history outcomes from the individual treatment plan.
questionnaire is completed. The history provides an Treatment approaches are designed to promote
account of the type, rate, and frequency of drug and access to and participation in 12-step self-help groups
alcohol use starting chronologically from the first us- posttreatment. A foundation is laid for lifelong skills
 THE DISEASE MODEL 277

that build on input and support from recovering of continued addictive behavior in comparison to be-
peers as a relapse prevention strategy. Since there is havior change necessary for recovery; (c) recognition
no biological cure, consistent maintenance of behav- that alcoholism is a disease, beyond the control of
ior change is required to prevent relapse. normal willpower; (d) reduction of shame and self-
blame as behavior dysfunction is attributed to dis-
ease; and (e) recognition of the need for help from
Self-Discovery
others in order to effect behavior change.
Initial treatment goals focus on recognition and ac-
ceptance of the problem. Since an elaborate defense
Self-Efficacy
system of denial maintains the progression of the ill-
ness, educational interventions are needed to pro- The next stage in the process of care builds self-effi-
mote self-discovery. Treatment interventions are cacy by focusing on Step 2 of Alcoholics Anony-
likely to include psychoeducational services, such as mous. Step 2 counseling emphasizes the restorative
bibliotherapy, group instruction, and lectures that ex- nature of recovery by facilitating hope for change.
plain the dynamics of alcohol and drug dependence. Since the control of drinking is not self-regulated,
Data from the alcohol and drug assessment are used alternative resources are needed to avoid addictive
to identify self-defeating consequences such as rela- behaviors. During this stage, there is an emphasis on
tionship problems, vocational difficulties and medi- the individual's capacity to recover by accessing re-
cal complications. The initial stage of counseling is sources beyond the limits of oneself. For example,
designed to promote acceptance of the illness, recog- treatment methods may include a daily journal of
nition of the need for help, and development of a positive events, daily meditation, or reading selec-
motivational foundation for continued change. tions from Alcoholics Anonymous (1955).
These psychological tasks or milestones assist the in- Alcoholics Anonymous (1939, 1955), one of the
dividual in understanding and applying Step 1 from first self-help books, was written by recovering alco-
Alcoholics Anonymous (1955), which reads, "We ad- holics. The first five chapters provide a hands-on ap-
mitted we were powerless over alcohol—that our proach to coping with daily stressors without drink-
lives had become unmanageable" (p. 59). ing. The remaining chapters provide an avenue for
The first step has two parts. The first phrase refers personal identification with biographical stories of re-
to the involuntary loss of control over alcohol and covery. Other sources of bibliotherapy are used as
provides the rationale for continuous abstinence. well, sometimes to enrich the application of the prin-
The second component refers to the devastating con- ciples of Alcoholics Anonymous (1955) for select pop-
sequences of the disease. Unmanageability is the ulations, such as the Dual Disorder Recovery Book
term used to refer to the personal, emotional, social, (1993) or Women's Way Through the 12 Steps (Cov-
and vocational problems engendered by recurrent ex- ington, 1994).
cessive consumption. It is during this stage that the concept of a Higher
To help personalize Step 1, the individual is Power is introduced. A Higher Power represents a
given an opportunity to tell his or her story to a peer positive resource that potentially impacts the quality
group of newly recovering individuals. The story of one's life. Rather than emphasizing institutional-
traces major life developments beginning with for- ized belief systems or dogma, spirituality is a self-de-
mative years, first drinking episodes, and the pro- fined, highly personalized experience. For some, it is
gression of drinking behavior and its effects on in- a supernatural source while for others a Higher
terpersonal relationships, family, and vocational Power may be a therapeutic support group, a counse-
development. The story provides a common ground lor, or AA itself. For most, it is a combination of a
that promotes fellowship and support for change as spiritual understanding that helps shape and give
similarities are identified. It is this process of shared meaning to life with the aid and support of other
fellowship that provides the basis for self-help. recovering peers.
Anticipated outcomes of Step 1 treatment meth- Anticipated outcomes from Step 2 treatment ac-
ods typically involve (a) self-awareness concerning tivities involve the development of a realistic opti-
the extent and severity of drinking behavior and its mism concerning the capacity to recover by access-
self-defeating consequences; (b) cost-benefit analysis ing available resources. There are self-reports of hope
278 TREATMENT

for a better quality of life and an emerging mental praisal of potentially problematic situations. It aids in
picture of a lifestyle free of alcohol and drugs. Emo- the evaluation of actions that could be constructively
tionally, there is less cynicism and the beginnings of taken while also recognizing limitations of one's ca-
a stronger self-image and self-esteem. Behaviorally, pacity to exert influence or control.
the individual is typically more inclined to avoid so- Counseling and treatment approaches associated
cial isolation. There is planned quiet time for reflec- with Step 3 are action-oriented. Counseling tech-
tion or meditation as a daily discipline. niques such as cognitive restructuring are sometimes
employed to challenge self-defeating attitudes, in an
effort to develop and reinforce more adaptive belief
Taking Action
systems. Likewise, behavior therapy techniques are
Individual and group counseling that help facilitate frequently integrated with Step 3 work in terms of
transition from Step 2 to Step 3 focus on the develop- behavioral prescriptions for change, assertiveness
ment of trust. During this stage, behavioral recom- training, and progressive relaxation training. These
mendations may focus on social skills assignments psychologically oriented techniques are applied in
that involve self-disclosures and risk-taking behaviors an effort either to assist the individual in understand-
in the practice of newly learned behavioral skills. ing the dynamics of Step 3 or to help more con-
Steps 1 and 2 of Alcoholics Anonymous provide the cretely to apply Step 3 to everyday living.
attitudinal foundation for change through self-assess- Expected outcomes from Step 3 treatment meth-
ment and education, while Step 3 focuses on taking ods can be observed in attitudinal and behavior
assertive action in response to newly formed or reaf- changes such as (a) accepting and acting upon feed-
firmed beliefs, expectations, and values. Step 3 of Al- back from trusted resources; (b) communicating a
coholics Anonymous reads, "Made a decision to turn more trusting attitude toward a process of change; (c)
our will and our lives over to the care of God as we assessing personal needs and asserting them realisti-
understood Him." cally without resorting to manipulation or aggression;
From a therapeutic vantage, this step signifies a (d) asking for help; (e) seeking the input of others
number of changes. First, the individual makes a before making decisions or acting on impulse; (f) risk-
conscious decision to trust emerging values that will ing the vulnerability to communicate perceptions,
eventually help shape daily decisions and actions. thoughts, and feelings to others; (g) communicating
Next, the step connotes a willingness to trust this more openly and directly; (h) utilizing resources be-
evolving spirituality to the extent that the individual yond oneself, such as advice of professionals, reading
is willing to relinquish his or her dysfunctional materials, and support from peers, to solve daily
modes of maladaptive functioning in favor of sug- problems; (i) practicing new behavior, such as assert-
gested methods of recovery. iveness, progressive relaxation, and social skills; (j)
It is also during this stage that introspection and maintaining and initiating a personal schedule of
self-responsibility are stressed. Early in treatment, quiet time, meditation, or inspirational reading; and
people often blame others for the etiology or mainte- (k) reducing maladaptive coping patterns, such as ex-
nance of their disease. Treatment methods are de- cessive control or self-centeredness.
signed to help shift the focus from blame to personal In contrast, some individuals may attain an un-
responsibility. Use of AA slogans as self-statements, derstanding of Step 3, yet have difficulties that are
such as "Easy does it," are taught and reinforced to manifested by such attitudinal behavioral patterns as
promote self-regulation of hyperarousal or reactivity (a) openly doubting their capacity to make and main-
to environmental cues. Treatment assignments may tain behavior changes; (b) expecting that circum-
involve consciously applying AA slogans as a method stances, events, and/or other people will change with-
to modulate emotionality and increase awareness of out perceiving themselves as a catalyst; (c) believing
behavioral coping options. Likewise, the Serenity that actions involving lifestyle changes are necessary
Prayer serves a similar function: "God grant me the for recovery, but doubting their personal capacity to
serenity to accept the things I cannot change, cour- implement these changes; (d) reporting continued
age to change the things I can, and wisdom to know anxiety and excessive worry; (e) being intermittently
the difference." The Serenity Prayer provides a spirit- immobilized in making small changes in everyday
ually oriented cognition that promotes realistic ap- behavior; (f) listening to input yet being mistrusting
 THE DISEASE MODEL 279

and slow to act on newly learned information; and strengths and personal resources. Step 4 processes of-
(g) relying on old, maladaptive coping styles. ten provoke negative feelings. Psychoeducational as-
Specific treatment interventions are designed to signments may focus on readings that identify the
reduce obstacles involving Step 3 milestones. Treat- difference between guilt and shame, or cognitive re-
ment techniques that are individually tailored to ad- structuring may be applied to counteract shame-pro-
dress these types of obstacles typically involve indi- voking beliefs.
vidual counseling, psychoeducational assignments, Some people have difficulty approaching their
involvement in groups emphasizing assertiveness work on Step 4, perhaps because of continued exces-
training and cognitive forms of therapy, pastoral sive blaming of others, preoccupation with anger and
counseling, and family conferences or topical group resentments, or anxiety from painful memories. Sub-
therapy sessions focusing on self-responsibility and sequently, individualized treatment strategies are
the dynamics of change. planned to address and reduce the emotional behav-
ioral obstacles to participation in a fourth-step treat-
ment process. For some, Step 4 may be modified by
Self-Inventory
focusing more exclusively on strengths and personal
Changes that occur as the result of treatment meth- resources, thereby reducing the perceived threat. For
ods associated with each of the steps are additive and others, Step 4 can be delayed until after a more sus-
self-renewing. New skills and insights are added as tained period of abstinence and emotional stability.
each step is applied to everyday living experiences. A Anticipated personality changes associated with
step is never entirely finished or completed but is Step 4 treatment assignments frequently involve a
reaffirmed and reapplied each day. For example, growing willingness to consider one's shortcomings
Step 4 is both a renewal and an elaboration of Step that serve as risk factors for relapse, a more balanced
1. Step 1's emphasis on the seriousness and extent of self-perception of strengths and limitations, and reso-
addiction, the involuntary nature of the condition, lution of shame and self-reproach.
and its harmful effects necessitates the use of psycho-
logically oriented skills involving introspection, real-
Letting Go
istic evaluation of informational sources, self-assess-
ment, and recognition and acceptance of human Step 5 treatment methods provide an opportunity for
shortcomings. Step 4 builds on these milestones to catharsis by sharing the contents of the Step 4 inven-
expand one's conscious awareness and behavioral tory with another person. Step 5 of Alcoholics Anon-
repertoire to engage in realistic self-appraisal of per- ymous reads, "Admitted to God, to ourselves, and to
sonal strengths and limitations. While Step 1's em- another human being the exact nature of our
phasis focuses on the dynamics of addiction, Step 4 wrongs." Treatment methods for Step 5 include in-
has a more inclusive focus on personality and inter- dividual conferences with a trusted chaplain or
personal functioning. Step 4 of Alcoholics Anony- spiritual adviser to lay a foundation for Step 5 self-
mous reads, "Made a searching and fearless moral disclosure. Step 5 is facilitated by an accepting envi-
inventory of ourselves." ronment where personal self-disclosures of sensitive
While providing a format for self-assessment, Step information are shared without judgment. The pro-
4 treatment methods integrate the affective changes, cess of honest disclosure is thought to be the essen-
attitudes, and behavioral skills from Steps 1, 2, and tial therapeutic value in this treatment process. At
3. A simple formula for comprehensive self-appraisal the conclusion of the inventory, the participant is
is used to evaluate major life dimensions. Input from free to request feedback or engage in a dialogue re-
significant others, family, therapists, and newly recov- garding the inventory with the fifth-step listener.
ering peers is used to help evaluate problematic traits Anticipated effects of Step 5 treatment activities
or behavior patterns, existing strengths, and potential usually involve a greater willingness to identify risk
blocks to continued growth and change. factors for relapse, accepting responsibility for one's
Treatment methods applied to Step 4 are both own behavior change, having a greater awareness of
supportive and educational. The inventory is confi- the disease's impact on character development, rec-
dential, allowing the individual an opportunity to re- onciling with one's own spiritual beliefs and values,
alize past problems and mistakes while considering increasing the motivation to continue with Steps 6-
280 TREATMENT

12, and often, observable relief of shame, guilt, and ROLE OF THE THERAPIST
self-reproach.
While step work is often prescribed sequentially, A key treatment modality of the disease model is the
different steps are applied to address varying prob- mentoring relationship between a primary therapist
lems. For example, an individual with significant (chemical dependence counselor) and an individual
grief and dysphoria may begin work on Step 2 as a client. The relationship provides the vehicle by
method of developing hope prior to working on Step which coaching and counseling occur that help
1. Likewise, Step 4 work is sometimes prescribed in move the individual toward incremental behavior
conjunction with Step 1 when there is considerable changes.
resentment, to facilitate an unburdening of anger The training of chemical dependency counselors
and blame. The therapeutic value of each step is ap- varies from state to state. Typically, counselors are
plied prescriptively according to the presenting needs either certified or licensed by a state regulatory
of the individual. agency. There is a decided preference in the field for
candidates who either are recovering or have experi-
ence with 12-step programs such as Al-anon. Formal
education ranges from an associate's degree to mas-
Continuing Care
ter's level preparation. Usually, the counselor has
The initial phase of recovery is usually associated completed a certified training program and/or a su-
with Steps 1-5. These first steps are most closely as- pervised clinical internship in addition to educa-
sociated with the evolution of a spiritual awakening, tional preparation that specifically addresses the clin-
where the individual metaphorically wakes up to the ical dynamics of chemical dependence. Current
reality of his or her situation and accepts the guid- trends support the movement of counselor-training
ance and counsel of others to acquire the skills for programs to baccalaureate or master's degree pro-
sober living. These attitudes and behaviors are re- grams.
newed and reinforced by Steps 6-12, which are com- The counselor plays a dynamic role by promot-
monly referred to as relapse prevention steps, since ing change through a carefully planned agenda
their focus addresses the continued elaboration of of intervention that builds on eclectic counseling
skills learned in Steps 1-5. approaches consistent with 12-step methodology.
Posttreatment services, or continuing care, in- Counselors assess the extent and severity of alcohol
crease the quality of recovery by helping to prevent and drug use, integrate diverse information from the
relapse. Based on variability of severity, continuing- multidisciplinary team, develop treatment plans, fa-
care options are individually prescribed. One-to-one cilitate group and individual counseling, conduct
counseling and referral to a 12-step self-help support family conferences, develop continuing-care plans,
group are frequently recommended for those individ- and coordinate related case management activities.
uals with supportive family and social environments, Counseling skills include relationship building,
employment, and relatively successful treatment re- confrontation, emotional support, behavioral coach-
sponse. ing, problem solving, homework assignments, and
Many are referred to mental health professionals psychoeducation. Counselors often use their recov-
for the treatment of mental health complications ery experience to coach, role-model, and motivate.
such as unresolved childhood trauma, serious rela-
tionship dysfunction, or poorly controlled depression
and anxiety. For those individuals with unstable fam- COMMON OBSTACLES TO
ily and social environments, prior unsuccessful treat- SUCCESSFUL TREATMENT
ment attempts, unresolved mental disorder, and lim-
ited vocational options, halfway house placement is There are several potential obstacles to the successful
recommended. Halfway house services provide conti- delivery of the Minnesota model form of treatment.
nuity of care by maintaining a central focus on the One obstacle, which can be inferred from above, is
disease model, application of the 12 steps, and com- the comprehensiveness of the resources needed to
munity reintegration as a recovering person. implement the model as it is intended. However, if
 THE DISEASE MODEL 281

they are not available or fundable within an agency processes and their effect on treatment outcome. Pa-
itself, creativity can be used to aggregate the re- tients with a greater commitment to abstinence and
sources needed from the surrounding community. stronger intentions to avoid high-risk situations
achieved higher abstinence rates. Among those who
did relapse, those with a greater commitment to Al-
CLIENT CHARACTERISTICS coholics Anonymous and a stronger belief in a
Higher Power had less severe relapses than those
Several studies have examined the extent to which who did not hold these beliefs.
client characteristics may impede or counterindicate Because of the nature of the Minnesota model or
Minnesota model treatment. Variability of the client 12-step facilitation treatment, particular subgroups of
population is an important factor in the study of alcoholic or drug-dependent individuals may be
treatment response. Although research addresses this more likely to have a less than favorable treatment
issue, there are limited studies that focus exclusively response. For example, individuals with mental dis-
on predictive factors for treatment response to the orders such as schizophrenia and related conditions
disease model. Early efforts attempted to evaluate de- or those with severe personality disorders such as bor-
mographic or descriptive variables as predictors of derline or antisocial are likely to have difficulty with
treatment response. In terms psychopathology, wom- both the relational qualities of the treatment model
en reported less problem drinking posttreatment and and its spiritual dimension. The cognitive nature of
depressed mood as a precursor to relapse and had the treatment approach precludes individuals with
a higher rate of returning to abstinence following a severe cognitive dysfunction.
drinking episode (Helzer et al., 1985). Negative emo- Because of the biopsychosocial nature of the dis-
tional states such as depression and anxiety have ease model, application of select treatment modal-
been associated with posttreatment drinking (Hatsu- ities within or outside the Minnesota model may be
kami & Pickens, 1980; Pickens, Hatsukami, Spicer, & indicated to address the special needs of youth, indi-
Svikis, 1985). viduals with comorbid conditions, and those suffer-
However, more recent endeavors have failed to ing from social instability and economic disadvan-
identify predictive demographic or other standard tage.
background variables in the study of treatment re-
sponse to the disease model. For example, in a study
of over 1,000 men and women admitted to a disease EMPIRICAL DATA ON THE
model residential facility, Stinchfield and Owen EFFECTIVENESS OF DISEASE
(1998) found that variability was evenly distributed MODEL TREATMENT
in terms of treatment outcome. Variables such as co-
morbid conditions, age, gender, employment, and re- The disease model of treatment is one of the most
lational support did not have predictive value for widely used forms of inpatient and residential alco-
treatment outcome. holism and drug dependence treatment in the
In a study of individual client types and response United States (Fuller, 1989; Miller et al., 1995). Per-
to different models of treatment, Project MATCH haps because of its theoretical appeal, anecdotal evi-
(1997) did not identify variables for treatment out- dence, or development apart from academic institu-
comes relevant to the disease model in terms of indi- tions, the disease model has not been extensively
vidual client variability. It was found that people with tested. In Fuller's (1989) review of alcoholism treat-
lower levels of psychopathology did better in the 12- ment outcome literature, most studies conducted
step facilitation model than in the other two treat- were found to have methodological flaws, yet Fuller
ment models; the converse, however, was not true. contended that from a broad perspective, the disease
No other demographic, mental health, alcohol sever- model of treatment is effective.
ity, or other background characteristics predicted a Several studies of disease-model-type programs
better outcome in any of the models tested. have been published. Hazelden conducted a series
Morgenstern, Frey, McCrady, Labouvie, and of studies on its patients. Laundergan (1982) ana-
Neighbors (1996) examined specific disease model lyzed 12-month follw-up data collected on 3,638 cli-
282 TREATMENT

ents treated at Hazelden between 1973 and 1975 and Hoffmann and Harrison (1991) published a large-
found that 53% of the 50% contacted reported ab- scale outcome report on two groups of patients fol-
stinence. The low response rate compromised the lowed via their outcome system, called the Chemi-
accuracy of these results. Gilmore (1985) analyzed cal Abuse Treatment Outcome Registry (GATOR).
similar 12-month outcome data on 1,531 clients ran- Combined, over 3,000 clients, most from Minnesota-
domly selected for follow-up between 1978 and 1983. model-type treatment programs, were followed for 2
With a response rate of 75%, she found that 89% were years. The response rates for the two groups were
abstinent or reported lower use. Higgins, Baeumler, 53% and 37%. Of these, about two thirds reported
Fisher, and Johnson (1991) analyzed 12-month out- abstinence for the full year after treatment. After cor-
come data on 1,655 clients treated at Hazelden in recting for bias and low response rate, the authors
1985 and 1986. They found that 61% were abstinent suggested that a more accurate abstinence rate for
during the year after treatment. However, while the these groups was probably closer to 40%.
response rate was reported to be 72%, rather liberal Recent attempts have been made to more defini-
exclusionary criteria were used. Most recently, a more tively study the effectiveness of alcoholism treatment
rigorous Hazelden outcome study was completed, an- models by studying the efficacy of matching treat-
alyzing the pretreatment and posttreatment use levels ment approaches to specific client characteristics.
of 1,083 patients treated from 1989 to 1991. At the The National Institute on Alcohol Abuse and Alco-
1-year outcome, 71% of the patients were contacted; holism (NIAAA), in a rigorously controlled study
of these, 53% reported continuous abstinence, and called Project MATCH, evaluated multisite trials of
an additional 35% had reduced their drinking and patient treatment matching. Project MATCH eval-
drug use (Stinchfield & Owen, 1998). uated whether different types of clients responded
McLellan et al. (1993) published a study report- differently to three different types of treatments: (a)
ing outcomes of patients from four private treatment disease model or 12-step facilitation, (b) cognitive
centers, two inpatient and two outpatient. While the behavioral treatment, or (c) motivational enhance-
programs varied somewhat in characteristics, all four ment therapy. Over 12 weeks, treatment services
programs were based on the 12 steps of Alcoholics were conducted by qualified therapists using a stan-
Anonymous, had a goal of abstinence, and utilized a dard treatment protocol. Treatment outcome data re-
multidisciplinary team to deliver services. A response vealed that (a) participants without severe psycho-
rate of 94% was achieved, and patient reports were pathology had significantly higher rates of abstinence
verified via urinalysis and breathalyzer. Six months in outpatient 12-step facilitation treatment than in
after treatment, 59% were abstinent from alcohol, cognitive behavior therapy; (b) participants in 12-step
and 84% were abstinent from drugs during the 30- facilitation aftercare services had slightly fewer drink-
day window preceding follow-up contact. There were ing episodes; and (c) 12-step facilitation outcomes
differences across the four programs, attributable to were generally comparable or, in some instances,
intensity of services. It is worth noting, however, that more favorable (Project MATCH Research Group,
the two inpatient programs yielded an average absti- 1997).
nence rate of 71%, while the two outpatient pro-
grams averaged an abstinence rate of 48%.
Walsh and her colleagues (1991) designed a STRENGTHS AND WEAKNESSES OF
randomized study to compare the effectiveness of THE DISEASE MODEL
employee assistance program referrals to inpatient
hospital treatment, or participation in Alcoholics There are three main strengths of the disease model
Anonymous, or a choice of either of these two op- approach that directly affect clients: (a) Clients bene-
tions. Ten hospitals were used as treatment sites, so fit not only from their counselors' input and interac-
consistency in model was unlikely; however, we do tions, but from their peers as well; (b) other people
know that all programs were abstinence-based. Two who are further ahead in the recovery process, even
years after treatment, 37% of those hospitalized, 16% if by just a matter of a few days, provide credible and
of those assigned to Alcoholics Anonymous (with no hopeful role models for the client; and (c) clients
treatment), and 17% of those given a choice reported treated in the disease model become part of a sup-
abstinence. port group of other recovering people that extends
 THE DISEASE MODEL 283

beyond the walls or timeline of the treatment pro- search data. As a theory or body of knowledge, it is
gram. By becoming familiar with and integrated into neither static nor complete. The early work of Jelli-
Alcoholics Anonymous groups, clients have access to nek serves as a conceptual umbrella under which
support 24 hours a day, 7 days a week, in nearly every new dimensions or scientific findings may be added
part of the world. The disease model provides a cost- to explain the multidimensional nature of the illness.
free system of lifelong support through referral to a Key characteristics of disease model theory typically
12-step self-help group. include an emphasis on the biological underpin-
From a methodological perspective, a major nings of addictive behavior; genetic contributions to
strength of the 12-step facilitation treatment model is the disease's etiology; involuntary loss of control over
its holistic approach to recovery. This model is built behavior; predictable progression of symptoms; nega-
on both a biopsychosocial and a spiritual foundation, tive consequences affecting social, vocational, psy-
and it has the capacity to integrate innovations as chological, and ethical or spiritual domains; rigidly
knowledge is gained regarding the nature of the ill- ingrained psychological defense mechanisms; and re-
ness and the recovery process. The disease model peated failure of attempts to reduce or control drink-
serves as a conceptual umbrella which covers diverse ing behavior.
treatment approaches, thus maximizing opportuni- Abstinence is the principle prescription of the dis-
ties for effective treatment. The framework of the ease model for recovery. Consequently, treatment
model endorses core values that embrace the inher- implications are broad and far-reaching, ranging
ent worth and dignity of each person by recognizing from specific skills training to assignments requiring
the capacity to change based on education, fellow- major life decisions. Treatment processes provide the
ship, and therapy. skills necessary to develop a lifestyle that is centered
The model's greatest strength is also potentially on values to help shape and give meaning to life's
its greatest limitation. Since the model relies on a everyday occurrences, and to avoid, resist, or refuse
multidisciplinary team, services can be time-consum- alcohol in high-risk situations.
ing and costly. Some would argue that the time and The 12-step facilitation model, or Minnesota
money spent are a wise investment the costs are com- model, is a natural outgrowth of the disease model.
pared to those of continued addictive behavior. For Twelve-step facilitation modalities are typically char-
example, in general, untreated alcoholics have health acterized by the use of a multidisciplinary team to
care costs at least 100% higher than nonalcoholics, address the biopsychosocial nature of the illness, a
and this disparity may continue for as long as 10 strong spiritual dimension, emphasis on the daily op-
years before entry into treatment (Blose & Holder, erationalization of the 12 steps as problem-solving
1991; Holder, Longabough, Miller, & Rubonis, and coping mechanisms, psychoeducation and bibli-
1991). Nonetheless, the model demands time, atten- otherapy, and fellowship and peer self-help in addi-
tion, and effort for the principles and practices to tion to group and individual therapy. Posttreatment
work. recommendations routinely involve referral to a 12-
Other limitations pertain to potential problems in step self-help support group for relapse prevention
implementing the disease model of treatment. If too and continuing care in addition to counseling, men-
dogmatically interpreted, this form of treatment be- tal health services, and in some cases, extended care
comes distorted and presented in a confrontive, re- such as halfway house placement.
ligious, or generic (rather than individualized)
manner. When this occurs, the core therapeutic
Note
principles and methods of the model are obscured,
and many clients are naturally resistant and unable Correspondence regarding this manuscript should be
to benefit from it. sent to Dr. Timothy Sheehan, Hazelden, Box 11, Cen-
ter City, MN 55012. E-mail: tsheehan@hazelden.org

SUMMARY
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Morgenstern, J., & McCrady, B. S. (1992). Curative fac- M. E. Hilton (Eds.), Alcohol in America (pp. 26-50).
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Eighth Special Report to the U.S. Congress on Alco- hol dependence (pp. 121-137). New York: Springer-
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 16

Treatment Models and Methods:

Family Models

Timothy J. O'Farrell
William Fals-Stewart

In the past 30 years, considerable progress has been Although alcoholism and drug abuse were histori-
made in the theoretical development, clinical appli- cally conceptualized as an individual problem best
cations, and outcome research related to marital and treated on an individual basis (e.g., Jellinek, 1960), a
family treatment of alcoholism and drug abuse. A large and growing body of research suggests that fam-
number of literature reviews have concluded that ily members often play a central role in the lives
marital and family treatment produces better marital of alcoholics and drug abusers (Stanton & Heath,
and substance use outcomes than nonfamily meth- 1997). In turn, an increasing number of researchers
ods (e.g., O'Farrell, 1992; Stanton & Shadish, 1997). and clinicians have examined family factors relevant
Furthermore, enthusiasm for understanding the role to substance use disorders, and the clinical appli-
family members may play in the development, main- cations of marital and family therapy have grown
tenance, and treatment of alcohol and other drug considerably over the last 30 years. It is now recom-
problems has not been limited to the research com- mended that clinical practice include family mem-
munity. The popular literature on families and sub- bers in the substance-abusing patient's treatment. In
stance misuse has grown into an industry over the fact, the Joint Commission on Accreditation of Health
last decade, with a wide range of books describing Care Organizations (JCAHO) standards for accredit-
codependency, enabling, adult children of alcohol- ing substance abuse treatment programs in the
ics, and so forth appearing regularly on bookstore United States now require that an adult family mem-
shelves. Additionally, different varieties of profes- ber who lives with the identified patient be included
sional and self-help support groups for family mem- at least in the initial assessment process (Brown,
bers of alcoholics and addicts are now readily avail- O'Farrell, Maisto, Boies, & Suchinsky (1997). In this
able in most communities. chapter, we (a) briefly describe the historical roots

287
288 TREATMENT

of family-based interventions with psychoactive sub-

Early Psychodynamic Models
stance use disorders; (b) explore the theoretical basis
of family models of substance abuse etiology and In the 1930s, social workers treating alcoholic men
maintenance; (c) examine methods of marital/family in state mental institutions began to interview pa-
therapy in the treatment of alcoholism and drug tients' spouses and found they were significantly
abuse; (d) briefly summarize the empirical data on distressed and consistently reported high levels of
the effectiveness of family-based interventions for depression, anxiety, and somatic concerns (Lewis,
substance abuse; and (e) review the strengths and 1937). The theoretical models developed to explain
limitations of family treatment for substance abuse these observations were psychodynamically oriented,
and the future research needed in this area. postulating that wives of alcoholics were disturbed
women who resolved their neurotic conflicts by mar-
rying alcoholic men (Whalen, 1953). These early
models placed responsibility for the alcoholic's con-
HISTORICAL ORIGINS OF THE tinued drinking largely on the disturbed spouse.
FAMILY TREATMENT MODEL
AND ITS APPLICATIONS Early Sociological Stress Models
TO SUBSTANCE ABUSE
In the 1950s and 1960s, sociological explanatory
models emerged to explain the observation that
Early Developments in the Family Model
spouses of alcoholic men were psychologically dis-
of Treatment of Substance Abuse
tressed. Based on interviews with women attending
Although it is likely that people have been listening Al-Anon meetings, Jackson (1954) suggested that
to each other's family problems and responding with symptoms observed in these wives were the result of
advice for as long as there have been families, only stress from living with an alcoholic partner. Addition-
in the last century has a profession developed whose ally, she reported that families developed and em-
sole purpose is to deal with family-based problems ployed various coping strategies to deal with the
(Broderick & Schrader, 1981). Formal family treat- stress created by the alcoholic family member. In
ment has its roots in the social work movement of contrast to the psychodynamic explanations de-
the late 1800s; charity organizations developed to aid scribed earlier, this stress and coping model placed
the poor and disadvantaged routinely worked with responsibility for family problems with the alcoholic
families (Rich, 1959). However, family-based con- rather than the spouse.
ceptualizations and treatment models for psychologi-
cal and psychiatric problems as we know them today
Contemporary Family-Based
were foreshadowed by the work of the early psycho-
Conceptualizations of Alcoholism
analysts, who recognized the importance of early
and Drug Abuse
family relationships in shaping personality (e.g.,
Jung, 1910) and theorized that individual psycho- Over the last three decades, three theoretical per-
pathology might result from family conflict (e.g., Ad- spectives have come to dominate family-based con-
ler, 1917). The family therapy movement, as it is of- ceptualizations of substance use disorders (Gondo-
ten called, began in the early 1950s, when therapists li & Jacob, 1990; O'Farrell, 1995). The best known
and researchers, unknown to one another at the of these and the most widely used is the family dis-
time, began to interview families in order to under- ease model, which views alcoholism and other drug
stand the problems manifested by one family mem- abuse as an illness suffered not only by the alcoholic,
ber (Guerin, 1976). From this practice grew the no- but also by family members. The family systems ap-
tion that family dynamics contributed to etiology and proach applies the principles of general systems the-
maintenance of different disorders and that address- ory to families, with particular attention paid to how
ing family dysfunction was a potentially beneficial in- families maintain a dynamic balance between sub-
tervention for identified patients and the family as a stance use and family functioning and how their in-
whole (Stanton & Heath, 1997). teractional behavior is organized around alcohol or
 TREATMENT MODELS AND METHO FAMILY MODELS 289

drug use. Behavioral approaches assume that family negative consequences often associated with drink-
interactions serve to reinforce alcohol- and drug-us- ing or drug taking.
ing behavior. We will now review each of these ap- The family disease approach typically involves
proaches in more detail, providing (a) a brief review separate treatment for family members without the
of their historical antecedents, (b) their current status substance-abusing patient present. Treatment often
and clinical applications, and (c) a review of relevant consists of psychoeducational groups about the dis-
constructs and terms associated with each model. ease concept of alcoholism and codependency; refer-
rals to Al-Anon, Al-Ateen, or Adult Children of Alco-
holics groups; and individual and group therapy to
The Family Disease Model
address various psychological issues. In general, the
Since the founding of Alcoholics Anonymous (AA), family disease approach advocates that family mem-
the family unit has been one of the main foci of the bers should not actively intervene to try to change
disease concept of alcoholism. Several AA publica- the substance-abusing patient's drinking or drug use
tions include information and advice to family mem- but should detach and focus on themselves in order
bers of alcoholics (e.g., Alcoholics Anonymous, 1976). to reduce their own emotional distress and improve
AA's sister organization, Al-Anon, was founded in 1949 their own coping (Al-Anon Family Groups, 1981;
to assist and support family members and friends of Laundergan & Williams, 1993).
alcoholics. The contemporary family disease model At present, the family disease approach has very
of alcoholism is perhaps best exemplified by the limited research support (O'Farrell, 1995). Neverthe-
widely read books by Black (1982) and Wegsheider less, family interventions based on this model are the
(1981), each of which describes children raised in most commonly used in substance abuse treatment
alcoholic families and how their experiences in these programs and have strongly influenced public per-
families influence their adult behavior. More re- ceptions of the effect of substance use on the family.
cently, other authors (e.g., Beattie, 1987; Schaef,
1986) have focused on how the disease of alcoholism
Family Systems Models
manifests itself symptomatically in spouses and inti-
mate partners (e.g., low self-esteem, anxiety about in- In the 1970s and 1980s, family systems approaches
timacy and separation, and enmeshment in dysfunc- became increasingly influential among substance
tional relationships). abuse treatment professionals and have since been
Alcoholism is viewed as a "family disease," with applied to the treatment of alcoholism and drug
family members of alcoholics suffering the disease of abuse. This model suggested that a reciprocal rela-
"codependence," a term that is often used to describe tionship exists between family functioning and sub-
the process underlying the various problems ob- stance use, an individual's drug and alcohol use be-
served in the families of individuals who abuse psy- ing best understood in the context of the entire
choactive substances. Little consensus exists as to family's functioning. According to family systems
how the term should be defined or operationalized, theory, substance abuse in either adults or adoles-
but according to Schaef (1986), codependence is a cents often evolves during periods in which the indi-
disease that parallels the alcoholic disease process vidual family member is having difficulty addressing
and is marked by characteristic symptoms (e.g., exter- an important developmental issue (e.g., leaving the
nal referencing, caretaking, self-centeredness, control home) or when the family is facing a significant crisis
issues, dishonesty, frozen feelings, perfectionism, and (e.g., marital discord). During these periods, sub-
fear); others have also attempted to define specific, stance abuse can serve to (a) distract family members
identifiable symptoms of codependence (e.g., Cer- from their central problem or (b) slow down or stop
mak, 1986). The hallmark of codependency is en- a transition to a different developmental stage that is
abling, which, as the term implies, is defined as any being resisted by the family as a whole or by one of
set of behaviors that perpetuates the psychoactive its members (Stanton & Todd, 1982).
substance use. These include making it easier for the The major exponents of the application of family
alcoholic or drug abuser to engage in substance use systems approaches to alcoholism have been Peter
or shielding the alcoholic or drug abuser from the Steinglass and his colleagues (e.g., Steinglass, Ben-
290 TREATMENT

nett, Wolin, & Reiss, 1987). In a series of early de- ing member, subsequent sobriety is likely to threaten
scriptive studies of hospitalized alcoholics on a re- homeostasis and may be resisted on some level.
search unit, Steinglass and colleagues (Steinglass, In the family systems approach, therapists use a
Davis, & Berenson, 1977; Steinglass, Weiner, & number of techniques to clarify the core issues in
Mendelson, 1971; Weiner, Tamerin, Steinglass, & the family and promote changes in family interaction
Mendelson, 1971) studied the interactions between patterns. Therapists try to redefine roles, identify im-
an alcoholic father and son, a pair of alcoholic both- plicit and explicit rules that govern family members'
ers, and alcoholics and their spouses. Comparisons behaviors, and define and reinforce boundaries be-
were made in the pattern of interactions when the tween family members. In addition, once the thera-
alcoholic patients were sober and when they were pist understands the function of substance abuse in
intoxicated. These researchers observed certain posi- the family, he or she can reframe it by explaining
tive changes in interactional behavior associated with how the behavior has come about and what function
drinking, which they referred to as "adaptive conse- it serves in the family (Fishman, Stanton, & Rosman,
quences" (Davis, Berenson, Steinglass, & Davis, 1982).
1974). More specifically, they noted that drinking The family systems approach has also been used
stabilized family roles, allowed for expression of af- to conceptualize and treat families in which adults
fect, resulted in greater intimacy among family mem- or adolescents abuse drugs other than alcohol. Per-
bers, and enabled family members to explore topics haps the most well developed is Stanton and Todd's
that they would typically avoid when sober. (1982) use of structural-strategic therapy with heroin-
In subsequent studies, Steinglass (1979, 1981) addicted patients participating in methadone mainte-
compared families with an alcoholic member who nance. These authors emphasized concrete behav-
was drinking, sober, or in transition from one drink- ioral changes, which included focus on family rules
ing status to another. Families in which the alcoholic about drug-using behavior and the use of weekly
was sober were the most flexible in their overall func- urine tests to give tangible evidence of progress. Ad-
tioning (i.e., they demonstrated more flexibility dur- ditionally, the intervention attempted to alter and in-
ing laboratory-based problem-solving tasks and had a terrupt repetitive family interactional patterns that
balance between the time they spent together and maintained drug use. At 1-year follow-up, results
time spent apart when at home). In contrast, drink- showed that patients who participated in this family-
ing families were the most rigid in their family roles based treatment were using illicit psychoactive drugs
and functioning. In comparison to the other family less frequently than patients who received nonfamily
types, families with an alcoholic member in transi- treatment consisting of methadone and individual
tion from one drinking status to another were de- counseling. Family systems therapy has also been used
scribed as intermediate in their problem-solving abil- with drug-abusing adolescents (e.g., Lewis, Piercy,
ity and general family functioning. Sprenkle, & Trepper, 1990).
The family systems approach to treating sub-
stance abuse focuses on the interactional rather than
the individual level. Thus, identifying and addressing
Behavioral Models
underlying family issues or processes that have neces-
sitated the development of the substance abuse in Behavioral marital and family therapy for substance
one or more family members are crucial to therapy. abuse is an extension of the basic constructs of learn-
From a family systems perspective, drug or alcohol ing theory. The central principle is that behaviors,
use by a family member serves an important function including drug and alcohol use, are learned and
for the family, helping to maintain the homeostasis maintained through positive and negative reinforce-
of the family system (i.e., balance, stability, and equi- ment, which can come from familial interactions.
librium). It is assumed that the family's organiza- Within the behavioral approach, social learning the-
tion (i.e., structure and function) helps to maintain ory incorporates aspects of the stimulus-response
homeostasis and that family members will resist models of operant and classical conditioning but ex-
changes that threaten homeostasis. Thus, if a family pands beyond these models to include cognitive pro-
has functioned as a stable unit with a substance-abus- cesses (chapter 14, this volume; Collins, 1990).
 TREATMENT MODELS AND METHODS: FAMILY MODELS 291

Early observational studies of marital communi- ages emphasizes the importance of setting goals and
cation patterns between alcoholic men and their practicing new ways of interacting during the treat-
wives lent support to the hypotheses that drinking be- ment sessions and at home between sessions.
havior could be reinforced by family interactions. O'Farrell's (1993) BMT couples group program
Hersen, Miller, and Eisler (1973) found that during consists of 10-12 initial sessions conducted weekly
a structured problem-solving interaction task, wives with each couple and 10 weekly BMT couples group
looked at their alcoholic husbands more frequently sessions. Initial sessions consist of (a) an initial inter-
when the husbands were discussing alcohol than view; (b) crisis intervention for drinking or marital
when they were discussing other topics, and that hus- crises that must be resolved prior to further work; (c)
bands spoke more during alcohol-related than during negotiation of an Antabuse contract in which the al-
non-alcohol-related communications. These results coholic patient takes disulfiram while the spouse ob-
suggested that spouses might actually be reinforcing serves and verbally reinforces the alcoholic patient
alcohol use by paying more attention to alcohol- for taking the medication; (d) assessment of the
related conversations. A number of interactional stud- drinking and relationship problems and feedback to
ies have also reported increases in positive communi- the couple of the assessment results to increase moti-
cation behaviors associated with alcohol consump- vation for continued treatment; and (e) preparation
tion (e.g., Billings, Kessler, Gomberg, & Weiner, for participation in the couples BMT group. The
1979; Frankenstein, 1982). Thus, despite the nega- BMT couples group sessions consist of 10 weekly
tive consequences that alcohol misuse may have on meetings of four to five couples in which homework
a dyadic relationship, these studies suggest that there assignments and behavioral rehearsal are used to
are also positive changes in the relationship associ- help couples (a) maintain abstinence and decrease
ated with drinking. These findings have an important arguments related to drinking by monitoring compli-
treatment implication, namely, that increasing posi- ance with the Antabuse Contract, reviewing urges to
tive interactions without the presence of alcohol drink, and providing crisis interventions for drinking
might serve to reduce alcohol use. episodes; (b) acknowledge and initiate daily caring
With certain exceptions, family-based behavioral behaviors; (c) plan shared rewarding activities; (d)
treatment models have been used most frequently learn communication skills and problem-solving
with alcoholic couples. Three general reinforcement strategies; and (e) plan for maintenance of therapeu-
patterns are typically observed in substance-abusing tic gains at the end of the group.
families: (a) reinforcement for drinking behavior in Noel and McCrady (1993) referred to their BMT
the form of attention or caretaking, (b) shielding of the program as "Alcohol-Focused Spouse Involvement
alcoholic from experiencing negative consequences re- with Behavioral Marital Therapy" (see also Ep-
lated to his or her drinking, and (c) punishment of stein & McCrady, 1998; McCrady & Epstein, 1995).
drinking behavior ( McCrady, 1986; McCrady & Ep- The program consists of interventions designed to (a)
stein, 1995). In turn, behaviorally oriented treatment change the alcoholic's drinking behavior, (b) change
generally focusses on changing spousal or family in- the spouse's behavior that triggers and reinforces the
teractions that serve as stimuli for abusive drinking or alcoholic partner's alcohol use, and (c) enhance the
that trigger relapse, improving communication and dyadic relationship. Functional analysis, stimulus
problem-solving abilities, and strengthening coping control, rearranging contingencies, cognitive restruc-
skills that reinforce sobriety. turing, planning alternatives to drinking, problem
Two empirically supported behavioral marital solving, and posttreatment maintenance planning are
therapy (BMT) approaches with alcoholic couples used to help the alcoholic patient to stop drinking
are O'Farrell's Antabuse contract plus BMT couples and the spouse to stop triggering and reinforcing al-
group and McCrady's work combining BMT with al- cohol use. BMT procedures, such as planning for
cohol-focused spouse involvement. Both approaches fun activities, communication skills training, and ne-
stress that couples treatment for alcoholism must ad- gotiation and problem-solving, are used to enhance
dress the drinking of the alcoholic as well as the over- the marital relationship.
all adjustment of the spousal system in order to be In two recent investigations, Fals-Stewart and col-
effective. Furthermore, each of these treatment pack- leagues (Fals-Stewart, Birchler, & O'Farrell, 1996;
292 TREATMENT

Fals-Stewart, O'Farrell, Finneran, & Birchler, 1996) evidence of the importance of parent-child interac-
have treated drug-abusing patients and their intimate tions and family socialization in the development of
partners using BMT. They found that husbands who alcohol and drug abuse. For example, Harburg,
received BMT in addition to individual-based treat- Davis, and Caplan (1982) found that offspring tend
ment (i.e., individual and group counseling) had bet- to imitate their perception of their parents' drinking,
ter outcomes, in terms of reduced drug use and im- particularly that of the same-sex parent. In a sample
proved dyadic adjustment, than husbands assigned to of young adult men, Clayton and Lacy (1982) found
receive an equally intensive individual-based treat- a significant positive relationship between perceived
ment only. siblings' drug use and respondents' intention to use.
Thus, from a social learning perspective, children
are socialized by their parents and siblings peers into
FAMILY MODEL IN RELATION TO adult behaviors, including substance abuse.
ETIOLOGY AND MAINTENANCE OF Other investigators have examined the role of
SUBSTANCE ABUSE family interaction in the etiology of substance abuse.
Bennett and Wolin (1990) found that transmission of
alcoholism is more likely if there is continued inter-
Family Model of Etiology
action between alcoholic parents and adult children.
of Substance Abuse
Additionally, adult males have an increased probabil-
For centuries, philosophers have commented on the ity of developing alcoholism if they have regular con-
familial nature of substance abuse. However, it was tact with the alcoholic parents of their wives. Wolin,
not until the past few decades that Plutarch's anec- Bennett, Noonan, and Teitelbaum (1980) demon-
dotal assertion that "drunks beget drunkards" came strated that when one or both parents in a family
under careful scientific scrutiny. Numerous studies were alcoholics, their children were likely to have
have shown that the rates of alcoholism are substan- problems with alcohol misuse if family rituals—din-
tially higher in relatives of alcoholics than in relatives nertime, evening holidays, holidays, and so forth—
of nonalcoholics, children of alcoholics demonstrat- were disrupted during the period of heaviest parental
ing a three- to fourfold increased risk for developing drinking. Conversely, families whose rituals re-
the disorder (e.g., Schuckit, 1987). Several major mained essentially intact in spite of parental drinking
twin studies found that the concordance rate for alco- were the least likely to have offspring who became
holism was significantly higher for monozygotic (i.e., alcoholic. Furthermore, Steinglass et al. (1987) re-
identical) twins than for dizygotic (i.e., fraternal) ported that families that required sobriety of their
pairs (e.g., Hrubec & Omenn, 1981). Adoption stud- members in order to participate in family rituals
ies (i.e., the study of individuals separated soon after were less likely to experience transmission of alcohol-
birth from their biological relatives and raised by ism to their children than families in which there
nonrelative adoptive parents) indicate that individu- were no such rules.
als who had biological parents with severe alcohol
problems were significantly more likely to have alco-
Model of Maintenance of Substance Abuse
holism themselves than if their surrogate parents
and Framework for Treatment
were alcoholic (Goodwin, 1979).
Although these results suggest a genetic media- As with etiology, maintenance of alcohol- and drug-
tion of alcoholism, heredity is best used to explain using behavior is influenced by the interplay of bio-
an increased biological vulnerability to alcoholism. logical, individual, environmental, interpersonal, so-
Genetic models do not explain the processes under- cial, and familial factors. Using a social learning
lying the decision to begin using psychoactive sub- framework, McCrady and Epstein (1995) described
stances or the pattern of use (e.g., light drinking, a model the provides an integrated conceptualization
binge drinking). Clearly, the etiology of substance of these maintenance factors, which they referred to
abuse is multidetermined by biological, psychologi- as the S-O-R-C model (p. 371). Drinking is conceptu-
cal, and environmental pathways (Hesselbrock, 1986; alized as a response (R) elicited by environmental
Hill, 1994). Even given genetic factors in the devel- stimuli (S), such as time of the day or the smell of
opment of alcoholism, there is also strong empirical alcoholic beverages, that occur prior to drinking and
 TREATMENT MODELS AND METHODS: FAMILY MODELS 293

are mediated by organismic (O) factors, such as crav- drug use; and (e) modification of family patterns of
ing, withdrawal symptoms, or negative affective states interaction that interfere with family functioning.
(e.g., anger, depression, anxiety) and maintained by
a positive consequence (C) of drinking, including ces-
sation of withdrawal symptoms and alleviation of THERAPEUTIC CHANGE
negative affect. As noted by the authors, this model
has been applied to alcohol problems but presum- The family treatments described below have been di-
ably applies also to families in which members use rected to moving the substance abuser to the action
other drugs. stage of initiating abstinence, to stabilizing the
At the family level, a variety of antecedents to and change in substance use and family relationships
consequences of substance use can occur. Poor com- once change has begun, and to maintaining recovery
munication and problem solving, arguing, financial and preventing relapse. Many of the methods de-
stressors, and nagging are often described as anteced- scribed come from a behavioral approach because
ents to substance use by family members. Conse- this approach has specified its interventions more
quences of drug use can be positive or negative. For fully than have other approaches and because our
example, certain behaviors by a non-substance-abus- own work has focused on behavioral marital therapy
ing spouse or other family members, such as avoid- (BMT) for alcoholism (O'Farrell, Choquette, & Cut-
ing conflict with the drug-abusing spouse when he ter, 1998) and for drug abuse (Fals-Stewart, Birch-
or she is intoxicated, are positive consequences of ler, & O'Farrell, 1996). Although behavioral approaches
substance use and can inadvertently reinforce sub- have been used mainly with couples and spouses,
stance-using behavior. Conversely, partners' avoiding some studies have focused on broader family constel-
the drug user and making disapproving verbal com- lations (e.g., Hedberg & Campbell, 1974) or have
ments about his or her substance abuse are among worked with the substance abuser's parent (e.g.,
the most commonly reported negative consequences Ahles, Schlundt, Prue, & Rychtarik, 1983; Sisson &
of substance use (Becker & Miller, 1976). Although Azrin, 1993). Further, many of the behavioral meth-
these behaviors are normal reactions of family mem- ods used with spouses and couples can be easily
bers to alcohol or drug use, they are usually counter- translated for use with dyads other than spouses or
productive, serving as further cues for substance use. with broader family constellations (see O'Farrell,
Other negative effects of substance use on the family, 1995, for examples).
such as psychological and physical problems of the
spouse and more behavioral and school problems
Assumptions of the Family Model
among children in these environments, increase
About How People Change
stress in the family system and may therefore lead
to substance use (Moos, Finney, & Cronkite, 1990). Our behavioral approach to couple and family ther-
Thus, there is a complex, reciprocal relationship be- apy with substance abusers does not have a separate,
tween the substance use and the functioning of the unique set of assumptions about how people change.
family. The model encompasses current notions about how
From this social learning model of maintenance people change in terms of a stages-of-change model.
of substance abuse, McCrady and Epstein (1996) de- An individual can progress through a series of stages
rived a family-involved treatment model that has five of change: (a) precontemplation, in which the indi-
major tasks: (a) engagement of family members, pref- vidual is not concerned about changing the behavior
erably the identified substance abuser and (ideally) in question; (b) contemplation, in which the individ-
several other family members; (b) assessment and ual becomes concerned about and begins to consider
identification of antecedents and consequences of changing the behavior; (c) action, in which the indi-
substance use, as well as any organismic mediating vidual actually changes the behavior and stabilizes
factors; (c) reduction or elimination of substance use this change for an initial period; (d) maintenance,
before addressing family functioning; (d) modifica- in which the behavior change remains stable; or (e)
tion of antecedents of substance use, reinforcement relapse, when the individual returns to the problem
of consequences of substance use, and use of rein- behavior (Prochaska & DiClemente, 1983). The
forcement for reduction or cessation of alcohol and family model emphasizes the role of the family in
294 TREATMENT

influencing an individual's progression through these mation and to learn of important material (e.g., plans
various stages of change. For example, a family for separation, fears of violence) that individuals may
members' concern that individuals have an alcohol be reluctant to share during the conjoint portion of
or drug problem may move the individuals from pre- the interview. More detailed information about the
contemplation, where they have little or no concern substance abuse and family relationships can be ob-
about their alcohol/drug use, into contemplation, tained in subsequent sessions.
where they begin to consider the possibility of To gather more detailed information about the
change. Conversely, individuals who begin to be- substance abuse problem, we recommend certain as-
come concerned about their own alcohol/drug use sessment procedures. The Time Line Follow-Back
(contemplation) may not move to the action stage or Interview (Sobell & Sobell, 1996), a structured inter-
may revert to precontemplation when a close family view that uses a calendar and specialized interview-
member encourages them to continue their current ing methods, can be used to reconstruct the quantity
behavior, perhaps because the family member also is and frequency of the substance abuser's drinking and
a heavy drinker or an illicit dug user. drug use behavior during the 6-12 months prior to
the interview. A breath test and a drug urine screen
can detect any very recent substance use. Finally, to
Key Interventions in the Model
measure problems due to, respectively, alcohol and
drug abuse, we suggest the Drinker Inventory of Con-
Assessment Procedures
sequences (Miller, Tonigan & Longabaugh, 1995)
In the initial interview with a substance abuser and and the Addiction Severity Index (McLellan et al.,
family member(s) seeking marital or family therapy, 1985).
the therapist needs to (a) determine what stage the To gather more detailed information about family
substance abuser is in in the process of changing his relationships, we use the following assessment proce-
or her addiction; (b) evaluate whether there is a need dures. To determine the overall level of satisfaction
for crisis intervention prior to a careful assessment; experienced in the relationship, we use the Dyadic
and (c) orient the clients to the assessment proce- Adjustment Scale (Busby, Crane, Larson & Christen-
dures. In the initial session, the therapist's clinical sen, 1995; Spanier, 1976) for couples and the Family
interview gathers information about a series of issues. Assessment Measure (Skinner, Steinhauer, & Santa
First, the therapist inquires about the substance abus- Barbara, 1995) for other family constellations. The
er's drinking and drug use, especially recent quantity Conflict Tactics Scale (Straus, 1979) assesses the
and frequency, whether the extent of physical depen- extent of verbal and physical abuse experienced.
dence on alcohol or drugs requires detoxification, Among couples, we evaluate (a) steps taken toward
what led to seeking help at this time and prior help- separation and divorce with the Marital Status Inven-
seeking efforts, and whether the substance abuser's tory (Weiss & Cerreto, 1980); (b) specific changes
and family member's goal is to reduce the drinking desired in the relationship with the Areas of Change
or drug use or to abstain either temporarily or perma- Questionnaire (Weiss & Birchler, 1975); (c) sexual
nently. Second, the stability of the marriage and fam- adjustment (O'Farrell, Kleinke, & Cutter, 1997); and
ily relationships is examined in terms of current (d) communication skills, especially when talking
planned or actual separation as well as any past sepa- about conflicts and problems (e.g., Murphy & O'Far-
rations. Third, recent family violence and any fears rell, 1997).
of recurrence are discussed. Fourth, current or recent After the assessment information has been gath-
suicidal ideation or behavior of either the substance ered, the clients and therapist meet for a feedback
abuser or family members and any past instances of session in which the therapist shares impressions of
such behavior are examined. Finally, the therapist the nature and severity of the substance abuse and
determines whether there are any substance-abuse-re- family problems and invites the clients to respond to
lated or other crises that require immediate attention. these impressions. The first goal of the feedback is to
Allowing 75-90 minutes for the initial session and increase motivation for treatment by reviewing in a
including 5-10 minutes separately with each person nonjudgmental, matter-of-fact manner the quantity
provides sufficient time to gather the needed infor- and frequency and the negative consequences of the
 TREATMENT MODELS AND METHODS: FAMILY MODELS 295

substance use. The second goal of the feedback ses- that has been negotiated. The session moves from
sion is to prepare the clients for subsequent therapy a review of homework from the previous session to
sessions. considering important events of the past week. The
therapist identifies a specific concern from the past
week related to recovery or relationships that can be
Typical Treatment Goals
addressed in the session. The goal is to resolve the
A behavioral approach has two basic objectives in or- concern or to identify steps that can be taken to be-
der to stabilize short-term change in the alcohol or gin to resolve the concern. Then, the session may
drug problem and in the marriage and family rela- consider new material, such as instruction in and re-
tionships. The first goal is to eliminate abusive drink- hearsal of skills to be practiced at home during the
ing and drug use and support the drinker's efforts week. It ends with assigning homework.
to change. To this end, a high priority is changing Generally, the first few sessions focus on decreas-
ineffective alcohol-related interactional patterns such ing negative feelings and interactions related to past
as nagging about past drinking and drug use but ig- or possible future substance abuse and on increas-
noring current sober behavior. Therapists can en- ing positive exchanges. This focus decreases tension
courage abstinent alcohol or drug abusers and their about substance use and builds goodwill. Both are
families to engage in behaviors more pleasing to necessary for dealing with marital/family problems
each other, but if they continue to talk about and and desired relationship changes in later sessions by
focus on past or "possible" future drinking, fre- using communication and problem-solving skills
quently such arguments lead to renewed drinking training and behavior change agreements.
(Maisto, O'Farrell, McKay, Connors, & Pelcovits,
1988). They then feel more discouraged than before
Description of Major Techniques
about their relationship and the substance abuse
of the Treatment
problems, and are less likely to try pleasing each
other again. The second goal is to alter general mari- Initiating Change and Helping the Family When
tal and family patterns to provide an atmosphere that the Substance Abuser Resists Treatment Four
is more conducive to sobriety. This goal involves marital/family therapy approaches address the diffi-
helping the family repair the often extensive relation- cult and all-too-common case of the substance
ship damage incurred during many years of conflict abuser who is not yet willing to stop drinking and
over alcohol and drugs, as well as helping family drugging. Three of the approaches try to help the
members find solutions to relationship difficulties spouse and family members to motivate the uncoop-
that may not be directly related to substance abuse. erative, denying substance abuser to change. Com-
Finally, families must learn to confront and resolve munity reinforcement training for families is a pro-
relationship conflicts while avoiding relapse. gram for teaching the family member (usually the
wife of a male substance abuser) (a) how to reduce
physical abuse to herself, (b) how to encourage so-
Typical Structure of Therapy Sessions
briety, (c) how to encourage seeking professional
Once assessment is complete and initial obstacles treatment, and (d) how to assist in that treatment
have been overcome, the behavioral approach we (Sisson & Azrin, 1993). The Johnson Institute "inter-
use to help stabilize short-term change in the alcohol vention" procedure involves three to four educational
and drug problem and associated marital/family dis- and rehearsal sessions to prepare family members.
cord usually consists of 10-20 therapy sessions, each During the intervention session itself, family mem-
of which lasts 60-75 minutes. Sessions tend to be bers confront the substance abuser and strongly en-
moderately to highly structured, with the therapist courage entry into a substance treatment program
setting the agenda at the outset of each meeting. A (Liepman, 1993). The unilateral family therapy (UFT)
typical session begins with an inquiry about any approach assists the family member to strengthen his
drinking or drug use or urges to drink or use drugs or her coping capabilities, to enhance family func-
that have occurred since the last session, including tioning, and to facilitate greater sobriety on the part
compliance with any sobriety contract (see below) of the substance abuser (Thomas & Ager, 1993).
296 TREATMENT

UFT provides a series of graded steps the family can ingests alcohol, is widely used in treatment for per-
use prior to confrontation. sons with a goal of abstinence. Often, Antabuse ther-
A fourth and final approach is a group program apy is not effective because the alcoholic discontin-
for wives of treatment-resistant substance abusers (Dit- ues the drug prematurely. This contract has been
trich, 1993). This program tries to help wives cope used by a number of investigators (e.g., Azrin, Sisson,
with their emotional distress and concentrate on Meyers, & Godley, 1982). It is designed to maintain
their own motivations for change rather than trying Antabuse ingestion and abstinence from alcohol and
to motivate the substance abuser to change. This ap- to decrease alcohol-related arguments and interac-
proach borrows many concepts from Al-Anon, by far tions between the drinker and his or her family.
the most widely used source of support for family Participation in AA, NA, Al-Anon, Rational Re-
members troubled by a loved one's substance abuse covery, and other self-help groups is often part of the
problem. Al-Anon advocates that family members de- behavioral contracts we negotiate. Weekly drug urine
tach themselves from the substance use in a loving screens are part of the contracts for those who have
way, accept that they are powerless to control the current drug problems. Urine screens can provide ev-
substance abuse, and seek support from other mem- idence that the drug abuser is "clean" in order to
bers of the Al-Anon program (Al-Anon Family Groups, reduce the family member's distrust and to facilitate
1981). the family member's reinforcement of the desirable
behavior of the substance abuser. As with any other
Behavioral Contracting Written behavioral con- behavior that is part of a "sobriety contract," as we
tracts, although different in many specific aspects, call the various forms of behavior contracts we use,
have a number of common elements that make them we review attendance at self-help meetings and drug
useful. The substance abuse goal is made explicit. urine screen results at each therapy session.
Specific behaviors that the substance abuser and the
family member(s) can do to help achieve this goal Decreasing Family Members' Behaviors That Trig-
are also detailed. The contact provides daily social ger or Reward Drinking Noel and McCrady (1993)
reinforcement for sobriety and reduces negative in- implemented procedures to decrease spouse behav-
teractions about drinking or drugs. Finally, the agree- iors that trigger or reward abusive drinking. For ex-
ment decreases the family member's anxiety and ample, they presented an illustrative case study of a
need to control the substance abuser. female alcohol abuser, Charlotte, and her husband,
In the sobriety trust contract (O'Farrell, 1995), Tom. The couple identified behaviors by Tom that
each day at a specified time, the substance abuser triggered drinking by Charlotte (e.g., drinking to-
initiates a brief discussion with the family member gether after work, trying to stop her from drinking,
and reiterates his or her intention not to drink or use arguing with her about drinking). Charlotte reacted
drugs that day. Then, the substance abuser asks if by criticizing Tom until he left her alone, where-
the family member has any questions or fears about upon she would drink still more. Moreover, Tom un-
possible drinking or drug use that day and answers wittingly reinforced Charlotte's drinking by protect-
the questions and attempts to reassure the family ing her from the consequences of her drinking (e.g.,
member. The family member is not to mention past by helping her to bed when she was drunk, cleaning
drinking or any future possible drinking beyond that up after her when she drank). Noel and McCrady
day. The substance abuser and the family member helped the couple find mutually comfortable and
agree to refrain from discussing drinking or drugs at agreeable methods to reverse Tom's behavior that
any other time, to keep the daily trust discussion very had inadvertently promoted Charlotte's drinking.
brief, and to end it with a positive statement to each Tom decided to give up drinking. He worked hard
other. to change his feelings that he must protect Charlotte
The Antabuse (disulfiram) contract adds to the so- from the negative consequences of her drinking. The
briety trust contract daily Antabuse ingestion by the therapists also taught Tom to provide positive rein-
alcoholic in the presence of the family member. An- forcers (such as verbal acknowledgment and going to
tabuse (disulfiram), a drug that produces extreme movies and other events together) only when Char-
nausea and sickness when the person taking the drug lotte had not been drinking.
 TREATMENT MODELS AND METHODS: FAMILY MODELS 297
Other Methods Focused on Substance Use Other the couple under therapist supervision, (c) assign-
major techniques, particularly in a behavioral ap- ment for homework, and (d) review of homework
proach, are used to promote abstinence from sub- with further practice. O'Farrell (1993) gives more de-
stance use: (a) increasing motivation for change by tails on these procedures.
using the decisional matrix and the alcohol autobiog-
raphy (McCrady & Epstein, 1995); (b) incorporating
Active Ingredients of the Treatment
basic cognitive behavioral techniques (Carroll, 1998)
delivered in the context of couples or family therapy Data are not available on the active ingredients of
so that the spouse or family members can help the any type of family-based treatment, so we will base
alcoholic or drug abuser learn and implement such our comments on our conceptual understanding and
skills such as self-recording, functional analysis, and clinical experience of a behavioral approach. Active
relapse prevention techniques; and (c) teaching cop- ingredients of a behavioral approach to marital and
ing skills such as problem solving, cognitive restruc- family therapy are based on the assumption that fam-
turing, and assertiveness (including drink refusal and ily members can reward abstinence and that sub-
assertiveness within the marriage or family relation- stance abusers from happier families with better
ship). communication have a lower risk of relapse. This ap-
proach works directly to increase relationship fac-
Interventions to Improve the Marital and Family tors conducive to sobriety. The alcoholic and the
Relationship Two major goals of interventions that family member, often the spouse, are seen together
are focused on the substance user's marital/family re- to build support for sobriety through the use of be-
lationships are (a) to increase positive feeling, good- havioral contracting to directly reward abstinence
will, and commitment to the relationship and (b) to and through work to decrease family members' be-
resolve conflicts, problems, and desires for change. haviors that trigger or reward drinking. The treat-
Increasing positive interchanges through increasing ment works to increase relationship cohesion and
positive feelings and activities can build relationship improve communication skills because substance
satisfaction and family cohesion, thus producing a abusers in more cohesive families have better treat-
more positive family environment and reducing the ment outcomes (Moos et al., 1990) and because ar-
risk of relapse. Methods used include increasing guments and conflicts from faulty communication
pleasing behaviors, planning recreational activities, often lead to relapse (Maisto et al., 1988). Finally,
and enacting core symbols of couple and family substance abusers who receive marital or family ther-
meaning. Resolving conflicts and problems is also im- apy often stay in treatment longer and are less likely
portant. Inadequate communication is a major prob- to dropout of treatment than those who receive indi-
lem for alcohol and drug abusers and their spouses vidually based treatment (Stanton & Shadish, 1997),
and families (e.g., Fals-Stewart, Birchler, & O'Far- probably because of encouragement by the family
rell, in press; O'Farrell & Birchler, 1987). Inability member to continue treatment sessions. This is im-
to resolve conflicts and problems can cause abusive portant because longer outpatient treatment leads to
drinking and severe marital and family tension to re- better outcomes, especially among patients with
cur (Maisto et al., 1988). Teaching couples and fami- more severe problems (e.g., Gottheil, 1992; McLel-
lies how to resolve conflicts and problems can re- lan, Arndt, Woody, & Metzger, 1993; McLellan et
duce family stress and decrease the risk of relapse. al., 1996; O'Farrell et al., 1998).
Methods used include training in the communica-
tion skills of listening, expressing feelings directly,
Role of the Therapist
and using planned communication sessions, and in
learning to negotiate and compromise and to use
Typical Training of the Therapist
specific agreements to resolve conflicts and desires
for change. The general sequence in teaching cou- A typical marital/family therapist in substance abuse
ples and families skills to increase positive inter- has a master's degree or doctorate in psychology, so-
changes and resolve conflicts and problems is (a) cial work, or counseling. Training should include
therapist instruction and modeling, (b) practice by courses on the nature and treatment of both sub-
298 TREATMENT

stance abuse and marital and family problems, as approximation to desired behavior despite significant
well as supervised clinical experiences providing in- shortcomings.
dividual, couple, and family counseling with alcohol Other therapist qualities can promote successful
and drug problems. Therapists using a behavioral ap- marital/family therapy. Therapists should empathize
proach also need training in basic cognitive behav- with each person in the therapy and not take sides
ioral methods for treating substance abuse (e.g., Car- favoring one person over the other on a consistent
roll, 1998). basis or join the family in scapegoating the substance
abuser. Being positive and using humor construc-
tively in therapy can contribute to patients' feeling
comfortable. Practical knowledge of the financial
Stance of the Therapist
and legal issues commonly faced by substance abus-
Certain therapist attributes and behaviors are impor- ers and their families can also help. A further helpful
tant for successful marital and family therapy with stance, often used by therapists in BMT, is to act as
alcoholics and drug abusers. From the outset of the educator or "coach" by teaching cognitive behavioral
therapy, the therapist must structure treatment so techniques to deal with the substance use (e.g., func-
that addressing the alcohol and drug abuse is the first tional analysis, self-monitoring) or relationship issues
priority, before attempts to help the couple or family (e.g., communication skills).
with other problems. Many of our clients have had Finally, therapists need to take a long-term view
previous unsuccessful experiences with therapists of the course of change; both the alcohol or drug
who saw the couple in therapy without dealing with problem and the associated marital and family dis-
the drug and alcohol abuse. The hope that reduction tress may be helped substantially only by repeated
in marital or family distress will lead to improvement efforts, including some failed attempts. Such a long-
in the substance abuse problem rarely is fulfilled. term view may help the therapist encounter relapse
More typically, recurrent negative incidents and in- without becoming overly discouraged or engaging in
teractions related to ongoing substance use under- blaming and recriminations with the substance abus-
mine whatever gains have been made in marital and er and the family. The therapist should also maintain
family relationships. contact with the family long after the problems have
Therapists must be able to tolerate and deal effec- apparently stabilized. Leaving such contacts to the
tively with strong anger in early sessions and at later family usually means that no follow-up contacts will
times of crisis. The therapist can use empathic listen- occur until the family is back in a major crisis again.
ing to help each family member feel he or she has
been heard and to insist that only one person speaks
Use of the Therapist-Patient Relationship
at a time. Helping defuse intense anger is important,
to Promote Change
as failure to do so often leads to a poor outcome
(Gurman & Kniskern, 1978). An important function of the therapist-patient rela-
Therapists need to structure and take control of tionship is to keep the patient and the family mem-
treatment sessions, especially the early assessment bers coming to therapy, especially early in treatment,
and therapy phase and, later, at times of crisis (e.g., when risk of dropping out is high. Patients are likely
episodes of drinking or drug use or intense family to continue in therapy if they consider the therapist
conflict). Structured therapy sessions with a relatively a knowledgeable and helpful guide to the process of
directive, active therapist are more effective than is a substance abuse and relationship recovery. As de-
less structured mode of therapy. Many therapists' er- scribed above, therapists who develop successful rela-
rors involve difficulty establishing and maintaining tionships with their patients have the ability to put
control of the sessions and responding to the myriad "first things first" by giving priority to the substance
forms of resistance and noncompliance presented by use problem, to defuse and manage anger, to be fair
couples and families. Therapists must steer a middle and show an evenhanded understanding of each per-
course between lack of structure and being overly son's viewpoint, and to steer a steady course through
controlling and punitive in response to noncompli- the confusing emotions and family conflicts encoun-
ance. Therapists need to clearly establish and en- tered in substance abuse recovery. The therapeutic
force the rules of treatment and also acknowledge relationship is strengthened when the therapist takes
 TREATMENT MODELS AND METHODS: FAMILY MODELS 299

an active role to help clients deal with everyday prob- protect the family from further substance-related
lems encountered between sessions in coping with problems and to suggest more constructive methods
recovery, relapse, and relationships. Finally, when- to achieve the same goal.
ever possible, it helps to have clients leave therapy Multiple active substance abusers in the same fam-
sessions on a positive note, feeling as good as or bet- ily present a difficult obstacle. Couples in which
ter than when they arrived. This makes them want to both partners abuse alcohol or drugs are a good ex-
return for the next session and promotes continued ample. In contrast to couples in which only one
treatment. member abuses alcohol or drugs, role conflict con-
cerning drug use is less likely to be present when
both partners abuse drugs and will not serve to moti-
Common Obstacles to
vate these partners to stop using drugs or alcohol.
Successful Treatment
Additionally, depending on how much of a drinking
Despite their seeming suitability for marital or family or drug-using partnership these couples have formed,
therapy, many substance abusers and their families substance use may become an important shared rec-
present the therapist with substantial obstacles. A com- reational activity, and more frequent substance use
mon problem encountered is pressing substance may actually increase relationship satisfaction (Fals-
abuse-related crises (e.g., actual, impending, or threat- Stewart, Birchler, & O'Farrell, in press; Wilsnack &
ened loss of job or home; major legal or financial Wilsnack, 1993).
problems) that preclude a serious and sustained fo- Other common obstacles to successful treatment
cus on marital or family issues. The therapist can are comorbid psychopathology in the substance
help the family devise plans to deal with the crisis or abuser and/or the family member and resistance to
refer them elsewhere for such help, often after estab- change in the family system and subsequent sabotag-
lishing a behavioral contract to support abstinence as ing of the treatment by family members.
described above. Other assessment and therapy pro-
cedures can be started when the crisis has been re-
solved. CHARACTERISTICS OF CLIENTS MOST
Potential for violence is a common problem, in LIKELY TO RESPOND TO THE MODEL
that half or more of substance abusers have engaged
in domestic violence in the year before treatment
Clients Who Are the Best Candidates for
(Fals-Stewart & O'Farrell, 1995; O'Farrell & Mur-
This Type of Treatment
phy, 1995). Unless the violence has been so severe
that there is an acute risk of violence that could Unfortunately, studies examining predictors of re-
cause serious injury or could be life-threatening, sponse to marital and family therapy with substance
BMT can generally be successful. In such cases, con- abusers are not yet available. One reason for the lim-
flict containment is an explicit goal of the therapy ited research in this area has been the general lack of
from the outset, and specific steps are taken to pre- heterogeneity in study samples thus far. Nonetheless,
vent violence. clinical experience and studies of factors that predict
Blaming and recriminations by the spouse and acceptance and completion of behavioral (Noel, Mc-
family in frequent conversations about past or possi- Crady, Stout, & Nelson, 1987; O'Farrell, Kleinke, &
ble future drinking or drug use present another ob- Cutter, 1986) and systems approaches to couples
stacle in couple or family sessions. It usually does not therapy for alcoholics (Zweben, Pearlman, & Li,
help for the therapist to interpret these actions to the 1983) provide some information on the clients most
family as an attempt to punish the substance abuser likely to benefit from such treatment. The clients
or sabotage his or her recovery. Overtly disapproving most likely to accept and complete couples therapy
of the blaming behavior also does not help. These have the following characteristics: (a) they have a
responses by the therapist tend to elicit defensiveness high school education or more; (b) they are em-
from the family members, who often feel the thera- ployed if able and desirous of working; (c) they live
pist is blaming them for the substance abuser's prob- together or, if separated, are willing to reconcile for
lem. A more effective approach is for the therapist the duration of the therapy; (d) they are older; (e)
to sympathetically reframe this behavior as trying to they have more serious alcohol or drug problems of
300 TREATMENT

longer duration; (f) they enter therapy after a crisis, is potentially life-threatening, it is better to treat the
especially one that threatens the stability of the mar- substance abuser and the family member(s) sepa-
riage or of family relationships; (g) the spouse and rately rather than together (Murphy & O'Farrell,
other family members living with the patient do not 1996). Although domestic violence is frequent among
have serious alcohol and drug problems; (h) the sub- substance abusers (Fals-Stewart & O'Farrell, 1995;
stance abuser, the spouse, and the other family mem- O'Farrell & Murphy, 1995), most of this violence is
bers do not have additional serious psychopathology; not so severe that it precludes couples therapy. In
and (i) family violence that has caused serious injury fact, we recently showed for the first time that domes-
or is potentially life-threatening is absent. tic violence, which was quite elevated among male
Further, evidence that the substance-abusing pa- alcoholics and their spouses in the year before BMT,
tient is motivated to change and to take an active decreased significantly in the first and second year
role in a psychologically oriented treatment ap- after BMT and, among remitted alcoholics, returned
proach also suggests a potential for benefiting from to the levels experienced by nonalcoholic couples
BMT (O'Farrell et al., 1986). Such evidence in- (O'Farrell & Murphy, 1995; O'Farrell, Van Hut-
cludes contact with the treatment program person- ton, & Murphy, in press). Another contraindication
ally initiated by the substance abuser and a history of for BMT may be severe psychopathology in the sub-
successful participation in other outpatient counsel- stance abuser or the spouse (McCrady & Epstein,
ing or self-help programs (as opposed to those ad- 1995). Nonetheless, our clinical experience suggests
mitted to detoxification only for relief of physical that at times, BMT is effective with such cases when
distress, without further active ongoing treatment it is used along with appropriate individual and psy-
participation). Abstinence, keeping scheduled ap- chopharmacological treatment and when the BMT
pointments, and completing any required assign- sessions proceed slowly and are carefully tailored to
ments in the initial month of outpatient treatment the special needs of such clients.
are process measures that seem to predict likely ben-
efit on a clinical basis.
These characteristics may sound like those of EMPIRICAL DATA ON THE
model clients who are likely to benefit from nearly EFFECTIVENESS OF THE FAMILY
any treatment method. However, clients do not have MODEL FOR SUBSTANCE ABUSE
to fit these criteria for therapists to use the treatment
methods described in this chapter. Rather, the meth- Empirical data on the effectiveness of the family
ods have to be adapted for some of the more difficult model for treating substance abuse differ somewhat
cases—generally, by going slower, individualizing for alcoholism and drug abuse. In terms of alcohol-
the approach to a greater degree, and dealing with ism, a recent report reviewed 23 studies of marital or
more varied and more frequent obstacles and resist- family therapy with alcoholics that included a con-
ances. trol group —usually an individual treatment of some
type (see O'Farrell, 1995, for details). Eight "early
eclectic" studies, which were conducted primarily
Contraindications of Treatment for
before 1975 and could not be easily categorized into
Substance Abuse Based on Family Model
one theoretical orientation, showed that family-based
The main contraindications of treatment for sub- treatment was superior to individual treatment.
stance abuse based on a family model relate to legal There were 14 studies of behavioral marital/family
and safety issues. When there is a court-issued re- therapy, of which 11 showed clear superiority for
straining order for the spouses not to have contact marital/family therapy, 2 showed mixed results with
with each other, they should not be seen together in marital/family therapy superior only for some pa-
therapy until the restraining order is lifted or modi- tients or some outcome measures, and 1 study
fied to allow contact in counseling. Some situations showed no difference between behavioral marital/
present concerns for the safety of participants in cou- family therapy and the control group. In contrast, the
ple/family therapy. If the clinical assessment indi- one family systems study showed no difference be-
cates that there is an active and acute risk of severe tween family systems therapy and the control group.
domestic violence that could cause serious injury or Finally, no controlled studies have been done on the
 TREATMENT MODELS AND METHODS: FAMILY MODELS 301

popular family disease (codependency) approach. rectly aids not only substance abuse recovery but also
Thus, although family systems and family disease ap- family relationships and individual coping of family
proaches are popular and influential in the alcohol- members. Recent studies extending the impact of
ism treatment community, we do not know whether BMT/BCT to reductions in violence (Fals-Stewart &
they are effective because they have not been stud- O'Farrell, 1995; O'Farrell & Murphy, 1995) and very
ied. In contrast, behavioral approaches have rela- favorable cost-benefit results (O'Farrell et al., 1996;
tively strong research support but are not yet widely Fals-Stewart et al., 1997) with both alcoholics and
used. The behavioral methods in alcoholism have drug abusers further extends the outcome domains
been applied primarily to couples and spouses in that show documented improvements with this ap-
studies of behavioral marital therapy. Support for proach. A weakness of the approach is the greater
BMT has been strengthened by recent studies show- complexity of the therapy given the multiple rela-
ing (a) that domestic violence is reduced after BMT tionships and influences that must be dealt with.
and (b) that alcohol-related hospital and jail costs de- Working with couples and families requires special-
creased markedly after BMT, cost savings due to re- ized training and skills beyond what are typical for
duced hospitalizations/jailings being over five times staff in many substance abuse treatment programs.
more than the cost of delivering BMT (O'Farrell et Another weakness is that for the most part, the im-
al., 1996). pact of marital/family therapy on the substance abus-
In terms of drug abuse, Stanton and Shadish (1997) er's children has not been examined. A final weak-
reviewed randomized controlled outcome studies ex- ness is that many studies have not included broad,
amining family/marital treatment for drug abuse. heterogeneous samples, so that we have relatively lit-
They concluded from six studies of adult drug abus- tle information on the effectiveness of marital/family
ers and nine studies of adolescent drug abusers that therapy with substance abusers who are women or
couples or family therapy (a) produces better out- members of minority groups or who have serious co-
comes than individual counseling, peer group ther- morbid psychiatric problems.
apy, and family psychoeducation and (b) is a cost-
effective adjunct to methadone maintenance. In con-
trast with studies on alcoholism, most studies on drug SUMMARY
abuse have focused on the relationship between drug
abusers and their parents, rather than on couples and Family models of treating alcoholism and drug abuse
spouses. Most drug abuse studies have used a family have evolved over the past 60 years into contempo-
systems rather than a behavioral approach. A notable rary models consisting of behavioral, family system,
exception is recent work showing that adding BMT and family disease approaches. A substantial research
to outpatient individual drug abuse treatment pro- literature supports family-based treatment of both al-
duced less drug use and fewer drug-related problems, coholism and drug abuse. In the alcoholism research
better relationship outcomes, and better cost-benefit literature, behavioral approaches to couples and
ratios and cost-effectiveness in the year after treat- spouses predominate and have strong support, while
ment than did individual treatment of similar inten- in the alcoholism clinical literature family systems
sity without BMT (Fals-Stewart, Birchler, & O'Far- and family disease approaches are popular and influ-
rell, 1996; Fals-Stewart, O'Farrell, & Birchler, 1997). ential but remain virtually unstudied. In the drug
abuse research literature, family systems approaches
to the subsystem of the addict and the parent pre-
Strengths and Weaknesses of the Family
dominate and have support; only recently have be-
Model of Treatment for Substance Abuse
havioral approaches to couples been studied with
McCrady and Epstein (1996) describe a number of drug abuse. Research knowledge is limited by the ab-
strengths and weaknesses of the family model of sence of studies of the very popular family disease
treatment for substance abuse. The relatively strong approach with alcoholics, the lack of family treat-
empirical support for treatment based on the model ment research on alcoholics, the limited attention to
is an important strength. Family involvement is asso- couples therapy research on drug abusers, and the
ciated with better compliance with treatment and lack of attention to gender and ethnicity in alcohol-
with better treatment outcome. This approach di- ism and drug abuse studies. Clinicians encounter
302 TREATMENT

family issues daily as they treat substance abuse. and nonalcoholic couples during drinking and non-
Family methods with empirical support are ready for drinking sessions. Journal of Studies on Alcohol, 40,
clinical use so that we can improve our efforts to 183-195.
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 17

The Therapeutic Community

Treatment Model

George De Leon

Therapeutic communities have been treating sub- The therapeutic community is a drug-free modal-
stance abusers for more than three decades. Originat- ity that utilizes a social psychological approach to the
ing as an alternative to conventional medical and treatment of drug abuse. Its characteristic setting is a
psychiatric approaches, the therapeutic community community-based residence in urban and nonurban
(TC) has established itself as a major psychosocial locales. However, TC programs have been imple-
treatment modality for thousands of chemically in- mented in a variety of other settings, both residential
volved individuals. However, not all residential drug and nonresidential (hospitals, jails, schools, halfway
treatment programs are TCs, not all TCs are in resi- houses, day treatment clinics, and ambulatory clin-
dential settings, and not all programs that call them- ics). TCs offer a wide variety of services, including
selves TCs employ the same social and psychological social, psychological, educational, medical, legal,
models of treatment. Indeed, the label therapeutic and social advocacy. These services, however, are co-
community is widely used, often to vaguely represent ordinated in accordance with the TC's basic self-
its distinct approach in almost any setting, including help model. This chapter presents the therapeutic
community residences, hospital wards, prisons, and community as a unique social psychological ap-
homeless shelters. One effect of this labeling has proach to the treatment of substance abuse. Its
been to cloud understanding of what the TC is as a model and methods are grounded in a theoretical
drug treatment approach, how well it works, where it framework that has evolved from both clinical and
works best, and for which client it is most appropriate. research experience.

306
 THE THERAPEUTIC COMMUNITY TREATMENT MODEL 307

HISTORICAL ORIGINS OF THE TC the theoretical framework of the TC model and

AND ITS APPLICATION TO method elaborated in other writings (De Leon,
SUBSTANCE ABUSE 1994b, 1995).

Early Development of the TC Model

Status of the Model and Its Applications
Therapeutic communities for addictions appeared a
Today, the TC modality consists of a wide range
decade later than TCs in psychiatric hospitals pio-
of programs serving a diversity of clients who use a
neered by Jones (1953) and others in the United
variety of drugs, and who present complex social psy-
Kingdom (see Kennard, 1983; Rapoport, 1960).
chological problems in addition to their chemical
Emergence of the psychiatric TC is viewed within
abuse. Client differences as well as clinical require-
the context of what some have termed the third revo-
ments and funding realities have encouraged the de-
lution in psychiatry, one which signaled the use of
velopment of modified residential TCs with shorter
group methods and milieu therapy (Rapoport, 1960).
planned durations of stay (3, 6, and 12 months), as
Although the name therapeutic community evolved
well as TC-oriented day treatment and outpatient
in these hospital settings, there is no clear evidence
ambulatory models. Correctional facilities, medical
of any direct influences of psychiatric TCs on the
and mental hospitals, community residences, and
origins and development of addiction TCs.
shelter settings, overwhelmed with alcohol and illicit
To date, there is no comprehensive history of the
drug abuse problems, have implemented TC pro-
addiction therapeutic community. However, some
grams within their institutional boundaries. TC
literature does contain limited surveys of the evolu-
agencies have incorporated basic elements of the
tion of therapeutic communities (e.g., Bratter, Brat-
TC's drug-free philosophy and view of "right living"
ter, & Heimberg, 1986; Brook & Whitehead, 1980;
into education and prevention programs for schools
Deitch, 1974; De Leon & Ziegenfuss, 1986; Glaser,
and communities.
1974; Kennard, 1983; Kooyman, 1992). TC con-
The TC's basic social learning model has been
cepts, beliefs, and practices can be traced to indirect
amplified with a variety of additional services: family,
influences of religion, philosophy, psychiatry, and
educational, vocational, medical, and mental health.
the social and behavioral sciences. Immediate ante-
Staffing composition has been altered to include in-
cedents of the addiction TC are Alcoholics Anony-
creasing proportions of traditional mental health,
mous (AA) and religious reform and temperance
medical, and education professionals to serve along
movements in North America, although ancient pro-
with recovered paraprofessionals (e.g., Carroll & So-
totypes exist in all forms of communal healing and
bel, 1986; De Leon, 1994b; Winick, 1990-1991).
support.
The traditional TC model described in this chapter
Contemporary therapeutic communities for ad-
is actually the prototype of a variety of TC-oriented
dictions derive from Synanon, founded in 1958 by
programs.
Charles Dederich with other recovering alcoholics
and drug addicts. Evolution of the modern addiction
TC following Synanon can be readily sketched in
Key Constructs and Terms
the genealogy of programs that proliferated during
the 1960 and 1970s in North America, and eventu- The TC can be distinguished from other major drug
ally in Europe (see, for example, Brook & White- treatment modalities in two fundamental ways. First,
head, 1980; De Leon & Ziegenfuss, 1986; Glaser, the TC offers a systematic treatment approach guid-
1974; Kooyman, 1992). To a considerable extent, ba- ed by an explicit perspective on the drug use disor-
sic elements of the TC model and method were der, the person, recovery, and right living. Second,
honed in these programs that consisted of similar de- the primary "therapist" and teacher in the TC is the
signs; subscribed to shared assumptions, concepts, community itself, consisting of the social environ-
and beliefs; and engaged in similar practices. These ment, peers, and staff who, as role models of success-
commonalties may be viewed as the essential ele- ful personal change, serve as guides in the recovery
ments of the therapeutic community which make up process. Thus, the community is both the context in
308 TREATMENT

which change occurs and the method for facilitating cumulate with continued substance abuse. Addiction
change. is a symptom, not the essence of the disorder. Thus,
Full accounts of the perspective and method are the problem is the person, not the drug.
provided in other writings (e.g., De Leon, 1994a; De In the TC view, the sources of the addiction dis-
Leon & Rosenthal, 1989). Briefly, substance abuse is order are social and psychological. Typical anteced-
a disorder of the whole person. Regardless of social ents include socioeconomic disadvantage, ineffective
class or primary drug differences, substance abusers parenting, negative role models, and deviant social
share important similarities. Most reveal some prob- learning. Biological factors are acknowledged as im-
lems in socialization, cognitive/emotional skills, and portant for some abusers, but only as a predisposition
overall psychological development. This is evident to use chemicals in order to induce altered mental
in their immaturity, poor self-esteem, conduct and and emotional states. Although valuable for illumi-
character disorder, or antisocial characteristics. Re- nating individual differences, the biological factors
covery is a developmental process of incremental and social psychological history of the individual are
learning toward a stable change in behavior, atti- not considered sufficient causes nor reasons for cur-
tudes, and values of "right living" associated with rent behavior. The emphasis is on the individuals'
maintaining abstinence. own contribution to their problems in the past and
The quintessential feature of the TC approach to their solutions in the present. Thus, regardless of
may be termed community as method (De Leon, the validity of historical influences, assuming respon-
1994b). What distinguishes the TC from other treat- sibility for one's conduct and attitudes is the key to
ment approaches (and other communities) is the personal change.
purposive use of the peer community to facilitate so-
cial and psychological change in individuals. In a
View of Maintenance of Substance Abuse
therapeutic community, all activities are designed to
produce therapeutic and educational change in indi- Abuse of any substance is viewed as overdetermined
vidual participants, and all participants are mediators behavior. Physiological dependency is secondary to
of these therapeutic and educational changes. the wide range of circumstances that influence and
then gain control over an individual's drug use be-
havior. Invariably problems and situations associated
HOW THE TC MODEL RELATES TO with discomfort become regular signals for resorting
THEORY OF THE ETIOLOGY AND to drug use. For some abusers, physiological factors
MAINTENANCE OF SUBSTANCE USE may be important, but for most, these remain minor
relative to the general social and psychological defi-
cits that accumulate with continued substance abuse.
View of Etiology of Substance Abuse
The therapeutic community views substance abuse
View of Right Living
as a disorder of the whole person. Although individu-
als differ in choice of substance, abuse involves some Therapeutic communities adhere to certain precepts
or all the areas of functioning. Cognitive, behavioral, and values as essential to self-help recovery, social
and mood disturbances appear, as do medical prob- learning, personal growth, and healthy living. These
lems. Thinking may be unrealistic or disorganized. emphasize explicit values that determine how indi-
Values are confused, nonexistent, or antisocial. Fre- viduals relate to themselves, peers, significant others,
quently, there are deficits in verbal, reading, writing, and the larger society. They include, for example,
and marketable skills, and whether couched in exis- truth and honesty (in word and deed), the work
tential or psychological terms, moral issues are appar- ethic, learning to learn, personal accountability, eco-
ent. Physical addiction or dependency must be seen nomic self-reliance, responsible concern for others
in the wider context of the individual's psychological and peers ("brother's/sister's keeper"), family respon-
status and lifestyle. For some abusers, physiological sibility, community involvement, and good citizenry.
factors may be important, but for most, these remain Residents reveal ill-formed personal identities,
minor relative to the social and psychological prob- that is, how they label, perceive, and accept them-
lems that precede and the behavioral deficits that ac- selves, which relates to their history of drug use as
 THE THERAPEUTIC COMMUNITY TREATMENT MODEL 309

well as to their early background. For most residents, emphasis on earned achievement, absolute honesty
the onset of regular drug use occurred in their early in word and in action, and learning to share private
teens or even younger, and profoundly altered the experiences. Community elements such as encoun-
course of healthy identity development. Regardless ter challenge false images and foster self-objectifica-
of their chronological age, they reveal an arrested tion, in terms of personal identity, and strengthen the
stage of personal identity closer to that of adolescents. individual's critical self-perceptions. Of special rele-
In summary, rather than a physical disease, sub- vance to personal identity is community acceptance
stance abuse is viewed as a complex social psycholog- of the authentically revealed individual.
ical disorder of the whole person, consisting of recur-
ring negative patterns of behaving and thinking and
poor emotional management. These self-defeating or THERAPEUTIC CHANGE
destructive patterns reveal a disorder in lifestyle, self-
identity, and individual function. In the TC perspec- Assumptions of the TC Model About
tive, recovery means a change in lifestyle that can be How People Change
achieved only by living differently in terms not only
of behaviors and attitudes but of values and beliefs. The TC treatment model reflects the four views of
Regardless of differences in their social backgrounds, its perspective and community-as-method approach.
residents in TCs have lost or never acquired values Disorder of the whole person means that change is
to guide healthy, productive lifestyles. Learning or multidimensional. Change must be viewed along
relearning these values requires teaching and prac- several dimensions of behavior, perceptions, and ex-
tice in a real community that explicitly reinforces periences. Change is facilitated by the community,
how individuals can "live right" with themselves, which consists of multiple interventions. Recovery
with others, and in society. unfolds as developmental social learning, which can
be described in terms of characteristic stages of
change. Based on its perspective, the aim of treat-
Rationale of How the TC Model ment is a global change in the individual to develop
of Treatment Follows From the a positive lifestyle and personal identity. These social
Theory of Substance Abuse and psychological goals of the TC shape its treat-
Recovering people innovated the TC as a setting for ment regimen as well as define several broad as-
individuals to learn an alternative lifestyle. Their in- sumptions concerning its view of recovery.
tuitive understanding of the relevance of community
as method is explicit in their perspective on the dis-
Recovery as a Developmental Process
order, the person, transforming lifestyles, and identi-
ties. Changing the whole person requires the 24- Change in the TC can be understood as a passage
hour-a-day setting of community life in which indi- through stages of incremental learning. The learning
viduals display the full range of their behavior and that occurs at each stage facilitates change at the
attitudes. Unlike the psychotherapy hour or group next, and each change reflects movement toward the
therapy sessions, which sample relatively little of the goals of recovery.
individual over a long period of time, the complexity
of the "whole" individual is gradually revealed in the
Motivation
varied situations of community life: in its social per-
formance demands, its multiple participant roles, Recovery depends on pressures to change—positive
and relationships with others. and negative. Some clients, driven by stressful exter-
Community as method fosters change in the so- nal pressures, seek help. Others are moved by more
cial and personal elements of identity. It provides op- intrinsic factors. For all, however, remaining in treat-
portunities and context for developing positive social ment requires continued motivation to change. Thus,
identity in its focus on social participation, mutual elements of the rehabilitation approach are designed
responsibility, relationships based on trust, and val- to sustain motivation or detect early signs of pre-
ues of right living. Community also shapes and mature termination. Although the influence of
strengthens the element of personal identity in its treatment depends on the person's motivation and
310 TREATMENT

readiness, change does not occur in a vacuum. Reha- separate interventions. Thus, a complete assessment
bilitation unfolds as an interaction between the cli- of change in the whole person includes both the ob-
ent and the therapeutic environment. jective behavioral dimensions and subjective changes
reflected in self-perceptions and experiences. The
objective dimensions are discussed for purposes of
Self-Help and Mutual Self-Help
illustration.
Strictly speaking, treatment is not provided but made Behavioral change can be described along four
available to the individual in the TC environment, broad dimensions that reflect the TC perspective.
through its staff and peers and the daily regimen of The dimensions of community member and social-
work, groups, meetings, seminars, and recreation. ization refer to social development of the individual
However, the effectiveness of these elements is de- specifically as a member in the TC community, and
pendent on the individual, who must fully engage in generally as a prosocial participant in the larger soci-
the treatment regimen. Self-help recovery means that ety. The developmental and psychological dimen-
the individual makes the main contribution to the sions refer to the evolution of individuals as unique
change process. Mutual self-help emphasizes the fact persons in terms of their basic psychological func-
that each individual in the process contributes to tion, personal growth, and identity. Each dimension
change in others. The main messages of recovery, pictures the same individual from different aspects in
personal growth, and right living are mediated by terms of observable behavioral indicators.
peers through confrontation and sharing in groups, Changes in the four behavioral dimensions are
by example as role models, and as supportive, en- assessed informally by peers on a daily basis in a vari-
couraging friends in daily interaction. ety of settings. They are also assessed formally by staff
for purposes of evaluating general progress, phase
graduations, job changes, or disciplinary actions.
Social Learning
Changes in subjective domains such as self-percep-
Negative behavioral patterns and attitudes and dys- tion, self-efficacy, and various healing experiences
functional roles were not acquired in isolation, nor are assessed informally through client disclosure to
can they be changed in isolation. Therefore, recovery peers and staff, in any setting.
depends not only on what is being learned, but on
how, where, and with whom learning occurs. This
Treatment Goals
assumption is the basis for the community itself serv-
ing as healer and teacher. Learning occurs by doing The primary psychological goal is to change the neg-
and participating as a community member; a socially ative patterns of behavior, thinking, and feeling that
responsible role is acquired by acting the role. predispose to drug use. The main social goal is to
Changes in lifestyle and identity are gradually develop a responsible, drug-free lifestyle. Stable re-
learned through participating in the varied roles of covery, however, depends on a successful integration
community life supported by people and relation- of these social and psychological goals. Behavioral
ships involved in the learning process. Without these change is unstable without insight, and insight is in-
relationships, newly learned ways of coping are sufficient without felt experience. Thus conduct,
threatened by isolation and the potential for relapse. emotions, skills, attitudes, and values must be inte-
Thus, a healthy perspective on self, society, and a life grated to ensure enduring change in lifestyle and a
philosophy must be affirmed by a network of others positive personal and social identity.
to ensure a stable recovery.

Typical Modality for Treatment Delivery

Key Interventions in the Model
The multidimensional view of the individual and
disorder requires a multidimensional, social psycho-
Assessment Procedures
logical treatment most efficiently delivered in a com-
Partitioning the "whole" individual into separate di- munity-based residential setting. TC-oriented pro-
mensions is a somewhat artificial device analogous grams can be implemented in nonresidential as well
to attempts at classification of the TC milieu into as institutional settings modified for the special char-
 THE THERAPEUTIC COMMUNITY TREATMENT MODEL 311

acteristics of the client served or the institutional sign and supervise resident job functions, and over-
boundaries. see house operations. Clinically, staff conduct thera-
peutic groups (other than peer encounters), provide
individual counseling, organize social and recre-
The TC Traditional Model
ational projects, and confer with significant others.
Traditional TCs are similar in planned duration of They decide matters of resident status, discipline,
stay (15-24 months), structure, staffing pattern, per- promotions, transfers, discharges, furloughs, and
spective, and rehabilitative regimen, although they treatment planning.
differ in size (30-600 beds) and client demography. The new client enters a setting of upward mobility.
Although there is increasing diversity among con- Resident job functions are arranged in a hierarchy ac-
temporary TC-oriented programs, most incorporate cording to seniority, clinical progress, and productiv-
the common components of the program model (Mel- ity. Job assignments begin with the most menial tasks
nick & De Leon, in press). These can be outlined in (e.g., mopping the floor) and lead vertically to levels
terms of the TC structure, or social organization, and of coordination and management. Indeed, clients
its process in terms of the individual's passage through come in as patients and can leave as staff. This social
stages of change within the context of community life. organization of the TC reflects the fundamental as-
Full narrative descriptions of the TC programs are pects of its rehabilitative approach, work as education
provided in other writings (e.g., De Leon & Rosen- and therapy, mutual self-help, peers as role models,
thai, 1989; De Leon & Ziegenfuss, 1986). and staff as rational authorities.

Work as Education and Therapy

TC STRUCTURE: BASIC COMPONENTS
In the TC, work mediates essential educational and
The social organization of the TC is composed of therapeutic effects. Work and job changes have clini-
relatively few staff and stratified levels of resident cal relevance for substance abusers in TCs, most of
peers—junior, intermediate, and senior—who con- whom have not successfully negotiated the social
stitute the community, or family, in the residence. and occupational world of the larger society. Vertical
This peer-to-community structure strengthens the in- job movements carry the obvious rewards of status
dividual's identification with a perceived, ordered and privilege. However, lateral job changes are more
network of others. More important, it arranges rela- frequent, providing exposure to all aspects of the
tionships of mutual responsibility to others at various community. Typically, residents experience many
levels in the program. lateral job changes that enable them to learn new
The daily operation of the community itself is the skills and to negotiate the system. This increased
task of the residents, working together under staff su- involvement also heightens their sense of belonging
pervision. The broad range of resident job assign- and strengthens their commitment to the commu-
ments illustrates the extent of the self-help process. nity.
These include conducting all house services (e.g.,
cooking, cleaning, kitchen service, minor repair),
Mutual Self-Help
serving as apprentices, running all departments, and
conducting house meetings, certain seminars, and The essential dynamic in the TC is mutual self-help.
peer encounter groups. The day-to-day activities of a TC are conducted by
Staff are composed of TC-trained clinicians and the residents themselves. In their jobs, groups, meet-
other human service professionals. Primary clinical ings, recreation, and personal and social time, it is
staff are usually former substance abusers who them- residents who continually transmit to each other the
selves were rehabilitated in TC programs. Other staff main messages and expectations of the community.
consist of professionals providing medical, mental
health, vocational, educational, family counseling,
Peers as Role Models
fiscal, administrative, and legal services.
The TC is managed by staff who monitor and Peers as role models and staff as role models and
evaluate client status, supervise resident groups, as- rational authorities are the primary mediators of the
312 TREATMENT

recovery process. Members who demonstrate the ex- COMPONENTS OF A GENERIC

pected behaviors and reflect the values and teachings TC PROGRAM MODEL
of the community are viewed as role models. This is
illustrated in two main attributes. The perspective and approach of the traditional TC
Resident role models "act as if." They behave as provide the conceptual basis for defining the basic
the person they should be, rather than as the person components of a generic TC program model, which
they have been. Despite resistance, perceptions, or can be adapted for special populations and various
feelings to the contrary, they engage in the expected settings, both residential and nonresidential.
behaviors and consistently maintain the attitudes and
values of the community. These include self-motiva-
Community Separateness
tion, commitment to work and striving, positive re-
gard for staff as authority, and an optimistic outlook TC-oriented programs have their own names—often
toward the future. In the TC view, acting as if is not innovated by the clients—and are housed in a space
just an exercise in conformity but an essential mech- or locale separated from other agency or institutional
anism for more complete psychological change. programs or units and generally from the drug-re-
Feelings, insights, and altered self-perceptions often lated environment. In the residential settings, clients
follow rather than precede behavior change. remain away from outside influences 24 hours a day
Role models display responsible concern. This for several months before earning short-term day-out
concept is closely akin to the notion of "I am my privileges. In the nonresidential "day treatment" set-
brother's/sister's keeper." Showing responsible con- tings, the individual is in the TC environment for
cern involves willingness to confront others whose 4-8 hours and then is monitored by peers and fam-
behavior is not in keeping with the rules of the TC, ily. Even in the least restrictive outpatient settings,
the spirit of the community, or the knowledge that is TC-oriented programs and components are in place.
consistent with growth and rehabilitation. Role mod- Members gradually detach from old networks and re-
els are obligated to be aware of the appearance, atti- late to drug-free peers in the program.
tude, moods, and performance of their peers, and to
confront negative signs in these. In particular, role
A Community Environment
models are aware of their own behavior in the overall
community and the process prescribed for personal The inner environment of a TC facility contains
growth. communal space to promote a sense of commonality
and collective activities (e.g., groups, meetings).
Walls display signs which state in simple terms the
Staff as Rational Authorities
philosophy of the program, the messages of right liv-
Staff foster the self-help learning process through ing and recovery. Corkboards and blackboards iden-
their managerial and clinical functions described tify all participants by name, seniority level, and job
above and in their psychological relationship with function in the program. Daily schedules are also
the residents as role models, parental surrogates, and posted. These visuals display an organizational pic-
rational authorities. TC clients often have had diffi- ture of the program that the individual can relate to
culties with authorities, who have not been trusted and comprehend, factors which promote affiliation.
or perceived as guides and teachers. Thus, they need
a successful experience with an authority figure who
Community Activities
is viewed as credible (recovered), supportive, correc-
tive, and protective in order to gain authority over To be effectively utilized, treatment or educational
themselves (personal autonomy). Implicit in their services must be provided within a context of the
role as rational authorities, staff provide the reasons peer community. Thus, with the exception of indi-
for their decisions and explain the meaning of conse- vidual counseling, all activities are programmed in
quences. They exercise their powers to teach and collective formats. These include at least one daily
guide, facilitate and correct, rather than to punish, meal prepared, served, and shared by all members; a
control, or exploit. daily schedule of groups, meetings, and seminars;
 THE THERAPEUTIC COMMUNITY TREATMENT MODEL 313

team job functions; and organized recreational/lei-

Work as Therapy and Education
sure time, ceremonies, and rituals (e.g., birthdays,
phase/progress graduations). Consistent with the TC's self-help approach, all cli-
ents are responsible for the daily management of the
facility (e.g., cleaning, activities, meal preparation
Staff Roles and Functions
and service, maintenance, purchasing, security, coor-
The staff are a mix of recovered professionals and dinating schedules, preparatory chores for groups,
other traditional professionals (e.g., medical, legal, meetings, seminars). In the TC, the various work
mental health, and educational) who must be inte- roles mediate essential educational and therapeutic
grated through cross-training that is grounded in the effects. Job functions strengthen affiliation with the
basic concepts of the TC perspective and commu- program through participation, provide opportunities
nity approach. Professional skills define the function for skill development, and foster self-examination
of staff (e.g., nurse, physician, lawyer, teacher, ad- and personal growth through performance challenge
ministrator, caseworker, clinical counselor). Regard- and program responsibility. The scope and depth of
less of professional discipline or function, however, client work functions depend upon the program set-
the generic role of all staff is that of community ting (e.g., institutional vs. freestanding facilities) and
member who, rather than providers and treaters, are client resources (levels of psychological function, so-
rational authorities, facilitators, and guides in the cial and life skills).
self-help community method.

Phase Format
Peers as Role Models
The treatment protocol, or plan of therapeutic and
Members who demonstrate the expected behaviors educational activities, is organized into phases that
and reflect the values and teachings of the commu- reflect a developmental view of the change process.
nity are viewed as role models. Indeed, the strength Emphasis is on incremental learning at each phase,
of the community as a context for social learning re- which moves the individual to the next stage of re-
lates to the number and quality of its role models. covery.
All members of the community are expected to be
role models: roommates; older and younger resi-
dents; and junior, senior, and directorial staff. Thera- TC Concepts
peutic communities require these multiple role mod-
els to maintain the integrity of the community and There is a formal and informal curriculum focused
ensure the spread of social learning effects. on teaching the TC perspective, particularly its self-
help recovery concepts and view of right living. The
concepts, messages, and lessons of the curriculum
A Structured Day are repeated in the various groups, meetings, semi-
The structure of the program relates to the TC per- nars, and peer conversations, as well as in readings,
spective, particularly the view of the client and recov- signs, and personal writings.
ery. Ordered, routine activities counter the character-
istically disordered lives of these clients and distract
Peer Encounter Groups
from negative thinking and boredom, factors which
predispose to drug use. Structured activities of the The main community or therapeutic group is the
community facilitate learning self-structure for the encounter, although other forms of therapeutic, edu-
individual in time management, planning, setting cational, and support groups are utilized as need-
and meeting goals, and, in general, accountability. ed. The minimal objective of the peer encounter is
Thus, regardless of its length, the day has a formal similar in TC-oriented programs: to heighten indi-
schedule of varied therapeutic and educational activ- vidual awareness of specific attitudes or behavioral
ities with prescribed formats, fixed times, and routine patterns that should be modified. However, the en-
procedures. counter process may differ in degree of staff direction
314 TREATMENT

and intensity, depending on the client subgroups communication and interpersonal skills, examine
(e.g., adolescents, prison inmates, the dually disor- and confront behavior and attitudes, and offer in-
dered). struction in alternate modes of behavior.
There are four main forms of group activity in the
TC: encounters, probes, marathons, and tutorials.
Planned Duration of Treatment
These differ somewhat in format, objectives, and
The optimal length of time for full program involve- method, but all attempt to foster trust, personal dis-
ment must be consistent with TC goals of recovery closure, intimacy, and peer solidarity to facilitate
and its developmental view of the change process. therapeutic change. The focus of the encounter is
How long the individual must be program-involved behavioral. Its approach is confrontation, and its ob-
depends on his or her phase of recovery, although a jective is to modify negative behavior and attitudes
minimum period of intensive involvement is re- directly. Probes and marathons have as their primary
quired to ensure internalization of the TC teachings. objective significant emotional change and psycho-
logical insight. Tutorial groups stress learning of
skills. With the exception of the encounter, which is
Continuity of Care
peer-led, the groups are conducted by staff assisted
Completion of primary treatment is a stage in the by senior peers.
recovery process. Aftercare services are an essential The four main groups are supplemented by a
component in the TC model. Whether imple- number of ad hoc groups that convene as needed.
mented within the boundaries of the main program These vary in focus, format, and composition. For
or separately as in residential or nonresidential half- example, gender-, ethnic-, or age-specific theme
way houses, or ambulatory settings, the perspective groups may utilize encounter or tutorial formats. Ad-
and approach guiding aftercare programming must ditionally, sensitivity-training, psychodrama, conven-
be continuous with that of primary treatment in the tional-Gestalt, emotionality, relapse-prevention, and
TC. Thus, the views of right living and self-help re- 12-step groups are employed to varying extents.
covery and the use of a peer network are essential to One-to-one counseling balances the needs of in-
enhancing appropriate use of vocational, educa- dividuals with those of the community. Peer ex-
tional, mental health, social, and other typical after- change is ongoing and constitutes the most consis-
care or reentry services. tent form of informal counseling in TCs. Staff
counseling sessions are both formal and informal and
usually conducted as needed. The staff counseling
TC Process: Basic Program Elements
method in the TC is not traditional, as is evident in
The recovery process may be defined as interaction its main features: transpersonal sharing, direct sup-
between treatment interventions and client change. port, minimal interpretation, didactic instructions,
Unlike other treatment approaches, however, the TC and concerned confrontation.
is a community milieu whose daily regimen consists
of structured and unstructured activities and social
Community Enhancement Activities
intercourse occurring in formal and informal set-
tings. All of these constitute the treatment interven- These facilitate the individual's assimilation into the
tions in the process. These activities may be grouped community and strengthen the community's capabil-
into three main elements: therapeutic educative, ity to teach and to heal. They include the four main
community enhancement, and community and clin- facilitywide meetings. The morning meeting, semi-
ical management. nars, and the house meeting are held each day, and
the general meeting is called when needed.
Morning meetings convene all residents of the fa-
Therapeutic Educative Activities
cility and the staff on the premises after breakfast to
These consist of various group and individual coun- initiate the day's activities with a positive attitude, to
seling. They promote expression of emotions, divert motivate residents, and to strengthen unity. This is
negative acting out, permit ventilation of feeling, and accomplished through a planned program of recita-
resolve personal and social issues. They increase tion of the TC philosophy, songs, readings, and skits
 THE THERAPEUTIC COMMUNITY TREATMENT MODEL 315

conducted by peers. This meeting is particularly im- or community is based on an earning process. Fi-
portant in that most residents of TCs have never nally, privileges provide explicit feedback in the
adapted to the routine of an ordinary day. learning process. They are one of the tangible re-
Seminars convene every afternoon, usually for 1 wards that are contingent on individual change. This
hour. The seminar collects all the residents together concrete feature of privilege is particularly suitable
at least once during the working day. Most seminars for individuals with histories of performance failure
are conducted by residents, although sometimes led or incompleteness.
by staff and outside speakers. Of the various meetings Therapeutic communities have their own specific
and groups in the TC, the seminar is unique in its rules and regulations that guide the behavior of resi-
emphasis on listening, speaking, and conceptual be- dents and the management of facilities. The explicit
havior. purpose of these is to ensure the safety and health of
House meetings convene nightly after dinner, the community; however, their implicit aim is to
usually for 1 hour, and are coordinated by a senior train and teach residents through the use of disci-
resident. The main aim of these meetings is to trans- pline.
act community business, although they also have a In the TC, social and physical safety are prerequi-
clinical objective. In this forum, social pressure is ju- sites for psychological trust. Thus, disciplinary sanc-
diciously employed to facilitate individual change tions are invoked against any behavior that threatens
through public acknowledgment of positive or nega- the safety of the therapeutic environment. For exam-
tive behaviors by certain individuals or subgroups. ple, breaking one of the TC's cardinal rules—such
General meetings convene only when needed, as no violence or threat of violence—can bring im-
usually to address negative behavior, attitudes, or in- mediate expulsion. Even threats as minor as the theft
cidents in the facility. These meetings, conducted by of a toothbrush or a book must be addressed.
staff, are designed to identify problem people or con- The choice of sanction depends on the severity of
ditions or to reaffirm motivation and reinforce posi- the infraction, time in the program, and history of in-
tive behavior and attitudes in the community. fractions. For example, verbal reprimands, loss of
privileges, or speaking bans may be selected for less
severe infractions. Job demotions, loss of residential
Community and Clinical Management
time, and expulsion may be invoked for more serious
These activities maintain the physical and psycholog- infractions.
ical safety of the environment and ensure that resi- Although often perceived as punitive, the basic
dent life is orderly and productive. They protect the purpose of contracts is to provide a learning experi-
community as a whole and strengthen it as a context ence by compelling residents to attend to their own
for social learning. The main activities — privileges, conduct, to reflect on their own motivation, to feel
disciplinary sanctions, and surveillance —have both some consequence of their behavior, and to consider
management and clinical relevance in the model. alternate forms of acting under similar situations.
In the TC, privileges are explicit rewards that re- Contracts also have important community func-
inforce the value of achievement. Privileges such as tions. The entire facility is made aware of all disci-
job promotions, furloughs, room privacy, and peer plinary actions. Thus, contracts deter violations. They
leadership roles are accorded by overall clinical prog- provide vicarious learning experiences for others. As
ress in the program. Displays of inappropriate behav- symbols of safety and integrity, they strengthen com-
ior or negative attitude can result in loss of privileges, munity cohesiveness.
which can be regained by demonstrated improve- The TC's most comprehensive method for assess-
ment. Because privilege is equivalent to status in the ing the overall physical and psychological status of
vertical social system of the TC, loss of even small the residential community is the house run. Several
privileges is a status setback that is particularly pain- times a day, staff and senior residents walk through
ful for individuals who have struggled to raise their the entire facility from top to bottom, examining its
low self-esteem. Moreover, since substance abusers overall condition. This single procedure has clinical
often cannot distinguish between privilege and enti- implications as well as management goals. House
tlement, the privilege system in the TC teaches that runs provide global "snapshot" impressions of the fa-
productive participation or membership in a family cility: its cleanliness, planned routines, safety proce-
316 TREATMENT

dures, morale, and psychological tone. They illumi- Thus, the "active treatment ingredients" of the
nate the psychological and social functioning of TC approach are contained in the relationship be-
individual residents and peer collections. House runs tween the individual and the community. These in-
provide observable, physical indicators of self-man- gredients are defined in terms of four interrelated
agement skills, attitudes toward self and the program, components of community as method: (a) the com-
mood and emotional status, and the residents' (and munity context, which consists of peer and staff rela-
staffs) general level of awareness of self and the phys- tionships and daily regimen of planned activities
ical and social environment. (meetings, groups, individual peer and staff counsel-
Most TCs utilize unannounced random urine ing, work, meals, recreation); (b) the community's
testing or incident-related urine-testing procedures. expectations, which consist of the explicit standards
Residents who deny the use of drugs or refuse urine and implicit demands for individual participation in,
testing on request are rejecting a fundamental expec- and use of, its context; (c) community assessment,
tation in the TC, which is to trust staff and peers which consists of peers' and staffs formal and infor-
enough to disclose undesirable behavior. The volun- mal observations of the individual's progress in meet-
tary admission of drug use initiates a learning experi- ing community expectations; and (d) community re-
ence, which includes exploration of conditions pre- sponses to assessment, which consist of various forms
cipitating the infraction. Denial of actual drug use, of feedback, instruction, positive and negative sanc-
either before or after urine testing, can block the tions, and consequences. It is in striving to meet
learning process and may lead to termination or community expectations and standards for participa-
dropout. tion that the individual achieves his or her social and
When positive urine is detected, the action taken psychological goals.
depends on the drug used, time and status in the
program, previous history of drug and other infrac-
Role of the Therapist
tions, and locus and condition of use. Actions may
involve expulsion, loss of time, radical job demotion, The social environment, consisting of daily regimen
or loss of privileges for specific periods. Review of the of activities, provides residents with myriad social
"triggers" or reasons for drug use is also an essential learning opportunities. It is staff, however, who are
part of the action taken. responsible for sustaining an environment that en-
hances the self-help learning process for a single resi-
dent and/or the entire community.
Active Ingredients of the Treatment
All activities/interventions of the social environment
Therapist Training
(e.g., the structure and process components) are de-
signed to produce therapeutic and educational change Staff composition in the TC consists of a mix of tra-
in individual participants, and all participants are ditional and nontraditional professionals in a variety
mediators of these therapeutic and educational of clinical, management, administrative, and sup-
changes. The interrelationship among these activities portive service positions. Treatment program person-
provides "global intervention" of the community, nel are directly responsible for the day-to-day clinical
which results in individual social and psychological and operational activities of the residential facility.
change. The efficacy of this global intervention, how- Nontraditional professionals generally have recovery
ever, depends on the individual's participation in the experience as well as formal training in human ser-
program. Participation means that the individual en- vices. Traditional professional staff consists of social
gages in and learns to use all of the elements of the workers, psychologists, psychiatrists, and nurses,
community as tools for self-change. Therefore the ov- some with recovery experience. Regardless of their
erarching aim of treatment is sustaining individuals' background, all staff must be integrated through
full participation in the community in order to cross-training in the basic concepts of the perspec-
achieve their goals of lifestyle and identity change. tive, community approach, program model, and
And participation is the most comprehensive mea- methods of the TC in order to ensure effective im-
sure of change. plementation of the program.
 THE THERAPEUTIC COMMUNITY TREATMENT MODEL 317

and emphasis, and each impacts the individual resi-

Stance of Therapist
dent and the community in different ways.
The primary counseling staff in the standard TC
does not routinely engage in formal psychotherapy,
Common Obstacles to
although they may use some conventional psycho-
Successful Treatment
therapy techniques and typical therapeutic effects of-
ten occur such as emotional breakthroughs and pow- A majority of admissions fail to complete the full
erful insights. However, counselors are discouraged course of treatment. Although research shows that
from using conventional therapeutic language or many of these noncompleters show benefits, the
methods and from conceptualizing themselves as, global social and psychological goals of the TC are
therapists. not fully realized. Thus, the obstacles to successful
Therapeutic counseling sessions may be con- treatment are the factors which contribute to prema-
ducted directly with the resident in planned private ture dropout. Though not fully understood, some of
conversations. These generally address crisis events these factors associated with characteristics of the cli-
in the resident's family life or personal issues of par- ent and implementation of the treatment protocol
ticular sensitivity, such as motivation, psychological are briefly listed:
symptoms, sexual orientation, sexual abuse, past vio-
lence. The goal of these sessions is resolution of is- • Client suitability. Many substance abusers who
sues that threaten the resident's commitment or abil- enter TCs cannot tolerate the structured regi-
ity to remain in the peer community. Staff primarily men and demands of these programs.
• Client motivation. Client motivation continu-
advises, supports and instructs, and in some cases re-
ally fluctuates during the course of the residen-
fers the resident to mental health therapists or other
tial stay. Thus, there is constant emphasis on
service professionals. Thus, counseling in the stan- sustaining motivation—particularly in the early
dard TC is both part of the therapeutic process and phases of treatment.
reinforces the community as the method in the ther- • Conflicts. The intensity of community life in
apeutic process (The modified TC programs for du- the TC fosters conflict between residents, and
ally disordered populations, however, have success- between residents and staff.
fully incorporated conventional psychotherapists and • External pressures. Residents in TCs often ex-
therapeutic strategies into the community approach perience pressures from family or employers to
[see De Leon, 1993b, 1997].) leave treatment prematurely.
• Flight into health. Most admissions to TCs
show improvements within the first 3 months
of treatment, which may paradoxically stimu-
Therapist/Patient Relationship and late many to leave prematurely.
the Change Process • Environmental risk. Recent research indicates
that TC programs vary in their adherence to
Staff role distinctions in the TC can be contrasted essential elements of the model. In particular,
with mental health treatment and human service pro- differences in the internal and surrounding en-
viders in conventional treatment settings. For exam- vironment of the program may contribute to
ple, among case managers, counselors, and therapists dropout (Jainchill, Messina, & Yagelka, 1997).
in other settings, the relationship between client and • Staff training. Staff require an understanding
staff is viewed as the primary therapeutic alliance. In of the theory and rationale for the treatment
the TC, the essential therapeutic alliance is the cli- protocol. Recovered staff with TC experience
are often inflexible in their response to indi-
ent's relationship with the peer community. Primary
vidual differences. Their clinical skills and
treatment staff assume various roles to enhance this
knowledge may be limited by their narrow ex-
relationship. Four main staff roles can be identified: perience and training rather than conceptual
facilitator/guide, rational authority, counselor/thera- understanding of the TC approach. Converse-
pist, and community manager. Although these roles ly, traditionally trained human services profes-
obviously merge, interchange, and overlap constant- sionals in TCs lack experience with personal
ly, each is recognizable in its distinct characteristics recovery and are limited by concepts, language,
318 TREATMENT

and perspectives of their professional training. hol, and pills, although in recent years most report
In particular, they have difficulty acclimating cocaine/crack as their primary drug of abuse. Re-
to the primacy of the peer community as the search has documented that individuals admitted to
method for treatment. TCs reveal a considerable degree of psychosocial dys-
• Funding policy. Recent changes in health care
function in addition to their substance abuse. Al-
policy have resulted in shorter planned dura-
though clients differ in demography, socioeconomic
tions of treatment. These changes impose lim-
its in implementing the TC treatment protocol background, and drug use patterns, psychological
based upon its perspective. profiles obtained with standard instruments appear
remarkably uniform, as evident in a number of TC
studies (e.g., Biase, Sullivan, & Wheeler, 1986;
CHARACTERISTICS OF CLIENTS MOST Brook & Whitehead, 1980; De Leon, 1976, 1980,
LIKELY TO RESPOND TO THE MODEL 1984, 1989; Holland, 1986; Kennard & Wilson 1979;
Zuckerman, Sola, Masterson, & Angelone, 1975).
Psychological profiles reveal drug abuse as the
Social and Psychological Profiles
prominent element in a picture that mirrors the fea-
Residents in traditional programs are usually men tures of both psychiatric and criminal populations.
(70-75%), but admissions of women have been in- For example, the character disorder characteristics
creasing in recent years. Most community-based TCs and poor self-concept of delinquent and repeated of-
are integrated across gender, race/ethnicity, and age, fenders are present, along with the dysphoria and
although the demographic proportions differ by geo- confused thinking of emotionally unstable or psychi-
graphic regions and in certain programs. In general, atric populations. These profiles vary little across age,
Hispanics, Native Americans, and patients under 21 sex, race, primary drug, or admission year and are
years of age represent smaller proportions of admis- not significantly different from those of drug abusers
sions to TCs. in other treatment modalities.
About half of all admissions are from broken Recent studies indicate that over 70% of admis-
homes or ineffective families. A large majority have sions reveal a lifetime nondrug psychiatric disorder
poor work histories and have engaged in criminal ac- in addition to substance abuse or dependence. One
tivities at some time in their lives. Among adult ad- third have a current or continuing history of mental
missions less than one third have been employed full disorder in addition to their drug abuse. The most
time during the year before treatment, more than frequent nondrug diagnoses are phobias, generalized
two thirds have been arrested, and 30-40% have had anxiety, psychosexual dysfunction, and antisocial per-
prior drug treatment histories (e.g., De Leon, 1984; sonality. There are only a few cases of schizophrenia,
Hubbard, Rachal, Craddock, & Cavanaugh, 1984; but lifetime affective disorders occurred in over one
Simpson & Sells 1982). third of those studied (De Leon, 1993a; Jainchill,
Among adolescents, 70% have dropped out of 1989, 1994; Jainchill, De Leon, & Pinkham 1986).
school, and more than 70% have been arrested at Thus, drug abusers who come to the TC do not ap-
least once or involved with the criminal justice sys- pear to be mentally ill, as do patients in psychiatric
tem. More have histories of family deviance, fewer settings, nor are they simply hard-core criminal types.
have had prior treatment for drug use (De Leon & However, they do reveal a considerable degree of
Deitch 1985; Holland & Griffen 1984), but more of psychological disability.
the younger adolescents have had treatment for psy-
chological problems (Jainchill, 1997). Approximately
Clients Who Are Best Candidates
30% of adult admissions and 50-70% of adolescent
for Long-Term Residential TCs
admissions to long-term residential TCs are criminal
justice referrals, although some TC programs exclu- There is no typical profile of the substance abusers
sively serve criminal justice referrals (De Leon, who succeed in residential therapeutic communities.
1993a; Jainchill, 1997; Tims, De Leon, & Jainchill, However, the need for long-term treatment in TCs is
1994). based on clinical and research experience. The clini-
The majority of TC admissions have histories of cal indicators of long-term residence in TCs can be
multiple drug use including marijuana, opiates, alco- briefly summarized across five main domains:
 THE THERAPEUTIC COMMUNITY TREATMENT MODEL 319

1. Health and social risk status. Most abusers who ness, and suitability are not criteria for admission to
seek treatment in the TC experience acute stress. the TC, the importance of these factors often
They may be in family or legal crisis or at significant emerges after entry into treatment, and if they are
risk to harm themselves or others, so that a period of not identified and addressed, they are related to early
residential stay is indicated. However, clients suitable dropout (De Leon, 1993a; De Leon & Jainchill,
for long-term residential treatment reveal a more 1986; De Leon, Melnick, Kressel, & Jainchill, 1994).
chronic pattern of stress that induces treatment seek- Overall, the picture that residents present when
ing and, when relieved, usually results in premature entering the TC is one of health risk and social cri-
dropout. They require longer term residential treat- ses. Drug use is currently or recently out of control;
ment because they are a constant risk threat, and individuals reveal little or no capacity to maintain
they must move beyond relief seeking to initiate a abstinence on their own; social and interpersonal
genuine recovery process. function is diminished; and their drug use either is
2. Abstinence potential. In the TC's view of sub- embedded in or has eroded to a socially deviant life-
stance abuse as a disorder of the whole person, absti- style. Although individuals may differ in the severity,
nence is a prerequisite for recovery. Among chronic extent, or duration of the problems in each area, all
users, the risk of repeated relapse can subvert any require the residential TC to initiate change. As
treatment effort, regardless of the modality. Thus, the elaborated below, however, clients' levels of motiva-
residential TC is needed to interrupt out-of-control tion and readiness to change and their perceived
drug use and to stabilize an extended period of absti- need for residential TCs are overarching indicators
nence in order to facilitate a long-term recovery pro- for this treatment approach.
cess.
3. Social and interpersonal function. Inadequate
Contraindications for Residential
social and interpersonal function not only results
TC Treatment
from drug use but often reveals a more general pic-
ture of immaturity or an impeded developmental his- Traditional TCs maintain an open-door policy with
tory. Thus, a setting such as the TC is needed—it respect to admission to residential treatment. This
focuses upon the broad socialization and/or habilita- understandably results in a wide range of treatment
tion of the individual. candidates, not all of whom are equally motivated,
4. Antisocial involvement. In the TC view, the ready, or suitable for the demands of the residential
term antisocial also suggests characteristics which are regimen. Relatively few are excluded, because the
highly correlated with drug use. These include be- TC policy is to accept individuals who elect residen-
haviors such as exploitation, abuse and violence, atti- tial treatment—regardless of the reasons influencing
tudes of mainstream disaffiliation, and the rejection their choice. However, there are two major guide-
or absence of prosocial values. Modification of these lines for excluding clients: suitability and community
characteristics requires the intensive resocialization risk. As discussed above, suitability refers to the de-
approach of the TC setting. gree to which the client can meet the demands of
5. Suitability for the TC. A number of those seek- the TC regimen and integrate with others. This in-
ing admission to the TC may not be ready for treat- cludes participation in groups, fulfilling work assign-
ment in general or suitable for the demands of a ments, and living with minimal privacy in an open
long-term residential regimen. Assessment of these community, usually under dormitory conditions.
factors at the time of admission provides a basis for Community risk refers to the extent to which clients
treatment planning in the TC, and sometimes for present a management burden to the staff or pose a
appropriate referral. Some indicators of motivation, threat to the security and health of the community
readiness, and suitability for TC treatment are accep- or others.
tance of the severity of drug problem; acceptance of Specific exclusionary criteria most often include
the need for treatment ("can't do it alone"); willing- histories of arson, suicide, and serious psychiatric
ness to sever ties with family, friends, and current disorder. Psychiatric exclusion is usually based on a
lifestyle while in treatment; and willingness to sur- documented history of psychiatric hospitalizations
render a private life and to meet the expectations of or prima facie evidence of psychotic symptoms on
a structured community. Although motivation, readi- interview (e.g., frank delusions, thought disorder,
320 TREATMENT

hallucinations, confused orientation, or signs of seri- ment) and on composite indices for measuring indi-
ous affect disorder). Generally, clients on regular psy- vidual success. Maximum to moderately favorable
chotropic regimens are excluded because use of outcomes (based on opioid, nonopioid, and alcohol
these usually correlates with chronic or severe psy- use; arrest rates; retreatment and employment) occur
chiatric disorder. Also, regular administration of psy- for more than half of the sample of completed clients
chotropic medication, particularly in the larger TCs, and dropouts (De Leon, 1984; Hubbard et al., 1989;
presents a management and supervisory burden for Simpson & Sells, 1982).
the relatively few medical personnel in these facili- There is a consistent positive relationship be-
ties. There are examples of integrating into main- tween time spent in residential treatment and post-
stream TCs some clients requiring psychiatric medi- treatment outcome status. For example, in long-term
cation (Carroll & Sobel, 1986). And as discussed in TCs, success rates (on composite indices of no drug
the last section, modified TCs for mentally ill chemi- use and no criminality) at 2 years posttreatment ap-
cal abusers requiring medication have been success- proximate 90%, 50%, and 25%, respectively, for grad-
fully implemented. uates/completers and dropouts who remain more
Clients requiring medication for medical condi- than and less than 1 year in residential treatment.
tions are acceptable in TCs, as are handicapped cli- Improvement rates over pretreatment status approxi-
ents or those who require prosthetics, providing they mate 100%, 70%, and 40%, respectively (De Leon,
can meet the participatory demands of the program. Wexler, & Jainchill, 1982).
Because of concern about communicable disease in In a few studies that investigated psychological
a residential setting, TCs require tests for conditions outcomes, results uniformly showed significant im-
such as tuberculosis and hepatitis prior to entry into provement at follow-up (e.g., Biase et al., 1986; De
the facility or at least within the first weeks of admis- Leon, 1984; Holland, 1983). A direct relationship
sion. has been demonstrated between posttreatment be-
Policy and practices concerning testing for HIV havioral success and psychological adjustment (De
status and management of AIDS or AlDS-related Leon, 1984; De Leon & Jainchill, 1981-1982).
complex (ARC) have recently been implemented by
most TCs. These emphasize voluntary testing, with
Retention
counseling, special education seminars on health
management and sexual practices, and special sup- Dropout is the rule for all drug treatment modalities.
port groups for residents who are HIV-positive or For therapeutic communities, retention is of particu-
have a clinical diagnosis of AIDS or ARC (De Leon, lar importance because research has established a
1997; McKusker & Sorensen, 1994). firm relationship between time spent in treatment
and successful outcome. However, most admissions
to therapeutic community programs leave residency,
EFFECTIVENESS: EMPIRICAL DATA
many before treatment influences are presumed to
be effective.
A substantial evaluation literature documents the ef-
Research on retention in TCs has been increas-
fectiveness of the TC approach in rehabilitating drug
ing in recent years. Reviews of TC retention research
abusers (e.g., Condelli & Hubbard, 1994; De Leon,
are contained in the literature (e.g., De Leon, 1985,
1984, 1985; Hubbard et al., 1989; Institute of Medi-
1991; Lewis, McCusker, Hindin, Frost, & Garfield,
cine, 1990; Simpson & Curry, 1997; Simpson &
1993). Studies focus on several questions, includ-
Sells, 1982; Tims et al., 1994; Tims & Ludford,
ing retention rates and client predictors of dropout.
1984). The main findings on short- and long-term
The key findings from these may be briefly summa-
posttreatment follow-up status from single program
rized:
and multiprogram studies are now briefly summa-
rized.
Retention Rates
Success and Improvement Rates
Dropout is highest (30-40%) in the first 30 days of
Significant improvements occur on separate out- admission and declines sharply thereafter (De Leon &
come variables (drug use, criminality, and employ- Schwartz 1984). This temporal pattern of dropout
 THE THERAPEUTIC COMMUNITY TREATMENT MODEL 321

is uniform across TC programs (and other modal-

Current Modifications of the TC Model
ities). In long-term residential TCs, completion rates
average 10-20% of all admissions. One-year reten- Most community-based traditional TCs have ex-
tion rates range from 15% to 30%, although more panded their social services or have incorporated
recent trends suggest gradual increases in annual re- new interventions to address the needs of their di-
tention compared to the period before 1980 (De verse admissions. In some cases, these additions en-
Leon, 1989). hance but do not alter the basic TC regimen; in oth-
ers, they significantly modify the TC model itself.

Predictors of Dropout
FAMILY SERVICES APPROACHES
There are no reliable client characteristics that pre-
dict retention, with the exception of severe criminal- The participation of families or significant others has
ity and/or severe psychopathology, which are corre- been a notable development in TCs for both adoles-
lated with earlier dropout. Recent studies point to cents and adults. Some TCs offer programs in indi-
the importance of dynamic factors in predicting re- vidual- and multiple-family therapy as components of
tention in treatment, such as perceived legal pres- their adolescent, nonresidential, and (more recently)
sure, motivation and readiness for treatment (e.g., short-term residential modalities. However, most tra-
Condelli & De Leon, 1993; De Leon, 1993a; De ditional TCs do not provide a regular family therapy
Leon & Jainchill, 1986; Hubbard et al., 1989; Scho- service because the individual in residence rather
ket, 1992; Siddiqui, 1989). than the family unit is viewed as the primary target
Only a few studies have assessed self-reported rea- of treatment. Thus, family psychoeducational and
sons for leaving treatment prematurely. Findings participation activities and support groups are offered
from these suggest the importance of client percep- to enhance the TC's rehabilitative process for the res-
tion factors as reasons for early dropout. These idential client by establishing an alliance between
mainly reflect low readiness for treatment in general significant others and the program.
or perceived unsuitability for the TC life in particu-
lar (e.g., De Leon, 1993a; De Leon & Wexler, 1983).
While a legitimate concern, retention should not be PRIMARY HEALTH CARE
confused with treatment effectiveness. Therapeutic AND MEDICAL SERVICES
communities are effective for those who remain long
enough for treatment influences to occur. Although funding for health care services remains in-
The outcome studies reported were completed on sufficient for TCs, these agencies have expanded ser-
an earlier generation of chemical abusers, primarily vices for the growing number of residential patients
opioid addicts. Since the early 1980s, however, most with sexually transmitted and immune-compromising
admissions to residential TCs have been multiple conditions, including HIV seropositivity, AIDS, syphi-
drug abusers, primarily involved with cocaine, crack, lis, hepatitis B, and, recently, tuberculosis. Screening,
and alcohol, with relatively few primary heroin users. treatment, and increased health education have been
Studies in progress evaluate the effectiveness of the sophisticated, both on site and through links with
TC for the recent generation of abusers (Hubbard et community primary-health-care agencies.
al., 1970; National Treatment Improvement Evalua-
tion Study, 1997). Although still preliminary, these
Aftercare Services
studies confirm the effectiveness of modified TCs for
special populations of substance abusers, such as Currently, most long-term TCs have links with other
those with co-occurring mental illness (e.g., Sacks, service providers and 12-step groups for their gradu-
De Leon, Bernhardt, & Sacks, 1997), adolescents ates. However, the TCs with shorter term residential
(Jainchill, 1997), and inmates in state correctional components have instituted well-defined aftercare
facilities (e.g., Graham & Wexler, 1997; Lipton, programs both within their systems and through links
1995; Lockwood, Inciardi, Butzin, & Hooper, 1997; with other non-TC agencies. There are limits and
Wexler & Lipton, 1993). issues concerning these aftercare efforts because of
322 TREATMENT

discontinuities between the perspectives of the TC 1986). Certain subgroups of these patients are treated
and other service agencies. These are outlined along within the traditional TC model and regimen, which
with a fuller discussion of aftercare in TCs in other requires some modification in services and staffing.
writings (De Leon, 1990-1991). For example, psychopharmacological adjuncts and
individual psychotherapy are used for selected pa-
tients at appropriate stages in treatment. Neverthe-
Relapse Prevention Training
less, the traditional community-based TC models
Based on their approach to recovery, traditional TCs still cannot accommodate substance-abusing patients
have always focused on the key issues of relapse with serious psychiatric disorders. As described in re-
throughout all the stages of the program. Currently, cent literature (De Leon, 1997), these primary psy-
however, a number of TCs include special work- chiatric substance-abusing individuals require spe-
shops on relapse prevention training (RPT), using cially adapted forms of the TC model.
curriculum, expert trainers, and formats developed
outside of the TC area (e.g., Marlatt, & Gordon,
Multimodal TC and
1985). These workshops are offered as formal addi-
Patient-Treatment Matching
tions to the existing TC protocol, usually in the reen-
try stage of treatment. However, some programs in- Traditional TCs are highly effective for a certain seg-
corporate RPT workshops into earlier treatment ment of the drug abuse population. However, those
stages, and in a few others, RPT is central to the pri- who seek assistance in TC settings represent a broad
mary treatment protocol (e.g., Lewis & Ross, 1994). spectrum of patients, many of whom may not be suit-
Clinical impressions supported by preliminary data able for a long-term residential stay. Improved diag-
of the efficacy of RPT within the TC setting are fa- nostic capability and assessment of individual differ-
vorable, although rigorous evaluation studies are still ences have clarified the need for options other than
in progress (McCusker & Sorensen, 1994). long-term residential treatment.
Many TC agencies are multimodality treatment
centers, which offer services in their residential and
12-Step Components
nonresidential programs depending on the clinical
Historically, TC graduates were not easily integrated status and situational needs of the individual. The
into AA meetings for a variety of reasons (see De modalities include short- (less than 90 days), medi-
Leon, 1990-1991). In recent years, however, there um- (6-12 months), and long-term (1-2 years) resi-
has been a gradual integration of AA/NA/CA (Co- dential components and drug-free outpatient services
caine Anonymous) meetings during and following (6-12 months). Some TCs operate drug-free day
TC treatment because of the wide diversity of users treatment and methadone maintenance programs.
socially and demographically and the prominence of Assessments attempts to match the patient to the ap-
alcohol use regardless of the primary drug. The com- propriate modality within the agency. For example,
mon genealogical roots found in TCs and the 12- the spread of drug abuse in the workplace, particu-
step groups are evident to most participants in these, larly cocaine use, has prompted the TC to develop
and the similarities in the self-help view of recovery short-term residential and ambulatory models for em-
far outweigh the differences in specific orientation. ployed, more socialized patients.
Today, 12-step groups may be introduced at any To date, the effectiveness of TC-oriented multi-
stage in residential treatment but are considered modality programs has not been systematically evalu-
mandatory in the reentry stages of treatment and in ated, although several relevant studies are currently
the aftercare or continuance stages of recovery after under way. Of particular interest are the comparative
leaving the residential setting. effectiveness and cost-benefits of long- and short-term
residential treatment. Thus far, however, there is no
convincing evidence supporting the effectiveness of
Mental Health Services
short-term treatment in any modality, residential or
Among those seeking admission to TCs, increasing ambulatory. More detailed descriptions of the appli-
numbers reveal documented psychiatric histories cations and modifications of the TC model are pro-
(e.g., De Leon, 1989; Jainchill, 1989; Jainchill et al., vided elsewhere (De Leon, 1997).
 THE THERAPEUTIC COMMUNITY TREATMENT MODEL 323

STRENGTHS AND WEAKNESSES OF ever, must ultimately resolve in favor of the indi-
THE MODEL FOR SUBSTANCE ABUSE vidual.
The TC model appears most appropriate only for
Although TCs have been successfully treating sub- certain subgroups of substance abusers, notably the
stance abusers for some 30 years, an explicit theoreti- most serious users, and those who are socially devi-
cal framework of the model and method is a recent ant. In the past, the traditional addiction TC was
development. The strengths and weaknesses of the clearly not appropriate for well-socialized addicts, or
TC approach are based on clinical experience sup- for those with serious psychiatric illness. Thus, the
ported by developing research. Not unexpectedly, generality of effectiveness remains to be fully docu-
some of the strengths of the TC are also its weak- mented.
nesses. More generally, the TC is a high-demand treat-
ment that appears appropriate for clients who are
highly motivated and ready to change, and who per-
Strengths ceive the TC environment as suitable. The contribu-
tion of these selection factors has tended to cloud
The TC remains the treatment of choice for the se-
interpretations of effectiveness.
vere, antisocial, or socially disaffiliated substance
The TC model has assumed that the issues of af-
abuser. For this population of substance abusers, the
tercare are adequately addressed in the reentry stage
goals of lifestyle and identity change remain para-
of the residential program. Thus, until recently, the
mount but require long-term treatment involvement,
model has not provided for well-developed aftercare
regardless of changes in health care policy. Neverthe-
networks to maintain treatment gains. The pressure
less, the model has also proved to be generalizable,
of cost containment has further challenged the rele-
evident in the current adaptations for special popula-
vancy of the long-term residential model and has un-
tions and settings. Studies in progress confirm the
derscored distinctions between primary treatment
effectiveness of modified TCs for special populations
and aftercare.
of substance abusers such as those with co-occurring
The TC illustrates the complexity of a commu-
mental illness (e.g., Sacks et al., 1997), adolescents
nity as method model of treatment. Multiple inter-
(Jainchill, Bhattacharya, & Yagelka, 1995), and in-
ventions—formal and informal—address multiple di-
mates in state correctional facilitates (e.g., Lipton,
mensions of the individual in a process of change,
1995; Lockwood et al., 1997; Wexler & Graham,
defined as a dynamic interaction between the indi-
1994; Wexler, Falkin, & Lipton, 1990).
vidual and the community. Empirical research on
The TC model is the best example of an effective
such a complex model is difficult to implement. Ab-
self-help, recovery-oriented approach to the treatment
stracting the "active treatment elements" of the TC
of substance abuse. Contrasted with conventional
process poses methodological challenges similar to
medical and mental-health-oriented approaches, the
those in researching villages or family systems. Nev-
model underscores the importance of empowering
ertheless, several decades of research have estab-
the individual in the change process, the use of peer
lished firm evidence of the effectiveness of the
communities as a method of facilitating change, and
model. And the recent development of a theoretical
the reality of achieving long-term, sustained changes.
framework is guiding current research into the treat-
ment process.
Weaknesses
The TC approach is inherently limited in its respon- SUMMARY
sivity to individual differences. Although the individ-
ual is the constant focus of the TC, the structure and The TC is a powerful social psychological alternative
process elements of a peer community as method to pharmacological treatments of substance abuse
approach are relatively inflexible in meeting the and related problems. It provides a comprehensive
unique needs of individuals. Thus, in TC programs, approach guided by an explicit perspective. The TC
there is a constant tension between the needs of the is oriented to recovery, not simply abstinence or
individual and those of the community, which, how- symptom reduction. It stresses and provides the set-
324 TREATMENT

ting for individuals to change lifestyles and identities. Carroll, J. F. X., & Sobel, B. S. (1986). Integrating men-
Thus, it remains the treatment of choice for the se- tal health personnel and practices into a therapeutic
vere drug abuser: the unhabilitated, the antisocial, community. In G. De Leon & }. T. Ziegenfuss
the socially disaffiliated, and many adolescents. How- (Eds.), Therapeutic communities for addictions: Read-
ings in theory, research and practice (pp. 209-226).
ever, it is also adaptable to many settings and popula-
Springfield, IL: Charles C Thomas.
tions. Finally, though the TC model is systematic
Condelli, W. S., & De Leon, G. (1993). Fixed and dy-
and structured, it can integrate various effective ele-
namic predictors of client retention in therapeutic
ments of other approaches, such as family therapy, communities. Journal of Substance Abuse Treatment,
relapse prevention, and mental health. 10, 11-16.
The increasing diversity of TC-oriented programs Condelli, W. S., & Hubbard, R. L. (1994). Client out-
for special populations and the integration of staff comes from therapeutic communities. In F. M.
and various treatment and service components from Tims, G. De Leon, & N. Jainchill (Eds.), Therapeu-
other approaches pose both challenge and opportu- tic community: Advances in research and application
nity to the therapeutic community. Continued modi- (NIDA Research Monograph, NIH Publication No.
fication and adaptability of TC programs contain the 94-3633, pp. 80-98). Rockville, MD: National Insti-
risk of dilution of a basic model, which has proved tute on Drug Abuse.
Deitch, D. A. (1974). Treatment of drug abuse in the
its effectiveness. Conversely, these developments also
therapeutic community: Historical influences, cur-
portend the evolution of a generic TC approach use-
rent considerations, and future outlooks. National
ful for a wide diversity of populations and problems.
Commission on Marihuana and Drug Abuse (Vol. 4,
pp. 158-175).Washington, DC: Government Print-
Key References ing Office.
De Leon, G. (1976). Psychological and socio-demo-
De Leon, G. (1994). Therapeutic communities. In M.
graphic profiles of addicts in the therapeutic commu-
Galanter & H. D. Kleber (Eds.). The American Psy-
nity. (Final report of project activities under National
chiatric Press textbook of substance abuse treatment
Institute of Drug Abuse Grant No. DA-00831). Rock-
(pp. 391-414). Chicago: American Psychiatric Press.
ville, MD: National Institute on Drug Abuse.
De Leon, G. (1995). Therapeutic communities for ad-
dictions: A theoretical framework. International Jour- De Leon, G. (1980). Therapeutic communities: Training
nal of the Addictions, 30, 1603-1649. self evaluation. (Final report of project activities un-
De Leon, G. (1997). Community as method: Therapeu- der National Institute of Drug Abuse Grant No.
tic communities for special populations and special 1H81-DAO). Rockville, MD: National Institute on
settings. Westport, CT: Greenwood Press. Drug Abuse.
De Leon, G. (1984). The therapeutic community: Study
of effectiveness. Treatment Research Monograph Se-
References ries, DHHS Publication No. (ADM) 85-1286. Rock-
Biase, D. V., Sullivan, A. P., & Wheeler, B. (1986). Day- ville, MD: National Institute on Drug Abuse.
top miniversity—Phase 2: College training in a ther- De Leon, G. (1985). The therapeutic community: Sta-
apeutic community: Development of self-concept tus and evolution. International Journal of the Addic-
among drug free addict/abusers. In G. De Leon & tions, 7, 823-844.
J. Ziegenfuss, Jr. (Eds.), Therapeutic communities for De Leon, G. (1989). Therapeutic communities for sub-
addictions: Readings in theory, research and practice stance abuse: Overview of approach and effective-
(pp. 121-130). Springfield, IL: Charles C Thomas. ness. Psychology of Addictive Behaviors, 3(3), 140-
Bratter, T. E., Bratter, E. P., & Heimberg, J. F. (1986). 147.
Uses and abuses of power and authority within the De Leon, G. (1990-1991). Aftercare in therapeutic
American self-help residential therapeutic commu- communities. International Journal of the Addictions,
nity: A perversion or a necessity? In G. De Leon & 25(9A-10A), 1229-1241.
J. T. Ziegenfuss (Eds.), Therapeutic communities for De Leon, G. (1991). Retention in drug-free therapeutic
addictions: Readings in theory, research and practice communities. In R. W. Pickens, C. G. Leukefeld, &
(pp. 191-208). Springfield, IL: Charles C Thomas. C. R. Schuster (Eds.), Improving drug treatment (Na-
Brook, R. C., & Whitehead, I. C. (1980). Drug-free ther- tional Institute on Drug Abuse Research Monograph
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De Leon, G. (1993a). Cocaine abusers in therapeutic De Leon, G., & Schwartz, G. (1984). Therapeutic com-
community treatment. In F. M. Tims (Ed.), Cocaine munities: What are the retention rates? American
treatment: Research and clinical perspectives (NIDA Journal of Drug and Alcohol Abuse, 10, 267-284.
Publication No. 93-3639, pp. 163-189). Washing- De Leon, G., & Wexler, H. (1983). Perceived quality of
ton, DC: Government Printing Office. adjustment 5 years after therapeutic community treat-
De Leon, G. (1993b). Modified therapeutic communi- ment. Paper presented at the American Psychological
ties for dual disorder. In J. Solomon, S. Zimberg, & Association convention, Los Angeles.
E. Shollar (Eds.), Dual diagnosis: Evaluation, treat- De Leon, G., Wexler, H., & Jainchill, N. (1982). Suc-
ment, training, and program development (pp. 147- cess and improvement rates 5 years after treatment
170). New York: Plenum Press. in a therapeutic community. International Journal of
De Leon, G. (1994a). A recovery stage paradigm and Addictions, 17, 703-747.
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peutic Communities of America 1992 Planning Con- tic communities for addictions: Readings in theory,
ference, Paradigms: Past, Present and Future, Chan- research and practice. Springfield, IL: Charles C
tilly, Virginia (pp. 116-122). Edited and Published Thomas.
by Manisses Communications Group, Providence, Glaser, F. B. (1974). Some historical and theoretical
RI. background of a self-help addiction treatment pro-
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chiatric press textbook of substance abuse treatment Graham, W. F., & Wexler, H. K. (1997). The amity
(pp. 391-414). Chicago: American Psychiatric Press. therapeutic community program at Donovan prison:
De Leon, G. (1995). Therapeutic communities for ad- Program description and approach. In G. De Leon
dictions: A theoretical framework. International Jour- (Ed.), Community as method: Therapeutic communi-
nal of the Addictions, 30, 1603-1649. ties for special populations and special settings. West-
De Leon, G. (Ed.). (1997). Community as method: Ther- port, CT: Greenwood Press.
apeutic communities for special populations and spe- Holland, S. (1983). Evaluating community based treat-
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De Leon, G., & Deitch, D. (1985). Treatment of the ences about effectiveness. International Journal of
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2 years after treatment in a therapeutic community. use. Journal of Psychoactive Drugs, 16, 79-90.
American Journal of Drug and Alcohol Abuse, 8, 465- Hubbard, R. L, Craddock, S. G., Flynn, P. M., Ander-
497. son, J., & Etheridge, R. M. (1970). Overview of 1-
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motivation, readiness and suitability (CMRS) as cor- outcome study (DATOS). Psychology of Addictive
relates of treatment tenure. Journal of Psychoactive Behavior (Special Issue), 11(4), 261-278.
Drugs, 8, 203-208. Hubbard, R. L., Marsden, M. E., Rachal, J. V., Har-
De Leon, G., Melnick, G., Kressel, D., & Jainchill, N. wood, J. J., Cavanaugh, E. R., & Ginzburg, H. M.
(1994). Circumstances, motivation, readiness and (1989). Drug abuse treatment: A national study of ef-
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nal of Drug and Alcohol Abuse, 20, 495-515. Institute of Medicine. (1990). Treating drug problems: A
De Leon, G., & Rosenthal, M. S. (1989). Treatment in study of the evolution, effectiveness, and financing of
residential therapeutic communities. In T. B. Karasu public and private drug treatment systems. Report by
(Ed.), Treatments of psychiatric disorders (Vol. 2). the Institute of Medicine Committee for the Sub-
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 18

Self-Help Groups for Addictions

Joseph Nowinski

Individuals with substance abuse problems pursue addictions are increasingly confronted with the need
many different paths in their efforts to deal with the not only to be aware of such community-based re-
problem. Data suggest that many are able to reduce, sources, but also to actively facilitate patients' utiliza-
control, or stop alcohol or drug use without resorting tion of them as an adjunct to professional treatment.
to either formal treatment or self-help groups (Price, The pressure to augment formal treatment with self-
Cottier, & Robins, 1991; Sobell, Sobell, & Toneatto, help comes both from patients themselves and from
1991). In general, it is a desire to deal with the psy- third-party payers who are interested in cost-effective-
chosocial consequences of substance abuse, as op- ness. In this age of managed care, the professional
posed to a desire to reduce use per se, that appears to therapist or treatment program cannot reasonably ex-
motivate help seeking (Marlatt, Tucker, Donovan, & pect to be the sole source of therapeutic efforts. With
Vuchinich, 1997), and most substance abusers who this in mind, this chapter will attempt to educate the
do seek help tend to seek medical care prior to avail- practitioner regarding the most popular self-help
ing themselves of formal substance abuse treatment groups that are available, the key elements of self-
or self-help (Pokorny, Kanas, & Overall, 1981). Still, help as it pertains particularly to the addictions, and
a significant number of substance abusers do turn to how to effectively facilitate patients' utilization of
professional treatment and/or self-help groups at these programs. We must appreciate, however, that
some point in their efforts to stop or control use. an individual's decision to turn to a self-help group,
This chapter will discuss the major self-help or- much like the decision to seek formal treatment, is
ganizations currently available as resources for per- not likely to be an act of first resort in the process of
sons who are troubled by addictive behaviors. Prac- his or her efforts to deal with a substance abuse prob-
titioners who are asked to help individuals overcome lem. Rather, as noted above, the data suggest that

328
 SELF-HELP GROUPS FOR ADDICTIONS 329

such decisions are typically preceded by significant pear to have represented an idea whose time had
psychosocial consequences of substance abuse. come. Following the success of AA, a number of sim-
ilar groups, based on the same 12-step model of re-
EARLY DEVELOPMENT OF THE SELF- covery, emerged, including Al-Anon (1966) for fam-
HELP MOVEMENT FOR ADDICTIONS ily members of alcoholics and Narcotics Anonymous
(1987) for drug abusers. Meanwhile, those wishing
The modern self-help movement for addictive behav- to return to a more Oxford-like Christian Fundamen-
iors had its origins in the Oxford Groups, which were talist fellowship formed religiously based fellowships
a precursor to Alcoholics Anonymous. The Oxford such as the Calix Society (Calix, undated) and Over-
Group was an international, nondenominational, comers Outreach (1988; Bartosch & Bartosch, 1985).
and theologically conservative evangelical organiza- Of these organizations, AA remains by far the most
tion whose stated goal was to instill in its members ubiquitous, with approximately 89,000 registered
what it considered fundamental Christian precepts groups (AA, 1993) and over 1.7 million members
(Kurtz, 1988). The Oxford Group meetings that were (AA, 1990a) worldwide.
attended by Bill Wilson and other alcoholics inspired Following on the popular success of AA, a virtual
him not only with the members' kindness but with "12-step movement" emerged (Room, 1993), so that
their emphasis on spiritual renewal and fellowship as by 1988, it was estimated that there were approxi-
keys to personal transformation. mately 125,000 separate chapters of various 12-step
Alcoholics Anonymous (AA) eventually evolved groups in this country and abroad (Madara & Meese,
from the Oxford movement, taking with it the Ox- 1988). This movement now extends well beyond the
ford emphasis on fellowship and faith (as opposed to issues of alcoholism and drug addiction and includes
self-determinism), on the virtues of taking one's 12-step fellowships for "emotional addiction" (Emo-
"moral inventory" and making amends to others tions Anonymous, 1978), "food addiction" (Overeat-
harmed by one's faults (including addiction), on ers Anonymous, 1980), and "sex addiction" (August-
public confession or "sharing" of one's experiences, ine Fellowship, 1986), to name a few.
and on service to others as cornerstones of sobriety. Returning to the problem of substance abuse and
What differentiated AA from the Oxford movement addiction, a number of secular self-help organizations
was its less dogmatic, more pluralistic view of the have also emerged in recent years, including Self-
concept of God, which AA refrained as a "Higher Management and Recovery Training, or SMART.
Power." Thus, AA became an organization which, (1996); Rational Recovery, or RR (Trimpey, 1992);
while emphasizing the need for faith, as well as the Women for Sobriety (1993a, 1993b); Moderation
importance of humility as a condition for recovery Management (1996); and Secular Organizations for
from addiction, could be receptive to a much a Sobriety, or SOS (undated a, undated b). These
greater diversity of spiritual beliefs. groups, as well as the various 12-step groups, all aim
It is noteworthy that from its beginnings, AA and to help individuals overcome alcohol or drug prob-
the 12-step movement did not regard alcoholism as lems. They differ significantly, however, with respect
primarily a medical illness so much as a spiritual and to philosophy, strategies, and organization.
psychological one. All of the early influences on Bill
Wilson and his colleagues, and subsequently on AA,
were either spiritual—as embodied, for example, in A CLASSIFICATION OF
the Oxford Groups—or psychological. Wilson specif- "SELF-HELP" GROUPS
ically cited the writings of the psychologist William
James and the psychiatrist Carl Jung as being influ- A closer examination of this plethora of groups and
ential in the conceptual development of AA. organizations suggests that the generic use of term
self-help in itself requires some clarification. Accord-
CURRENT STATUS OF THE ing to the steps and traditions of Alcoholics Anony-
SELF-HELP MOVEMENT mous, for example, attempting to overcome alco-
holism through se//-help is precisely the problem.
AA and its 12-step program of recovery from alcohol- Following on the example set by the Oxford Groups,
ism (Alcoholics Anonymous [AA], 1952, 1976) ap- 12-step programs like AA, NA, and the others cited
330 TREATMENT

above explicitly advocate forgoing self-help and an based not so much on common wisdom and support
exclusive reliance on willpower (i.e., radical self-de- from fellow sufferers as on social science and psy-
termination) in favor of group help (i.e., fellowship) chology. Unlike pure peer-support groups such as
plus faith in some Higher Power as a means of con- AA, these programs are in fact professionalized to var-
quering addiction. ying degrees. Rational Recovery (RR) offers profes-
The term mutual help has been suggested as per- sionally conducted courses and discussion groups
haps being more descriptive than self-help (Mc- through a national network of Rational Recovery
Crady, personal communication, 1996), for the sim- Centers for a fee (Rational Recovery Systems, un-
ple reason that most of the groups and programs dated). Rational Recovery also states that it "is defi-
discussed here rely heavily on support and counsel nitely not a 'support' group" (L. Trimpey, 1996) but
from fellow sufferers. As we will see, the "self-help" a treatment program whose basis is the Addictive
movement is in reality more pluralistic than that la- Voice Recognition Technique (Trimpey, undated).
bel implies. Not all "self-help" groups for addictions, S.M.A.R.T. Recovery programs also utilize profes-
for example, are equally democratic in organization, sionally facilitated groups, though in this case the fa-
nor are all based in this tradition of advice derived cilitators are volunteers. Still, S.M.A.R.T. trainers are
from the common experience of members who have professionals who must go through a standardized
struggled with the same problem. training. They do not emerge as natural leaders from
Anthropologists and sociologists have used terms the context of a fellowship of peers. S.M.A.R.T. Re-
such as folk—as, for example, in referring to folk covery employs techniques derived from cognitive
medicine—(Borkman, 1990) and informal help (Pow- behavioral therapies, and its content clearly repre-
ell, 1990) to denote the difference between help that sents the work of behavioral science professionals
is delivered by trained individuals (i.e., "professional" (S.M.A.R.T., 1996).
help) and help which is based primarily in common This writer has used the term fellowship (Nowin-
wisdom that is derived from accumulated experi- ski, 1996; Nowinski & Baker, 1992) when referring
ence. This distinction has clear application to 12-step specifically to 12-step groups. However, this label
groups such as AA, as well as to some secular pro- would also seem appropriate to denote those mutual
grams, such as Women for Sobriety, which operate help organizations, like Women for Sobriety, that are
on these principles of peer assistance and common founded on the principles of peership and that are
wisdom. Bill Wilson, cofounder of AA, referred to intentionally nonprofessional. The term guided self-
this stream of common wisdom as the "group con- help, in contrast, could more accurately describe
science" (Bill W., 1948/1992) and described it this those programs, like S.M.A.R.T. Recovery, that rely
way: to a greater or lesser extent on trained professionals
to deliver their programs. The reader may find this
We believe that every AA group has a conscience. distinction useful both in understanding the dynam-
It is the collective conscience of its own mem- ics of the various groups discussed here and when
bership. Daily experience informs and instructs recommending them to patients.
this conscience. When a customary way of doing A second useful distinction among mutual help
things is definitely proved to be the best, then that organizations concerns the issue of spirituality. Clear-
custom forms into AA tradition, (p. 24) ly, some mutual help organizations, such as AA and
its fellow 12-step fellowships, deliberately advocate
Although relying in many ways on a fund of some form of spiritual belief in the form of a Higher
knowledge similar to what is the basis of folk medi- Power and consider such a belief vital to recovery.
cine, groups such as AA and Women for Sobriety are Granted, AA defines this Higher Power so loosely
much more organized than the relatively unstruc- that the group itself as opposed to a deity is accept-
tured systems which terms like folk medicine and in- able as one's Higher Power, as the following excerpt
formal help connote. from Twelve Steps and Twelve Traditions (AA, 1952)
Not all self-help groups share this same tradition indicates:
of basing their programs on the accumulated experi-
ence of peers. Some, such as S.M.A.R.T. Recovery You can, if you wish, make A.A. itself your
(1996) and Rational Recovery (Trimpey, 1992), are "higher power." In this respect they are certainly
 SELF-HELP GROUPS FOR ADDICTIONS 331

a power greater than you, who have not even drinking. In its literature, MM describes itself as be-
come close to a solution, (p. 27) ing "for people who want to reduce their drinking"
(MM, 1996, p. 1).
Alcoholics Anonymous is sometimes taken for a The above classification schema is summarized
religious organization, which it clearly is not. In fact, in table 18.1, which lists a number of the more popu-
AA moved away from the Oxford Groups, where it lar mutual help organizations.
had its beginnings, for this very reason. This caveat
notwithstanding, most 12-step fellowships differ from
what we could call their secular counterparts in the OVERVIEW OF MUTUAL HELP GROUPS
extent to which spirituality is integral to their philos-
ophy. In general, people who elect to go to 12-step In this section we will examine some of the more
groups are at the very least more amenable to some popular mutual help groups, following the above
form of spiritual belief than those who prefer other classification schema.
groups. Some of these groups, such as Secular Or-
ganizations for Sobriety, specifically state in their lit-
erature that they are intentionally nonreligious: Spiritual Fellowships
Clearly, the 12-step fellowships are the most ubiqui-
S.O.S. is not a spin-off of any religious or secular tous of the spiritually based mutual help programs.
group. There is no hidden agenda, as S.O.S. is They include Alcoholics Anonymous, Narcotics
concerned with achieving and maintaining so-
Anonymous, and Cocaine Anonymous (CA) for sub-
briety (abstinence), not religiosity. (SOS, undated
stance abusers, as well as the collateral fellowships of
a, p. 3)
Al-Anon, Al-Ateen, and Nar-Anon, which were estab-
Other mutual help groups, such as Women for lished by and for the benefit and support of signifi-
Sobriety, do not reject spirituality and the idea of a cant others of substance abusers. All of these fel-
Higher Power so much as they leave it out of their lowships are modeled closely after the 12 steps of
programs. For example, Women for Sobriety sum- Alcoholics Anonymous. Also included among the
marizes its philosophy as follows: spiritual fellowships are the Calix Society and Over-
comers Outreach.
The WFS program is based upon metaphysical
philosophy. The Fifth Statement, "I am what I Alcoholics Anonymous
think," is the entire basis for the program. (Kirk-
patrick, 1982, p. 2) In 1992, Alcoholics Anonymous, by far the largest
mutual help program for substance abusers, had
In its literature, Women for Sobriety (WFS) sug- 89,000 groups registered worldwide (AA, 1993). This
gests there is no inherent incompatibility with utiliz- represented an increase of some 2,000 groups over a
ing both WFS and AA as aids to sustaining one's re- period of only 3 years (AA, 1990a). Moreover, these
covery. Rather, WFS emphasizes the need for wom- statistics may actually understate the size of this fel-
en to turn to other women as peers who can best lowship, since it is not a requirement of AA that ev-
understand their experience and support their re- ery group register itself with the central office, and it
covery. is common knowledge within the fellowship that
This dimension—of spiritual versus secular—is quite a few groups opt not to register, preferring to
also useful with respect to understanding mutual grow solely by word of mouth.
help groups and referring patients to them. In an independent national survey, 3.1% of the
A third dimension which is relevant when classi- adult population indicated that they had ever been to
fying mutual help groups concerns their stated goals. an AA meeting, and 1.5% indicated they had been
For virtually every program described here, with the to one in the past year (Room & Greenfield, 1991).
exception of Moderation Management (1996), the These prevalence data were roughly three times as
goal is abstinence from the use of alcohol or drugs. great as AA's own estimates of its prevalence based
In contrast, Moderation Management (MM), as the on contemporaneous membership surveys (AA, 1990a).
name implies, seeks to teach skills needed to control Because of its size, its organization, and its influence
332 TREATMENT

TABLE 18.1 Classification of Mutual Help Organizations

Fellowships

Spiritual Secular Guided self-help groups

Alcoholics Anonymous Secular Organizations for Sobriety S.M.A.R.T. Recovery

Narcotics Anonymous Women for Sobriety Rational Recovery
Cocaine Anonymous Moderation Management3
Calix Society
Overcomers Outreach

"Moderation Management states that its goal is to help individuals reduce drinking; all others state that abstinence is
the goal.

on society as a whole, AA has been described as more which this spiritual renewal is achieved is a gradual
than a mutual help program. At least one sociologist
has made the case that AA and its 12-step program
could be considered a social movement (Room, No one among us has been able to maintain any-
1993). thing like perfect adherence to these principles.
The 12 steps of Alcoholics Anonymous are pre- We are not saints. The point is, that we are will-
sented in table 18.2. Narcotics Anonymous, Al-Anon, ing to grow along spiritual lines. The principles
and other 12-step programs all advocate following we have set down are guides to progress. We
these same steps as a program of recovery, the ideal claim spiritual progress rather than spiritual per-
result of which is a "spiritual awakening" (Step 12). fection. (AA, 1976, p. 60)
This is significant, because the 12-step program is
not merely a program for staying sober. The founders This conceptualization of recovery as primarily a
of AA (and other 12-step programs) regarded addic- process of spiritual growth (and therefore of alcohol-
tion as a part of a larger spiritual crisis and therefore ism as primarily a spiritual malady) is unique to 12-
viewed recovery as a process of spiritual renewal, step programs. For them, recovery is not merely stay-
only part of which is staying sober. The process via ing sober. On the contrary, 12-step fellowships have

TABLE 18.2 The 12 Steps of Alcoholics Anonymous

Step 1 We admitted we were powerless over alcohol—that our lives had become unmanageable.
Step 2 Came to believe that a Power greater than ourselves could restore us to sanity.
Step 3 Made a decision to turn our will and our lives over to the care of God as we understood him.
Step 4 Made a searching and fearless moral inventory of ourselves.
Step 5 Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
Step 6 Were entirely ready to have God remove all these defects of character.
Step 7 Humbly asked Him to remove our shortcomings.
Step 8 Made a list of all persons we had harmed, and became willing to make amends to them all.
Step 9 Made direct amends to such people wherever possible, except when to do so would injure them or others.
Step 10 Continued to take personal inventory and when we were wrong promptly admitted it.
Step 11 Sought through prayer and meditation to improve our conscious contact with God as we understood him,
praying only for knowledge of His will for us and the power to carry that out.
Step 12 Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics
and to practice these principles in all our affairs.

Note. From Alcoholics Anonymous (1976).

 SELF-HELP GROUPS FOR ADDICTIONS 333

a name for someone who stays sober without pursu- the first time how insincere his previous protesta-
ing a program of spiritual renewal: the "dry drunk" tions actually were. (Tiebout, 1953, p. 65)
(Solberg, 1983).
The founders of AA (and other 12-step programs), Resistance to the above idea of surrender, like re-
then, regarded addiction as a part of a larger spiritual sistance to acceptance, is also part of what is meant
crisis and regarded recovery as a process of spiritual by denial in the context of 12-step groups. On a
renewal, only part of which is staying sober. This pro- practical level, the newcomer to AA will be asked in
cess begins with admitting that one's efforts to con- time to "surrender" to the program. The practitioner
trol drinking have failed and that as a result, life has should understand that this means embracing the 12-
become unmanageable (Step 1). This is also com- step program and following the traditions and the
monly referred to as acceptance within the 12-step counsel of fellow members. Surrender, like true ac-
culture. Acceptance was defined by the psychiatrist ceptance, represents the resolution of any inner
Harry Tiebout (who was in fact Bill Wilson's thera- doubts about whether one can control drinking and
pist) as follows: represents a willingness to take whatever action is
necessary in order to stay sober.
Acceptance appears to be a state of mind in Alcoholics Anonymous and other 12-step meet-
which the individual accepts rather than rejects ings vary in format. Open meetings, for example, are
or resists: he is able to take things in, to go along defined as ones which may be attended by persons
with, to cooperate, to be receptive. Contrariwise, who do not necessarily acknowledge that they have
he is not argumentative, quarrelsome, irritable, or an alcohol (or drug) problem, as well as by those
contentious. It is necessary to point out that no men and women who are willing to admit that they
one can tell himself or force himself wholeheart-
have a drinking (or drug) problem. Thus, open meet-
edly to accept anything. One must have a feel-
ings are appropriate for clients who are undecided
ing—conviction—otherwise acceptance is not
wholehearted but halfhearted with a large ele- about whether they have a problem with alcohol. In
ment of lip service. (Tiebout, 1953, p. 60) contrast, closed meetings are to be attended only by
men and women who acknowledge a problem and
When working with clients who are involved in a have the "desire to stop drinking" that is cited in AA
12-step program, the practitioner should understand literature as the sole "requirement" for membership
that resistance to the above idea of acceptance is es- in the fellowship (AA, 1952, p. 139).
sentially what is meant by the term denial. The first Meetings typically last from 1 hour to an ll/i
step asks that the individual do more than recognize hours. Each has a chairperson, who is elected by the
that she or he has a drinking problem; it asks that he membership, and a secretary. The chairperson and
or she humbly accept on this emotional level the re- the secretary change periodically, though in keeping
ality that personal efforts to control drinking have with the AA tradition of decentralization, there is no
failed and that life has become unmanageable. This set standard.
level of acceptance implies a degree of openness to Meetings are governed by established rules of eti-
change. Newcomers to AA and other 12-step groups quette. These are primarily transmitted orally to new-
can expect to be confronted sooner or later on this comers. Most important of these is the rule of ano-
issue of acceptance. nymity. Members typically identify themselves by
The second and third steps of the 12-step program their first names only. In addition, members are
are often linked together through the concept of sur- strongly encouraged to regard everything that is said
render. Surrender follows from acceptance and has in an AA meeting as confidential. Additional rules of
been conceptualized as a readiness to change: etiquette include not interrupting or questioning a
speaker, respecting one's right not to speak (i.e.,
"passing"), and avoiding dual relationships with
After an act of surrender, the individual reports a
sense of unity, of ended struggles, of no longer members of the group. That is not to say that AA
divided inner counsel. He knows the meaning of members do not socialize with one another; on the
inner wholeness and, what is more, he knows contrary, socializing before and after meetings is
from immediate experience the feeling of being commonplace, as are various AA social events. How-
wholehearted about anything. He recognizes for ever, dating among members of the same group is
334 TREATMENT

discouraged, as is any romantic involvement at all Step Meetings In step meetings, the format is to
during one's first year of AA participation. read one of the 12 steps and for members to share
Several types of meetings are described below. their thoughts about how they as individuals are
Keep in mind that each type can be either "open" or "working" that step: how they are attempting to im-
"closed." For instance, an AA meeting schedule may plement it in their day-to-day lives, as the 12th step
list a number of "open speaker" and "closed speaker" advises them to do. Through attending step meet-
meetings. ings, newcomers have an opportunity to learn how
others have interpreted the steps and how they relate
Speaker Meetings At speaker meetings, which are to lifestyle and attitude changes that are associated
highly recommended for newcomers as well as for with "recovery" versus merely staying sober. Some
those who are undecided about whether they have a step meetings limit themselves to the first 3 steps,
problem, members of the group as well as occasional whereas others include all 12 steps as topics for re-
"guest speakers" relate the story of their addiction flection and discussion.
and recovery. The format of these meetings is as fol-
lows: how things were, what happened, and how things Specialty Meetings In addition to the above ge-
are now. These are basically tales of addiction and neric types of meetings, there are also a growing
renewal. This is perhaps the strongest tradition number of specialty meetings, for example, men's
within AA and other 12-step fellowships and can be meetings and women's meetings, meetings for gays
traced to the Oxford Groups with their emphasis on and lesbians, meetings for professionals, and meet-
public confession as a spiritual path. ings for specific ethnic groups. To the extent that
Storytelling accomplishes several things, begin- participation in such groups facilitates identification
ning with creating a bond of commonality—of and bonding, newcomers may find them useful.
shared experience—among the members of the
group. Despite their outward differences in form, the Narcotics Anonymous, Cocaine Anonymous,
process of addiction is remarkably similar across sto- Nicotine Anonymous
ries and promotes identification and bonding. The Narcotics Anonymous (NA), Cocaine Anonymous
newcomer to AA is strongly encouraged to "identify, (CA), and Nicotine Anonymous, as their names im-
not compare." ply, are 12-step fellowships modeled closely after AA.
Storytelling also helps members to maintain their All are spiritually based fellowships that are open to
memories of the consequences that are associated those who wish to recover from substance abuse us-
with substance abuse and addiction. AA believes that ing the 12-step model. Narcotics Anonymous has
any tendency to forget the unpleasant past is danger- published its own version of the "AA Big Book" (Al-
ous. Fading memories of negative consequences as- coholics Anonymous), titled Narcotics Anonymous
sociated with alcohol abuse can effectively under- (1987). It includes the same 12-step program used by
mine one's motivation to stay sober and to stay active AA, merely substituting the word narcotics for alco-
in the fellowship. One suggested method for staying hol, as well as stories of recovery that are very similar
sober is "remembering your last drunk" (AA, 1975). in theme to those that make up the second half of
Advice such as this, as well as relating personal histo- Alcoholics Anonymous. Like the other 12-step pro-
ries (so-called drunkalogs) are therefore intended not grams, such as Cocaine Anonymous and Nicotine
to glorify substance abuse but to keep the memory of Anonymous, NA follows the same traditions and is
its consequences alive. organized the same way that AA is.
Their inherent compatibility facilitates the use of
Discussion Meetings The format in discussion several programs concurrently by persons who abuse
meetings is to select a topic (e.g., gratitude, self-cen- multiple psychoactive substances. For example, it is
teredness, resentments) and share thoughts about it. not uncommon to find someone attending AA, NA,
Typically, either the chairperson selects the topic or and Nicotine Anonymous meetings concurrently.
the members do so in rotation. Sometimes, the topic
is a reading from the Big Book or another AA publi- Al-Anon, Nar-Anon, Alateen, and Alatot No dis-
cation. cussion of spiritually based mutual help fellowships
 SELF-HELP GROUPS FOR ADDICTIONS 335

for substance abusers would be complete without ers Outreach reports "approximately 1,000" groups
some mention of Al-Anon, Nar-Anon, Alateen, and (Overcomers Outreach, 1988) worldwide.
Alatot. These companion fellowships to AA, NA, and Overcomers Outreach and Calix do not view
other 12-step fellowships for substance abusers were themselves as competitive with or incompatible with
established by and for concerned significant others AA; rather, they view themselves as complementary
of alcohol abusers. They parallel AA, using the same to AA, but as offering programs that place greater em-
AA 12-step program, which begins with admitting phasis on Christian or Catholic doctrine than AA it-
one's own powerlessness over a loved one's addiction self does. For example, Overcomers Outreach de-
(Step 1). fines itself as follows:
Al-Anon reports that it has 30,000 known groups
worldwide (Al-Anon Family Groups, 1996). Of Al-
Overcomers Outreach groups are not intended to
Anon members, 85% are female (Al-Anon Family replace Alcoholics Anonymous, Al-Anon, etc. but
Groups, 1993), compared to 35% of AA members are designed to be a supplement from the Chris-
(AA, 1993). Of AA members, 56% are between the tian perspective where A.A.'s 12 Steps to recovery
ages of 30 and 50 (AA, 1993) as are 57% of Al-Anon are directly related to their corresponding Scrip-
members (Al-Anon Family Groups, 1996). These tures. (Overcomers Outreach, 1988, p. 2)
data suggest that demographically as well as philo-
sophically these two self-help programs do indeed In its traditions and its structure, Overcomers
complement one another. Outreach remains faithful to the principles of AA. It
The objective of Al-Anon and the related fellow- is, for example, intentionally nonprofessional, sub-
ships like Nar-Anon is caring detachment (Al-Anon scribes to the principle of anonymity, and so on.
Family Groups, 1985; Carolyn W., 1984; Nowinski, Therefore, participation in AA is not at all inconsis-
in press). Caring detachment, much like the concept tent or incompatible with participation in Overcom-
of recovery itself, is complex but consists in part in ers Outreach. The essential difference lies in OO's
allowing the substance abuser to experience the nat- identification of Jesus Christ as the Higher Power
ural consequences of his or her substance abuse, and and its reliance on Christian faith for its spiritual
to focus on one's mental health and spiritual growth foundation. Table 18.3 summarizes the way in which
as opposed to becoming preoccupied with the sub- Overcomers Outreach relates Scripture to the twelve
stance abuser. Caring detachment is thought to help steps of Alcoholics Anonymous.
restore balance in relationships and families—a bal- A perusal of table 18.3 reveals some of the early
ance that is disrupted when one member falls victim roots of AA in the Oxford Groups, especially the em-
to addiction. phasis on confessing one's faults and sins to others,
as well as on personal humility.
Overcomers Outreach, Calix Society Alcoholics The Calix Society, like OO, recognizes the 12-
Anonymous and the other 12-step fellowships have step program of AA as "the best therapy for those af-
been deliberately nondenominational since their in- flicted with the disease of alcoholism" (Calix, un-
ception. Overcomers Outreach (OO), founded in dated a). It, too, however, bases its existence on the
1985 (Overcomers Outreach, 1988, undated) and need for some to connect themselves to a more dog-
the Calix Society, founded in 1947 (Calix Society, matic spirituality. Thus:
undated a, b), were founded by and for Christians
and Catholics, respectively. These spiritual fellow-
ships do not limit themselves to problems of alcohol For Catholics. . . something more is needed.
They realize that the A.A. program advocates re-
or drug abuse but state that they are open to men
course to a "higher power" and God, but they also
and women suffering from any form of addictive be-
know that A.A. is necessarily nondenominational.
havior, from alcoholism to sexual addiction. They Having been raised in a Church rich in tradition,
are much smaller than AA and the other nondenom- dogma and ritual, these recovering alcoholics be-
inational 12-step fellowships. Calix, for example, lists gin to yearn once again for the faith they probably
a total of 42 chapters in the United States, 3 in Can- have neglected or abandoned. (Calix Society, un-
ada, and 29 in Great Britain (Calix, 1995). Overcom- dated a, p. 1)
336 TREATMENT

TABLE 18.3 Christian Scripture Correlates of the 12 Steps of AA

AA step Scripture correlates

Step 1 We felt we were doomed to die and saw how powerless we were to help ourselves; but that was good, for
then we put everything into the hands of God, who alone could save us. (2 Corinthians 1:9)
Step 2 A man is a fool to trust himself! But those who use God's wisdom are safe. (Proverbs 28:26)
Step 3 Trust in the Lord completely; don't ever trust yourself. In everything you do, put God first, and he will
direct you and crown your efforts with success. (Proverbs 3:5-6)
Step 4 Let us examine ourselves and repent and turn again to the Lord. Let us lift our hearts and our hands to
Him in heaven. (Lamentations 3:40-41)
Step 5 Admit your faults to one another and pray for each other so that you may be healed. (James 5:16)
Step 6 So give yourselves humbly to God .. . then, when you realize your worthlessness before the Lord, He will
lift you up, encourage and help you. (James 4:7-10)
Step 7 But if we confess our sins to Him, He can be depended on to forgive us and to cleanse us from every
wrong. (John 1:9)
Step 8 If you are standing before the altar . . . and suddenly remember that a friend has something against you,
leave your sacrifice there and go and be reconciled . . . and then come and offer your sacrifice to God.
(Matthew 5:23-24)
Step 9 You can pray for anything, and if you believe, you have it; it's yours! But when you are praying, first forgive
anyone you are holding a grudge against, so that your Father in heaven will forgive you your sins too.
(Mark 11:24-25)
Step 10 But how can I ever know what sins are lurking in my heart? Cleanse me from these hidden faults. And
keep me from deliberate wrongs; help me to stop doing them. Only then can I be set free of guilt!
(Psalm 19:12)
Step 11 If you want better insight and discernment, and are searching for them as you would for lost money or
hidden treasure, then wisdom will be given you, and knowledge of God Himself; you will soon learn the
importance of reverence for the Lord and of trusting Him. (Proverbs 2:3-5)
Step 12 Quietly trust yourself to Christ your Lord and if anybody asks why you believe as you do, be ready to tell
him, and do it in a gentle and respectful way. (1 Peter 3:15)

Note. From Overcomers Outreach (1988).

Calix meetings utilize the 12 steps of Alcoholics Secular Organizations for Sobriety
Anonymous but also rely on the participation of vol-
Secular Organizations for Sobriety (SOS) was found-
unteer priests to help members interpret and work
ed in 1985 by James Christopher, an individual who
the steps in ways consistent with Catholic dogma.
had been sober since 1978, initially achieving sobri-
ety with the help of AA (Christopher, 1988, 1989).
Secular Fellowships Later, Christopher decided that the spiritual nature
of AA and other 12-step fellowships was either un-
Secular fellowships are organized along the same
necessary or counterproductive:
lines—most notably being intentionally nonpro-
fessional and decentralized—as the spiritual fellow-
ships. However, they do not advocate any theistic Studies of religions and cults have consistently
proved that people tend to convert at times of
belief. More than merely nondenominational, the
great stress or failure in their lives. These are the
secular fellowships eschew belief in any "higher
times when promises of enlightenment and cures
power" as necessary for recovery from addiction. The for pain are most appealing. People don't look for
primary secular fellowships for the addictions in- proof or evidence or even coherence in belief.
clude Secular Organizations for Sobriety and Wom- They see someone throwing them a life-preserver,
en for Sobriety. and they grab it. Put in this context, it is easy to
 SELF-HELP GROUPS FOR ADDICTIONS 337

see why the religious fervor that permeates AA's matic. Table 18.4 compares some of the advice of-
meetings and literature has gone unchallenged fered by SOS (undated c) to that offered by AA (1975).
for so long. (SOS, undated b, p. 1) A perusal of table 18.4 suggests that SOS and AA
share a great deal on the pragmatic level. Their dif-
Though secular in its approach, SOS, like AA, ferences appear to lie primarily in whether spiritual
advocates abstinence as the only viable goal for alco- faith is necessary for sustained recovery.
holics and addicts:

To break the cycle of denial and achieve sobriety, Women for Sobriety
we first acknowledge that we are alcoholics and Women for Sobriety (WFS) describes itself as "an
addicts. We reaffirm this truth daily and accept organization whose purpose is to help all women re-
without reservation the fact that, as clean and so-
cover from problem drinking through the discovery
ber individuals, we cannot and do not drink or
of self, gained by sharing experiences, hopes and en-
use, no matter what. (SOS, undated a, p. 3)
couragement with other women in similar circum-
stances" (Women for Sobriety [WFS], undated b, p.
SOS reports that as many as 96% of its members
3). WFS sees itself and AA as "complementary" but
have had prior involvement with AA, and that 70%
strongly advocates that women involved in AA also
describe themselves as atheists or agnostics (SOS,
attend WFS since it believes that women have spe-
1996), suggesting that SOS is primarily a self-selected
cial needs that cannot be satisfactorily met through
group of individuals who have left AA but who are
AA (Kirkpatrick, 1982):
nonetheless interested in group support to sustain
their recovery.
The problems of most women are tied to the
Like other fellowships, SOS is decentralized to
male-female relationship, and these problems
a considerable degree. Though guided by a shared cannot be talked about or thoroughly explored in
philosophy, SOS groups, like all AA groups, are each a mixed group. Too often in mixed groups the
self-supporting. The approach taken to maintaining men dominate and the women have little chance
sobriety is a highly pragmatic one. However, it should to express themselves or to speak about what is
be pointed out that 12-step fellowships are also prag- truly bothering them. (Kirkpatrick, 1982, p. 2)

TABLE 18.4 Comparison of Advice Offered by SOS and AA

SOS AA

Attend as many SOS meetings as you can. Take what Sometimes an AA member will talk about the various
you can use from these and leave the rest. parts of the program in cafeteria style—selecting what
he likes and letting alone what he does not want.
Get names and phone numbers from other sober alcohol- When we stopped drinking, we were told repeatedly to
ics/addicts at meetings. Use these phone numbers. get AA people's telephone numbers and, instead of
Practice calling people when you're feeling okay so drinking, to phone these people. Once the first call is
that you'll be able to call more easily when you're in made, it is much, much easier to make another when
need of help. it is needed.
Try putting some simple structure into your life: get up When we first stopped drinking many of us found it use-
and get dressed at a regular time, take a walk before or ful to look back at the habits surrounding our drinking
after dinner. Be gentle with yourself. Sobriety skills and, whenever possible, to change a lot of the small
aren't developed overnight. things connected with drinking.
Choose to stay sober one day at a time. We have found it more realistic—and more success-
ful—to say, "I am not taking a drink just for today."
Keep plenty of mineral water, soda, and/or fruit juices on Many of us have learned that something sweet-tasting, or
hand. almost any nourishing food or snack, seems to dampen
a bit the desire for a drink.

Note. From SOS (undated c) and AA (1975).

338 TREATMENT

The above notwithstanding, it should be noted in WFS. This view is further affirmed in WFS litera-
that AA and other 12-step fellowships have seen their ture, which states: "Guilt, depression, low (or no)
greatest rate of growth in recent years among women self-esteem are the problems of today's woman and
(AA, 1990b), including women-only groups. This de- dependence upon alcohol temporarily masks her real
gree of acceptance of AA on the part of women led needs, which are for a feeling of self-realization and
one reviewer to conclude, "I now believe that A.A., self-worth" (WFS, undated a, p. 1).
a fellowship originally designed by and composed The strategies for change that WFS favors include
primarily of men, appears equally or more effective positive reinforcement through support, approval,
for women than for men" (Beckman, 1993, p. 213). and encouragement; positive thinking as emphasized
WFS subscribes to the same guidelines (confi- in its New Life Acceptance Program; and taking care
dentiality, nonprofessionalism, decentralized and of one's physical health.
self-supporting, etc.) that govern other mutual help
fellowships. WFS also advocates abstinence from al-
Guided Self-Help Groups
cohol and drugs as the desired result of recovery. It
seeks to help women achieve this through group sup- We turn now to a consideration of those groups
port. WFS describes its meetings as "a conversation which offer guided self-help. As opposed to the fel-
in the round" (WFS, 1993a, p. 1). The groups are lowships, these programs all rely on the use of
small (a size of 6-10 is recommended) and last a trained leaders or facilitators. They are more central-
maximum of an hour and a half. They are run by a ized than the fellowships. In addition, some (but not
"moderator" who is not a trained professional but a all) of the guided self-help programs charge fees for
woman in recovery who is well versed in the WFS their services. The programs we will examine in-
philosophy. The moderator opens the meeting and clude S.M.A.R.T. Recovery, Rational Recovery, and
reads the "13 statements" of WFS (1993a). These Moderation Management.
statements, listed in table 18.5, form the basis of the
WFS New Life Acceptance Program (WFS, 1993a).
S.M.A.R.T Recovery
This New Life Acceptance Program clearly im-
plies that problems of self-esteem and self-acceptance S.M.A.R.T. Recovery is "an abstinence-based, not-
lie at the heart of substance abuse problems in for-profit organization with a sensible self-help pro-
women; conversely, recovery involves a process of gram for people having problems with drinking
gaining self-acceptance through active involvement and using" (S.M.A.R.T. Recovery, 1996, p. 2). In its

TABLE 18.5 The Women for Sobriety New Life Acceptance Program

1. I have a life-threatening problem (that once had me).

2. Negative thoughts destroy only myself.
3. Happiness is a habit I will develop.
4. Problems bother me only to the degree I permit them to.
5. I am what I think.
6. Life can be ordinary or it can be great.
7. Love can change the course of my world.
8. The fundamental object of life is emotional and spiritual growth.
9. The past is gone forever.
10. All love given returns.
11. Enthusiasm is my daily exercise.
12. I am a competent woman and have much to give life.
13. I am responsible for myself and my actions.

Note. From Women for Sobriety (1993a).

 SELF-HELP GROUPS FOR ADDICTIONS 339

TABLE 18.6 S.M.A.R.T. Recovery: Key Areas of Awareness and Change

Key area Topics/exercises

Building motivation Building Motivation

Am I Hooked Yet?
Do I Have to Quit?
Coping with urges Coping With Urges
Recognizing and Resisting Urges
New Ways to Cope
Stopping an Addiction
Catch the Wave
Refusing that First Drink
S.M.A.RT. Reality Check
Problem solving Problem Solving
Rational-Emotive Therapy's A-B-C Theory of Emotional Disturbance
The ABCs of Gaining Independence From Addictive Behavior
Exchange Vocabulary
Rational Beliefs to Increase Frustration Tolerance
Confidence-Building and Anxiety-Reducing Rational Beliefs
Anger-Reducing Rational Beliefs
Some Methods for Managing Anger
Forward Steps to Recovery
Backward Steps Into Addictive Behaviors
Lifestyle changes Lifestyle Change
Our Beliefs Affect Our Socializing
Ten Rational Beliefs About Decision Making
Self-help recovery homework suggestions

Note. From S.M.A.R.T. Recovery (1996).

conceptualization of alcoholism and addiction, in rational-emotive therapy (Ellis & Harper, 1975).
S.M.A.R.T., much as does Women for Sobriety, em- Meetings end with each member being asked to say
phasizes that people drink or use drugs as a means something about what he or she intends to do in the
of coping. However, both drinking and using in turn coming week to support his or her recovery ("home-
create problems. Accordingly, the S.M.A.R.T. pro- work"). Following the end of the formal meeting,
gram emphasizes building alternative coping skills as members are encouraged to socialize and exchange
the key to recovery. phone numbers. S.M.A.R.T. Recovery, like most of
S.M.A.R.T. issues a standard meeting outline that the programs described here, relies on voluntary con-
begins with a general welcoming with special atten- tributions from members to support itself. Like other
tion paid to newcomers. Members are asked next to guided self-help programs, it uses trained profession-
share something positive that they have learned or als to run meetings; these individuals, however, are
done as a result of attending meetings. Members are not paid for their services.
then polled to see who, if anyone, may need some
extra time to deal with concerns or problems. The
Rational Recovery
bulk of the hour-and-a-half meeting time is then de-
voted to a discussion of one of S.M.A.R.T. Recovery's Rational Recovery (RR) is a guided self-help program
main themes using one of the structured exercises based on the addictive voice recognition technique
that have been developed by S.M.A.R.T. Recovery. (AVRT) that was developed by Jack Trimpey (1992,
These themes and associated exercises are presented 1996). Training in AVRT as well as RR materials are
in table 18.6. offered by Rational Recovery Systems, Inc., for a fee.
S.M.A.R.T. Recovery makes extensive use of cog- In its advertising, RR makes the following claim:
nitive behavioral theory and technique as set forth "AVRT shows that the sole cause of addiction is the
340 TREATMENT

Addictive Voice—the thinking and feeling that sup-

Moderation Management
ports your use of alcohol or other drugs. By learning
to recognize your Addictive Voice, you can com- Moderation Management (MM; Kishline, 1996) is
pletely recover from any substance addiction in a the sole program for substance abusers which openly
mercifully brief time" (Rational Recovery Systems advocates moderation as a long-term goal as opposed
[RRS], undated, p. 1). to abstinence (MM, 1996). This program, which em-
Rational Recovery is fundamentally a cognitive phasizes progressive changes in lifestyle to support
behavioral approach which frames addiction in terms moderation, does recommend abstinence initially
of an internal conflict between a primitive "beast (for 30 days), presumably as a litmus test for modera-
brain," which craves the substance one is addicted tion. MM indicates that it "is not for alcoholics or
to, and a "healthy adult brain," whose goal is to stay chronic drinkers" but "is intended for problem drink-
in control of one's behavior and abstain from sub- ers who have experienced mild to moderate levels of
stance use (Trimpey, undated). RR does not view the alcohol-related problems" (MM, 1996, p. 2).
cravings associated with the beast brain as physiologi- It appears that it is only through an accurate self-
cal so much as psychological. Addictive drinking or assessment can one decide the difference between
using is thought to be the result of the irrational be- "mild to moderate" and "severe" consequences of
lief of this beast brain: "It views alcohol or drugs as substance abuse. Alcoholic Anonymous also suggests
necessary to survival" (Trimpey, undated, p. 2). a "test period" as an aid to self-diagnosis:
The Rational Recovery program seeks to help in-
dividuals overcome addiction through teaching them We do not like to pronounce any individual as
the addictive voice recognition technique, which in- alcoholic, but you can quickly diagnose yourself.
volves learning to separate the irrational beliefs asso- Step over to the nearest barroom and try some
ciated with the beast brain from one's rational con- controlled drinking. Try to drink and stop
abruptly. Try it more than once. It will not take
sciousness: one's "neocortical authority" (Trimpey,
long for you to decide, if you are honest with
undated, p. 2).
yourself about it. (AA, 1976, p. 31)
One may learn AVRT through reading Rational
Recovery Systems, Inc., literature, or through attend- AA and other abstinence-based mutual help pro-
ing one of its Rational Recovery Centers, which are
grams essentially use the same empirical definition
described as offering "a unique service for substance of addiction, summarized in Alcoholics Anonymous
addiction that is intended to replace addiction treat- (1976):
ment and extended recovery group involvement"
(RRS, undated, p. 5). Thus, it appears that in contrast We have seen the truth demonstrated again and
to the other programs described here, RR does not ad- again: "Once an alcoholic, always an alcoholic."
vocate ongoing involvement in a mutual help pro- Commencing to drink after a period of sobriety, we
gram. In fact, RR describes its groups in this way: "RR are in a short time as bad as ever. (p. 33)
groups are lay-led discussion groups centering around
AVRT. Long-term involvement is discouraged unless Moderation Management also seeks to use an
in a leadership role" (RRS, undated, p. 4). empirical definition: It is for those individuals who
In summary, RR is based in a cognitive behav- do not quickly find themselves returning to their pre-
ioral view of addiction as an internal process in abstinence level of substance use following a period
which rational beliefs prevail over irrational cravings of sobriety, and who can sustain moderate use. The
and result in sobriety. The key is to learn the addic- clinically relevant question then becomes: After how
tive voice recognition technique (i.e., to reframe many failures at moderation is moderation no longer
cravings, thoughts, and emotions associated with sub- a viable goal?
stance use as artifacts of a "beast brain"). RR does The Moderation Management program, much
not, however, identify itself with other mutual help like that of S.M.A.R.T. Recovery, utilizes a cognitive
programs, stating instead, "RR is definitely not a 'sup- behavioral model of addiction. The MM "nine step"
port' group. We only teach people how to quit addic- program for moderation (see table 18.7) includes
tions in a mercifully brief period of time" (Trimpey, many strategies for change that are drawn from the
1997, personal communication). cognitive behavioral literature. MM also recom-
 SELF-HELP GROUPS FOR ADDICTIONS 341

TABLE 18.7 The Moderation Management Nine-Step Program

1. Attend MM meetings and learn about the program of Moderation Management.

2. Abstain from alcoholic beverages for 30 days and complete Steps 3 through 6 during this time.
3. Examine how drinking has affected your life.
4. Write down your priorities.
5. Take a look at how much, how often, and under what circumstances you used to drink.
6. Learn the MM guidelines and limits for moderate drinking.
7. Set moderate drinking limits and start weekly "small steps" toward positive lifestyle changes.
8. Review your progress and update your goals.
9. Continue to make positive lifestyle changes, attend meetings for ongoing encouragement and support, and help newcomers
to the group.

Note. From Moderation Management (1996).

mends a number of self-help books, all of which offer intentionally and consistently employs interventions
many cognitive behavioral strategies for moderation. (reinforcement, role playing, etc.) designed to
The primary difference between MM and S.M.A.R.T. achieve that goal. The extra clinical effort required
appears to lie not so much in their techniques as in by the active facilitation approach can be justified in
their respective goals (i.e., moderation versus absti- part by findings which suggest that compliance with
nence). recommended treatment protocols is generally corre-
lated with more positive treatment outcomes (Co-
wen, Jim, Boyd, & Gee, 1981; Horwitz & Horwitz,
INTEGRATING MUTUAL HELP GROUPS 1993).
WITH PROFESSIONAL PRACTICE In order to be an effective active facilitator, the
therapist must first be much more knowledgeable
Practitioners can approach the issue of integrating about the mutual help group being referred to than
mutual help into a comprehensive treatment plan in is necessary under a passive approach. The therapist
one of two ways, the first of which could be called must have a good understanding of the philosophy,
passive facilitation. In this approach, the therapist goals, and structure of the fellowship or program that
may recognize the usefulness of a mutual help pro- is being utilized in order to understand the specific
gram—say, AA and/or Al-Anon — as an adjunct to nature of any patient resistance that may arise.
treating a substance abuser and his or her significant In addition to a clear understanding of the work-
other. The therapist may earnestly recommend atten- ings of the mutual help group that is being integrated
dance at meetings and may go so far as to provide into the treatment plan, the active facilitator is aware
the patient with a current meeting schedule. Follow- of the process which is associated with active involve-
up on this therapeutic recommendation, however, ment in mutual help, and she or he devotes a good
under the passive approach, is typically limited to amount of therapeutic time and effort to guiding that
asking the patient if she or he has gone to any meet- involvement. Resistance to involvement is identified
ings and if so how she or he reacted to it. Attendance by the active facilitator as something to be worked
may be reinforced; on the other hand, working through with the patient. This process, whose goal is
through resistance to attendance is rarely identified as bonding with the group, typically proceeds through
an additional treatment goal. several stages, as described below.
In the second approach, active facilitation, the
therapist in effect makes active involvement in one
Mutual Help Group Involvement
more mutual help groups an integral part of the
and the Process of Bonding
treatment plan. In other words, compliance with the
recommendation that the client utilize a mutual The goal of active facilitation is the bonding of the
help group is a separate treatment goal. The therapist patient to a mutual help group as an integral part of
342 TREATMENT

treatment and an independent treatment goal. The even interests. The motivation behind drawing these
process of bonding typically proceeds through several contrasts quickly becomes apparent: The client is
stages, as described below. emphasizing differences in order to justify not identi-
fying with the group. She or he is resisting the bond-
ing process. For example, instead of identifying with
Attendance
what has been aptly called the "core story" (Fowler,
Bonding to a mutual help group obviously begins 1993) of Alcoholics Anonymous—a story which in-
with attendance. Not surprisingly, resistance often is volves a journey from powerlessness and hopeless-
most evident at this very point. In this regard, it is ness to empowerment and renewal through commit-
very helpful if the therapist is familiar with the format ment to "a new community of interpretation and
and the ground rules of the mutual help group that action" (Fowler, 1993, p. 116)—the resistant client
the client is being referred to. Knowing in advance may reject the notion of powerlessness out of hand
what to expect when one walks into a meeting—be and cling to the idea that willpower alone will still
it an AA meeting, a S.M.A.R.T. Recovery meeting, a succeed, in the face of ample evidence that this has
Women for Sobriety, or a Moderation Management not been the case. As Fowler (1993) pointed out,
meeting—combined with knowing the client's psy- however, "There is a kind of power that issues from
chodynamics puts the therapist in a position to antic- acknowledged powerlessness" (p. 116). That power
ipate issues and thereby help the client overcome an- has its roots in collective identification and bonding
ticipatory anxiety. and a willingness to trust in the collective wisdom of
Clients who experience social anxiety, who ex- those who have made the same journey. To the ex-
press exceptional shame about their substance abuse, tent that the therapist can help the resistant client
or who worry about potential exposure may hesitate identify with key elements of other members' stories,
to take even the first step toward utilizing a mutual she or he also helps indirectly to empower the client.
help group, which is to get to a meeting. These wor- This is true regardless of what mutual help group
ries can often be dealt with if the client is educated is involved, since all of them implicitly assume that
by the therapist as to what to expect. Role playing willpower is not enough and that group support is a
around potential issues (e.g., "Let's practice how you key to sustaining sobriety.
would introduce yourself") would be another way
to desensitize anxiety. Similarly, problem solving
around accessibility issues (e.g., child care, transpor- Participation
tation) can facilitate the process of involvement. Fi-
Once a newcomer has gotten to the point where she
nally, the therapist can make specific suggestions
or he is attending meetings and beginning to identify
(e.g., "Just go and listen the first few times") as a
with others, bonding can be further facilitated by en-
means of helping a client get started on using mutual
couraging active participation.
help.

Networking Networking is an important part of all

Identification
mutual help groups. Virtually all of the groups dis-
Another step in the bonding process is taken when cussed here, with the possible exception of Rational
the newcomer to a mutual help group begins to iden- Recovery (which discourages long-term involve-
tify with other members of the group. "Identify, don't ment), encourage members to build a support net-
compare" is the advice often given to the AA new- work by establishing contact with other members on
comer. The therapist can expect to encounter some a regular basis. Alcoholics Anonymous (1975) calls
resistance, and the more that resistance can be this telephone therapy. The therapist should encour-
worked through, the more the client can be expected age this as well, justifying it as SOS (undated c) sug-
to begin to bond with the self-help group of choice. gests: as a means of establishing a social safety net in
Most often, client resistance at this stage takes the advance of the actual need for one. Through tele-
form of drawing contrasts between himself or herself phone and personal contact (before or after meet-
and others in the group. These contrasts may be ings), the newcomer begins to make new friends and
based on age, education, religiosity, income, and establish himself or herself in a new peer group—
 SELF-HELP GROUPS FOR ADDICTIONS 343

one that is moving away from substance abuse to- be expected to be uncomfortable with such things
ward a healthier lifestyle. and reluctant to wholeheartedly participate in them.
Typical rituals include reciting the Serenity Prayer,
Sponsorship The concept of sponsorship appears acknowledging and celebrating members' "anniver-
unique to 12-step fellowships. The role of the spon- saries" of sobriety, storytelling, and so on. Other tra-
sor could be described as that of guide and/or men- ditions that newcomers can take part in include do-
tor. The relationship to the sponsor is especially im- ing what is called "service work": setting up chairs,
portant for the newcomer. Without a sponsor, the making coffee, cleanup. These simple contributions
client is apt to turn to the therapist for advice and to the group can also help to bond the newcomer to
support when that advice and support could be ob- it over time and should be encouraged. Newcomers
tained through the mutual help group. The therapist who are socially shy and inclined to be quiet listeners
should therefore consistently encourage and coach at meetings can begin to bond through volunteering
the client to find an initial ("temporary") sponsor. for service work. Because AA and its sister 12-step
This should be someone who is of the same sex as fellowships are intentionally decentralized, many in-
the client, who is active in the fellowship, who has dividual groups develop unique rituals and tradi-
established some sobriety, who leads what the client tions. The therapist is likely to hear of these from
perceives to be a healthy lifestyle, and whom the cli- the newcomer who reports back on his or her latest
ent respects. The newcomer should be advised to use experiences with the group. By understanding the
this sponsor for the first year of sobriety and then to important role that these rituals and traditions play
consider changing sponsors. This is consistent with in cementing the relationship to the group, and by
AA tradition. encouraging the newcomer to "give it a try" and
In judging whether the newcomer-sponsor rela- "keep an open mind," the therapist can play a signifi-
tionship is working, the therapist should inquire as cant role in transferring the locus of therapeutic
to how often the newcomer speaks to the sponsor change from the client-therapist relationship to the
(this should be often) and whether the sponsor is client-group relationship.
making specific suggestions about meetings, coping
with urges, dealing with emotions, and so on. The
sponsor is not a therapist; on the other hand, a good EFFECTIVENESS OF MUTUAL HELP
sponsor has much wisdom to share. Developing a re-
lationship with a sponsor constitutes an important Probably the best studied of the self-help groups is
step toward bonding with the larger fellowship. Alcoholics Anonymous, which conducts triennial
surveys of its own membership. Other mutual help
Rituals and Traditions Rituals and traditions have groups do not do so. According to its most recent
always been a vehicle whereby the individual bonds survey (AA, 1993), 35% of active members had been
to a group. It is not surprising, therefore, that many sober for over 5 years, and another 34% of active
mutual help groups deliberately incorporate rituals members had been sober between 1 and 5 years. A
and traditions into their programs. Women for Sobri- prior survey (AA, 1990b) reported that 40% of AA
ety, for example, begins each meeting by reading the newcomers who remained active in the fellowship
13 statements of its "new life" program, then asks for 1 year stayed sober for a second year.
members to "stroke" themselves, and ends each There is also some evidence that stronger bond-
meeting by joining hands and reciting the WFS ing to the program promotes recovery. For example,
motto: "We are capable and competent, caring and a meta-analysis of studies of AA concluded that "AA
compassionate, always willing to help another, members who 'work the program' are more likely to
bonded together in overcoming our addictions" have a better status with respect to their drinking be-
(WFS, 1993b, p. 1). S.MAR.T. Recovery meetings havior" (Emrick, Tonigan, Montgomery, & Little,
incorporate a ritual wherein members share "suc- 1993, p. 27). In this regard, "working the program"
cesses" from the week before. means attending meetings regularly, getting a spon-
Twelve-step fellowships are replete with rituals sor, leading a meeting, and doing service work.
and traditions which bond members together. The As encouraging as the above data may seem, it is
newcomer who is ambivalent about the group can important to qualify them. Although there is evi-
344 TREATMENT

dence that individuals who actively work the AA pro- Al-Anon Family Groups. (1985). A/-Anon faces alco-
gram have a promising outcome with respect to holism (2nd ed.). New York: Al-Anon Family Group
drinking, 60% of individuals cease their involvement Headquarters.
in AA within a year (AA, 1990b). This in effect sug- Al-Anon Family Groups. (1993). A/-Anon family groups
gests that AA "works for those who work it" at the 1993 survey. Virginia Beach, VA: Al-Anon Family
Group Headquarters.
same time that it suggests that only a minority of
Al-Anon Family Groups. (1996). Fact sheet for profes-
those who give AA a try stay with it.
sionals. Virginia Beach, VA: Al-Anon Family Group
The overwhelming majority of outcome research
Headquarters.
reports on the overall effectiveness of a single treat-
Alcoholics Anonymous. (1952). Twelve-steps and twelve
ment model, and/or on the comparative effectiveness traditions. New York: Alcoholics Anonymous World
of two or more competing models, for example, cog- Services.
nitive behavioral treatment versus 12-step facilitation Alcoholics Anonymous. (1975). Living sober: Some
versus motivational enhancement therapy (Project methods A.A. members have used for not drinking.
MATCH Research Group, 1997). Some analyses of New York: Alcoholics Anonymous World Services.
treatment outcome studies have suggested that over- Alcoholics Anonymous. (1976). Alcoholics Anonymous:
all, a cognitive behavioral approach is most effica- The story of how many thousands of men and women
cious (Miller et al., 1995), whereas others have re- have recovered from alcoholism (3rd ed.). New York:
ported that alternate treatments can be equally Alcoholics Anonymous World Services.
effective (Project MATCH Research Group, 1997). Alcoholics Anonymous. (1990a). Alcoholics Anonymous
It must be noted, however, that these are studies not 1989 membership survey. New York: Alcoholics
of mutual help but of professionally delivered treat- Anonymous World Services.
Alcoholics Anonymous. (1990b). Comments on A.A.'s
ments with differing theories and treatment strate-
triennial surveys. New York: Alcoholics Anonymous
gies.
World Services.
Hard data on the effectiveness of mutual help
Alcoholics Anonymous. (1993). Alcoholics Anonymous
groups is limited and also hampered by methodologi-
1992 membership survey. New York: Alcoholics Anon-
cal pitfalls. For example, because of the diversity ymous World Services.
within AA and other 12-step fellowships, it is all but Augustine Fellowship. (1986). Sex and love addicts
impossible to establish a "standard dose" of treat- anonymous. Boston: Augustine Fellowship, Sex and
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effective, and no doubt all do work for some people. Bartosch, B., & Bartosch, P. (1985). Guidebook for Over-
Exactly how effective they are in general at reducing comers Outreach 12 step support groups. Anahein,
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management and recovery training; Member's man- Women for Sobriety. (1993b). Who we are. Quakertown,
ual. Beachwood, OH: S.M.A.R.T. Recovery Self- PA: Author.
Help Network. Women for Sobriety, (undated a). Are you a woman who
Sobell, L. C., Sobell, M. B., & Toneatto, T. (1991). Re- drinks to cope? Quakertown, PA: Author.
covery from alcohol problems without treatment. In Women for Sobriety, (undated b). Women and addic-
N. Heather, W. R. Miller, & J. Greeley, (Eds.), Self- tions: A way to recovery. Quakertown, PA: Author.
control and addictive behaviors (pp. 192-242). New
York: Macmillan.
 19

Pharmacotherapies

Wayne S. Barber
Charles P. O'Brien

Intuitively, one might seek a solution to the problems reduction of drug craving, acknowledging the re-
of chemical dependence in molecules that oppose markable tensions that drive the experienced sub-
the actions of the offending agents of addiction—if stance user to "pick up." This line of inquiry has
you will, as antidotes to substances of misuse. And been pursued vigorously in an effort to thwart the
there are a number of appealing targets for pharma- seductive impact of crack cocaine on those devoted
cological attack. In theory, then, should a compound to its immediate reward, recognizing the significant
be developed that blocks the effect of an addicting influence of craving in maintaining dependent co-
agent, whether at a specific receptor site or more caine use. Current studies utilizing positron emission
centrally at a locus of reinforcement, one's opportu- tomography (PET) scans seek to expose those dy-
nity to develop or maintain the addicted state could namic neurophysiological processes central to the
be reduced or even eliminated. Yet this has not craving experience, with hopes that determining an
proved to be so. As an example, naltrexone, which anatomic locus, with the attendant biochemical in-
effectively blocks opiate effects at the |i-receptor, has teractions that subserve this phenomenon, will en-
found minimal acceptance among those who have able the development of compounds that can oppose
become opiate-dependent, most likely because of re- it. Even with the sense of promise that underlies
luctance to forsake the euphoric reward they find in such investigation, there remains a healthy skepti-
substance use. While most can attain abstinence cism that the social and psychological pressures
with comparative ease, with or without medical sup- which support drug seeking and drug use cannot be
port, few can sustain it, succumbing instead to the countered by an attack on craving alone.
multiple pressures that foster relapse. Thus far, the greatest success in the effort to med-
Alternatively, research efforts might focus on the icate the disorders of drug addiction has been found

347
348 TREATMENT

in compounds that substitute for the addicting sub- substitution of long-acting, cross-tolerant compounds
stance by providing modest reinforcement just suffi- for the substance of abuse, administered in a sched-
cient to mollify drug craving and prevent the discom- uled taper of dosage that permits homeostatic re-
fort of withdrawal, while producing blockade of those equilibration toward the original drug-naive state.
subjective effects sought from the primary agent of Supportive care may include medications that re-
abuse. Thus, methadone may be utilized in mainte- duce assorted discomforts that may be part of this
nance programs which permit the addict to return to restorative process. Toxic use may require aggressive
a life of useful function without risking full exposure intervention to counter the effects of noxious intoxi-
to the biopsychosocial pressures which promote re- cation or the more serious dangers of acute overdose.
turn to addictive use. The behaviors of compulsive use may be countered
Such cautious statements are not intended to dis- through medication effects which reduce the subjec-
courage the quest to identify compounds that can tive or rewarding effects of substance use or dampen
safely medicate these distinct events in the addictive the impact of drug craving. Those biological pres-
cycle. On the contrary, we wish to describe lines of sures which promote release might be challenged by
inquiry that have explored the benefit of many varied suppressing the experience of drug craving.
medications in the treatment of the addictions and Since comorbid conditions may challenge a pa-
give promise of even greater successes with discover- tient's capacity to address the tasks of recovery, spe-
ies yet to follow. Yet such efforts must be understood cific medical treatment should be pursued whenever
in a broader awareness that addiction is fundamen- indicated. Yet it is important that one remain cau-
tally a disorder of behavior, comprising of compul- tiously aware that several major psychiatric disorders
sive drug seeking and poorly controlled use, and best may be mimicked by substance use and/or with-
addressed by an integrated program of medical, psy- drawal. In many instances, the consideration of spe-
chological, and social services. The damaging psy- cific pharmacological treatment for these conditions
chosocial consequences of years of dependent use re- would best be delayed while observing for their spon-
quire time and patience to remediate and repair. taneous remission as part of the process of recovery.
Behavior patterns encoded during thousands of drug It is the intent of this chapter to explore what is
ingestions are not eliminated simply by detoxifica- known regarding effective specific pharmacological
tion, nor are they substantially assuaged even during treatments of the varied problem states encountered
the early months of rehabilitation. Thus, the chronic, with the major substances of abuse, and to describe
relapsing nature of this illness holds the recovering additional avenues of research which may bear fruit
addict in continuing jeopardy of relapse, as he or she in the not too distant future.
seeks to develop and refine those tools of self-man-
agement so crucial to the maintenance of recovery.
Medications which can smooth the patient's passage ALCOHOL
through the dangers and discomforts of detoxification
and entry into rehabilitation or deter his or her re- The Roman philosopher Seneca once sought to dis-
turn to dependent use can play a critical role in the tinguish a "man who is drunk" from one who "has
patient's continuation in treatment and commitment no control over himself. . . who is accustomed to get
to recovery. drunk, and is a slave to the habit" (O'Brien &
Chafetz, 1991, pp. 88-89). Two millennia later, the
problems of alcohol persist and continue to com-
POTENTIAL THERAPEUTIC TARGETS mand our attention. Until recently, pharmacological
OF MEDICATIONS approaches to the treatment of alcoholism focused
on detoxification, finding little to offer during the
Good clinical care requires a clear-thinking aware- long-term psychosocial adjustments required of the
ness of the varied components of the addiction expe- alcoholic during rehabilitation. But during the past
rience, coupled with focused efforts to crisply define decade, there has been increasing interest in the
the targets of one's specific therapeutic efforts. The prospect of reducing craving, consumption, and re-
detoxification treatment of withdrawal (those drug- ward through psychotropic approaches in support of
opposite effects released by drug absence) centers on the comprehensive biopsychosocial treatment of this
 PHARMACOTHERAPIES 349

multifaceted illness. Several medications have al- be particularly attentive to the possibility of concur-
ready shown themselves to be effective in this regard, rent hypoglycemia, initiating glucose replacement
and there is reason to expect that more are on the only after pretreatment with thiamine 100 mg IM to
way. avoid the risk of precipitating the emergence of the
Wernicke-Korsakoff syndrome (WKS).
Alcohol's Pharmacolgical Effects
Treatment of Withdrawal
In recent years, there has been mounting evidence
that ethyl alcohol exerts major effects on certain ion While proportionately few patients encounter serious
channel-receptor complexes, most prominently N- medical difficulties during withdrawal, most will find
methyl-D-aspartate (NMDA) and y-aminobutyric acid the course softened by specific pharmacological
(GABAA). While these ion fluxes are thought to be treatments available for detoxification, that process of
substantially relevant to alcohol's intoxicating, amne- clearing alcohol from the body while permitting
sic, and ataxic effects, there are no indications that readjustment of all systems to functioning in the ab-
they contribute to the phenomena of craving or rein- sence of alcohol. One in twenty will experience
forcement (O'Brien, Eckardt, & Linnoila, 1995). In significant medical distress comprising of tremulous-
contrast, there is substantial evidence that the crucial ness, tachycardia, diaphoresis, restlessness, and even
triggers of relapse are mediated through the endoge- alcohol-withdrawal-based seizures. Malnutrition, elec-
nous opioid system, and that medications specifically trolyte imbalance, infection, gastritis, or traumatic in-
targeted toward suppressing opioid expression can be jury may contribute to the severity of the patient's
of substantial benefit to an alcoholic's establishment condition. While good nursing care alone greatly re-
and maintenance of recovery (O'Brien et al., 1995). duces the severity of the syndrome, specific medical
Meanwhile, research efforts continue to consider the interventions are sometimes required. In most cases,
participation of other neurotransmitter systems in the outpatient detoxification is as effective as hospital-
quest for comprehensive understanding of alcohol's ization yet at far less cost (Hayashida et al., 1991),
full biochemical effect. In this section, we shall sur- although there are four general conditions that man-
vey those medications currently in use for the several date inpatient treatment: (a) the demonstrated in-
components of detoxification treatment, as well as ability to discontinue use despite appropriate out-
those found effective or promising in the process of patient treatment, (b) the concomitant presence of
rehabilitation. medical or psychiatric conditions warranting close
observation, (c) an inadequate psychosocial support
system, and (d) the necessity to interrupt a living situ-
Treatment of Toxic Consequences of Use
ation that strongly reinforces substance abuse.
Physicians have long been involved with the acute
problems presented by toxic alcohol ingestion.
Uncomplicated Medical Detoxification
Whether confused, combative, or comatose, this pa-
tient is still best served by supportive and symptom- The major objective of the pharmacological treat-
atic treatments not specifically focused on the bio- ment of withdrawal is the prevention of seizures, de-
chemistry of alcoholism. Safe harbor has not been lirium, and arrhythmias. As the suppression of anxi-
found in extensive trials with naloxone, GABA antag- ety, restlessness, tremor, and insomnia is important
onists, or high doses of amphetamines or caffeine. to patient comfort, relief of these symptoms will in-
Good airway maintenance, support of vital signs, as- crease patients' retention in treatment and enhance
sessment of psychiatric status including risk for sui- their chance for successful recovery. The basic phar-
cide, and attentive observation during hepatic pro- macological principle assumes the rapid substitution
cessing of elevated blood levels are the core of proper for alcohol with a cross-tolerant drug which can then
treatment. Of course, careful diagnostic attention be tapered in measured dosage over the next several
should be directed toward the search for contributing days. Most clinicians regard the various benzodiaze-
medical illnesses, concurrent use of illicit substances, pines (BZD) as the treatment of choice for detoxifi-
and pathological medical consequences of excessive cation of alcohol in the absence of concurrent seda-
alcohol intake, both acute and enduring. One should tive abuse, largely based on their smooth efficacy,
350 TREATMENT

modest risk for escalating dependency, and greater UK, in clinical trials in United States). Acting at the
index of safety. Barbiturates, which are equally cross- autoreceptor, these drugs can moderate adrenergic
tolerant with alcohol but have a poor margin of safety symptoms, but at the risk of unwanted hypotension.
regarding respiratory depression, may be held in re- Others employ p-blockers such as propranolol (Inde-
serve for nonresponsive cases or situations of mixed ral) or atenolol (Tenormin) seeking to reduce crav-
dependence on alcohol and sedatives. ing and the duration of withdrawal. Some challenge
The manner of detoxification and the selection of this practice with the concern that such treatment
specific BZD vary between clinicians and programs masks the presence of tremor and cardiovascular in-
but generally fall into one of two categories of ta- dicators of withdrawal severity that must be observed
pered support: in order to properly titrate withdrawal medication
1. Symptom-triggered dosing, monitored by stan- (Jaffe, Kranzler, & Ciraulo, 1992).
dardized, semiquantitative severity assessment scales
such as the Modified Selective Severity Assessment Alcoholic Hallucinosis
(MSSA) or the Clinical Institute Withdrawal Assess-
ment for Alcohol scale-revised (CIWA-Ar) (Sullivan, An occasional patient will present with nonthreaten-
Sykora, Schneiderman, Naranjo, & Sellers, 1989), ing, ego-dystonic, and usually auditory hallucina-
which track perturbations of vital signs, tremor, cog- tions, accompanied by more intense expression of
nitive responsiveness, and motor restlessness as an in- the withdrawal signs and symptoms characteristic of
dex of physiological instability. Selection of a specific uncomplicated withdrawal. Inpatient treatment, in-
BZD then varies with the following factors: cluding augmented dosing of the BZD of choice, is
a. Long-acting BZDs such as chlordiazepoxide generally sufficient care. Once withdrawal symptoms
(Librium), diazepam (Valium), and clonazepam have stabilized, hallucinations have ceased, or the
(Klonopin) may be begun in loading doses that sub- patient falls asleep, one may return to the protocol
stantially self-taper through their production of active employed for the uncomplicated state. The use of
metabolites that sustain a gradually dwindling blood phenothiazines is to be avoided given the risks of hy-
level over several days without continued dosing. potension and lowered seizure threshold (Jaffe et al.,
Such a program is more popular in inpatient settings, 1992).
where attentive medical care and patient monitoring
can be assured. Delirium Tremens
b. Short-acting BZDs comprising lorazepam (Ati- This toxic psychosis, characterized by extreme agita-
van), oxazepam (Serax), and temazepam (Restoril), tion, threatening ego-syntonic hallucinations (visual
which produce no active metabolites, are hence less > auditory > tactile in frequency of occurrence), and
likely to yield toxic accumulations that may be par- marked physiological destabilization, merits prompt
ticularly hard to monitor in an outpatient setting. Re- hospitalization in a full-service medical facility pro-
sponsible outpatient detoxification will require that viding fluid replacement, vitamin supplementation,
the patient attend the clinic daily over 5-10 days for full medical monitoring, and seizure precautions in
ongoing clinical evaluation, management of BZD a quiet setting without disturbing stimulation. Halo-
pharmacotherapy, and the dispensing of vitamins. peridol may be needed for control of the psychosis,
2. Scheduled sedative administration using fixed with a dosage range of 0.5-2.0 mg IM every 2 hr
schedules of medication administration under rather until hallucinations and agitation have sufficiently
general guidelines is appropriate only to inpatient subsided or the maximum of five doses has been
settings. Properly conducted, this format provides given. Special attention should be directed to the
safe and adequate care while requiring less staff monitoring of fluid intake and output, electrolyte
involvement, but at the cost of longer hospital stays shifts, risk of cardiac arrhythmias, and appearance of
and frequent oversedation. WKS (Jaffe et al., 1992).

Symptomatic Relief of Adrenergic Overflow Related Pharmacological

Management Issues
Some clinicians seek to further reduce patient dis-
tress with the use of oc-adrenergic agonists such as Thiamine depletion, caused by compromised nutri-
clonidine (Catapres) or lofexidine (available in the tion and impaired intestinal absorption, mandates re-
 PHARMACOTHERAPIES 351

placement, given 100 mg PO or IM daily over 10-30 These and subsequent studies revealed remark-
days. One must be alert to begin this treatment prior able safety from toxicity or meaningful side effects at
to the giving of glucose, which when given prema- the standard dose of 50 mg/day. Nausea and vomit-
turely can precipitate the emergence of WKS. ing were the more common complaints, followed by
Potassium depletion can realistically be encoun- headache, anxiety, diminished energy, depressed
tered and contribute to fatigue, muscle weakness, mood, skin rashes, and blunted alertness. As these
and the appearance of cardiac arrhythmias. This de- side effects typically resolve spontaneously within a
pletion can be readily reversed with potassium chlo- few days, such symptoms may represent a mild with-
ride supplementation until normal oral intake of drawal response to the blockade of endogenous opi-
food has been attained. oid stimulation. While hepatotoxicity has been seen
Withdrawal seizures can occur between 24 and at dosages many times this therapeutic level, there
48 hr following the onset of a falling blood-alcohol has been no evidence of reactively elevated liver en-
concentration. These are typically grand mal and zymes in the many populations of treated subjects
nonfocal and rarely more than two in number. Sei- observed over several decades. Reports of anticipated
zures occurring outside this window or in an atypical dysphoria or neuroendocrine change have been min-
presentation should alert one to seek other causes, imal (Berg, Pettinati, & Volpicelli, 1996).
most frequently concomitant dependence on BZDs.
The use of phenytoin is discouraged, since parenter- Drug-Drug Interactions Since a 50-mg dose will
ally it is poorly absorbed and slow to establish thera- competitively inhibit the effects of intravenous her-
peutic blood levels (Alldredge, Lowenstein, & Si- oin for 1-3 days, careful inquiry should be made re-
mon, 1989). Moreover, it has not been demonstrated garding the possible concomitant use of opioids. One
to affect withdrawal seizures in laboratory animals. should also be watchful that patients do not attempt
The clinician's BZD of choice should provide suffi- to override the opioid blockade by self-administering
cient treatment unless the patient is simultaneously high doses of alcohol and/or opioids which might
withdrawing from BZDs, in which case phenobarbi- yield life-threatening results should they remain in
tal is to be preferred. the body beyond the duration of naltrexone's clinical
Total body magnesium depletion in the face of effects. Clinical experience reveals no difficulty when
normal serum concentration could account for the taken concurrently with disulfiram or common psy-
lethargy, weakness, and decreased seizure threshold chotropics at usual dosages.
common in the withdrawal state, although many cli-
nicians view this as a distributional phenomenon not Clinical Treatment For the treatment of alcohol-
requiring supplementation. ism, 50 mg/day PO is sufficient. Experience suggests
that patients should be maintained at this level for 6
months or longer to provide sufficient time to estab-
lish sturdy psychosocial tools to maintain recovery
Treatment During Rehabilitation
in the absence of this maintenance support. One
should initiate treatment with 25 mg/day PO for the
Anticraving Agents
first 2 days to minimize the intrusion of initial side
Beginning with animal observations that alcohol in- effects. Preliminary clinical laboratory testing should
creases endogenous opioid activity, and that opioid include urine screen for opioids, hepatic profile
blockers reduce alcohol consumption in ethanol-pre- (aspartate aminotransferase [AST], alanine amino-
ferring rats and monkeys, formal studies of this phe- transferase [ALT], y-glutamyltransferase [GGT], and
nomenon in humans was undertaken, utilizing the bilirubin), hepatitis screen, complete blood count,
long-acting |l/6-antagonist naltrexone (Revia). The and, when applicable, pregnancy testing. Treatment
Philadelphia Study found significant reductions in should not be initiated when a transaminase level is
rate of relapse, drinking days, alcohol craving, and found to be >3 times the upper limit of normal. Peri-
the subjective experiencing of an alcoholic "high" odic retesting of liver function is suggested, espe-
(Volpicelli, Alterman, Hayashida, & O'Brien, 1992). cially for patients older than 40. The use of naltrex-
Confirmatory studies in New Haven yielded similar one is contraindicated in the setting of acute
findings, with a marked decrease in drinking days hepatitis, liver failure, or any other condition causing
and alcohol consumption (O'Malley et al., 1992). significant hepatocellular dysfunction, as indicated
352 TREATMENT

by an elevated bilirubin (Berg et al., 1996). Because plored the use of serotonergic antidepressants as pos-
very high doses of naltrexone used in clinical trials sible inhibitors of alcohol's subjective reward or of a
of obese patients resulted in increased liver enzymes, patient's alcoholic cravings. No studies to date have
the package insert warns about the possibility of liver supported the efficacy of these classes of drugs for
damage. In reality, naltrexone is not dangerous to the this purpose. Nonetheless, several studies have dem-
liver. Naltrexone is metabolized in the liver and usu- onstrated improved mood in depressed alcoholics
ally results in improved liver function because pa- treated with imipramine or fluoxetine, while more
tients drink less alcohol. It is imperative that patients recently, desipramine has proved effective for de-
be detoxified from all substances of abuse prior to pressed outpatients recovering from alcohol depen-
initiating this treatment. Accordingly, a naloxone dence. While preliminary reports of open trials from
challenge may be indicated should a patient seem each of these research teams hinted of a specific ben-
not to be candid regarding possible current opioid efit in reducing drinking, this was not sustained in
use. the final analysis of more stringently controlled trials.
Accordingly, while some argue compellingly for the
use of serotonergic antidepressants to relieve depres-
Sensitizing Agents
sion secondary to a heavy use of alcohol, there is no
Until the recent Food and Drug Administration convincing evidence that these medications will re-
(FDA) approval of naltrexone in the treatment of al- duce alcohol use, whether or not the patient is cur-
coholism, disulfiram (Antabuse) was the only avail- rently depressed (Litten & Allen, 1995).
able medication for use in the maintenance of re-
covery. By inhibiting aldehyde dehydrogenase, an Anxiety States Four studies have addressed the
enzyme in the pathway responsible for the metabo- question of benefit to anxious alcoholics by treat-
lism of ethanol, it promotes an aversive response ment with buspirone, a serotonin 1A partial agonist.
upon the ingestion of alcohol. The consequent accu- While three of these studies variously described di-
mulation of acetaldehyde produces generalized phys- minished anxiety, reduced craving, reduced drink-
ical discomfort, including vasodilation, headache, ing, and enhanced treatment retention, the more
tachycardia, pronounced diaphoresis, hypotension, carefully designed study found no difference be-
nausea, vomiting, generalized weakness, vertigo, and tween buspirone and placebo in the treatment of
confusion. Adverse effects are common, through the anxiety or alcohol dependence. Significantly, this
inhibition of several enzyme systems. Drug-drug in- was the only study that did not provide psychosocial
teractions include the reduced clearance of all BZDs treatment to the cohort (Litten & Allen, 1995).
except lorazepam, oxazepam, and temazepam and
the tricyclics imipramine and desipramine, leading
Failures and Hangers-on
to an increase in their elimination half-lives (Jaffe et
al., 1992). Extensive investigation of lithium in a multicenter
The most carefully controlled and credible stud- VA study found it to be no more effective than pla-
ies regarding disulfiram's efficacy find it lacking, cebo, regardless of the presence of depression. Like-
yielding an effect no better than that obtained with wise, dopamine and serotonin precursors augmented
placebo (Fuller et al., 1986). Nonetheless, disulfiram with carbidopa failed to demonstrate benefit. The
may be of benefit to healthy, motivated patients who GABAA receptor agonist acamprosate claimed effi-
are able to understand the consequences of their cacy in two controlled studies for the treatment of
drinking while so medicated and wish to utilize this alcoholism, and further controlled clinical trials are
aversive support to their commitment to sobriety. warranted. Two separate trials of bromocriptine, a
The appropriate maintenance dose is 250 mg/day. relatively nonspecific D2 dopamine receptor agonist,
proved contradictory. In a recent double-blind study,
tiapride, a DI receptor antagonist, halved the con-
Pharmacotherapy Directed
sumption of alcohol and doubled the number of abs-
at Comorbid Conditions
tinent days. The size of the claimed therapeutic
Major Depression Aware that ethanol produces ef- effect clearly warrants further investigation. Finally,
fects in serotonergic pathways, researchers have ex- y-hydroxybutyrate, an endogenous sedative thought
 PHARMACOTHERAPIES 353

by some to mimic alcohol's reinforcing effects, der would become apparent only in those who were
seemed to reduce alcohol use, but only after 2 predisposed, had access, and were inclined to look
months of treatment (O'Brien et al., 1995). These outside themselves for comfort.
encouraging results deserve to be confirmed. Dole and his colleague Marie Nyswander were
aware of the German development during World
War II of methadone, as a longer acting opiate anal-
OPIOIDS gesic. In contrast to morphine and heroin, it is well
absorbed orally, so that its administration by this
Opium, smoked for centuries in the pursuit of plea- route delays its action and tempers its effect; thus
sure, was quickly recognized as providing relief of limiting its euphoric reward and the consequent risk
subjective discomfort. Once morphine was isolated of respiratory depression, while suppressing with-
in the early 1800s as the most potent ingredient of drawal and blocking the anticipated effect of subse-
the opium poppy, its efficacy as an oral analgesic was quent self-administration.
quickly established. Of course, the arrival of the hy- Thus was born the concept of methadone mainte-
podermic syringe midcentury found it to be even nance (Dole & Nyswander, 1965), soon to lead to
more powerful when administered parenterally. As the implementation of dedicated clinics throughout
the quest for even greater efficacy provided her- the nation—with treatment that greatly improved the
oin—a morphine derivative that was far more potent quality of life for patients and those upon whom their
and rapid acting—it became the substance sought on lives impacted, although it did not fully spare the
the streets. addict from the tentacles of the disease.
By the turn of the 19th century, heroin was well As the exploration into opiate effects swiftly ad-
known as a drug of addiction, competing with co- vanced, several important studies gave support to
caine and opiates in patent medicines for popularity. Dole's concept of a deficiency disorder. The discov-
Societal pressures demanded that the use of such ery of the opiate receptor and its endogenous opiate
drugs be outlawed, prompting passage of the Har- system in 1973 (Pert & Snyder, 1973) provided a
rison Narcotics Act in 1914 and its aggressive imple- mechanism for explaining such a disease state.
mentation following World War I. The federal facili- Chemical determinations of endogenous blood lev-
ties required to house and treat this new class of els found significant elevations in children with a
criminals afforded an opportunity to study the behav- propensity toward respiratory depression that could
iors of opiod addicts in a controlled setting. It was be suppressed by naloxone, indicating the presence
soon noted that withdrawal, while physiologically of an opiod-mediated mechanism. Preoperative lev-
turbulent, uniformly proceeded to prompt and safe els of endogenous opioids were found to correlate
completion. Yet an intense desire to return to use with a patient's subsequent requirement for analgesic
remained and was usually acted upon shortly follow- relief (O'Brien, 1992). Stress was found to induce an
ing release from incarceration. Clearly, behavioral is- increase in endogenous opiod production in labora-
sues were strongly at play. tory animals, providing a model to explain the preva-
As the urbanization of America advanced, active lence of post-traumatic stress disorder (PTSD) in pa-
heroin use became concentrated in the major cities, tients with baseline low levels of endogenous opiod
supported by enhanced routes of transportation de- activity (O'Brien, 1992).
veloped in the wake of World War II. With the adop- It is thus conceivable that one's susceptibility to
tion of mandatory minimum sentencing in the opiate dependence is in part determined by innate
1950s, forces favoring punishment were at logger- activity of the endogenous opioid system, although
heads with efforts to provide medical treatment. In there are as yet no human data to support this hy-
this context, Vincent Dole in New York City es- pothesis. Since not all opioid abuse advances to de-
poused a belief that opiate addiction was in fact a pendence, as demonstrated by the proportion of
metabolic disorder—if you will, a deficiency disease American soldiers who did not resume their depen-
involving an inadequate capacity to manufacture in- dent use upon returning home from Vietnam, per-
trinsic opiates, so that the potential addict would seek haps those who remained addicted were those who
to satisfy her or his needs through external sources were constitutionally primed. Of course, the possibil-
(Dole & Nyswander, 1967). Of course, such a disor- ity remains that a more permanent requirement for
354 TREATMENT

opioid supplementation could be created in certain nity for greater attention to personal needs, including
individuals by the chronic administration of opiate medical care, diet, and interpersonal relationships.
drugs. For them, living without an externally en- A large body of research has shown that metha-
hanced opiate supply might become difficult, or done maintenance is most successful when coupled
even impossible. Either of these two scenarios pro- with a variety of therapeutic services, including regu-
vides support for the concept of maintenance treat- lar client contact and urine drug monitoring (Cooper,
ment. 1989). Employed in this manner, it is widely regarded
as the best treatment for the greatest number of pa-
tients struggling with opioid dependence.
Maintenance Treatments
As with any treatment, the use of methadone poses
Given this history, it is not beyond understanding certain problems: (a) Methadone produces physical
that agonist maintenance therapy has become the dependence, more than satisfying the urges of most
most reliable and durable treatment of heroin addic- street users; drug diversion must be impeded by dis-
tion. The goals of such an approach are to discour- pensing in an oral format not amenable to injection,
age use while facilitating the extinction of classically with watchful supervision over the patient's act of in-
conditioned drug craving. gestion, and (b) detoxification from methadone takes
Methadone maintenance is based on two essential significantly longer than detoxification from heroin;
pharmacological principles: (a) protecting against patients express many complaints of their prolonged
withdrawal and (b) reducing the effects of self-ad- discomfort during this process, even though the in-
ministered opiates through the mechanism of cross- tensity of specific symptoms is generally less.
tolerance. When opioids are given orally, hence Intuitive reasoning suggests that years of treatment
slowly absorbed, the onset of their effects is quite would harmfully suppress endogenous opioid produc-
gradual, and euphoria and sedation are largely tion, yet studies fail to find evidence of problems even
avoided. With skillful dosing there is no interference in patients maintained for many years (O'Brien, Tere-
with normal activities such as working, attending nius, Nyberg, McLellan, & Eriksson, 1988). Greater
school, or taking care of a family. The relatively high concern surrounds the clinical observation that pa-
and stable opioid maintenance dose produces cross- tients tend to have difficulty achieving stable drug-free
tolerance to additional opiates, thus reducing their status after extended treatment with methadone, so
rewarding effects. that many patients choose to continue with substitu-
Dosing of methadone begins with 20-30 mg daily, tion treatment indefinitely. Fortunately, studies of
followed by increases of 5-10 mg every 2-3 days until long-term treatment have found no evidence of toxic
the patient no longer complains of withdrawal discom- effects from prolonged use (Kreek, 1978).
fort. Better compliance has been found in dosage LAAM (l-a-acetylmethadol), originally synthe-
ranges exceeding 60 mg/day, although current envi- sized in the search for longer duration pain relief, is
ronments well supplied with high-purity heroin find now employed as an alternative to substitution ther-
many patients require > 100 mg/day to block the effect apy with methadone, since its longer duration of ac-
of available street drug. During the period of stabiliza- tion permits less frequent dosing, thus reducing the
tion of dosing, most patients continue to use but with risk of diversion of take-home doses. Compared with
less intensity and regularity. methadone, LAAM produces less euphoria, hence
Methadone aids in the rehabilitation of opiate ad- possesses lower abuse potential. However, this ad-
dicts in several ways: (a) by producing a more level vantage of longer duration is countered by delays in
and stable physiological state, less disruptive to the onset, requiring an initial period of uncomfortable
homeostatic balance of the organism than the multi- adjustment which discourages some experienced
ple daily dosing required by shorter acting heroin; methadone users. Accordingly, many programs first
(b) by diminishing the potential reward of the street stabilize their patients with methadone, later transfer-
drug, permitting the diminution of those habits ring to LAAM in a ratio of 6:5 over methadone.
maintaining compulsive heroin use; (c) by freeing Standard dosing utilizes a three times weekly
the addict sufficiently from drug seeking and the cy- schedule, with the Friday dose increased by 20-40%.
cles of use to become more available to the benefits Most heroin users are begun on 20-40 mg qod, grad-
of psychotherapy; and (d) by permitting the opportu- ually increasing by 10 mg weekly until cravings and
 PHARMACOTHERAPIES 355

withdrawal symptoms have been successfully sup- for the (0,-receptor that it could block virtually all the
pressed. One must take care that 2-day doses of effects of usual doses of opiates, including heroin;
LAAM never exceed 120 mg. Those with low opioid hence, further use would be abandoned. Would that
usage should be titrated cautiously, given LAAM's this were so. Trials with detoxified street addicts
delayed onset of action. Once stabilized, many pa- found little enthusiasm for naltrexone since "it keeps
tients report full suppression for as long as 72 hr, you from getting high." Without any reinforcement,
while experiencing less sedation, euphoria, or nod- few were sufficiently motivated to persist with their
ding than with methadone. treatment.
Buprenorphine (a partial agonist/antagonist) pre- Nonetheless, antagonist maintenance does have
sents with a different twist. As a partial agonist with its role in the treatment of a subgroup of highly mo-
a compelling affinity for the fl-receptor, it is suffi- tivated patients: those who find compelling psy-
ciently stimulating to satisfy craving and block with- chosocial rewards in resisting a return to use. Skilled
drawal, while by its avid occupancy of the receptor professionals such as physicians or pharmacists, espe-
site, it blocks the effect of street opioids that the ad- cially those whose work requires them to have access
dict may choose to self-administer. Thus, buprenor- to controlled substances, embrace this treatment
phine blends the strengths of methadone and naltrex- with particular interest since it permits the continua-
one in an alliance of effects that may prove even tion of their careers. Extended studies of federal pro-
more effective (a) as a weak agonist, thereby satisfy- bationers on work release find rehabilitation success
ing cravings and blocking withdrawal, two crucial rates on naltrexone blockade equal to that of inmates
contributors to reinforcement; yet lacking that inten- without a drug history (Brahen, Henderson, Ca-
sity of opiod stimulation which can induce respira- pone, & Kordal, 1984). A recent controlled study of
tory depression; (b) as an antagonist, preferentially federal probationers (Cornish et al., 1997) found a
occupying the (0,-receptor, thereby blocking any stim- 50% reduction in reincarceration rate for parolees
ulation by more potent street drugs that the addict randomly assigned to naltrexone compared to con-
may self-administer; (c) effectively absorbed sublin- trols.
gually (but not if swallowed), permitting convenient, Naltrexone has clinical activity in blocking the ef-
noninvasive, observed administration; and (d) provid- fects of administered opiates for as long as 72 hr. It
ing long duration of action, affording smooth and sta- is well absorbed when given orally and does not dem-
ble control which prevents the vicissitudes of ex- onstrate tolerance to its antagonism of opiate effects.
treme physiological and/or psychological variations. Since it is not a controlled substance, it can be pre-
Moreover, even when its use is abruptly discon- scribed or administered by any licensed physician.
tinued, withdrawal symptoms are minimal. For the management of highly motivated patients,
Buprenorphine maintenance with a sublingual naltrexone can play an important role in a compre-
dose of 8 mg daily compares well with 30-60 mg hensive treatment program.
daily methadone with respect to treatment retention, A necessary first step in antagonist treatment is
medication compliance, adherence to a counseling effective detoxification from current opiate use, using
regimen, and the frequency of opioid-positive urines one of the several methods described below. Users of
(Johnson, Jaffe, & Fudala, 1992). Currently under heroin require 4-5 days, and those on methadone
study in a combined formulation with naloxone to almost twice as long. Before initiating antagonist
discourage diversion, it has yet to be approved by the maintenance treatment, a naloxone challenge test is
FDA for administration in maintenance treatment. indicated to rule out residual dependence. A positive
response indicates a delay of at least 24 hr before
testing again.
Discouraging Use Through Blockade:
Once the system is opiod-free, naltrexone may be
Opiate Antagonist Treatment
employed for relapse prevention, beginning with a
We indicated at the outset that the benefits of block- dose of 25 mg PO, repeated in 1 hr if no problem
ade to discourage use are more implied than real. side effects occur. One may then continue with 50
The synthesis of naltrexone in 1963 provided an op- mg daily, with the option of switching to dosing three
portunity to test the efficacy of a seemingly perfect times weekly when circumstance permit (Monday-
antidote: a molecule with such compelling affinity Wednesday-Friday: 100 mg-100 mg-150 mg). Com-
356 TREATMENT

pliance is maintained by monitoring of ingestion and sometimes intentionally deceitful. One must remain
confirming expected progress in treatment according particularly alert to the risks of multiple dependen-
to the patient's engagement in psychotherapy, perfor- cies with their complex biological interactions.
mance on the job, and the absence of drug positive Detoxification can be approached in several dif-
urine screens. ferent ways, varying with the philosophies and capa-
Side effects are mild and infrequent, usually lim- bilities of individual programs: Unassisted or "cold
ited to abdominal discomfort, headache, and mildly turkey" detoxification depends upon a safe and sup-
increased blood pressure, possibly due to opioid with- portive setting that is prepared to guide the addict
drawal. Those who experience persisting abdominal through a significantly uncomfortable but not life-
distress should remain on a schedule of daily dosing. threatening several days in the absence of specific
There are no known medical risks for a healthy pa- pharmacological treatment. For dependence on her-
tient taking naltrexone. Laboratory findings in large oin, this takes 4-5 days, and for methadone some-
trials give no evidence of significant abnormalities what longer. Benzodiazepines on an as-needed basis
despite the generally compromised health of addict- may be offered to reduce muscle cramping and agita-
ed individuals. While experimental dosing well out- tion.
side the therapeutic range has resulted in elevated Substitution detoxification customarily utilizes
transaminase levels, even these changes were tran- methadone as an opiate agonist, as described above,
sient and reversible upon discontinuation of the providing a relatively smooth and predictable with-
medication. Notwithstanding, opiate-addicted per- drawal. This medication can be administered for
sons with liver failure should not be treated with nal- purposes other than pain management only in spe-
trexone. Patients presenting with AST or ALT cially licensed facilities. One typically begins with a
> two times the upper limit of normal should not dose of 10 mg PO which usually proves sufficient to
start the medication, and treatment should be dis- suppress withdrawal. Most patients will require a
continued in any patient whose levels exceed three repeat of this dosage two to three times further
times normal. No data are yet available for pregnant throughout the first day, then tapering by 5 mg over
woman or for children. No significant drug-drug in- a 5-6 day period. Minimal withdrawal symptoms will
teractions have been identified. still be noticed during this detoxification phase, as
Special attention should be paid to the need for well as over the ensuing 1-2 weeks. Many programs
treatment of pain. Patients should discontinue treat- begin with an extended methadone stabilization pe-
ment several days in advance of elective surgery riod for up to 3 months leading to explicit detoxifica-
should opiate medication need to be administered. tion, feeling this reduces the frequency of relapse.
In emergencies, it is best to use nonopioid anesthesia Nonopioid detoxification, usually employing clo-
and postoperative pain medication, although if nec- nidine (Catapres), has been widely espoused as an
essary, it would be possible to override naltrexone alternative to substitute dosing with narcotics (Gold,
blockade with carefully supervised higher opiate Redmond, & Kleber, 1979), especially since it can
dosing. be done in any traditional medical setting without a
special license. Several lines of evidence converge to
suggest that a major component of the opiate with-
Detoxification
drawal syndrome is rebound central adrenergic hy-
This description of the methods used for detoxifica- peractivity. Clonidine activates autoreceptors in the
tion from chronic opioid use has been intentionally locus coeruleus, producing presynaptic inhibition of
left to the end of this section since its fundamental adrenergic outflow. Careful study indicates clonidine
concepts are best described in the previous discus- can be most successfully employed on an inpatient
sions of agonist and antagonist maintenance. This is basis, perhaps because of the relative absence of cues
not meant to understate its position of central impor- triggering an urge to pick up. On an outpatient basis,
tance in the pharmcopeia of addiction management. it appears to be most effective for well-motivated opi-
Medication for detoxification should never be oid addicts who are willing to tolerate some dis-
prescribed by a cookbook approach, but by thought- comfort. Target symptoms include nausea, vomiting,
ful titration in concert with careful patient observa- abdominal cramps, diaphoresis, tachycardia, and hy-
tion. Patient reports are commonly unreliable and pertension. It does not alleviate the generalized
 PHARMACOTHERAPIES 357

aches, anxiety, restlessness, insomnia, and opioid nearly half a million American lives are lost yearly to
cravings so characteristic of withdrawal. The most exposure to tobacco products (Rose, 1996), while an
frequent side effects, although usually mild, are seda- even greater number find their lifestyle compromised
tion, hypotension, and fainting. by compulsive use, public opinion has shifted to
The typical dosage regimen begins with 0.1-0.2 make nicotine addiction a major target of political
mg three to four times daily, raised to a total of 1-2 concern.
mg/day as required. Gradual withdrawal then pro- Although the incidence of smoking was all but
ceeds by taper over a 6- to 10-day period. It is essen- halved over the quarter century following the Sur-
tial that blood pressure be regularly monitored for geon General's first report, use has now held steady
the possible development of significant hypotension. for almost a decade, reflecting the intransigence of
Other techniques espoused as effective include a the habit in this subset of the smoking population.
combined naltrexone and clonidine detoxification That they have been entrapped by their dependence
conducted over 4-5 days (Stine & Kosten, 1992), is supported by data regarding their struggle to stop.
said to limit patient discomfort to restlessness, insom- While one third of America's smokers seek to quit in
nia, and muscle cramps, while simultaneously per- any given year, fewer than 7% will abstain for a full
mitting initiation of naltrexone maintenance. Rapid year, and the majority will return to smoking within
detoxification under anesthesia (methohexital or mi- 3 days (Henningfield, Schuh, & Jarvik, 1995). This
dazolam) with naltrexone is claimed to precipitate is indeed a persuasive addiction.
quick and manageable abstinence (Loimer, Lenz,
Schmid, & Presslich, 1991), although there remains
Delivery System
substantial concern about the medical risks, not to
mention a precipitous entry into the rehabilitation Central to our understanding of the nature of this
phase without adequate psychological preparation. process is an appreciation of the efficiency of the de-
There is no evidence that a particular method of de- livery system. Each inhalation of cigarette smoke pro-
toxification produces a better outcome over the long vides an intense concentration of ionized nicotine to
term. Without maintenance treatment, most of the the alveoli, carried by adhesive tars that ensure its
detoxified opiate addicts relapse within 6 months, no presentation to the mucosal surface. Rapidly diffused
matter what kind of detoxification was performed. into the pulmonary circulation, it becomes instanta-
Naloxone, a short-acting opiate antagonist, has neously available to brain tissue, prior to any mean-
value in the treatment of overdose as well as for the ingful dilution by peripheral distribution. And it
diagnosis of physical dependence on opioid drugs. leaves as abruptly as it arrived. Such brief spikes of
While poorly absorbed from the gut, it is rapidly me- intense stimulation provide as swift and powerful an
tabolized when given parenterally, yielding a prompt induction of a drug-dependent state as has yet been
but brief effect of opioid blockade. In the event of found (Volkow, Ding, Fowler, & Wang, 1996).
opioid-induced respiratory depression, airway support
should be paired with naloxone hydrochloride 0.01
Pharmacological Effects
mg/kg intravenously to reverse the effect. A positive
diagnosis of opioid dependence is indicated when While nicotine's effects on peripheral ganglia and
brief, immediate withdrawal occurs following subcu- the neuromuscular junction have long been recog-
taneous or intramuscular injection in the dosage nized, it is now acknowledged that reinforcement oc-
range of 0.4-0.8 mg. This effect is short-lived, ending curs through the drug's pharmacodynamic interac-
in less than 1 hr. tions with central nicotinic cholinergic receptors in
the ventral tegmentum, culminating in dopaminer-
gic neurons of the nucleus accumbens (Rose, 1996),
NICOTINE just as for every other known agent of addiction. Tol-
erance is rapidly acquired and, following an over-
Following decades of contentious dispute, the debate night washout, even more swiftly reacquired with
over harm caused by cigarette smoking and the role each new smoking day (Henningfield et al., 1995).
of nicotine addiction in maintaining smoking behav- This phenomenon—tachyphylaxis —may contribute
iors has finally been put to rest. Recognizing that to the smoker's disappointment with alternative nico-
358 TREATMENT

tine delivery systems. The signs and symptoms of through the act of smoking. Several formats for alter-
withdrawal ensue within several hours following the native nicotine delivery have been employed.
latest cigarette, primarily displayed as increased crav- Nicotine polacrilex was the first replacement de-
ing, anxiety, irritability, and appetite associated with livery system to become generally available in this
decreased heart rate and cognitive acuity (Hughes, country. Approved by the FDA in 1984 in a 2-mg
1996). This experience is described as ranging from chewable formulation, it is now also available in a 4-
generally unpleasant to frequently intolerable. Urges mg dose that significantly improves quit rates. Since
to renew smoking may recur for many years (Henn- nicotine in solution can be absorbed only in a basic
ingfield et al., 1995). Behavioral mechanisms con- medium, it is imperative that the patient be in-
tribute to this high relapse rate. Conditioning is es- structed to avoid the ingestion of acidic beverages
pecially powerful because of almost instantaneous (coffee, tea, soft drinks, fruit juices) prior to chewing.
reward from smoked nicotine (Haxby, 1995). And When it is properly administered, blood levels rise
smoking rituals provide powerful cues that become substantially within 30 min to 1A-1A those achieved
conditioned stimuli. When nicotine's effect on mood through smoking (Hughes, 1996). Recent studies in-
and cognition is perceived as positive, repetition of dicate a fixed schedule of administration is more ef-
the experience will be sought. Nicotine withdrawal's fective than polacrilex chewed ad libitum (Haxby,
robust effect on weight gain, clearly established as a 1995; Hughes, 1996), perhaps because it improves
consequence of smoking (Eisen, Lyons, Goldberg, & compliance. Common side effects of objectionable
True, 1993), can be a strong deterrent to abstinence. taste, difficulty chewing, and stomach upset tend to
It should be clear that a comprehensive treatment compromise compliance (Rose, 1996).
program is required to address these multivariate fac- The transdermal patch was first approved by the
tors. FDA late in 1991, several dosage strengths having
arrived on the market since. Intended to achieve and
maintain steady-state blood levels within 2 days, they
Treatment
yield plasma levels roughly similar to those encoun-
Most contemporary treatment programs combine be- tered in the trough of smoking, just prior to initiating
havioral therapies with pharmacological support of the next cigarette (Rose, 1996). Side effects are lim-
withdrawal. Behavioral strategies currently in favor ited to erythema at the site of application, which can
include health education, self-management tactics be minimized by varying the position of the patch,
such as self-monitoring and cue extinction, and re- and initial insomnia, which usually clears rapidly.
lapse prevention training. The virtues of cognitive Sixteen-hour patches are available, intended to re-
behavioral therapy have frequently been empha- duce insomnia, but they have proved to be no more
sized. Largely abandoned as proven to be ineffective effective in supporting sleep, with the drawback of
include the tactics of nicotine fading, sequential fil- lessened protection against craving for the first ciga-
tration, acupuncture, hypnosis, and the aversive ex- rette the next morning. While caution is advised for
perience of rapid smoking (Haxby, 1995). those with a history of coronary artery disease, research
The goal of any detoxification treatment is reduc- indicates that use of the patch, even in high-dose reg-
tion of withdrawal discomfort sufficient that the pa- imens (44 mg/day), does not produce increased risk
tient can concentrate on the tasks of acquiring dura- over that of continued smoking (Benowitz, Zevin, &
ble tools of recovery. While nicotine replacement Jacob, 1997). Patients with unstable coronary artery
does not appear to shorten withdrawal, it can sub- disease should be advised not to begin patch therapy.
stantially reduce the severity of symptoms to much Compliance with patch treatment is substantially bet-
more tolerable levels, approximating the degree of ter than that with nicotine polacrilex (Rose, 1996).
discomfort ordinarily encountered in the second or Clinical investigators differ in their preference of
third month of cold turkey abstinence (Henningfield patch dosage, duration of use, and choice of associ-
et al., 1995). The objectives of such replacement ated behavior therapy. The most common recom-
therapy include (a) reduced intensity of withdrawal mendation is for an initial dosage of 22 mg daily dur-
symptoms, (b) partial satiation of craving through the ing the first 4 weeks, followed by 2-4 weeks of
satisfaction of tolerance, and (c) partial satisfaction of graduated taper. Studies employing higher dosage
those effects the individual may seek to repeat protocols for heavy smokers demonstrate dose-re-
 PHARMACOTHERAPIES 359

sponse relationships in providing symptomatic relief duce upper airway sensations that resemble those of
from withdrawal, but no difference in long-range ab- smoking, possibly of benefit to those who depend
stinence, and at the cost of an increase in side effects. upon this experience. Their advantage of self-titra-
Investigators have sought in vain to predict dosage tion is somewhat offset by side effects of throat irrita-
requirements based upon subject's customary ciga- tion and coughing (Rose, 1996). Recent studies indi-
rettes per day or baseline levels of nicotine's more cate that the abuse liability of both spray and inhaler
stable metabolite, cotinine. Most now advocate the is substantially lower than that of cigarettes (Schuh,
individualization of nicotine dosing based on the Schuh, Henningfield, & Stitzer, 1997).
principles of therapeutic drug monitoring, especially
for those patients begun on high-dose regimens
Other Pharmacologic Approaches
(Gourley, Benowitz, Forbes, & McNeil, 1997).
Meta-analyses indicate the use of either nicotine In previous years, over-the-counter compounds have
polacrilex or transdermal patches can double quit utilized silver acetate for its aversive distaste effect to
rates (Fiore, Smith, Jorenby, & Baker, 1994; Silagy, deter continued smoking. Given poor patient com-
Mant, Fowler, & Lodge, 1994). Some investigators pliance and absence of benefit in placebo-controled
advocate combining the gum and patch, seeking trials (Haxby, 1995), the FDA removed it from the
even better outcomes (Silagy et al, 1994). Both are market as ineffective and of unproven safety. Lobe-
relatively effective in relieving the withdrawal symp- line, a weak nictoine receptor agonist, has not been
toms of drowsiness, difficulty concentrating, and irri- found to be effective (Haxby, 1995; Henningfield et
tability (Rose, 1996). While craving is little affected al., 1995). The relief of physiological dimensions of
in the early stages, later weeks find replacement pro- withdrawal expected from clonidine has not been
vides substantial amelioration (Faberstrom, Schnei- forthcoming, affording benefit only to women with
der, & Lunell, 1993). The most common duration no alteration of quit rates (Haxby, 1995; Henning-
of detoxification treatment is 8 weeks, acknowledging field et al., 1995; Rose, 1996). Some claim greater
that particularly resistant smokers may require ex- promise in the nicotine receptor antagonist meca-
tended maintenance. While it seems intuitive that mylamine, marketed as an antihypertensive, which,
associated psychotherapeutic support would assist re- combined with patch treatment, has improved absti-
covery, carefully conducted studies have yielded con- nence threefold (Rose, 1996), but at the cost of trou-
flicting results (Dale, Hunt, & Offord, 1995; Jorenby blesome side effects, including sedation, hypoten-
et al., 1995). Nonetheless, most investigators advo- sion, and syncope (Henningfield et al., 1995).
cate concomitant behavior therapy, and some feel Since many subjects report that smoking relieves
only cognitive behavioral therapy is of proven effi- anxiety and/or depressed mood, studies have ex-
cacy (Hughes, 1996). plored the potential benefit of both antianxiety medi-
cation and antidepressants. Benzodiazepines have
not been effective (Haxby, 1995). While earlier stud-
Alternative Delivery Vehicles
ies suggested that buspirone modified the withdrawal
Although not yet approved for general clinical use, experience, a subsequent randomized, placebo-con-
two additional delivery formats are currently in active trolled trial failed to demonstrate an effect (Haxby,
investigation. A nicotine nasal spray, administered 1995). Tricyclics proved ineffective while exacerbat-
0.5 mg of nicotine to each nostril in response to the ing the weight gain of withdrawal (Haxby, 1995).
urge to smoke, shows evidence of relieving craving The response to fluoxetine and related serotonin-spe-
more quickly than either gum or patch (Henning- cific reuptake inhibitors (SSRIs) was equivocal (Hax-
field et al., 1995; Rose, 1996). It appears to be most by, 1995).
effective with more highly dependent smokers (Rose,
1996). More recently, inhalers, which deliver vapor-
Comorbid Psychiatric Conditions
ized nicotine base at 13% the strength of cigarette
smoke, have been found particularly effective in Over the past 15 years, clinical investigators have be-
damping the intense cravings of the first abstinent come progressively aware of a significant relationship
week (Hughes, 1996). While requiring many more between smoking and several common psychiatric
puffs to approach the delivery of a cigarette, they pro- disorders. The diagnoses of major depression, schizo-
360 TREATMENT

phrenia, generalized anxiety disorder, and/or other drawal, it began to appear that buproprion had spe-
substance use disorders apply to more than one third cific utility not only for easing depressed mood but
of all smokers (Breslau, Kilbey, & Andreski, 1991), for enhancing smoking cessation itself (Ferry &
predicting a poorer outcome in achieving absti- Burchette, 1994; Hurt et al., 1997). Recently ap-
nence. A carefully crafted prospective study found proved by the FDA for this indication, it was shown
disproportionately high relapse rates in recovering al- to significantly improve quit rates in two placebo-
coholics and subjects with past diagnoses of either controlled, double-blind trials of non-depressed sub-
major depression or bipolar disorder (Glassman, jects, including some concurrently receiving trans-
1993). It has been established that 50% of all psychi- dermal patch therapy. Current dosage recommenda-
atric patients smoke (Glassman, 1993), twice the rate tions are for 150 mg for 3 days followed by 150 mg
found in the general population. Three quarters of bid thereafter, to begin at least 1 week prior to the
once-depressed smokers experienced the return of intended quit date in order to achieve steady-state
depressive mood during their first week of with- dynamics. Continuation of treatment is indicated for
drawal (Glassman et al., 1993). Thus, the evidence at least 7-12 weeks.
strongly suggests that major depression, especially
when recurrent, amplifies both the likelihood of
Drug-Drug Interactions
smoking and difficulty in stopping. Moreover, it is
equally clear that for those with such a history, absti- The benzopyrenes in smoke are powerful inducers
nence can induce the onset of severe depressive re- of the P4;0 hepatic enzyme systems (Hughes, 1996).
lapse (Glassman et al., 1993). Plainly, particular care Accordingly, smokers have higher requirements for
must be exercised while providing smoking cessation some medications and, in abstinence, need adjust-
therapy to patients who have been depressed. ment. Medications known to be so affected include
Although the nature of the relationships is less the antidepressants imipramine, desipramine, clomi-
clear, there are also demonstrable associations be- pramine, and doxepine; the antipsychotics clozepine,
tween both cigarette smoking and generalized anxiety fluphenazine, and haloperidol; and the benzodiaze-
disorder, and between cigarette smoking and alcohol- pines desmethyldiazepam and oxazepam (Hughes,
ism (Glassman & Covey, 1995). And recovering alco- 1996). Caffeine concentrations increase 250% upon
holics with a past history of depression are rarely able smoking cessation (Hughes, 1996). Should patients
to give up smoking (Glassman & Covey, 1995). seek to discontinue coffee concomitantly with smok-
Of all the nosological groups, by far the greatest ing, they should be made aware of the caffeine absti-
proportion of smokers is found in those diagnosed nence syndrome.
with chronic schizophernia (Glassman & Covey,
1995). While the specifics of the relationship have
Future Considerations
yet to be established, it is known that negative symp-
toms are exacerbated during smoking withdrawal It is apparent there is much yet to be known re-
(Glassman & Covey, 1995), the administration of garding the effects of nicotine on the central nervous
nicotine reverses this (Glassman, 1993), and the re- system, especially its influence on addictive illness
quirement for neuroleptic medication is greater in as well as other psychiatric disorders. Of particular
the 90% of chronic schizophrenics who smoke interest is the recently described finding in ro-
(Glassman & Covey, 1995). It has been suggested dent models suggesting that the nicotine-induced
that their nicotine intake per puff is significantly release of endogenous opioids may be a factor in
greater than that of other smokers (Olincy, Young, & nicotine dependence (Malin et al., 1996a, 1996b),
Freedman, 1997). As one then might suspect, their just as it appears to be for alcoholism (O'Malley
success in smoking cessation is negligible (Glass- et al., 1992; Volpicelli et al., 1992). Perhaps opiate
man & Covey, 1995). antagonists could prove useful in diminishing nico-
tine reinforcement of smoking behaviors. Mean-
while, current efforts continue to focus on refining
Bupropion (Zyban)
our awareness of specific interactions with the intent
While exploring the possible usefulness of antide- to improve the individualization of smoking-cessa-
pressant medication in alleviating nicotine with- tion strategies.
 PHARMACOTHERAPIES 361

COCAINE thinking and behavior. These latter effects are thought

to be produced by the blocking of presynaptic reup-
The unfolding of yet another cycle of cocaine popu- take of norepinephrine (NE), serotonin, and dopa-
larity over the past two decades has generated active mine (DA), prolonging the action of these neuro-
exploration of its biological effects, taking advantage transmitters upon their receptors. Accordingly, the
of recent advances in technology. As in previous epi- search for a pharmacological solution to the prob-
demics, early enthusiasm for its presumed safety as a lems of cocaine use and dependence have focused
sophisticated euphoriant yielded quickly to renewed especially on interactions at these receptors.
awareness of its remarkable potential for harm, by As of this writing, no drug has been found that
both its toxic effects and the likelihood of addiction. significantly reduces cocaine use; yet recent ad-
With the arrival of inexpensive crack in the mid- vances have sharpened research focus on several
1980s came the greater threat of easy street availabil- promising targets. In expectation there will be agents
ity coupled with a delivery system optimally primed of specific utility in the not too distant future, it may
to promote rapid dependence. Thus, despite a signif- be helpful to summarize the history of salient devel-
icant decline in recreational use over the past de- opments to date.
cade, the incidence of regular use has greatly intensi-
fied, yielding the multiple consequences of more
Monaminergic Receptors
users who become addicted, more disrupted lives,
more serious medical consequences, and greater so-
Norepinephrine
cial disruption by associated criminal behaviors.
As of this writing, effective medical treatment of Appreciation of the dysphoric mood following dis-
cocaine dependence continues to be supportive, de- continuation of cocaine use provided the rationale
voted to managing the vicissitudes of acute intoxica- for clinical trials with antidepressants, reasoning that
tion, responding to the discomforts of early absti- by decreasing withdrawal dysphoria, one might re-
nence, and providing substantive training in the tools duce pressures toward relapse. Trials with desipra-
of recovery. Nonetheless, widespread concern with mine (DMI) in the early 1980s claimed facilitation
the personal, social, and economic consequences of of early abstinence (Gawin et al., 1989), although
cocaine use continue to drive intense efforts to find laboratory-based investigation found no reduction in
pharmacological solutions to this international prob- self-administration by human subjects despite alter-
lem. Important targets of pharmacological treatment ations in the subjective effects described with use
are those experiences which support continued use (Witkin, 1994). All subsequent placebo-controlled,
or predispose to relapse, craving, and reward. double-blind trials found DMI to be ineffective in
Cocaine's physiological effects occur in multiple the treatment of cocaine dependence (Mendelson
areas. Medical problems are caused by its actions as & Mello, 1996), although one demonstrated im-
a sympathomimetic agent producing systemic hyper- provement in psychiatric status (Arndt, Dorozynsky,
tension through a combination of tachycardia and Woody, McLellan, & O'Brien, 1992).
increased peripheral resistance, sometimes eventuat-
ing in myocardial infarction or cerebral vascular ac-
Serotonin
cident; by its anesthetizing of the cardiac conduction
system, producing life-threatening dysrhythmias and As it became clarified that DMI primarily influenced
sudden death; by increased heat production through NE reuptake, attention was directed toward seroton-
skeletal muscle activity, coupled with a restriction in ergic compounds, given growing recognition of co-
heat loss due to peripheral vasoconstriction, yielding caine's intense binding to the serotonin uptake site
hyperthermia; and in higher doses leading to seizures (Rite, Lamb, Goldberg, & Kuhar, 1987). Yet, no com-
and/or toxic encephalopathy through heightened pounds have been found to show particular promise.
central stimulation. Preclinical investigation of specific serotonin receptor
Behavioral effects come from its action as a psy- antagonists such as ritanserin yielded contradictory re-
chostimulant, producing euphoria, a sense of en- sults, while a recent clinical trial found no ritanserin
hanced energy and clarity of thought, increased loco- effect in blocking cue-elicited cocaine dependence
motor activity, and occasional paranoid psychotic (Ehrman, Robbins, Cornish, Childress, & O'Brien,
362 TREATMENT

1996). Studies of the serotonin reuptake inhibitors flu-

Dopamine Agonists
oxetine (Mendelson & Mello, 1996) and sertraline
(Witkin, 1994) have failed to demonstrate an effect in Substantial effort has been devoted to developing ef-
reducing cocaine dependence. fective substitution therapy. Early studies with meth-
ylphenidate were disappointing since only those with
concomitant attention deficit disorder demonstrated
Dopaminergic Receptors
benefit (Gawin, Riordin, & Kleber, 1985). Specific
The discovery of multiple dopamine (DA) receptor DI antagonists bromocriptine (Witkin, 1994) and
sites and of compounds that selectively interact with pergolide (Malcolm, Butto, Philips, & Ballenger,
them made it pertinent to search for more particular 1991) were investigated as potential antidotes to
and specific targets of cocaine's actions, seeking to crash and craving but were abandoned because of
identify those effects instrumental to the initiation contradictory results and problem side effects (Wit-
and maintenance of addiction (Witkin, 1994). kin, 1994). Considerable attention has been paid to
An early theoretical approach postulated that the amantadine, an anti-Parkinsonian medication with
prolonged use of cocaine depleted DA (Dackis & complex pharmacological effects, including those
Gold, 1985), producing anergia, anhedonia, de- which increase DA concentrations at the synapse.
pressed mood, and (with abstinence) marked craving, Yet, despite early enthusiasm (Alterman et al., 1992;
possibly constituting a withdrawal syndrome related Witkin, 1994), a recent double-blind, placebo-con-
to disturbances in DA function (Gawin & Kleber, trolled trial found it not only to be ineffective in the
1986). Perhaps pharmacotherapies which increased treatment of cocaine dependence but possibly con-
DA activity would alleviate mood disturbances, pro- tributing to a rebound increase in cocaine use fol-
moting withdrawal, and thereby reducing craving lowing discontinuation of this agent (Kampman et
and the risk of relapse. Yet subsequent inpatient stud- al., 1996).
ies, without the customary conditioned cues of the Recent reports of a dissociation between actions
using environment, found minimal evidence of this of D] and D2 receptors in rats suggest a specific target
putative state (Satel et al., 1991). for further medication development. D2-like agonists
In recent years, it has become apparent that with were found to increase craving and aggravate addic-
cocaine, as with all other agents of addiction, rein- tion, thus discouraging further exploration of com-
forcement occurs in dopaminergic neurons of the pounds that interact with this site. Dplike agonists
nucleus accumbens (Kornetsky & Porrino, 1992), a did not (Self, Barnhard, Lehman, & Nestler, 1996).
finding which insists upon exploration of potential Instead, they prevented cocaine-primed reinstate-
agonists and antagonists at that site. Earlier self-ad- ment of use (Rothman et al., 1989). These findings
ministration studies pointed to a prominent role for offer cautious hope of finding an anticraving agent
the postsynaptic receptor. analogous to naltrexone's efficacy for alcoholism.

Dopamine Antagonists Dopamine Reuptake Inhibitors

As evidence developed linking the blockade of DA As studies showed that cocaine's behavioral effects
reuptake to the behavioral effects of cocaine (Ritz et correlate directly with its blockade of the reuptake of
al., 1987), it was rational to speculate that excessive DA (Ritz et al., 1987), investigators were encouraged
accumulation of DA might be responsible. Thus, it to search for compounds which act upon this presyn-
was undertaken to counter this at the postsynaptic aptic receptor. The expectation was that partial ago-
receptor with an agent that opposed DA's effects. nists occupying this site could mimic the effects of
Nonetheless, compounds designed to antagonize the cocaine, yet with greatly reduced intensity, thus pre-
postsynaptic receptor, including haloperidol and venting the behavioral effects of cocaine. Mazindol,
flupenthixol, were found to be clinically ineffective marketed as a short-term anorectic and pharmacolog-
and associated with unpleasant to potentially danger- ically similar to cocaine, was reported to reduce co-
ous side effects, particularly with repeated adminis- caine intake and craving in open trials of methadone-
tration (Witkin, 1994). maintained patients. Yet animal studies suggested the
 PHARMACOTHERAPIES 363

likelihood of mutual exacerbation of cocaine's toxic-

Antikindling Effects
ity (Witkin, 1994).
Following work claiming that cocaine kindled sei-
zures in animal models, open clinical trials suggested
GBR 12909 that carbamazepine could reduce both cocaine crav-
ing and cocaine use, as measured by a decrease in
This piperazine derivative, originally intended as an
cocaine-positive urines over a brief span. Yet subse-
antidepressant, has been shown to preferentially bind
quent trials found it to be no better than placebo
to the dopamine transporter (DAT) with 500 times
(Cornish et al., 1995; Malin et al., 1996a).
the affinity of cocaine, thus blocking cocaine's effects
Thus, while no strong argument can be made for
(Rothman et al., 1989). Since it totally substitutes for
benefit from currently available medications in the
cocaine in discrimination studies and selectively de-
reduction of cocaine use, recent research has tar-
creases self-administration by rhesus monkeys (Glowa
geted two areas of particular promise for medication
et al., 1995), it bodes well for a similar effect in dis-
development:
couraging cocaine use in humans. Moreover, its re-
ported slower onset of action diminishes the extent
• Maintenance treatment via substitution therapy
of a euphoric reinforcement, while prolonging its du- with compounds such as GBR 12909 or PPT
ration of activity. Subsequent work implies its prom- • DI agonists and D[ antagonists reported in ani-
ise may extend beyond that of maintenance treat- mal models to inhibit reinstatement of cocaine
ment. Revisiting the DA depletion hypothesis, it may self-administration.
be postulated that DAT upregulation in cocaine ad-
diction leads to reactive DA depletion in abstinence.
Perhaps long-term treatment with GBR 12909 would SEDATIVES/HYPNOTICS
return DAT densities to normal, thus bypassing the
withdrawal symptoms of DA depletion during absti- These oft prescribed and sometimes abused medica-
nence (Telia, Landenheim, Andrews, Goldberg, & tions form the final group of agents which respond
Cadet, 1996). PPT [2-propanoyl-3-(-4-toyl)-tropane], to specifically targeted pharmacological interven-
currently under study in rhesus monkeys, is de- tions, largely those which employ like or cross-toler-
scribed as producing an effect similar to that of GBR ant compounds to ameliorate the discomforts of
12909 at the DAT (Nader, Grant, Davies, Mach, & withdrawal.
Childer, 1997). Both compounds are currently being
studied for safety and efficacy in human subjects. Benzodiazepines

Safe clinical management of the use or abuse of

these compounds requires an awareness of the con-
Agents with Other Putative
cept of differential tolerance. Since an individual
Mechanisms of Action
will develop tolerance separately to the various bio-
logical effects of an agent, a discrepancy may exist
Opioid-Medicated Effects
between tolerance acquired for euphoric effects and
It has been speculated that endogenous opioid sys- that for effects on vital functions, such as respiration
tems in the brain may be involved in the reinforcing or blood pressure. Tolerance is quickly established
effects of cocaine in a manner similarly to those hy- for the sedating effects of benzodiazepines, more
pothesized with alcohol. If true, this could provide a slowly toward respiratory depression, and minimally
single therapeutic approach to the management of with respect to BZD-induced memory loss. Accord-
both heroin and cocaine. Yet initial enthusiasm for ingly, the window of safety narrows somewhat with
buprenorphine in preclinical investigation was soon extended use, especially when forgetful insomniacs
countered by evidence that the effect was insuffi- may unknowingly repeat their dose of hypnotic. For-
ciently specific, lacked a good dose-response curve, tunately, a competitive antagonist, flumazenil, is
and was not enduring. Subsequent human studies available for IV infusion in cases of accidental or in-
have been less than convincing (Witkin, 1994). tentional overdose.
364 TREATMENT

Detoxification may be accomplished through sub- engenders far greater risk and commonly requires
stitution with a like or cross-tolerant long-acting com- carefully supervised inpatient treatment.
pound administered in a scheduled taper. Chlordiaz-
epoxide or clonazepam are those most commonly
employed. While the great majority of BZD users AGENTS RESPONDING TO SPECIFIC
continue with their prescribed therapeutic dosage, SUPPORTIVE INTERVENTIONS
regular use beyond 4 months finds the patient prone
to withdrawal symptoms upon discontinuation. In
Hallucinogens
general, the withdrawal state is one of drug-opposite
effects, centering on CNS hyperarousal. First to ap- Since the early 1990s, use of these agents by young
pear is profound rebound anxiety and insomnia, ac- people has again been on the rise. The temporary
companied by general restlessness. Tremor, sweating, alteration of thought, perception, and mood which
anorexia, and myoclonus are often noted. Tachycar- they induce does not commonly bring users to medi-
dia, hypertension, and agitation may also be seen. cal attention. Yet patients will occasionally present
Later developments can include confusion, deper- with complaints of panic anxiety as part of a "bad
sonalization, perceptual distortions, paresthesia, hy- trip." Reassurance and a calm atmosphere usually
peracusis, and photophobia. While rare, seizures can provide sufficient treatment, although low doses of
occur during the early withdrawal period, typically BZDs may be employed to mute dysphoria. Phency-
within 3 days of discontinuation of drug use. Seizure clidine (PGP, angel dust) deserves special mention
risk is increased substantially by the concomitant use because its reinforcing qualities readily promote
of other sedating agents, particularly ethanol. Abrupt abuse, especially when rapidly administered by
termination of administration is never wise; rather, smoking. Psychotic thinking generated by lower
gradual taper over several weeks is preferred. On oc- doses advances to hallucinations as use increases and
casion, propranolol has been used to assuage auto- sometimes progresses to hostile or assaultive behav-
nomic excitation. Sedating tricyclic antidepressants ior. On occasion, the degree of agitation may warrant
may be employed to assist sleep. BZDs given by IV titration, or even haloperidol if
Escalating or high-dose dependence presents far driven by psychotic ideation. One should avoid using
more serious issues of management. Whether begun anticholinergic antipsychotics such as chlorproma-
as street use to augment the potential high of metha- zine or thioridizine, which may augment the delir-
done or curb the crash after cocaine, or combined ium. PGP's dose-related anesthetic effects lead to stu-
with alcohol or other sedatives in attempted self- por and coma in heavy abusers, accompanied by
medication of anxiety or depression, it constitutes de- muscular rigidity, rhabdomyosis, and hyperthermia.
pendent use with the attendant risks of multiple sub- Early signs of intoxication in those with a history of
stance abuse and addictive behavior. The likelihood PGP use warn of the need for emergency care. No
of seizure is more pronounced, and the risk of fatal receptor antagonist is known.
respiratory depression greatly increased, particularly
when combined with barbiturates. Assessment for in-
Gannabis
patient management is indicated, with the prospect
of a troublesome detoxification treated with long-act- Marijuana, hemp, hash, and pot are all names for
ing BZDs or phenobarbital, and active supportive this controversial drug. Since the 1970s, it has been
management. known to be capable of producing physical depen-
dence (Jones, Benowitz, & Herning, 1981), but most
users take it occasionally and do not develop with-
Other Agents
drawal symptoms. Specific cannabinoid receptors
While no longer so frequently seen, dependence on have been identified throughout the brain, and their
barbiturates, glutethimide, and ethchlorvynol can density and widespread location suggest that they
still be encountered, usually abused in combination may play an important, yet unknown, role in brain
with other agents. Because the tolerance to euphoria function (Devane, Dysanz, Johnson, Melvin, &
occurs more rapidly and extensively than tolerance to Howlett, 1988). An endogenous ligand has been
brain stern depressant effects, the use of these agents identified (Devane et al., 1992). A withdrawal syn-
 TABLE 19.1 Clinical Uses of Pharmacological Agents for the Treatment of Addictive Illnesses
Opioids Alcohol Nicotine Cocaine Benzodiazepines

Emergency antidote Receptor antagonist Naloxone Flumazenil

Prevents effect Receptor antagonist Naltrexone Mecamylamine?
Provides moderate effect while Receptor agonist Methadone Nicotine
deterring withdrawal LAAM
Provides weak effect while deter- Partial receptor agonist Buprenorphine GBR 12909?
ring withdrawal PPT?
Diminishes effect Receptor agonist Naltrexone DI agonists
Detoxification — Minimizing Long acting cross tolerant agent Methadone Benzodiazepines Benzodiazepines
withdrawal discomfort Phenobarbital Phenobarbital
Detoxification — Reducing with- Receptor blockade plus sympa- Naltrexone plus
drawal discomfort thomimetic damping clonidine
Aversive deterrent Noxious agent Disulfiram Silver acetate
366 TREATMENT

drome typical of that seen with other sedatives has The fourth generation of progress (pp. 1745-1755).
been described by heavy users, comprising height- New York: Raven Press.
ened tension and anxiety, restlessness, sleep disturb- Rose, J. E. (1996). Nicotine addiction and treatment.
ance, and changes in appetite (Wiesbeck et al., Annual Review of Medicine, 47, 493-507.
1996). Recent reports in rodent models identified a
diminution of corticotropin-releasing factor (CRF) References
release in the amygdala in response to stimulation
with a marijuana-like ligand, similar to that seen with Alldredge, B. K., Lowenstein, D. H., & Simon, R. P.
other agents of abuse. Blocking of the cannabinoid (1989). Placebo-controlled trial of intravenous di-
phenylhydantoin for short-term treatment of alcohol
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87, 645-648.
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Yurgelun-Todd, 1996), investigators have intensified tained patients. Archives of General Psychiatry, 49,
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Benowitz, N. L., Zevin, S., & Jacob, P. (1997). Sources
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dence.
use of nicotine nasal spray, transdermal nicotine,
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SUMMARY AND CONCLUSIONS Berg, B. J., Pettinati, H. M., & Volpicelli, J. R. (1996).
A risk-benefit assessment of naltrexone in the treat-
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of Clinical Psychopharmacology, 12, 203-209. Wiesbeck, G. A., Schukit, M. A., Kalmijin, J. A., Tipp,
Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, J. E., Bucholz, K. K., & Smith, T. L. (1996). An
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 20

Relapse Prevention: Maintenance of

Change After Initial Treatment

Lori A. Quigley
G. Alan Marlatt

Early research on the effectiveness of treatment for and colleagues (Hunt et al., 1971), roughly two
substance use focused on resumption of substance thirds of individuals who received treatment for
use as the primary outcome variable (Hunt, Bar- smoking cessation, alcohol abuse, or heroin addic-
nett, & Branch, 1971). Regardless of the amount, du- tion returned to substance use within 3 months of
ration, or consequences of use, any posttreatment use treatment. A much smaller percentage remained
was considered a "relapse" and tantamount to treat- continuously abstinent through 1-year posttreatment
ment "failure." Thus, two outcomes were possible: (less than 35% for alcohol use and less than 25% for
treatment success, defined as complete and continu- smoking and heroin use). For a large proportion of
ous abstinence, and treatment failure, defined as any individuals treated for addictive behavior, resump-
posttreatment use. As research in this field has pro- tion of substance use is the most likely outcome.
gressed, a variety of outcomes associated with im- This high rate of relapse following treatment is likely
proved status, yet short of complete and total absti- to lead to a continuous "revolving door" back into
nence, have been acknowledged, and there is greater treatment.
acceptance of diverse pathways toward improvement Regardless of the method used to achieve absti-
(Miller, 1996). Even so, return to problematic use nence or a reduction in substance use, relapse pre-
continues to be a challenge in the addictive behav- vention (RP; Marlatt & Gordon, 1985) techniques
iors treatment field. can be utilized to maintain changes attained during
Rates for the resumption of substance use follow- the course of treatment. Skills to decrease the proba-
ing abstinence-oriented treatment are uniformly high bility of a return to maladaptive substance use can
across addictive behaviors. In an early study by Hunt be taught to clients regardless of the methods em-

370
 RELAPSE PREVENTION: MAINTENANCE OF CHANGE AFTER INITIAL TREATMENT 371

ployed to achieve initial abstinence or moderation. Within the area of addictive behaviors, recent ap-
The goals of RP are twofold. The first goal is to pre- plications have included programs which are devel-
vent a lapse or initial return to substance use (or oped for groups lower in problem severity (Marlatt et
transgression of one's goal) so that a full-blown re- al., 1998) and which address other problems of im-
lapse, defined as return to problematic use, is less pulse control, including obesity (Fremouw &
likely. The second goal is successful management of Damer, 1992), other forms of disordered eating (Ori-
relapse episodes, if they do occur, to prevent exacer- moto & Vitousek, 1992; Rankin, 1989), and sexual
bation or continuation of maladaptive substance use. deviance (Marshall, Hudson, & Ward, 1992). RP
RP techniques may also be utilized to facilitate ini- techniques have also been combined with other
tial changes in addictive behaviors. forms of therapy in behavioral marital therapy (Mc-
Marlatt and Gordon's (1985) RP approach was Crady, 1993; O'Farrell, 1993) and treatment for de-
originally developed as a maintenance program for pression (Wilson, 1992), schizophrenia (Kavanagh,
individuals who had undergone treatment to moder- 1992), panic disorder (Brown & Barlow, 1992), ob-
ate or discontinue substance use. It was developed to sessive-compulsive disorders (Emmelkamp, Kloek, &
extend and enhance therapeutic gains and to reduce Blaauw, 1992), chronic pain (Nicholas, 1992), mari-
the possibility of recycling back through treatment. tal distress (Truax & Jacobson, 1992), social compe-
Rather than viewing those who experience initial tence (Azar, Ferguson, & Twentyman, 1992), and
lapse episodes as "treatment failures" who are victims stuttering (Andrews, 1992).
of an underlying disease process, the RP approach
views such episodes as errors or temporary setbacks
that might be expected from someone who is in the THE RP MODEL AND LINKAGE TO
process of learning new coping behaviors. Viewed in THEORY OF ETIOLOGY AND
this way, these episodes may provide valuable lessons MAINTENANCE OF SUBSTANCE USE
in preventing future episodes. Lapses to use, and re-
lapses, therefore, are part of a learning process rather Marlatt and Gordon's RP model is based on an "ad-
than a final outcome of treatment. Attributions for dictive behaviors model," with its roots primarily in
a return to substance use which involve uncontroll- social learning theory in conjunction with social and
able causes may lead to a return to problematic use cognitive psychology (Bandura, 1977; Lang & Mar-
and to demoralization on the part of clients as well latt, 1982; Mackay, Donovan, & Marlatt, 1991; Mar-
as treatment providers. In a recent prospective al- latt & Gordon, 1985). Addictive behaviors, from this
cohol treatment outcome study, Miller, Westerberg, standpoint, develop as acquired or overlearned hab-
Harris, and Tonigan (1996) found that endorsement its. To the extent that a substance is used to cope
of a disease model of alcoholism was strongly predict- with unpleasant situations, experiences, or emotions,
ive of relapse by 6 months. This suggests that the way the behavior may also be viewed as a learned mal-
clients conceptualize their substance-related prob- adaptive coping strategy. Such habits may be learned
lems, including their attributions of controllability, through a combination of both classical and operant
may play a key role in successful behavior mainte- conditioning processes, which may not be under the
nance. individual's direct control. Individuals struggling
Although the RP model was developed primarily with addictive behaviors, therefore, are not held ac-
as a maintenance program, it is also utilized as a countable for the development of an addiction, just
strategy for the initiation of behavior change. RP as they are not held responsible for their learning
strategies may be used in conjunction with other ini- histories.
tiation strategies designed to enhance motivation for The model assumes a biopsychosocial etiology,
change such as motivational interviewing (Miller & the specific determinants of which may vary greatly
Rollnick, 1991) or even disease model approaches. among individuals. Such influences may include bi-
RP approaches were initially developed with sub- ological and genetic vulnerabilities, environmental
stance-related behaviors (e.g., smoking, drinking, and/or situational factors, family history of substance
heroin use) and other impulse control problems use, substance use by peers, early experience with
(e.g., gambling, pedophilia) in mind. substances, and beliefs and expectancies about the
372 TREATMENT

effects of a substance. Social and societal influences states (e.g., cirrhosis). The substance-taking behavior
may play a large role in the development of addictive itself is not a disease.
behaviors. Within the RP model, individuals who
struggle with addictive behavior patterns are not
viewed as categorically different ("alcoholic" or HOW THE RP TREATMENT APPROACH
not) from those who do not. Rather, they are viewed FOLLOWS FROM THE RP THEORY OF
as being at a different place along a continuum from SUBSTANCE ABUSE
nonuse and nonproblem use to severe problem
use. Regardless of the factors involved in the development
The RP model views the development of addic- or maintenance of substance use problems, RP strat-
tive behaviors as multiply determined and main- egies may be used to minimize the likelihood of con-
tained. However, the factors involved in the devel- tinued maladaptive substance use. RP is a compensa-
opment of potentially harmful habits may not tory model (Brickman et al., 1982); that is, regardless
necessarily be the same factors involved in their of the factors leading to a problem, an individual can
maintenance. Maintenance of substance use may be compensate by assuming personal responsibility for
primarily driven by the drug's short-term reinforcing behavior change (Marlatt & Gordon, 1985). In this
effects. A drug's predictability in providing some re- self-management model, an individual may learn to
lief, if only temporarily, to an individual who has not identify the determinants of his or her own problem
developed alternative ways of handling unpleasant substance use and develop strategies to affect success-
situations or emotions may foster continued reliance ful behavior change.
on drug taking as an attempt to cope. Perceived lack As a self-management approach, the RP model
of alternative coping strategies combined with low considers the individual (rather than a higher power
self-efficacy (Bandura, 1977; Marlatt, Baer, & Quig- or a group) to be the responsible agent of change.
ley, 1995), or confidence in one's ability to effec- The individual is taught skills and strategies to recog-
tively carry out alternative coping strategies, may nize and successfully navigate the situations which
serve to maintain a maladaptive pattern of substance may have led to relapse in the past. Essentially, treat-
use. An individual may not have developed skills to ment utilizing the RP approach is empowering and
perform more appropriate, less harmful behaviors or trains individuals to act as their own therapists with
may lack confidence in his or her ability to perform regard to managing their addictive behavior patterns.
a more appropriate behavior successfully.
Not all addictive behaviors develop as maladap-
tive coping responses that may have their origin in KEY CONSTRUCTS AND TERMS IN
skill deficits. Use of psychoactive substances, particu- THE RP TREATMENT MODEL
larly the use of alcohol, is generally a socially ac-
cepted practice among adults in many societies. Al- Following initial abstinence or attainment of the in-
cohol use, for example, in addition to its reinforcing dividual's goals, sooner or later the client will en-
pharmacological effects, is also reinforced socially. counter a high-risk situation, defined as any situation
Potentially problematic behaviors may become in- that poses a threat for resumed or excessive substance
corporated into an individual's lifestyle with little use. High-risk situations can be classified as having
forethought as to possible risks or negative long- either intrapersonal or interpersonal determinants
term consequences. Some short-term negative conse- (Cummings, Gordon, & Marlatt, 1980; Marlatt &
quences may be accepted as a small price to pay for Gordon, 1980). In an analysis of over 300 initial re-
the benefits derived from the drug-taking behavior. lapse episodes involving return to cigarette, alcohol,
Until such negative consequences begin to accrue, or heroin use, or to overeating or gambling, three
or more serious consequences occur, individuals primary events emerged which classified over 70%
may not be motivated to examine and/or change of initial relapse episodes as retrospectively assessed
their behavior. Maladaptive substance use is not (Cummings et al., 1980). Negative emotional states,
viewed as a symptom of an underlying disease, al- classified as intrapersonal determinants, such as
though it is acknowledged that substance habits may anger, boredom, anxiety, frustration, and depression,
result in serious health consequences or disease accounted for about 35% of relapse trigger episodes.
 RELAPSE PREVENTION: MAINTENANCE OF CHANGE AFTER INITIAL TREATMENT 373

Two types of interpersonal determinants were other curs, a decrease in self-efficacy is likely to occur, of-
primary determinants of initial lapses. Interpersonal ten characterized as a feeling of hopelessness about
conflict and social pressure accounted for 16% and ever being able to manage substance-related behav-
20% of trigger episodes, respectively. Interpersonal ior. The probability of lapsing is increased to the ex-
conflict involved ongoing conflictual relationships tent that decreased self-efficacy is combined with
(e.g., tension in marital relationship) or recent con- positive outcome expectancies for the initial effects of
flict with another person (e.g., argument with a co- substance use. Positive outcome expectancies are the
worker). Social pressure included both direct verbal short-term positive effects or immediate gratification
persuasion by another to engage in the discontinued one anticipates receiving through use of the sub-
behavior (or to exceed one's established limit) and stance.
indirect pressure, such as being in the company of A lapse, or initial return to substance use or trans-
others who are engaging in the same behavior. gression of one's goal, may follow from the inability
The remaining initial relapse situations were clas- to cope with a high-risk situation and associated low-
sified as negative physical states (3%), positive emo- ered self-efficacy (Marlatt et al., 1995). Whether a
tional states (4%), testing personal control (5%), and lapse precipitates a relapse, usually defined as a re-
urges and temptations (8%)(all intrapersonal deter- turn to maladaptive or pretreatment levels of sub-
minants) and positive interpersonal emotional states stance use, appears to be determined in part by one's
(interpersonal). The reliability and validity of this re- reaction to and attributions for the initial lapse. Indi-
lapse taxonomy has been recently evaluated by three viduals can experience strong negative reactions to
research teams (Lowman, Allen, Stout, & The Re- their transgression of a goal or initial episode of non-
lapse Research Group, 1996) and is discussed in the abstinence, particularly when they have personally
section below, which addresses empirical support for committed to a goal of moderation or abstinence.
the RP model. The clinical utility of Marlatt's relapse The magnitude of this abstinence violation effect
taxonomy is to provide a framework for understand- (AVE) or goal violation effect (GVE; Marlatt & Gor-
ing a client's unique situation and characteristics that don, 1985) in the case of a moderation goal is likely
may serve as proximal determinants for relapse so that to influence the probability that this initial transgres-
treatment is appropriately planned (Marlatt, 1996). sion will precipitate a full-blown relapse.
The AVE is conceptualized as the interplay of
two cognitive affective elements: cognitive dissonance
A COGNITIVE BEHAVIORAL (Festinger, 1964) and a negative self-attribution ef-
MODEL OF RELAPSE fect. Cognitive dissonance, as theorized by Festinger
(1964), arises when one's behaviors are not congru-
Figure 20.1 presents Marlatt's model of the relapse ent with one's self-image or beliefs about oneself.
process. When a high-risk situation is encountered, When an individual who has made a commitment
an individual may or may not invoke the use of a to a goal of abstinence uses the forbidden substance,
cognitive or behavioral coping response in an attempt cognitive dissonance may result, as the drug-taking
to deal with the situation without using the unde- behavior is incongruent with the new self-image of
sired substance (or exceeding a limit for that sub- an "abstainer." Cognitive dissonance is presumed to
stance). If a coping response is utilized effectively, involve an internal conflict involving guilt ("I did a
the individual is likely to respond with increased self- forbidden thing") which individuals are motivated to
efficacy to cope successfully with future similar situa- resolve. The individual may resolve this conflict ei-
tions (Marlatt et al., 1995). ther by providing a rationalization for the behavior
Alternatively, the individual may be unable or ("I was overwhelmed by the situation and therefore
unwilling to cope with the high-risk situation. In not responsible for my behavior"), thereby maintain-
this case, there may be a skill deficit on the part ing her or his self-image, or by changing the self-
of the individual, the performance of a learned cop- image to be congruent with her or his behavior ("I
ing response may be blocked due to anxiety brought guess this just proves I'm a drunk after all"). Recogni-
on by the situation, or the situation may not be rec- tion of the inherent difficulties of a situation, cou-
ognized as being a risky one until it is too late to pled with an awareness of coping deficits, may serve
initiate an appropriate coping response. If this oc- to motivate an individual to learn how to better pre-
 Decreased
Coping Increased Probability
Response Self-Efficacy of Relapse

Behavior Change
Initiation High-Risk
Situation
Perceived Control

Decreased Lapse: Abstinence/Goal

Self-Efficacy Violation Effect:
Initial Use increased
Plus Dissonance Conflict
No Coping of Substance Probability
or Goal and Self-Attribution
Response Positive (guilt and perceived of Relapse
Transgression
Outcome loss of control)
Expectancies
(for initial effects
of substance)

FIGURE 20.1 A cognitive behavioral model of the relapse process.

 RELAPSE PREVENTION: MAINTENANCE OF CHANGE AFTER INITIAL TREATMENT 375

pare for future situations and to get back "on the benefits and costs of both changing and not chang-
wagon" or moderation plan. Self-attributions for a ing the behavior. A decision matrix assesses the bene-
lapse that do not acknowledge the inherent chal- fits and costs which are both immediate and delayed
lenges of the high-risk situation but that are largely and is used to build motivation for behavior change
personalized and negative ("I'm a failure; I have no and to identify potential barriers. In addition to iden-
willpower and can't control my drinking") may lead tifying common motivators for change (e.g., im-
to lowered expectations for future success at behavior proved health), this technique is useful in identifying
change. Resolution of cognitive dissonance by chang- idiosyncratic motivations for use or quitting. Such id-
ing one's self-image to be congruent with a behav- iosyncratic beliefs, when inaccurate, may be chal-
ioral transgression (e.g., "This proves I am an ad- lenged by the therapist. An example of a completed
dict") may precipitate continued use and increase decision matrix is presented in figure 20.2.
the probability of full-blown relapse. Some clients keep a copy of the decision matrix
to refer to, especially during times when motivation
may be waning, in order to provide themselves with
THERAPEUTIC CHANGE a reminder of the reasons for embarking on the jour-
ney. The salience of these reasons may shift over
time as various successes, setbacks, and challenges
Assumptions of the RP Model of How
occur throughout the behavior change process. Addi-
People Change and Key Interventions
tional motivational enhancement strategies such as
Because the RP model is rooted in behavior theory, those described by Miller and Rollnick (1991) may
it focuses on the "unlearning" of maladaptive associa- be used to further sustain behavior change efforts.
tions and behaviors and on learning more adaptive Another area to assess is the client's self-image as
behaviors. Behavior change efforts are facilitated by a drug user or drinker. Clients often have a difficult
sharing with clients an understanding of the theoreti- time thinking of themselves as other than an "addict"
cal model and the assumptions underlying the RP or "alcoholic" and may either feel shame or stigma
approach. Metaphors are recommended to clarify or perhaps have an overly romanticized view of this
the process of behavior change (Marlatt & Fromme, lifestyle. To heighten awareness of self-image, clients
1987). As an example, the transition from problem can provide a historical autobiography of their drug
substance use to nonuse may be viewed metaphori- or alcohol use. This autobiography should include
cally as a journey. Three main phases are involved: descriptions of alcohol or substance use in their fami-
preparation, departure, and taking the journey itself. lies of origin and the reasons for initiating substance
Different strategies are employed during each phase use, along with the feelings, experiences, and persons
of this journey. associated with use. Clients are also encouraged to
write a description of themselves as a nonuser or as
a moderate drinker or nondrinker. To this end, cli-
Preparing for the Journey
ents may benefit from imagery and covert-modeling
Strategies related to preparation for the journey are techniques geared to the development a new self-
utilized with those who have not yet embarked on a image.
behavior change process. These techniques are de- A person who is very motivated to change an ad-
signed to assess motivation, commitment, and self- dictive behavior but who believes that he or she lacks
efficacy for change. Initial motivation should be as- the skills and abilities to carry this out may experi-
sessed early in the process and enhanced if necessary ence low self-efficacy, often in response to previous
to ensure adequate strength of motivation to affect quit or moderation attempts that failed. For success-
successful behavior change. ful habit change in the addictions domain, efficacy
Those considering a behavior change (for addic- can best be evaluated by assessing the client's degree
tive or other behaviors) often have ambivalent feel- of confidence and skill level in successfully manag-
ings about quitting (as well as continuing) the prob- ing not to lapse in a variety of risky situations. The
lematic behavior. To address this ambivalence, the Siruational Confidence Questionnaire (SCQ-39; An-
decision matrix exercise (Marlatt & Gordon, 1985) is nis & Graham, 1988) provides such an assessment
designed to lead a client through a discussion of the for alcohol use, and the Substance Abuse Relapse
376 TREATMENT

Immediate Consequences Delayed Consequences

Positive Negative Positive Negative

To Stop/ Spouse/family & Denial of gratification Improved health Denial of gratification

Moderate employer approval Disapproval from Improved associated with
Drinking Financial gain drinking buddies relationships with drinking
Enhanced self- Self-consciousness family
efficacy when others are Financial gain
drinking Enhanced self-control
Withdrawal discomfort and self-esteem
Increased irritability or Increased career
boredom potential

To Continue Immediate Low self-control and Continued Increased health risks

Drinking gratification self-esteem gratification Job/financial loss
Withdrawal discomfort Negative physical Decreased self-
Maintain self-image effects control and self-
and status with Family tension esteem
drinking buddies Social disapproval Family disapproval
Financial loss

FIGURE 20.2 Decision matrix for alcohol moderation/cessation.

Assessment (SARA; Schoenfeld, Peters, & Dolente, facilitated by emphasizing that clients are capable of
1993) is used for alcohol and other substances. The successful behavior change.
SCQ-39 assesses strategies that a client would em- Before embarking on the behavior change jour-
ploy in high-risk situations and ratings of confidence ney, clients are encouraged to self-monitor their
in executing coping behaviors. The SARA can be drinking or drug-taking behavior. Clients may be
used to assess coping skills and situations likely to asked to keep a log of all aspects of their current
lead to relapse based on a client's substance use be- drug-taking episodes, including type and quantity
havior chain. Both measures can be used to identify consumed, time of day, where they were and with
situations in which self-efficacy is low and areas whom, and their mood state. Any positive or negative
where skills training is needed. Prior to the initiation experiences associated with the episode are recorded
of behavior change, skills can be taught that enhance in this self-monitoring log. This log enables thera-
efficacy for change. pists and clients to identify the functional role of sub-
There are several general strategies used within stance use as well as triggers (moods, persons, or
the RP framework. First, clients are treated as con- places) which may present the highest risk for re-
sulting partners, rather than as patients in a "one- sumed use. In addition, a more comprehensive as-
down" role, and are encouraged to assume shared sessment of drug use situations may be beneficial to
responsibility for treatment and more objectivity re- develop safer navigational routes for the impending
garding the substance problem. Meetings with the journey. The Inventory of Drinking Situations (IDS;
therapist are presented as opportunities to engage in a Annis, 1982) provides such an assessment for drink-
productive and objective discovery process rather than ers by self-report of the frequency with which the cli-
as a confessional session. Second, goal setting, which ent drank heavily over the past year in various situa-
breaks longer term objectives down to a schedule of tions. The IDS was derived from Marlatt's taxonomy
realistic subgoals, also enhances client self-efficacy. of relapse situations (Marlatt & Gordon, 1980, 1985).
Third, role-playing tasks are used to practice newly ac- Contexts involving higher frequency of heavy use in
quired coping skills. Fourth, change in self-image is the past may be presumed to present the highest risk
 RELAPSE PREVENTION: MAINTENANCE OF CHANGE AFTER INITIAL TREATMENT 377

for future drinking. Assessment of relapse fantasies lenging situations include the following: coping with
may also provide clues regarding potential risks. temptation to use; coping with initial use of the sub-
stance (or transgression of moderation goal); the ab-
stinence (or goal) violation effect; and ineffective de-
Departure
cision making.
In the behavior change process, the quit date or the The first few days of behavior change are particu-
day starting treatment may be viewed as a departure larly risky in terms of giving in to cravings or urges to
day. Many procedures can be used to help initiate resume substance use. Cravings often are mediated
cessation, or change, but the RP model favors those cognitively by the subjective value or importance of
that encourage personal responsibility and self- the immediate positive effects one expects from en-
agency. The choice of how to stop, whether gradual gaging in the addictive behavior. An urge represents
reduction, detoxification, or abrupt "cold turkey," is an intention to engage in a behavior to gratify or sat-
made by considering clients' beliefs about what will isfy craving. Thus, both urges and cravings are medi-
be best given their unique situations. Pros and cons ated by positive outcome expectancies for the immedi-
of each method should be discussed with clients be- ate effects of the substance or the benefits anticipated
fore decisions are made. Clients are encouraged to from indulgence in the drug-taking behavior. These
set a "date of departure" for their journey or quit outcome expectancies develop from several potential
date. This date should be carefully chosen so as to sources: (a) classical conditioning, in which drug
not coincide with stressful life events (stormy weath- cues serve as conditioned stimuli for a conditioned
er) and to allow adequate time for preparation, in- craving response; (b) exposure to high-risk situations
cluding the enlistment of social support and acquisi- coupled with low self-efficacy for coping; (c) physical
tion of skills needed for the journey. Adjustments to dependence or withdrawal; (d) personal and cultural
the environment through stimulus control procedures beliefs about expected effects of substance or behav-
to remove cues associated with prior maladaptive ior; and (e) environmental settings where consump-
substance use (e.g., discarding drug use parapherna- tion takes place (Marlatt, 1985a).
lia) are necessary for a successful launching. In addi- Because positive outcome expectancies for the ef-
tion, planning substitute activities and stocking up on fects of a substance may play an influential role in
nonharmful substances may facilitate the departure. the relapse process, these expectancies should be as-
A well-plotted course is a key feature of a successful sessed early in treatment. Individuals may have come
journey. The moment of departure may be marked to rely on a substance to modulate mood or behavior
by an individualized departure ceremony in recogni- due to their beliefs about the effects of that sub-
tion of the commitment made and the destination of stance. For example, a person who drinks to become
a healthier lifestyle. less anxious in social situations may experience the
need to use alcohol in a variety of situations that
evoke social anxiety. Reliance on a substance due to
The Journey
beliefs about the effects of the substance (rather than
Despite a well-chosen course and fair weather upon the actual pharmacological effects) is closely related
departure, events occur once en route which can to psychological dependency. Positive and negative
challenge the less seasoned traveler. The prepared outcome expectancies regarding both continuation
traveler is informed about the possibility of inclem- and cessation of substance use should be assessed.
ent weather, engine problems, or flat tires (i.e., possi- This information may help a client identify reasons
ble lapses en route) and other navigational chal- for substance use. For some clients, a relationship
lenges and must plan accordingly. Even the most between psychiatric symptoms and substance use
well-prepared individual is likely to encounter diffi- may become apparent.
cult situations once behavior change is initiated. Re- Measures to explore clients' substance-related ex-
lapse rates are particularly high during the first 3 pectancies include the Comprehensive Effects of Al-
months of behavior change. For this reason, clients cohol scale (CEOA; Fromme, Stroot, & Kaplan,
need to be warned about the importance of remain- 1993), the Effects of Drinking Alcohol scale (EDA;
ing vigilant and equipped for this possibility. Chal- Leigh, 1987, 1989), the Alcohol Effects Question-
378 TREATMENT

naire (AEQ; Rohsenow, 1983), the AEQ-3 (George inal goal, making an immediate recovery plan, and
et al., 1995), and the Alcohol Expectancy Question- reviewing the events leading up to the lapse, an indi-
naire (Brown, Christiansen, & Goldman, 1987) for vidual is in a position to learn valuable information
alcohol-related expectancies. Fewer measures exist about his or her high-risk situations and potential ar-
for assessing expectancies for other drugs; however, a eas for learning effective coping strategies.
section of the SARA (Schoenfeld et al., 1993) can be Feelings of guilt and attributions of self-blame or
used to assess prominent emotions anticipated after uncontrollability for a lapse are characteristics of the
substance use (see also chapter 11 in this volume). abstinence violation effect (AVE) described earlier.
To counter urges and cravings, the therapist edu- This reaction, though normal, is likely to occur when
cates the client about the immediate and longer term one has previously made a strong commitment to a
effects of engaging in the addictive behavior. Many goal of abstinence and has experienced a slip or
individuals perceive their cravings to be physiologi- lapse. The magnitude of the reaction is related to
cally based. Urges and cravings can be reframed as several factors, including the strength of the prior
a cognition-based desire for immediate gratification, commitment and the amount of time or effort in-
rather than a biological need. Clients are then en- vested in the goal. The stronger the magnitude of
couraged to pursue healthier means of gratification the AVE, the greater the likelihood of exacerbation
(e.g., exercise or massage) to assuage their urges. In following an initial lapse (Curry, Marlatt, & Gordon,
addition, clients are instructed to externalize their 1987; Marlatt, 1985a).
urges to use ("I am experiencing a craving for a Several strategies can assist a client who is strug-
drink") rather than to identify with them ("I need a gling with the cognitive affective aftermath of a lapse.
drink"). Development of a sense of detachment from At the earliest opportunity, the lapse should be de-
cravings allows a client to more objectively observe briefed with the therapist through an in-depth explo-
this process and invoke the use of cognitive and be- ration of the lapse situation. The lapse can be re-
havioral coping strategies. For a client who believes framed as a mistake, a valuable learning opportunity
that the strength of cravings will continue to increase rather than a failure experience. Attributions and
over time until he or she succumbs to them, a thera- cognitive distortions (such as catastrophizing) related
pist can point out that over time, cravings, like an to the lapse are assessed. If necessary, the therapist
ocean wave, will build in intensity, peak, and eventu- gently challenges these attributions and distortions.
ally subside. The client's challenge, therefore, is to The lapse can be reattributed to the riskiness of the
learn to ride out these waves of craving without "wip- situation (rather than client self-attribution of blame),
ing out." This is a technique metaphorically de- and to inadequate coping ability rather than to inad-
scribed as urge surfing (Marlatt, 1985a, 1994). equate effort. Clients experiencing a lapse should be
encouraged to renew their commitment and motiva-
tion to the target goal. These techniques increase the
Dealing with a Lapse
likelihood of successfully coming away from a lapse
The second navigational challenge is responding to experience without risk of exacerbation to a relapse.
and coping with lapses. Coping with lapses has both In some cases, so much is learned from a lapse expe-
behavioral and cognitive affective elements. On the rience that the individual ends up ahead in overall
behavioral end, clients develop a specific, pre- improvement; this type of lapse can be viewed as a
planned course of action to follow in the event of "prolapse."
substance use. This can be outlined on a reminder Many times, the events leading up to a lapse are
card to be carried with the individual at all times and preventable. After a lapse, a therapist helps the client
includes coping strategies such as leaving the area, process the events leading up to and including the
engaging in an alternative activity, or asking for help decision to use. A microanalysis of these events some-
from others in a crisis situation. An individual who times reveals "minidecisions" leading up to the lapse
has just lapsed should be encouraged to remain calm episode. These "minidecisions" are often discounted
and not give in to feelings of guilt or self-blame for by the individual during the actual course of events
the incident. Such feelings are framed as a normal leading up to a lapse. In a retrospective analysis of
reaction to lapse, to avoid the escalation of the sub- these decisions, however, a covert planning process
stance use. By renewing the commitment to the orig- leads to a "setup" for lapsing. These minidecisions,
 RELAPSE PREVENTION: MAINTENANCE OF CHANGE AFTER INITIAL TREATMENT 379

or seemingly irrelevant decisions (SIDs), set the stage the wayside as their substance-related activities in-
for a lapse by placing the individual in a high-risk creased. For others, recreational activities have be-
situation. An example would be the case of an alco- come strongly associated with use of the problem
holic in abstinence-based treatment who "decides" to substance. Activities such as physical exercise and
go to a bar "just to visit his old friends and watch meditation can help restore balance and have been
TV," and ends up giving in to social pressure to associated with reductions of addictive behaviors
drink. The lapse which results appears to be justified (Murphy, Pagano, & Marlatt, 1986). These activities
to both the individual and others, which serves to may decrease a client's perception of self-deprivation
minimize the personal responsibility an individual and need for self-indulgence.
will decide to accept responsibility for the lapse. To
avoid this, RP therapists encourage clients to explore
the earliest decisions leading off course to teach bet- ASSESSMENT PROCEDURES
ter decision making and recognition of some deci-
sions as "red-flagged" choice points for relapse (Mar- Throughout the discussion of RP techniques, we
latt, 1985a). have referred to various instruments that are utilized
in treatment-related assessment. In this section, we
will focus on initial assessment of the client. During
Lifestyle Balance
the first session, an overview of the RP approach is
Decisions which lead one to be dangerously close to provided by the therapist, and a history of the prob-
the precipice of a lapse are more likely to occur lem behavior is solicited. A detailed assessment of
when the one's lifestyle is unbalanced. A balanced substance use and substance-related risk behaviors is
lifestyle is one in which an individual's daily activities conducted. Initial use and last period of use are ob-
contain a sufficient pattern of enjoyable activities tained, including the typical quantity and frequency
and coping resources to balance out the impact of and pattern of use, the route of administration (oral,
daily and ongoing life stressors. When stressors out- smoked, inhaled, or injected), the length of the typi-
weigh one's coping resources, one may rely on and cal run, and the largest amount of the substance
justify the addictive behavior as an attempt to restore taken in the recent past. Symptoms of physical de-
some (temporary) sense of balance (e.g., "I deserve pendence should also be assessed. If an individual
to get high after the day I've had"). To the extent is moderately to severely physically dependent on a
that clients are unaware of other outlets for stress re- substance, a monitored detoxification may be in
duction, they are more likely to resume the addictive order.
behavior. Information about past use of a substance also
Helping a client to achieve a balanced lifestyle is provides valuable information to guide treatment. A
an important component of RP. A balanced lifestyle client is asked about the heaviest period of use, the
is one in which external demands and activities (the quantity and frequency of use during that time, and
shoulds) do not outweigh the activities which bring the longest period of abstinence from each problem
self-fulfillment and pleasure (the wants) (Marlatt, substance. A treatment history should also be ob-
1985b). To determine the degree of lifestyle imbal- tained, including aspects of previous treatment the
ance, several assessment techniques are available. client found to be most and least useful. A detailed
The Life Experiences Survey (Sarason, Johnson, & assessment of consequences and risk behaviors is also
Siegel, 1978) assesses major life events. In addition, conducted. This assessment covers interpersonal, oc-
an assessment of typical workday and weekend activi- cupational and/or academic, legal, financial, and
ties can be conducted with a client's rating of where health-related risks and consequences and those re-
along a "want-should" continuum an activity falls. lated to the general psychological well-being of the
The Daily Want-Should Tally Form (Marlatt, 1985b) client. An assessment of motivation and commitment
is one format for such an assessment which also in- to change and substance-related outcome expectan-
cludes an assessment of daily satisfaction. cies is conducted, utilizing some of the techniques
As an assessment of pleasurable daily events, discussed previously (e.g., decision matrix, autobiog-
clients can be asked about their leisure time activi- raphy). Other psychiatric symptomatology is also as-
ties. Many clients have cast recreational activities by sessed, as many individuals struggling with substance
380 TREATMENT

abuse are also comorbid for other psychiatric disor- substance use, as well as positive and negative conse-
ders. Treatment within the RP model may be tai- quences associated with this use. Supervision from a
lored to the unique needs of dually diagnosed cli- colleague who is proficient with these strategies will
ents. be invaluable for therapists beginning to incorporate
these techniques into their clinical repertoire.
As described previously, the therapist adopts a col-
TYPICAL TREATMENT GOALS legial stance with respect to the client. This is in con-
trast to a "top-down" doctor-patient relationship, in
According to the RP model, the client chooses which a client is less likely to accept personal respon-
whether to pursue a goal of abstinence or modera- sibility for treatment and expects treatment to be ad-
tion. The therapist can offer guidance as this de- ministered by the "expert" to a passive "patient." A
cision is made and recommend abstinence if the collegial relationship allows both client and therapist
client's situation contraindicates any alcohol or sub- to observe the change process from an objective per-
stance use. Although an abstinence goal may be spective and allows both to analyze client data with
more appropriate for a particular client, if the client some detachment.
is unwilling to commit to abstinence but is willing
to work toward moderation, then this decision should
be honored by the therapist. From a harm reduction
COMMON OBSTACLES TO
perspective (Marlatt, 1998; Marlatt & Tapert, 1993),
SUCCESSFUL TREATMENT
reductions from abusive to moderated use of a sub-
stance are steps in a more healthful direction and
There are several obstacles to successful treatment.
should be reinforced by the therapist. The choice of
One of the most common is that a client who has
treatment goal can be revisited during the course of
lapsed may experience so much shame associated
therapy, since clients experiencing setbacks while
with the abstinence violation effect that he or she
pursuing a moderation goal may decide that absti-
may not return for the next session. In this case, the
nence might be more easily attained. It is interesting
therapist is encouraged to take an active role in pur-
that in one treatment outcome study, about a quarter
suing the client in order to normalize the client's
of the clients were found to be continuously absti-
emotional reaction to the lapse and to assist the cli-
nent for 12 months despite receiving treatment
ent in getting back on track toward the goal.
which was oriented toward drinking moderation
Other barriers to successful treatment include
(Miller, Leckman, Delaney, & Tinkcom, 1992).
ambivalence and environmental stressors. Motiva-
tional ambivalence may be managed by a review
of a client's original decision matrix, which serves as
THE ROLE, TRAINING, AND
a reminder of the reasons for pursuing behavior
STANCE OF THE THERAPIST
change and increases motivation for change. Unfore-
seen environmental stressors leading to lapses may
Training in the RP model varies from reading clini-
also threaten treatment success.
cal literature, to workshop attendance, to participa-
tion in certification programs. In addition to a solid
background in mental health and in the physiologi-
cal processes and biochemical effects of substance CHARACTERISTICS OF CLIENTS MOST
use, a strong foundation in behavioral theory and LIKELY TO RESPOND TO THE MODEL
clinical supervision is recommended for those who
wish to incorporate RP strategies into their clinical Controlled clinical trials of the RP model reviewed
work. by Carroll (1996) have shown the relative effective-
Firm grounding in behavior theory and behavior ness of RP over more insight-oriented or interper-
therapy best enables a counselor or therapist to assist sonal forms of therapy for individuals who were
a client in evaluating emotional states and situations greater in global psychopathology or sociopathy or
which are likely to lead to or maintain maladaptive who had a higher level of severity of substance use.
 RELAPSE PREVENTION: MAINTENANCE OF CHANGE AFTER INITIAL TREATMENT 381

RP has not been shown to be contraindicated for Twenty-four studies were reviewed which met these
any specific client group. However, as with other criteria. Of these, 12 were based on smoking cessa-
forms of therapy, individuals who have cognitive im- tion, 6 on treatment for alcohol problems, 1 on mari-
pairments may require adaptation of RP strategies to juana, 3 on cocaine, and 2 on treatment for other
facilitate therapeutic change. substances.
When compared to no-treatment control groups,
RP-based treatments fared positively at both posttreat-
EMPIRICAL DATA ON THE ment and follow-up periods of up to 1 year. Relative
EFFECTIVENESS OF THE RP MODEL to minimal treatment controls (including attention
controls and standard treatment), only half of the RP
treatments were shown to be significantly more effec-
Evaluation of Marlatt's Relapse Taxonomy
tive in the immediate posttreatment period. How-
An evaluation of the reliability and predictive validity ever, for studies which included longer research
of Marlatt's relapse taxonomy was conducted by the follow-up evaluations, RP generally fared more posi-
Relapse Replication and Extension Project (RREP; tively, as evidenced by such outcomes as lower re-
Allen et al., 1996). This project involved research lapse rates and continued improvement over time
teams at three sites and evaluated relapse precipitants relative to minimal treatment controls. This "delayed
utilizing both prospective and retrospective indices. emergent effect" (Carroll, 1996) is consistent with
The results of the RREP provided moderate support learning theory upon which RP strategies are based,
for the reliability of Marlatt's relapse category taxon- where improvement may reflect acquisition of and
omy (Longabaugh, Rubin, Stout, Zywiak, & Low- greater facility with coping skills over time. RP was
man, 1996). The taxonomy was most reliable for the comparable to alternative psychotherapies (e.g., in-
classification of negative emotional states, testing per- terpersonal psychotherapy and a 12-step recovery
sonal control, negative physical states, and social support group) at both posttreatment and follow-up
pressure. Categories which were less reliably classi- (Carroll, 1996). However, interaction effects favoring
fied included interpersonal conflict, both intraindi- RP for more severely impaired clientele were ob-
vidual and interpersonal enhancement of positive served. Participants who had greater psychopathol-
emotional states, and urges and temptations. The re- ogy, sociopathy, or severity of substance use tended
lapse taxonomy provided limited predictive validity to fare better when treated with RP. There were no
when utilized to predict first episode of heavy drink- differential treatment effects for those lower in im-
ing (drinking to a blood alcohol level of 0.10 ml/ pairment in these domains.
dl) from clients' retrospective reports of pretreatment Thus, the literature demonstrates treatment effec-
relapse episodes (Stout, Longabaugh, & Rubin, tiveness of RP when compared to no treatment, simi-
1996). This is not surprising if relapse is to be viewed lar short-term but greater long-term improvement
not as a static but as a dynamic process (Marlatt, when compared to minimal treatments indicating an
1994). In general, the research literature is useful for emergent treatment effect, and comparable effective-
the identification of distal determinants of relapse ness to alternative therapies for those at a lower level
which the skillful clinician should bear in mind. of impairment. More severely impaired substance
abusers may differentially benefit from RP over alter-
native therapeutic approaches.
Evaluation of the RP Model
A recent controlled clinical trial evaluated the ef-
Carroll conducted a review of controlled clinical tri- fectiveness of RP compared with discussion-only and
als of Marlatt and Gordon's (1985) RP Model (Car- no-additional-treatment control groups for a sample
roll, 1996). Only studies were reviewed which re- of 60 severely alcohol dependent men (Allsop, Saun-
ported substance use as a primary outcome variable ders, Phillips, & Carr, 1997). Those receiving the RP
and which specifically evaluated the effectiveness treatment had greater increases in pre- and posttreat-
of RP as either the primary form or a component ment self-efficacy relative to the discussion-only con-
of substance abuse treatment relative to no treat- trol group. Those receiving RP also had a signifi-
ment, minimal treatment, or alternative treatments. cantly higher probability of total abstinence and a
382 TREATMENT

longer survival time to initial lapse than both control ed by treatment providers, perhaps due to its intuitive
groups. These effects were significant at 6 months appeal. More research is needed to further refine the
posttreatment, but the effects diminished by 12 RP model and its clinical applications.
months posttreatment.
Key References
Strengths and Weaknesses of the RP Model Dimeff, L. A, & Marlatt, G. A. (1995). Relapse preven-
for Treatment of Substance Abuse tion. In R. K. Hester & W. R. Miller (Eds.), Hand-
book of alcoholism treatment approaches: Effective al-
A great strength of the RP model is its intuitive ap-
ternatives (2nd ed., pp. 176-194). Boston: Allyn &
peal to therapists and clients. The model has been
Bacon.
widely adopted by practictioners working with sub- Marlatt, G. A, & Gordon, J. R. (Eds.). (1985). Relapse
stance abusers, and adaptations have been made to prevention: Maintenance strategies in the treatment
this model for different clinical problems. As the sub- of addictive behaviors. New York: Guilford Press.
stance abuse treatment field is continuously evolving, Wilson, P. H. (Ed.). (1992). Principles and practice of
controlled clinical trials may lead to refinement of relapse prevention. New York: Guilford Press.
the model and greater emphasis on one or more
components for successful treatment outcome.
References

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Andrews, G. (1992). Stuttering. In P. H. Wilson (Ed.),
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Principles and practice of relapse prevention (pp.
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draws upon cognitive and behavioral treatment ap- Annis, H. M., & Graham, J. M. (1988). Situational Con-
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Strategies for lifestyle balance are also viewed as key 483-491.
Brown, T. A, & Barlow, D. H. (1992). Panic disorder
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and panic disorder with agoraphobia. In P. H. Wil-
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can help a client to identify situational challenges tion (pp. 191-212). New York: Guilford Press.
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Leigh, B. C. (1987). Beliefs about the effects of alcohol relapse: Implications for the maintenance of behav-
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 21

Treatment of Drug and Alcohol

Abuse: An Overview of Major
Strategies and Effectiveness

John P. Allen
Raye Z. Litten

The chapters in this section of the text describe sev- dence is largely congruent with tenets of Alcoholics
eral approaches to the treatment of substance abuse Anonymous (AA) itself, other AA-based peer support
problems. While these strategies differ significantly groups, and the so-called Minnesota model.
from each other, nevertheless, each has demon- A key aspect of the disease model is the notion
strated efficacy. In this overview chapter we will that dependence is progressive. Based on retrospec-
briefly summarize key information from the chap- tive accounts of AA members, Jellinek, an early alco-
ters. With the exception of the section dealing with holism researcher, identified four stages in its devel-
medications, references will not be provided here opment. In the symptomatic phase, there is an
since the citations are given in full in the underlying increase in tolerance and drinking to relieve tension.
text chapters. The prodromal phase is characterized by drinking
with greater frequency and quantity. "Blackouts" are
the hallmark feature of the prodromal stage. The cru-
THE DISEASE MODEL STRATEGY cial phase is marked by loss of control and recurrent
efforts both to limit drinking and to rationalize it
Of the approaches presented, the oldest is the disease when it occurs. At this point, the alcoholic's lifestyle
model. It conceptualizes alcohol and drug depen- centers on alcohol consumption. The chronic phase
dence as chronic physical illnesses. Dependence is includes prolonged periods of intoxication, deteriora-
viewed not as symptomatic of another psychiatric tion in behavioral and ethical functioning, and sub-
condition but as a primary problem with biological, stantial physical and cognitive loss.
emotional, and spiritual underpinnings and present- A key feature of the disease model, and one
ing features. This theorization of substance depen- which distinguishes it from more contemporary ap-

385
386 TREATMENT

preaches, is its emphasis on "denial." The alcoholic philosophy and content and to assist individuals suf-
is believed to have an elaborate system of personality fering drug problems. A number of other 12-step pro-
defenses against acknowledgment of the severity and grams have also arisen that focus on the unique
consequences of drinking. Denial of the problem needs of particular kinds of clients, such as those
makes self-motivated change difficult. A major goal sharing common religious or philosophical beliefs.
of treatment, therefore, is to reduce denial and resis- So, too, a variety of types of family member support
tance to change. groups have developed, often incorporating a philos-
Because dependence is viewed as such a perva- ophy similar to that of AA. Finally, the 12-step philos-
sive phenomenon, treatment must be comprehensive ophy has inspired other types of programs dealing
and directed toward fundamental change in biologi- with nonsubstance abuse but addictionlike problems.
cal, interpersonal, emotional, and spiritual function- While AA, NA, and several related programs are spir-
ing. In fact, a multidisciplinary team is needed since itual in nature, "secular" self-help programs also ex-
major change must occur in very different spheres of ist. These include Women for Sobriety, Secular Or-
life functioning. In addition to ensuring the safety of ganizations for Sobriety, S.M.A.R.T. Recovery, and
the withdrawal process, physicians and nurses address Rational Recovery.
physical pathology that may have been prompted by Nowinski's chapter discusses how therapists can
or ignored during the period of heavy drinking. integrate peer support groups into formal treatment.
Comprehensive psychological assessment identifies This seems to be a rather original topic in the litera-
patient traits and characteristics relevant to response ture since at least in some instances in the past, rela-
to treatment. Since spirituality is posited as an im- tions between professionals and peer support groups
portant feature of the disease, chaplains also play a have been characterized by distrust. To actively facil-
salient role in treatment. They assist the patient in itate client participation in a self-help group requires
examining value systems, coping with guilt, and deal- that the therapist have a solid grasp of the philoso-
ing with loss. Finally, counselors, often recovering phy, goals, and nature of the self-help program and
people themselves, play a key role in treatment plan- expend time and effort guiding the client toward
ning in treatment. involvement in it. In particular, consistency across
While there has been little research on efficacy the client's, therapist's, and group's views on absti-
of treatments based on the disease model, it is very nence versus moderation as the goal of treatment is
likely the most common approach assumed by treat- important. Often, the self-help group and the thera-
ment facilities in the United States. There appear pist espouse total abstinence. If the client feels that
to be several reasons. The approach is quite com- moderation is an appropriate goal, the therapist might
prehensive and has inherent appeal to recovering al- review previous attempts at moderation and evaluate
coholics and staff with medical backgrounds who how successful they have been.
conceptualize behavioral phenomena in disease con- The therapist should also be aware of the "steps,"
structs. The model is older than most others. Also, or sequential tasks, of the self-help program. Using
the disease model has incorporated many of the AA as his primary example, Nowinski reviews the first
treatment techniques developed by newer, learning- three steps and discusses in some detail how the ther-
theory-based strategies. Unfortunately, this approach apist can reinforce progress in achieving them.
tends to be quite labor-intensive and costly. Research While he recommends that the therapist facilitate
on its efficacy is clearly warranted. the client's involvement in the first three steps of AA,
Nowinski suggests that the sponsor, a more experi-
enced AA member chosen by the client to serve as
PEER SUPPORT GROUPS his or her personal AA resource and experiential
mentor, assist in achieving the other nine steps.
AA is the largest and most widely known self-help The therapist can also perform a variety of activi-
group for treating persons with alcohol or, for that ties to encourage the client to "bond" with the self-
matter, other behavioral problems. Approximately help group. These include fostering involvement by
3% of the adult population of the United States has reducing worries or shame over participation and by
at some time attended an AA meeting, and half of describing in advance the format of sessions or, in
these have attended during the past year. Narcotics the case of AA, explaining the different types of ses-
Anonymous (NA) was established to parallel AA in sions, such as speaker meetings, step meetings, and
 OVERVIEW OF MAJOR STRATEGIES AND EFFECTIVENESS 387

discussion meetings. The therapist can also reduce "readiness" to change by assessing their standing in
anxiety by strategies such as encouragement, practi- five putative stages in the change process. The stages
cal suggestions, and role play of basic participation range from precontemplation, in which the patient
skills surrounding meeting activities, such as how to is unconcerned about the problem, through stages
introduce oneself. Helping the patient become inte- dealing with active consideration of the problem and
grated with the self-help group may also take the needs for action to resolve it, concrete corrective ac-
form of helping him or her to identify with other tions, and sustenance of efforts to keep the problem
participants and begin networking with them outside at bay.
sessions. These strategies should facilitate establish- A third technique for assessing motivation is the
ment of a positive peer group, aid the patient in se- psychometric instrument Stages of Change Readi-
lecting and working with a sponsor, and reinforce ac- ness and Treatment Eagerness Scale (SOCRATES),
ceptance of various group customs and traditions of the content of which differs from that of URICA by
the group. being specific to substance abuse. It assesses three
In particular, AA has proved quite popular in the motivational vectors: recognition of the problem, am-
United States, and results from Project MATCH sug- bivalence, and taking steps toward change.
gest that attendance at AA, and more especially per- Rollnick and his colleagues have also developed
sonal involvement in the program, is associated with a "Readiness Ruler," a visual-analogue, continuous
more favorable treatment outcome, regardless of the scale that allows patients to indicate on a line their
formal treatment to which the patient was assigned. degree of motivation from 1 (not ready to change) to
Nevertheless, a causal link between AA and favorable 10 (trying to change).
treatment outcome has yet to be established. One One of the most encouraging developments in
would also hope that alternative peer support groups treatment of alcoholism has been recognition that
would propagate to assist recovering alcoholics who even fairly brief interventions varying, from as short
do not readily affiliate with AA or ascribe to its tenets. as 5 minutes to four sessions, can result in substantial
change for at least "at-risk," early-stage problem
drinkers. Granted the low cost of brief intervention,
ENHANCING TREATMENT its effectiveness, and the high prevalence of alcohol
MOTIVATION abuse as a public health problem, greater attention
should be given to incorporating brief intervention
One of the strongest predictors of days of abstinence into general medical practice.
and reduction of level of alcohol consumption on Miller and his colleagues have argued that there
days when Project MATCH outpatients did drink are six elements which underlie the effectiveness of
was motivation, and indeed, substance abuse treat- these interventions and even apparently of more ex-
ment counselors seem to ascribe success of patients tended treatments.
in treatment to motivational factors. In their chapter, The chapter concludes by offering additional rec-
Yahne and Miller discuss several procedures for as- ommendations for the therapeutic style that a coun-
sessing motivation, suggest strategies for enhancing selor should adopt in interviewing patients. These
motivation, and allude to its role in brief intervention include expressing empathy and listening in a reflec-
for alcohol problems. tive, nonjudgmental way; helping the patient be-
Four procedures for evaluating motivation are de- come more aware of the discrepancy between ad-
scribed. The "decisional balance" approach involves dictive behavior and personal goals and values;
asking patients to list the advantages (benefits) of sub- avoidance of argumentation; encouraging adoption
stance abuse for them in one column on a piece of of new perspectives; and reinforcing the patient's be-
paper and the disadvantages (costs) in an adjoining lief that he or she is capable of changing.
column. The authors note that this exercise may it-
self influence motivational factors and serve as a ba-
sis for direct discussion with the patient. BEHAVIORAL AND COGNITIVE
Second, a standardized instrument, such as the BEHAVIORAL TREATMENTS
University of Rhode Island Change Assessment
(URICA), may be used. Subscale scores on the Strategies for effecting behavioral change based on
URICA help the counselor determine patients' learning theory are employed for treating a host of
388 TREATMENT

psychological problems including substance abuse. URICA and the SOCRATES are recommended for
Fundamental learning principles allow for initiation this.
and regulation not only of overt behaviors, such as Several features characterize behavioral and cog-
taking illicit drugs or drinking excessively, but also of nitive behavioral therapies. In that patients may be
covert behaviors such as the urge to drink and cogni- "at-risk" drinkers rather than physically dependent on
tive expectancies that use of alcohol and drugs will alcohol, moderation may be the goal of treatment.
lead to positive consequences such as pleasure, relief Nevertheless, with illicit drugs, abstinence is more
of tension, enhanced mood, and so on. commonly the measure of success. The goals of this
Specific interventions derive from various behav- family of interventions tend to be quite specific and
ioral theories, most notably classical conditioning, may include attendance at treatment sessions, com-
operant conditioning, modeling, and social learning pletion of extratherapy assignments, or reduced use.
theory. Cue exposure, for example, is an extension Unlike disease model approaches, behavioral in-
of classical conditioning since it instantiates an ex- terventions are generally brief and targeted. Treat-
tinction paradigm in which the patient is presented ment is typically conducted in weekly outpatient ses-
with conditioned stimuli of substance use without sions. The first third of the hour therapy session
pairing to unconditioned stimuli. In time, the condi- reviews recent substance use and overall functioning.
tioned response of craving and its biological corre- The second third is typically didactic and includes
lates diminishes. To the extent that craving may lead skills training and practice. The final third is devoted
to actual use of the substance, its diminution should to planning for the week ahead and discussing how
assist in maintaining abstinence. the new skills will be implemented.
A variety of contingency management approaches Carroll then describes several major learning-
have been employed in treatment of drug and alco- based types of treatment and discusses the nature of
hol abuse. These strategies involve providing positive their active components (i.e., the specific factors
reinforcers for nonuse or punishments for use. Imita- which elicit desired positive change). She concludes
tion and practice of drink refusal skills represent an her chapter by presenting results of several controlled
application of Bandura's theory of behavioral mod- clinical trials of treatment efficacy.
eling.
More recent approaches include helping the pa-
tient to manage moods or change cognitions that FAMILY MODELS OF TREATMENT
might lead to substance abuse.
In her chapter, Carroll also emphasizes the key For the most part, O'Farrell and Fals-Stewart orga-
role of functional analysis in developing a treatment nize their presentation on family treatments for sub-
plan. The therapist must understand the full topogra- stance abuse around three major models.
phy of the problem before developing a strategy to The "family disease model" views substance
remediate it. This includes identification of the stim- abuse as an illness suffered by family members as
uli for, conditions for, and consequences of use, as well as by the index case. In its philosophy of sub-
well as features of the patient's social, emotional, stance abuse, Al-Anon typifies the family disease
cognitive, and physical environment that bear on model. Codependence is a major construct of this
use. view. Codependence is believed to parallel substance
Beyond clinical interview, several standardized dependence as a disease and refers to family reac-
instruments may assist in the functional analysis. tions to substance abuse. These may include control
These include the Time-Line Follow Back, Drinker issues, external referencing, fear, and emotional
Inventory of Consequences, Cocaine Craving Ques- blunting. Codependence often includes "enabling,"
tionnaire, and Cocaine Relapse Interview. the constellation of behaviors by significant others
In addition to determining the pattern of abuse that, often unwillingly, reinforce abuse. Enabling in-
and the stimuli that elicit and reinforce it, it is ex- volves shielding the client from the natural negative
tremely important that the therapist delineate the pa- consequences of substance abuse that might have de-
tient's deficits and assets in skills to cope with these terred it in the future.
stimuli. Finally, assessment includes determination Under the family disease model, treatment of
of the patient's current motivation to change. The family members is generally conducted separately
 OVERVIEW OF MAJOR STRATEGIES AND EFFECTIVENESS 389

from that of the index patient. The emphasis is on Feedback on results of the assessment procedures
helping them resolve their own problems rather than enhances treatment motivation and allows for devel-
on actively intervening with the abuser. opment of treatment goals.
The "family systems model" assumes a reciprocal Several major strategies of marital family therapy
relationship between the family's functioning and are described. Particular attention is given to behav-
the substance abuse. Substance abuse may distract ioral contracting. Contracts are written and focus on
family members from directly confronting other specific behaviors. Commonly employed are the "so-
problems such as marital discord on leaving home. briety trust contract," involving a daily affirmation by
Curiously, interactional behaviors, such as emotional the patient of the intention to not use alcohol or
expression, may actually improve during periods of drugs that day, as well as including an opportunity to
heavy drinking. resolve family members' concerns over efforts to re-
Therapy entails treating the family as a unit rather frain from use. The contract also provides that this
than focusing on the individual with the abuse prob- will be the only time during which substance abuse
lem. Therapy is designed to redefine roles and per- will be discussed.
sonal boundaries as well as to identify the interplay Disulfiram contracts involve the patient's agree-
between substance abuse and family functioning. ment to take the medication daily in the presence of
"Behavioral models" are the most heavily re- a family member. Other behavioral contracts may fo-
searched of the treatments discussed in the chapter. cus on participation in peer support recovery groups
Such approaches incorporate constructs of learning as well as submission to drug urine screens.
theory. Family interactions are believed to provide A variety of interventions to improve marital and
positive and negative reinforcers for substance abuse. family relationships are described. Patients who may
In some instances, positive interactions may actually be expected to be ideal candidates for marital family
reinforce abuse. McCrady notes, for example, that therapy seem to be better educated, employed, co-
caretaking or attention may reinforce drinking be- habiting, older, and more seriously involved with
haviors. substance abuse. A stable, nonviolent, nonabusing
Behavioral marital therapy emphasizes setting home environment is also believed to have positive
goals related to drinking and modeling more effec- prognostic significance. Patients who are more moti-
tive ways of responding to drinking or modifying the vated to change, often following a recent crisis, are
stimuli that may prompt drinking. It also includes also likely to do better.
training in new ways of interacting and communicat-
ing with each other.
Therapy is usually conducted on an outpatient THERAPEUTIC COMMUNITY
basis in a series of weekly sessions. Assessment proce- TREATMENT
dures precede formal intervention. Initially, a deter-
mination is made about whether the patient requires A very different approach to treatment of substance
detoxification. This is done primarily by evaluating abuse, especially drug abuse, is the therapeutic com-
recent quantity and frequency of alcohol consump- munity. These programs are drug-free and incor-
tion and degree of physical dependence. The Time- porate a social psychological strategy for achieving
Line Follow Back, breath analysis, and drug urine behavior change. While traditionally therapeutic
screening may assist in assessing recent use patterns. communities were stand-alone residential programs
The Drinker Inventory of Consequences and Addic- lasting perhaps up to 2 years, because of funding re-
tion Severity Index may aid in determining severity alities and variations in the clients now served, their
of adverse effects of substance abuse. Earlier attempts application has now extended to a variety of other
at treatment are also reviewed, as well as the extent settings, including outpatient and day treatment cen-
to which the patient and his or her family are moti- ters. Many of these modified therapeutic communi-
vated for achieving goals of moderation or absti- ties are characterized by shorter lengths of stay.
nence. A distinguishing feature of this type of interven-
Quality and stability of family relationship are tion is that the change agent is seen as the commu-
evaluated by use of a large battery of psychometric nity itself rather than a specific person. The social
instruments identified by the authors. environment, as well as peer and staff role models, is
390 TREATMENT

seen as the active component of behavior change. All to complete the full course of treatment. He offers
activities in the therapeutic community are purpos- several possible reasons. Some involve client charac-
ively designed to produce change, and all partici- teristics like low tolerance for structure and inade-
pants in the program are mediators of change. quate motivation. Others involve external factors like
The therapeutic community model envisions sub- familial pressures, staff inadequacies, and funding
stance abuse as a disorder of the whole person rather limitations.
than as simply a dysfunctional habit. While differing While these communities maintain a generally
in peripheral ways such as demographics, all sub- "open-door" policy for admission, patients who seem
stance-dependent patients are believed to reveal an unable to meet the demands of the intensive regi-
arrested state of personal identity not unlike that of men or who would appear to pose a risk to other
adolescents. participants are generally excluded.
Recovery and maintenance of abstinence are seen
as a developmental process to achieve attitudes and
values of "right living," truth, adherence to the work
ethic, accountability, responsibility, self-reliance, and MEDICATIONS
so on.
Recovery proceeds through a series of stages of Over the past decade, research activity on medica-
incremental learning, with each stage building on tions development for alcoholism and drug treatment
the previous one and advancing the client to the goal has burgeoned. The fruits of this effort have been
of recovery. Patient motivation is important, as are particularly recognized by the Food and Drug Ad-
self-help and mutual help. Proponents of the model ministration (FDA) approval of several pharmacolog-
believe that negative behavioral and attitudinal roles ical agents for alcohol, opiate, and nicotine depen-
are best modified by participating in the therapeutic dence.
community as a socially responsible participant. The two most promising agents for treating alco-
Assessment is comprehensive in that it considers hol dependence are naltrexone and acamprosate.
objective behavioral dimensions as well as self-per- Each has now been approved in over 15 countries.
ceptions. Rather than relying on psychometric mea- Naltrexone, an opioid antagonist, was first ap-
sures, assessment is done primarily by peers and staff proved for alcoholism treatment in the United States
on a daily basis and in a variety of settings. in December 1994. This approval was based on re-
Physical features of the therapeutic community sults of two clinical trials (O'Malley et al., 1992; Vol-
are seen as important aids to the change process and picelli, Alterman, Hayashida, & O'Brien, 1992). These
establishment of a sense of commonality with other 3-month studies demonstrated that naltrexone treat-
members. The programs are housed separately from ment leads to reduction in both frequency and
other institutional programs and are given names. amount of drinking by alcoholics. Interestingly, the
Tenets of program philosophy are posted on wall dis- type of psychosocial intervention which it accompan-
play signs. Daily schedules and member status infor- ies seems to influence treatment outcome from nal-
mation are also displayed on cork boards or black- trexone. O'Malley et al. (1992) found that alcoholics
boards. treated with naltrexone and weekly supportive ther-
While the staff includes traditional professionals apy emphasizing abstinence enjoyed a high rate of
(such as physicians and mental health providers), all abstinence, while naltrexone-treated patients receiv-
staff function as members of the community who ing weekly coping-skills/relapse-prevention therapy
serve to facilitate and guide the self-help community achieved lower rates of relapse to heavy drinking if
methods. they did sample alcohol.
The program is highly structured and includes O'Malley et al. (1996) followed the patients after
strong components of work (e.g., facility mainte- naltrexone treatment ceased. Some residual effect of
nance and program management) and education. naltrexone was evident for an additional 4 months.
Confrontive encounter groups are designed to At the end of the 6-month follow-up period, patients
heighten individual awareness of attitudes or behav- treated with naltrexone were found less likely to meet
iors that should be modified. the criteria for alcohol dependence or abuse than
De Leon notes that a majority of admissions fail placebo-treated patients.
 OVERVIEW OF MAJOR STRATEGIES AND EFFECTIVENESS 391

Two studies indicate that patient compliance is A variety of studies have suggested that good com-
essential for naltrexone to be efficacious. Volpicelli pliance improves disulfiram's contribution to treat-
et al. (1997) replicated their earlier naltrexone proj- ment outcome (Allen & Litten, 1992). For example,
ect while employing a more diverse population of Chick et al. (1992) found that when disulfiram in-
alcoholics and utilizing a less intense psychosocial take was observed, patients assigned to the drug expe-
intervention. In contrast to results of their earlier rienced fewer days drinking and consumed less alco-
study, across the board, naltrexone produced only hol than did those on placebo.
modest effects in reducing alcohol consumption. Perhaps most intriguing, preliminary studies have
However, among compliant patients (i.e., those who indicated that patients with concurrent cocaine
took the medication at least 90% of the time), it and alcohol problems reduced both their alcohol
proved far more effective than placebo, reducing the and cocaine intake as a function of disulfiram treat-
number of days drinking (3% versus 11%) and pre- ment (Carroll et al., 1993; Higgins, Budney, Bickel,
venting relapse to heavy drinking (14% versus 52%). Hughes, & Foerg, 1993).
Similarly, Chick et al. (1992; Litten & Fertig, Finally, antidepressant and anxiolytic medications
1996) found that while, in general, 3 months of nal- may be useful in treating alcoholics suffering co-
trexone treatment failed to yield significant differ- morbid depression and anxiety disorders. Mason,
ence from placebo, naltrexone compliance (based on Kocsis, Ritivo, and Cutler (1996) and McGrath et al.
correct pill count on at least 80% of patient return (1996) have reported that the tricyclic antidepres-
visits) was associated with benefits in both frequency sants desipramine and imipramine reduce depressive
and level of drinking. symptoms and, to some extent, drinking behavior.
Acamprosate has also demonstrated effectiveness Recently, Cornelius et al. (1997) showed that fluoxe-
in treating alcoholism. Lipha Pharmaceuticals con- tine, a selective serotonin reuptake inhibitor (SSRI),
ducted 11 independent trials, employing over 3,000 ameliorates depression and reduces frequency and
alcohol-dependent patients. Analyses of the pooled amount of drinking in inpatients suffering major de-
data indicated that patients treated with it were twice pression and alcohol dependence. Interestingly, the
as likely to remain abstinent than those treated with SSRIs have not demonstrated a high degree of effi-
placebo (Mann, Chabac, Lehert, Potgieter, & Hen- cacy in reducing drinking by alcoholics who are not
ning, 1995). Results of several of these independent depressed.
trials have now been published. These include Buspirone, a partial 5-HTiA agonist, appears effec-
multisite, 6- to 12-month trials in France (Paille et tive in reducing anxiety symptoms and increasing
al., 1995), in Germany (Sass, Soyka, Mann, & treatment retention in subjects suffering from alco-
Zieglgansberger, 1996), in Austria (Whitworth et al., holism and an anxiety disorder (Litten, Allen, & Fer-
1996), and in the Netherlands, Belgium, and Lux- tig, 1996; Malec, Malec, & Dongier, 1996). How-
embourg (Geerlings, Ansoms, & van den Brink, ever, it does not appear to have a primary effect on
1997). All of the studies showed an increase in com- drinking outcome (Kranzler et al., 1994; Malec, Ma-
plete abstinence for acamprosate-treated subjects. lec, Gagne, & Dongier, 1996; Malcolm et al., 1992).
Acamprosate is well tolerated, the most common Progress in treating opiate addiction with medica-
side effect being diarrhea. The mechanism under- tions has also been made. Several approaches have
lying its action remains unknown, although recent been developed to detoxifying opiate dependent pa-
research indicates it blocks the glutamate receptor tients (Meandziga & Kosten, 1994). These include
(Spanagel & Zieglgansberger, 1997). slow methadone withdrawal, therapy with clonidine
Although disulfiram has been available for 50 (an alpha 2-adrenergic agonist that reduces sympa-
years, surprisingly few well-designed studies have thetic activity), clonidine/naltrexone treatment, and
been conducted. The most rigorous study was per- buprenorphine detoxification. An advantage of bu-
formed by Fuller et al. (1986). This was a nine-site prenorphine, a long-acting partial opioid agonist/an-
VA trial that included 605 alcohol-dependent pa- tagonist, is that it partially mitigates withdrawal symp-
tients. Although neither abstinence rate nor time to toms.
first drink distinguished the disulfiram and placebo Methadone, L-alpha-acetylmethadol (LAAM),
groups, disulfiram patients who did sample alcohol and naltrexone have been approved in the United
drank on fewer days. States to treat opiate dependence. In this regard,
392 TREATMENT

methadone, a long-acting opioid agonist, is the most field, 1994; Rose, Levin, Behm, Adivi, & Schur,
effective and safe pharmacological maintenance 1990; Schneider et al., 1996; Transdermal Nicotine
treatment (Litten, Allen, Gorelick, & Preston, 1997). Study Group, 1991). Nicotine replacement is now
It reduces subjective effects of heroin and other illicit readily available in different forms as an adjunct
opiates, through a mechanism of cross-tolerance. It treatment to stop smoking. These include nicotine
also diminishes crime and needle sharing, thus re- polacrilex (nicotine gum), transdermally delivered
ducing risk of AIDS. In order for methadone to be nicotine (nicotine patch), and nasal nicotine spray.
fully effective, patients must be adequately dosed, All have been approved by the FDA, with the nico-
monitored closely for medical problems, and pro- tine gum and the nicotine patch now being sold over
vided psychosocial therapy (McLellan, Arndt, Metz- the counter.
ger, Woody, & O'Brien, 1993). Recently, bupropion (Zyban), a medication ap-
LAAM, another opioid agonist, approved in the proved to treat depression under the trade name
United States in 1993, is similar to methadone. The Wellbutrin, has been approved by the FDA. The sus-
main difference is that LAAM is administered only tained-release form of bupropion has been effica-
every 3 days in contrast to methadone, which is given cious in increasing abstinence rates (Glaxo Well-
daily. A disadvantage of LAAM is the long time re- come, 1997). The mechanism of this "anticraving"
quired to achieve initial stabilization, thus increasing agent is still unknown. It may be related to the drug's
relapse risk (Jaffe, 1995; Herman, Vocci, Bridge, & ability to block neuronal uptake of dopamine, a neu-
Litten, 1996). rotransmitter believed to be involved in the positive
Naltrexone would seem to be an ideal medication reinforcement of smoking.
since it blocks opioid receptor sites, thus preventing In contrast to the success in alcohol, opiate, and
activation by heroin and other illicit opiates. How- nicotine dependence, no medication has consistently
ever, unlike its role in alcoholism treatment, naltrex- shown efficacy in the treatment of cocaine addiction.
one has not proved very successful in treating opiate A range of pharmacological agents have been investi-
dependence, most likely due to poor patient compli- gated, including stimulants, antidepressants, cocaine
ance (Jaffe, 1995; O'Brien & McLellan, 1996). antagonists, dopaminergic agents, serotonergic medi-
Nonetheless, naltrexone therapy appears useful for cations, opioid agents, and anticonvulsants (Litten et
individuals highly motivated to quit. Health care pro- al., 1997; Mendelson & Mello, 1996). Several areas
fessionals, business executives, and probationers are of research are currently being pursued. First, medi-
among these (Meandziag & Kosten, 1994). cations are being investigated that bind specifically
Finally, buprenorphine reduces heroin use, to the dopamine transporter but do not cause stimu-
blocks subjective and physiological effects of other latory effects similar to cocaine (Giros, Jaber, Jones,
opiates, and augments treatment retention (Bickel et Wightman, & Caron, 1996; Volkow et al., 1997).
al, 1988; Johnson, Jaffe, & Fudala, 1992; Strain, Second, new agents that bind specifically to subtype
Stitser, Liebson, & Bigelow, 1994). The agent is safe dopamine receptors are being explored. Dopaminer-
and less liable to abuse potential than methadone gic agents have profound effects on cocaine-seeking
and can be withdrawn or tapered with relative ease behavior (Self, Barnhart, Lehman, & Nestler, 1996).
(Litten et al., 1997). Buprenorphine is expected to Finally, progress has been made in developing co-
be approved by the FDA in the near future. caine antibodies and other agents that alter pharma-
New pharmacological agents and devices have re- cokinetics of cocaine once it is ingested (Rocio et al.,
cently been developed to curb smoking. This topic 1995).
of research activity reflects concern over the large Unfortunately, no medications are yet available to
number of cigarettes smokers in America, currently treat patients suffering abuse of other drugs, such as
over 60 million. Nicotine remains the most heavily marijuana, anabolic steroids, phencyclidine (PGP),
used drug in America. and inhalants (Wilkins & Gorelick, 1994). The
Several studies have shown that the nicotine re- mainstay treatments consist of psychosocial thera-
placement increases abstinence rates by occupying pies and pharmacological intervention to at least al-
the nicotine receptors and thus reducing craving leviate the drug-induced medical and psychiatric
(Hughes et al., 1991; Keenan, Jarvik, & Henning- symptoms.
 OVERVIEW OF MAJOR STRATEGIES AND EFFECTIVENESS 393

CONCLUSION References
Allen, J. P., & Litten, R. Z. (1992). Techniques to en-
The treatments discussed in this chapter reflect the hance compliance with disulfiram. Alcoholism: Clin-
rich diversity of strategies available for treating pa- ical and Experimental Research, 16, 1035-1041.
tients with alcohol and drug abuse problems. The Bickel, W. K., Stitzer, M. L., Bigelow, G. E., Liebson,
approaches differ along several dimensions, includ- I. A., Jasinski, D. R., & Johnson, R. E. (1988). A
ing the importance that patient motivation is as- clinical trial of buprenorphine: Comparison with
sumed to have in determining outcome; the extent methadone in the detoxification of heroin addicts.
to which abuse is seen as fairly endogenous or char- Clinical Pharmacology and Therapeutics, 43, 72-78.
Carroll, K., Ziedonis, D., O'Malley, S., McCance-Katz,
acterological to the patient versus simply an ac-
E., Gordon, L, & Rounsaville, B. (1993). Pharmaco-
quired, counterproductive behavioral pattern; the
logic interventions for alcohol- and cocaine-abusing
role of assessment (especially psychometric proce- individuals. American Journal on Addictions, 2,
dures) in establishing a treatment plan; the amount 77-79.
of responsibility that the patient personally bears in Chick, J., Gough, K., Falkowski, W., Kershaw, P., Hore,
resolving the problem; the intensity of treatment re- B., Mehta, B., Ritson, B., Ropner, R., & Torley, D.
quired; the desirability of participation by others in (1992). Disulfiram treatment of alcoholism.Brifrs/i
treatment; and the role of the therapist. Journal of Psychiatry, 161, 84-89.
Despite their diversity, research evidence exists in Cornelius, J. R., Salloum, I. M., Ehler, J. G., Jarrett, P.
varying degrees suggesting that each of the strategies J., Cornelius, M. D., Perel, J. M., Thase, M. E., &
may be effective. Therapists and patients thus now Black, A. (1997). Fluoxetine in depressed alcoholics:
A double-blind placebo-controlled trial. Archives of
have a broad range of choices in their attempts to
General Psychiatry, 54, 700-705.
resolve substance abuse problems. Future research
Fuller, R. K., Branchey, L., Brightwell, D. R., Derman,
on treatment should aid in identifying the "active in- R. M., Emrick, C. D., Iber, F. L, James, K. E., La-
gredients" of the various options and, perhaps, even- coursiere, R. B., Lee, K. K., Lowstam, I., Maany, I.,
tually allow reasoned integration across approaches. Neiderhiser, D., Nocks, J. J., & Shaw, S. (1986). Di-
So, too, it should ultimately be possible to determine sulfiram treatment of alcoholism: A Veterans Admin-
under which conditions a particular intervention istration cooperative study. Journal of the American
should be chosen. By describing and documenting Medical Association, 256, 1449-1455.
the key features of current strategies, the authors of Geerlings, P. J., Ansoms, C., & van den Brink, W.
chapters in this section of the text have advanced (1997). Acamprosate and prevention of relapse in al-
coholics. European Addiction Research, 3, 129-137.
these goals.
Giros, B., Jaber, M., Jones, S. R., Wightman, R. M., &
Caron, M. G. (1996). Hyperlocomotion and indiffer-
ence to cocaine and amphetamine in mice lacking
Key References the dopamine transporter. Nature, 379, 606-612.
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Clinical and Experimental Research, 20, 859-876. tients abusing cocaine and alcohol. American Jour-
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Jaffe, J. H. (1995). Pharmacological treatment of opioid Mason, B. J., Kocsis, J. H., Ritvo, E. C., & Cutler, R.
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Brady, K., & Thevos, A. (1992). A placebo-controlled Paille, F. M., Guelfi, J. D., Perkins, A. C., Royer, R. J.,
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Malec, E., Malec, M. A., Gagne, M. A., & Dongier, immunization. Nature, 378, 727-730.
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ning, S. (1995, December). Acamprosate improves Sass, H., Soyka, M., Mann, K., & Zieglgansberger, W.
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Self, D. W., Barnhart, W. J., Lehman, D. A., & Nestler, Volpicelli, J. R., Alterman, A. I., Hayashida, M., &
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G. E. (1994). Comparison of buprenorphine and
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 V

Practice Issues
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 22

Legal and Ethical Issues

Frederick B. Glaser
David G. Warren

There are things that one does, and

there are things that one does not do.
—Yiddish Proverb

Clinical encounters consistently raise ethical, legal, times the legal limit in his jurisdiction). The
and moral questions. Value judgments are an inte- clinician knows that Ralph always drives to the
gral and unavoidable aspect of the therapeutic situa- treatment facility.
tion. To make a sharp distinction between clinical • Mark, a 23-year-old unemployed man, is re-
situations and ethical, legal, and/or moral situations ferred to treatment by his probation officer fol-
lowing his arrest for possession of cocaine. Ini-
is not tenable. "Implied in therapy," notes one com-
tially guarded in treatment, Mark develops a
mentator, "are beliefs about human nature, pathol-
positive relationship with his therapist and grad-
ogy, how people should live, and the assumption that ually begins to divulge more of his drug history
the therapist is an ethical person" (Woody, 1990, p. and drug use pattern. He acknowledges that he
134). Consider the following fictional vignettes: continues to sell drugs on occasion as a means
to obtain money. Mark's probation officer con-
• Joan, a 31-year-old secretary, seeks therapy for tacts his therapist regularly for updates on
depression. In the course of the initial inter- Mark's progress. The therapist has an appropri-
view, she reveals she has recently learned that ately endorsed release from Mark to speak with
she is HIV-positive. However, she is afraid to in- the probation officer.
form her companion. They have lived together • Maria, a 58-year-old widow, is an episodic
for 10 years and have never used condoms. drinker who is self-referred to treatment. She
• Ralph, a 47-year-old accountant, is referred to reports that she has been abstinent for the last
outpatient alcohol treatment by his employer. 6 weeks. Maria has a daily responsibility for the
Ralph comes to his therapy group visibly intoxi- care of her two granddaughters while her
cated, registering a blood alcohol level of 263 daughter works. The children are 1 and 3 years
mg/100 ml on a breathalyzer (more than three old. She tells her therapist that she occasionally

399
400 PRACTICE ISSUES

"loses her temper" with the children, but only civil disobedience exemplified by Thoreau, Gandhi,
when she is hung over after a heavy drinking and Martin Luther King, Jr. In medicine, one may
bout. She denies ever drinking while caring for cite the current controversy around physician-assisted
the children. suicide, apparently widely practiced but technically
illegal in most jurisdictions. In substance abuse,
In contemporary therapeutic practice, situations many have felt it ethically imperative to mount nee-
like these are common. They raise important ques- dle exchange programs to reduce the spread of intra-
tions about what the therapist should do. Such ques- venously transmitted HIV infection despite state and/
tions are not easy to answer but, at the same time, or local laws restricting access to "paraphernalia."
are very important. The safety and well-being of both That legally sanctioned behavior may be unethi-
the client and other persons may be significantly de- cal is exemplified by the Nuremberg trials following
pendent on whether and how the therapist decides World War II, in which the plea of many defendants
to deal with them. This chapter will attempt to pro- that their conduct conformed to the legalities of Na-
vide a basis for considering and working through the tional Socialist Germany was not accepted by the tri-
ethical, legal, and moral dilemmas raised by these bunal as a mitigating factor in actions construed as
and other clinical situations. "crimes against humanity." A more contemporary ex-
Ethics and the law have to do with right conduct. ample is the continuing controversy surrounding the
They provide guidance as to what one ought to do application of the death penalty, especially in cases
under many different circumstances. In this regard, involving women and minors. In medicine, many
they are related to morality. The Oxford English Dic- states have legislatively adopted lethal injection as
tionary defines ethics as "the science of morals" and their means of execution, but physicians often feel it
moral(s) as "of or pertaining to the distinction be- is unethical or immoral and will not participate. In
tween right and wrong . . . in relation to the actions substance abuse, the ethical propriety of withholding
. . . of responsible beings; ethical" (Oxford English information critical to a criminal investigation on the
Dictionary, Vol. 3, p. 312; Vol. 6, p. 653). According grounds that federal confidentiality laws prohibit its
to Black's Law Dictionary (6th ed., 1990), "Law, in release has been an issue. In the 1994 revision of
its generic sense, is a body of rules of action or con- their book Ethics for Addiction Professionals, Bissell
duct prescribed by controlling authority and having and Royce (1994) stated:
binding legal force" (p. 884). Generally speaking,
ethics and morals are the guides for right conduct, Whether or not a given behavior is legal or illegal
and law is the enforcement of right conduct. does not determine whether or not it is ethical.
Concerns about right conduct are among the old- There are good laws and bad laws. Sometimes the
est and most persistent of human concerns. The courts are able to render justice, at other times
they cannot. For example, physicians attempting
Code of Hammurabi, the Ten Commandments, and
to protect themselves from malpractice suits may
the oath of Hippocrates have long been with us and
sometimes perform unnecessary procedures. Ad-
are still actively debated today. But codes of conduct diction professionals may feel torn between the
are not necessarily ancient. The Nuremberg code, need to protect themselves or their institution
which is the most pertinent ethical guideline in re- from litigation and the desire to spare the patient
search on human subjects, was formulated only 50 unneeded discomfort or expense, (pp. 1-2)
years ago (Shuster, 1997). Legislative bodies, profes-
sional organizations, and judicial jurisdictions con- What constitutes right behavior is deeply imbed-
stantly update existing codes and formulate new ded in culture and philosophy and hence changes
ones. Guidelines for conduct are not lacking, and across time and place, as do culture and philosophy.
keeping up with their provisions is not an easy task. "The Law" is frequently deferred to as universal and
Although for purposes of discussion we will treat immutable; yet, for example, laws in the two contigu-
ethical and legal issues separately, in reality they are ous areas of Canada and the United States have
closely related. Laws are often based upon ethical evolved in very different ways, and laws are very dif-
considerations, and ethical and moral conduct is ferent in different Canadian provinces and in dif-
usually consonant with the law. But conflicts may ferent states of the United States. Even within juris-
arise between ethics and the law. That ethical con- dictions, ethical and legal guidelines are neither
duct may be illegal is an element of the tradition of complete (they do not cover all situations) nor con-
 LEGAL AND ETHICAL ISSUES 401

sistent (they may contradict each other) nor perma- codes of ethics as well as state and federal laws, insti-
nent (both courts and legislatures continually make tutional protocols, and social mores. Confidentiality
and revise laws). Ethical and legal precepts are con- has become commonly accepted as a fundamental
stantly challenged, debated, interpreted, and modi- "patient's right," grounded in the legal principle of
fied (Spring, Lacoursiere, & Weissenberger, 1997). privacy and the ethical principle of autonomy. In the
To discuss in any detail morality, which involves case of therapists in federally assisted substance abuse
the relative adjudication of values and (as noted) is programs, there is a detailed federal rule (42 Code
closely related to ethics and to the law, would go of Federal Regulations, Part 2) that spells out in great
beyond the purpose of this chapter. Suffice it to say detail requirements for the confidentiality of patient
here that in the health care professions generally and records. The provisions of the code are discussed
in the field of substance abuse in particular, there below.
has been a determined attempt to brand moral con- Numerous dilemmas arise for all therapists in at-
siderations as antiquated and irrelevant, and to pro- tending to the duty of confidentiality. Some of these
pose that standard clinical practice is grounded in a are highlighted by the vignettes regarding the cases
totally objective and morally neutral science. We of Joan, Ralph, Mark, and Maria presented at the
view such a position as not only misguided but naive beginning of this chapter. They will be discussed in
in the extreme, and ultimately dangerous. The exam- some detail in the appropriate section on ethical con-
ple of the atomic scientists who ultimately came to siderations that follows. In this way, both the legal
regard their work as morally repugnant should have and ethical aspects of these cases, which as noted are
exploded for all time the myth of a science exempt not readily separable, can be discussed at the same
from moral considerations. Interested readers are re- time.
ferred to recent works on morality (Midgley, 1991; In general, however, a therapist's responsibility
Wilson, 1993); the latter deals specifically with the to patients with regard to confidentiality is not as
moral aspects of substance abuse. straightforward as it appears. It is easy to give alle-
Neither this chapter nor ethical and legal guide- giance to confidentiality but more difficult to follow
lines themselves can necessarily provide an infallible it in practice. The legal duty is not always clear be-
guide to right conduct for a specific therapist in a cause there are numerous exceptions created by dif-
particular situation at a given place and time. While fering state laws and conflicting court decisions.
science, at least in the view of some, searches for and Even if a therapist is knowledgeable about the law,
on occasion discovers the immutable principles of new legal interpretations and changes are continu-
nature, ethical, moral, and legal discourse is an on- ally occurring. Even if a therapist is especially consci-
going process that rarely reaches any ultimate con- entious about respecting a patient's privacy, there are
clusions. Accordingly, the informed reader will view often administrative and practical barriers. A further
with skepticism whatever advice may be offered in complication sometimes is a patient's own disregard
what follows and will apply it creatively to the for the right of privacy.
unique circumstances in which he or she practices.
At the close of this chapter we will offer some guide-
Confidentiality in the Health Care Setting
lines for resolving the legal, ethical, and moral di-
lemmas that arise in the course of therapeutic prac- There is an innate sensitivity in therapists about
tice. maintaining a modicum of privacy in the therapeutic
environment. Each of us in our sometime role as a
patient expects to be treated with personal respect
LEGAL ISSUES FACING both for our bodies and our backgrounds. Therefore,
PRACTITIONERS nearly every health care facility provides physical sur-
roundings designed to promote personal security,
such as soundproofed rooms for history taking and
Providing Respect to Others:
psychotherapy, changing rooms, and closed examina-
The Duty of Confidentiality
tion rooms. Health care facilities also take detailed
All health care providers are to varying degrees famil- precautions to maintain security for patient records.
iar with the duty of confidentiality. It is bred into A considerable amount of information is learned
professional training and bolstered by professional about patients in the course of taking histories and
402 PRACTICE ISSUES

doing physical and mental examinations. Neither sure or can waive the right of confidentiality, either
providers nor patients generally expect these facts expressly (e.g., consent forms routinely contain a pro-
and observations to become public information. We vision for disclosure for insurance purposes) or im-
take for granted the ethical responsibility to maintain pliedly (when the patient files a lawsuit).
confidentiality in the health care setting, and in stan-
dard clinical situations, confidentiality is usually pro-
vided. But many clinical situations are not "stan-
The Federal Regulations: Confidentiality in
dard." For example, the situations outlined in the
Substance Abuse Treatment
vignettes all raise important issues regarding confi-
dentiality, and they are by no means unusual. For therapists who work in federally assisted alcohol
and drug treatment programs, the rules of confidenti-
ality of patient information are uniquely stringent.
The General Law of Confidentiality
They are comprehensively prescribed by federal reg-
There are two components of the principle of pri- ulations. This makes it both easier and more prob-
vacy, which underpins the laws and regulations gov- lematic for the therapist. The regulations are com-
erning patient confidentiality in the therapeutic envi- prehensive and spell out nearly all circumstances,
ronment. First, the principle of privacy as it relates but they are also inflexible and unusually detailed.
to the body requires that therapists seek the patient's Some might say that they are excessively restrictive,
authorization before touching the patient. To touch making referrals and interprofessional communica-
without such authorization is, technically, battery. tions more difficult.
Authorization to touch, or to otherwise examine the The addiction field generally is very well aware of
patient, is termed informed consent. Such consent is, the federal regulations and in fact urged their origi-
for example, routinely obtained in writing prior to nal adoption in the early 1970s. The intent of the
any invasive surgical procedure. For counseling and regulations is to combat the presumed stigma that is
psychotherapy, the patient's consent is often provided associated with alcohol and drug problems and that
either orally or by the patient's actions (implied con- is thought to discourage individuals from seeking
sent), such as continuing to attend sessions and to treatment. The method is to cover treatment pro-
engage in therapeutic activities. grams with secrecy, restricting disclosure of nearly all
Second, the principle of privacy as it relates to the information about persons participating in the pro-
patient's background requires that a therapist main- gram. The regulations in general go beyond tradi-
tain records and other information about patients in tional rules of confidentiality and even beyond exist-
an appropriately confidential manner. The law of ing legal precedents; for example, they do not take
confidentiality with respect to written records is em- into account the duty to warn (discussed below).
bodied in a variety of federal and state statutes as well The federal regulations on confidentiality apply
as court decisions. Fundamentally, the law holds that to all programs that are "federally assisted." Thus,
a patient's records should be seen only by those nec- program that are purely private in nature (and in
essarily involved in the patient's care and treatment, which the costs to the patient for treatment are not
and that a therapist should not ordinarily reveal in- covered by federal insurance programs) are not gov-
formation obtained in the course of the therapist-pa- erned by these regulations. A working knowledge of
tient relationship. the general points contained in the federal regula-
There are exceptions that permit or require dis- tions, including the technical definition of federally
closure of patient information, based on the nature assisted, is essential for any therapist. The general
of the information (e.g., communicable diseases and rules are summarized in table 22.1.
child abuse must be reported in most jurisdictions), For the therapist in a private health care setting
the setting (e.g., in a teaching hospital, medical rec- or private practice, then, there is a general expecta-
ords are permissibly used in teaching and research as tion of confidentiality, albeit with some exceptions to
well as treatment), the use of the information (it can the rule. For the therapist working in a federally as-
be subpoenaed for litigation), and other situations sisted substance abuse program, however, there is the
(state laws provide specific requirements for disclo- added problem of the observance of the specific fed-
sure). Above all, a patient can authorize the disclo- eral regulations on confidentiality. This must be
 LEGAL AND ETHICAL ISSUES 403

TABLE 22.1 Summary of the Provisions of the Federal Regulations on Confidentiality for
Substance Abuse Programs

The records or other information concerning any patient in a federally assisted alcohol or drug abuse program shall not
be disclosed, except as stated in the rule, regardless of any other federal or state laws.
Disclosure means any communication about a patient, including verification of information already known by the in-
quirer, and records, whether or not they are in writing.
A patient is any person who has applied for, participated in, or received an interview, counseling, or any other service,
including an evaluation after a criminal arrest. Every patient admitted to a program must be given a written summary of
the federal regulations.
A program is defined as federally assisted if it receives federal funds in any form, has federal tax exempt status, is au-
thorized by the federal government (e.g., licensed to provide methadone or certified for Medicare), or is conducted di-
rectly by the federal government (e.g., an employee assistance program in a federal agency).
Hospitals and other general medical facilities are considered "programs" if they have an "identified" unit or staff
which specializes in substance abuse services. Some emergency rooms consider themselves"programs" because of an un-
expected court ruling in 1989 which narrowly interpreted the regulations.
Many program managers and even legal advisers have also read the regulations narrowly. The regulations themselves
are written in a very restrictive manner and invite literal interpretation. There are, however, exceptions to the general
rule that permit limited disclosures with patient consent and a few without patient consent. The examples are described
specifically in the regulations and relate to the following situations:

1. Written patient consent (a detailed model consent form is included in the regulations)
2. Information to third-party payers and funding sources (only with patient consent)
3. Reports to employers (only with patient consent)
4. Reports to the criminal justice system (only with patient consent)
5. Reporting of aggregated program data or nonidentifying case histories
6. Communication made to other staff members
7. Reporting patient admissions to a central registry to prevent multiple patient enrollment
8. Immediate medical emergency of the patient or another individual
9. Subpoenas and court-ordered disclosures (the grounds and scope are limited by the regulations)
10. Requesting law enforcement assistance for patient crimes on program premises or against program personnel
11. Scientific research (safeguards are provided by the regulations)
12. Audits and evaluations, provided the inspectors certify confidentiality
13. Reporting of child abuse and neglect, if required by state law
14. Qualified service organizations (i.e., outside agencies contracted to perform vocational counseling, data process-
ing, accounting, legal services, urinalysis, etc.) provided the organizations certify confidentiality

done in a way that promotes good care as well as LEGAL ISSUES FACING CLIENTS
patient trust in the program.
To walk this tightrope requires a clear under- As policymakers have come to appreciate the sig-
standing of the regulations and a pragmatic applica- nificance of substance abuse and have attempted to
tion of their perhaps overly stringent provisions, address some of the problems it poses, federal and
Therapists are well advised to study the regulations state statutes and regulations have become in-
and legal explanations of them in order to under- creasingly germane to the field. They create rights
stand them and to avoid mistakes. Every facility and responsibilities for individuals both within the
should make copies available to therapists and clients treatment setting and in other settings. In this sec-
who request them. In many instances in which di- tion, we will summarize some of the more significant
lemmas arise, therapists may wish to seek legal ad- legal issues and current legal trends. But (as noted
vice as to the meaning of the regulations within the above) regulations may vary considerably from one
context of applicable local and state laws. Violating jurisdiction to another, and because they are subject
the regulations is punishable by a fine of up to $500 to change (often quite sudden change), generaliza-
for a first offense or up to $5,000 for each subsequent tion to a particular set of circumstances may be haz-
offense. ardous. The laws and regulations pertinent to sub-
404 PRACTICE ISSUES

stance abuse are also highly detailed and can be Many states have enacted "zero tolerance" levels for
covered herein in only a general way. For any ther- drivers under age 18; that is, any detectable level of
apist whose clients have legal issues, a thorough blood alcohol in such an individual will trigger the
knowledge of what is locally relevant, or consultative specified legal sanctions. In the wake of some highly
access to a source of such knowledge, is indispens- publicized cases, the U.S. Department of Transporta-
able. tion issued Drug and Alcohol Testing Rules that
came into effect on January 1, 1995, covering em-
ployers with at least 50 drivers who have commercial
General Provisions
licenses.
With regard to alcohol, it is illegal in most jurisdic-
tions for individuals under the age of 21 to purchase,
Workplace Laws and Regulations
possess, or use beverage alcohol. Previously, the age
provisions varied from state to state, but with the Since substance abusers in treatment may also be
threatened forfeiture of funds from the federal high- employed, therapists should develop an understand-
way trust, all 50 states have raised the minimum ing of the rules and regulations that apply to them in
drinking age to 21. Most jurisdictions formerly had the workplace. Current alcoholics and rehabilitated
legal prohibitions against public intoxication that drug abusers are protected by the Americans with
could result in various penalties, including imprison- Disabilities Act (ADA). But current illegal drug users
ment. With the rise of interest in treating alcohol and employees who use alcohol on the job are not
problems as a therapeutic rather than a criminal mat- protected; employers are free to take reasonable dis-
ter, public intoxication laws have largely been taken ciplinary actions against such employees, and the
off the books. Disorderly conduct while under the employees cannot enter rehabilitation programs to
influence of alcohol, however, remains a criminal of- escape consequences. A major complication of this
fense in most jurisdictions. law is that court interpretations of "current drug use"
With regard to narcotics and other drugs, their are inconclusive at this time. Employee Assistance
possession and use, irrespective of age or other pa- Programs (EAPs) generally encourage entry into re-
rameters, is prohibited except for medical reasons. habilitation programs as an alternative to dismissal.
Laws regarding cannabis (marijuana) tend to be Employer-mandated drug and alcohol tests are gen-
more variable than for other drugs. Two states have erally allowed under the ADA.
recently passed referenda making cannabis prepara- Provisions of the Family and Medical Leave Act
tions available by prescription, raising an issue of (FMLA) also apply to drug and alcohol problems.
conflict between federal and state regulations. In re- The Drug-Free Workplace Act of 1988 (DFWP) ap-
cent years, laws in some jurisdictions have been en- plies to all federal grant recipients and those busi-
acted against possession with intent to sell, specifying nesses having contracts with the federal government
the amounts (usually large) that permit such a worth more than $25,000. While the act neither re-
charge to be lodged. quires nor prohibits drug testing of employees, test-
State statutes regarding the operation of a motor ing is subject to the laws of the various states and
vehicle under the influence of alcohol or drugs are to specific federal laws governing the transportation
a patchwork of different standards and enforcement industry. State laws may provide for such activities as
procedures. Some use the term driving while im- mandated testing for certain employees (e.g., school
paired or intoxicated (DWI), while others speak of bus drivers) for specified drugs, denial of unemploy-
driving under the influence (DUI). All of them pro- ment benefits, and denial of workmen's compensa-
hibit the operation of motor vehicles while under the tion benefits to employees who are injured on the
influence of an intoxicant, narcotic, or hallucino- job as a result of using illegal drugs or alcohol or
genic to the extent that the driver's "normal facul- who tested positive for illegal drugs or alcohol. The
ties" are impaired. All of them also prohibit driving National Labor Relations Act governs development
with an unlawful blood alcohol level; many states of a DFWP in a workplace subject to a "private sec-
specify a level of 100 mg/100 ml or higher, but oth- tor" collective bargaining agreement, including drug
ers have recently lowered this level to 80 mg/100 ml. testing components.
 LEGAL AND ETHICAL ISSUES 405

rates, amphetamines, and other drugs, but under

Drug Testing
tightly regulated conditions. Both the federal Drug
Guidelines of the National Institute on Drug Abuse Enforcement Agency (DEA) and professional licens-
regulate drug testing undertaken pursuant to federal ing boards aggressively monitor this area. Therapists
law. But the drug-testing component of a DFWP having such clients are well advised to become famil-
may be subject to state statute as well. Different states iar with the provisions of the relevant laws and regu-
have taken different approaches. Some recognize an lations in their jurisdictions.
employer's right to require testing as part of a Most jurisdictions also have laws against the pos-
DFWP, while others do not. In most states, employ- session of "paraphernalia," that is, equipment that is
ers are free to test employees and applicants for jobs employed for the self-administration of drugs, such as
for drugs and alcohol, and most state laws on testing needles and syringes. Whatever surface validity such
simply regulate or limit tests in some way rather than provisions may have, their deterrent value is doubt-
prohibiting them. No state prohibits all workplace ful, and in some jurisdictions they have been used
drug testing. But some state statutes require reason- to impede the development of needle and syringe
able cause for testing (as opposed to routine testing), exchange programs. Such programs are designed to
and some prohibit random testing. prevent the spread of infectious diseases among us-
Existing federal and state statutes do not answer ers, especially AIDS. Individuals are provided with
all the legal and ethical questions that are posed by sterile injection equipment if they hand in used
drug testing, and they pose many others. For exam- equipment.
ple, defense attorneys commonly raise scientific and In general, persons with alcohol or drug problems
procedural questions about testing when workers are are not legally required to undergo treatment. But a
discharged or disciplined. When and how was the person under the influence of alcohol or drugs who
test performed? How reliable was the procedure? commits a crime may be required by a court to un-
Was the employee's freedom in some way abridged dergo treatment. Caution should be exercised when
by inappropriate employer conduct? Many of these this occurs. Recent (1997) decisions in three judicial
issues are discussed in current guidebooks, such as districts have held that mandatory referral to Alcohol-
the Attorney's Guide to Drugs in the Workplace ics Anonymous (AA) as the sole treatment option is
(Denenberg & Denenberg, 1996). a violation of the separation of church and state pro-
visions of the First Amendment to the Constitution:
Griffin v. Coghlin in the New York State Court of
Other Issues
Appeals, Kerr v. Farrey and Lind in the U.S. Court
Some states have a human rights act or antidiscrimi- of Appeals for the Seventh Circuit (Wisconsin, Illi-
nation law that covers individuals with physical or nois, and Indiana), and Warner v. Orange County
mental disabilities. Most state statutes, however, mir- Department of Probation in the U.S. Court of Ap-
ror the Americans with Disabilities Act in providing peals for the Second Circuit (New York, Connecti-
that a current drug abuser or someone who uses alco- cut, and Vermont). But this difficulty is readily miti-
hol on the job is not a qualified individual with a gated if non-AA treatment options are made available
disability. Recent federal legislation eliminates drug and the patient is permitted to choose the kind of
addiction and alcoholism as a basis for social security assistance he or she prefers.
and supplemental security income disability benefits. There are some programs, such as the federal
Some professionals in the treatment community Treatment Alternatives to Street Crime (TASC), that
have decried this action as damaging to the stability systematically divert alcohol and drug offenders from
of treatment programs. Others have seen it as a call the judicial to the therapeutic system. The creation
for more effective prevention programs. of drug courts is a similar effort in which therapists
Therapists may encounter clients such as physi- and court officials are brought together to provide
cians, nurses, and pharmacists who have run afoul of assistance to clients. In instances of substance abuse,
the federal or state laws governing the use of con- as in instances of mental illness, there have been
trolled substances. These laws permit the medical many attempts to mitigate criminal responsibility
use of listed drugs such as opiates, cocaine, barbitu- when a crime has been committed under the influ-
406 PRACTICE ISSUES

ence of alcohol or drugs. In general, however, the Alcohol and drug problems can be understood in
courts have not accepted such a defense (cf. Finga- a variety of ways (Brower, Blow, & Beresford, 1989;
rette, 1979). Miller & Kurtz, 1994; Siegler & Osmond, 1968;
Siegler, Osmond, & Newell, 1968). For example, in
a pure medical model, the individual is seen as hav-
ETHICAL ISSUES FACING ing fallen ill through no fault of his or her own. In a
PRACTITIONERS moral model, the individual is seen as deliberately
choosing to behave badly. The role of the helper var-
ies accordingly. In the medical model, the principal
The Duty of Care
responsibility for dealing with the patient's behavior
Important ethical issues can be generated when one belongs to the helper, while in the moral model the
person asks another for help. What constitutes right principal responsibility belongs to the person being
behavior for the person to whom such a request is helped (cf. Brickman et al., 1982). In other models,
addressed? Or to put it in other terms, what is the the responsibilities are differently divided.
duty of care that is generated by such a request? Perhaps because the way they conduct therapy
A logical first step in deciding whether to respond seems natural to them, therapists often do not explic-
to a request for help is to determine precisely what it itly reflect upon the assumptions and implications of
is the helper is being asked to do. This is often not their clinical methods. They would do well to study
immediately apparent and may require some explo- the options that are available in terms of models of
ration. One team of investigators found that there alcohol and drug problems, and to determine which
were significant differences between what the patient of them most closely approximates their own prac-
actually wanted and what the therapist thought the tice. Only with a thorough understanding of his or
patient wanted (Lazare, Eisenthal, & Wasserman, her own conceptual framework can a therapist truly
1975). There has been little subsequent study of this gauge what duty of care he or she owes in agreeing
issue, but long experience suggests that such differ- to try to help a given patient. A concurrent advantage
ences in perception continue to obtain. to such reflection is that it enables one to determine
Once the help seeker's request has been clarified, whether there is congruence between the patient's
the issue is whether a duty of care exists to respond expectations of the therapeutic situation and one's
to it. An important element of this calculus has to do own (Brickman et al., 1982). If there is not, the likeli-
with the appropriateness of the request. Therapists hood of a positive result is greatly diminished.
are not omnipotent. Not every therapist can respond
appropriately to every request for help. If the request
The Undistributed Duty of Care
for help is inappropriate, it should be renegotiated.
If this cannot be accomplished, help may appropri- Let us assume (a) that what the patient is requesting
ately be declined. Ideally, one would then redirect has been clarified, (b) that the therapist agrees that
the help seeker to a more appropriate source of assis- the request is reasonable, and (c) that the patient and
tance. But even when this is not possible, it is ethi- therapist are operating within compatible conceptu-
cally imperative not to accede to requests for help alizations of the presenting problem. Under these cir-
that one realistically is not able to provide, or that cumstances, it is reasonable for the therapist to un-
one believes are inappropriate to provide. dertake a duty of care to the patient. It now becomes
Even if the request for assistance has been clari- important to understand that duties of care may dif-
fied and realistic goals have been set that are mutu- fer importantly in terms of their object. That is, one
ally agreeable to client and clinician, there are fur- must consider to whom the duty of care is owed.
ther issues to take into account in determining the The duty of care is often viewed as being owed
nature and extent of the duty of care. Among these exclusively to the individual who has requested help
are conceptual issues. How both the help seeker and and who is the recipient of care, that is, the patient
the help provider construe the nature of the problem or client. In such instances one may speak of an un-
to be dealt with in treatment may affect what they distributed duty of care. As ethical, legal, and moral
both understand to be the duty of care. reflection upon the therapeutic situation has evolved
 LEGAL AND ETHICAL ISSUES 407

over time, however, the issue of to whom the duty of the theoretical possibility of a future liability suit
care is owed has become increasingly complex. from the companion.
While there are indeed situations in which the duty If it is concluded that the therapist owes a duty
of care is owed exclusively to the designated patient, of care to Joan's companion, several difficult options
there are also situations in which it is owed at least present themselves. In many jurisdictions, the report-
in part, and sometimes entirely, to some other indi- ing of HIV infections to the local health authorities
vidual or entity. In such situations, one may speak of is mandatory. However, carrying the investigation to
a partially or wholly distributed duty of care, in con- the positive person's sexual contacts is often done
trast to an undistributed duty of care. only where they are indiscriminate, and that does not
If a patient presenting for treatment has symptoms appear to be the case in this instance. Further com-
that are largely self-regarding, it may be reasonable plicating the issue is that, while a spouse is often cov-
to conclude that he or she is owed an undistributed ered by mandatory reporting statutes, a long-term
duty of care. That is, in such an instance, the thera- companion is often not covered. What is to be done?
pist can focus his or her therapeutic attention almost The therapist could encourage the patient to be
exclusively upon the patient. An example would be open with her companion and subsequently take her
the development of a social phobia in an unmarried at her word that she has told him. Or the therapist
individual. In such a case ethical, legal, and/or moral could seek the client's permission to tell her com-
dilemmas are less probable, though still possible. For panion about her HIV infection. Or if the client re-
example, if a therapist provides only psychoanalyti- fuses either to tell her companion or to permit the
cally oriented psychotherapy, but the possibility exists therapist to do so, the therapist could break confiden-
that behaviorally oriented therapy will be more effec- tiality and warn the companion, justifying this action
tive in this particular instance, a dilemma may arise on the grounds of the threat to the companion's life.
regarding referral. And concern about possible sexual But breaking confidentiality for any reason is often
involvement of therapists and their patients is not viewed as ipso facto unethical and may be illegal,
mitigated by an undistributed duty of care. particularly under the federal confidentiality statue
for substance abusers, which does not appear to rec-
ognize the duty to warn (see table 22.1).
The duty of a therapist to warn others who may
The Partially Distributed Duty of Care
be in danger from a patient under care was raised by
Where there is a partially distributed duty of care — the Tarasoff case and others (Curran, 1975; Dickens,
that is, where the duty of care is owed in part to some 1986; Eberlein, 1980). Tarasoff was a young woman
other individual or entity—ethical, legal, and/or who was threatened with death and was subsequently
moral dilemmas are very likely to arise. This is espe- murdered by a patient (not in this case a substance
cially so if the therapist-client interaction falls within abuser) who was under care. His caregivers, who
the scope of the federal confidentiality guidelines. were aware of his threats, were found liable for not
The case of Joan, outlined in the first paragraph of directly warning Tarasoff and her family of the dan-
this chapter, illustrates what may be a partially dis- ger she was in. The therapists did alert the local po-
tributed duty of care. lice, who detained the future murderer briefly but let
The client has sought help for depression. But him go; the court ruled that this action was insuffi-
she has also indicated that she is HIV-positive, that cient to protect the therapists from liability. A critical
she has not revealed this information to her compan- element of the Tarasoff decision was that the pa-
ion, and that they engage in unprotected sexual rela- tient's caregivers were aware of the specific persons
tions. The companion is presumably therefore at (Tarasoff and her family) who would be harmed if
high risk of contracting an HIV infection or, if he the patient's threats were carried out. Courts making
has already done so, of delaying the institution of rulings prior to the promulgation of the federal confi-
treatment. The dilemma arises whether the therapist, dentiality statutes have generally insisted that nondis-
now in possession of this information, thereby owes closure in the therapeutic situation must yield to the
a duty of care to the client's companion, as well as "supervening interest of society," and that therapists
to the client. From a legal standpoint, there is at least are expected to act as "agents of society dutybound
408 PRACTICE ISSUES

to control potentially disruptive forces" (Fleming & the sole remaining option and is itself illegal. The
Maximov, 1974, pp. 1033, 1035-1036). authors are aware of cases in which therapists and
Joan's case is not unique in raising ethical dilem- facilities pursuing this course of action have been
mas related to a partially distributed duty of care. In sued by patients. The courts have generally found
any case in which it becomes apparent that the duty the therapists and/or their institutions guilty of un-
of care is owed in part to someone other than the lawful restraint but have assessed nominal penalties
patient, a dilemma arises because of the countervail- (e.g., $1). Given the enormous sums that can be in-
ing requirement of confidentiality. Each of the case volved in liability settlements, this may be considered
examples given at the beginning of this chapter illus- on balance a satisfactory outcome.
trates this point. Let us move on to the case of Mark, who is on
In the case of Ralph, the intoxicated accountant probation for possession of cocaine. His therapist,
who always drives to treatment sessions and who cur- who knows that Mark is occasionally selling cocaine,
rently has a blood alcohol level well in excess of the has an "appropriately endorsed" release of informa-
permitted legal limit, the therapist may also have a tion from the patient to talk to his probation officer.
duty of care to the person or persons who could be The therapist considers providing this information to
injured by Ralph as he attempts to drive home. This Mark's probation officer. But he is concerned that
is not only an ethical but a legal question. Case law if he does so, he may be breaching confidentiality;
precedents in many jurisdictions make it likely the moreover, the patient's probation may be violated
therapist would be held legally and financially liable and the patient incarcerated.
for any damages caused by Ralph. Some jurisdictions One could posit that the therapist owes a duty of
have server liability laws which hold that those who care to those to whom his client may sell an illegal
purvey alcoholic beverages to intoxicated persons are and dangerous, even potentially fatal, drug. In a re-
similarly liable. While these laws do not specifically cent and highly publicized case, the celebrity father
apply to therapists, the general principle could be of a drug abuser who died of an overdose has pub-
viewed as applicable. licly pursued his son's alleged provider through the
As with Joan, there are several options with regard mass media, by implication holding the provider at
to Ralph. He might be persuaded to remain under least partly responsible for his son's death. Alterna-
the surveillance of the therapist until his blood alco- tively, the duty to warn might be construed as requir-
hol level reverts to normal; given its elevated status, ing the therapist to take action.
this would take a long time. Alternatively, he could On the other hand, a drug user, unlike the com-
be persuaded to leave his car at the facility and be panion of Joan in the first example or those who
driven home by a friend or a taxi. Some companies could be injured by the intoxicated Ralph in the sec-
have contracted with private providers to make this ond example, is actively and deliberately participat-
service available to their employees as a benefit, with ing in an enterprise known to be illegal, dangerous,
no cost to the employee. and even potentially fatal. To what extent does this
Should such options not be feasible, the alterna- vitiate the duty of care that may be owed by Mark's
tives become far more problematic. One that is fre- therapist to these individuals, if at all? In common
quently exercised is not to interfere with the patient's practice in the substance abuse field, the purchase
leaving the treatment setting but to inform the police and/or sale of illegal drugs by clients is not reported
immediately upon his departure. However, liability to enforcement officials, perhaps because the behav-
could be incurred if the police find the intoxicated ior is considered largely involuntary.
individual too late or fail to locate him or her at all. Under the federal confidentiality statute, a sub-
Alternatively, the police could be asked to come to stance abuse therapist may, with appropriate consent,
the treatment setting and discuss the matter directly make reports to the criminal justice system. Indeed,
with the patient. Either action involves a breach of the statute helpfully provides a model form for the
confidentiality if carried out without the patient's ex- release of information. However, "the consent form
plicit consent, which is unlikely to be granted in must be recognized for what it is: nothing more than
such circumstances. evidence that informed consent has been obtained.
Forcible restraint of the intoxicated individual Virtually the only way to obtain informed consent is
and/or confiscation of his or her keys often becomes through a conversation" (Vaccarino, 1978). That is,
 LEGAL AND ETHICAL ISSUES 409

the therapist and the patient must have discussed the mother. The children may be in danger. What is in-
release of information in detail, until the therapist is volved in Maria's episodes of loss of temper? It is pos-
satisfied the patient has a clear and exact understand- sible that physical abuse of the children may have
ing of how sensitive information provided to the ther- occurred, or could occur, especially if Maria is drink-
apist will be dealt with. ing actively while the children are in her care.
Patients have testified in subsequent legal actions To be sure, she has stated that she does not drink
that they signed a consent form as a matter of rou- under these circumstances, and in general, the self-
tine, and that those who obtained the written consent report of persons who use alcohol excessively is valid
failed to have such a crucial conversation with them. (Babor, Stephens, & Marlatt, 1987). But such valid-
In some cases, courts have agreed with the patient: ity may be compromised when there are direct and
"The over-riding importance of the conversation can- certain consequences of what is reported, and it is
not be minimized. . . . Informed consent should al- generally understood that reporting child abuse to
ways be viewed in terms of the direct discussion be- the relevant authorities is legally mandatory in most
tween the [therapist] and the patient" (Vaccarino, jurisdictions. Further, loss of temper during a hang-
1978, p. 455). It seems unlikely that Mark's therapist over cannot reasonably be considered devoid of the
had specifically stated he would report Mark to his possibility of physical abuse on a prima facie basis.
probation officer if he learned the patient was selling Certainly, the therapist needs to explore with Ma-
drugs. Under those circumstances, Mark would not ria the details of her interaction with her grand-
be likely to have divulged this information. There- daughters. But this may well leave the issue unre-
fore, despite "an appropriately endorsed release from solved. Permission could be sought from Maria to
Mark to speak with the probation officer," one could discuss details of her case with her daughter; seeking
conclude that informed consent on this point does collateral information is a commonplace of clinical
not exist, and that divulging the information does practice in the addiction field generally. However, to
constitute a legal breach of confidentiality. raise the issue of possible child abuse with Maria's
Finally, there is the consideration that if Mark's daughter without indicating explicitly in the conver-
freedom were abrogated by the therapist's disclosure, sation with Maria preceding the collateral interview
Mark's therapy would end. The therapist's percep- that this will be done vitiates informed consent (see
tion of the likelihood that Mark would benefit from the discussion on informed consent in the case of
therapy could therefore become a factor in the calcu- Mark above).
lus leading to a decision as to what to do. Beyond It is not beyond the realm of possibility that Maria
this, the therapist may take into account the financial might agree to an explicit discussion with her daugh-
implications of Mark's loss to therapy. If, as can hap- ter regarding whether physical abuse had occurred
pen, the income from Mark's treatment represents or was likely to occur. This would smooth the way
a significant portion of the therapist's income, the for the collateral interview but might not resolve the
therapist should be appropriately cautious that this issue. The possibility exists that Maria and her
factor does not unduly influence his decision. daughter will collaborate in covering up the physical
In the final case vignette of Maria, a 58-year-old abuse of the children, out of her daughter's loyalty to
widow who is self-referred to treatment for episodic Maria or for other reasons. If at the close of the col-
drinking, the therapist has learned that she has daily lateral interview the therapist continues to feel in
responsibility for the care of her young granddaugh- doubt regarding the facts of the case, it may be nec-
ters. Maria admits to having lost her temper on occa- essary to set the wheels in motion for an independent
sion with the children as a consequence of her drink- evaluation by an external agency.
ing. But she reports she has been abstinent for 6 Once again, this therapeutic situation raises a di-
weeks and denies that she drinks while she is caring lemma with regard to the issue of breach of confi-
for the children; her loss of temper, she says, occurs dentiality. The current federal confidentiality statute
only when she has been hung over from a heavy covering substance abusers in treatment does provide
drinking bout. for the reporting of child abuse where state law
Once again, the duty of care that the therapist makes this mandatory. But this does not necessarily
owes to Maria may be partially distributed; it may be resolve the ethical dilemma in this particular case. As
owed in part to Maria's grandchildren and to their noted at the beginning of the chapter, what is legal is
410 PRACTICE ISSUES

not necessarily ethical, and vice versa. If a blanket the principle of confidentiality. This is particularly so
assurance of confidentiality has been issued, or ap- with regard to the provisions of the current federal
pears to have been issued, and is then violated, an regulations regarding the treatment of persons with
ethical problem exists. There is also the issue of po- problems related to drugs or alcohol. They project a
tential future child abuse. Laws in general become high level of confidentiality, approaching the abso-
operative only when an action has occurred, not be- lute. We surmise that the purpose of such a high
cause it might occur. It could be argued that if the standard is to encourage prospective clients to enter
mother of the children has been made aware of the treatment. That high levels of confidentiality assur-
possibility of physical abuse, any duty of care to the ance would accomplish this desirable end is certainly
children in this regard has been discharged, since possible, though to our knowledge no empirical data
protecting the children has now become the moth- are available to support it.
er's responsibility. Perhaps the reader will find these Few, however, would disagree that confidentiality
arguments persuasive; perhaps not. The authors do as a general principle is a critical component of the
not find them so. therapeutic situation, and that its protection requires
Our detailed consideration in this section of the vigilance and energy on the part of therapists. Pro-
four fictitious case vignettes presented at the outset gram directors as well as therapists have been incar-
has yielded a quite consistent finding with major le- cerated on occasion when they refused to back down
gal, ethical, and moral implications. In many thera- on protecting the confidentiality of their program
peutic situations, the therapist will discover that he records, and we applaud their highly principled ac-
or she owes a duty of care not only to the designated tions. There have also been egregious instances of
patient but to other individuals or entities as well. the violation of confidentiality, particularly in the po-
We have termed this a partially distributed duty of litical arena; it is manifestly a principle that requires
care. The case examples do not exhaust all of the ethical and legal protection, at least to some degree.
circumstances in which a partially distributed duty of Thus, in situations in which the duty of care is
care may arise. partially distributed, it is likely that the therapist's
The degree to which therapists are ethically ethical responsibility to a person other than the des-
obliged to consider the welfare of persons or entities ignated patient will come into conflict with the ther-
other than their patients or clients must always be apist's ethical responsibility to maintain confidential-
a matter of judgment in each individual case. The ity. Under these circumstances, the therapist faces an
overriding ethical principle, we believe, is that all in- ethical dilemma, which arises "when two or more
dividuals have a substantial level of responsibility for values, principles, or obligations conflict and uncer-
other individuals. Therapy is not apart from life but tainty prevents [an] intuitive response" (Woody,
is an integral part of life. As life itself is subject to 1990, p. 133). Nor are therapeutic situations in
legal and ethical constraints, so therapy must be simi- which there is an undistributed duty of care (see
larly subject to such constraints. Legal and ethical above) or a wholly distributed duty of care (see be-
concerns do not stop at the therapist's door. Individu- low) devoid of such dilemmas. The question then
als in our society are highly interdependent; the ac- becomes how one goes about solving ethical dilem-
tions of anyone may affect everyone, and any action mas. This will be the subject of the next major sec-
of any individual is virtually certain to affect others tion of the chapter.
in a significant manner. Therapeutics must take this
into account. The principle of responsibility for oth-
The Wholly Distributed Duty of Care
ers, after all, is not really a new idea. In the fourth
chapter of Genesis, Cain asks whether he is his Before proceeding to that discussion, however, it is
brother's keeper. The response is generally interpre- necessary to mention a final variant of the distribu-
ted as being in the affirmative. tion of the duty of care. Thus far, we have discussed
In addition to showing that a partially distributed situations in which the duty of care (a) is owed
duty of care often comes into being in the therapeu- wholly to the designated patient and (b) is owed
tic situation, the case examples also show that this partly to the designated patient and partly to other
kind of duty of care often comes into conflict with individuals and/or institutions. We have now to con-
 LEGAL AND ETHICAL ISSUES 411

sider situations in which the duty of care (c) is owed, to the more common therapeutic situation so that
at least in theory, not at all to the individual who is this misconception may be quite frequent.
the subject of the clinician's attentions but entirely This similarity may have implications for the ther-
to another individual or, more commonly, an institu- apist, too. He or she may be lulled into a suspension
tion. of responsibilities to the third party and revert to act-
This third situation, which may be termed a ing on behalf of the patient. Indeed, it is difficult to
wholly distributed duty of care, occurs when the clini- accept that some allegiance is not owed to the pa-
cian is acting at the behest of (and commonly in the tient, even under these circumstances. With the pro-
employ of) a third party. A person who is at other jected growth of managed care and of group rather
times a caregiver may examine individuals on behalf than individual practice situations, the opportunity
of a court of law, for example, to determine compe- to explore the legal, ethical, and moral implications
tency to stand trial. Under such circumstances, it of a wholly distributed duty of care is likely to be
may seem to the individual being examined that he much greater in the future.
or she is being cared for by a helping professional as
he or she would ordinarily be. But this is not the
case. RESOLVING ETHICAL DILEMMAS
It is crucial under such circumstances for the in-
dividual being dealt with by the therapist to under- As we have tried to show, ethical, legal, and moral
stand that the helping professional is an agent of the dilemmas are a common feature of clinical situa-
court or of another institution and is not the individ- tions. Moreover, such dilemmas arise not necessarily
ual's personal agent, and that the professional's con- because therapists fail to behave appropriately
clusions may be contrary to the individual's interest. (though this may happen), but because they are in-
Another way of saying this is that informed consent herent in the therapeutic situation itself. This being
under such circumstances is crucial. Failure to pro- so, it becomes important to understand how to pro-
vide a precise understanding of the agency of the cli- ceed toward a solution to a given ethical dilemma
nician—that is, in whose interest he or she is act- that represents the best compromise between the
ing—constitutes an unacceptable level of deception. competing laws, regulations, values, principles, or
Similar circumstances apply when the caregiver obligations involved.
is in the employ of a company, such as an employee Precisely because there is always something to be
assistance program or, as is increasingly common, a said in favor of either of the horns of an ethical di-
managed-care organization. In a typical situation, an lemma, resolving such situations is not an easy pro-
individual may meet with a professional employed cess. And for the same reason, whatever solution is
by a managed-care organization whose assignment is reached will often be less than completely satisfac-
to determine whether the organization should pro- tory. A knowledgeable commentator has observed, "It
vide care to the individual. Serious concerns have seems that any decision we make will violate one or
already surfaced that professionals in these circum- another value which we hold dear" (Hundert, 1987,
stances may base their therapeutic decisions not p. 839). He goes on to explain:
upon the needs of the individual but on the profit
margin of the organization. Unfortunately, the many values that bear on any
Such situations seem to be relatively straightfor- given dilemma are what philosophers call "in-
ward. One simply informs the individual of the facts commensurable." That is, it is impossible to
of the situation and then proceeds. Once again, how- quantify just how much one value (say, social
welfare or telling the truth) is "worth" in terms of
ever, the matter is more complex than it may appear.
another value (say, individual liberty or relief
There is evidence that irrespective of what individu-
from suffering). Yet, as we choose among possible
als may be told in a discussion on informed consent, actions, we are often forced to balance one in-
they nevertheless persist in believing that a clinician commensurable value against another, to balance
will invariably act in their interest (Appelbaum, a patient's individual liberty against social welfare,
Roth, & Lidz, 1983). Being dealt with by a clinician to balance our standards of truth-telling against
in the employ of a third party is sufficiently similar the relief of suffering, (p. 839)
412 PRACTICE ISSUES

Woody (1990) has proposed a "pragmatic model" remain. It may be the case, as the epigraph to this
for resolving ethical concerns in clinical practice. chapter would have it, that "there are things that one
She suggests that there are five "decision bases" or does, and there are things that one does not do," but
sources of information regarding right conduct that in the therapeutic situation, it is not always an easy
therapists should consult in the process of arriving at matter to tell the difference.
the best solution: (a) theories of ethics, (b) profes-
sional codes of ethics, (c) professional theoretical
Note
premises, (d) the sociolegal context, and (e) the per-
sonal/professional identity. Her fundamental sugges- The opinions expressed in this chapter are those of the
tion is that each of these five decision bases should authors and not necessarily those of the editors. The au-
be systematically plumbed for all of the information thors would like to thank Barbara McCrady, Elizabeth
it can yield that is relevant to the specific case, and Epstein, and Renee Willis for their constructive com-
that all of this relevant information should then be ments on earlier drafts of the chapter.
weighed and balanced in arriving at the best solu-
tion. She helpfully provides examples of actual cases Key References
in which this approach proved effective in formulat-
ing a resolution of an ethical dilemma. Bissell, L, & Royce, J. E. (1987). Ethics for addiction
Yet she candidly admits that the use of these professionals (2nd ed.). Center City, MN: Hazelden.
guidelines does not eliminate all difficulties. Each of Spring, R. L., Lacoursiere, R. B., & Weissenberger, G.
(1997). Patients, psychiatrists, and lawyers: Law and
the "decision bases" may provide conflicting infor-
the mental health system (2nd ed.). Cincinnati, OH:
mation. She notes, for example, that "there are sev-
Anderson.
eral theories of ethics, and a given decision is likely
Woody, J. D. (1990). Resolving ethical concerns in clin-
to vary depending on which theory is used" (p. 134).
ical practice: Toward a pragmatic model. Journal of
She recognizes that a given therapist may be a mem- Marital and Family Therapy, 16, 133-150.
ber of more than one professional organization, each
of which may have its own ethical code, and that
"the various codes may not mesh on some issues" (p. References
138). Different professional theories "will offer di-
Appelbaum, P. S., Roth, L. H., & Lidz, C. (1983). The
verse and contradictory positions on how to serve the
therapeutic misconception: Informed consent in psy-
client's welfare" and often "are largely unvalidated chiatric research. International Journal of Law and
hypotheses" (p. 139). They also "take diverse posi- Psychiatry, 5, 319-29.
tions on the personhood and personal influence of Babor, T. F., Stephens, R. S., & Marlatt, G. A. (1987).
the therapist versus neutrality and technical compe- Verbal report methods in clinical research on alco-
tence" (p. 143). While expressing the hope that her holism: Response bias and its minimization. Journal
theoretical model "will promote increased objectiv- of Studies on Alcohol, 48, 410-424.
ity," she concludes that "In the final analysis we are Bissell, L., & Royce J. E. (1994). Ethics for addiction
left with the messy reality that clinical decision mak- professionals (2nd ed.). Center City, MN: Hazelden.
ing consists of an unpredictable mix of intuition and Brickman, P., Rabinowitz, V. C., Karuza, J., Coates, D.,
rationality" (p. 144). Cohn, E., & Kidder, L. (1982). Models of helping
As may well be imagined, it is often more difficult and coping. American Psychologist, 37, 368-384.
Brower, K. J., Blow, F. C., & Beresford, T. P. (1989).
to negotiate these troubled waters alone than it
Treatment implications of chemical dependency
would be in the company of a knowledgeable pilot.
models: an integrative approach. Journal of Sub-
In many locations, experienced ethicists are available
stance Abuse Treatment, 6, 147-157.
for consultation, and many institutions have ethics
Curran, W. J. (1975). Law-medicine notes: confidential-
committees that are well versed in the resolution of ity and the prediction of dangerousness in psychiatry.
dilemmas of this kind. Their help can be sought and New England Journal of Medicine, 293, 285-286.
may be useful. The same may be said for lawyers Denenberg, T. S., & Denenberg, R. V. (Eds.). (1996).
who specialize in health law. Ultimately, though, the Attorney's guide to drugs in the workplace. Chicago:
inherent ethical difficulties in clinical situations will American Bar Association.
 LEGAL AND ETHICAL ISSUES 413

Dickens, B. M. (1986). Legal issues in medical manage- spectives with which it is often confused. Journal of
ment of violent and threatening patients. Canadian Studies on Alcohol, 55, 159-166.
Journal of Psychiatry, 31, 772-780. Shuster, E. (1997). Fifty years later: the significance of
Eberlein, L. (1980). Legal duty and confidentiality of the Nuremberg code. New England Journal of Medi-
psychologists: Tarasoff and Haines. Canadian Psy- cine, 337, 1436-1440.
chologist, 21, 49-58. Siegler, M., & Osmond, H. (1968). Models of drug ad-
Fingarette, H. (1979). How an alcoholism defense works diction. International Journal of the Addictions, 3,
under the ALI Insanity test. International Journal of 3-24.
Law and Psychiatry, 2, 299-322. Siegler, M., Osmond, H., & Newell, S. (1968). Models
Fleming, J. G., & Maximov, B. (1974). The patient or of alcoholism. Quarterly Journal of Studies on Alco-
his victim: The therapist's dilemma. California Law hol, 29, 571-591.
Review, 62, 1025-1068. Spring, R. L., Lacoursiere, R. B., & Weissenberger, G.
Hundert, E. M. (1987). A model for ethical problem (1997). Patients, psychiatrists, and lawyers: Law and
solving in medicine, with practical applications. the mental health system (2nd ed.). Cincinnati: An-
American Journal of Psychiatry, 144, 839-846. derson.
Lazare, A., Eisenthal, S., & Wasserman, L. (1975). The Vaccarino, J. M. (1978). Consent, informed consent,
customer approach to patienthood: Attending to pa- and the consent form. New England Journal of Medi-
tient requests in a walk-in clinic. Archives of General cine, 298, 455.
Psychiatry, 32, 553-558. Wilson, J. Q. (1993). The moral sense. New York: Free
Midgley, M. (1991). Can't we make moral judgments? Press.
New York: St. Martin's Press. Woody, J. D. (1990). Resolving ethical concerns in clin-
Miller, W. R., & Kurtz, E. (1994). Models of alcoholism ical practice: A pragmatic model. Journal of Marital
used in treatment: Contrasting AA and other per- and Family Therapy, 16, 133-150.
 23

Credentialing, Documentation,
and Evaluation

Theresa B. Moyers
Reid K. Hester

There are two conflicting aspects to a discussion of professions including physicians, psychologists, social
credentialing, documentation, and evaluation. On workers, and counselors. Unlike most other health
the one hand, these topics are typically not as inter- problems, the treatment of substance abuse has also
esting as the clinical material our clients bring to been powerfully influenced by recovering substance
therapy. On the other hand, they are, in a number abusers, and intervention by paraprofessionals is still
of ways, helpful in improving the effectiveness of the an accepted standard of care in many settings. Re-
interventions we use with clients. Our goal in this cent changes, including legal consequences for mal-
chapter is to provide a road map to understanding practice as well as pressure from third-party payers,
these topics and to help locate additional resources have stimulated a need for treatment providers in the
to pursue credentialing, improve documentation, addictions field to demonstrate proficiency in the
and/or improve the effectiveness of treatment with specific treatment they provide. While it was pre-
evaluation. viously possible to practice safely under the umbrella
of a professional degree in a related field or even the
hard-won experience of recovering from an addic-
CREDENTIALING FOR tion, it is now prudent for providers to obtain creden-
TREATMENT OF tials indicating a standard of specific competence in
SUBSTANCE USE DISORDERS the treatment of chemical dependency. The follow-
ing is a brief overview of the manner in which vari-
Like most complex and devastating health problems, ous professionals currently obtain documentation of
the treatment of addiction draws upon a variety of such competence.

414
 CREDENTIALING, DOCUMENTATION, AND EVALUATION 415

dictive behaviors. State licensure laws are highly vari-

Physicians
able and may demand as little as 1 year of supervised
There currently is not a board-certified medical spe- experience and 120 hours of classroom instruction
cialty for addictions, although there are plans to es- or as much as 3 years of supervised experience and
tablish a board of addiction medicine. At this time, 450 hours of classroom instruction for an entry-level
physicians wishing to show proficiency in the treat- license. Some states do not require a license for
ment of substance abuse may sit for a certification counselors wishing to provide substance abuse treat-
examination through the American Society for Ad- ment.
diction Medicine (ASAM). Certification requires In addition to state licensure, there are two na-
successful completion of a national examination, one tional organizations which certify competency for ad-
year's full-time involvement in the field of alcohol- diction counselors. The International Certification
ism and other drug dependencies, and 50 hours of Reciprocity Consortium (ICRC) issues certification
continuing education (CE) pertaining to alcoholism for three types of practitioners: (a) alcohol and drug
and drug treatment. In addition to ASAM certifica- counselors, (b) clinical supervisors, and (c) preven-
tion, a specialty certification in addiction psychiatry tion specialists. Alcohol and drug counselors need 3
is available through the American Psychiatric Associ- years of supervised experience, 270 hours of educa-
ation. tion, and 300 hours of training specifically related to
the 12 core functions of substance abuse treatment.
The National Association of Alcohol and Drug
Abuse Counselors (NAADAC) also certifies three dif-
Psychologists
ferent levels of providers: (a) National Certified Ad-
Likewise, psychologists do not have a board specialty dictions Counselor Level I, which requires 3 years'
for addictive behaviors. There are plans to add an supervised experience; (b) National Certified Ad-
addictions specialty to the American Board of Profes- dictions Counselor Level II, which requires a bacca-
sional Psychology (ABPP) diplomate examinations. laureate degree, 5 years' experience, and 450 class-
This would be intended to demonstrate advanced room hours in substance abuse content; and (c)
clinical competence. Currently, doctoral-level psy- Master Addictions Counselor, which requires a
chologists wishing to show competence in the treat- master's degree, 2 years' postmaster's experience, and
ment of addictions may obtain a Certificate of Pro- 550 classroom hours of substance abuse content.
ficiency in the Treatment of Alcohol and Other NAADAC certification requires counselors to pass an
Psychoactive Substance Use Disorders, developed by examination specific to each level.
the College of Professional Psychology of the Ameri- Counselors will probably choose between these
can Psychological Association. This Certificate is de- two organizations depending on the requirements of
signed to show entry-level proficiency. It requires their state licensing board; many state boards borrow
successful completion of a national examination and the exams from either the ICRC or the NAADAC
documented experience treating addictions for one as their entry-level examination. Membership in one
year. organization does not preclude membership in the
other, and each offers particular benefits which may
be of interest to specific applicants.

Counselors

Counselors are not defined by their educational

Social Workers
backgrounds as are other disciplines. Depending on
the state, individuals may or may not need a specific At this time, there is no organization which certifies
educational degree to call themselves counselors. proficiency for social workers for the treatment of ad-
Typically, a counselor is someone who has either ed- dictive behaviors. Social workers wishing to focus
ucation or experience in a health-related field. their clinical activities in this area are eligible to ob-
There are several routes available for counselors tain both licensure through states boards and certifi-
who wish to show proficiency in the treatment of ad- cation through either the ICRC or the NAADAC.
416 PRACTICE ISSUES

DOCUMENTATION demographic information about the client and a clear

picture of the addiction, including consequences of
Many therapists consider record keeping one of the use in all life domains, dependence or medical se-
banes of their existence. Why bother to keep detailed quelae, and some measure of consumption. In addi-
notes on interactions with clients when the grist of tion, an assessment interview should yield a diagnosis
clinical work should take precedence? Clinicians of- from a formal coding system such as DSM-IV (Amer-
ten feel that they are forced to make a choice be- ican Psychiatric Association, 1994) or ICD-9 (World
tween writing notes about their clients and seeing Health Organization, 1980). A more complete assess-
them. This dilemma has intensified with the ava- ment would include evaluation for comorbid psychi-
lanche of documentation often required by man- atric disorders known to be more common in this
aged-care organizations and accrediting agencies. population, including mood disorders and antisocial
That said, there are some compelling reasons to doc- personality disorder, as well as a determination of sui-
ument what we do. cidal and homicidal risk.
Written documentation of client contacts forms a Assessment standards from JCAHO for 1997-
record which serves at least three functions. First, 1998 state that all clients receiving treatment for
and most important, a written record allows the clini- chemical dependency should, in addition to a stan-
cian to provide consistent treatment. Second, docu- dard assessment, have specific items relating to sub-
mentation is a legal record to provide evidence in stance abuse addressed. (See table 23.1 for examples
the event that there is some question about the type of the intent of these standards.)
or quality of care clients have received. Finally, the Such documentation is difficult even under con-
chart provides a yardstick for certifying agencies (e.g., ditions where substance use is recent, the interviewer
Joint Commission on Accreditation of Health Care is skilled, the client is highly functional, and the cli-
Organizations [JCAHO] and National Committee ent is prepared to discuss his or her substance abuse
on Quality Assurance) and managed-care organiza- openly. A more typical clinical scenario is one in
tions to assess the quality of care given by the organi- which the client's substance use has spanned many
zation as a whole as well as individual practitioners. years, perhaps with a variety of different drugs. There
In general, all client contacts which lead to may be medical, legal, and social consequences of
meaningful clinical interactions should be docu- this use, and the client may be forgetful, irritable,
mented with a chart note. This would include, for or dishonest when reporting his or her history. The
example, phone calls and consultations with other interviewer may have limited interest in the goal of
professionals about the client's care but would not assessment, perhaps viewing it as a hurdle prior to
include a simple phone call to cancel and resched- the honest work of therapy. Furthermore, the time
ule an appointment. The intent of the documenta- allotted to complete substance abuse assessments is
tion is to provide an ongoing record of the client's typically limited.
progress as well as any information which would be Within this more typical scenario, the value of a
needed in the event that another professional should structured assessment instrument becomes obvious.
undertake care of the client. Chart notes should in- Structured assessments ensure that important infor-
clude an assessment, a treatment plan, a discharge mation will not be disregarded or forgotten. They
summary, and notes for each client contact. Specific provide an efficient method for gathering a large
requirements for therapists treating substance-depen- number of data in a limited time, and they often
dent clients are discussed below. have the added advantage of yielding standardized
indicators of client functioning which can be used as
follow-up measures after treatment completion. Al-
Assessment
len and Columbus (1995) profiled many such stan-
A thorough assessment is necessary to discover the dardized instruments as well as data on reliability
extent and severity of substance use as well as client and validity for each in an excellent sourcebook pro-
problems and functioning in other domains which vided free of charge by National Institute on Alco-
may influence treatment. At a minimum, the assess- hol Abuse and Alcoholism and includes self-report
ment should contain an introduction to the relevant questionnaires and structured clinical interviews (see
 CREDENTIALING, DOCUMENTATION, AND EVALUATION 417

TABLE 23.1 Joint Commission on Accreditation of Health Care Organizations: Intent of

Special Assessment of Individuals in Chemical Dependency Programs and Services

Factors assessed and considered in providing services to the individual served include
—Identifying the physical, emotional, behavioral, and social functioning of the individual before the onset of chemi-
cal dependency.
—Evaluating the effects that chemical dependency has had on each individual's physical, emotional, and social well-
being.
—Evaluating patterns of use, for example, continuous, episodic, or binge use.
—Identifying consequences of use, for example, legal problems, divorce, loss of friends, job-related incidents, finan-
cial difficulties, blackouts, and memory impairment.
—Assessing the history of physical problems associated with chemical dependency to help substantiate the diagnosis,
to anticipate potential medical problems related to chemical withdrawal management, to identify the individual's
level of function, and to help the individual who is minimizing the physical consequences of dependence.
—Assessing information about the use of alcohol or other drugs by family members to enhance understanding of the
individual's behavioral dynamics and help determine the potential for extended-family support, as well as the im-
pact of family circumstances on treatment.
—Assessing each individual's spiritual orientation, which may relate to the dependency in terms of how the individual
views himself or herself as an individual of value and worth. Spiritual orientation is not considered synonymous
with an individual's relationship with an organized religion.
—Assessing any previous treatment and response to the treatment to see whether the individual responded appropri-
ately to the treatment and if expected outcomes were achieved. If not, what revisions were made, if any?
—Assessing whether the individual has experienced a history of abuse (including physical or sexual abuse as either
the abuser or the abused) that may affect the individual's ability to address his or her dependence.

Note. From Comprehensive Accreditation Manual for Behavioral Health Care 1997-98. (1996). Used with permission of the Joint Commission
on Accreditation of Health Care Organizations. JCAHO, Oakbrook, IL.

also chapter 11). The specific instrument selected A treatment plan should list specific behavioral
will be determined by the needs of the practitioner, goals for the problems identified, criteria for deter-
the agency or hospital, and the client populations mining success, and an estimated time frame for
served. completion. It should reflect collaboration with the
client and should include his or her unique prob-
lems, perceptions, and solutions.
Treatment Plan
For those working in JCAHO-accredited settings
A treatment plan is any written document which (e.g., hospitals), there are standards for formulating
specifies the interventions that will be used to ad- treatment plans, but they do not have components
dress symptoms identified in the assessment. For specific to treating substance abuse. In general, these
chemical dependency, every treatment plan should standards require that the treatment provider involve
include goals of change in drinking and/or drug use, other members of the multidisciplinary team such as
problems achieving initial abstinence or moderation dietitians, recreational therapists, mental health pro-
of consumption, relapse prevention, and mainte- viders, and family members, when appropriate.
nance of abstinence or return to nonharmful use. Ad- There is also an emphasis on periodic review and
ditional components directly related to substance revision of the treatment plan at timely intervals
abuse that may require notation include craving and (Joint Commission on Accreditation of Healthcare
urges, social pressures to use, and skills training. A Organizations, 1996).
variety of other concerns may be addressed in a As with assessment, the task of writing a treatment
chemical dependency treatment plan when ap- plan can sometimes be seen as a time-consuming pa-
propriate, including cognitive testing, therapy with perwork hurdle before beginning urgently needed
family members, vocational rehabilitation, and recre- treatment. Nevertheless, treatment plans written by
ational enrichment. When comorbid psychiatric dis- experienced clinicians often reflect the unique needs
orders are identified in the treatment plan, specialists and qualities of the client so vividly that the client
may be designated to address these issues. can be "seen" by the reader. One exercise for the
418 PRACTICE ISSUES

novice writer of treatment plans is to imagine that dangered, this must be reported. Naturally, it is pru-
other providers are reading the plan and trying to dent to include clients as much as possible in the
identify the client from his or her notations (i.e., process when such disclosures must be made.
"name that client"). This may help to bring the Finally, providers may be compelled to release
unique characteristics of the client to the document, confidential information when presented with a sub-
reflecting the careful thought the clinician has actu- poena. Laws vary among states, and providers usually
ally given to the problems he or she is treating. consult with an attorney before complying with sub-
poenas. Nevertheless, this, along with the other lim-
its of confidentiality, should be discussed with clients
Discharge Summary
before beginning treatment.
The discharge summary provides a concise summary
of the client's problems and the treatment provided.
It also describes any recommended future care. It is Confidentiality of Clients Participating in
written at the point that the provider or program no Treatment Outcome Studies
longer maintains active responsibility for care of the Clients who participate in federally funded treatment
client (i.e., when treatment has ended). It should outcome studies have additional protections of pri-
serve as a reference for future providers who may vacy provided by a confidentiality certificate. A confi-
need to examine a history of several hospitalizations dentiality certificate is issued by the funding institute
or treatment episodes. (e.g., National Institute on Alcohol Abuse and Alco-
holism) to the principal investigator of the study. The
Confidentiality certificate authorizes those therapists and researchers
connected to the study to withhold the names and
Many clients expect a shroud of confidentiality to identifying characteristics of study participants. The
surround their treatment for substance abuse. They Public Health Service Act (42 U.S.C) states, "Per-
expect providers to honor their ethical and legal obli- sons so authorized to protect the privacy of such indi-
gations regarding privacy of the therapeutic interac- viduals may not be compelled in any Federal, State,
tion. However, this shroud of privacy can be pierced or local, civil, criminal, administrative, legislative, or
by others outside the therapeutic relationship. Insur- other proceedings to identify such individuals." This
ance and managed-care organizations may demand protection of confidentiality is permanent.
specific information about the treatment plan and di-
agnoses. By using their insurance benefits, clients re-
linquish their right to keep such information private
from these organizations. Clients may not under- EVALUATION
stand this, and it is the therapist's obligation to edu-
cate clients before any confidential information is Providing treatment without evaluating the outcome
discussed. Clients wishing to protect their privacy is like playing golf in the fog. The practitioner can
may choose to pay for their treatment themselves. marvel at the power of his or her swing and how well
the ball has left the head of the club but still have
no idea if the ball is anywhere near the hole or even
Legal Obstacles to Maintaining on the fairway. Evaluation tells the provider whether
Confidentiality the ball ended up on the fairway or in the rough.
There are certain circumstances in which a provider
can be compelled to release confidential information
Types of Evaluation
against the wishes of the client. If the provider be-
lieves that clients are a genuine risk either to them- There is a range of intensity and complexity in the
selves or to another person, he or she is legally obli- continuum of evaluation efforts. At one end are indi-
gated to attempt to prevent harm. This may include vidual practitioners who consistently follow up with
informing authorities of such a risk, thereby violating their clients after therapy is completed. Within insti-
confidentiality. Similarly, in many states, if the pro- tutions, evaluation might involve programwide fol-
vider has a reasonable suspicion that a child is en- low-up of clients after treatment. More systematic
 CREDENTIALING, DOCUMENTATION, AND EVALUATION 419

evaluations include quality assurance (QA) and for- ment in a variety of domains gives a more complete
mal treatment outcome research. picture of the client's substance use, the conse-
QA is a reciprocal process of assessing client out- quences of it, and the helpfulness of treatment.
comes and then using those outcomes in a feedback There are a variety of instruments to help provid-
loop to enhance treatment within the program. Areas ers collect outcome data (Allen & Columbus, 1995).
of investigation are typically chosen if they are high- Some require relatively little effort, although most
risk, high-volume, or problem-prone. QA results, be- are comprehensive enough to answer research and
cause they are intended for institutional improve- programmatic questions about outcomes. Typically,
ment, should not be published without prior review these measures are linked to the pretreatment evalua-
by an institutional review board (IRB) and the con- tion. Ideally, both assessment and follow-up instru-
sent of the participants involved. ments should be selected prior to treatment. How-
Formal substance abuse treatment research usu- ever, even without such forethought, a variety of
ally, but not always, involves more detailed evalua- interesting questions can be answered when clients
tion of outcomes and must survive IRB review prior return for follow-up after completing treatment. It
to implementation. While the results can be used to also gives the therapist an opportunity to offer addi-
improve treatment within a specific program, as QA tional and/or different treatment if the client's out-
does, they are also typically published to contribute comes are unsatisfactory.
to the body of scientific knowledge. Because of the
overlap in these two activities, practitioners with ex-
pertise in research and substance abuse are ideally CONCLUSION
suited for planning and implementing QA activities
and treatment research. Credentialing, documentation, and evaluation, while
all involving paperwork, provide benefits to clients,
structure to the treatment process, and protection for
Outcome Measures in Evaluation
the provider. Credentialing provides some assurance
Although abstinence has traditionally been the "gold to clients that providers are competent to deliver the
standard" in evaluating substance abuse treatment, treatments they offer. Documentation in the form of
relying on it as a single or primary measure of effec- assessment and treatment planning helps the pro-
tiveness is fraught with difficulty. First, complete ab- vider conceptualize the case and provides a record
stinence constitutes an unrealistic and unhelpful of treatment efforts. Evaluation helps providers and
standard of success. Since the treatment literature programs alike know the impact of their efforts and
consistently documents very low abstinence rates can inform them about the types of clients with
even with the best treatment available (Miller et al., whom they are most successful.
1995), providers do themselves a disservice by not
using a continuum of success to evaluate client out-
comes. Furthermore, clients may moderate their RESOURCE LIST
drinking or drug use in a variety of ways that reduce American Psychological Association, College of Profes-
harm to themselves and others without totally ab- sional Psychology, 750 First St. NE, Washington,
staining. The use of continuous measures is a more DC 20002-4242; 202-336-6100; 202-336-5797 (fax);
sensitive measure of treatment success. For example, E-mail apacollege@apa.org; web site: www.apa.org.
the number of drinks per drinking day in the month American Society of Addiction Medicine, 4601 N. Park
prior to follow-up will provide a more accurate pic- Ave., Suite 101, Upper Arcade, Chevy Chase, MD
ture of outcome than simply determining if the cli- 20815.
International Certification Reciprocity Consortium,
ent has maintained abstinence or not.
3725 National Dr., Suite 213, Raleigh, NC 27612;
Second, measuring treatment effectiveness using
919-781-9734; 919-781-3186 (fax).
only consumption belies the complexity of the recov- Joint Commission on Accreditation of Healthcare Or-
ery process. Clients may improve along a variety of ganizations, One Renaissance Blvd., Oakbrook Ter-
dimensions, including alcohol and/or drug use, psy- race, IL 60181.
chological functioning, vocational status, familial National Association of Alcohol And Drug Abuse Coun-
and social functioning, and physical health. Assess- selors, Certification Commission, 1911 N. Fort Myer
420 PRACTICE ISSUES

Dr., Suite 900, Arlington, VA 22209; 1-800-548- Joint Commission on Accreditation of Healthcare Or-
0497; 1-800-377-1136 (fax); E-mail naadac@internet ganizations. (1996). Comprehensive accreditation man-
mci.com. ual for behavioral health care 1997-98. Oakbrook,
National Committee on Quality Assurance, 2000 L St. IL: Author.
NW, Suite 500, Washington, DC 20036; 202-955- Miller, W. R., Brown, J. M., Simpson, T. L., Hand-
3500; 202-955-3599 (fax). maker, N. S., Bien, T. H., Luckie, L. F., Montgom-
ery, H. A., Hester, R. K., & Tonigan, J. S. (1995).
What works? A methodological analysis of the alco-
References
hol treatment outcome literature. In Handbook of al-
Allen, J., & Columbus, M. (Eds.). (1995). Assessing alco- coholism treatment approaches: Effective alternatives
hol problems: A guide for clinicians and researchers. (2nd ed., pp. 12-44). Needham Heights, MA: Al-
Bethesda, MD: National Institute on Alcohol Abuse lyn & Bacon.
and Alcoholism. World Health Organization. (1980). ICD 9 CM: Inter-
American Psychiatric Association. (1994). Diagnostic national classification of diseases 9th revision clinical
and statistical manual of mental disorders (4th ed.). modification. Ann Arbor, MI: Commission on Pro-
Washington, DC: Author. fessional and Hospital Activities.
 24

Interfaces between Substance Abuse

Treatment and Other Health and
Social Systems

Susan J. Rose
Allen Zweben
Virginia Stoffel

The purpose of this chapter is to develop a frame- tings. The multiplicity of needs experienced by per-
work for examining the issues surrounding the inter- sons abusing a range of substances, as well as public
relationships of the wide variety of service settings en- and private treatment innovation initiatives, have
countered by substance abusers. It familiarizes the been the driving forces behind a more coordinated
reader with the multiplicity of needs experienced by system of care. However, the development of such
persons with substance-use-related problems, ana- systems, in which diverse settings with diverse goals
lyzes the challenges to the current system of service must interact, requires reaching better consensus on
provision presented by these complex needs, identi- problem definition, goals, procedures, methods, re-
fies the barriers to coordinated care, and suggests ar- ferral pathways, and available resources.
eas for further development of "best practice" with
persons abusing alcohol and other drugs.
In part as a result of using a broader definition of DESCRIPTION OF NETWORK OF
alcoholism and drug abuse, more persons with sub- AGENCIES WITH WHICH SUBSTANCE
stance use problems are being identified at earlier ABUSERSINTERFACE
stages and from a greater variety of sources. For ex-
ample, persons abusing alcohol and drugs can be The boundaries of the alcohol or drug abuse
identified in child protection programs, voluntary (AODA) service system frequently overlap with those
family support agencies, employee assistance pro- of other, related systems, including but not limited
grams, health maintenance organizations, inpatient to child protection systems, primary health care pro-
and outpatient psychiatric facilities, public financial viders, social service systems, criminal justice in-
support programs, and vocational rehabilitation set- stitutions, vocational rehabilitation programs, health

421
422 PRACTICE ISSUES

insurance companies, and the substance abuse treat- (means-based fines, community service, restitution,
ment system. A beginning description of some of the day reporting centers, court-mandated outpatient
types of agencies with which substance abusers come treatment, etc.). More intrusive and restrictive alter-
in contact is necessary to understand the scope of natives include intensive supervision of probation,
their treatment needs and the complications of coor- curfews or house arrest, halfway houses or work re-
dinating these services. lease centers, boot camps, and incarceration for vary-
Child protection systems are designed to identify ing amounts of time and in detention centers, jails,
children at risk of abuse or neglect, and to provide or prisons with varying degrees of security.
for their safety through a continuum of services from Vocational rehabilitation programs emphasize
prevention to reunification and adoption. These sys- work preparation, job-seeking skills, and matching
tems are charged with the protection of minor chil- workers with disabilities to jobs which fully utilize
dren from further harm in their immediate environ- their talents. Employment is used as a key variable in
ments, reducing the risk of future harm to their safety determining successful treatment outcomes for drug
through preventing further maltreatment, improving abuse rehabilitation programs (Platt, 1995).
parental functioning, or removing to permanent sub- Health insurance companies, responding to the
stitute homes children who are adjudicated as being devolution of responsibility and financing of services
unable to ever live safely with their birth families from federal to state auspices, have been a critical
(Downs, Costin, & McFadden, 1996). influence in the development of a model of coordi-
Primary health care providers include providers of nation among treatment systems, as a way to hold
both physical and behavioral health care (mental down the escalating costs of physical and behavioral
health), and the venues of their practice can be cate- health care. As both private and public systems of
gorized into acute, subacute, and long-term settings. care have continued to migrate toward the use of
Acute settings are primarily emergency rooms, hospi- managed care methods, appropriate frequency, and
tal units, 24-hour beds, crisis lines, and outreach intensity and a continuum of care have been empha-
units. Subacute settings include hospitals, ambula- sized as the standard for best practice (Rose &
tory care programs, day treatment programs, inten- Keigher, 1996). To progress toward this goal, health
sive outpatient programs, in-home programs, mental care insurance companies have partnered with health
health centers, and individual practitioners. Long- maintenance organizations (HMOs), managed care
term settings are primarily mental health centers, res- companies (MCOs), and other, more innovative
idential care units or institutions, and practitioners' strategies. The results have been sometimes awkward
offices. Medications are used for physical and severe attempts at coordination among settings with dispa-
mental health disorders, or for more time limited rate goals, procedures, theoretical orientations, and
mood disorders arising from adjustment problems or methods.
acute trauma. Substance abuse practitioners have often found
Nonmedical, community-based agencies consti- themselves in the middle of these changes in the
tute the bulk of the social services system. These so- health care insurance industry, having to master a
cial service agencies provide counseling, support, ad- complex set of requirements for precertification of
vocacy, concrete resources, housing assistance, and substance abuse treatment. These precertification re-
a variety of needed services for people to maintain quirements are unique to specific insurance plans
themselves in the community. Persons seeking help and often make it more difficult to plan treatment
from these settings often do so for a full range of across a variety of clients with individual service
family, individual or marital problems or for other needs. Thus, length of inpatient and outpatient care
life adjustment difficulties. can be dictated by the quality of the insurance cover-
The legal system is a complex array of levels of age, rather than by a standard of best practice among
retribution and rehabilitation initiatives. The balance professional caregivers.
between these two approaches drives a range of op- The current alcohol and drug treatment system is
tions for offenders, from the least restrictive forms of not a unitary entity, but a collection of types of ser-
court supervision to the most restrictive: incarcera- vices. It includes social and medical model detoxifi-
tion in federal penitentiaries. Least restrictive alterna- cation programs, short- and long-term treatment pro-
tives include court-mandated education, diversion grams, methadone maintenance programs, long-term
programs, and some types of intermediate sanctions therapeutic communities, and self-help adjunct pro-
 INTERFACES BETWEEN SUBSTANCE ABUSE TREATMENT AND OTHER SYSTEMS 423

grams (Center for Substance Abuse Treatment stance use problem behaviors (Institute of Medicine,
[CSAT], 1994a). These services themselves maintain 1990). Inherent in these innovations is a recognition
variation in treatment goals and philosophies regard- that persons can be placed on a continuum of prob-
ing abstinence as a prerequisite or as a long-term lem behaviors stemming from their substance use,
goal of treatment. There is also wide variation in ranging from those with severe difficulties (e.g., med-
practitioner requirements among service settings, in- ical, psychiatric, and legal complications) to those
cluding physicians, psychiatrists, psychologists, social with mild or moderate difficulties (e.g., interpersonal
workers, nurses, certified alcoholism counselors, stress). Nonspecialized community agencies that in-
other rehabilitation therapists, and recovering para- teract with substance abusers need to have available
professionals. Medication is used primarily to treat a repertoire of strategies to address the diverse treat-
the complications of addiction, and most programs ment needs of these persons. These strategies include
attempt to end a patient's use of all medications with- methods of screening and assessment of problem be-
in a prescribed period of time. Central to the grow- haviors, use of brief intervention methods, and refer-
ing treatment system are consumer-developed self- ral compliance techniques for those with more seri-
help groups, such as Alcoholics Anonymous (AA), ous problems.
Narcotics Anonymous (NA), Cocaine Anonymous, The first component to consider in assessing the
and Rational Recovery, that serve as an important ad- service network is what definitional parameters are
junct to professional treatments. used to identify alcohol and drug problems. Nonspe-
As substance abusers increasingly use and come cialized settings should have established criteria for
in contact with many nonspecific settings in the determining which individuals are suitable for inter-
complex public and private service system, critical vention in the nonspecialized setting and which per-
challenges to coordination can occur between per- sons might more appropriately be served in a special-
sons seeking help and providers. In particular, how ized facility. The development of such criteria
an individual identifies his or her problem is not al- implies that the agency has the capacity to make dis-
ways consistent with how a service provider might tinctions among individuals with varying levels of se-
identify the same problem. A young mother in the verity of their alcohol or drug problems (Cooney,
child welfare system might see her problem as how Zweben, & Fleming, 1995). Individuals identified as
to have her child returned to her care, while the having mild or moderate levels of severity might be
court might interpret the problem as how to keep suitably treated by agency staff trained in brief inter-
her from further court involvement, and the social vention modalities, while those with more severe
service agency might view the problem as how to problems might more properly be referred to special-
strengthen her coping abilities. These multiple per- ist facilities (Zweben & Barrett, 1997).
spectives must be taken into account in the defini- The second component to consider is what inter-
tion utilized by settings in identifying substance use vention modalities have been incorporated into the
problems, the intervention modalities employed to practice protocols of the agency professionals. Recent
detect and treat substance use problems, and the developments in substance use research suggest that
strategies used to effect a referral to other settings. In brief interventions are a viable, cost-effective alterna-
addition, the barriers presented by particular defini- tive to more extensive specialized methods of treating
tional perspectives, inconsistent goals established in individuals who have lower levels of problem severity
relation to care, the level of client choice in the es- stemming from drinking or drug use (Zweben &
tablishment and implementation of treatment goals, Fleming, in press). Brief interventions have been em-
and the resources available to meet these goals need ployed in a variety of nonspecialized settings such
explication. as employee assistance programs (EAPs), emergency
rooms, and criminal justice programs, to treat nonde-
pendent drinkers and other drug-using populations
EXAMINING THE SERVICE NETWORK (Zweben & Fleming, in press). They can also be em-
FOR TREATING SUBSTANCE ployed to enhance the motivation of more severely
USE PROBLEMS dependent users to engage in specialized treatments.
The third component to consider is what kinds of
Innovations in substance abuse treatments are lead- strategies nonspecialized settings use to effect com-
ing to the adoption of a broader definition of sub- pliance with referral to more specialized substance
424 PRACTICE ISSUES

use treatment programs. In this country, failure rates needs. Once clients are engaged in a particular treat-
for referrals to alcohol treatment programs range ment, efforts are made to involve them in all aspects
from 70% to 90% (Babor, Ritson, & Hodgson, 1986; of decision making about their treatment goals and
Soderstrom & Cowley, 1987; Stephen, Swindle, & action plan. Depending upon the severity of sub-
Moos, 1992). In British substance abuse treatment stance use problems and the preferences of clients,
programs, the rate of dropout after only one session treatment might be aimed at "problem-free drink-
is about 44% (Rees, Beech, & More, 1984; Thorn et ing," reducing harmful consequences of the abuse
al., 1992). Substance abusers have multiple needs (e.g., engaging in a needle exchange program), or
that are difficult to address through the auspices of total abstinence. In addition, in this model, an epi-
one single setting, and these settings are not always sode of drinking or drug use is considered "norma-
able to effect a referral when specific services outside tive" and does not necessarily constitute a total re-
their capabilities are required (Institute of Medicine, lapse or treatment failure.
1990). Effective referral compliance strategies must Specialized settings which mandate abstinence as
be implemented when persons with more severe de- a condition for treatment participation (e.g., proba-
pendence are identified and referred to specialized tion and parole agencies) and request regular AA at-
treatment settings.Failure to move toward resolution tendance may be in conflict with referral sources
of these differences can act as a barrier to effective which promote client choice and individualized
referrals and coordination of care. treatment goals. Nonspecialized programs which
view relapse as a rationale for discontinuation of ser-
vices (e.g., family support programs) may be in con-
BARRIERS TO COORDINATING CARE flict with those treatment settings which promote
BETWEEN COMMUNITY AND harm reduction as a goal or which view relapse as a
SPECIALIZED SETTINGS "normative" aspect of the recovery process (cf. Aus-
tin, Bloom, & Donahue, 1992). For example, some
A significant barrier to coordinated care is that some social service agencies require the client to stop
practitioners in nonspecialized settings have main- drinking before family counseling can begin, and
tained restrictive views of alcohol and drug problems they negotiate differences between client and prac-
despite the introduction of new paradigms into the titioner concerning how the problem behaviors will
substance abuse field. From this more restrictive per- be addressed in the treatment situation. An addi-
spective, substance abuse is considered a degenera- tional example from our own drinking checkup pro-
tive disorder, and the course of the "illness" is ex- gram is that it has been difficult to secure referrals
pected to progressively worsen unless total abstinence from court (e.g., DWIs) and EAPs because of our
is achieved and sustained. In this "disease" model, willingness to consider moderate drinking a goal for
single violations of abstinence (e.g., 1-2 drinks) participants. Clients themselves will be reluctant to
would be tantamount to relapse. At the same time, participate in treatment where there are serious dis-
clients are seen as "powerless" to regulate their own parities between referral source and specialist prac-
problem behaviors, and therefore, reliance is placed titioner with regard to the above issues.
on self-help groups such as AA or NA fellowship. In A third barrier is the availability of resources
these programs, clients are requested to perform a within the setting and within the community to ad-
variety of tasks (e.g., 12 steps) necessary for maintain- dress a continuum of care for persons with substance-
ing an abstinent lifestyle. abuse-related problems. Relevant treatment modal-
Other practitioners have moved away from medi- ities are not always available for persons who are
cal models and toward a public health perspective identified along the continuum of substance-use-re-
on alcohol and drug problems. In the latter model, lated difficulties, despite the ability to effect a referral
clients are viewed as having varying levels of severity or develop common goals in relation to substance
of alcohol or drug problems with differing medical use. This has become an increasingly problematic is-
and psychosocial needs and individual and social sue in nonurbanized areas with only limited re-
coping resources. Individuals seeking help for their sources devoted to substance abuse. For example, in
alcohol or drug problems are given the opportunity Tennessee, in 1995, it was estimated that only 36%
of choosing from a continuum of treatment modal- of the state had any coverage for alcohol or substance
ities available that are relevant to their individual abuse treatment ("Switch To Managed Care,"
 INTERFACES BETWEEN SUBSTANCE ABUSE TREATMENT AND OTHER SYSTEMS 425

1995). In other areas, only limited aspects of a con- event in incidents of sexual abuse (Smith & Kunju-
tinuum of care may be available. It may be only an krishman, 1985) and physical abuse, and as a factor
AA group, or a family service agency, or an outpa- in chronic neglect (Leonard & Jacob, 1988).
tient mental health center available within a 30-mile While some child protection authorities have
radius. taken the position that any evidence of prenatal expo-
The dilemmas and barriers inherent in the coor- sure or use of illegal substances is prima facie evi-
dination of multiple agencies with which persons dence of maltreatment (Roberts, 1990), such connec-
with substance use problems interact can be de- tions have yet to be demonstrated. It is estimated that
scribed for a variety of service systems. The child 5 million women of childbearing age—and more
protection services system, however, is particularly specifically, 27% of women aged 18-25—used alco-
emblematic and merits more detailed analysis. It hol or illicit drugs in 1988 (National Institute on
highlights in particular the difficulties in trying to Drug Abuse, 1992; U.S. Government Accounting
coordinate care among systems with different defini- Office, 1990). One study of hospital discharges re-
tions of substance use problems, different interven- ported an estimate of 38,000 drug-exposed babies
tion methods, and different goals and resources. born in 1987, representing a 361% increase in num-
ber of drug-exposed newborns between 1979 and
1987 (Dicker & Leighton, 1991). Other studies have
CHILD PROTECTION SERVICES estimated the number to be closer to 300,000 (Chas-
noff, 1992). The percentage of children born with
Substance abusers interact with this system at all lev- some type of illegal substance exposure in utero has
els: prevention, family support, investigation, case been variably estimated to be between 2% and 11%
planning, in-home services, substitute care, and (American Academy of Pediatrics, 1990; Besharov,
adoption. They can come into contact with the sys- 1989; Chasnoff, 1989).
tem either through bearing a child with alcohol or However, more children are born alcohol-ex-
drug exposure, through evidence of substance abuse posed than drug-exposed, and the consequences can
as a contributing factor to initial allegations of child be more profound (Earth, 1993a). The risk of fetal
abuse and neglect, or through a caretaker's inability alcohol syndrome (FAS) in an alcohol user's preg-
to keep a child at home safely. nancy has been estimated at 10% (Rossett & Weiner,
Estimates of the incidence of substance abuse in 1984; Sokol & Abel, 1992). The cost of providing
the 2.9 million reports of child maltreatment filed care for one drug-exposed child with some signifi-
annually in this country have ranged from 25% to cant physiological or neurological impairment is esti-
84% (Leonard & Jacob, 1988; Tracy, Green, & mated at $750,000 over the lifetime of the child, and
Bremseth, 1993) with an average estimate of 26% the cost for one residential treatment episode for a
(Daro & McCurdy, 1994). Approximately 10 million substance-abusing mother and her children is about
children are living in households with an adult sub- $40,000 (Barth, 1993b).
stance abuser, and 675,000 children annually are se- Despite the reality that child protection services
riously maltreated by substance-abusing caretakers and substance abuse treatment are overlapping areas
(Daro & Mitchell, 1989). of practice, child welfare workers continue to have
The agreement of child protection systems on a limited training in screening for substance abuse
definition used to identify substance use problems problems, in determining the level of risk posed to
among parents is not consistent across jurisdictions. minor children, or in offering any intervention be-
Alcohol and substance use are identified as problems sides referral to specialized programs (Tracy & Far-
by child protection workers when they interfere with kas, 1994). Tracy (1994) reported that child welfare
the parents' ability to care for a child, both at the workers even doubt their right to ask parents about
time of an initial allegation and when assessing readi- their substance use because the workers lack the nec-
ness for reunification of a child with her or his fam- essary interviewing and assessment skills in this area.
ily. Child abuse and neglect are suspected to be Child protection workers are commonly called
more likely in families with a substance-abusing par- upon to make a referral to a more specialized treat-
ent (Daro, 1988; Gelles & Cornell, 1990; Starr, ment setting for substance users, due to court orders
1982; Straus, 1980; Wolock & Horowitz, 1979). In for such treatment or the recognition of the parents
particular, substance abuse is viewed as a triggering themselves of the role of substance abuse in their
426 PRACTICE ISSUES

inability to care for their children. Unwanted preg- also few programs that provide for residential units
nancy can be one of the first unintended conse- for women and their children in various stages of re-
quences of problem drinking or illegal drug use (Ew- covery; however, these may be further developed by
ing, 1991), and for some substance-abusing mothers, the move toward more integrated systems of care
the birth of a drug-exposed baby or the removal of conceptualized under block granting for states.
their children can be a powerful incentive to enter There are two major categories of circumstances
treatment. For others, the anger over a child's place- which might cause a substance abuse practitioner to
ment, the guilt about delivering a drug-exposed baby, initiate a report to child protection authorities. First,
or the stress of the baby's condition can diminish al- anytime alcohol use interferes with parents' ability to
ready limited parenting skill and lead to increased care for the physical and emotional needs of their
use or resumption of use (Freier, Griffith, & Chas- child, compromising the child's safety and resulting
noff, 1991). Specific referral compliance strategies, in neglect of the child, authorities should be con-
however, continue to be the reliance on the author- tacted to investigate the risk. An example of such be-
ity of the court to effect the referral. haviors might be a parent's engaging in alcohol or
Significant barriers to any coordination between drug-taking binges away from the home and leaving
child protection agencies and other systems are a the child alone for days at a time. Another situation
narrow view of substance use and conflicting goals. might be when a parent drinks at home and fails to
Conflicting goals between the child protection sys- feed, clothe, or attend to the child for long periods of
tem and the substance abuse treatment system re- time. An additional scenario might be when a parent
volve around the problems of treating caretakers endangers the safety of the child by engaging in dan-
while protecting dependent children from harm. gerous activities while drinking (driving or passing
This conflict can best be seen by the role of relapse. out while smoking).
While relapse can be seen as an expectable part of a A second major category of concern that would
substance abuse disorder, it raises significant ques- warrant protective service intervention is anytime
tions for the care and safety of dependent children. parents exploit their child in order to use or maintain
Confidentiality is also a significant factor reduc- their own substance abuse habit, resulting in misuse
ing pathways to collaboration and cooperation be- or abuse of the child. This would include having
tween child protection and substance abuse treat- children steal drugs or alcohol, requiring children to
ment systems. Increasing attempts to institute charges work or prostitute themselves for money to obtain
against women who give birth to drug-exposed babies drugs or alcohol, or giving alcohol or drugs to chil-
have resulted in substance-abusing pregnant women dren to use.
not seeking prenatal care or not reporting their use In considering making a request for investigation
for fear of prosecution, placing the child at even by protective service authorities, practitioners must
greater risk. Further, the criminalization of substance consider the age and vulnerability of the child, fam-
use during pregnancy has raised ethical questions ily and community resources available to the individ-
about physicians' obligation to report suspected child ual, and the specific laws about reporting child abuse
maltreatment if such a report is likely to result in the and neglect in their community. When a protective
incarceration of the mother. service concern arises in the course of treating an indi-
The resources necessary to encourage coordina- vidual with substance-abuse-related problems, this
tion between child protection systems and substance concern should first be discussed with the individual
abuse treatment programs are limited. Successful with emphasis placed on the consequences of the sub-
programs for substance abusers in child protection stance abuse behavior for the safety of the child.
take into account both the parent's recovery goals of
sobriety and the family's goals of protecting and car-
ing for the child's well-being (Tracy & Farkas, 1994). PRIMARY HEALTH CARE PROVIDERS
Home-based family preservation programs serve only
a small percentage in the child protection system, an Research findings indicate that drug and alcohol
estimated 20,000 children (Earth, 1993a), and have problems play a significant role in a large number of
been reported to be least effective with substance- cases seen in primary health care settings. Nowhere
abusing families (Spaid & Fraser, 1991). There are is the problem more evident than in emergency
 INTERFACES BETWEEN SUBSTANCE ABUSE TREATMENT AND OTHER SYSTEMS 427

rooms of general hospitals (Institute of Medicine, agreed to participate in specialized treatment (cited
1990). Alcohol use has been implicated in injuries in Babor et al., 1986).
resulting from automobile collisions, falls, fires, ho- The low rates of compliance among primary-care
micides, assaults, suicide attempts, and near drowns patients has led to the use of referral compliance
(National Institute on Alcohol Abuse and Alcoholism methods in combination with screening methods in
[NIAAA], 1990). Approximately 40% of individuals these health care settings (Cooney et al., 1995). Strat-
treated for head injuries in emergency room settings egies such as feedback and advice incorporated into
have been previously treated for alcohol problems a 15-30 minute health promotion interview have
(Stephens-Cherpitel, 1988). About 50% of admis- proved to be effective with primary-care patients (cf.
sions of Level I trauma centers have been found to Elvy, Wells, & Baird, 1988; Fleming, Cotter, & Tal-
be legally intoxicated, and a substantial proportion of boy, 1997; Goldberg, Millen, Richard, Psaty, &
those found with positive blood alcohol levels experi- Ruch, 1991). In a recent study conducted in pri-
ence some degree of alcohol-related problems (Sod- mary-care settings, Fleming, Barry, Manwell, John-
erstrom & Crowley, 1987). Within an inpatient med- son, and London (1997) showed that combining
ical setting, about 20-25% of those being treated for screening with a brief intervention approach can re-
trauma have been found to have alcohol-related diffi- sult in 10-30% reduction in alcohol use among pa-
culties (Waller, 1988). Similarly, there has been an tients seen in these settings.
association between alcohol use and a variety of From a systems perspective, failure to provide ad-
medical problems, including gastrointestinal disor- equate screening and referral in primary-care health
ders (e.g., peptic ulcer), hypertension, and orthope- settings can be attributed to a number of factors. De-
dic problems such as fractures (Institute of Medicine, spite available evidence, payees such as insurance
1990). For these reasons, the Institute of Medicine companies and health care maintenance organiza-
(1990) recommended that alcohol screenings be tions are not convinced that providing screening and
conducted for persons coming to medical settings intervention for substance use problems will reduce
and that depending upon the seriousness of the prob- health care utilization and related costs (Zweben &
lems, either a brief intervention or a referral for spe- Fleming, in press). Consequently, financial incen-
cialized intervention be offered. tives are not offered to providers for undertaking the
Despite the connection between substance use training in standardized screening and intervention
problems and medical disorders, there has been a protocols for alcohol and drug problems that are cur-
significant lack of routine alcohol- and drug-screen- rently available to providers (cf. NIAAA, 1995, 1990).
ing programs in primary-care health settings. For ex- Providers that are familiar with the standardized re-
ample, it has been revealed that only 55% of Level I ferral protocols are reluctant to employ these tech-
trauma centers regularly obtain blood alcohol levels niques without receiving additional compensation
in their patients and that only a few centers routinely from payees.
provide referrals for alcohol problems (Soderstrom & "Carve-outs" serve as an another impediment to
Cowley, 1987). Similarly, alcohol use by pregnant the development and implementation of secondary
women is not routinely identified despite the harm prevention programs in primary-care settings. In
associated with the drinking (Serdula, Williamson, many managed care settings, providers are required
Kendrick, Anda, & Byers, 1991). to send individuals with alcohol or drug problems to
Primary-care settings that strive to provide routine outside settings (i.e., carve-outs) that provide stand-
screenings have had difficulty in fulfilling their refer- alone treatment for substance use problems.Often
ral compliance goals (Stephen et al., 1992, cited in these carve-outs are located at quite a distance from
Cooney et al., 1995). Data obtained from the Veter- the primary-care setting, and there is little communi-
ans Administration show that 10% of individuals cation between the referral source and the special-
identified as having alcohol problems actually enroll ized treatment setting. Lacking financial incentives
in specialist treatment programs (Stephen et al., and busy with everyday clinical concerns, providers
1992). Similar findings have been observed in non- often fail to find the time to follow up on referrals to
VA medical facilities. A study conducted by the Ad- specialized treatment programs. The lack of commu-
diction Research Foundation in Toronto, Canada, nication between primary-care provider and special-
found that only 14% of identified hazardous drinkers ist practitioner can impact negatively on referral
428 PRACTICE ISSUES

compliance rates. As indicated earlier, the majority systems employ persons from many disciplines and
of these referrals fail to enter or remain in these spe- include crisis lines, outreach units, day treatment
cialized treatment programs. programs, intensive outpatient programs, in-home
There are a number of circumstances in which a programs, family service centers, community mental
practitioner might initiate collaboration with a pri- health centers, and individual practitioners. Persons
mary-care physician. First, when an individual is ex- seeking help from these settings often do so for less
periencing symptoms of alcohol or drug withdrawal, severe substance use problems; for a full range of
a primary-care physician should make a determina- family, individual, or marital problems that are re-
tion whether the person requires detoxification in an lated to their substance use; or for other life adjust-
inpatient or outpatient setting before participating in ment difficulties exacerbated by substance use. Such
behavioral treatment. Second, when individuals af- clients may or may not relate these life difficulties to
flicted with medical complications resulting from the their substance use.
substance use problems (such as gastrointestinal, car- Identification of substance use in social service
diovascular, and hematological diseases), a primary- settings is hampered by this inability to connect sub-
care physician should treat these disorders either stance use with life problems. Nondependent prob-
prior to or during the course of behavioral treatment. lem drinkers in voluntary social service settings focus
Third, when individuals are receiving medications on issues which initially brought them into the set-
for psychiatric diagnoses (such as depression, affec- ting, such as marital conflict, domestic violence, and
tive disorders, and anxiety), a primary-care physician employment problems, and do not make a connec-
should monitor the dosage levels of these medica- tion between their alcohol use and psychosocial is-
tions to handle side effects. sues (Cooney, Zweben, & Fleming, 1995; Zwe-
Recently, it has been recommended that primary- ben & Barrett, 1997). Shaw, Cartwright, Spratley,
care collaboration is necessary when a pharmaco- and Harwin (1978) reported that only 9% of nonde-
therapy component has been added to behavioral pendent problem drinkers in social service settings
treatment. Medications such as acamprosate and nal- were able to acknowledge their drinking as a primary
trexone have been found to be effective with sub- problem. Even among the more dependent popula-
stance-abusing populations, especially when com- tion, frequent heavy drinkers with higher incomes
bined with behavioral treatment (Carroll, 1997). and educational levels are less likely to report both
Such medications have been employed to address dependence symptoms and alcohol-use-related con-
some of problems related to relapse, including dys- sequences than those with lower incomes and less
phoria and cravings/urges for alcohol. Primary-care education (U.S. Department of Health and Human
physicians must assess the suitability of clients for Services [DHHS], 1993).
these medications as well as be responsible for their Compounding the problem of the lack of aware-
medical management while receiving them. This re- ness of substance abuse is the lack of adequate
quires a complete medical examination to rule out screening and identification of these problems at in-
clients who may experience adverse consequences take. Even when presented with clients with sub-
from the drug. For example, individuals with renal stance use difficulties, practitioners in social service
disease, hepatic failure, and diabetes are routinely ex- settings do not define them as the problem. In a
cluded from receiving acamprosate. Medical man- study of 100 cases from four different agencies, only
agement of these clients entails reviewing serum 5 cases were identified as containing a substance
chemistry panels and assessing side effects resulting abuse problem, despite subsequent interviews that re-
from the medication. vealed 39 of the cases had some level of substance
abuse (Kagle, 1987).
Other than for more severe alcohol dependence,
SOCIAL SERVICE SETTINGS screening for substance abuse has not been a usual
part of agency practice. Googins (1984) reported that
The social service system consists of a variety of non- only 40% of social service agencies included ques-
medical, nonhospital-based, community-based private tions about an individual's drinking history (or that
for-profit and not-for-profit social agencies. These of family members) in their intake procedures.
 INTERFACES BETWEEN SUBSTANCE ABUSE TREATMENT AND OTHER SYSTEMS 429

While there are a number of screening instruments ary, and diversionary populations. These offenders
available for use among professionals in secondary have extensive involvement with drugs and alcohol,
settings, professionals are not always knowledgeable both prior to and during the commission of crimes
or trained in their use (Van Wormer, 1987). (U.S. Bureau of Justice Statistics, 1990). Many of-
When a referral is made by a social service fenders who are addicted to drugs and alcohol then
agency, it is typically to a more conventional treat- become readdicted within a short period of time after
ment facility, which usually requires a commitment release from correctional supervision (Maddux &
to abstinence, regular attendance at self-help groups, Desmond, 1981).
and participation in an intensive treatment regimen Services within the criminal justice system aimed
that includes alcohol and drug education and group at substance abusers include efforts both within the
therapy. Many of the nondependent users who ap- criminal justice institutions and through limited ac-
proach social service settings for care are not ready cess to community-based agencies. Community-
to undergo the rigorous demands or expectations based initiatives include prevention and early identi-
made of participants in traditional treatment pro- fication programs (e.g., Drug Abuse Resistance Edu-
grams, which may not be applicable to the range of cation [DARE]), community-based residential pro-
issues encountered by them. grams as an alternative to revocation for probation
Providers in more specific substance abuse set- and parole violators, day reporting centers providing
tings should consider initiating referrals to social ser- substance abuse treatment of varying intensities by
vice agencies in the community when any family, public or private treatment agencies, home confine-
legal, employment, or financial issues are identified ment or curfews that allow substance abusers release
in either assessment or ongoing treatment phases of to seek treatment from community programs, and
contact. Practical questions should be raised early self-help groups in a community setting. Initiatives
about the need for additional social services, and cli- within the criminal justice system itself include sub-
nicians should specifically ask about concrete needs. stance abuse programs offered by probation or cor-
Additionally, during the end phase of treatment, pro- rections agencies on-site, specialized substance abuse
viders must also explore what family, legal, voca- caseloads in probation and parole agencies, and self-
tional, or financial problems have not been resolved help groups offered within a justice institution.
despite resolution of the substance-related problems The problem of how substance use problems are
and must consider referral to community social ser- defined is significant when criminal justice institu-
vice agencies as part of discharge planning. tions attempt to coordinate with other treatment sys-
tems. Just the use of most substances is illegal, either
by virtue of the substance itself or the age and status
LEGAL SYSTEM of the user (e.g., the use of alcohol by minors or the
use of alcohol while driving a vehicle). Thus, sub-
Substance abusers often come into contact with the stance use at any level is defined as a crime, requir-
legal system as a result of their substance use. Legal ing legal sanctions, treatment being secondary to the
problems may include driving while intoxicated or system goal of deterrence and punishment.
under the influence (DWI, DUI) offenses, possession The impact of differing goals is problematic in
or sale of controlled substances, acts of violence attempts to coordinate substance abuse treatment
while intoxicated, or disorderly conduct. Some per- with any aspect of the legal system. The emphasis in
sons with substance use problems can be motivated the criminal justice system on punishment as a goal
to seek treatment by their contact with the legal sys- leads to more specific goal of incapacitation or re-
tem; however, treatment services during incarcera- stricting the offender's opportunity to engage in fur-
tion are limited. ther use. Because a number of substances are illegal
The criminal justice system has extensive contact in and of themselves, one-time use can result in such
with substance abusers, as criminal populations are restriction. This goal of no use or immediate and to-
disproportionally involved in the use and abuse of tal abstinence is often incompatible with substance
both alcohol and illegal drugs (Shaffer, Nurco, & abuse programs that have controlled use or reduced
Kinlock, 1984), both in the incarcerated, probation- amount of consumption as a goal. It is clearly in con-
430 PRACTICE ISSUES

flict with treatment programs that view relapse or pe- VOCATIONAL REHABILITATION SYSTEMS
riodic, episodic use as an expectable stage in the re- AND THE EMPLOYMENT SETTING
covery process. This conflict makes it problematic at
best for a substance abuser to be open in revealing Vocational rehabilitation programs emphasize work
the extent and frequency of his or her use to clini- preparation, job-seeking skills, and matching workers
cians who are often required to report to criminal with disabilities to jobs which fully utilize their tal-
justice officers about their progress. ents. Employment is used as a key variable in deter-
Rehabilitation approaches in the criminal justice mining successful treatment outcomes for drug
system are less common and depend on several key abuse rehabilitation programs (Platt, 1995). Employ-
ingredients, the first being a reliable assessment of ment problems are common for persons with sub-
the offender's needs and some means of responding stance use disorders, yet comprehensive vocational
to the needs identified from this assessment (CSAT, services are not readily available to them (Schotten-
1994a). Lurigio and Swartz (1994) reported that diffi- feld, Pascale, & Sokolowski, 1992). Comprehensive
culties in evaluation and treatment of substance- rehabilitation programs report that alcohol-related in-
abusing offenders in urban environments were re- juries account for up to 79% of rehabilitation pa-
lated to the movement of participants as well as the tients (Hubbard, Everett, & Kahn, 1996), with prein-
need for multiagency involvement. Urinanalysis jury prevalence of alcohol dependence reported in
screens are often the first step in an assessment as from 29% to 68% of persons with head injuries (Ruff
well as a means of providing information about re- et al., 1990). For persons with spinal cord injuries,
lapses during ongoing treatment and continuing preinjury levels of alcohol and drug problems were
care. Their limitation as a diagnostic tool is in their found to be similar at postinjury, ranging from 17%
exclusive use, as they measure only recent use and to 79% (Heinemann, 1991; Heinemann, Goranson,
provide little information about extent, history, or Ginsburg, & Schnoll, 1989). Access to pain and spas-
other important assessment variables. ticity medications, combined with the experience of
Referral compliance is effected in legal systems pain, spasticity, depression, and frustration, may con-
through a series of coercive methods relative to the tribute to abuse of prescription medications by the
magnitude of the offense related to the substance person with a spinal cord injury (Hubbard et al.,
use. While this type of coercion is unique to legal 1996).
systems and may be viewed as counter to best prac- In addition to vocational rehabilitation programs,
tice methods, Gostin (1991) suggested that such business- and industry-based programs for preven-
mandatory treatment enhances reduction in morbid- tion, detection, and referral for workers and family
ity, mortality, and the criminality associated with sub- members with problems related to substance abuse
stance abuse. are prevalent. Employee assistance programs have
The availability of resources continues to be a sig- been in place since the 1970s to deal with the total
nificant barrier to coordination of care for substance spectrum of problems which might impact workers,
users in the criminal justice system. Probation and including substance abuse, family and marital, legal,
parole agencies are faced with increasing numbers of psychiatric, and financial problems (Roman & Blum,
offenders under supervision who have been ordered 1993). Employees may self-refer to the EAP, be re-
to comply with outpatient substance abuse treat- ferred by a work peer, or be referred by a supervisor
ment, but for whom limited or no treatment is avail- due to absenteeism or poor work performance. After
able (CSAT, 1994a; Falkin, Prendergast, & Anglin, making a referral, EAP personnel may be involved in
1994). In addition to the magnitude of the demand posttreatment aftercare, follow-up, and working with
for services in this population, the complexity of managed-care personnel to recommend cost-effective
treatment issues for substance abusers involved in the and quality programs. More intensive follow-up has
criminal justice system is also an obstacle to coordi- been shown to significantly reduce substance abuse
nation. Many providers outside the legal system cite disability costs, treatment cost, and further hospital-
security and safety as reasons for not offering services izations (Erfurt & Foote, 1988).
to substance-abusing offenders, restricting availability Persons with substance use disorders interact with
of care even further (Petersilia, 1990). vocational rehabilitation systems in a variety of ways.
 INTERFACES BETWEEN SUBSTANCE ABUSE TREATMENT AND OTHER SYSTEMS 431

Problems with performance, productivity, absentee- ment. The complexity of issues around referral and
ism, and supervisory relationships may capture the treatment compliance in a program where substance
attention of the employer and precipitate an em- abuse problems were addressed in an integrated sup-
ployee assistance program referral. Although the ported employment program found that monitoring
frontline approach may involve monitoring perfor- compliance, lack of funding and appropriate treat-
mance and require that the individual complete a ment, withdrawal of services for noncompliance, and
substance abuse treatment program, should the prob- problems with family support and transportation
lem get worse and the individual lose his or her job, were identified as issues (Groah, Goodall, Kreu-
more formalized vocational rehabilitation interven- tzer, & Sherron, 1990).
tion may be indicated. Persons with physical or men- For example, a supported employment program
tal disabilities may be involved in the vocational re- at the University of Virginia for individuals with trau-
habilitation system due to their identified disability, matic brain injury found that an education program
and the substance use disorder may be uncovered identifying risks and consequences of substance
over time. A comprehensive substance abuse treat- abuse, an emphasis on abstinence to help those with
ment program might regularly address vocational is- memory problems, and providing medical and psy-
sues and involve clients in vocational programs chological reasons for abstinence to be important as-
aimed at stabilizing their function at work as part of pects of the substance abuse treatment component.
the treatment approach. Employment problems are common for persons
Screening and assessment for substance use disor- with substance use disorders, yet comprehensive vo-
ders is not commonly included in the vocational re- cational services are not readily available to them
habilitation process, unless identified as a problem (Schottenfeld et al., 1992). A comprehensive sub-
in the initial referral process. Identification of alco- stance abuse treatment program might regularly
hol abuse in clients with chronic mental illness and address vocational issues and involve its clients in vo-
physically induced trauma by rehabilitation counse- cational programs aimed at stabilizing their function-
lors was found by Ingraham, Kaplan, and Chan ing at work as a part of the treatment approach.
(1992) to be underestimated. In a content analysis of
the rehabilitation literature, only 20 of 1,743 articles
addressed alcohol and drug abuse issues, primarily in
traditional vocational rehabilitation programs (Bens- DISCUSSION: TOWARD THE
hoff, Janikowski, Taricone, & Brenner, 1990). Identi- DEVELOPMENT OF A BEST
fication of substance use disorders in vocational reha- PRACTICE MODEL
bilitation program participants in an adult prison
release program was identified as a key variable in In the search for best practice models, multiple
success on parole, with emphasis placed on acquisi- forces are driving the trend toward coordination
tion of marketable job skills and psychological coun- among systems that interact with substance abusers.
seling for substance use disorders while incarcerated First is an awareness of the increasing magnitutde of
(Anderson, Schumacker, & Anderson, 1991). the population of persons abusing a wide range of
Goals of the workplace via EAPs and vocational substances. As the definitional parameters for sub-
rehabilitation programs typically focus in two direc- stance abuse increase, more persons are included in
tions: one toward job placement and stability, and the population of concern. Second is the variety of
the other toward abstinence or involvement in sub- settings with which these persons interact. As greater
stance abuse treatment. Although these goals can be recognition develops of the continuum of severity of
consistent with one another, they may be empha- problems experienced by persons using substances,
sized differently by the system measuring outcome more service systems are developing methods of
(Roman & Blum, 1993). identifying persons with a range of substance use
Referral compliance strategies related to alcohol problems among their target populations. Third is
and other drug specialized treatment services are en- the incursion of managed-care methods into both the
hanced when involvement in vocational rehabilita- private and public care systems that emphasize coor-
tion services is a condition of continued employ- dinated systems and a continuum of care. The need
432 PRACTICE ISSUES

to develop more cost-conscious methods of care in into daily routines of medical practices delivered by
line with the principle of parsimony (the least treat- a physician or intervention specialist such as a nurse,
ment necessary is the best treatment) argues for in- health educator, and physician assistant and are con-
corporating brief interventions into standard practice sistent with secondary prevention activities carried
protocols (and evaluating their effectiveness) for out in relation to other medical conditions such as
treating persons with the full range of substance use diabetes, hypertension, and depression.
problems. In criminal justice systems, assessment and
Minimally, the components of such a coordi- screening should occur at pretrial hearings, as well
nated system of care must include (a) a network with as at admission to incarceration. Judges could be ad-
a continuum of care for persons with all levels of vised about the substance abuse treatment options
substance use problems, (b) the development of staff and encouraged to consider them during these hear-
skills in screening for substance use problems and ings-
motivational enhancement for treatment and refer- Third, coordination of ongoing care requires
ral, (c) methods of coordinating this care among set- more systemic change. Linkages between systems
tings, and (d) the incorporation of brief interventions can occur through joint training (e.g., child protec-
in all settings. tion workers and probation officers), the devel-
First, a network of care must be able to accommo- opment of joint protocols between related agencies
date various levels of severity and disability, motiva- (i.e., social service and mental health), and institu-
tion, and compliance as well as different goals in re- tion of specific procedures to facilitate referrals at an
lation to abstinence. This continuum of care must institutional level (e.g., common intake forms). The
include acute stabilization systems for a range of sub- development of a communitywide care management
stance-abuse-related problems, including psychiatric, team has been attempted in child welfare (i.e., "wrap
financial, child care, and legal. Continuity of care around services") and might be successfully utilized
must be established between programs and compo- in the treatment of adult substance abusers.
nents, as well as over time. Fourth, incorporating brief interventions into
Second, all treatment contacts with persons in standard practice protocols for treating persons with
nonspecialized settings should include basic screen- the full range of substance-use-related problems
ing for substance use problems, most especially all should be encouraged. Increased use of brief inter-
frontline staff should be trained in the use of these ventions provides more targeted treatment and in-
screening methods (CSAT, 1994b). This type of train- creases the gatekeeping function of practitioners in
ing must be clearly connected to the primary purpose specialized and nonspecialized settings. In nonspe-
of the setting and the awareness of how undiagnosed cialized settings such as hospitals, EAPs, and child
and untreated substance abuse problems can prevent welfare systems, brief intervention can also serve as a
the attainment of the more primary goal of the setting case-finding technique, reducing barriers to care by
(i.e., the protection of children, the amelioration of identifying and treating alcohol use problems com-
symptoms of a specific mental disorder, the reduc- plicating the primary focus of care.
tion of reoffending, the completion of vocational The lack of education about specific methods and
training, the reduction of physical symptomatology, the rationale for the use of brief interventions acts as
or the maintenance of financial stability). a barrier to their use by practitioners in nonspecial-
In child protection agencies, more easily adminis- ized settings. Empirical evidence that addresses the
tered screening instruments (e.g., Michigan Alcohol- effectiveness and implementation of brief interven-
ism Screening Test [MAST]) can be used routinely tions should be included not just in professional
in investigations of allegations of abuse and neglect. journals specific to the field of alcoholism treatment,
More objective safety assessment instruments are be- but also in professional journals with a more general-
ing developed in a number of child welfare jurisdic- ized audience (e.g., child welfare, mental health,
tions (e.g., Child Well-Being Scales), and it would criminal justice, public welfare, women's issues, ger-
be consistent with these methods to add screening ontology, and health). Such material might also be
for substance use problems. included through in-service training workshops for
In primary-care settings, methods of screening persons in nonspecialized settings. The focus of such
and brief intervention could easily be incorporated education and training should be on a public health
 INTERFACES BETWEEN SUBSTANCE ABUSE TREATMENT AND OTHER SYSTEMS 433

approach with an emphasis on primary prevention Groah, C., Goodall, P., Kreutzer, J. S., & Sherron, P.
and the early intervention aspects of secondary pre- (1990). Addressing substance abuse issues in the con-
vention. text of a supported employment program. Cognitive
Rehabilitation, 8(4), 8-12.

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 VI

Issues in Specific Populations

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 25

Treatment of Persons with Dual

Diagnoses of Substance Use Disorder
and Other Psychological Problems

Richard N. Rosenthal
Laurence Westreich

The practical textbook on the treatment of addictive to rational scientific distinctions in biological vulner-
disorders should include a chapter on dual diagnosis ability, chronicity, psychosocial impairment, or po-
because of the historical disconnection between the tential for treatment.
organized mental health delivery system, its atten- Detailed coverage of the topic of comorbidity could
dant public and private services, the professional easily fill an entire book. Therefore, this chapter will
training programs that fuel them, and the traditional attempt to address important concepts that the authors
addiction treatment system that serves patients with believe are important to the clinical approach to pa-
addictive disorders. As a result, clinicians are typi- tients with substance use disorders (SUDs) and to pro-
cally undereducated in one of the two clinical do- vide sufficient factual information to reinforce ac-
mains. Patients with both addictive disorders and ceptance and retention of those concepts. For the
other mental disorders are frequently underdiag- heuristic goals of this chapter, the set of mental disor-
nosed and almost certainly undertreated. In addition, ders not related to substance use needs to be charac-
the lack of attention to addiction treatment in the terized. Previous attempts have called these disorders
training of mental health professionals and of appro- functional as contrasted to organic, or other mental
priate attention to mental disorders in training addic- disorders. This chapter will simply call those disorders
tion professionals, as well as the fact that many reim- non-substance-related (NSR) mental disorders.
bursement methodologies reinforce a tradition of
singular diagnosis, all contribute to nontreatment of OVERVIEW
even recognized disorders. The current dichotomy is
a result of history, politics, expedience, economics, As the bulk of the addiction treatments supplied by
cultural traditions, and belief systems and its not due the mental health delivery system in the first half of

439
440 ISSUES IN SPECIFIC POPULATIONS

the 20th century were psychodynamic in nature, the National Comorbidity Survey (NCS) lifetime preva-
focus upon the continued failure to regain control of lence rate of all DSM-III-R (American Psychiatric
addictive behavior led dynamic theorists to concep- Association [APA], 1987) alcohol, drug, and mental
tualize the addict as having a personality structure (ADM) disorders is 48.0%, and the 12-month preva-
that generally precluded analytic treatment. With the lence is 29.5% (Kessler et al., 1994). The 48% ADM
failure of traditionally applied psychotherapy to treat disorder prevalence includes disorders such as simple
addiction, the concept of addictive personality was de- phobias and mild adjustment disorders that tend to
veloped, characterizing this population as having poor be self-limited and generate little clinical attention.
frustration tolerance, manipulativeness, insincerity, The NCS lifetime prevalence for any substance
and superego lacunae. This attitude among the trend- use disorder is 26.6%, for other mental disorders is
makers in mental health led to a further disenfran- 21.4%, and for both disorders is 13.7%. Of the 48%
chisement of the addicted population from the mental of the U.S. population with lifetime ADM disorders,
health delivery system. In self-fulfilling terms, there less than half (21%) will have only one disorder,
arose a widespread belief that since addicts were not whereas 27% will have two or more disorders (Kes-
treatable by the analytic method, they therefore were sler et al., 1994). In any year, the prevalence rate for
not treatable. This is a bias that persists to this day comorbid substance use and other mental disorders
both in the mental health domain and in the general is 2.7% (Kessler et al., 1994), of which fewer than
public. Mental health workers have tended to look at half receive any treatment (Kessler et al., 1996). Of
substance use disorders as bad behavior that compli- the population with 12-month severe disorders (psy-
cates the treatment of other mental disorders, rather chosis, mania, or needing hospitalization), 89.5%
than as independent disorders requiring specific treat- had three or more lifetime ADM disorders (14% of
ment by knowledgeable practitioners. the sample). The high prevalence rate of psychiatric
The emergence of self-help groups gave first to al- morbidity is therefore concentrated in about one
coholics and then to other substance-dependent peo- sixth of the population with three or more comorbid
ple an approach attained by trial and error to achieve disorders. Yet, among this group, fewer than half ever
and maintain abstinence. The self-help philosophy have specialty mental health or addiction treatment
underscored much of the approach of the professional (Kessler et al., 1994). From a utilization/costs per-
addiction treatment community. Over time, these ap- spective, comorbid disorders of patients are under-
proaches provided a philosophical view about addic- recognized and undertreated, yet those that are treat-
tion that was different from the view within the mental ment seeking use a disproportionately large share of
health delivery system. Based on an expanding knowl- available treatment resources. It is thus important to
edge and philosophical base, these alcohol and sub- focus on this population, not only because of the his-
stance dependence treatment systems developed edu- torical difficulty in entering and maintaining these
cational and professional licensure pathways that were patients in treatment, but also because of the obvious
by and large in parallel with, but separate from, the economic impact this subpopulation has compared
traditional mental health training pathways. At pres- with patients with only a single ADM disorder.
ent, regulatory agencies are stabilizers of a nonuni- Data from the Epidemiologic Catchment Area
fied view of addiction and mental disorder, due to Study (EGA) of the National Institute of Mental
the typical pattern of licensing programs and paying Health, a non-treatment-seeking community sample,
for treatment of either chemical dependence or NSR have been used to estimate U.S. population lifetime
mental disorders, but not both. prevalence rates for DSM-III (APA, 1980) Axis I
mental disorders (affective, anxiety, and schizophre-
nia) and antisocial personality disorder, for alcohol
INCIDENCE AND PREVALENCE
abuse and dependence, and for other substance
abuse and dependence (Regier et al., 1990). Among
General Epidemiology
persons with addictive disorders, any comorbid men-
Prevalence rates of both mental disorders and sub- tal disorder occurs at greater than expected rates,
stance use disorders are much higher than clinicians with 37% lifetime prevalence for alcohol abuse/de-
typically believe. Derived from a nationally represen- pendence and 53% for other drug abuse or depen-
tative sample of 8,098 persons in the community, the dence. EGA data also demonstrate that a history of
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 441

mental disorder increases lifetime odds ratios for any Howell, & Malcolm, 1992). In addiction treatment
alcohol or drug disorder to 2.7 over normal risk val- settings, there are high comorbidity rates for Axis II
ues (Regier et al., 1990) and 10-20 times greater disorders. Kranzler, Satel, and Apter (1994) found
than expected for patients with schizophrenia, ma- among cocaine-dependent inpatients that 70% met
nia, or antisocial personality disorder (Boyd et al., criteria for at least one Axis II diagnosis; the mean
1984). Thus, NSR psychopathology is a risk factor for number of Axis II diagnoses among these patients
substance abuse. was 2.54. The most common Axis II diagnosis was
borderline (34% of all patients), followed by antiso-
cial and narcissistic (each 28%), avoidant and para-
Comorbidity in Treatment-Seeking Samples
noid (each 22%), obsessive-compulsive (16%), and
Househould sample prevalence rates are compelling dependent (10%).
enough from the epidemiological point of view, but
the rates of comorbidity in treatment-seeking popula- Specific Mental Disorders
tions are even higher. The highest rates of comorbid
disorders are typically found in institutional popula- Table 25.1 summarizes EGA data for lifetime preva-
tions such as hospital inpatient and outpatient psy- lence of SUD in persons with various Axis I NSR
chiatric units, substance abuse treatment programs, mental disorders.
and jails (Hien, Zimberg, Weisman, First, & Acker-
man, 1997; Jordan, Schlenger, Fairbank, & Caddell, Depression and SUD
1996; Kokkevi & Stefanis, 1995; Regier et al., 1990). Up to 40% of mixed groups of substance abusers
Surveys of inpatient and outpatient psychiatric have concurrent DSM-III Axis I diagnoses in addi-
facilities indicate that 20-50% of psychiatric patients tion to drug and alcohol dependence (Mirin, Weiss,
have concurrent problems with alcoholism or sub- Michael, & Griffin, 1988; O'Brien, Woody, & Mc-
stance abuse (Galanter, Castaneda, & Ferman, 1988). Lellan, 1984). Conversely, subgroups of the popula-
There is a high rate of alcohol and substance abuse tion (e.g., young adult males) with moderate to se-
among patients hospitalized with psychiatric disor- vere depressive disorders have substance abuse in
ders (Fernandez-Pol, Bluestone, & Mizruchi, 1988; 44-48% of cases (Schuckit, 1985). These rates of
Fischer, Halikas, Baker, & Smith, 1975; Richard, substance abuse co-occurring with depression are in
Liskow, & Perry, 1985), a rate that may be inflated excess of the 1-month (3.8%) and the lifetime (16.4%)
due to higher rates of treatment-seeking among pa- prevalence rates of substance use disorders in the
tients with comorbidity (Berkson, 1946). In a study general population, or the 9.3% 1-month prevalence
of public hospital psychiatric inpatients, 55.9% had rate of substance abuse disorders in males aged
current psychoactive substance use disorders (Leh- 18-24 years, as estimated from EGA data (Regier et
man, Myers, Corty, & Thompson, 1994). The most al., 1988). Similarly, the lifetime prevalence rate of
common substances used by patients in psychiatric major depression is clearly overrepresented among
treatment are nicotine, alcohol, marijuana, and co- patients with substance use disorders who seek addic-
caine. The reported rates vary from 30% to 70%, and tion treatment (24.3%) compared with the 5.8% life-
are highest in populations with most acuity or se- time prevalence of major depression in the general
verity. population (Regier et al., 1988; Ross, Glaser, & Ger-
In those patients seeking treatment in addiction manson, 1988). Major or minor depression also ap-
treatment centers, there is wider variation in reports pears to be a risk factor for increased cocaine abuse
of concurrent mental illness, including reports that in a 2.5-year follow-up study of 268 opioid addicts,
seem low when compared to epidemiological sam- as those with increased cocaine abuse at follow-up
ples. One reason for these lower rates is that certain were more likely to have depressive disorders (Kos-
settings (e.g., traditional therapeutic communities) ten, Rounsaville, & Kleber, 1987).
typically screen out patients with severe mental ill-
ness or in need of psychotropic medication. For ex-
Bipolar Disorder and SUD
ample, rates have been found for bipolar disorder as
low as 2-4% in alcoholic inpatients (Hesselbrock, Of all Axis I disorders, bipolar disorder is the most
Meyer, & Keener, 1985; Lydiard, Brady, Ballenger, likely to co-occur with substance use disorders. The
442 ISSUES IN SPECIFIC POPULATIONS

TABLE 25.1 Lifetime Prevalence of SUD in Persons with Axis I NSR Mental Disorders

Any substance Alcohol diagnosis Other drug, diagnosis

Major depression 27.2% 1.9a 16.5% 1.3a 18.0% 3.8a

Bipolar I disorder 60.7% 7.9 46.2% 5.6 40.7% 11.1
Schizophrenia 47.0% 4.6 33.7% 3.3 27.5% 6.2
Anxiety disorders 23.7% 1.7 17.9% 1.5 11.9% 2.5
Panic disorder 35.8% 2.9 28.7% 2.6 16.7% 3.2
Phobia 22.9% 1.6 17.3% 1.4 11.2% 2.2
Obsessive-compulsive 32.8% 2.5 24.0% 2.1 18.4% 3.7

Note. Adapted from Regier et al. (1990).

This column lists odds ratios.

EGA estimate of the lifetime prevalence of any sub- cocaine dependence, Weiss, Mirin, Griffin, Gunder-
stance abuse or dependence among persons with any son, and Hufford (1993) found that 74% had at least
bipolar disorder (I & II) is 56.1% and with Bipolar one personality disorder, of which 69% of Axis II di-
I disorder is 60.7% (Regier et al., 1990). This high agnoses remained relatively stable independent of
comorbidity rate has been demonstrated in clinical current drug use patterns. Resnick and Resnick (1986)
samples (Brady, Casto, Lydiard, Malcolm, & Arana, emphasized the borderline or narcissistic personality
1991; Miller, Busch, & Tanenbaum, 1989; Reich, organization of many compulsive cocaine users.
Davies, & Himmelhoch, 1974; Winokur et al., 1995).
Patients with harder-to-treat subtypes of bipolar disor-
Schizophrenia and SUD
der (e.g., mixed, rapid-cycling) are more likely to
have substance use disorders (Brady & Sonne, 1995; Longitudinal studies have shown that young adults
Calabrese & Delucci, 1990; Keller et al., 1986). Anti- (aged 18-30) with schizophrenia and related disor-
social personality disorder is the only NSR mental ders commonly abuse drugs and alcohol (25-60%)
disorder with a documented higher rate of comorbid (Test, Knoedler, Allness, & Burke, 1985; Test, Wal-
substance use disorder than bipolar disorder. lisch, Allness, & Ripp, 1989). These high rates of
substance abuse co-occurring with schizophrenia ex-
ceed the 3.8% 1-month and the 16.4% EGA lifetime
Personality Disorder and SUD
prevalence rates of substance use disorders in the
Helzer and Pryzbeck (1988) reported from EGA data general population, or the 9.3% 1-month prevalence
a strong risk relationship of alcoholism for antisocial rate of substance use disorders in males aged 18-24
personality disorder (ASPD), with a lifetime ASPD years (Regier et al., 1988). Compared with the life-
prevalence of 15% in alcoholic men compared with time prevalence of schizophrenia in the general pop-
4% in nonalcoholic men. ASPD and antisocial be- ulation (1.3%), among patients with substance use
havior are frequent in individuals with alcoholism disorders seeking addiction treatment the lifetime
and occur three times more frequently in males than prevalence rate of schizophrenia is overrepresented
in females (48% vs. 15%). In a sample of 716 treat- (7.4%) (Regier et al., 1988; Ross et al, 1988). Among
ment-seeking opioid abusers, the most common NSR psychiatric inpatients, stimulants such as cocaine and
diagnosis was ASPD, seen in 25.1% (Brooner, King, amphetamines are more likely to have been abused
Kidorf, Schmidt, & Bigelow, 1997). In families by schizophrenia patients than by other diagnostic
where there is both ASPD and alcoholism in one or groups (Richard et al, 1985; Treffert, 1978).
both biological parents, the risk for alcoholism in the
offspring increases over that for either disorder alone.
Panic Disorder and SUD
Rounsaville et al. (1991) reported that 32.9% of treat-
ment-seeking cocaine abusers met DSM-//I-R cri- From EGA estimates, persons with panic disorder
teria for ASPD. Among 50 patients hospitalized for have a 35.8% lifetime prevalence of any substance
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 443

disorder (Regier et al., 1990). From NCS estimates, ADHD was found in 23% of the combined sample.
in any 12-month period 16% of people with panic ADHD typically has an earlier onset than substance
disorder have a substance use disorder (Kessler et al., use disorder, but both predominate in males, tend to
1996). Alcohol treatment settings have yielded life- run in families, appear to have a genetic component,
time prevalence rates of panic disorder from 2% to and share high rates of comorbidity with antisocial
21%, again, generally higher than prevalence of personality and mood and anxiety disorders (Bieder-
panic disorder from epidemiological samples of the man, Newcorn, & Sprich, 1991; Wilens, Biederman,
general population, where the rates are 1.4-3.5% Spenser, & Frances, 1994).
(Kessler et al., 1994). Interestingly, although the life-
time panic disorder prevalence rates for women are
about twice those for men in general population CONCEPTUALIZING PROBLEMS OF
samples, male relatives of agoraphobics are at in- THE DUALLY DIAGNOSED
creased risk for alcohol disorder, whereas female rela-
tives are at increased risk for agoraphobia. EGA data
Extrinsic/Systemic Problems
also show an increased risk of panic disorder in co-
caine abusers (Anthony, Tien, & Petronis, 1989), The largest current problem for patients with comor-
and cocaine has been implicated in preciptating bid substance use and other mental disorders is the
panic disorder (Aronson & Craig, 1986). lack of integrated treatment systems at the national,
state, and local levels that could provide for compre-
hensive diagnosis and appropriate, integrated treat-
Posttraumatic Stress Disorder and SUD
ments. The fourth edition of the Diagnostic and Sta-
Among substance abusers, substance abuse appears tistical Manual (DSM-IV; APA, 1994) classifies drug
to be a predisposing factor for the development of addiction as a series of diagnosable mental disorders,
posttraumatic stress disorder (PTSD) (Cottier, Comp- yet most treatment for patients with concurrent sub-
ton, Mager, Spitznagel, & Janca, 1992) and is a com- stance use and mental disorders is not delivered in a
mon comorbid diagnosis (Hyer, Leach, Boudewyns, & specialty mental health or even an addiction setting
Davis, 1991). Clinical samples of substance abusers (Narrow, Regier, Rae, Manderscheid, & Locke, 1993).
have demonstrated high rates of comorbid PTSD Due to traditional gaps in the training of clini-
symptoms both among male veterans (McFall, cians, diagnoses of comorbid substance use disorders
Mackay, & Donovan, 1991) and civilian women (Ko- are frequently missed in patients presenting acutely
vatch, 1986), although women have twice the risk of with symptoms of a mental disorder. Patients com-
men of developing PTSD (Kessler et al., 1994). PTSD plaining of mental symptoms do not usually offer in-
appears both to increase the risk for relapse in patients formation about patterns of alcohol and drug use. A
with substance use disorders and to be associated with study of 75 patients admitted to an acute psychiatric
poorer treatment outcome, but this has not been well inpatient ward (Ananth, Vandeater, Kamal, & Brod-
documented (Brown & Wolfe, 1994). sky, 1989) demonstrated the potential for missing a
dual-diagnosis problem. When initially evaluating
the patients, the emergency departments made 4
Attention Deficit Hyperactivity
drug abuse/dependence diagnoses, while 29 diagno-
Disorder and SUD
ses were made on the inpatient service. By carefully
In adult patients with attention deficit hyperactivity reevaluating the patients using the Diagnostic Inter-
disorder (ADHD), several studies have demonstrated view Schedule (DIS), researchers made 187 drug
an elevated, even doubled, risk of substance use dis- abuse/dependence diagnoses (i.e., many of the 75 pa-
orders compared with the general population (Bied- tients met criteria for abuse/dependence involving
erman et al., 1993, 1995). In ADHD adults, lifetime more than one substance). The authors attributed
alcohol use disorders range from 17% to 45%, and their success in making the previously missed diag-
other substance use disorders range from 9% to 30% noses of substance abuse/dependence to structured
(Biederman et al., 1993). Wilens, Spenser, and Bied- history and physical examinations and the time lapse
erman (1994) found in reviewing studies of adult and between the initial diagnoses and their own "second
adolescent patients with substance use disorders that look" at the patients.
444 ISSUES IN SPECIFIC POPULATIONS

"the big picture." In order to do this, clinicians must

Dual-Diagnosis Concept:
expand their repertoire of concepts and language be-
Clinically Inadequate
yond what they learned during training.
Dual diagnosis is frequently a misnomer, given the
high rates of patients comorbid for three or more life- Self-Medication Hypothesis The traditional men-
time ADM disorders (Kessler et al., 1994). Com- tal health model of addictive disorders was based
monly, these patients have three and four or more upon psychodynamic explanations, such as bolster-
current diagnoses, including multiple other medical ing ego defenses, reducing painful affects, and quell-
conditions. Recent popularization of the dual-diag- ing intolerable rage. The self-medication hypothesis,
nosis concept has led to increased recognition in the first put forth by Freud in 1884 (1974) and explored
field but also to increased reductionism. When con- by other psychoanalytic thinkers (Khantzian, 1985,
sidering treatment alternatives, labels like MICA 1990; Rado, 1933), postulates that the choice of
(mentally ill chemical abuser), SAMI (substance- drugs that a person abuses is based upon the drug's
abusing mentally ill), or CoAMD (co-occurring addic- specific ability to modulate intense painful affects or
tion and mental disorder) do not adequately describe impulses. It has been argued that self-medication
the breadth and depth of clinical presentations and cannot be validated as an explanation of drug abuse
problems of patients with mental disorders in the because addicts continue to use drugs and alcohol in
context of substance abuse or dependence. The dual- spite of the worsening of substance-induced psychiat-
diagnosis patient is a deceptive concept because it im- ric symptoms (Miller & Fine, 1993). This reasoning
plies a clinical category that has internal consistency. does not rule out self-medication as an etiological
As we build a differential therapeutics, treatments factor in addiction, with the initiation of compulsive
should become more, not less, specific. Therefore, use in spite of negative states or consequences being
the dual-diagnosis concept is reductionistic and adds a hallmark of the disorder. Although self-medication
no specificity in exchange for a loss in descriptive may be an etiological pathway for substance use dis-
resolution. Clinicians know intuitively that specific orders, psychodynamic interpretations of addictive
treatment will differ substantively in organization, behaviors alone are not sufficient to stop the addic-
content, and timing for a married Caucasian male tive process.
suburban corporate executive with a panic disorder
and alcohol abuse, from that of a homeless 17-year- Disease Model of Chemical Dependency A popu-
old African-American inner-city girl who is a high lar model that is of heuristic value and has become
school dropout and who suffers from both schizo- associated with mainstream chemical dependence
phrenia and crack cocaine dependence. Yet each has treatment is the disease model of addiction, a model
a "dual diagnosis." and operating philosophy quite different from tradi-
tional psychodynamic and psychobiological theories.
The proponents of the disease concept of addiction
Limitations of Traditional Models of
thought that it was an error to consider alcoholism a
Addictive Disorders
symptom of another disorder. The model stresses that
Many of the mental health and chemical depen- chemical addiction is a chronic, relapsing, and pro-
dency models contain some serious limitations. It gressive illness. Rather than being the fault of the
is vital, however, to find the right words to communi- patient, the disease becomes the responsibility of the
cate between domains that have separate philosoph- patient; that is, the patient needs to work with the
ical structures, languages, and worldviews. The treating clinician to maintain sobriety or else the dis-
mental health and chemical dependency systems ease will sicken the patient, cause dysfunction and
typically have several groups of providers (mental disability, and ultimately prove fatal. This approach
health, alcoholism, substance abuse) who have been offers patients a diagnosis rather than name calling
trained within separate guilds, each having an intrin- or blaming and is one remedy to unilateral applica-
sic and often disparate philosophy and technical lan- tion of the moral model of addiction (see below).
guage. It is imperative that clinicians attempting to The disease model brings addiction treatment into
understand the diagnosis and treatment of patients closer apposition with evolving psychiatric modes of
with comorbid mental disorder and addiction get treatment, and makes things more concrete and
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 445

structured for the providers of treatment. (See chap- sponsibility and willpower to imply that people who
ter 15 for a more comprehensive explication of the are addicted, rather than being trapped in a cycle of
model.) reinforced behaviors, are free to stop by choice.
A number of problems exist with the disease Thus, addicts are deemed morally bankrupt because
model. It does not conform to Koch's Postulates of a they choose to continue socially unacceptable ac-
classical disease. The definition, while useful to char- tions. Name calling ("dope fiend") and blaming are
acterize a process, is phenomenologically vague. The responses that fall within the moral model of addic-
model is often attributed to Jellinek (1952), yet his tion. This is a posture that the general population
approach to alcoholism explicated several typologies adopts out of tradition, ignorance, and fear, and that
that differed in onset, severity, pattern, and chronic- clinicians adopt partly out of cultural identity and
ity of use. Further, the understanding by patients through countertransference feeling. These attitudes
with addictive disorders that they have a chronic ill- serve a defensive purpose that allows people to avoid
ness can become a factor in their demoralization. uncomfortable feelings and impulses. In clinicians,
Similarly, patients can use the disease concept for the moral model may become a justification for act-
secondary gain, to rationalize maintenance of sub- ing on their own frustration and disappointment with
stance use, to resist change, and to avoid responsibil- patients' failure to meet treatment objectives. Thus,
ity for bad behavior. the moral model must be held up for scrutiny when
It is important to understand that the disease it is invoked. Interventions based on this model may
model is just that, a model, and can impede the de- add to the patients' already significant levels of self-
velopment of differential therapeutics for substance loathing and demoralization.
use disorders if taken too concretely. Treatments de-
rived from reductionistic and idealized models have
Problems Intrinsic to Patients with
the suggestion of panacea (e.g., 28-day inpatient re-
Comorbid Disorders
habilitation). This Procrustean tendency has been in
part responsible for the difficulty we face today in
Effects of Comorbidity on
treating patients with comorbid addictive and mental
Trajectory of Illness
disorders. For example, one common belief about
treatment from within the chemical dependency/dis- The rates of relapse to substance abuse or exacerba-
ease model domain is that a patient who is still using tion of mental disorder are higher in patients with
a substance of abuse is not yet ready for treatment. comorbidity (Renz, Chung, Fillman, Mee-Lee, &
While this strategy may increase the efficiency of Sayama, 1995). According to data from the National
staff effort in a selected population, it ignores current Comorbidity Survey (Kessler et al., 1994; Warner,
thinking on motivation (Osher & Kofoed, 1989; Pro- Kessler, Hughes, Anthony, & Nelson, 1995), the 12-
chaska & DiClemente, 1984), considering only peo- month prevalence for any substance use disorder is
ple in the "action" or "active treatment" category to 11.3% (drug dependence alone, 2.8%), yet only 19%
be "patients" (see "Stages of Treatment" below). It is of patients with alcohol dependence and 25% with
also likely that a high percentage of those deemed other substance dependence are in treatment in a
"not motivated for treatment" by traditional methods year (Warner et al., 1995). Psychiatric comorbidity
have comorbid mental disorders. In contrast, patients tends to drive up service utilization. For example, co-
with comorbid severe disorders are able to be re- occurring anxiety or depressive disorders increase the
tained in integrated outpatient treatment that focuses rate of some sort of treatment of alcoholics to 41%
upon "precontemplation and contemplation" or "per- and other drug disorders to 63% in 1 year (Warner
suasion and engagement" and uses sobriety as a goal et al., 1995). Young patients with substance abuse and
rather than as a prerequisite of treatment (Hell- schizophrenia spend much of their time admitted to
erstein, Rosenthal, & Miner, 1995; Ries & Comtois, inpatient services and have more frequent but shorter
1997; Ziedonis & Fisher, 1996). stays than patients with schizophrenia and no sub-
stance abuse (Richardson, 1985).
The Moral Model and Countertransference The
moral model essentially blames the patient for the The Effect of Concurrent NSR Mental Disorders
addiction. The model uses the concepts of moral re- on the Outcome of Addiction Treatment Among
446 ISSUES IN SPECIFIC POPULATIONS

alcoholics, those with psychiatric symptoms (mood Substance Abuse Affects the Course of NSR Men-
lability, depression, dysphoria) have a higher suicide tal Disorders In patients with chronic mental ill-
rate (Berglund, 1984), and comorbid psychiatric di- ness, drug and alcohol abuse negatively affect ap-
agnoses generally predict a poorer treatment out- propriate behavior and are associated with poorer
come at 1 year (Rounsaville, Dolinsky, Babor, & psychiatric treatment outcome (McCarrick, Mander-
Meyer, 1987). More specifically, concurrent antiso- scheid, & Bertolucci, 1985; Pepper & Ryglewicz,
cial personality disorder generally predicts lower 1984). Drug abuse is significantly associated with an
treatment retention and a poorer addiction treatment increased rate of rehospitalization in patients with
outcome (Alterman & Cacciola, 1991; Kranzler, Del schizophrenia (Craig, Lin, El-Defrawi, & Goodman,
Boca, & Rounsaville, 1996; Leal, Ziedonis, & Kos- 1985) and bipolar disorder (Brady, Casto, et al., 1991).
ten, 1994; Schuckit, 1985). The presence of psy- In patients with schizophrenia, alcohol and other
chotic symptoms in patients with addictive disorders substance abuse both decrease global functioning
is associated with poorer outcome for substance (Kovasznay et al., 1997) and increase the risk for tar-
abuse treatment, and the degree of psychiatric im- dive dyskinesia (Bailey, Maxwell, & Brandabur, 1997;
pairment is more predictive of drug abuse treatment Dixon, Weiden, Haas, & Sweeney, 1992). Heavy
outcome than any other pretreatment factor, includ- cannabis use is associated with earlier and more fre-
ing substance abuse severity (Kosten, Rounsaville, & quent psychotic relapse in schizophrenia (Linszen,
Kleber, 1985; LaPorte, McLellan, O'Brien, & Mar- Dingemans, & Lenior, 1994). Similarly, bipolar dis-
shall, 1981; McLellan, Luborsky, Woody, O'Brien, & order patients with comorbid substance use disor-
Druley, 1983; O'Brien et al, 1984). In opioid abus- ders, compared to those without, have more hospital
ers, psychiatric comorbidity is also associated with a admissions (Brady, Casto, et al., 1991; Reich et al.,
more severe substance use disorder (Brooner et al., 1974), shorter time to relapse (Tohen, Waternaux,
1997). In light of the high risks for psychiatric comor- & Tsuang, 1990), an earlier mood disorder onset,
bidity and the impact of that comorbidity upon ad- more dysphoria, and worse clinical course (Sonne,
diction treatment outcome, all addicted patients Brady, & Morton, 1994), including a poorer response
should be screened for other NSR mental disorders. to lithium (Albanese, Bartel, Bruno, Morgenbes-
Comorbid personality disorders have been recog- ser, & Schatzberg, 1994). Concurrent alcohol depen-
nized increasingly as an important variable in the tra- dence is associated with increased suicidality among
jectory and treatment of chronic substance abuse. depressed patients (Cornelius et al., 1995). Patients
Nace, Davis, and Gaspari (1991) found at least one with borderline personality disorder and antisocial
DSM-III-R personality disorder in 57% of treatment- personality disorder have an increased vulnerability
seeking substance abusers. Personality disorders seem to the development of affective instability and psy-
particularly crucial in accounting for high treatment chosis (Fyer, Frances, Sullivan, Hurt, & Clarkin,
dropout and relapse rates (Nace, Saxon, & Shore, 1988; Schuckit, 1985) and are at high risk for sub-
1986). Alcoholics with ASPD have an earlier onset stance use disorders (Kessler et al., 1994) that clini-
of alcoholism, more polysubstance abuse, and poorer cians recognize as complicating the clinical course.
prognosis (Stabenau, 1984). Sociopathy among sub- Clinically unrecognized addictive disorders may ac-
stance abusers is associated with high treatment drop- count for many of the dramatic events in the treat-
out and poorer treatment outcome (Leal et al., 1994; ment of these patients.
Woody, McLellen, Luborsky, & O'Brien, 1985). For
example, Woody et al. (1984) found that the pres-
ence of antisocial personality disorder in opioid ad- ISSUES IN ASSESSMENT
dicts predicted poor outcome in either supportive
expressive or cognitive behavioral psychotherapy dur-
Understanding Dual Diagnosis
ing methadone maintainance treatment. More re-
cently, Nace and Davis (1993) demonstrated differ- Since patients dually diagnosed with mental illness
ential 1-year follow-up outcomes by presence of and addiction typically present for treatment with a
personality disorder with respect to decreases in types confusing array of psychiatric symptoms and physi-
of abused substances and degree of life satisfaction cal findings, the clinician must begin the assessment
in 100 substance abuse patients. with an open mind to possible diagnoses. Although
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 447

a working diagnosis or set of diagnoses should be de- (1992) outlined five major patterns of interaction (ta-
cided upon as soon as possible, the clinician should ble 25.2). Although few patients fall clearly into one
remain wary of premature closure, which can subject demarcated category, the exercise of considering
the patient to incorrect and potentially harmful treat- phenomenology, time course, and etiology will help
ment. Using knowledge of DSM-IV, experience with the clinician derive the most efficacious treatment.
common presentations of the dually diagnosed, and The first interaction, predisposition/risk, has been
the necessary patience in waiting for drug-induced documented above in the epidemiological data from
syndromes to clear, the astute clinician can effi- the EGA (Regier et al., 1990) and the NCS (Kessler
ciently diagnose and treat the dually diagnosed pa- et al., 1994) studies. Earlier onset of bipolar disorder
tient. is seen in patients who develop SUDs compared to
Given the potentially disastrous implications of those who do not, suggesting that an earlier age of
missing a connection between psychiatric symptoms onset may put individuals at risk for SUDs (Dun-
and substance use, clinicians should use probing ner & Feinman, 1996). Another potential way for the
questions and diagnostic patience. Having diagnosed increased vulnerability for drug abuse to manifest is
co-occurring mental illness and addictive disorder, through self-medication of states related to mental
the clinician is faced with the task of understanding disorders. For example, negative symptoms in schizo-
the interactions, if any, between the two or more phrenia may predispose affected individuals to subse-
conditions. In order to clarify the relationship be- quent substance use disorders (Schneier & Siris,
tween substance use and psychological symptoms, 1987): Amphetamine has been shown to markedly
the clinician should assess (a) when mental symp- improve the anhedonia, anxiety, and hypochondria-
toms first occurred and, if an exacerbation, when sis seen in negative-symptom schizophrenia patients
they began again; (b) when symptoms of SUD first (Cesarec & Nyman, 1985), and negative symptoms
occurred, whether the symptoms preceded the onset are acutely and significantly reduced in schizophre-
of substance abuse (Schuckit & Hesselbrock, 1994), nia patients who have used cocaine (Serper et al.,
and if a relapse, when they began again; (c) what 1995). The data suggest that abuse of stimulants in
subjective effects use of substances has on mental this population might be quite directed.
symptoms (relief, exacerbation); (d) what effects up- Dysphoria has been implicated as a prime cause
on mental symptoms cessation (if any) of drug use of relapse in substance abusers (Litman, Stapleton,
has; and (e) what effects amelioration of psychiatric Oppenheim, Peleg, & Jackson, 1983; Marlatt & Gor-
symptoms has on patterns of substance use. In a para- don, 1985), and one report suggests that patients with
digm for understanding interactions between NSR co-occurring seasonal dysphoria and cocaine abuse
mental disorders and SUDs, Weiss and Collins demonstrate fluctuations in cocaine craving that par-

TABLE 25.2 NSR-SUD Interaction Models

Interaction Example

NSR psychopathology (Axis I/Axis II) as a risk factor for The depressed patient who "treats" dysphoria with an il-
substance use disorder licit substance such as cocaine
Psychiatric symptoms developing in the course of a The cocaine user who experiences paranoia while using
chronic intoxication and following the course of the the substance, and whose symptoms remit with cessa-
substance use tion of drug use
Psychiatric disorder which occurs as a consequence of Panic attacks which are triggered by cocaine use, and
substance use but persists after cessation of substance which persist long after abstinence from cocaine has
use been achieved
Substance abuse and psychiatric symptomatology mean- Anorexia nervosa patient who finds cocaine a perfect
ingfully linked over time mood enhancer and anorectic agent
No relationship between substance abuse and psychiatric The depressed alcoholic whose symptoms do not remit
symptomatology with prolonged abstinence from alcohol

Note. Adapted from Weiss and Collins (1992).

448 ISSUES IN SPECIFIC POPULATIONS

allel their cyclic changes in mood (Satel & Gawin, in patients with an underlying diathesis including
1989). In patients with comorbid cocaine abuse and mania (Strakowski, Tohen, Stoll, Faedda, & Good-
depression, it is often unclear whether the depressive win, 1992), panic disorder (Aronson & Craig, 1986),
symptomatology is a result of the neurotoxic and so- or schizophrenia (Linszen et al., 1994; McLellan,
cial effects of cocaine use or antedated the develop- Woody, & O'Brien, 1979; Sevy, Kay, Opler, & van
ment of the substance abuse disorder. The specific Praag, 1990; Turner & Tsuang, 1990). Chronic sub-
affect that is purportedly modulated by cocaine is de- stance use may also precipitate a DSM-/V persisting
pression/dysphoria (Khantzian, 1985). Weiss, Mirin, substance-induced disorder such as alcoholic hallu-
Michael, and Sollogub (1986) described concurrent cinosis, which, although substance-induced, is not
DSM-HI affective disorders in 53.5% of a group of self-limited and continues indefinitely after cessation
cocaine abusers comprising a depressed subgroup, of substance use.
who valued the euphorigenic effects, and a bipolar/ The fourth interaction is altered trajectory: Pa-
cyclothymic subgroup, who augmented hypomanic tients with NSR mental disorders may benefit from
symptoms or alleviated depressive symptoms. Pa- the effects of abused drugs in such a way that the
tients with schizophrenia have reported that cocaine trajectory of the illness is modified. For example, as
use decreases dysphoria and increases sociability patients with negative symptoms in schizophrenia
(Dixon, Haas, Weiden, Sweeney, & Francis, 1991). may achieve some diminution of anhedonia, amoti-
The second interaction described by Weiss and vation, akinesia, and social withdrawal through the
Collins (1992) is substance-induced disorders which use of stimulants (Rosenthal, Hellerstein, & Miner,
are typically self-limited: mood, anxiety, and other 1994), stimulants may cause changes in the temporal
disorders that are independent of NSR psychiatric ill- stability of negative symptoms (Lysaker, Bell, Bioty, &
nesses and typically follow the time course of intoxi- Zito, 1997).
cation or withdrawal. There are factors (family his- Fifth, there may be instances where substance use
tory, temperament, affect/anxiety regulation) that and other mental disorders, although present concur-
may increase a person's vulnerability to the develop- rently, are not meaningfully interrelated.
ment of transient mental symptoms in the context of
substance use disorders, without the person's having
a diagnosable NSR disorder. For example, in Cau-
Conducting a Differential Diagnosis
casian populations, certain dopamine transporter ge-
notypes may predispose to paranoia in the context Differential diagnosis involves examination of a com-
of cocaine use (Gelernter, Kranzler, Satel, & Rao, plex relationship between substance abuse and psy-
1994). chiatric symptoms. In the DSM-IV (APA, 1994),
In addition to substance-induced disorders, drugs most diagnosis is polythetic (i.e., made by identifying
of abuse can also exacerbate the symptoms of under- a threshold number of symptoms from a list rather
lying mental disorders, often in a self-limited way, than fitting criteria to a specific symptom that all
without causing a full-blown relapse of the NSR dis- members of the diagnostic category have). Frequent-
order. Compared to schizophrenia patients without ly, chronologically primary and secondary diagnoses
SUDs, substance abuse in schizophrenia is corre- cannot be established during the initial evaluation.
lated with an increase in hallucinations (Sokolski et Patients with substance use disorders may present ret-
al., 1994) and thought disorder (Cleghorn et al., rospective falsification or distortion of personal his-
1991). Prevalence rates for auditory hallucination are tory, so the clinician should obtain collateral history
higher in schizophrenia patients who abuse crack from significant others, if possible. Establishing a pri-
than in those who do not (Rosenthal, Hellerstein, & mary and secondary diagnosis may be helpful to
Miner, 1992a). Also supporting a vulnerability mod- planning treatment, as the clinical picture tends to
el, schizophrenia patients are differentially sensitive run the course of the primary disorder (Brown et al.,
to methylphenidate-induced increases in thought dis- 1995; Schuckit, 1985). For example, patients with
order compared to normals (Levy et al., 1993). primary alcoholism have significantly fewer episodes
The third interaction is initiation: Chronic sub- of affective disorder than bipolar patients with secon-
stance use may precipitate NSR psychiatric illness dary alcoholism (Winokur et al., 1995).
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 449

pital with psychiatric diagnoses, researchers using a

Cross-Sectional Analysis: Insufficient for
structured interview (SCID) found that 53.6% of the
Making DSM-TV Diagnoses
subjects had no freestanding psychiatric disorder out-
Most diagnostic categories in DSM-IV have specified side the addiction problem (i.e., presenting psychiat-
intervals over which the symptoms must occur in or- ric symptoms were directly related to substance
der to reach threshold. Therefore, cross-sectional abuse) (Lehman et al., 1994).
analysis is insufficient for making DSM-IV diagnoses Careful history taking, as well as medical, neuro-
without information about interval and duration in a logical, and toxicological screening are essential to
historical context. This is of specific importance elucidate causes of symptoms as being due to direct
when attempting to understand the nature of mental actions of drugs, drug withdrawal, independent med-
symptoms in the context of substance abuse. There- ical problems, or medical ramifications of substance
fore, diagnoses may have to be made over time, with abuse. Every patient assessed for mood, anxiety, cog-
serial treatment contacts that clarify the relationship nitive, stress, relationship, or job-related problems
of the onset and persistence of mental symptoms to should be asked about alcohol and other substance
the intervals over which substance abuse took place. use patterns. Patients who are seen with new-onset
Standardized assessment provides a more compre- complaints of mental symptoms should have a medi-
hensive appraisal of multiple substance abuse than cal screening and physical examination in the absence
routine clinical procedures (Ananth et al., 1989; Ro- of a clear prior history of mental disorder without
senthal et al., 1992a). In a set of studies on an inpa- concurrent substance abuse or dependence. Many
tient dual-diagnosis unit, diagnoses of DSM-III-R mental symptoms can be induced by intoxication
substance abuse/dependence in schizophrenia pa- with a substance of abuse or its withdrawal in a habit-
tients revealed 10.9% abusing or dependent upon uated person.
three or more substances by retrospective chart re- The way in which symptoms change with cessa-
view, 16.0% by routine clinical methods, and fully tion of drug use may also provide an important clue
90.0% using structured research interviews (Rosen- to the etiology of those symptoms. In a recent inpa-
thai et al., 1992a). Even the use of a simple rating tient study, 40% of 171 males recently detoxified
scale of alcohol and substance use severity from 1 from alcohol experienced multiple anxiety symptoms
(none) to 5 (extremely severe) increases the ability of and had significantly elevated levels of state anxiety
clinicians to make distinctions between presence or at admission (> 75th percentile) that typically re-
absence of current substance-related problems, with turned to the normal range by the second week of
reasonable concurrent validity with more compre- treatment (Brown, Irwin, & Schuckit, 1991). This is
hensive instruments (Carey, Cocco, & Simons, 1996.) not the typical course for generalized anxiety disor-
der, and only 4% fulfilled criteria for generalized
anxiety symptoms after 3 months' sobriety (Schuckit,
Substance-Induced Disorders
Irwin, & Brown, 1990).
In attempting to elucidate the causes of mental
symptoms in patients with histories of concurrent
Psychosis and Substance Use Disorders
substance use disorders, the clinician must differenti-
ate symptoms due to the effects of substances from There is an underrecognized clinical population of
those intrinsic in NSR mental disorders. Intoxication patients who present with psychotic symptoms and a
or withdrawal states due to substances of abuse fre- history of substance abuse but who do not meet crite-
quently cause symptoms of mood, anxiety, psychotic, ria for NSR mental disorders. These patients are typi-
and/or personality disorders. In the acute care set- cally treated acutely as if they had an NSR mental
ting, it is often difficult to ascertain the time of onset illness (Szuster, Schanbacher, McCann, & McCon-
of either symptoms of psychosis or substance use dis- nell, 1990). Substance-abusing patients demonstrate
orders, making definitive NSR/substance-induced di- acute psychotic symptoms due to direct effects of
agnoses restricted (Kane & Selzer, 1991; Rosenthal, substance abuse (Brady, Lydiard, Malcolm, & Bal-
Hellerstein, & Miner, 1992b; Shaner et al., 1993). In lenger, 1991; Satel, Southwick, & Gavin, 1991; Szus-
a study of 435 patients admitted to an inner-city hos- ter et al., 1990), independent NSR mental disorders
450 ISSUES IN SPECIFIC POPULATIONS

(Weiss & Collins, 1992), or some combination of the

Stimulant-Induced Depression
two (Rosenthal et al., 1994). Recent evidence sug-
gests that even among patients with psychotic symp- Clinical observation shows that stimulant abusers ex-
toms and concurrent substance use disorders, there hibit symptoms of depressive disorders that may be
are patient characteristics such as formal thought dis- different from major depression or dysthymia. Post,
order or bizarre delusions that significantly predict a Kotin, and Goodwin (1974) administered intrave-
diagnosis of schizophrenia, while intravenous co- nous cocaine to patients who had major depression
caine abuse and a history of drug detoxification or and found that this caused first euphoria, then dys-
methadone maintenance predict substance-induced phoria, demonstrating the ability of cocaine to di-
delusional disorder or hallucinosis (Rosenthal & rectly cause symptoms of a mood disorder. Gawin
Miner, 1997). The default assumption regarding and Kleber (1986) described a three-phase sequence
acutely presenting patients with substance use disor- of post-cocaine-abstinence symptomatology, where
ders and psychotic symptoms should be that the DSM-III diagnoses of primary depressive disorders
symptoms are substance-induced until otherwise were given only if symptoms were persistent beyond
demonstrated. This strategy reduces the potential 10 days of sobriety. Cross-sectional analysis of symp-
harm of untreated withdrawal states (Becker & Hale, toms in the first 6 days (crash phase) of cocaine absti-
1993; Brown, Anton, Malcolm, & Ballenger, 1988) nence led to a diagnosis consistent, except for dura-
or the unnecessary exposure to neuroleptic treatment tion of symptoms, with melancholic depression in
of patients differentially sensitive to adverse effects 70% of the subjects. However, with a 10-day cutoff,
(Olivera, Kiefer, & Manley, 1990; Ziedonis, Kos- depression was diagnosed in 33% of the subjects:
ten, & Glazer, 1992). 13% major depression and 20% dysthymia, each
clearly higher than the rate of depression in the gen-
eral population. The investigators suggested that pri-
Mood Disturbance and
mary diagnoses of psychiatric disorder are suspect in
Substance Use Disorders
cocaine abusers because protracted, binge-indepen-
Similarly, mood symptoms, especially depressive- dent syndromes could still be secondary to cocaine
spectrum symptoms, are exceedingly common in abuse (Gawin & Kleber, 1986). Similarly, Weiss,
substance use disorders and are commonly diagnosed Griffin, and Mirin (1989) found a diagnosis of major
and treated by unsophisticated clinicians as primary depression in 13% of 149 hospitalized cocaine abus-
mood disorders. The ability of commonly abused ers but also found that depressive symptoms corre-
drugs to induce mood syndromes that resemble func- lated less well with a diagnosis of major depression
tional psychiatric disorders is well documented, espe- after 2-4 weeks of cocaine abstinence.
cially with respect to alcohol-induced mood disor-
ders. Frequently, there is a decrease in the intensity
Substance-Induced Personality Changes and
of depressive mood once sobriety is established
Independent Personality Disorders
(Brown & Schuckit, 1988; Brown etal., 1995; Dorus,
Kennedy, Gibbons, & Ravi, 1987). Dorus and col- Although clinicians who treat addictions are well
leagues (1987) found that 66% of 50 alcoholic sub- aware of the changes that occur in the interpersonal
jects had Beck Depression Inventory scores (BDI) functioning and lifestyle of people who develop sub-
greater than 17 within 24 hours of the last drink. At stance use disorders, the diagnosis of substance-in-
24 days after cessation of alcohol, only 16% had BDI duced personality disorder is used infrequently. As
scores greater than 17. Substance abusers may have the patient becomes involved in the drug lifestyle, he
a substance-induced mood disorder or concurrent or she begins to change priorities, shifting interper-
NSR major depression, or both. A subclass of pa- sonal values from egalitarian to utilitarian. As more
tients with substance use disorders and mood symp- time and energy are spent in obtaining money to pro-
toms have a complex picture: a chronic low-grade cure drugs and deceiving others, there is an increase
mood disorder such as dysthymia or atypical depres- in interpersonal exploitiveness, often with the onset
sion, which may predispose the patient to develop of "street" behavior, crime, and so on. Interestingly,
alcohol dependence, in which an even more intense 33% of treatment-seeking cocaine abusers in a study
depressive syndrome is induced. by Rounsaville and colleagues (1991) met DSM-HI-R
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 451

criteria for antisocial personality disorder (ASPD), abuse is the norm for chemically dependent patients
but only 8% met the diagnosis by more restrictive under 35 years of age (State of New York, 1991).
Research Diagnostic Criteria (Spitzer, Endicott, & Models for discrete alcoholism and substance abuse
Robins, 1978), where ASPD symptoms that are clear- treatments are increasingly seen as inadequate. There
ly due to substance abuse are excluded. Among 37 is an appropriate movement in many state govern-
of 50 cocaine-dependent inpatients that met criteria ments to consolidate the provision of alcohol and
for DSM-III-R (APA, 1987) personality disorders, drug treatment services.
19% had personality diagnoses that were made exclu-
sively under conditions of drug use (Weiss et al.,
1993.) TREATMENT
Patients who come to therapists or treatment cen-
ters with mood lability and suicidal ideation, and
Reductionism and the Philosophy
who are manipulative, needy, demanding, dysphoric,
of Treatment Design
and impulsive, are frequently labeled borderline. As
with other diagnoses, the clinician must make care- In recovery language, once you are a pickle, there is
ful assessments to make a primary diagnosis of DSM- no going back to being a cucumber. It is important
IV borderline personality disorder (BPD). Many pa- that clinicians not assume that appropriate treatment
tients with alcohol or substance abuse disorders can is a sort of undoing of first causes. A complex etiology
look quite labile, dysphoric, and impulsive when in of substance dependence does not necessarily imply
a state of chronic intoxication and acute crisis, and that the treatment of choice must address etiological
they frequently have high-intensity mood disorder factors. This may be why earlier psychodynamic at-
symptoms (Rosenthal et al., 1992a). They can have tempts at treating conditions assumed to be underly-
mixed personality disorders, or BPD with a concomi- ing the addictions frequently resulted in failure. In
tant panic, anxiety, or major depressive disorder, the staging of treatment, attenuating current patho-
which may be missed without rigorous diagnostic logical behavior may be more important than ad-
thinking. Patients with BPD often regress under dressing predisposing conditions.
stress when they increase their alcohol or drug in-
take. This further disinhibits an already impulsive
Reductionism Applied to Comorbid
person and often increases the sense of crisis, dyspho-
Psychiatric and Addictive Disorders
ria, and suicidality.
Clinicians tend to use treatment approaches based
upon etiological models generated from their own
Comorbidity of Alcohol Use
traditional treatment domain, either mental health or
Disorders and Other SUDs
chemical dependence. As a result, the patient with a
Currently, mixed addictions are common, and this is chronic mental disorder may do poorly in traditional
certainly true of patients with comorbid other mental substance abuse treatment that tends to be intolerant
disorders as well. Traditionally, there was a concep- of inappropriate or bizarre behavior (LaPorte et al.,
tual distinction between "alcoholism" and "drug ad- 1981; McLellan et al., 1983). Traditional forms of
diction." Today, it is clear that alcoholism and sub- substance abuse treatment, such as those seen in
stance dependence cross all social strata, and that therapeutic communities and drug rehabilitation
distinctions between legal/illegal use and type of programs, can be very structured and confronta-
personality are insufficient to explain addiction. On tional, with intense group interaction and display of
balance, it is important to note that over half of the affect (Rosenthal, 1984). This treatment is likely to
alcoholics (56.3%) and about 30% (29.5%) of drug be unsuitable for a patient with a severe disorder
abusers in the community have no other mental dis- such as schizophrenia, given the association of both
orders. However, 20.7% of people with alcohol abuse high expressed emotion and relapse (Vaughn & Leff,
and dependence have a lifetime prevalence of drug 1976) and intensive treatment and poorer long-term
abuse, and about 46% of drug abusers have a lifetime adjustment (Drake & Sederer, 1986) in schizophre-
prevalence of alcohol abuse or dependence (Regier nia. Conversely, patients with substance use disorders
et al., 1990). Combined alcohol and other drug often do poorly in a traditional psychiatric milieu,
452 ISSUES IN SPECIFIC POPULATIONS

where there is a more permissive environment (Pin- high psychiatric severity based on the psychiatric se-
sker, 1983). Substance abuse treatment programs verity scale of the Addiction Severity Index (ASI;
more rigidly control the environment because these McLellan, Luborsky, Cacciola, & Griffith, 1985), it
patients have a high incidence of personality disor- revealed that although treatment selection had no
ders (Kessler et al., 1994; Miller & Ries, 1991) and/or impact on outcome for the groups with low and high
characteristics, that resemble pathological character psychiatric severity, for those in the group with me-
traits (Miller & Fine, 1993). Therefore, patients with dium psychiatric severity outcome was heavily af-
manipulativeness, impulsivity, interpersonal exploit- fected by the choice of treatment program. More
iveness, and poor frustration tolerance are generally recently, McLellan and colleagues (1997) demon-
taxing for staff to treat in a permissive environment strated that patients in private addiction treatment
where they can disrupt a therapeutic milieu. programs matched to a minimum of three profes-
sional sessions directed at important family, employ-
ment, or psychiatric problems stayed longer in treat-
Bottom-Up: More Effective Than Top-Down
ment, were more likely to complete treatment, and
If one considers the wide variety of comorbidity and had better treatment outcomes. Another study of du-
severity in thinking about differential therapeutics for ally diagnosed outpatients in an integrated program
patients with comorbid disorders, it should be clear with severity-based treatment phases demonstrated
that one standard approach will not serve all patients, that cases with high total severity (psychiatric symp-
although traditional approaches have been program- toms, substance abuse, level of dysfunction) typically
matic ("top-down"). It is becoming clearer that it is receive more case management and medication ser-
not sensible to attempt programmatic approaches to vices (Ries & Comtois, 1997).
treatment matching, but that "bottom-up" planning A simple typology model, suggested to the first
of individual services based upon the severity and author by Stephan Larkin of the New York State Of-
phasing of a patient's problems (see "Sequencing of fice of Mental Health, can assist the clinician in the
Treatment" below) has merit. Accurate diagnosis is overall assessment of and treatment planning for pa-
of paramount importance because of the obvious im- tients presenting with both mental symptoms and a
plications for treatment planning and prognosis. substance abuse history (Rosenthal, 1993), but it is
Within the diagnostic frame, one can then explore no substitute for the hard work of elucidating accu-
what patient characteristics (e.g., demographics, rate diagnoses. The model assigns the patient to one
symptoms, behaviors) are correlated with the best of four categories based upon severity of mental dis-
outcome of specific interventions. order and severity of the substance use disorder (table
25.3; see also Ries, 1993). A simple instrument such
as the four-dimensional Case Manager Rating Form
Typology by Problem Severity
(Comtois, Ries, & Armstrong, 1994), which rates se-
Another critical factor for framing clinical interven- verity of psychiatric symptoms and substance abuse
tion is problem severity. Although treatment match- symptoms (as well as functional disability and treat-
ing for alcoholism alone seems to have little impact ment noncompliance) on a 0-6 anchored scale, can
on general outcomes of outpatient treatment (Project be used to make high- and low-severity attributions.
Match Research Group, 1997), the severity of psychi- Other models have attempted to categorize clinically
atric pathology has a significant impact on substance useful subtypes by differentiating chronologically pri-
abuse treatment outcome and is specifically related mary and secondary disorders with the notion that
to treatment selection. the overall course of illness tends to run with the
High-psychiatric-severity cases may respond less primary disorder (Hien et al., 1997; Schuckit, 1985).
well to standard care due to a failure to provide ade- A new, unpublished model by Minkoff and Rossi
quate "doses" of treatment services for their multiple (1997) attempts to integrate stages of treatment (see
problems (Alterman, McLellan, & Shifman, 1993). "Sequencing of Treatment" below) into a four-box
McLellan et al. (1983) evaluated 722 addicted sub- model, and it is probable that future guidelines for
jects at their 6-month follow-up after treatment in six care will develop this approach.
different rehabilitation programs. When the patients Patients in the high-NSR-psychopathology-high-
were separated into groups with low, medium, and substance-severity category are typically those with
 TABLE 25.3 Four-Box Severity Model

High NSR psychopathology Low NSR psychopathology

High substance severity

Diagnostic categories Mentally ill chemical abusers: schizo- Primary substance use disorders ± person-
phrenia, schizoaffective, bipolar, deterio- ality disorders; substance-induced disor-
rated personality disorders, and polysub- ders; toxic/withdrawal psychoses; mood
stance abusers and anxiety disorders
Characteristic behaviors Chronic psychosis with exacerbations: de- More "street smart," labile, manipulative,
teriorated social skills, cognitive impair- drug seeking; primary or secondary soci-
ment, agitated, bizarre, grandiose opathy; work and legal problems
Substance abuse patterns Severe functional psychopathology and Persistent substance dependence or se-
persistent severe drug dependence vere abuse/binging behavior
Level of functioning Very low functioning, homeless, severely Fair functioning when sober; may be dis-
and persistently mentally ill (SPMI) enfranchised from family, community
Structure/support need Great need for support, esteem, safety Structure most useful
Stress tolerance Poor stress tolerance Varying stress tolerance
Treatment strategies Mentally ill chemical abuser (MICA) Detoxification; TC or rehab model with
unit for acute stabilization, detoxifica- clear contract; intensive, supportive, real-
tion, medication; form alliance, easy ity; cut through denial; offer substitutive
early goals, longer view toward absti- behaviors; use leverage to enforce goal;
nence, recovery; repeat simple recovery cognitive behavior therapy, psychoedu-
concepts; engage and persuade, attention cation
to reengagement
Treatment problems Disorganization, poor judgment, denial Impulsivity/compulsivity is major prob-
are major obstacles; multiple relapses; lem; multiple relapses
low social support/housing
Low substance severity
Diagnostic categories Severe psychiatric disorders and sub- Low degree of functional impairment
stance abuse/misuse e.g., dysthymia, phobias, Cluster "C" per-
sonality disorder, substance-induced disor-
ders
Characteristic behaviors Psychopathology exacerbated by sub- Consistent low-level interpersonal or vo-
stance abuse, some MICA cational problems, or acute crisis
Substance abuse patterns Low-grade use; binging during exacerba- Chronic low-level abuse, or chronic epi-
tions of mental disorder sodic binging
Level of functioning Wide range of function, susceptible to de- Variable, usually moderate to high
creases during episodes of drug use
Structure/support need Much support and structure needed Structure useful
Stress tolerance Fair to poor stress tolerance Good to fair stress tolerance
Treatment strategies Stabilization of acute decompensation, Can make use of structured intervention
detox if needed, compliance with psych with confrontation, reality-based orienta-
meds, education about effects of abused tion; contingency management useful;
drugs; confront only when indicated; supportive or insight-oriented therapy as
skills training including relapse pre- indicated; make maladaptive behavior
vention ego-dystonic
Treatment problems Denial of drug abuse, contributing to Rigidity of character defenses and capac-
noncompliance with treatment and re- ity to postpone consequences, interfering
lapse of NSR disorder with treatment, engagement

Note. Adapted from Rosenthal (1993).

454 ISSUES IN SPECIFIC POPULATIONS

diagnoses of substance dependence and severe NSR prevention work, and peer support. Case manage-
disorders, such as schizophrenia, bipolar disorder, or ment services can be useful with disorganized pa-
other psychotic disorders, or Cluster A and B person- tients.
ality disorders, such as borderline, schizotypal, or an- Low-NSR-psychopathology-high-substance-sever-
tisocial with severe deterioration in psychosocial ity patients are typical of the patients with substance
functioning. The drug use is of high severity and dependence seen in addiction treatment programs.
contributes to chronic impairment in psychosocial Patients are not free of psychopathology, but their
functioning, cognitive disorganization, and noncom- higher baseline level of functioning allows them to
pliance with treatment. This group usually needs in- make use of the more structured and confrontational
patient hospitalization in specialized units for acute environment of addiction treatment settings. These
stabilization, medical detoxification, and initiation of patients often have substance-induced mood, anxiety,
pharmacotherapy for NSR mental disorders (Axis I), personality, and brief psychotic disorders superim-
as well as some form of structured, integrated psychi- posed upon primary personality, mood, and anxiety
atric and substance abuse treatment for subacute disorders, but their baseline functioning is not se-
treatment, prophylaxis of relapse, and longer term verely impaired when the substance use disorder is
maintenance. Family involvement for patient sup- in remission. When in crisis, they may need medi-
port and for family psychoeducation should be cally managed inpatient admission for detoxification.
started in the acute phase. Case management (see These patients tend to be able to make use of the
below) is often necessary for outreach and engage- standard array of phase-specific addiction treatment
ment in outpatient treatment. Sobriety is typically a services, but it is likely that psychosocial functioning
goal of treatment, which is conducted with a harm is increased by proper attention to problem areas
reduction model. Patients, once engaged in treat- other than substance use disorders, including treat-
ment, benefit from integrated treatment consisting of ment of comorbid NSR mood and anxiety disorders.
substance abuse counseling, medication manage- Patients in the low-NSR-psychopathology-low-
ment, psychoeducation about mental illness and substance-severity category are higher functioning at
drugs of abuse, relapse prevention skills training, self- baseline and show less psychosocial impairment due
help groups, and peer support. Later treatment fo- to either substance misuse/abuse or concurrent men-
cuses upon recovery of psychosocial function, relapse tal disorders such as dysthymia, generalized anxiety,
prevention, and vocational rehabilitation, if war- adjustment disorders, situational stress, and Cluster
ranted. C and less severe cluster B personality disorders.
High-NSR-psychopathology-low-substance-sever- These patients often present to private clinicians and
ity patients have severe mental disorders needing in- to outpatient clinics for treatment, usually with a
tensive mental health services but have lower inten- complaint related either to a single diagnostic focus
sity of substance-related dysfunction, often fulfilling or to another problem area, such as their relationship
abuse criteria. Patterns often show binging during pe- or job. Because of lower overall severity, these pa-
riods of exacerbation of a primary NSR mental disor- tients respond robustly to interventions aimed at in-
der with superimposed substance-induced disorders. creasing motivation toward abstinence, to cognitive
Acute exacerbations of the mental disorder are best approaches, to medication for low-severity comorbid
treated with inpatient, partial hospital, or intensive NSR disorders, and to dynamic therapies, once con-
outpatient psychiatric treatment. In the subacute crete methods for maintaining sobriety have been es-
phase, where the patient becomes engaged in treat- tablished.
ment, he or she can be treated in an integrated dual- Although the four-box model generalizes pathol-
diagnosis day-treatment-outpatient group or, if the ogy into high and low severity, a dichotomous ap-
patient is reasonably well integrated, an addiction re- proach has been developed with SUD treatment
covery program that operates in close parallel with populations that also attends to severity of psycho-
the mental health services. In either case, the patient pathology and SUD. There is recent evidence of va-
must receive psychoeducation about mental illness lidity for a multidimensional typology of alcohol
and drugs of abuse, medication management, sup- (Babor et al., 1992) and cocaine dependence (Ball,
port for medication compliance, addiction counseling Carroll, Babor, & Rounsaville, 1995) based upon
services, support to attend self-help groups, relapse Type B having higher premorbid risk factors (family
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 455

history, childhood behavior problems, personality, treatment, outpatient alcohol/drug counseling, and
age of onset), higher dependence/abuse severity, self-help groups. Provided there is an appropriate di-
more psychosocial impairment, more antisocial be- agnostic evaluation that assesses the impact of the
havior, and higher psychiatric comorbidity than NSR mental disorder upon the addiction treatment,
Type A. patients with lower severity mental disorders may be
treated on detoxification inpatient units, if that level
of care is necessary, and transitioned to residential,
Current Treatment Modalities and Settings
partial hospital, or intensive outpatient treatment.
for the Dually Diagnosed
Some patients may not need the protection of a
Because the clinical experience of individuals who 24 hour medically managed unit and thus can be
have focused upon treatment of comorbid substance treated for mild exacerbations of NSR illness and
use and mental disorders far outweighs the extent of acute relapse to SUD or crisis states in the context
empirical research on specific inteventions for spe- of partial hospital or intensive outpatient treatments.
cific comorbid disorders, most of what is recom- These patients usually have some type of community
mended in this section has an experiential/rational structure in the form of an interested and supportive
basis and has yet to be validated scientifically. None- family, a structured living environment, and/or a vo-
theless, it should be clear that no one programmatic cational endeavor. The extent to which the services
approach by either substance abuse treatment or are provided by staff who are cross-trained in addic-
mental health systems will suffice to adequately ad- tions and NSR disorder treatment and who are com-
dress comorbid disorders. This places the onus upon fortable rendering medication management, outpa-
the clinician to derive the best fit of clinical services tient withdrawal management, engagement into
and treatments with the highest degree of integration recovery work, psychoeducation about drugs of abuse
possible for patients. This will often require creativity and mental illness, cognitive behavioral approaches
and flexibility on the part of the clinician, with occa- is the extent to which a single program can optimally
sional chafed egos resulting from contact with sys- address the range of typical problems of dually diag-
tems that will not move to address the real clinical nosed patients.
problems.

Longer Term Issues

Acute/Short-Term Issues
Therapeutic Community for High-Severity Disor-
For acutely ill patients, the appropriate intensity of ders Patients who are unable to make use of outpa-
services will depend upon the presenting severity of tient treatment are often referred to residential thera-
illness, as well as other factors such as medical risk or peutic communities (TC). Only complete removal
need for protection from self- or other-directed harm. from an environment that supports substance abuse,
Special-purpose dual-diagnosis inpatient units gen- coupled with a long-term (6-month to 2-year) com-
erally serve to perform a sophisticated differential di- mitment to total immersion in a peer-supported sub-
agnostic evaluation of the high-severity patient, de- stance-dependence-treatment milieu is believed to
toxify the patient from drugs and alcohol, stabilize have sufficient effect on the addict to allow him or
the patient's acute mental disorder using psycho- her to return to sober living in the community. Many
tropic medications if indicated, engage the patient TCs have transitional programs that allow the patient
in early sobriety, and make recommendations about in later stages of treatment to work in the community
further treatment. Rediagnosis may be made after or continue educational pursuits. Although opiate
resolution of acute symptoms. Hospitalization pro- addicts are the stereotypical residents of a therapeutic
vides a concrete interruption of the patient's daily community, trends over the past decade indicate that
routine, vocational or educational milieu, and inter- crack and cocaine addicts have been populating
personal relationships, any or all of which may be many of the beds in these programs (see chapter 17).
contributing to the maintenance of the patient's ad- When psychiatric patients are treated for sub-
dictive behavior. Follow-up recommendations may stance abuse in the highly controlled environment of
include combinations of services in the community, a traditional therapeutic community, those with se-
such as partial hospitalization, outpatient psychiatric vere mental illness have poor outcomes (McLellan
456 ISSUES IN SPECIFIC POPULATIONS

et al., 1983). Drug rehabilitation programs typically one form of treatment must come first may be due
lack the clinical resources to manage aberrant behav- to an insufficiently broad understanding of addic-
ior, and they typically screen out patients who have tions and mental disorders treatment. However, in
histories of suicidal behavior and those who need certain cases, there may be a strategic reason to pur-
psychoactive medications. In many therapeutic com- sue a serial approach to treatment.
munity settings, substance abuse treatment employs For example, with PTSD, both serial and concur-
confrontational techniques in the context of heated rent models have been applied. Reduction in PTSD
group interaction and strong displays of affect (Ro- symptoms might decrease risk for relapse by decreas-
senthal, 1984). There is an association between high ing dysphoric states, but proponents of serial treat-
exposure to expressed emotion and relapse in schizo- ment believe that stable sobriety must be achieved
phrenia (Vaughn & Leff, 1976). Therefore, confron- before the PTSD is addressed (Brinson & Treanor,
tational or uncovering approaches (Drake & Sederer, 1988; Roy, 1984; Moyer, 1988). Advocates for con-
1986) may exacerbate symptoms in patients with psy- current approaches state that the risk of substance
chotic disorders, rendering the classical TC less ap- use relapse is reduced when the traumatic events are
propriate for dual-diagnosis patients with more severe addressed earlier in treatment (Bollerud, 1990). Not
disorders. yet addressed in the literature are differential treat-
However, integration of mental health services ment models based on the sequencing in which the
can make a difference in the TC setting, as dem- PTSD and the SUD developed.
onstrated by two recent studies. Carroll and Mc-
Ginley (1997) demonstrated that while higher psy- Integrated Treatment
chopathology was inversely related to treatment
Patients with a substance use disorder and a co-oc-
outcome, the use of enhanced mental health staffing
curring severe mental illness such as schizophrenia
in a TC with addicts who had severe mental disor-
have difficulty being treated adequately within the
ders contributed to significant treatment benefits at 6
format of traditional provider systems, and it is rea-
months. For patients with NSR mood and psychotic
sonable and important to investigate combining and
disorders, Westreich, Galanter, Lifshutz, Metzger,
integrating services to these patients (Drake, Mueser,
and Silberstein (1996) demonstrated 33% program
Clarke, & Wallach, 1996; Rosenthal et al, 1992b).
completion rates in a residential drug-free TC lo-
Early studies suggested that treatment with a dual fo-
cated in a homeless shelter. In this TC model, com-
cus was beneficial for certain diagnostic groups with
munity confrontation of "bad" behavior was modu-
respect to maintenance of level of function (Kofoed,
lated to the capacity of the resident to tolerate it.
Kania, Walsh, & Atkinson, 1986) and decreased rates
Therapeutic communities fare better with patients
of readmission to hospital (Hellerstein & Meehan,
with personality disorders, who are probably a large
1987). Recent models of integrated treatment synthe-
percentage of the patients seeking treatment; none-
size traditional mental health and addiction counsel-
theless, the overall dropout rate from TC treatment
ing into an approach that appears seamless to pa-
in the first 30 days has been relatively high.
tients with respect to philosophical underpinnings,
treatment approach, and psychoeducational content
Sequencing of Treatment (Minkoff, 1989; Ries, 1993; Rosenthal et al. 1992b).
In dually diagnosed patients with severe disorders,
Two traditional approaches to treating dually diag-
service integration has an important retention effect,
nosed persons are serial treatment, where either the
and patients who remain in treatment improve (Hell-
NSR mental disorder or substance use disorder is ad-
erstein et al, 1995). In dually diagnosed patients
dressed first, and parallel treatment, where both dis-
with less severe disorders, coordinated psychiatric
orders are addressed concurrently, but typically with-
services and addiction rehabilitation services also
out formal interaction of the clinicians or programs
may lead to better outcome (McLellan et al, 1997).
involved. Generally, neither approach represents a
well-reasoned treatment strategy; both are the result
Stages of Treatment and States of Change
either of lack of coordination of local mental health
and substance abuse provider systems or of limita- Recently, two groups have described the change pro-
tions of the treating clinicians. Clinicians' belief that cess as occurring in stages. Prochaska and DiCle-
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 457

mente (1984, 1986; Prochaska, DiClemente & Nor- vides interventions appropriate to the patient's stage
cross, 1992), focusing on the treatment of substance of readiness to change is likely to result in a higher
use disorders, have suggested that individuals prog- rate of retention and, thus, better outcome. Several
ress through five stages of motivational readiness to instruments have been used to determine the pa-
change: precontemplation, contemplation, prepara- tient's current motivational stage. McHugo, Drake,
tion, action, and maintenance. In the precontempla- Burton, and Ackerson (1995) derived a psychometri-
tion stage, the person is generally underaware of a cally reliable and valid scale that operationalizes
problem and has no intention to change the behav- eight stages based upon patient behaviors such as fre-
ior. In the contemplation stage, the person is aware quency of clinical contact, quantity of drug use, and
of the problem but is not ready to make a decision timing of recovery milestones. The Recovery Attitude
and may weigh the pros and cons of the addictive and Treatment Evaluator Questionnaire (RAATE-
behavior. In the preparation stage, the person intends QI; Smith, Hoffman, & Nederhoed, 1995) measures
to stop the addictive behavior and may have taken five dimensions used for treatment matching in dual-
preliminary steps, such as cutting down on drug use diagnosis patients: motivation/denial, resistance to
and mapping out a treatment program that makes continuing care, biomedical acuity, psychiatric acu-
sense. In the action stage, people commit time and ity, and environmental support status.
energy to modifying their behavior and their environ-
ment to support the achievement of a targeted goal.
Recovery Is Nonlinear:
Maintenance is the stage of relapse prevention, where
The Virtue of Persistence
stabilization of behavioral change and integration of
the methods of maintenance of recovery occur; it In dual-diagnosis patients, the recovery process is not
lasts indefinitely after the action stage. linear, and exacerbations of both disorders are epi-
Paralleling the work of Prochaska and his col- sodic. Patients often cycle repeatedly through differ-
leagues, Osher and Kofoed (1989) described five treat- ent phases of treatment. When they come back into
ment phases for the severely mentally ill patient with contact with health care providers, they may be in
SUD: engagement, persuasion, active treatment, main- an earlier motivational stage or even in denial that
tenance, and relapse prevention. In this model, en- a problem really exists. In contrast to conventional
gagement is an early-stage intervention to motivate wisdom, if treatment can "stay with" the patient over
the patient toward contact with the provider and is time attenuation of both the substance use and the
most appropriate to the precontemplation stage. In mental disorders is possible (Hellerstein et al., 1995).
the persuasion stage, appropriate to the contempla- With the more severe disorders, the time frame of
tion stage, the therapist focuses on motivating the pa- recovery often needs to be extended. Patients with
tient to realize that there is a problem which needs comorbid severe mental illness and substance use
both professional intervention and the participation disorders may need more than 2 years to gain stable
of the patient. Active treatment focuses on both the sobriety (Drake, McHugo, & Noordsy, 1993).
preparation and action stages, and in severely men-
tally ill patients, the achievement of stable sobriety
Integrating Psychological Therapies
may take an extended period of time. Relapse pre-
vention uses techniques that are appropriate to the There is no one-size-fits-all treatment for dual-diag-
maintenance stage. nosis patients because there is little homogeneity
Attempting to use the treatment methods appro- within diagnostic sets, and even less across the many
priate for a later stage while the person is at an earlier permutations of possible diagnoses of substance use
stage results in a therapist-patient mismatch. For ex- and other mental disorders. Treatment must be indi-
ample, while the patient is in the stage of precontem- vidualized to the problem severity of the patient,
plation, vigorous use of injunction and confrontation rather than relying upon program-driven or philoso-
typical of the contemplation/persuasion stage, rather phy-driven approaches to care. Supportive treatment
than engagement, typically results in a rupture of the components, common factors of all therapies (Pin-
therapeutic alliance and the development of an "ex- sker, Hellerstein, Rosenthal, Muran, & Winston,
patient." With dual-diagnosis patients, retention in 1996), are the basis for the approach with dually di-
treatment is often half the battle. Treatment that pro- agnosed patients. Practically speaking, elements of
458 ISSUES IN SPECIFIC POPULATIONS

supportive therapy, cognitive behavioral measures, patient who has something to lose. For a 45-year-old
and behavioral reinforcement techniques can be in- married patient with children who has a mortgage
tegrated into individualized treatment. Even in dy- on the house, is active in community activities, and
namically based psychotherapies, elements of relapse belongs to the country club, sending a letter to the
prevention (Marlatt & Gordon, 1985) should be chairman of the board of the brokerage firm where
structured into the therapy to arm patients with a the patient is a vice president at the next urine toxi-
range of choices and behaviors to mobilize in the cology positive for cocaine is likely to be an effective
context of internal and external triggers to use. Most intervention. In contrast, for the homeless, crack-de-
dual-diagnosis patients benefit from both interper- pendent 18-year-old patient who has schizophrenia,
sonal support and cognitive restructuring in the form but no relatives or friends, the problem is less what
of new information and skills building. Cognitive be- she has to lose than where therapeutic leverage can
havioral therapies teach patients how to cope with be applied at all. This latter patient is more likely
strong affects and how to promote or repair adaptive to respond to positive reinforcement. Nonetheless, in
skills such as problem solving or substance refusal spite of a lack of studies demonstrating its effective-
skills. For psychotherapy with these patients, non- ness, contingency management of payee benefits ap-
punitive confrontation and support without being pears to be in widespread practice (Ries & Dyck,
overresponsible (enabling) or fostering regression are 1997).
therapeutic challenges. Motivational enhancement techniques, initially
Timing of intervention is important with dual-di- used for higher functioning problem drinkers (Mill-
agnosis patients, both on the macro level (see "Stages er & Rollnick, 1991), have been used in the treat-
of Change" above) and in the interpersonal process ment of more severely ill dual-diagnosis patients
between therapist and patient. For example, patients (Ziedonis & Fisher, 1996). Ziedonis and Trudeau
who are depressed usually have decreased energy (1997) described a motivation-based treatment mod-
and concentration to put into the work of recovery. el (MET) for dual-diagnosis patients that includes in-
The rate of remission of depressive symptoms is con- terventions specifically targeted to the motivational
sistent with the primary diagnosis in that symptoms stages of change (Prochaska & DiClemente, 1984)
remit more rapidly among patients with primary al- described above. For example, in MET, low-motiva-
coholism than among those with primary affective tion patients have harm reduction goals, whereas
disorder (Brown et al., 1995), a difference that affects high-motivation patients have abstinence as a goal.
when the patient will be able to make use of more Motivational enhancement techniques (Miller, Zwe-
intensive and complex information and emotional ben, DiClemente, & Rychtarik, 1992; see also chap-
processes. In patients with SUD and bipolar disorder, ter 13) are used in the precontemplation, contempla-
because of initial difficulties internalizing the cogni- tion, and preparation stages.
tive strategies, a 12-week course of relapse prevention
group therapy had to be extended to 20 weeks in or-
Integrating Pharmacotherapies
der to demonstrate significant effects upon drug use
(Weiss et al., 1997). Typically, in addicted patients Differential diagnosis is essential to achieve maxi-
who have the psychological-mindedness and ego de- mum clarity about which syndromes are indepen-
velopment to make use of it, psychodynamic treat- dent mental disorders that need medication for acute
ment may be useful in later stages of treatment, or subacute stabilization, and which arise in the con-
when the patient has developed a concrete method text of substance use. Without that clarity, inappropi-
of maintaining sobriety and a firm working alliance ate medicating as well as over- or undermedicating
with the therapist, so that the anxiety-provoking pro- are likely. Given the clinical complexities in manag-
cedures of expressive treatment do not lead to relapse ing comorbid mental disorders among substance
(Kaufman & Reoux, 1988). abusers, there is an increasing role for psychiatrists to
Certain interventions work better with some pop- collaborate in addiction treatments conducted by
ulations of persons comorbid for substance use disor- other professionals (see chapter 19).
ders and other mental disorders than with others. For Basic principles of pharmacotherapy for dually di-
example, there is good reason to expect that contin- agnosed patients are: (a) Do not provide pharmaco-
gency management can work reasonably well with a logical treatments for substance-induced disorders
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 459

acutely, except for safety or medical management and SUD. As with the pharmacotherapy of substance
reasons; (b) treat all treatable NSR mental disorders, use disorders, the efficacy of pharmacotherapy of co-
avoiding, if possible, medications with a high abuse morbid NSR disorders is likely to be increased in the
liability; (c) use parsimony in choosing and dosing context of appropriate psychosocial interventions, in-
medications, but don't undertreat; (d) syndromes are cluding those that increase medication compliance
less risky to treat than symptoms; and (e) psychoedu- (Volpicelli et al., 1997). Core principles that serve to
cation and support for compliance are critical. frame the basis of pharmacological treatment of
When considering pharmacotherapy for patients dual-diagnosis patients are listed in table 25.4 (see
with substance use disorders, medication-responsive Gastfriend, 1993).
comorbid disorders, if not acute and substance-in-
duced, should be treated. At least 3 weeks of absti-
Pharmacotherapy of SUD
nence from alcohol appears to be necessary to consis-
tently differentiate the groups with dual diagnoses Pharmacotherapy of SUD is covered in detail in
into primary and secondary (substance-induced) on chapter 19 and will be described here only briefly.
the basis of current depressive symptoms (Brown et Medication of SUD can follow by several strategies:
al., 1995). However, the initial treatment of a sub- (a) substitution, using agonists during detoxification
stance-induced mood disorder is detoxification and or maintenence (e.g., opioid or nicotine replace-
support. Clinicians can use the dysphoria and anxi- ment); (b) blocking the effects of drugs with antago-
ety associated with drug use to motivate engagement nists (e.g., naltrexone); (c) contingency management
in treatment and attainment of sobriety. through aversive agents (e.g., disulfiram); (d) use of
In actual practice, disorders that are substance-in- agents that reduce craving; (e) use of medications for
duced but persist more than a month or so after ces- comorbid NSR or substance-induced disorders; (f)
sation of substance use may respond to medication. use of medications for comorbid medical disorders
The timing of the intervention is dependent upon (Wilkins, 1997); and (g) use of agents that reduce
the type of symptoms, their severity, their effects constitutional vulnerability (e.g., impulsivity, nega-
upon general quality of life, and, more specifically, tive symptoms) to drug use. The main problem with
capacity to maintain sobriety. Use of psychotropic pharmacotherapy in SUDs is similar to other modes
medications with low abuse liability, such as neuro- of treatment, namely, compliance with the regimen.
leptics for persisting hallucinosis or serotonin reup- Methadone maintenance programs exist both as hos-
take blockers for persisting depression, is less risky pital-based and freestanding private clinics in the
to sobriety than using medications with high abuse community with more than 150,000 slots for opiate-
liability such as benzodiazepines for anxiety disorders dependent people (National Institute on Drug Abuse,
or stimulants for ADHD. For example, low-grade de- 1995). Although methadone maintenance remains
pressive symptoms may persist months after cessation controversial even after decades of documented posi-
of alcohol or cocaine. As stated earlier, if one finds tive treatment outcomes (Ball & Ross, 1991; Condel-
that the depression predated the onset of the addic- li & Dunteman, 1993), it is a mainstay for thousands
tive disorder, as in primary dysthymia, then the disor- of well-functioning people with intractable opiate de-
der should be treated. If the disorder is secondary but pendence. There is high psychopathology among
persists for weeks to months despite sobriety and opioid-dependent persons, demonstrated in both epi-
some recovery, and if the symptoms are of sufficient demiological (Kessler et al., 1994) and clinical sam-
intensity to interfere with the recovery process, then ples (Rounsaville, Weissman, Kleber et al., 1982;
it may be treated. However, in SUD patients, the Rounsaville, Weissman, Crits-Cristoph et al., 1982),
medication of individual symptoms (e.g., anxiety, and it is clear that diagnosed NSR mental disorders
dysphoria, or insomnia) is potentially more risky than can and should be treated pharmacologically in this
medicating clusters of symptoms that meet syndro- population, where appropriate (Nunes et al., 1995).
mal criteria (e.g., panic disorder or major depres- Compared with opioid substitution pharmaco-
sion), even if secondary. therapy, there are no effective substitutive medica-
Pharmacotherapy is typically only one of several tions for alcohol or stimulant dependence. Other
treatment modes that is essential for the stabilization types of medications may support sobriety in the con-
and recovery of patients with NSR mental disorders text of psychosocial treatment. The opiate antagonist
460 ISSUES IN SPECIFIC POPULATIONS

TABLE 25.4 Key Elements of a Dual-Diagnosis Pharmacotherapy Contract

1. Medication is part of a rational psychosocial treatment package and will be discontinued if other primary treatment
elements are neglected.
2. Medication is not a substitute for the work of recovery.
3. Urine or blood testing may be required on demand to provide objective clinical data on the course of addiction treat-
ment, or to determine if there are adequate blood levels of prescribed medication.
4. Medication will be used only as prescribed. Any need for changes must first be discussed with the physician. A unilat-
eral change in medication by the patient is often an early sign of relapse.
5. The purpose of medication is to treat disorders characterized by predetermined target symptoms. If medication proves
ineffective, it will be discontinued.
6. Once target symptoms remit, a process of dose tapering may be initiated to determine the minimum dose (including
discontinuation) necessary to maintain healthy function.
7. Medication may not be necessary on a long-term basis.

Note. Adapted from Gastfriend (1993).

naltrexone has shown utility in the treatment of alco- disorder is ruled out mood disorders should be
hol dependence (Volpicelli et al., 1997). Disulfiram treated. In the absence of a comorbid mood or anxi-
(Antabuse) can be used as an aversive support for so- ety disorder, fluoxetine probably should not be used
briety from alcohol in patients with NSR mental dis- to maintain abstinence or reduce drinking in high-
orders who can (a) understand the risks of concur- risk/severity (Type B) alcoholics, as it has been dem-
rent alcohol use; (b) responsibly avoid contact with onstrated to result in poorer drinking-related out-
any alcohol-containing substance, like hair spray or comes than placebo treatment (Kranzler, Burleson,
after-shave; and (c) withstand impulses to use alco- Brown, & Babor, 1996).
hol. Therefore, patients with cognitive impairment Depression and dysphoria are common in co-
or impaired judgment due to severe mental illness caine-abusing patients (Gawin & Kleber, 1986; Nunes,
are less suitable candidates. There are no medica- Quitkin, & Klein, 1989; Weiss et al., 1986) and are
tions that have been demonstrated to reliably reduce associated with poorer substance abuse treatment
drug craving that are not based on the substitution outcome (Hodgins, el-Guebaly, & Armstrong, 1995;
model. LaPorte et al., 1981; Woody, O'Brien, & Rickels,
1975). Depression appears to be a risk factor for in-
creased cocaine abuse in opioid addicts, as those with
Pharmacotherapy of Mood Disorders
increased cocaine abuse at 2.5 year follow-up were
According to Marlatt and Gordon (1985) and Litman more likely to have depressive disorders (Kosten et al.,
et al. (1983), dysphoric mood related to depression, 1987). In the laboratory, Childress and colleagues
loneliness, anger, or frustration is the most common (1994; Childress, McLellan, Natale, & O'Brien, 1987)
precipitant of relapse in addictive disorders. In pa- have demonstrated that negative mood states can
tients with alcohol dependence and major depres- elicit both conditioned withdrawal and craving and,
sion, the tricyclic antidepressants imipramine (Mc- when these are induced, can trigger drug use in sub-
Grath et al., 1996) and desipramine (Mason, Kocsis, stance abusers. The inability to self-soothe a dys-
Ritvo, & Cutler, 1996) are effective in treating the phoric state also has implications for relapse in that
mood disorder but have equivocal effects on drinking after cocaine cue exposure, cocaine-dependent sub-
behavior. A recent placebo-controlled study by Cor- jects who are unable to reduce their arousal/craving
nelius and colleagues (1997) demonstrated the effi- have a higher risk of treatment failure (Margolin,
cacy of fluoxetine in reducing not only mood symp- Avants, & Kosten, 1994).
toms in depressed alcoholics, but also the frequency Concurrent mood disorder was an important pre-
and amount of drinking. Since persisting depression dictor of poor treatment outcome in one controlled
can interfere with the process of recovery and psy- study (Ziedonis & Kosten, 1991), but of good out-
chosocial rehabilitation, once a substance-induced come in another (Carroll, Nich, & Rounsaville,
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 461

1995). Several recent studies, while not finding sig- poor overall anxiolytics, and psychosocial interven-
nificant overall effects of antidepressant medications tions should include those that increase medication
for cocaine abuse, have found that patients who were compliance. Kranzler (1996), in a review of placebo-
depressed were more likely to respond (Margolin et controlled trials, suggested that the use of the non-
al., 1995; Nunes et al., 1995; Ziedonis & Kosten, benzodiazepine anxiolytic buspirone in anxious alco-
1991). Patients who respond to antidepressants may holics for a minimum of 4-6 weeks at a substantial
be those who abuse cocaine in an attempt to self- dose helps with treatment retention and reduces both
medicate dysphoria or depression (Kosten, 1989). In anxiety symptoms and heavy drinking. Panic disorder
addition, SUD patients whose depressive symptoms is responsive to many medications with low abuse
are not due to primary depression may also have a liability, such as serotonin selective reuptake blockers
differential response to tricyclic medication (Nunes and imipramine, as well as those with high abuse
et al., 1995). In all, patients with cocaine-induced liability, such as alprazolam. Unless other methods
dysphoria who present with depressive mood may be have repeatedly failed to address concurrent severe
more constitutionally vulnerable to the mood-modu- anxiety, the use of benzodiazepines, except for con-
lating effects of external reinforcers and therefore, trol of acute withdrawal or psychotic agitation, is
may benefit from medication for mood disorder. probably ill advised in patients with SUD because
Similarly, in bipolar disorder patients, there is a of the high liability for abuse and the potential for
higher probability of remission of an alcohol use dis- dangerous synergistic effects (e.g., overdose) with al-
order than in primary alcoholism patients without bi- cohol and other sedative hypnotics.
polar disorder (Winokur et al., 1995).

Pharmacotherapy of Psychotic Disorders

Pharmacotherapy of Anxiety Disorders
Because intoxication or withdrawal can induce psy-
Anxiety symptoms are very common in SUD pa- chotic states or exacerbate preexisting psychotic dis-
tients. The traditional addictions approach has been orders, acute psychosis is best handled symptomati-
to support the patient through anxious times by hav- cally with safety the primary concern. This means
ing the patient go to self-help meetings; talk to a using sedative medications such as lorazepam for
sponsor, loved one, or friend; or engage in distracting psychotic agitation and deferring the use of antipsy-
behaviors. Clinicians have appropriate concerns that chotic medication until the clinical picture is clear-
reducing some of the dysphoria early in treatment er (see "Psychosis and Substance Use Disorders"
may decrease motivation amd engagement in the above). The time course of psychosis that is sub-
work of recovery. The prevailing attitude has been stance-induced generally follows the activity or with-
that anxiety in SUD is related to intoxication or with- drawal cycle of the type and amount of the drug
drawal states and abates over time with continued used. For example, with the short action of cocaine,
sobriety. Although this is true in many instances cocaine delusional disorder rarely lasts more than a
(Brown et al., 1991), in others, there are co-occurring few days, whereas the chronic use of amphetamine
primary anxiety disorders that, left untreated, inter- (a longer acting drug) may induce delusions that
fere with recovery by either increasing the risk of re- may take weeks to clear. Once a presumptive diagno-
lapse or decreasing the patient's ability to participate sis of an NSR psychotic disorder or a substance-in-
in psychosocial rehabilitation (e.g., social phobia re- duced persisting psychosis is made, then treatment
ducing participation in therapeutic groups). Clearly, with an antipsychotic medication is warranted. In pa-
psychotherapeutic interventions focused upon direct tients with severe mental disorders and SUDs, com-
anxiety reduction and developing coping skills are pliance with medication is essential for stabilization
first-line interventions in this population, including and recovery. Even with medication compliance,
those with panic or PTSD symptoms. The primary persisting psychosis is not infrequent in schizophre-
pharmacotherapy guidelines in this case are safety, nia and other psychotic disorders and typically inter-
efficacy, and low abuse liability. Once the commit- feres with the process of recovery. Because negative
ment is made to pharmacotherapy of anxiety, corol- symptoms may increase the risk for substance abuse
lary psychoeducational treatment components should (Rosenthal et al., 1994; Schneier & Siris, 1987),
underscore that the patient's drugs of abuse make newer, atypical antipsychotics such as clozapine and
462 ISSUES IN SPECIFIC POPULATIONS

olanzepine that appear to have higher efficacy on niche are exposed over time to the knowledge and
negative symptoms may be of differential value in practice of clinicians in other domains, often a useful
substance-abusing schizophrenia patients (Buckley, learning experience. In the public service system that
Thompson, Way, & Meltzer, 1994). generally treats the high-substance-abuse-severity-
high-psychopathology patient, a specialized form of
case management has been generated. Case manag-
OTHER UNIQUE ISSUES IN TREATING ers steer the patient among various mental health,
THE DUALLY DIAGNOSED addiction, medical, housing, and entitlement ser-
vices, serving in an ombudsman capacity with agen-
cies, and providing on-the-fly clinical support. A ma-
Continuity of Care
jor focus is upon early intervention in drug abuse
Because of their often confusing presentations, du- relapse (i.e., locating patients, escorting them to 12-
ally diagnosed patients must have continuity of care step meetings, detoxification or other services as nec-
over time and across disciplines. The chronic, pro- essary, and intervening to support sobriety).
gressive, and relapsing nature of both NSR and
SUDs makes continuity of care imperative for main-
Social and Environmental Needs,
tenance of therapeutic gains. If possible, treatment
Including Issues of the Homeless
should be delivered in an integrated manner, es-
pecially for severely mentally ill patients (see In order to recover from a major mental illness and
"Chronically Mentally 111 Substance Abusers" below) an addictive disorder, the dually diagnosed person
(Hellerstein et al., 1995; Minkoff, 1989; Ries, 1993; needs, at a minimum, a safe, drug-free living envi-
Rosenthal et al., 1992b). Parallel but not integrated ronment, a reasonable means of support, and sup-
delivery of services is associated with a rapid and sta- portive social contacts. Unfortunately, these seem-
tistically significant decrease in treatment retention ingly simple needs often go unmet for the person at
of patients with severe mental illness and substance the lowest end of the socioeconomic scale, who may
use disorders (Hellerstein et al., 1995). By combining have drifted there by virtue of serious coexisting dis-
psychiatric and addiction treatment, the patient par- orders.
ticipates in a sensible diagnosis and treatment plan Herman, Galanter, and Lifshutz (1991) found
that has the potential for addressing his or her prob- that 46 of 100 patients admitted to the Bellevue
lems. Dual-diagnosis Unit had been homeless (living in
shelters, missions, public buildings, streets, or parks)
on the day prior to inpatient admission. Interestingly,
Case Management: Singular Responsibility
34 had been homeless a majority of the time in the
in a Team Approach
2 months prior to admission, and 27 had been home-
Case management is a procedure whose utility in less a majority of the time in the 2 years prior to
dual-diagnosis patients increases with illness severity. admission. Homeless persons were more likely to at-
No one provider typically supplies all of the neces- tend "self-help" groups such as AA than nonhomeless
sary services that will stabilize a seriously ill dual- persons. The authors recommended specific psychi-
diagnosis patient in the community. In case man- atric outreach and the introduction of self-help
agement, one person in the network of different groups into the shelter system.
clinicians/programs that provide services to a particu- A safe living environment and the routine of work
lar patient takes responsibility for coordinating the or school promote stable recovery of dually diag-
treatment plan, communicating across providers, and nosed patients. The traditional mental health service
creating an overview of the case. Case management system, however, has been separate, both organiza-
can most easily be done within institutional settings tionally and financially, from such social service con-
but can also be done in the community, provided all cerns. This separation, in addition to its arbitrary and
clinicians participate. In this way, a team is created artificial nature, ignores the realities of treating a se-
that works in concert to provide the range of services verely ill dually diagnosed population.
deemed appropriate for a particular patient's care. An A successful program, housed inside a homeless
additional advantage is that clinicians isolated by shelter, concentrated on the treatment of severely
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 463

mentally ill men who both were also homeless and The AA member who is prescribed psychiatric
had substance use disorders (Westreich et al., 1996). medications should carefully review with his or her
The relatively high treatment completion rate (33%) prescribing doctor the addiction liability of each
and low incidence of drug use could be attributed medication. Although most AA groups and AA mem-
to the program's sophisticated care and —perhaps as bers are open-minded about psychiatric medication,
important—its provision of a supportive home. Al- if a member is criticized for taking these medications
though relatively expensive in the short term, such alternative meetings should be sought. Originating in
programs may prevent future emergency department the early 1980s, self-help groups such as Dual Recov-
visits and hospital admissions, reducing long-term ery or Double Trouble operate on a 12-step model
costs. Although the validity of this cost offset argu- but are inclusive of mental disorders other than ad-
ment has been demonstrated for the addicted popu- diction. One of the clear advantages of these self-
lation (Lewis & Kleinenberg, 1994), the scientific help groups is that they offer to patients with severe
community still awaits such a well-documented dem- mental disorders a chance to "fit in" without having
onstration for the dually diagnosed person. to disclose a psychiatric disability where it may not
be understood or having to feel deceptive by not re-
vealing a significant impediment to recovery. Dual
Potential Problems in Utilizing
recovery groups are by design more comfortable with
12-Step Programs
the concept of psychoactive medication than tradi-
tional 12-step meetings. At times, it may be benefi-
Self-Help Groups
cial to counsel dual-diagnosis patients who go to reg-
Thousands and thousands make use of Alcoholics ular 12-step meetings not to discuss their mental
Annonymous (AA) and other self-help groups in or- illness and medication, and to "take what you need
der to achieve and maintain sobriety, often without and leave the rest."
other professional contact. There are probably more
patients than qualified clinicians to treat them, and
Chronically Mentally 111 Substance Abusers
a large percentage of people with SUDs and/or NSR
mental disorders are never treated in a clinical set- A large measure of clinical difficulty and financial
ting (Kessler et al., 1996; Narrow et al., 1993). To pressure on society is found in a subset of the 14% of
the extent that dually diagnosed patients are deemed the population with three or more lifetime comorbid
able to make use of self-help recovery groups in the disorders, among whom are the severely and persis-
community, they should be supported by clinicians. tently mentally ill (SPMI). In a study of substance
Although peer-led groups like AA are often the abuse among the chronically mentally ill, Drake and
mainstay of treatment for the addicted person, the Wallach (1989) interviewed 187 chronically men-
groups do have a potential pitfall for persons with an tally ill persons and found that the dually diagnosed
NSR mental illness. Psychiatric medications have at patients, compared to those who were only mentally
times been an issue for people attending AA. All ill, were younger, more likely to be male, less able to
abused psychoactive substances are considered harm- maintain stable housing and financial stability, and
ful by AA, because of both concerns about develop- more likely to evidence hostility, suicidal thoughts,
ing new addictions and concern about medications and medication noncompliance.
interfering with true recovery. AA's official policy on The SPMI population has been poorly served by
medications, as stated in the AA booklets "To The both the traditional mental health care system and
Doctor" and "The AA Member and Medications," is the traditional substance abuse treatment system. Al-
to avoid interference with the legitimate prescription though managed-care organizations have also often
of medications. Most AA members adhere to this pol- found this population difficult to treat with a sensible
icy and, in the best tradition of AA, endeavor to have amount of financial risk, new carve-out designations
no opinion on matters not directly related to their for the SPMI population may prove beneficial over
fellow AA member's alcoholism. Unfortunately, over- the long term. By carving out this population from
zealous self-help members may pressure the person traditional capitation contracts and shifting responsi-
taking psychiatric medications to stop taking medica- bility to government or an appropriately funded pri-
tion, with predictable clinical results. vate system, managed-care organizations may do a
464 ISSUES IN SPECIFIC POPULATIONS

service by officially recognizing the very different

Assertive Case Management for
needs of the SPMI population from those of other
High-Severity Cases
groups of people.
Assertive community treatment (ACT) programs are
based on a model pioneered by Stein and Test
Integrated Treatment for
(1980; Olfson, 1990) for community treatment of se-
Severe Mental Illness
riously mentally ill patients. ACT programs (Olfson,
One simple model of treatment that has established 1990) have interdisciplinary staffs, generally directed
efficacy for severely mentally ill patients with SUDs by a psychiatrist, that provide community-based treat-
is the combined psychiatric and addictive disorder, ment for chronic psychiatric patients, focusing on is-
or COPAD, model. The treatment model consists of sues of daily living, basic material needs, and case
substance abuse counseling, supportive group psy- management, with a significant degree of outreach
chotherapy (Rosenthal, in press), psychiatric medica- in the community. In particular, such services pro-
tion management, and ad hoc crisis intervention, all vide frequent off-site visits, 24-hour-per-day availa-
integrated philosophically and geographically into bility, continuity of care, and assertive offering of
two group therapy sessions per week. Individual ses- treatment when patients begin to relapse. Drake,
sions with the psychiatrist are provided ad libitum for McHugo, and Noordsy (1993) found that 61% of
medication problems and so on. The persuasion and substance abusers with schizophrenia achieved stable
active treatment phases of dual-diagnosis treatment (> 6-month) remission from alcoholism at 4-year out-
as conceptualized by Osher and Kofoed (1989) are come in an integrated treatment program that in-
combined in the COPAD treatment (Hellerstein et cluded assertive case management. In another study,
al., 1995; Rosenthal et al., 1992b), along with the 42 patients with DSM-IV schizophrenia and sub-
engagement phase (Drake, Bartels, Teague, Noord- stance dependence were randomized to a control
sy, & Clark, 1993). Interventions at crisis points for group of integrated outpatient treatment or an experi-
schizophrenia patients with substance use disorders mental group of integrated treatment including a re-
must typically be aimed at engagement and persua- duced form of ACT called targeted assertive outreach
sion (Lehman, Herron, Schwartz, & Myers, 1993). (TAO). At 4 months, control subjects showed 27%
This model demonstrates strong retention ef- diminution in positive symptom severity compared
fects simply due to integrating services. Compared to to 51% for those receiving TAO services (community
a parallel treatment group that received addiction visits from team staff members; crisis intervention
and psychiatric services in different locations, at 4 and assertive outreach to support treatment compli-
months 69.6% of patients in integrated treatment re- ance, medication use, and attendance at scheduled
mained in treatment, compared to only 37.5% in the appointments; and direct support of attendance at
nonintegrated treatment (Hellerstein et al., 1995). 12-step programs) (Rosenthal, Hellerstein, & Miner,
Patients retained in treatment had significant reduc- 1997).
tions in both psychiatric and substance use symptom
severity. The success of COPAD was directly linked
Targeted Assertive Outreach
to the coordination of addiction and psychiatric care,
delivered by the same clinicians in the same physical TAO differs from other case management models by
space. By having an ongoing long-term relationship (a) reliance on in vivo assistance and training of pa-
with the patients, the clinicians were able to assess tients; (b) utilizing assertive case management staff
each presenting complaint in the context of their who are providers and not just brokers of aspects of
previous observations and accurately decide if the the service package; (c) heavy emphasis upon staff
symptoms warranted supportive psychotherapy, med- teamwork; (d) maintaining a 1:10-15 staff-to-patient
ication adjustment, or hospitalization. Patients who ratio; (e) ensuring that no team has a caseload
failed to engage in treatment had significantly more greater than 60 patients so that every worker can be
days in the hospital than those who began treatment, acquainted with every patient; (f) maintaining a long-
and failure to engage was strongly related to return to term commitment to patients that they can use the
a controlled environment (Hellerstein et al., 1995). services as long as needed (Bond, 1990); (g) 24-hour
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 465

availability of team members; and (h) a clinical su- flexible understanding of substance abuse theory and
pervisor who is also on the team. As stated above, psychiatry is necessary for the competent treatment
recovery is understood to be nonlinear. Therefore, of dually diagnosed patients.
the TAO team assists patients as they cycle through Access to just such an understanding is described
initial and subsequent engagement phases of treat- in a demonstration project described by Minkoff
ment (Ridgely, 1991). TAO focuses upon "rerecruit- (1989). In this model of treatment for addicted peo-
ment" at points where the patient is most likely to ple with psychosis, traditional psychiatric treatment
have an exacerbation of illness, and TAO therapists is blended with chemical dependency treatment and
use their knowledge of the COPAD treatment (in- the principles of AA. Both the psychiatric and the
cluding drug counseling, psychoeducation, and sup- addiction conditions are assigned separate legitimacy
portive psychotherapy) to motivate and rerecruit from the standpoint of treatment, and specific efforts
subjects into more active treatment. Assertive com- are made to educate treating professionals in any ar-
munity treatment with an explicit focus upon en- eas of deficiency. Addiction professionals are taught
gagement and stabilization has been successful in about mental illness and the prescription of psycho-
maintaining dually diagnosed patients in long-term active medications as opposed to the abuse of licit
treatment (Drake, McHugo, & Noordsy, 1993). As and illicit psychoactive substances. Mental health
much attrition in treatment results from early drop- professionals are educated about the usefulness of
out of mixed-syndrome male schizophrenia patients self-help groups and about helpful prescribing prac-
(Miner, Rosenthal, Hellerstein, & Muenz, 1997), tices for the dually diagnosed.
they especially may benefit from these services. Pre- In summary, collaboration should by the watch-
liminary outcome data suggest that over and above word for addiction clinicians and mental health
the gains resulting from integration of addiction and professionals treating the dually diagnosed person.
mental health services, there is a differential effect of Ideally, the artificial distinctions between service de-
adding TAO-type services on psychiatric and alcohol livery domains will break down as knowledge of the
symptom severity (Rosenthal et al., 1997). interactions between addiction and mental illness
suffuses the education of health care workers. Staff
that are cross-trained in treatment of addictions and
NSR mental disorders will be best positioned to de-
Interfacing with Mental
liver comprehensive care. Also valuable is coopera-
Health Professionals
tion with sponsors and members from peer-led groups
There has been a long-standing split between work- who, although they may lack professional training, of-
ers in psychiatry and workers in substance abuse. ten bring a wealth of practical knowledge to their
Substance abuse workers have believed that mentally efforts to assist their peers.
ill patients are too difficult to treat with the confron-
tational methods of the therapeutic communities and
Committing a Patient
group therapies. In the traditional "drug-free" sub-
stance abuse treatment, there is no place for psycho- Laws vary from state to state regarding the commit-
tropic medications. Psychiatric practitioners have ment of mentally ill and addicted persons, and the
shied away from patients with substance abuse disor- clinician must know local statutes. However, a few
ders as too manipulative, noncompliant, challenging, common themes should be considered while con-
and frustration-intolerant. Because of this split be- sidering an involuntary commitment to treatment.
tween substance abuse and mental illness theory Although states do not permit the involuntary com-
(Miller & Gold, 1992), funding and research pat- mitment of an addicted person for treatment of ad-
terns have petrified the field into two camps. The diction, all states permit the involuntary commit-
dual-diagnosis patient has traditionally been ex- ment of a person who is an acute danger to self or
cluded from treatment in both communities. The others. Although continued addiction is often self-
care and treatment of dually diagnosed patients have destructive and has even been called "a suicidal
recently become a more legitimate (and better flight from disease" (Menninger, 1938), most states
funded) field of study within psychiatry. A broad and do not recognize addiction per se as a reason for
466 ISSUES IN SPECIFIC POPULATIONS

withholding a person's freedom and committing him ric diagnosis of substance abuse, and 24% had an
or her to treatment. Although many addiction profes- additional diagnosis of atypical depression, psychosis,
sionals would agree with the necessity of mandated or adjustment disorder with depressed mood (Fow-
addiction treatment for some populations (Platt, ler, Rich, & Young, 1986). In a recent review, Mur-
Buhringer, & Kaplan, 1988), few practical programs phy and Wetzel (1990) reported that although the
exist. lifetime risk of 2.0-3.4% for suicide in conservatively
The person who puts self or others in immediate diagnosed alcoholics is apparently small, the risk for
danger because of a mental disorder must be de- suicide in this group is 60-120 times that of the non-
tained and kept safe, regardless of etiology. But this psychiatrically ill and accounts for about 25.0% of all
sort of emergency hold can be justified only briefly suicides. In another study, 34 of 50 alcoholic suicides
while, for example, a person intoxicated with alcohol had depression that was mostly secondary to alcohol-
"sleeps it off' or a person who is agitated and threat- ism (Murphy, Armstrong, Hermele, Fischer, & Clen-
ening after using phencyclidine (PGP, "angel dust") denin, 1979). Clearly, a depressed mood in the con-
is sedated and allowed to recompensate to his or her text of drug and alcohol abuse increases the already
baseline mental state. large proportionate risk of suicide (Berglund, 1984).
When the question of commitment to longer The clinician should track prior history as one in-
term treatment arises, the clinician must examine dicator of acute suicidal risk in substance abusers.
the patient with an eye to finding mental illness For example, there are those patients who make sui-
other than addiction that meets legal criteria for cidal threats or actions only when intoxicated. Often,
commitment to treatment. For instance, a person patients with this pattern will respond to several
with impaired judgment due to chronic paranoid hours of observation and no longer evince suicidal
schizophrenia could benefit from involuntary com- symptoms when they sober up. Another pattern of
mitment, while a person with impaired judgment state-dependent suicidal risk in alcoholics is analo-
due to cocaine intoxication may need a brief holding gous to that observed in patients recovering from ma-
period until the intoxication has passed. The person jor depression. In this pattern, the patient becomes
with a documented mental illness can, in most states, more capable of acting on the suicidal impulse after
be held involuntarily if the clinician can show that becoming sober and has more cognitive tools with
discharge from a hospital is likely to result in danger which to assess his or her current life condition, be-
to the patient or others immediately or within some comes demoralized or despairing, and acts.
defined period of time. The psychotic break, especially the first psychotic
break for a schizophrenia patient, must be consid-
ered a potentially dangerous time for suicidal behav-
Dealing with Emergencies
ior because the patient may recognize the loss of
Emergency situations with the dually diagnosed pa- control over his or her thinking processes and the
tient are fraught with all the risk factors of each sepa- lifetime implications of the loss. The disinhibiting
rate disorder. Most worrisome is the suicide attempt effects of substances of abuse can only add to the
or parasuicidal action that often heralds the arrival of danger of committing an impulsive self-destructive
the dually diagnosed patient in the emergency de- act. Similarly, substance abuse among patients with
partment or admission unit. Because addiction is a bipolar disorder increases the suicide risk.
clear risk factor for completed suicide (Adams, Behavioral control of an agitated or dangerously
1985), and conditions like schizophrenia, major de- psychotic dual-diagnosis patient should be estab-
pression, and bipolar disorder (Breier, Schreiber, lished with sedative/hypnotic medications such as di-
Dyer, & Pickar, 1991) also increase the likelihood of azepam (Valium and others), lorazepam (Ativan and
a suicidal act, clinicians must make especially care- others), or clonazepam (Klonopin). The addition of
ful treatment and disposition plans for the dually di- antipsychotic medications such as haloperidol (Hal-
agnosed patient. Patients presenting to the emer- dol) and Prolixin (fluphenazine) can add substan-
gency service with a history of alcohol or drug abuse, tially to the antiagitation effect of the sedative/hyp-
depressed mood, and suicidal ideation or intent must notics but exposes the patient to the risks of side
be assessed carefully. A study of 133 suicides under effects and the dangerous interactions with street
age 30 years found that 53% had a principal psychiat- drugs associated with the antipsychotic medications.
 TREATMENT OF PERSONS WITH DUAL DIAGNOSES 467

Since antipsychotic medications have an acute seda- and NSR mental disorders. The relationships be-
tive effect but a delayed onset of antipsychotic effect, tween SUDs and NSR mental disorders are complex,
they are generally reserved for those patients known and there is evidence supporting the existence of
to have a freestanding psychiatric disorder not caused many forms of interaction. Until a differential trajec-
by a substance of abuse. tory of illness based upon order of onset is better ar-
A common emergency in the dually diagnosed ticulated, treatments should be based upon clinical
patient is relapse to the substance of abuse, often as- characteristics that already have known impact on
sociated with the recurrence of psychiatric symp- outcome, including severity of illness, motivational
toms. A brief "slip" or even a longer term relapse to state, cognitive capacity, medication responsivity,
the substance abuse should be framed as a learning and chronicity. Therefore, treatments should be indi-
experience in which the addict learns yet another vidualized to the individual patient's problem set.
cue or inciting factor to use of the illicit substance. When systemic roadblocks to this type of treatment
By carefully reviewing the events leading up to the are bypassed, even patients with chronic and severe
slip, the clinician can often help the patient identify disorders can establish a reasonable path of recovery.
dangerous situations, attitudes, or even objects that
can be avoided in the future. Key References
It is exceedingly important that clinicians be thor- Kessler, R. C., McGonagle, K. A., Zhao, S.f Nelson, C.
oughly familiar with typical intoxication and with- B., Hughes, M., Eshelman, S., Wittchen, H. U., &
drawal syndromes (see chapters 4-10). Clearly, ap- Kendler, K. S. (1994). Lifetime and 12-month peva-
propriate supervision can lead to emergency room lence of DSM-III-R psychiatric disorders in the
treatment and prompt resolution of psychiatric symp- United States: Results from the National Comorbid-
tomatology in patients who present with mental ity Study. Archives of General Psychiatry, 51, 8-19.
symptoms solely due to drugs of abuse (e.g., due to Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z.,
alcohol withdrawal or acute anxiety in cocaine intox- Keith, S. J., Judd, L. L, & Goodwin, F. K. (1990).
ication). This capacity to discriminate substance-in- Comorbidity of mental disorder with alcohol and
other drug abuse. Results from the Epidemiologic
duced symptoms is important to reduce the number
Catchment Area (EGA) Study. Journal of the Ameri-
of false-positive identifications of patients as mentally
can Medical Association, 264, 2511-2518.
ill chemical abusers and to direct those that might Schuckit, M. A., & Hesselbrock, V. (1994). Alcohol de-
have been diagnosed as such to more appropriate pendence and anxiety disorders: What is the relation-
treatment facilities. Admitting too many patients ship? American Journal of Psychiatry, 151, 1723-
without treatable acute mental disorders to services 1734.
for the psychiatrically ill stresses those systems by in-
creasing turnover rates, demoralizing staff, and so on. References
Adams, K. S. (1985). Attempted suicide. Psychiatric
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 26

Age-Limited Populations: Youth,

Adolescents, and Older Adults

Pilar M. Sanjuan
James W. Langenbucher

Historically, addictions research and treatment have employed in reference to the diagnoses of both abuse
focused on individuals in early or middle adulthood, and dependence in the fourth edition of the Diag-
ignoring both adolescents and older adults. Yet youth nostic and Statistical Manual of Mental Disorders
and the elderly differ from other substance users in (American Psychiatric Association [APA], 1994). Use
a variety of meaningful ways, including patterns refers to any subthreshold level of drug use. When
of use, course, and consequences; the presence of discussing adolescents and the elderly, we are often
unique risk factors; and the need for special assess- talking more about abuse than frank dependence.
ment and treatment measures. Adolescence is a criti-
cal period for intervention if we are to prevent future
health problems as well as the exponential increase ADOLESCENTS
in other consequences associated with continued
substance abuse. Older adults are an essential group
Description
to target as well, since we can expect an increase in
the number of older adults needing treatment as the
Epidemiology and Patterns of Use
population ages. Therefore, it would be useful to fos-
ter better understanding of geriatric and adolescent The distinction between use and abuse is particularly
substance abuse issues so that they can be better con- important in adolescent groups. Youthful experimen-
sidered in future policy initiatives. tation is common; most adolescents use psychoactive
The definition of substance abuse remains some- substances at some point but do not develop signifi-
what controversial (Langenbucher & Martin, 1996). cant problems. For some, though, this use becomes
For the purpose of this chapter, the term abuse is habitual and hazardous (Tarter, 1990). Table 26.1

477
478 ISSUES IN SPECIFIC POPULATIONS

shows percentages of nonexperimental use (use six drug use patterns (Martin, Arria, Mezzich, & Buk-
or more times) for high school students. Many of stein, 1993). Nevertheless, male secondary-school
these drugs are used simultaneously or within the students are more likely to use drugs and to use them
same period of time. Alcohol and tobacco are the more frequently than their female classmates, al-
most frequent combination among first-year college though this difference has declined since 1975
students (Martin, Clifford, & Clapper, 1992), fol- (Johnston, O'Malley, & Bachman, 1995).
lowed by alcohol and marijuana, tobacco and mari- Gender roles appear to mediate the difference in
juana, and then alcohol and hallucinogens. Estimates drug use between girls and boys more strongly than
of the rates of substance abuse and dependence biological sex, and it may be that the merging of gen-
among adolescents in the general population vary der roles in recent years is responsible for the grow-
from 2% found in a sample aged 9-18 (Kandel et ing similarity in drug use among male and female
al., 1997) to 6% in a sample aged 14-18 (Rohde, adolescents (Huselid & Cooper, 1994). On the other
Lewinsohn, & Seeley, 1996). Rohde et al. (1996) hand, persisting gender roles may be responsible for
found that an additional 17% had alcohol symptoms some sex differences in use patterns. For example,
or other alcohol problems but did not meet DSM-IV adolescent girls concerned about their weight start
criteria for a diagnosis. smoking at higher rates than boys with weight con-
Recent epidemiological studies show changes in cerns or female nondieters (French, Perry, Leon, &
adolescent drug use trends in recent years and chal- Fulkerson, 1994); thus, weight control may contrib-
lenge some stereotypes that emerged in earlier re- ute to the higher rates of tobacco smoking and stimu-
search. Lifetime use of multiple drugs is very com- lant use we now observe among teenage girls.
mon among adolescent alcohol abusers, and male In terms of other demographic findings, the dif-
and female alcohol users share quite similar poly- ference between rates of drug use for urban and rural

TABLE 26.1 1994 Percentages of Nonexperimental Use3 Among Students

Drug 8th grade 10th grade 12th grade

Alcohol (consumed) 29.2 47.1 61.5

Alcohol intoxication 7.4 20.1 36.3
Cigarettes 11.8 18.9 22.6
Marijuana 7.7 17.1 23.9
Other hallucinogens 1.2 2.6 4.6
LSD 1.0 2.2 4.2
Cocaine 1.0 1.3 2.2
Crack 0.7 0.5 1.1
Stimulants 3.2 5.0 5.7
Inhalants 5.1 4.6 5.1
Tranquilizers 0.8 1.3 1.8
Heroin 0.6 0.4 0.4
Other opiates0 - - 2.1
PCPC — — 1.1
Steroids 0.5 0.6 1.1
Note. From National Survey Results on Drug Use from the Monitoring the Future Study, 1975-1994: Vol.
1. Secondary School Students (pp. 44-46, 51), by L. D. Johnston, P. M. O'Malley, and J. G. Bachman
(1995). Washington, DC: US Government Printing Office (NIH Publication No. 95-4026). Adapted with
permission.
a
Used more than five times in their lifetime.
""Percentage of students who used regularly in their lifetime.
C
12th grade only.
 YOUTH, ADOLESCENTS, AND OLDER ADULTS 479

youth has decreased over the years and at this point cent is at risk for future substance abuse problems.
is quite small (Donnermeyer, 1992; Johnston et al., The goal of prevention or treatment efforts would
1995). African-American youths have lower rates of then be to decrease the number of risk factors while
substance use than Caucasians and Latinos (John- increasing the number of protective factors. The mul-
ston et al., 1995). However, caution must be used tiple-risk-factor idea has been expanded by several re-
when interpreting results from such groupings, since searchers to develop risk and protective factor indices,
important cultural and economic differences exist which together constitute a "vulnerability" index that
between ethnic subgroups of these populations (Gil- predicts both initiation of drug use and future drug
bert & Alcocer, 1988; Harper, 1988), which can ren- problems (Newcomb & Felix-Ortiz, 1992). However,
der race- or language-based distinctions somewhat ar- at this point, these models are less transferable to clini-
bitrary. Moreover, there is evidence that Latina cal methods.
females have lower levels of alcohol consumption Another promising early contribution is problem
than Latino males or Caucasian females, which may behavior theory (Jessor, 1987), in which substance
serve to mask the severity of male Latino consump- use by adolescents is characterized as one of several
tion. A similar phenomenon could be occurring deviant behaviors that occur together. Susceptibility
among African-Americans. It is also important to to this syndrome results from the interaction of the
note that most surveys of drug use among adolescents person and the environment.
are based on school populations and so do not take Peer cluster theory (PCT; Getting & Beauvais,
into account teenagers who have dropped out of 1987) is another important contribution. Instead of
school or who were absent the day of data collection. attributing the strong association between an adoles-
cent's use of substances and the drug use of their
peers to social pressure to use drugs, PCT outlines a
Unique Risk and Protective Factors
more complex mechanism with two main compo-
Risk factors are individual attributes, characteristics, nents: peer selection and peer influence. Peer selec-
situational conditions, or environmental contexts that tion is a process by which adolescents seek out and
increase the probability of drug abuse. Protective fac- form friendships with similar individuals; in peer in-
tors, on the other hand, are individual attributes, char- fluence, individuals in a peer group reciprocally mod-
acteristics, situational conditions, or environmental el drug use behavior. Psychological and social char-
contexts that inhibit, reduce, or buffer the probability acteristics of adolescents determine susceptibility to
of drug abuse (Clayton, 1992). A great deal of re- drug use and the probability of joining drug-using
search has been aimed at identifying individual fac- peer clusters and may contribute to the likelihood of
tors or clusters of factors and at deconstructing their the peer cluster moving toward further drug involve-
roles in the initiation of substance use. Research has ment.
also concentrated on risk and protective factors that Risk and protective factors do not function in iso-
are specific to problem use or abuse among adoles- lation; they often interact. For example, Chassin,
cents. This impressive volume of research has re- Curran, Hussong, and Colder (1996) studied the re-
sulted in a wide variety of theories as well as an abun- lation of parental alcoholism to adolescent substance
dance of potential risk and protective factors, many use over time. They were interested in whether pa-
of which can be viewed as steps on a pathway to in- rental alcoholism effects could be partially explained
creased risk. by parental affective or antisocial personality disor-
In one of the earlier studies, Bry, McKeon, and der, as well as in whether these parental disorders
Pandina (1982) demonstrated that drug use and drug exerted their effects through changes in parental
abuse were more likely and more severe with the in- monitoring and adolescent stress, emotionality, socia-
creasing number of risk factors to which the individ- bility, negative affect, and associations with drug-us-
ual has been exposed. This has become known as ing peers. The results of their structural model are
the multiple-risk-factor model. Although seemingly illustrated in figure 26.1. It is clear that the factors
simplistic, this model may be one of the most stable act upon each other, and it is this interaction to-
findings in the risk factor research. The ratio of the gether with direct effects that results in initial sub-
number of risk factors to the number of protective stance use (intercept) and escalation (slope). For ex-
factors can provide a good idea of whether an adoles- ample, alcoholism in the biological father was the
FIGURE 26.1 Final structural model. Standardized path coefficients are shown. For solid lines, p < .05; for dashed lines, p < .10,
%2 (62, N = 316) = 88.6, p = .01, Tucker-Lewis Fit Index = .95, Comparative Fit Index = .98. Note. From "The Relation of Parent
Alcoholism to Adolescent Substance Use: A Longitudinal Follow-Up Study," by L. Chassin, P. J. Curran, A. M. Hussong, & C.
R. Colder (1996) Journal of Abnormal Psychology, 105(1), p. 77. Copyright 1996 by the American Psychological Association, Inc.
Reprinted with permission.
 YOUTH, ADOLESCENTS, AND OLDER ADULTS 481

only parental disorder that had a direct effect on es- Although risk and protective factors can exert
calation of use. However, alcoholism in the biologi- their effects in a variety of ways that are not com-
cal father also has indirect effects through adoles- pletely understood at this time, there are some gen-
cent's stress, and to some extent through father's eral characteristics that have been identified con-
monitoring, on both initiation and escalation of use. sistently across studies (Pandina, 1996). However,
There have been several attempts to classify risk linear models of how these factors work may not be
and protective factors into more manageable catego- sufficient and do not capture the complexity in-
ries. Pandina (1996) has constructed a list of risk and volved. Risk and protective factors can be cumulative
protective factors with the intention of identifying or synergistic. They may differ qualitatively and
factors with strong empirical support and consolidat- quantitatively; thus, risk and protective factors that
ing related factors into more general categories (see seem to be opposite ends of the same continuum
table 26.2). For example, anxiety and negative affect (such as conventional values) may behave differently
are represented by the broader "emotional profile." depending upon whether they are acting as risk or
The risk and protective factors are further separated protective factors. Furthermore, risk and protective
into biological, psychological/behavioral, and social/ factors each vary in importance across individuals or
environmental factors, representing the biopsychoso- groups. For example, high IQ seems to operate as
cial aspect of the process. protective in some groups and as risk in others. Dif-

TABLE 26.2 Classification Schema for Risk/Protective Factors

Classes of factors Factors

Biological (genetic and constitutional) Genetic profile

Sensory processing disturbances
Neurocognitive alterations
Personal history of affective disorders, impulse disorders
Family history of alcoholism, drug abuse
Family history of impulse disorders (e.g., conduct disorder,
antisocial personality)
Family history of affective disorders and emotional disturb-
ance (e.g., depression, anxiety)
Psychological and behavioral (internal processes, Personality styles (e.g., sensation seeking, novelty seeking,
behavioral action profiles and repertoire, and harm avoidance, reinforcement sensitivity)
interpersonal interactional styles) Emotional profile
Self-regulation style (e.g., coping repertoire)
Behavioral competence
Self-efficacy/self-esteem
Positive and negative life events/experiences
Attitudes, values, beliefs regarding drug use
Social and environmental (familial interactions, peer Structure/function of family supports
interactions, institutional interactions, social/institu- Parenting styles
tional structures) Opportunities for development of basic competencies
Peer affiliations
Economic and social (including educational) opportunities
General social support structure
Availability of prosocial activities in relevant socioenviron-
mental structures (e.g., schools, communities, workplace)
Strength and influence of the faith community
Social norms, attitudes, and beliefs related to drug use
Availability and projected attractiveness of drugs and drug
use
Economic and social incentives of drug trafficking.

Note. From Risk and Protective Factor Models in Adolescent Drug Use: Putting Them to Work for Prevention (tables 8-11), by R. J. Pandina
(1996). Paper presented at the National Conference on Drug Abuse Prevention Research, Washington, DC. Adapted with permission.
482 ISSUES IN SPECIFIC POPULATIONS

ferent factors also fluctuate in influence at different ers. For example, "continued drinking despite a medi-
times during the life cycle and vary in significance cal problem" is much less prevalent than "drinking
for the emergence of drug use stages and outcomes. despite psychological problems," and job trouble is
The more extensively studied stage has been acquisi- less likely to occur since many adolescents do not
tion, which consists of priming, initiation, and exper- work, (Martin, Kaczynski, Maisto, Bukstein, & Moss,
imentation. Less well examined, but equally impor- 1995). Martin, Langenbucher, Kaczynski, and Chung
tant, are the maintenance stage (habit formation, (1996) identified three broad stages of alcohol prob-
dependence, and obsessive-compulsive use) and the lems in adolescents broadly sampled for all levels of
control stage (problem awareness, interruption/sus- alcohol involvement. The first stage was character-
pension, and cessation). Risk and protective factors ized by "heavy and heedless drinking" consisting of
are likely to act differently at each of these stages. tolerance, drinking more or longer than intended,
Furthermore, research has indicated that many fac- and much time spent using alcohol (dependence
tors operate differentially by age group (Scheier, symptoms), as well as repeated intoxication resulting
Newcomb, & Skager, 1994). There has not been in a failure to meet role obligations and social and
much focus on the fact that drug use is a continuum interpersonal problems due to drinking (abuse symp-
that is somewhat normally distributed. Most adoles- toms). The second stage, characterized by "psycho-
cents do not fall at either extreme: complete absti- logical dependence," included repeated attempts to
nence or heavy use. A recent investigation by cut down or stop using, reduced social and recre-
Schedler and Block (1990) revealed that those at ei- ational activities in favor of drinking, and continued
ther tail of the distribution are likely to have psy- drinking despite physical or psychological problems
chological problems as adults, although those ado- (dependence symptoms); hazardous use and legal
lescents who use heavily had significantly more problems (abuse symptoms); and persistent or recur-
problems than those who abstained altogether. This rent blackouts (an experimental domain). Stage 3
indicates that it might not be as useful to study initia- was represented by withdrawal (a dependence symp-
tion, which seems to be normative, as to study the tom). The evidence that abuse symptoms do not
transition to heavy use. Additionally, little attention necessarily precede dependence symptoms in adoles-
has been given to whether risk factors operate equally cents suggests limitations in the application of DSM-
for all substances or if they might function differently IV criteria for this population.
for different drugs, such as cigarette smoking versus A clear pathway is discernible in adolescents from
cocaine use. Overall, perhaps the most significant the use of licit to illicit substances. A number of stud-
characteristic of risk and protective factors is that ies, including Chen and Kandel (1995), Kandel and
they are subject to change and can be reduced or Logan (1984), Kandel, Yamaguchi, and Chen (1992),
induced. This indicates that the quantity of risk and Raveis and Kandel (1987), and Yamaguchi and Kan-
protective factors in an individual is an excellent tar- del (1984a, 1984b), indicate that adolescent drug use
get for intervention. begins with beer and wine, progresses to hard liquor
and cigarettes, then to marijuana, and then to other
illicit substances. Adolescents who have used drugs
Course
in a later class, such as other illicit substances, have
Adolescents with alcohol problems differ from adults usually already been through earlier classed drugs,
in the occurrence and the order of onset of symp- such as marijuana. However, use of an earlier drug
toms. Alcohol-dependent youths are much less likely class, such as marijuana, does not necessarily result
to experience withdrawal than adults with depen- in progression to the use of drugs in later classes,
dence diagnoses, due to the limited time span during such as other illicit substances. Among females, ciga-
which teenagers have been using alcohol heavily. rettes play a more important role in the initiation of
Furthermore, tolerance to alcohol is less specific to illicit drug use and can precede the use of marijuana
a dependence diagnosis in youths, suggesting that an without the use of alcohol. After using either alcohol,
increase in alcohol consumption may be a common marijuana, or other illicit drugs, some adolescents
developmental occurrence for adolescents. Other veer to the use of prescription drugs (with or without
symptoms of abuse and dependence used in DSM- medical authorization). Initiation to alcohol is usu-
IV are also less applicable to younger problem drink- ally completed by age 18, to cigarettes by age 19, to
 YOUTH, ADOLESCENTS, AND OLDER ADULTS 483

marijuana by age 20, and to hallucinogens by age 21. carried into adulthood does not have as many pri-
In general, the use of alcohol and cigarettes increases mary consequences as was once believed. Further re-
sharply during adolescence, stabilizes in the late search is clearly needed before a comprehensive un-
teens, and declines slightly in the late 20s. Overall, derstanding of teenage drug use consequences is
marijuana use peaks at age 19, stabilizes for 4-5 possible. It is known, though, that some adolescents
years, and then, at ages 23-24, begins a continuous continue drug abuse into adulthood, where there are
decline. In a sample of secondary-school students, more negative outcomes that are much better under-
Bailey (1992) found that use of illicit substances was stood.
predicted more by the rate of progression from Exceptions do exist to the paucity of documented
lighter use to heavier use than by the actual level of consequences of adolescent drug use. Injuries and
alcohol and cigarette use. fatalities resulting from driving while intoxicated are
The use of illicit drugs is less stable than the use perhaps the most intensely researched of these.
of alcohol and cigarettes, and those who continue, as Youths are overrepresented among drunk drivers in-
they age, to use illicit substances do so at lower levels volved in automobile accidents, possibly due to their
of intensity than those of younger age (Chen & Kan- inexperience in driving combined with increased
del, 1995). The majority of adolescents eventually risk-taking behaviors (Augustyn & Simons-Morton,
stop using most drugs in adulthood, a phenomenon 1995). The combination of risk taking with substance
known as maturing out. While age of onset is fre- use also results in an increase in other physically in-
quently identified as a predictor of whether an ado- jurious accidents among youth (Arria, Tarter, & Van
lescent will progress to "heavier" drug use, it is not Thiel, 1991).
necessarily associated with whether or not individu- Some other possible health-related consequences
als will moderate alcohol use or mature out of illicit of teenage drug use have been identified. It is known
substance use by age 30 (Labouvie, Bates, & Pan- that alcohol use impairs the body's ability to utilize
dina, 1997). Maturing out is best conceptualized as nutrients, and heavy use in adolescence suppresses
a developmental transition from adolescence to levels of growth hormones, increases production of
adulthood. As individuals enter their late 20s, they adrenal hormones, decreases testosterone levels, and
acquire a greater personal responsibility for their fu- increases availability of estrogen. These changes may
tures, cut down on behaviors that impede the pursuit lead to developmental deficits among youths who
of personal goals, and perceive long-term romantic drink heavily (Arria et al., 1991). Just how heavy use
commitment and parenthood as more important (La- must be to cause permanent and pathological dam-
bouvie, 1996). At this point, it is difficult to predict age is not currently known.
which groups of adolescents are more likely to suc- Substance use is a risk factor for suicide among
cessfully mature out of substance use; however, it is youths (Fowler, Rich, & Young, 1986). Alcohol is
likely that those factors that make the other elements more often implicated as a factor in suicide than
of the transition to adult roles more difficult will also other drugs, particularly when the drinker is de-
negatively affect substance use trajectories. pressed or has a conduct disorder (Crumley, 1990).
Death or, in some cases, brain damage can occur
from accidental overdoses with a number of sub-
Consequences
stances of abuse. Adolescents, a group less experi-
With respect to adolescent substance use and abuse, enced with drugs such as alcohol and more likely to
consequences are far more difficult to identify than be careless, may be at an increased risk of overdos-
risk factors. The risk factors for drug use described ing. Risk-taking and thrill-seeking behavior, possibly
above are likely to interact with actual substance use, enhanced by substance use, also results in increased
working synergistically to produce negative out- exposure to sexually transmitted diseases, and al-
comes. It is difficult to find evidence for many prob- though intravenous drug use is not as common
lems that seem to be obvious consequences of use, among adolescents, it is associated with increased ex-
such as educational impairment or social problems posure to HIV, hepatitis, and other viral as well as
(see Newcomb, 1987, for a review of a variety of the- bacterial infections (Adger & DeAngelis, 1994). In-
ories not yet supported empirically). One conclusion tranasal cocaine use is more common among adoles-
is that substance use during adolescence that is not cents, and recent research indicates that this (and
484 ISSUES IN SPECIFIC POPULATIONS

presumably intranasal use of other drugs as well) is adapted for use with adolescents usually have not
a probable route of transmission for hepatitis C been tested for reliability or validity with this popula-
(Conry-Cantilena et al., 1996). tion. Second, there is more ambiguity about what
Neurological damage from adolescent substance constitutes problem use in adolescents. Some argue
use is less prominent than it is in adults, probably that any use is a problem, while others feel that a
due to shorter exposure to drugs. However, heavy certain amount of substance use is developmentally
and consistent use of inhalants can result in neuro- normal for teenagers. Third, some youth present with
logical, renal, and hepatic damage (Blanken, 1993). problems unique to their developmental stage, such
While less clear, research has suggested that LSD as conflict with family members or distress in school.
use can exacerbate preexisting psychiatric disorders, Instruments for the evaluation of adolescent sub-
cause posthallucinogen perceptual disorder (i.e., stance use and abuse must be sensitive to the unique
"flashbacks"), and possibly lead to major depressive problems of substance use in adolescents.
disorders (Schwartz, 1995). PGP use can exacerbate The purpose of screening is to detect possible
or trigger a psychotic episode in schizophrenics and problems and identify potential cases (Miller, West-
individuals predisposed to schizophrenia (Weiss & erberg, & Waldron, 1995). The Problem Oriented
Millman, 1991). PCP use also causes short-term neu- Screening Instrument for Teenagers (POSIT) is spe-
rological impairment lasting beyond the euphoric ef- cifically designed to identify adolescents in need of
fects of the drug. However, conclusive evidence of further evaluation. The POSIT is an eight-page pa-
long-term neurological damage from PCP has not per-and-pencil questionnaire containing 139 yes/no
been found (Bates & Convit, in press). items available in both English and Spanish. It takes
Adolescents with substance abuse and depen- about 20-25 minutes to administer and covers 10
dence often suffer from comorbid psychiatric disor- functional areas: substance usefebuse, physical health
ders. These patients are commonly referred to as dual- status, mental health status, family relationships, peer
diagnosis or mentally ill chemical abusers (MICA). relations, educational status, vocational status, social
It is difficult to determine whether these comorbid skills, leisure and recreation, and aggressive behavior/
disorders are consequences of use, risk factors, or delinquency (Rahdert, 1991). The Drug Use Screen-
merely disorders that surfaced during the same devel- ing Inventory (DUSI) is a closely parallel instrument
opmental stage as substance use. Adolescence is of- with 150 items that can be used for the same pur-
ten the period of onset for many psychiatric illnesses pose (Tarter, 1990). Other recommended adolescent
in patients who do not have concurrent problems screening measures include the Adolescent Drinking
with psychoactive substances. Conduct and mood Index (ADI), which consists of 24 items representing
disorders are the most prevalent diagnoses concur- four domains of problem drinking; the Adolescent
rent with substance abuse and dependence (Kami- Alcohol Involvement Scale (AAIS), a 14-item screen-
ner, 1991; Kandel et al., 1997; Rohde et al., 1996). ing questionnaire; and the 40-item Personal Experi-
Adolescents with dual diagnoses may be at increased ence Screening Questionnaire (PESQ), which as-
risk for future problems. Substance abusing youths sesses problem severity, frequency and onset of use,
with comorbid conduct disorders have been found to defensiveness, and psychological functioning (Miller
be more likely to drop out of substance abuse treat- etal., 1995).
ment programs (Kaminer, Tarter, Bukstein, & Ka- Diagnostic instruments, often used after a positive
bene, 1992) and to have elevated rates of academic screen, are structured interviews based on DSM cri-
problems (Lewinsohn, Rohde, & Seeley, 1995). teria and are used in settings where a formal diagno-
sis is needed (Miller et al., 1995). The Adolescent
Diagnostic Interview (ADI; Winters & Henly, 1993)
Assessment and Treatment Issues
covers DSM-Itt-R (APA, 1987) symptoms of psycho-
active substance use disorders and follows a simple
Assessment
structured interview format that examines the history
The evaluation of substance use and abuse in ado- of use and provides a diagnosis of abuse or depen-
lescents can be difficult for three reasons. First, most dence for each of the major drug classes (Rahdert,
of the instruments designed specifically for youth 1991). Administration of the ADI takes about 45
have fairly thin empirical bases, and adult measures minutes and requires training (National Institute on
 YOUTH, ADOLESCENTS, AND OLDER ADULTS 485

Alcohol Abuse and Alcoholism [NIAAA], 1995). enhancing, or sustaining the drug use. Clinicians
While there has been an ongoing debate over the ap- may be interested in a fuller range of difficulties than
plication of DSM substance diagnoses for adoles- those covered in screening instruments, including
cents, currently there is no differentiation between problems that are separate from dependence symp-
adults and adolescents for DSM substance disorder toms and rates of use. The Rutgers Alcohol Problems
criteria. Consequently, the substance abuse sections Index (RAPI; White & Labouvie, 1989) is a 23-item
of the Structured Clinical Interview for DSM-IV instrument designed to assess adolescent problems
(SCID; First, Gibbon, Spitzer, & Williams, 1996), associated with alcohol use that are different from
the Psychiatric Research Interview for Substance and DSM symptoms (NIAAA, 1995). In addition, the 27-
Mental Disorders (PRISM; Hasin & Miele, 1997), item Young Adult Alcohol Problems Screening Test
and the Diagnostic Interview Schedule (child ver- (YAAPST) has been developed recently for use with
sion) (DISC; Fisher, Wicks, Shaffer, Piancentini, & college students to identify those who are experienc-
Lapkin, 1992) are also used to make DSM diagnoses ing multiple consequences from their drinking and
for adolescent substance disorders (Miller et al., to evaluate the severity of those consequences (Hurl-
1995; NIAAA, 1995). but & Sher, 1992).
Basic measures of substance use, simple quantity/ Motivation for drinking can predict treatment
frequency measures, can be useful but have limited outcome and relapse. There are two instruments for
application and provide only very general informa- measuring reasons for drinking designed especially
tion (Miller et al., 1995). A more sophisticated in- for adolescents. The Alcohol Expectancy Question-
strument for examining substance use is the Time- naire—Adolescent Version (AEQ-A; Brown, Chris-
line Follow-Back (TLFB; Sobell & Sobell, 1992). tiansen, & Goldman, 1987, as cited in Miller et al.,
The TLFB was designed for use with alcohol but can 1995), a 100 item self-report instrument, measures
be adapted for use with other drugs as well. Partici- the effects an adolescent expects from drinking and
pants provide retrospective estimates of their alcohol provides scores on seven different types of expec-
use over a specified time ranging up to 1 year. Holi- tancies. Another measure, the Alcohol Attitude Scale
days and special days such as birthdays or weddings for Teenagers (AAST) is a 54-item paper-and-pencil
are used as cues to aid the recall of drinking behavior questionnaire that can be used to assess three aspects
for those days and the periods inbetween them. It of alcohol attitudes: feelings, beliefs, and intentions
can be administered by an interviewer, paper-and- to act (Torabi & Veenker, 1986, as cited in Miller
pencil self-administered, or completed on a com- et al., 1995). Schafer and Brown (1991) designed a
puter. It takes about 30 minutes to cover use during Marijuana Effects Expectancy Questionnaire (MEEQ),
1 year and about 10-15 minutes to cover 90 days a self-report with 78 items, and a Cocaine Effects
(Sobell & Sobell, 1992). The Lifetime Drinking His- Expectancy Questionnaire (CEEQ), a self-report
tory (LDH; Skinner & Sheu, 1982) is another mea- with 71 items, for adults and have recently replicated
sure of alcohol use that could be adapted for use with the factor structures for adolescents.
other drugs. The LDH is used to obtain a lifetime or Better than selecting multiple discrete measures
long-term summary of patterns of alcohol use and to evaluate separate problem areas, one can select a
captures distinct phases and changes in a person's comprehensive assessment measure to provide a
drinking style (NIAAA, 1995). In a chronological complex understanding of a case. The Personal Ex-
fashion, the interviewer traces the participant's use perience Inventory (PEI; Winters & Henly, 1989), a
from initiation up to the present time, detailing fac- 45-minute paper-and-pencil questionnaire, was de-
tors associated with changes in patterns and styles of veloped as a part of the Chemical Dependency Ado-
drinking. It takes about 20 minutes to complete lescent Assessment Package in conjunction with the
(Skinner & Sheu, 1982). PESQ and the ADI. The PEI is a multiscaled instru-
Miller et al. (1995) pointed out that measures of ment for identifying the onset, nature, and degree of
alcohol consumption, although important, do not alcohol and other drug involvement, as well as per-
provide a full view of an individual's clinical picture. sonal risk factors that may precipitate or maintain
Often, adolescents brought to treatment for sub- substance abuse (Winters & Henly, 1989). The first
stance use also have a myriad of other family, school, part of the PEI is the Problem Severity Section, con-
or psychiatric problems that may be interacting with, sisting of five basic scales (personal involvement, ef-
486 ISSUES IN SPECIFIC POPULATIONS

facts from use, social benefits of use, personal con- areas, such as general behavior and school per-
sequences, and polydrug use), five clinical scales formance, providing support for the idea that some
(social-recreational use, psychological benefits use, adolescents may become nonproblem users (Alford,
transsituational use, preoccupation, and loss of con- Koehler, & Leonard, 1991).
trol), three response bias scales, and two drug use Flaws in the research notwithstanding, there has
history sections. The second part is the Psychosocial been some success in identifying factors associated
Section, consisting of nine personal risk factors, four with treatment outcome. Greater pretreatment sever-
environmental risk factors, six brief problem screens ity of drug use, early onset of use, criminal history,
(need for psychiatric referral, eating disorder, sexual educational failure (Catalano et al., 1991), low per-
abuse, physical abuse, family chemical dependency ception of family independence, and high percep-
history, and suicide potential), and two response bias tion of family control (Friedman, Terras, & Kreisher,
scales (Winters & Henly, 1989). The Comprehensive 1995) have been shown to predict poor treatment
Addiction Severity Index for Adolescents (CASI-A) is outcome. Factors operating during treatment that
a 45- to 90-minute semistructured interview modeled predict better outcome include motivation, per-
after the Addiction Severity Index (ASI) that assesses ceived choice in seeking treatment, rapport with cli-
several risk factors, symptomatology, and conse- nicians or staff, special services (education, voca-
quences of use within seven primary areas of func- tional training, relaxation training, recreation, and
tioning (Meyers, McLellan, Jaeger, & Pettinati, providing and discussing methods of contraception),
1995). The Teen Addiction Severity Index (T-ASI; and parental involvement (Catalano et al., 1991).
Kaminer, Wagner, Plummer, & Seifer, 1993), a Fewer studies have examined posttreatment vari-
semistructured interview with 126 questions, is an- ables, but thoughts and feelings about drugs and
other instrument modeled after the ASI but specifi- cravings for drugs, less involvement in productive ac-
cally designed to assess adolescents. Other recom- tivities, less satisfactory leisure activities (Catalano et
mended measures include the Adolescent Drug al., 1991), and poor skills (drug avoidance, self-con-
Abuse Diagnosis (ADAD), a structured interview of trol, social, and problem solving) are predictive of
150 items, designed by Friedman and Utada in 1989 poorer outcomes (Jenson, Wells, Plotnick, Hawk-
and also modeled after the ASI, and the Adolescent ins, & Catalano, 1993). Adolescents in treatment
Self-Assessment Profile (ASAP), a 203-item question- have special needs due to their unique develop-
naire developed by Wanberg in 1991 (both cited in mental position: They have a dependent position in
Miller et al., 1995). the family and in society; they are constrained by
their levels of physical, social, and cognitive develop-
ment; they are prone to influence from peers and
Treatment
popular culture; they have a strong need for educa-
Currently, there is a lack of quality research on ado- tional and vocational training; they are frequently
lescent substance abuse treatment. Existing studies victims of comorbid psychiatric disorders; and they
are characterized by incomplete and unclear report- frequently abuse many drugs at once (Bukstein,
ing, missing control groups, poor assessment mea- 1994).
sures, and inconsistent definitions of diagnoses and While the most common approach to adolescent
relapse (Bukstein, 1994; Catalano, Hawkins, Wells, treatment is the Minnesota Model based on the 12-
Miller, & Brewer, 1991; Liddle & Dakof, 1995). In step program of recovery designed for adults, the
a review of the research, Catalano et al. (1991) could unique needs of adolescents suggest specific guide-
conclude only that some treatment is better than lines for successful treatment programs. Treatment
none and that no one treatment demonstrated su- should be of sufficient intensity and duration to
periority over any other. Relapse rates vary across achieve maximum changes in attitude as well as be-
studies but can be fairly high. An investigation of out- havior, be comprehensive and targeted to multiple
comes in an Alcoholics Anonymous/Narcotics Anon- domains of the individual's life, be sensitive to indi-
ymous-based treatment program showed 2-year re- vidual cultural and socioeconomic realities, en-
lapse (from abstinence) rates of 39% for females and courage family involvement and improvement in
60% for males. However, it was also discovered that communication, incorporate a wide range of social
a fair percentage of relapsers had improved in other services, and provide aftercare (Bukstein, 1994). Cat-
 YOUTH, ADOLESCENTS, AND OLDER ADULTS 487

alano et al. (1991) suggested that treatment also in- ing to address the heterogeneity of the adolescent
clude academic and vocational experiences and in- substance-abusing population (Kaminer & Bukstein,
troduce behavioral skills training as a strategy for 1989) is another goal of program developers. The
maintaining treatment effects. Inpatient treatment is Youth Evaluation Services (YES; Babor, Del Boca,
indicated for adolescents who are severely physically McLaney, Jacobi, Higgins-Biddle, & Hass, 1991)
dependent, have failed outpatient programs, have is an assessment and case management program
moderate to severe psychiatric comorbidity, or need designed for the early identification, referral, and
to be isolated from their environment to allow un- monitoring of drug-abusing youth. The Adolescent
interrupted treatment (Kaminer & Bukstein, 1989). Assessment/Referral System (AARS), developed by
Several of the assessment instruments above can be National Institute on Drug Abuse (NIDA) (Rahdert,
used to determine whether an adolescent requires re- 1991), is a similar program, where comprehensive as-
ferral to inpatient treatment. Otherwise, outpatient sessment provides information for treatment referral.
treatment is preferable, since it is likely to be less Both the AARS and the YES programs are still in the
stigmatizing to the adolescent and allows him or her developmental stages but are promising approaches
to apply skills learned in treatment to real situations to the improvement of adolescent substance abuse
such as occur at home and at school. treatment. When possible, if an adolescent requires
Outpatient treatment provided by clinicians should referral to inpatient treatment, programs such as
focus on the specific needs of the adolescent. Often, these should be sought out.
adolescents brought by parents for substance use The discussion to this point has focused on one
treatment may actually have more severe problems very specific, important, and as yet understudied
in other areas, such as family issues, learning disabili- group: adolescent substance abusers. A group at the
ties, or problem behavior at school. A thorough as- other end of the age spectrum, elderly alcohol and
sessment should be conducted in order to identify drug users, is even more understudied and is of in-
the severity of substance use problems and whether creasing significance as its numbers increase as a pro-
it is accompanied by problems in other areas of the portion of the population. We now turn to this
adolescent's life. Treatment should concentrate on group, and to the peculiar challenges its poses in
those disturbed areas. Family functioning difficulties terms of assessment, treatment, and understanding its
are usually present for these adolescents, and family peculiar patterns of use and abuse.
intervention should be a central focus of any treat-
ment. Since some experimental use appears to be
normative for adolescents, adolescents who do not ELDERLY
yet warrant a substance abuse or dependence diagno-
sis may not require abstinence as a goal. Instead,
Description
treatment should be directed toward lowering the fre-
quency and quantity of use, preventing any rapid es-
Epidemiology and Patterns of Use
calation into problem use, and reducing harm from
casual use (such as drunk driving, exposure to dis- The use of alcohol and other intoxicants in general
ease, or accidental overdose). Risk and protective fac- declines with age, yet substance use among the el-
tors should be assessed, and treatment should also derly is a growing public health concern, one whose
aim at attempting to increase protective factors while significance is expected to increase with the "gray-
decreasing risk factors. ing" of America (Atkinson, 1990). Alcohol remains,
With regard to inpatient treatment, there is a trend as it is earlier in life, a commonly used drug: Re-
to develop alternatives to the Minnesota and 12-step searchers in the Epidemiologic Catchment Area (EGA)
models, with an emphasis on reducing the intensity Study, using DSM-III (APA, 1980) criteria queried
and cost of treatment (Bukstein, 1994). Behavioral in- by administration of the Diagnostic Interview Sched-
terventions (relapse prevention, skills training, and ule, found current rates of alcohol abuse and depen-
anger control training) appear especially promising, dence among the elderly as high as 3.7% in some ar-
as do some elements of family therapy, educational eas, with up to 10% of the elderly qualifying as "heavy
and vocational rehabilitation, and medications for co- drinkers" (Helzer, Burnham, & McEvoy, 1991).
existing psychiatric disorders. Patient-treatment match- Though, also as earlier in life, rates of alcohol prob-
ISSUES IN SPECIFIC POPULATIONS

lems decline as Americans approach retirement age, traditionally been neglected in the field (Langen-
the EGA data suggest that rates may again increase bucher & Martin, 1996) as a "category without a
after the age of 60 and may be particularly high content." This advice, however, is frustrated because
among males aged 75 and older (Eaton, Kramer, An- the types of impairment which DSM-IV suggests for
thony, Dryman, Shapiro, & Locke, 1989). In gen- identifying abuse in clinical populations—interfer-
eral, epidemiological data suggest that between 2% ence with functioning in an assigned role, use in
and 4% of Americans over the age of 65 have a diag- hazardous situations, legal problems, marital distress,
nosable alcohol problem, and that 10% or so drink and other social problems—are often not experi-
heavily, though there is substantial regional variabil- enced by the elderly for ecological reasons. The most
ity in these rates (Adams & Cox, 1995). The preva- common comorbid diagnosis for alcoholism in the
lence of alcohol problems also appears much higher elderly, serious depression, is also difficult to recog-
in ill and service-seeking groups. Lichtenberg, Gib- nize, since many cardinal vegetative and cognitive
bons, Nanna, and Blumenthal (1993), for example, symptoms (e.g., sleep disturbance, appetite and
found that 17% of geriatric patients in a medical weight loss, irritability, and inability to concentrate)
sample were alcohol abusers, with particular concen- are overlooked in the elderly or misattributed to age.
trations among the "young-old" (60-74 years old) These findings challenge the generalizability of a
and males. Nearly half (48%) of young-old men in "cookie cutter" approach to decision rules, in which
this sample were diagnosed with alcohol abuse or de- dependence in the elderly is assessed by the same set
pendence. of decision rules applied to younger drinkers.
Drug use, especially abuse of prescription drugs,
is also a problem among the elderly. The most signif-
Unique Risk Factors
icant problems appear to be the use of benzodiaze-
pines and narcotic analgesics such as CoTylenol The elderly are susceptible to many sources of risk
(Finlayson, 1995), to which the elderly are more that distinguish them from other clinical popula-
likely to have been exposed, for longer times, and at tions, including bereavement, caring for an ill spouse,
larger doses, than the young. These drugs are very negative social stereotypes, poverty, poor physical
frequently used in combination with alcohol: A study health and encroaching dementia, and special prob-
of 216 elderly alcoholics in treatment at the Mayo lems faced by minority and rural elderly (Roybal,
Clinic found that 19% had a concurrent drug abuse 1988). Prescription and over-the-counter (OTC) drug
or dependence diagnosis. Even illicit drug use, while use becomes increasingly common with advancing
presumed to be negligible among the elderly, is a age as the numbers and variety of chronic diseases
cause of concern, especially in urban areas and increase; the elderly are the principal users of pre-
among people of color (Rosenberg, 1995). Of the scription drugs, taking an average of about three dif-
more than 7,500 drug-related deaths reported to the ferent compounds on a daily basis (Malcolm, 1984).
Drug Abuse Warning Network in 1992, 10% oc- Risk of iatrogenic addiction is particularly high for
curred among persons aged 55 and above. Approxi- elders who smoke, drink, or suffer from depression
mately 23% of these seniors tested positive for opiates (Chrischilles, Foley, Wallace, & Lemke, 1992).
and 18% tested positive for cocaine at the time of Aged women may be at particular risk for alcohol
death. and drug abuse (Rodeheaver & Datan, 1988) be-
Because the aged have impaired ability to clear cause of social (widowhood), economic (poverty),
alcohol and other drugs, there may be no decline and psychological (loneliness) conditions associated
in hazardous use behaviors even when a decline in with their age and gender. Glantz and Backenheimer
absolute quantities consumed is observed (Mears & (1988) suggested that elderly women, with their
Spice, 1993; Vogel-Sprott & Barrett, 1984). For this heavy burden of social risk factors, may be more at
reason, it has been suggested that in the elderly, dan- risk for iatrogenic addiction to sedative/hypnotic and
ger lies in "abuse" as much as in frank dependence anxiolytic preparations than any other demographic
(Seymour & Wattis, 1992). group.
One of the most important areas of research lead- Besides social factors, the aged often experience
ing to the better identification of the addicted elderly cognitive, perceptual, motor, and other psychological
is the clarification of the abuse construct, which has limitations which may promote the use of alcohol or
 YOUTH, ADOLESCENTS, AND OLDER ADULTS 489

the abuse of prescription and OTC drugs. Loss of similar to Zimberg's early-onset type and reactive
judgment and rational capacity, along with a growing problem drinkers similar to Zimberg's late-onset
tendency to social estrangement, are characteristic of type —can be validated on a variety of descriptive
the sometimes subtle dementing processes that be- variables.
come increasingly prevalent as life advances into the The clinical significance of this typology may,
eighth decade, affecting 50% of the elderly popula- however, be less than one would expect. Treatment
tion in some samples. Compromised sleep regulation response has never been shown to favor either the
(Prinz, Vitiello, Raskind, & Thorpy, 1990) is another early-onset or the late-onset group. Rather, clinical
age-related condition that may tempt the use of alco- data now suggest that over time, the treatment needs
hol or other soporifics. In elderly individuals, sensory of the early- and late-onset groups converge, so that
deficits, particularly hearing loss, lead to social isola- in the early-onset group, the factors that once initi-
tion and the emergence of depression, loneliness, ated alcoholism have ceded control to factors that
and paranoia (Stein & Bienenfeld, 1992). In addi- maintain it, and these factors—depression, frailty,
tion, because of reduced resilience and mobility and losses, isolation, and so forth—are the same as those
an inability to tolerate harsh weather and walking initiating and maintaining drinking in the late-onset
conditions, they may be much more prone to depres- group. Treatment needs may therefore be the same,
sion and isolation in the winter months (Shah, 1992). regardless of the developmental pathway into alco-
These conditions both promote the use of alcohol holism in the elderly.
and other drugs and protect that use from observa-
tion by others.
Consequences

Changes in body composition in the elderly, includ-

Course
ing a decrease in lean tissue along with impaired
An important contribution to the description of el- liver and renal functioning, affect the pharmaco-
derly alcohol and drug abuse was Zimberg's (1983) kinetics of alcohol and other drugs and cause their
model of early- versus late-onset geriatric alcoholism. effects to be exaggerated. Therefore, the elderly drink-
The early-onset alcoholic's drinking was construed as er and drug user is especially prone to a host of prob-
an abusive drinking pattern that survived into old lems, including depression, restriction of functional
age; resulted in escalating social and psychological capacity and self-care ability (Colsher & Wallace,
distress, isolation, and increasing physical disabil- 1990), and devastating physical injuries resulting
ity; and was more likely to lead to liver disease, car- from loss of balance (Kelsey & Hoffman, 1987). Al-
diac problems, neurological disorders, and a host of cohol impairs capacity to abstract (Hamblin, Hyer,
other emotional and physical health compromises Harrison, & Carson, 1984), further aggravates age-
(Schuckit, 1982). In contrast, the late-onset drinker compromised sleep physiology (Prinz et al., 1990)
has experienced an exacerbation of normal (or even and sensory dysfunction (Thienhaus & Hartford,
below-normal) drinking practices because of escalat- 1984), and interferes with resolution of the grief pro-
ing social and psychological distress, isolation, and cess (Blankfield, 1983). Adverse drug reactions of all
increasing physical disability. Some suspect that late- sorts are particularly common in the elderly (Ives,
onset alcoholism is relatively common, as is the prev- Bentz, & Gwyther, 1987). Use of benzodiazepines,
alence of elderly iatrogenic drug addiction. Most barbiturates, and narcotic analgesics contributes to
agree that, in cross section, one half to two thirds of accidental injuries and falls (Sorock & Shimkin, 1988)
the elderly alcoholic population experienced an early and to confusional states (Larson, Kukull, Buchner, &
onset of abusive drinking, while one third to one half Reifler, 1987). Cognitive impairment resulting from
experienced a late onset; however, given the covert the use of drugs and alcohol can be a particular
nature of most cases of elderly alcoholism, these pro- problem for the elderly, especially when combined
portions are highly tentative and are subject to defini- with depression, since this clinical picture is often
tional constraints. A more recent adaptation of Zim- mistaken for irreversible dementia (Freund, 1984).
berg's scheme is found in Graham et al. (1995), Termed pseudodementia (Wells, 1979), this kind of
whose outreach and treatment work suggests that two misdiagnosis by even the best intentioned caregiver
elderly alcoholic subtypes—chronic alcohol abusers can have devastating consequences on the elderly in-
490 ISSUES IN SPECIFIC POPULATIONS

dividual's attribution of competency, even on his or affect-regulatory functions that characterize youthful
her personal liberty. users, none encompass the neuropsychological im-
Alcohol withdrawal is another particularly dan- pairment and the peculiarities of symptom expres-
gerous process for the elderly drinker, who may be at sion that mark the older drinker. Instead, subtyping
already heightened risk for hypertension, episodes of work with elderly groups is based on case study and
delirium, and even seizures. In addition, withdrawal clinical observation and lacks the rigor found else-
signs in the elderly may be misattributed by triage where in the field.
staff to problems with higher base rates such as infec- Neurocognitive impairment must be thoroughly
tion, pulmonary or cardiac problems, sidetracking assessed, particularly abstraction, learning, computa-
appropriate treatment. But even when appropriate tion, and visuospatial ability (Fein, Bachman, Fish-
detoxification occurs, older patients generally require er, & Davenport, 1990). Problems may be exacer-
hospitalization and careful monitoring as well as bated by nutritional deficits, head injury, comorbid
treatment of concurrent diseases, and withdrawal cognitive disorders including Alzheimer's and multi-
may carry a higher risk of mortality (Schuckit, 1982; infarct dementia, and other factors.
Thienhaus & Hartford, 1984).
The relationship between physical status, life events,
Assessment and Treatment Issues
and drinking in the elderly is becoming much better
understood (Valanis, Yeaworth, & Mullis, 1987). In
Assessment Issues
fact, the description of the elderly drinker as isolated,
depressed, and at increased risk for death is one of Numerous barriers to delivering quality substance
the most robust findings in the behavioral gerontol- abuse treatment services to the elderly have been
ogy literature (Robinson, 1989; Roca, Storer, Rob- identified. One group of barriers undercuts systemic
bins, & Tlasek, 1990; Sunderland, Molchan, Marti- incentives for accurate assessment and referral, in-
nez, & Vitiello, 1990). This is disturbing, since both cluding limited access to health and mental health
of the symptom complexes that might focus family care (Coyne & Gjertsen, 1993), lack of trained spe-
and professional attention, depression and alcohol- cialists in geriatric health and mental health care,
ism, are typically unrecognized in the elderly (Harp- and inadequate addictions treatment benefits under
er, Kotik-Harper, & Kirby, 1990; Rapp & Davis, prepaid health plans and Medicare/Medicaid (Roy-
1989), in part because they may take different forms bal, 1988). Another group of barriers makes it diffi-
than in younger adults. Even posttraumatic stress dis- cult to appropriately identify older problem drinkers
order (PTSD) is underrecognized, though not un- and get them to treatment and so can be usefully
common, among the elderly (Rosen, Fields, Hand, & discussed here.
Falsettie, 1989), many of whom are survivors of ex- One barrier to services involves the typical behav-
treme privation as children during the Great Depres- ior of the alcoholic elderly themselves, who, indis-
sion, or of gruesome violence in the wars of this cen- posed to seek health services, tend to age-in-place in
tury. an isolative fashion, undetected and untreated. For
We also need to better understand the interre- most elders with alcohol and other drug problems,
lationships between alcohol/drug use patterns and interventions occur on an emergency basis and at a
comorbid psychopathology in the elderly. Comorbid- late stage of problem development, precluding clini-
ity and subtyping studies stand at the forefront of one cally effective and cost-effective measures (Coyne &
of the most compelling issues in health services re- Gjertsen, 1993).
search—patient-treatment matching—yet well-con- Another barrier concerns the diagnostic practices
trolled studies of comorbidity among substance users of caregivers. The symptoms typically manifested in
(e.g., Helzer & Pryzbeck, 1988; Nace, 1990) have younger alcoholics—heavy consumption by objec-
focused increasingly on younger rather than older tive standards, work-related difficulties, driving ar-
subjects or have used exclusively male samples, a rests, marital problems—are not always apparent in
poor recipe for furthering knowledge of a clinical elderly alcoholics (Marion & Stefanik-Campisi, 1989),
group that is both elderly and more often female than whose signs and symptoms (loss of balance, confu-
younger subject groups. In addition, though most sion, depression) can be difficult to distinguish from
subtyping studies focus on the dyscontrol of ego and features of the normal aging process. Diagnosticians
 YOUTH, ADOLESCENTS, AND OLDER ADULTS 491

must be thoroughly schooled in the use of a high 1976) during mild pain crises may merely aggravate
index of suspicion but a low diagnostic threshold this natural tendency.
when evaluating drinking problems among the el- Though not enough is yet known about how to
derly if cases are not to be overlooked and inappro- assess alcoholism in the elderly, some promising de-
priately referred elsewhere simply because they fall velopments have been recently reported. For exam-
below the typical diagnostic threshold for younger ple, in the face of convincing evidence that one of
adults (Caracci & Miller, 1991). Even when symp- the most popular screening devices for alcoholism,
toms are robust, however, research suggests that many the Michigan Alcoholism Screening Test (MAST;
family members and even professional caregivers con- Selzer, 1971), is highly insensitive to alcohol prob-
spire in the elder's denial of a problem (Beresford, lems in the elderly (Blankfield & Maritz, 1990;
Blow, Brower, & Adams, 1988) because the complica- Maisto, Connors, & Allen, 1995), Blow (1991) devel-
tions of alcoholism in the elderly are perceived as so oped an elder-specific version, the MAST-G, with an
dire, life expectancy so short, and expectations for excellent sensitivity/specificity profile. The CAGE
improvement so limited. For example, Rains and Ditz- questionnaire (Ewing, 1984), too, appears to perform
ler (1994), in a study of 383 elderly patients referred well in the detection of elderly alcoholism (Buchs-
for outpatient geriatric assessment, found that alco- baum, Buchanan, Welsh, Center, & Schnoll, 1992;
hol consumption was common but rarely recognized Maisto et al., 1995). DeHart and Hoffmann (1995)
as a factor contributing to medical deterioration. Ad- have offered the U-OPEN screen—probing for un-
ams, Magruder-Habib, Trued, and Broome, (1992) planned use, objections from family and friends, pre-
found that about 14% of elderly emergency depart- occupation with drinking, emotional distress drink-
ment patients were current alcohol abusers but were ing, and neglect of responsibilities—as a highly sensi-
detected as such by their physicians in only 21% of tive indicator of alcohol problems in the elderly,
cases, a problem that may be particularly acute when though its specificity is unknown. Common to all of
patients are white, female, or educated beyond sec- these instruments is their disregard of alcohol toler-
ondary school (Curtis, Geller, Stokes, & Levine, ance, viewed by most authorities as an insensitive in-
1989). And even when elderly alcoholics are referred dicator of alcohol problems in the elderly. Instead,
to treatment and treatment begins, they are less likely the useful domains for assessment appear to combine
to be retained than younger patients (Booth, Blow, aspects of drinking for relief or relaxation, problems
Cook, & Bunn, 1992), especially when their drinking with family, guilt, isolative drinking, salience of
onset was earlier in life (Schonfeld & Dupree, 1991). drinking, and loss of control.
All of this points to a crucial need for the better under-
standing of symptom patterning, illness recognition,
Treatment
and help seeking in the alcoholic elderly, in order to
implement more efficient outreach services. Treatment needs among early- and late-onset alco-
Many factors combine to keep the elderly away holics may be parallel because of a convergence of
from caregivers who might recognize their problems maintaining if not etiological factors. It is therefore
with alcohol or other drugs. That alcoholic elderly possible to extract from the literature a common set
are far less likely to seek care than their sober peers of clinical targets for both early- and late-onset geriat-
may be due to a convergence of metabolic, health ric alcoholism. These can be used to supplement the
belief, and ecological factors: A flattening of the cognitive behavioral approach to addictions treat-
body's immune response to infection and trauma be- ment that is of growing interest to the field, so as to
cause of normal aging and heavy drinking, combined constitute an elder-specific treatment technology that
with neurocognitive impairment of the ability to rec- may produce improved outcomes over the standard
ognize illness when it exists, may result in elderly approach.
alcoholics' experiencing their physical problems as Though elder-specific addictions treatment is a rel-
diffuse and nonspecific, like fatigue and generalized atively new idea, a few reports have already emerged.
malaise, rarely exceeding a threshold that will lead The first (Wiens, Menustik, Miller, & Schmitz, 1982-
them in the face of ambulatory problems and trans- 1983) tested an elder-specific program based on aver-
portation difficulties to the physician's office. Alcohol sive counterconditioning to alcohol and its cues. Re-
analgesia effects (Cutter, Maloof, Kurtz, & Jones, sults were encouraging: Nearly two thirds (65.4%) of
492 ISSUES IN SPECIFIC POPULATIONS

subjects were abstinent at 1-year follow-up, a success cluding goal setting, stimulus control, and functional
rate comparable to that obtained with younger patients. analysis. Of special interest is the community-based
But problems with this treatment approach include nature of the program. However, COPA's emergence
medical risks of counterconditioning and its unaccept- in the unique Canadian health care environment, its
ability to a majority of treatment-eligible individuals. availability to the nonelderly (COPA admits a large
In a more sophisticated program, the Gerontology Al- proportion of middle-aged and "young-old" patients),
cohol Project of Dupree, Broskowski, and Schonfeld and especially its provision of services within open-
(1984) piloted a partial hospital approach with an em- ended treatment contracts make it difficult to gener-
phasis on functional analysis, self-management skills alize findings to the time-limited treatment of the el-
training, and reconstruction of social supports. Unfor- derly and very elderly in the U.S. system.
tunately, though the project generated some interest- Though quite limited, research on elder-specific
ing descriptive (e.g., Schonfeld & Dupree, 1991) and treatment reported so far, in addition to findings from
case study reports (Dupree & Schonfeld, 1989), reli- the literature in behavioral gerontology, prompts a
able outcome data have not been reported. number of recommendations for future development
Two elder-specific programs developed in Veter- of both treatment process and content. In terms of
ans Administration settings have been reported. At treatment process, while the group format is often
the Portland VA, Kofoed, Tolson, Atkinson, and Toth touted as the preferred mode in addictions units, the
(1987) found that elder-specific treatment was su- aged alcoholic may have difficulties in forming and
perior to mainstreaming with regard to treatment managing intimate bonds (Brantner, 1987). Elder-
retention, compliance, recovery from relapse, and specific treatment should therefore include a reduc-
abstinence at discharge, but the VA-based sample in- tion of group therapy in favor of additional individual
cluded only two females and is not generalizable. therapy and should also feature more obvious com-
The other study of an elder-specific program, also ponents, such as the use of visually and auditorially
limited to males, was reported from the VA Medical enhanced educational materials, as well as treatment
Center in Dallas (Kashner, Rodell, Ogden, & Gug- schedules that allow for impaired attentional capacity
genheim, 1992). In this study, 137 older patients and subject fatigue. Also, alcohol and drug abuse has
were randomly assigned to one of two inpatient units traditionally been treated in very-high-level-of-care
and followed for 1 year after discharge. One unit was and costly inpatient settings. McCrady et al. (1986),
a standard milieu of confrontative and 12-step- however, demonstrated the effectiveness and cost-ef-
oriented treatment: the other, an elder-specific unit, fectiveness of the intensive outpatient or partial hos-
offered reminiscence therapy and greater focus on pital setting, which has since become one of the
developing subjective self-worth and social relation- most rapidly expanding clinical modes in the addic-
ships. Patients in the elder-specific program were tions treatment industry. The behavioral gerontology
more than twice as likely to be abstinent at 1 year as literature suggests that the partial hospital may be
those in the traditional treatment unit, an effect that particularly suitable for the treatment of elders,
was magnified in patients above the age of 60. Unfor- whose anxiety, limited flexibility, and deeper roots in
tunately, the study's definition of age 45 and above the community make them resistant to overnight
as "older," its restriction to males, and its use of an stays away from home (as in standard inpatient care),
inpatient level of care reduce its usefulness as a guide yet whose needs for social support and network
to general program development. building cannot be met by very limited clinical con-
The most recent report on elder-specific treat- tact (as in standard outpatient care). The intense
ment is an evaluation of the Community Older Per- contact with treatment staff and other patients avail-
sons Alcohol (COPA) program in Toronto (Graham able in the partial hospital, combined with the partial
et al., 1995). In this study, the authors reviewed the hospital's ability to offer treatment for long calendar
demographic characteristics, typology, prognostic periods while controlling costs and maintaining the
factors, and clinical interventions applied to a large elder's daily contact with home, may make it an ideal
sample of community-dwelling alcohol and drug us- choice at the programmatic level for the treatment
ers. Though the COPA program is ostensibly "client- of addiction in the elderly.
centered" in orientation, the actual interventions ap- Other suggestions for improved content of treat-
plied—and those shown most efficacious—include a ment have also emerged. Dupree et al. (1984) have
variety of cognitive behavioral (CB) techniques, in- urged that treatment of the older alcoholic, like that
 YOUTH, ADOLESCENTS, AND OLDER ADULTS 493

of his or her more youthful peers, emphasize the First, demography urges us: Children of the baby
functional analysis of drinking behavior and the ac- boomers, now entering their reproductive years, will
quisition of improved self-management skills, includ- produce, within the next decade and a half, a large
ing the ability to identify high-risk situations, to em- group of adolescents. To this will be added a group
ploy drink-refusal and other coping skills, and to self- of elderly who, by early in the next century, will be
monitor urges and use behaviors. They also warn, 20% of the population. Failure to adequately provide
however, that most older alcohol and drug users re- specialized services to groups as large as these would,
quire vastly improved social support networks, and in our view, constitute a major planning failure in
that treatment should target the enlistment and hard- public health.
ening of social supports, through family, neighbor, Second, clinical needs urge us: Adolescence is a
and community involvement, and through teaching critical period for personal growth that must be navi-
communication and social skills to the older patient. gated successfully if severe consequences associated
These recommendations for treatment content are with substance use are to be avoided, and if personal
very similar to those used in Graham et al.'s (1995) potential is to be expressed fully. Similarly, old age
COPA program. In addition, treatment programmers is fraught with many dangers and disabilities without
express the need to intervene in problems which may the added health burden of alcohol and other drug
interfere with treatment completion by the elderly use.
(Dupree et al., 1984), since the elderly are so diffi- Third, science urges us: As this chapter makes
cult to identify and engage and may have relatively clear, we now understand many features of both ado-
few "chances" for success left to them. These prob- lescent and geriatric substance use which were for-
lems include serious illnesses, cognitive impairment, merly obscure, and we stand poised to benefit from
and a variety of logistical barriers (e.g., lack of trans- this progress in applied settings. The preference of ad-
portation, inability or unwillingness to venture out- olescents for multiple drug use (Kandel et al., 1992),
doors in the winter), so that effective elder treatment the diminishing gender differences in patterns of use
programs should have ready access to medical and among adolescents (Martin et al., 1993), and the role
neuropsychological consult services, and to commu- of peer selection as well as peer influence processes
nity agencies ready to provide the necessary logistical (Getting & Beauvais, 1987)—all have dramatic and
support. Finally, treatment of the elderly alcohol and meaningful implications for how we assess, treat, or
drug user should address the very prominent role of possibly prevent drug use among youth. Similarly, the
loneliness and depressive symptomatology in the el- importance of depression and cognitive impairment
derly (e.g., Colsher & Wallace, 1990; Warren, Grek, among older alcoholics (Sunderland et al., 1990) and
Conn, & Herrmann, 1989). Effective interventions the early promise of elder-specific treatment program-
include the use of CB techniques to teach the skills ming (Graham et al., 1995) have important bearing
necessary to rebuild the elder citizen's frayed social on clinical services for the elderly. Demographic pro-
network, but timely administration of antidepressant jections, acutely growing clinical need, prospects for
medication will also prove useful in many cases. scientific progress—our response to them must be as
creative and dedicated as has been our response to
SUMMARY other challenges with other clinical groups.

The age-limited populations of adolescents and the

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 27

Ethnic and Cultural

Minority Groups

Felipe G. Castro
Rae Jean Proescholdbell
Lynn Abeita
Domingo Rodriguez

THE MINORITY EXPERIENCE: in" by disavowing their ethnicity and disappearing

SOME COMMON ISSUES into the mainstream culture. By contrast, other eth-
nic persons, especially if they can rely on an ex-
Life Context Regarding the tended family or ethnic network of peers, resist these
Experience of Ethnicity social forces that induce assimilation. The manner
in which an ethnic person copes with this sense of
The experience of ethnicity and self-identification as difference and with social attitudes that discriminate
a person of color carry a special meaning for mem- against ethnicity, influences his or her preferred eth-
bers of the major ethnic/racial groups in the United nic identification and his or her attitudes towards as-
States. These groups are African-Americans, Hispan- similation into the mainstream culture.
ics/Latinos, Asian-Americans, Pacific Islanders, and The experience of ethnicity lies at the heart of
Native Americans/American Indians. To be a person group heritage, as it offers a sense of connectedness
of color is to be "different" somehow, and to feel a with a community of peers who share various values,
sense of separateness from mainstream American so- beliefs, symbols, and community norms. These shared
ciety (Ramirez, 1991). Some ethnic persons feel attributes promote a sense of kinship and affiliation
shame over this difference, while others feel pride. with the culture and forge a common identity that
In certain social environments or communities, binds a people, particularly in the face of discrimina-
ethnic differences (language, skin color, religious be- tion from others (Castro & Gutierres, 1997; Har-
liefs, lifestyle) prompt ridicule and discrimination. In wood, 1981).
these situations, some ethnic persons, children or Despite this sense of connectedness with ethnic
adults, especially if feeling isolated, attempt to "fit peers, the life of a person of color is often stressful.

499
500 ISSUES IN SPECIFIC POPULATIONS

For ethnic minority adolescents, the usual stressors

"Ethnicity" and Illicit Drug Use
of growth through adolescence are often compound-
ed by the pressures of responding to conflicting de- In survey research, ethnicity is a broad, superficial
mands made by two distinct cultures: the Euro- variable that seldom offers in-depth information
American culture and the youth's own ethnic culture about the ways in which the experience of ethnicity
(Castro, Boyer, & Balcazar, in press). In relation to (i.e., ethnic identity and lifestyle) relate to drug use
these demands, there are several reasons why persons and abuse. This superficial property of the variable
of color would use illicit drugs. Among those are (a) ethnicity has been referred to as ethnic gloss. (Trim-
for the pleasurable or reinforcing effect (the high) ble, 1995). In other words, an ethnic label does not
obtained from these drugs, (b) to cope with aversive capture the richness, complexity, and diversity of the
emotional states (e.g., anxiety or depression), and (c) experience of ethnicity.
to belong to a certain peer group (Khantzian, 1985; For example, the superficial demographic label of
Getting & Beauvais, 1987; Shiffman & Wills, 1985). ethnicity, such as American Indian, refers to mem-
In addition, for some people of color, selected psy- bers of that group but glosses over the diversity and
choactive drugs are used (d) as part of cultural or differences that exist within that group. Here, the la-
religious ceremonies, but not for recreational pur- bel American Indian refers to almost 2 million per-
poses. Except when used in solemn cultural ceremo- sons and to over 500 tribes, offering no information
nies, the casual or "recreational" use of illicit drugs about the identity of a given person or group and
often extends to abuse and then to dependence telling us little about that person's or that group's mo-
(American Psychiatric Association [APA], 1994). Ac- tivations to use drugs. In practice, the label of an
cordingly, the ongoing use of an illicit drug can be ethnicity must also be examined in conjunction with
regarded as maladaptive coping, especially when socioeconomic status to take into account real life-
used to cope with feelings of anger, anxiety, or de- style differences that exist within the group as related
pression or other forms of distress. to a person's economic and educational status and as
In looking at the relationship of ethnicity to the these factors may also relate to the use of illicit drugs
use of illicit drugs, the question arises: Does being an (Collins, 1995). More refined analyses that disaggre-
ethnic/racial minority person increase that person's gate broad ethnic categories such as American In-
chances of using illicit drugs? While the answer to dian, into more specific subcategories, such as Nav-
this question is complex, the basic answer is no. ajo adolescents from the Navajo reservation or urban
Clearly, a child born to ethnic minority parents is Americans Indians from Albuquerque would specify
not destined to use illicit drugs unless that child is subgroups or subcultures whose "experience of eth-
exposed to drug-filled environments and is led to be- nicity" and its related links to drug use may be more
lieve that illicit drug use offers certain rewards (eco- easily identified. This strategy calls for more local/
nomic or emotional) that are not otherwise available regional surveys that are designed specifically to ex-
by other means. Thus, while being "ethnic" in and amine drug use within a more specific region, as well
of itself does not "cause" illicit drug use, this does not as for more specific subgroups or subcultures within
mean that the experience of ethnicity is irrelevant to an ethnic category.
the risks of using illicit drugs. As noted previously, for From a related perspective, today progress is need-
ethnic minority youths the risk of using illicit drugs is ed to move us beyond contemporary demographi-
related to the adverse life conditions in which he or cally based descriptive analyses that offer limited in-
she is raised. Furthermore, not all minority persons sights into the link between ethnicity and rates of
experience adverse living conditions such as living drug use and abuse. Progress is thus needed in the
in poverty, racial discrimination, or alienation from development of culturally competent theory that cap-
mainstream social institutions. However, a dispropor- tures significant aspects of the experience of ethnicity
tionately large number of ethnic minorities do face as it relates to motivations and other factors that pro-
poverty and other adverse life conditions, and it is mote the use of illicit drugs among ethnic/racial
the composite experience of being a person of color youths and adults. In the drug field today, there exist
and being raised in an adverse environment that cre- over 40 contemporary theories on the antecedents
ates the setting conditions for illicit drug use and/or and consequences of drug use and abuse (Lettieri,
dealing in illicit drugs. Sayers, & Pearson, 1980). However, few of these the-
 ETHNIC AND CULTURAL MINORITY GROUPS 501

ories directly address the social process by which eth- nic/racial groups in the United States. These data are
nic and cultural factors may influence various as- abstracted from the U.S. Census and show that in
pects of illicit drug use. Moreover, these theories 1995, the United States had a population of 263 mil-
focus more on initiation, continuation, and transition lion residents that could be partitioned by ethnicity
to heavy use, while offering little detail on factors into the following groups: 193.9 million non-His-
that influence cessation, treatment efficacy, and re- panic whites (73.6%), 33.5 million African-Ameri-
lapse. Thus, well-developed theory on factors that af- cans (12.7%), almost 26.8 million Hispanics (10.2%),
fect drug use among ethnic minority persons remains almost 9.2 million Asian-Americans and Pacific Is-
limited. In summary, the field of drug abuse today landers (3.4%), and 1.9 million American Indians/
offers little in the areas of empirical data and theory- Native Americans (0.7%) (Campbell, 1996; U.S. Bu-
driven accounts that describe or explain specific as- reau of the Census, 1994). The projected U.S popu-
pects of cessation, treatment, and relapse, as these lation for the year 2000 is 276.2 million, with relative
occur among various ethnic and minority clients. increases in the total population percentages of His-
panics and Asian-Americans, while there will be rela-
tive reductions in the percentages of non-Hispanic
EPIDEMIOLOGICAL DATA ON whites and African-Americans (Campbell, 1996).
ETHNIC/RACIAL MINORITIES In 1995, when compared with a median age of
AND SUBSTANCE ABUSE 35.3 for members of the mainstream population
(non-Hispanic whites), each of the ethnic/racial pop-
Table 27.1 presents a comparison and contrast of se- ulations had a younger median age. Similarly, from
lected demographic data for each of the major eth- available data for 1992, African-Americans and His-

TABLE 27.1 Demographic Characteristics of the Major U.S. Ethnic/Racial Groups

Asian- American
African- American Indian/
Non-Hispanic American/ Hispanic/ and Pacific Native
Characteristic Total white black Latino(a) Islander American

Population3
1995 263.434 193.900 33.503 26.798 9.161 1.927
1995 percentage 100 73.6 12.7 10.2 3.4 0.7
2000 estimate 276.241 197.872 33.741 31.166 11.407 2.055
2000 percentage 100 71.6 12.2 11.3 4.1 0.7
1992 median age (%) 33.4 35.3 28.6 25.8 30.2 27.0
High school grad (%) 80.2 81.5 70.4 53.1 NA NA
School dropouts (%) 12.7 12.2 16.3 33.9 NA NA
1993 unemployed (%) 6.8 6.0 12.9 10.6 NA NA
1993 Median family income 36,812 38,909 21,161 23,901 NA NA
($)
1992 Families below poverty 11.7 8.9 30.9 26.2 11.9 NA
(%)
Lifestyle behaviors (%) — 41.5 34.3 34.9 — —
Exercise regularly
Two or more drinks per — 5.8 4.3 4.6 — —
day
Current smoker — 25.6 26.2 23.0 — —
20% or more overweight - 26.7 38.0 27.6 - -
Note. From U.S. Bureau of the Census. (1994). Statistical abstract of the United States-1994 (114th ed). Washington, DC: Government
Printing Office.

"Population numbers are in millions.

502 ISSUES IN SPECIFIC POPULATIONS

panics had lower levels of education than non-His- able difference among ethnic/racial groups in life-
panic whites. Whereas 81.5% of white adults ages 25 style and health behaviors was the percentage of
and older had completed high school or more, only members of these populations who were 20% or
70.4% of African-Americans, and only 53.1% of His- more overweight. Here, 38.0% of African-Americans
panics had done so. Also, as measured by the propor- were overweight relative to 27.6% of Hispanics and
tion of students who had dropped out of school at 26.7% of non-Hispanic whites. In summary, these
any time, relative to a rate of 12.2% for non-Hispanic data provide an overview of comparative differences
whites, 16.3% of African-Americans had dropped among these populations as examined by ethnic/ra-
out, and 33.9% of Hispanics had done so. These cial status.
data underscore the problem of educational under- For these ethnic/racial groups, table 27.2 presents
achievement among African-Americans and Hispan- demographic characteristics regarding substance use
ics, and especially as this relates to the risks of drug and AIDS cases. Using 1993 as the population base,
involvement among youth who drop out of school at table 27.2 shows that the total U.S. population was
an early age (Chavez, Edwards, & Getting, 1989). 257.9 million. For this population total, the popula-
Economic disparities between the white and mi- tion percentages for each of the major ethnic/racial
nority populations are also evident as measured by populations were non-Hispanic whites (74.4%), Afri-
indicators of economic resources. First, in 1993, the can-Americans (11.9%), Hispanics (9.7%), Asian-Amer-
rate of unemployment for non-Hispanic whites was icans (3.2%), and Native American Indians (1.8%).
6.0%. By contrast, among African-Americans, it was The Substance Abuse and Mental Health Services
12.9%, and among Hispanics, it was 10.6%. Second, Administration (SAMHSA) reports that nationally in
for non-Hispanic whites, the median family income 1993, there were 11.7 million illicit drug users (4.5%
was $38,909, compared with $21,161 for African- of the U.S. population) (Rouse, 1995). Among these,
Americans and $23,901 for Hispanics (U.S. Bureau the rates of illicit drug use covaried in close congru-
of the Census, 1994). Moreover, these data do not ence with the relative percentages of each ethnic/
show that many minority persons who worked full racial group within the general U.S. population.
time might still be underemployed, as they may have Thus, among illicit drug users, 74% were non-His-
worked at or near minimum wage, and without hav- panic whites, while 14% were African-Americans,
ing insurance benefits. As a result, many of these and 9% were Hispanics.
families could be categorized as "the working poor." The SAMHSA data also report on current "heavy
And among non-Hispanic whites, 8.9% of families drinking," which was defined as "drinking five or
lived below the 1992 poverty line, compared with more drinks per day on each of five or more days in
30.9% of African-Americans and 26.2% of Hispanics. the last 30 days." Among the 10.9 million Americans
Thus, as measured by various indicators of socio- who were classifiable as "heavy drinkers," 81% were
economic status in 1993, African-Americans and His- non-Hispanic whites, as compared with 9% who were
panics, as minority populations, exhibited a clear pro- African-Americans and 9% who were Hispanics. The
file of disadvantage relative to non-Hispanic whites. SAMHSA report also indicates that about 1% of cur-
Among these populations, certain patterns of rent heavy drinkers were Native American Indians,
health-related behaviors and lifestyle behaviors are Asian-Americans, and others.
also evident. According to the U.S. Bureau of the Table 27.2 also presents data from the SAMHSA
Census (1994), in 1990, 41.2% of non-Hispanic report on the major drugs of abuse at the time of
whites indicated that they exercised or participated treatment entry for members of the major ethnic/ra-
in sports on a regular basis, compared with 34.3% of cial groups. These data for 1993 show numbers of
African-Americans and 34.9% of Hispanics. By con- cases of illicit drug use and percentages by ethnicity,
trast, for alcohol consumption that involved consum- as reported by 6,679 treatment providers throughout
ing two or more drinks per day, non-Hispanic whites most of the United States (Rouse, 1995). Here, the
had a higher rate: 5.8% drank in this fashion, relative total number of cases (810,918), included 379,420
to 4.3% of African-Americans and 4.6% of Hispanics. African-Americans; 73,552 Hispanics; 8,478 Asian-
Furthermore, the population percentage of current Americans; and 31,240 Native American Indians.
cigarette smokers was highest among the African- As minority persons enter treatment two critical
Americans (26.2%), relative to 25.6% for non-His- questions are (a) Which is their principal problem
panic whites and 23.0% for Hispanics. One remark- drug? and (b) does the type of problem drug differ
 ETHNIC AND CULTURAL MINORITY GROUPS 503

TABLE 27.2 Demographic Characteristics of the Major U.S. Ethnic/Racial Groups, 1993-1995

Asian- American
African- American Indian/
Non-Hispanic American/ Hispanic/ and Pacific Native
Characteristic Total White Black Latino(a) Islander American

Population
1993a 257.927 191.899 30.768 25.085 8.298 1.878
1993 percentage 100 74.4 11.9 9.7 3.2 0.7
Ilicit drug use
Number of users'3 11.7 8.7 1.6 1.1 — —
Percentage users 100 74 14 9 - -
Heavy drinking
Number of usersb 10.9 8.9 1.0 0.9 — —
Percentage users 100 81 9 9 - -
Primary substance upon
treatment entry
Total Cases — 810,918 379,420 73,552 8,478 31,240
Alcohol (%) — 67.8 39.0 46.2 48.8 81.6
Cocaine (%) — 9.6 41.9 8.2 12.4 4.8
Heroin (%) — 10.6 12.9 34.2 17.1 4.8
Other (%) - 12.0 6.2 11.4 21.7 8.8
AIDS cases— men
Total cases 376,889 198,822 110,958 62,934 2,667 888
Percentage IDU 30.4 16.7 46.7 46.1 8.3 30.3
AIDS cases— women
Total cases 58,428 14,166 31,821 11,909 290 159
Percentage IDU 66.6 60.3 67.8 71.9 30.3 71.1

Note. From U.S. Bureau of the Census. (1994). Statistical abstract of the United States-1994 (114th ed). Washington, DC: Government
Printing Office; B. A. Rouse (1995). Substance abuse and mental health statistics sourcebook. DHHS Pub. No. (SMA) 95-3064. Washington,
DC: Government Printing Office.

"Population numbers are in millions.

b
Numbers of users are in millions.

by the ethnic/racial identity of the client? For each 379,420 cases involved treatment for the abuse of
ethnic/racial group, the percentages presented within cocaine as the principal problem drug. By contrast,
a column in table 27.2 indicate the proportion of the the second highest percentage for cocaine abuse is
total treatment cases for which a given drug (alcohol, observed for Asian-Americans, although with only
cocaine, heroin, and other) served as the principal 12.4% of over 8,000 cases involving a need for treat-
problem drug. For all groups, the highest proportion ment for the abuse of cocaine as the principal prob-
of cases was for treatment of alcohol abuse as the lem drug. Also by contrast, heroin appears as the
principal problem substance. However, for alcohol principal problem drug for Hispanics, with 34.2% of
abuse, remarkable differences appear by ethnic/racial over 73,000 cases involving a need for treatment for
status. For alcohol abuse, Native American Indians heroin abuse.
showed the highest proportion (81.6%) of clients Given the relationship between HIV infection
presenting for treatment who suffered from alcohol and illicit drug use, table 27.2 also presents 1993 data
abuse as their principal problem. This proportion is for AIDS cases among men and women. Here, it is
contrasted with the relatively lower proportions ob- noteworthy that nationally, the number of AIDS
served for non-Hispanic whites (67.8%), African- cases for men was about 6 times higher than for
Americans (39.0%), Hispanics (46.2%), and Asian- women. Among the ethnic/racial groups, the rates of
Americans (48.8%). AIDS cases among men relative to women ranged
By contrast, cocaine appears as the major prob- from 3 times to 14 times higher. Among men, the
lem drug for African-Americans, for whom 41.9% of rates of AIDS cases attributable to injection drug use
504 ISSUES IN SPECIFIC POPULATIONS

(IDU) were highest for African-Americans and for tices of persons from a given ethnic/racial group.
Hispanics, for whom 46% of these cases were attrib- Cultural competence has been defined as
utable to IDU.
While the total numbers of AIDS cases were con-
a set of academic and interpersonal skills that
siderably lower for women, the proportion of cases allow individuals to increase their understanding
among women that were attributable to IDU was re- and appreciation of cultural differences and simi-
markably high. Except for Asian-American women, larities within, among, and between groups. This
the percentage of women's cases attributable to IDU requires a willingness and ability to draw upon
exceeded 60%. Clearly, IDU was a significant risk community-based values, traditions, and customs
factor for HIV infection among women, although it and to work with knowledgeable persons of and
should be recognized that infection did not necessar- from the community in developing focused inter-
ily involve their own use of needles, but the sharing ventions, communications, and other supports.
(Orlandi, Weston, & Epstein, 1992, p. vi)
of needles contaminated by HIV or a sexual relation-
ship with a partner who used contaminated needles.
Moreover, these data on IDU suggest that needle Cultural competence is of paramount importance
cleaning had not been practiced sufficiently to pro- in the delivery of effective health and human services
tect many minority addicts from HIV infection. to members of diverse special populations, and it in-
In summary, the data presented in table 27.2 of- cludes but is not limited to service delivery to mem-
fer some specific features of illicit drug use related to bers of ethnic/racial populations. By contrast, when
ethnic/racial group. Thus, in 1993, for African-Amer- services fail to acknowledge and appreciate the val-
icans, cocaine abuse was the major problem, where ues, beliefs, and practices of persons of color, the re-
the use of injection as a route of drug administration sult may be that minority clients feel misunderstood
also increased the risk of HIV infection among Afri- or skeptical about the helpfulness of a service and
can-American men and women. For Hispanics, alco- ultimately drop out of treatment (Sue, 1977). The
hol abuse and heroin use appeared as the major health services literature indicates that clients are in-
problem drugs. In addition, for Hispanics, injecting clined to participate actively in their own treatment
drugs constituted a significant risk for HIV infection, when they feel that the services offered to them are
particularly among women. By contrast, Asian-Ameri- culturally responsive and thus helpful and worth at-
cans exhibited the lowest drug problem profiles, al- tending (Kolden, Howard, Bankoff, Maling, & Mar-
cohol abuse being the most notable problem drug. tinovich, 1997; Sue, Fujino, Hu, Takeuchi, & Zane,
However, the relatively lower rates of drug abuse 1991).
problems observed among Asian-Americans should The capacity to work effectively with members of
not be taken to mean that drug and alcohol abuse ethnic/racial populations is a matter of degree. As a
did not constitute significant problems for all mem- conceptual framework, a continuum of increasing
bers of Asian-American communities. And for Native cultural capacity has been proposed that underscores
American Indians, alcohol abuse appeared as the the importance of continued learning in the ongo-
most significant drug problem. The magnitude of ing process of building cultural competence (Cross,
this problem is evident if we examine the relatively Bazron, Dennis, & Isaacs, 1989; Kim, McLeod, &
high number of cases of substance abuse problems Shantzis, 1992). The lowest stage of cultural capacity
despite the relatively small size (less than 2 million) is cultural destructiveness, which involves negative at-
of the Native American Indian population in the titudes that regard minority cultures as "inferior" to
United States. the dominant mainstream culture. This type of
thinking prompts discriminatory and insensitive be-
havior toward the ethnic/racial culture and its peo-
CULTURAL COMPETENCE IN DRUG ple. This type of thinking when practiced within
ABUSE TREATMENT drug treatment programs is destructive. Here, having
the dual identity of "minority person" and "drug ad-
Cultural competence refers to the capacity of a ser- dict" could prompt a culturally destructive service
vice provider or of an organization to understand and provider to justify a denial of services.
work effectively with the cultural beliefs and prac- A step forward along the cultural capacity contin-
 ETHNIC AND CULTURAL MINORITY GROUPS 505

uum is cultural incapacity. This stage of cultural ca- larly common among drug-using minority clients
pacity endorses the notion of "separate but equal" who enter a drug treatment program.
treatment as a viable approach to service delivery to The next stage in this continuum is cultural com-
minority clients. The concern here is that separate is petence. Cultural competence is characterized by the
rarely equal. From this perspective, segregation and provider's capacity to examine and understand nu-
discrimination would be regarded as acceptable ways ances that must be appreciated with the introduction
to treat persons of color. Within the drug treatment of apparent contradictions as a complex case unfolds.
setting, the attitudes consistent with cultural incapac- Thus, cultural competence may be regarded as full
ity reflect counselor views that alternate treatments cultural empathy. With full cultural empathy, the
are acceptable because minority clients are seen as provider is able to examine, consider, weigh, and in-
incapable of benefiting from the conventional treat- terpret complex case information for a minority cli-
ment that is being offered. Here, it would be true ent. And in this complex process, the culturally com-
that clients who speak a different language may need petent provider is able to stand in the client's shoes
and could benefit from a separate form of treatment and thus is able to understand the client from the
(Sue et al., 1991). However, caution is needed to client's own cultural perspective. Thus, the provider
avoid making a linguistically separate program a less- is able to conduct effective interventions that pro-
er program in terms of content and resources offered mote positive treatment outcomes.
to these clients. Finally, the highest level of cultural capacity is
The next stage along the cultural competence cultural proficiency, which is characterized by the
continuum is cultural blindness. While this stage im- provider's capacity to understand in greater depth the
proves on the others, it also presents significant prob- qualities and issues involved in a minority client's
lems. The culturally blind viewpoint asserts that "all complex life situation. Cultural proficiency also in-
people are alike," and therefore, that all people volves the ability to understand nuances in greater
should be treated equally. While psychologically this depth, and to propose and design new approaches or
view appears democratic and equitable, it ignores the interventions that aid in the delivery of services to
issue of diversity and suggests that "one size fits all." ethnic/racial clients. Cultural proficiency also in-
Accordingly, service providers who espouse attitudes volves a commitment to research and leadership in
consistent with being culturally blind also express presenting new findings to others in order to increase
views that one should avoid dealing with ethnic and the knowledge base on how better to treat various
cultural issues because these issues serve only as dis- clients from diverse ethnic/racial populations (Cas-
tracters from the real work of recovery from drug tro, 1998).
abuse, and that attention to ethnic issues divides peo-
ple rather than bringing them together.
Moving forward along the cultural capacity con- MULTICULTURAL PERSPECTIVES
tinuum to a positive level, the next stage is cultural
sensitivity. Cultural sensitivity is the positive entry
Common Sociocultural Features Across
level of cultural capacity, in which the counselor is
Ethnic/Racial Groups
open to working with issues of culture and diversity.
The limitations of cultural sensitivity are that the pro- As noted previously, the demographic information
vider holds only a limited repertoire of knowledge available from the U.S. Census shows that economic
about a minority client's values, beliefs, traditions, insufficiency and its related social and psychological
and practices and may become perplexed when problems introduce a common set of challenges and
faced with complex issues and apparent contradic- a lower quality of life for many people of color (John-
tions based on a minority clients' complex life situa- son et al., 1995). Indeed, low socioeconomic status,
tion that may be difficult to interpret. At times, the the old notion of poverty, is the most prominent
culturally sensitive provider, while paying respect to common factor that creates similarity in the lives of
cultural issues, may still think in terms of stereotypes many African-Americans, Hispanics, Asian-Ameri-
and may think in terms of simplistic notions about cans, and Native American Indians. This is especially
the minority client's life situation. Issues of complex- the case for ethnic minority clients who enter drug
ity and the multiplicity of problems may be particu- treatment programs.
506 ISSUES IN SPECIFIC POPULATIONS

Covarying with lower socioeconomic status are erty. These middle-class challenges may be particu-
low levels of education, underemployment, lack of larly stressful for those minority professionals who
health insurance and thus limited access to health lack well-developed systems of social support that in-
care, and a set of health problems that are associated clude knowledgeable persons who understand their
with limited access to health services (American professional challenges from a distinctly ethnic mi-
Medical Association, 1991; Ginzberg, 1991). For mi- nority perspective (Comas-Diaz, 1997).
nority clients, these problems of poverty provide a
life context, background conditions against which
Unique Sociocultural Features
substance abuse problems must be examined. Epide-
by Ethnic/Racial Group
miological data for minority adolescents indicates
that their salient health and social issues include
African-Americans
high rates of school dropout, teenage pregnancy, self-
concept and ethnic identity conflicts, violence, and Overview African-Americans are the largest ethnic/
death by unintentional injuries such as motor vehi- racial minority population in the United States, with
cle accidents (Chavez et al., 1989; U.S. Bureau of an estimated population size in 1997 of 34 million
the Census, 1994). Similarly, for minority adults, sa- (Campbell, 1996; U.S. Bureau of the Census, 1994).
lient health and social issues include addiction to Since 1980, however, the African-American popula-
cigarettes; being overweight; having high blood pres- tion has exhibited an increase in the percentage of
sure, heart disease, diabetes, cancer, or another families that are maintained by a single parent: In
chronic degenerative disease; being unemployed or 1994, only 47% of African-American families con-
underemployed; and being a victim of violence, in- sisted of married couples (Bennett & DeBarros,
cluding homicide (Flack et al., 1995; U.S. Bureau of 1997). From 1970 to 1993, the annual high school
the Census, 1994). These complex and multiprob- dropout rate for African-Americans decreased from
lem social contexts observed frequently in the treat- 11% to 5%. Also, African-Americans with a higher
ment of ethnic/racial minority clients add to the al- level of education have shown considerable increases
ready difficult challenge of providing people of color in median yearly earnings relative to African-Ameri-
with effective drug abuse treatment. cans with less education. And African-American mar-
With all these mentioned, it must also be noted ried couples with children have exhibited a higher
that the minority experience does not always involve median family income compared with married Af-
life in lower socioeconomic status. In the past two rican-American couples that do not have children
decades, growing numbers of young adults from eth- (Bennett & DeBarros, 1997). These demographic
nic/racial backgrounds have advanced into the mid- trends reported by the U.S. Bureau of the Census
dle class, as many benefited from access to higher illustrate the economic advantages of African-Ameri-
education, including access by way of affirmative ac- cans who have been successful in obtaining a higher
tion/equal opportunity educational advancement education and who have established a stable and
programs. Accordingly, these adults and their chil- more conventional family system.
dren constitute a new young cohort of middle-class
minorities, some of whom have also been affected by Historical Perspective African-Americans are just
drug abuse and the need for drug abuse treatment. over 12% of the total U.S. population (U.S. Bureau
Middle-class minority adults and adolescents present of the Census, 1996). Over half of all African-Ameri-
cases that enjoy relatively greater social resources that cans currently live in the southeastern United States
aid in their recovery from drug abuse. However, (U.S. Bureau of the Census, 1995d), where many of
these middle-class minorities also experience the psy- their ancestors worked as slaves until the mid-1800s.
chological conflicts of facing new challenges and Although slavery ended in the nineteenth century,
family situations never before experienced by their equal rights for African-Americans were only given
parents or grandparents. For many new middle-class lip service until the 1950s. During the 1960s, the
minority professionals and their families, these new work of civil rights leaders and thousands of African-
challenges and conflicts may be just as troubling as Americans came to fruition as U.S. racial policy was
the challenges faced by their peers who live in pov- changed from one of "separate but equal" facilities
 ETHNIC AND CULTURAL MINORITY GROUPS 507

to one of racial integration. While the last two gen- for African-Americans, and churches often served as
erations have witnessed substantial changes in the meeting halls.
treatment of and opportunities for African-Ameri- Historically, the church, with its pastor and broad
cans, the current wave of anti-affirmative-action sen- network of brothers and sisters, has served as a reli-
timent is eroding various gains made during the civil able source of social support for many African-Ameri-
rights era. cans. Indeed, pastors are expected to help church
For African-Americans, the continued economic members during times of need by offering advice
impact of inequality in social policy and economic and direction (Robinson et al., 1995). Further, many
opportunity (racism) is revealed by statistics. The me- churches provide needed funding to church mem-
dian income for African-American families in 1994 bers when a tragedy occurs, as well as serving as soup
was $24,698, 36% lower than the median income for kitchens and homeless shelters for the poor of all
all U.S. families (U.S. Bureau of the Census, 1996). faiths.
One out of five (21%) of African-American families Another important aspect of the African-Ameri-
earns under $10,000. In 1994, of all African-Ameri- can culture is the role of women and the elderly.
can families, 27.3% lived below the poverty level, African-American elders are afforded a special rever-
compared with only 11.6% of all U.S. families com- ence, while women are often seen as the heart of the
bined. family (Robinson et al., 1995). In certain West Afri-
can tribes, from which many African-Americans are
Patterns of Drug Use Generally, substance use re- descended, women were considered the souls of soci-
mains a serious problem among African-Americans, ety, while the men were considered the heads of so-
although recent national surveys indicate that drug ciety.
use prevalence rates for a younger cohort of African- Today, the African-American family is strongly
Americans are decreasing (Johnson, O'Malley, & woman-centered, although it is not necessarily
Bachman, 1996; Watson, 1992). Also, the High woman-dominated, as the myth of the black matriar-
School Seniors Survey administered from 1985 to chy suggests (Gaines, 1994). In 1994, 46% of African-
1989 reveals that African-Americans who stayed in American families had a female head of household
school were less likely than Anglo-American students without a spouse present (U.S. Bureau of the Cen-
to use illicit drugs (Johnson, O'Malley, & Bachman, sus, 1996). By contrast, only 7% had a male head
1991). Specifically, only 4% of these African-Amer- of household without a spouse present. While these
ican youth reported using cocaine during the past figures highlight the role of women (Robinson et al.,
12 months, compared with 11% of Anglo-American 1995), caution is needed against labeling female-
youth. Also, 24% of these African-Americans reported headed households dysfunctional; it is often the case
marijuana use, compared with 38% of their Anglo- that children are coparented by one or more persons
American peers. These figures are promising, al- living in an extended-family system. In fact, many
though prevention and treatment efforts need to be African-Americans view child rearing as a communal
maintained to sustain this decreasing trend. responsibility, much as in the African proverb: "It
takes a whole village to raise a child."
Cultural Beliefs and Practices Drug treatment This concept of collectivism, or the concern for
staff should know about a number of cultural beliefs the welfare of the whole group is part of the multi-
and practices in order to work effectively with Afri- faceted philosophy behind Afrocentrism (White &
can-Americans. First, spirituality has long played an Parham, 1990). Afrocentrism places the needs and
important role in the lives of African-Americans. The interests of people with African ancestry at the heart
belief that a better life lies ahead has helped sustain of all discussions (Harris, 1992). It encourages Afri-
African-Americans through the trying times of slavery can-Americans and others to immerse themselves in
and overt racism (Robinson, Perry, & Carey, 1995). African history so that they may develop a new per-
The hymns and sermons of the African-American spective of the world that includes placing their lives
church were developed to inspire hope. For exam- within the context of this African history. The new
ple, during their struggle for equal rights in the 1950s outlook that emerges often changes the way people
and 1960s, gospel songs were a source of strength view existence, meaning, reality, and time. Existence
508 ISSUES IN SPECIFIC POPULATIONS

is changed from the Eurocentric view expressed by of the community, while they simultaneously head
Descartes ("I think, therefore I am") to the collectiv- a large percentage of single-parent households. The
ist Afrocentric perspective ("we are, therefore I exist") Afrocentric perspective to which many African-
(Harris, 1992, p. 156). Americans adhere employs a communal orientation
Thus, existence is viewed not in terms of individ- which lends a different perspective to existence,
ualism, but in terms of relationships with the com- meaning, reality, and time.
munity and nature; reality is restructured (Harris,
1992). This restructuring allows meaning to be
Latinos/Hispanics
found not in individualistic pursuits of a better job
or more money with which to buy material items, Overview Latinos/Hispanics constitute the second
but instead in forces found within the community. largest ethnic/racial minority population in the
From the Eurocentric point of view, these forces ap- United States, with an estimated population size in
pear to be external to the individual and therefore 1997 of 29.1 million (Campbell, 1996; U.S. Bureau
constitute a communal source from which to derive of the Census, 1994). Hispanics are one of the two
meaning. However, from the Afrocentric perspective fastest growing populations in the United States (the
these community forces are the expression of an indi- other is the Asian-American/Pacific Islander group):
vidual's potential. This transcendent order from By the year 2000, Hispanics are expected to have a
where meaning is found influences the African- population of 31.1 million and, by the year 2005,
Americans' perception of reality. Reality from the are projected to grow to 35.7 million and to surpass
Eurocentric perspective is defined by scientific dem- African-Americans as the largest ethnic/racial popula-
onstrations, but reality from the Afrocentric perspec- tion in the United States. Latino/Hispanics can be of
tive is defined by personal experience that captures any race, given that Latinos vary in skin color and
aspects that science is unable to demonstrate. appearance from light-complexioned to indigenous
Along with changes in the concepts of existence, dark brown and include black-complexioned Latinos
meaning, and reality, in Afrocentrism the concept of from the Caribbean (Cuba, the Dominican Repub-
time also changes (Harris, 1992). Instead of viewing lic, etc.).
time as linear, time is seen as cyclical. From this cy-
clical perspective, progress is no longer viewed as Historical Perspective In the United States, Lat-
something that is new today because it was not in inos/Hispanics are a composite group that includes
place yesterday. Instead, what appears to be change several subgroups, including Mexican-Americans,
may be more accurately seen as a recurrence in a Puerto Ricans, Cubans, and persons from Central
repeating cycle. and South America. The Spanish language and cer-
The Afrocentric perspective has influenced the tain cultural customs and traditions that are based
terms that African-American people use to describe on Catholicism and old Spanish culture bind many
themselves. The term black tends to be preferred by Hispanics with a sense of common culture: nuestra
people who do not identify with the time period be- cultura Latina (U.S. Bureau of the Census, 1993).
fore slavery, whereas the term African-American is Nonetheless, given their diversity in cultural and ra-
preferred by people who wish to acknowledge their cial backgrounds, various Latinos/Hispanics disagree
African heritage and to express a feeling of closeness about the term that should be used to refer to them.
to Africa, "the mother continent" (Robinson et al., The terms Latino (a) and Hispanic are general terms
1995). Within the African-American population, in- that refer to the overall population as a composite
dividuals differ in the extent to which they accept group (Aguirre-Molina & Molina, 1994). The U.S.
and espouse the core values of a traditional Afrocen- Census Bureau has adopted the term Hispanic in its
tric life orientation. surveys and publications. Some members of this pop-
To summarize, the long history of slavery and rac- ulation, such as those who live in northern New
ism experienced by African-Americans still affects Mexico, prefer the term Spanish American, as they
them in negative ways (e.g., economically) and in identify exclusively with their ancestors from Spain,
positive ways (e.g., spiritually). The church is a and not at all with Mexico. By contrast, other Lat-
strong source of social support for many African- inos/Hispanics prefer the term Latino for the male
Americans, and women are often viewed as the heart gender and Latina for female gender, noting that
 ETHNIC AND CULTURAL MINORITY GROUPS 509

Hispanic is an imposed term and refers to Spain, issue for Puerto Ricans is the issue of national and
whereas the many Latin American nations that ob- personal identity, as for over 300 years, Puerto Ricans
tained their independence from Spain prefer to have been colonized by Spain and then by the
avoid an identification with their colonizers. United States, thus not having had the comfort of a
While choice of identifying label may seem to be true sovereign identity for three centuries. As a
a trivial issue, its importance lies in the psychology group, Puerto Ricans are concentrated in the New
of personal and national identity, and in the social York and New England area, although other en-
meaning that comes from who a person is, and how claves live in various portions of the southeastern and
he or she self-identifies. As one example, persons southwestern United States.
from the United States may prefer to be known as Members of the third largest Hispanic group, Cu-
Americans (or as Notreamericanos among Latinos) bans and Cuban-Americans, are concentrated in
and might object to being called "English people" Dade County in southern Florida. Historically, a first
simply because they speak English and are from ar- wave of Cuban immigrants came to the United
eas colonized by Great Britain. States in the early 1900s after the Spanish-American
The largest of the Hispanic groups is Mexican- war of 1890. A second large wave of immigrants from
Americans. Mexican-Americans constitute over 60% Cuba came to the United States after the political
of the U.S. Hispanic population. Most of them are takeover of Cuba by Fidel Castro in 1959. Most of
concentrated in the states of California, Arizona, the Cuban refugees of the 1960s were middle-class
Colorado, New Mexico, and Texas. However, grow- Cubans, and thus, the culture and mindset of today's
ing enclaves of Mexican-Americans can be found in Cuban elders reflect this middle-class orientation. A
the Midwest, around the Chicago area, and in other third wave of Cuban immigrants came in the Mariel
parts of the country. A long history of conflict between boatlift in 1980 (Aguirre-Molina & Molina, 1994).
the United States and Mexico, including wars and Thus, differing cohorts of Cubans live in the United
border disputes, has led to the development of a bilin- States, although demographically the middle-class
gual/bicultural identity among the people in the value system of the second wave of Cuban immi-
Southwest who trace their roots to Mexico, but who grants prevails as the core orientation of Cuban
have been raised in the United States. Some Mexican- Americans today.
Americans, in recognition of their hybrid identity and
as an expression of cultural pride and political activ- Patterns of Drug Use Mexican-Americans, Puerto
ism, have chosen to call themselves Chicanos or Chi- Ricans, Cuban-Americans, and other Hispanics/Lat-
canas. Others, however, do not like to use this term. inos vary in their drug use in relation to the age co-
The large influx of documented and undocu- hort and the region of the country that is examined.
mented immigrants from Mexico and other parts of Heroin has been a main drug of use among several
Latin America have helped enrich the Mexican and generations of opiate-using families in East Los An-
other Latino influences found within U.S. Hispanic geles, California, and in San Antonio, Texas—fami-
neighborhoods that are called barrios. The presence lies that identify with gangs and with the pachuco or
of Spanish-language mass media and other sources cholo (wild and crazy homeboy) lifestyle (Des-
of cultural information and identity have sustained mond & Maddox, 1984; Moore, 1990). In the late
the Hispanic presence in the Southwest, in Los 1990s, heroin continues to be a drug that most ad-
Angeles, in San Antonio, and in other parts of the versely affects the lives of Mexican-Americans/Chi-
country, most notably in Miami, New York, and Chi- canos who live in certain lower-class barrios. As re-
cago. Spanglish, combined English and Spanish ported by SAMHSA, data from substance abuse
terms, reflects the hybrid, dual-culture identity of treatment admissions for 73,552 persons of Mexican
many Latinos/Hispanics. For example, instead of us- background show that the illicit drug of abuse most
ing the Spanish term mirar in referring to watching often has been heroin (34.2%), while the most fre-
something, a bilingual speaker may use the term wa- quently used legal substance has been alcohol (46.2%)
char, as in alii te wacho ("I'll see you around"). (Rouse, 1995, p. 80). Generally, health survey data in-
Puerto Ricans are U.S. citizens, many of whom dicate that among Hispanics, the use of illicit drugs
have a history of migration between the mainland and alcohol tends to increase with greater level of ac-
and the island of Puerto Rico. A major existential culturation (Amaro, Whittaker, Coffman, & Heeren,
510 ISSUES IN SPECIFIC POPULATIONS

1990), although gender and other factors also influ- sive are also considered to be acting as machos as
ence the extent of this relationship between drug use defined in this negative sense. This "Hollywood-
and level of acculturation. ized," more negative version of machismo has been
the more "colorful" and enduring version and the
Cultural Beliefs and Practices Catholicism and one that prevails as the sense in which the term ma-
"old Spanish culture" are potent sources of cultural cho is typically used today. When viewed as a DSM-
influence that have strongly affected the indigenous IV character or personality disorder (APA, 1994), ma-
cultural groups that were conquered by the Span- chismo can be seen as a personality disorder that fea-
iards. Today, this influence remains strong in the tures antisocial and/or narcissistic characteristics. For
form of the Spanish language, family beliefs and Hispanic drug addicts who exhibit these macho or
practices, and patterns of social interaction. And antisocial/narcissistic features, recovery from drug
within the core Hispanic/Latino culture, there exists abuse is likely to be complicated and more difficult,
a set of "traditional" values (Ramirez, 1991), al- as is any recovery from drug abuse when codiag-
though it is essential to note that Hispanics vary in nosed with strong aspects of personality disorder.
the extent to which they agree with and adopt as In summary, Hispanics are a heterogeneous pop-
their own various traditional Hispanic values, beliefs, ulation consisting of Mexican-origin people (Mexi-
and practices. can-Americans, Chicanes, Mexicans) as well as Puer-
Several of these values, beliefs, and practices will to Ricans, Cuban-Americans, and other Hispanics/
be reviewed here briefly. "Traditional" Hispanic cul- Latinos. Catholicism and old Spanish cultural val-
ture is primarily conservative. As one example, it ues, beliefs, and traditional practices govern the be-
features strong and distinct male and female gen- havior of most Hispanics in varying degrees, al-
der roles (Ramirez, 1991). Despite this traditional- though some of these factors are changing as the
ism, as the result of acculturation and moderniza- result of the forces of acculturation and moderniza-
tion, changes in the family structure are challenging tion. Extent of drug use and the type of drug used
these traditional beliefs and practices, although today by Hispanics/Latinos varies in relation to subgroup
some of these are still active in original or in modi- (gender, nationality, level of acculturation), region of
fied form. Some of the most prominent values within the country, or the community which is examined.
the Hispanic cultures are respeto (respect), the im-
portance of deference and obedience to elders and
Asian-Americans
to persons of higher rank (Marin & Marin, 1991);
personalismo (personalized relations), the impor- Overview Asian-Americans are perhaps the most
tance of attentiveness to the thoughts and wishes of diverse of the major U.S. ethnic/racial groups. In
others; and confianza (trust), the importance of de- 1994, the Asian-American and Pacific Islander popu-
veloping a strong interpersonal relationship, one that lation of the United States was estimated to be 8.8
features mutual trust, although the highest level of million, up from 7.3 million in 1990 (U.S. Bureau
trust is usually reserved for the most intimate of rela- of the Census, 1995a). The 1990 U.S. Census lists
tionships. 10 major subgroups under the general category of
Machismo is a pattern of beliefs and behaviors Asian-Americans and Pacific Islanders. In order of
that has had dual meanings and that has been linked their population size, these groups are Chinese, Fili-
to drug and alcohol abuse (Chavez et al., 1989; Des- pino, Japanese, Asian Indian, Korean, Vietnamese,
mond & Maddox, 1984). In its original and positive Hawaiian, Samoan, Guamanian, and other Asian or
sense, the responsible macho male was seen as a Pacific Islander. In 1990, the Asian and Pacific Is-
strong and able defender of the family. Accordingly, lander population was 7.2 million, the largest groups
at its root, machismo is a positive attribute that in- being Chinese, 1.64 million; Filipino, 1.41 million;
volves serving as a courageous and strong protector and Japanese, 847,000 (U.S. Bureau of the Census,
of the family. However, in the negative sense, ma- 1995a). In terms of percentage increase, the Asian-
chismo also refers to males who are irresponsible, American population is the fastest growing of all the
domineering, jealous, and violent, and who abuse al- U.S. ethnic/racial populations: in 1997, its popula-
cohol. Males who are insensitive to women, who are tion was 10.0 million, and in the year 2000, it is ex-
unfaithful and promiscuous, and who may be abu- pected to increase to 11.4 million (Campbell, 1996).
 ETHNIC AND CULTURAL MINORITY GROUPS 511

Historical Perspective The Chinese were the first have larger families, have a comparable level of me-
Asian immigrants to enter the United States in large dian family income, and have more females who
numbers (Kitano, 1974, 1980), as they were wel- have a college education and work year-round (Ben-
comed into the United States as a source of cheap nett & Martin, 1997).
labor. In the 1850s in California, Chinese immi-
grants participated in the construction of the railroad Patterns of Drug Use Unfortunately, the data on
and labored in various menial jobs that Americans patterns of drug use among Asian-Americans are lim-
would not take. ited. In the past, Asian-Americans as a group appear
The Japanese were the second Asian group to to have exhibited comparatively low levels of drug
come to the United States, also in response to the and alcohol abuse. Unfortunately, population-based
demand for cheap labor. Whereas the Chinese came national epidemiological data on Asian-American
from a primarily agricultural nation and thus exhib- and Pacific Islanders (APIs) have been almost nonex-
ited a rural and agrarian lifestyle, the Japanese came istent (Yu & Whitted, 1997). Thus, the perceived low
from a more industrialized nation and thus exhibited rates of drug use by APIs might reflect low levels of
a more industrialized lifestyle (Kitano, 1974). In the surveillance for that population, rather than actual
past, Japanese-Americans have been considered the low rates of drug use. Moreover, even for the avail-
"model minority," as they have actively pursued up- able data for Asian-Americans in general, Yu and
ward mobility, although by exhibiting a "low social Whitted (1997) have indicated that because of "lump-
profile," in which they avoided social confrontation ing diverse ethnic groups which do not even share a
and conflict with mainstream Euro-American soci- common history, linguistic roots, or religious belief,
ety. Accordingly, many Japanese-Americans have gross disparities in morbidity risks and mortality pat-
been successful in establishing a stable standard of terns between groups are glossed over" (p. 105).
living, despite many instances of racism and discrim- In contrast to the "model minority" syndrome,
ination, including the wartime evacuation of Japa- new data for recent immigrants from Japan and for
nese to internment camps from 1942 to 1945. De- higher acculturated U.S. citizens of Chinese back-
spite being confronted with adversity, most Japanese- ground have identified these subgroups of Asian-
Americans and many Chinese-Americans have a rel- Americans as exhibiting high rates of heavy alcohol
atively high level of education. For example, in consumption (Myers, Kagawa-Singer, Kumanyika,
1994, nearly 9 out of 10 Asian-American and Pacific Lex, & Markides, 1995). Moreover, rates of cigarette
Islanders 25 years and older had completed at least a smoking for some of the least acculturated Asian-
high school diploma, and a high proportion had at- American immigrants are also worthy of concern.
tained executive or professional occupations (U.S. The growing social observation that many new immi-
Bureau of the Census, 1995a). grants from China and from Southeast Asia are heavy
After the Japanese, Filipinos migrated to the cigarette smokers has been corroborated in part:
United States as nationals (similar to the case for High prevalence rates for current cigarette smoking
Puerto Ricans), as the United States owned the Phil- have been observed for Laotians (92.0%), Kampu-
ippines in the early 1900s? and thus, Filipinos were cheans (70.0%), and Chinese Vietnamese (54.5%)
able to come to the United States as a source of (Myers et al., 1995). Moreover, in the 1990s, with
cheap agricultural citizen labor (Kitano, 1974). Years the growing wave of new immigrants from lower so-
later, other Asian groups such as the Koreans and cioeconomic status that include Asian gang activity,
the Vietnamese came in waves following war in their drug problems that were heretofore less prevalent in
country (Locke, 1998). Asian-American communities have now emerged
The Asian-American population of the United among Asian-American adolescents and young adults.
States is very diverse in terms of great variability in
the languages spoken, their cultures, and their re- Cultural Beliefs and Practices Given the broad di-
cency of migration. Asian-Americans reside mostly in versity that exists within the Asian-American popula-
the western United States and mostly in metropolitan tion, it is difficult to make broad generalizations about
areas. Other characteristics of members of this group specific cultural practices. However, there does exist
are that relative to non-Hispanic whites, Asian-Ameri- a core set of Pan-Asian values that are based on Con-
cans have a higher level of educational attainment, fucianism, Buddhism, and Taoism (Dana, 1993).
512 ISSUES IN SPECIFIC POPULATIONS

Confucianism emphasizes order, the balance of (107,321); and Chippewa, (105,988) (U.S. Bureau of
forces, and filial piety. Buddhism emphasizes avoid- the Census, 1995b).
ing worldly activities in favor of an ascetic lifestyle While there are commonalities that are shared by
and the view that life involves suffering. Taoism em- Native American Indians, striking differences in val-
phasizes harmony between human beings and nature ues, customs, and history exist between tribes (Snipp,
and the avoidance of confrontation. 1989). These differences are partly the result of geog-
Thus, Pan-Asian values and practices that govern raphy, which has led to grouping Native American
the beliefs and behaviors of many Asian-Americans Indians based on location: Plains, Southwest, Eastern
include the following: (a) the importance of the fam- Woodlands, Great Basin, California, Plateau, and
ily as the unit of social and cultural activities, (b) the Northwest Coast (Snipp, 1989; Stubben, 1997).
importance of observing a social hierarchy of respect While this section discusses Native American Indians
and deference to elders or persons of higher social broadly, it should be noted that the diversity found
rank, (c) personal restraint and suppression of emo- among Native American Indians requires a knowl-
tion, (d) using discipline and self-directedness in ac- edge of specific tribal customs in order for a counse-
tion, and (e) the role of shame in motivating behav- lor or therapist to work most effectively with various
ior that is, actions that bring shame to the family individuals of American Indian heritage.
should be strongly avoided. Based on the Asian-
American person's level of cultural involvement in Historical Perspective When Europeans first ar-
traditional ways, and perhaps in relation to level of rived in North America, they considered the people
acculturation, individual Asian-Americans vary in the they encountered less than human and stripped them
extent to which they accept as their own and practice of basic civil rights (Clark, 1993). Over the next sev-
various Pan-Asian values, beliefs, and behaviors. eral centuries, people of European descent assaulted
In summary, APIs are a very diverse and fast-grow- the social, religious, and governmental practices of
ing ethnic population. While rates of illicit drug use Native American Indians (Clark, 1993). Part of this
appear to have been low in the past, limited health assault occurred during the 1800s and early 1900s as
data may have failed to document accurately the ex- Euro-Americans tried to force Native American Indi-
tent of the problem of drug abuse among APIs. Alter- ans to conform to their culture. For example, Native
nately, secular trends, including acculturative effects American Indian children were sent to boarding
and the drug-using behavior of new immigrants, may schools located far from their reservations. At these
actually be contributing to the higher rates of drug boarding schools, the children were not allowed to
use observed among APIs in some recent studies. speak their native languages or practice their tradi-
New epidemiological data guided by improved sam- tions. Despite such extreme attempts at forced assim-
pling methodologies for special or rare populations, ilation, these policies failed to attain their goals
along with improved conceptual categories and mea- (Olson & Wilson, 1986).
sures would aid in generating better data on the ex- In 1953, the U.S. Bureau of Indian Affairs (USBIA;
tent of illicit drug use among Asian Americans and U.S. Bureau of Indian Affairs, 1991) instituted an-
Pacific Islanders (Yu & Whitted, 1997). other assimilationist policy that relocated Native
America Indians to urban areas. Despite the training
and financial support provided by the Bureau of In-
dian Affairs, many Native American Indians suffered
Native American Indians
from poverty and disease and returned to their reser-
Overview Native American Indians constitute a di- vations (Snipp, 1989). Finally, the U.S. government
verse population, with more than 554 federally rec- ended its efforts to assimilate Native American Indi-
ognized tribes and Alaskan native villages, each with ans but left them with good reasons to be suspicious
unique customs, social organization, and ecology (U.S. of future policies.
Department of the Interior, 1996). Based on 1990 U.S. Today, Native American Indian tribes constitute
Census data, within a Native American Indian popula- sovereign nations and maintain their own govern-
tion of 1.93 million, the largest American Indian tribes ments that interface with the U.S. government
were Cherokee (369,035); Navajo, (225,298); Sioux (Clark, 1993). Native American Indians have dual
 ETHNIC AND CULTURAL MINORITY GROUPS 513

citizenship, so they may be citizens of both their own sults indicate that Native American Indians have a
tribal nation and the United States. As of the 1990 moderately positive self-image and do not feel very
Census, Native American Indians composed 0.7% of alienated. In addition, respondents did not express
the total U.S. population, making Native American feelings of powerlessness, social isolation, or norm-
Indians the smallest minority group in the United lessness. Also, the majority of respondents did not re-
States (U.S. Bureau of the Census, 1995b). In terms sent their current situation. Thus, working with Na-
of language, there are approximately 250 American tive American Indians requires sensitivity to their
Indian languages spoken in the United States today history and acknowledgment of grave injustices; nev-
(USBIA, 1991). Of the almost 2 million Native ertheless, it would be inaccurate to assume that most
American Indians documented by the U.S. Bureau American Indians are resentful of their current con-
of the Census (1995c), 90% could speak English, al- ditions or feel bad about themselves.
though 39% could not speak English very well; 23%
could speak a language other than English. As of the Patterns of Drug Use As noted earlier, the Native
1980 Census, the majority (53%) of Native American American Indian population is extremely diverse. Ac-
Indians lived on or near Indian lands; only 23.8% cordingly, tribes differ in the type of substance used
lived in urban areas (Snipp, 1989). most and in the severity of their substance use prob-
Living in poverty is a reality for many Native lems. While members of some tribes are plagued by
American Indians. The land the U.S. government alcohol abuse, adolescents in other tribes experience
chose for Native American Indian reservations was of problems with inhalant use (Closser & Blow, 1993).
little economic value, thus making it difficult for Na- Interestingly, although Native American Indians as a
tive American Indians to live prosperously (Beauvais, group have higher rates of alcoholism than the total
1992). Historical injustices, such as relocation, con- U.S. population, Native American Indians also have
tinue to impact the social and psychological func- more people who abstain entirely from alcohol use.
tioning of Native American Indians both on the res- The enormous variability in deaths due to violence
ervations and in urban settings, thus contributing to and alcohol abuse among some Native American In-
their levels of poverty. On average, Native American dian tribes raises questions that remain unanswered
Indian families earned $21,619 in 1990, 39% less about the causes and mechanisms that mediate these
than the average income for all American families differences (Yu & Whitted, 1997). This lack of an-
combined (U.S. Bureau of the Census, 1995c). Over swers reflects the significant knowledge gap that ex-
one in four Native American Indian families (27%) ists in our current understanding of the factors that
earn a wage that put them at or below the poverty affect the health and well-being of Native American
level. Indians.
Native American Indians have valid historical rea- It is known that alcohol consumption among
sons to resent the U.S. government and to feel hostile American Indians varies across time periods and
toward members of the majority culture. As de- from tribe to tribe. Variables that influence drinking
scribed above, the effects of racism have been experi- patterns are age, geography, social norms, and local
enced by Native American Indians for centuries, and political and legal policies. Urban Indian popula-
even in recent history, Native American Indian cul- tions have higher drinking rates than reservation pop-
ture has been portrayed negatively by the main- ulations. Unfortunately, binge drinkers (those who
stream media. While these facts have led many to consume more than five to seven drinks per episode)
hypothesize that Native American Indians may have constitute the largest proportion of those American
low self-esteem and feel hostile and alienated, careful Indians who drink alcohol (May, 1996).
research has revealed otherwise (Trimble, 1987). A Rates of tobacco use among American Indians
questionnaire on the psychological constructs of self- also vary by geographic region. Smoking rates among
perception and alienation was developed in conjunc- regions between 1985 and 1988 have ranged from
tion with 30 Native American Indian groups from 18% to 48% for men and from 15% to 57% for wom-
eight geocultural regions of the United States. The en (Sugarman, Warren, Oge, & Helgerson, 1992, as
questionnaire was then completed by 791 Native cited in Myers et al., 1995). Smokeless tobacco (chew-
American Indians from 114 different tribes. The re- ing tobacco and snuff) is also a problem among
514 ISSUES IN SPECIFIC POPULATIONS

American Indians, where rates of smokeless tobacco group disapproval and imposed feelings of guilt upon
use have been reported to be between 15% and 20% their return (Colorado, 1986).
among Plains Indian men, three to four times the Spirituality also plays a strong role in the lives of
rate among Anglo-American men. Native American Indians. In essence, spirituality
In addition to alcohol and tobacco use, some aims to achieve harmony between the mind, body,
American Indians consume high amounts of other spirit, and the environment (Olson & Wilson, 1986).
substances. The High School Seniors Survey (HSSS) Thus, spiritual leadership promotes harmony with
from 1990 included over 500 American Indian high others via the Native American Indian focus on ex-
school seniors (Johnson et al., 1991). The results in- tended-family relationships and group identity (Red
dicate that American Indian youth had the highest Horse, 1982). Spirituality and spiritual leadership
prevalence rates for the use of several illicit drugs, may well operate as strong motivators for avoiding
including marijuana (43%), hallucinogens (10%), the abuse of drugs because many tribes believe that
tranquilizers (8%), inhalants (7%), methaqualone substance abuse results from deviating from the natu-
(3.5%), and heroin (1%). Other prevalence rates in- ral order of things (i.e., losing the balance between
cluded cocaine at 15% and stimulants at 18%. the mind, body, spirit, and the environment) (Colo-
rado, 1986). As a traditional activity that promotes
Cultural Beliefs and Practices There are a num- spirituality, Red Horse (1982) endorsed the value of
ber of cultural aspects to consider when working with engaging spiritual leaders to provide spiritual guid-
Native American Indians. One of the most important ance during traditional ceremonies and through con-
aspects to understand is the involvement of extended temporary intertribal gatherings such as powwows.
kin relationships in the lives of Native American In- In sum, Native American Indians constitute a di-
dians (Red Horse, 1982). These relationships empha- verse group which shares a history of culturally de-
size the inclusion of community members of all ages structive policies and practices imposed by the U.S.
in daily activities, discussions, and ceremonies. Even government. Nevertheless, Native American Indians
the peers of Native American Indian youth are often continue to draw on their strengths to maintain cul-
relatives who are close to their own age (Beauvais, tural values and customs (Olson & Wilson, 1986).
1992). Given that peer influence is a powerful deter- Concepts which are central to the Native American
minant of individual substance use, a common main- Indian experience include extended kin relation-
stream approach to preventing and treating addiction ships, group identity, and spirituality. These concepts
problems is to help youth find abstinent friends. should be considered and understood when working
However, this approach may be difficult and unwise with Native American Indians.
for Native American Indian adolescents whose peers
are also part of their extended kin network (Beauvais,
1992). PRACTICAL CONSIDERATIONS IN
In addition to incorporating extended kin rela- TREATMENT AND SERVICE DELIVERY
tionships into their lives, Native American Indians
maintain a strong sense of group identity (Red Horse,
Client-Provider Relationships
1982). Sometimes, this group identity is so strong
that it creates a closed system. Especially in this situa- In the past, minority clients have questioned the util-
tion, outside helpers need to immerse themselves in ity of seeking mental health and drug abuse treat-
the community to "join" the group in order to earn ment from a mainstream human service agency
credibility before they can participate as helpers (Echeverry, 1997). The high dropout rate observed
(Szapocznik & Kurtines, 1989). Within the group, among many minority clients who have sought men-
Native American Indians respect the role of the in- tal health services has been remarkable, as it has
dividual, while group members are also mutually been observed to approach 50% after a single session
interdependent and will take on specific roles and (Sue, 1977). During the first session, if the therapist
responsibilities. Behavior that needs correcting is fails to engage the minority client in a manner that
considered the individual's responsibility. However, establishes rapport and raises positive client expecta-
individuals who leave the group to attend a sub- tions for help in treatment, then a minority client is
stance abuse treatment program may experience likely to drop out of treatment.
 ETHNIC AND CULTURAL MINORITY GROUPS 515

In the provision of drug treatment services to mi- that are delivered within local community-based or-
nority clients, the likelihood of client attrition de- ganizations (CBOs) will offer a more inviting setting
pends on several factors: the client's level of pre- for various clients, especially when these programs
paredness to participate in treatment (DiClemente & emphasize health promotion, lifestyle management,
Scott, 1997), whether the treatment is forced or vol- and relapse management as broader contexts in the
untary, the presence of psychopathology (Kolden et task of recovery from drug abuse (Marlatt, Tucker,
al., 1997), whether the treatment is inpatient or out- Donovan, & Vuchinich, 1997). Managed-care guide-
patient in form, and even if the client pays directly lines for allowable drug abuse treatment should take
or has the benefits of insurance coverage. However, into account these issues (Kushner & Moss, 1996).
as related to the client-provider relationship, the pres-
ence of cultural and/or linguistic mismatches is also
Assessment
a potential source of client-therapist clash that can
lead to limited client participation in a program of One aspect of enhanced therapist/counselor cultural
recovery (Sue, 1988). capacity (cultural competence) is to improve the ther-
For increased success in treatment, clients do not apist's skills at assessing and understanding the within-
necessarily need to be matched with their therapists group variability in a given ethnic/racial group. For
by ethnicity (ethnic matches). However, for effective each group, level of within-group variability can be
treatment, therapists do need to be knowledgeable assessed using a core dimension that ranges from
about ethnic clients' cultural background (cultural high cultural involvement and acceptance of the tra-
matches) (Sue et al., 1991). This point raises the ditional culture's values to low or no cultural involve-
need to train therapists and counselors in a way that ment. Dana (1993) referred to this key dimension as
builds their "cultural empathic" capacities and their a "moderator variable," a variable that identifies lev-
cultural competence, in order to meet the client els or gradations for this dimension.
more than halfway, and to create a therapeutic atmo- For African-Americans, this dimension is called
sphere that will motivate sustained client participa- Afrocentricity or Nigrescene (White & Parham, 1990).
tion. In addition, efforts at matching the intervention Measures of the Afrocentric worldview have been de-
to client characteristics, such as by severity of addic- veloped that aim to provide an indicator of an indi-
tion or by cultural orientation, may also improve cli- vidual's level of involvement within the traditional or
ent motivation for treatment and treatment outcome core African-oriented culture (Baldwin & Bell, 1985;
(Miller, 1989). Research that examines cultural fac- Montgomery, Fine, & James-Meyers, 1990).
tors in the client-treatment matching of ethnic/racial Similarly, for Hispanics and for Asian-Americans,
minorities is much needed (Castro & Tafoya-Bar- scales that measure level of acculturation assess this
raza, 1997). within-group variability, which ranges from being
Clearly, treatment for drug addiction won't work strongly culture-bound (low acculturated), to being
if the addict is not engaged and retained in treatment bilingual/bicultural, to being highly acculturated (cul-
(Onken, Elaine, & Boren, 1997). Onken and col- turally distant or assimilated). The ARSMA (Accul-
leagues point out that as an incentive to enter drug turation Rating Scale for Mexican Americans) was
treatment, drug addicts may seek to escape the social, developed in 1980 and has been a core scale from
financial, criminal, and medical problems related to which other scales have been derived to rate levels of
drug addiction. However, drug addicts also do not acculturation among Mexican-Americans and other
want to give up the pleasure associated with drug Hispanics (Cuellar, Harris, & Jasso, 1980). A similar
abuse. This conflicting situation creates a motiva- scale has been developed for use with Asian-Ameri-
tional problem for full participation in drug abuse cans (Suinn, Rickard-Figueroa, Lew, & Vigil, 1987).
treatment programs. In these approaches, three within-group types of
Given this context, how does one keep the drug individuals have been identified: (1) the low accul-
addict involved in his or her own treatment (Onken turated, individuals who identify strongly with the
et al., 1997)? From a different perspective, entering mother culture; (2) the bilingual/bicultural, those
a medically based treatment program has typically who have skills and an orientation to participate in
created a stigma, especially for ethnic minority cli- both cultures; and (3) the highly acculturated or as-
ents. Establishing more community-based programs similated, those who have little connection with the
 TABLE 27.3 Cultural Orientation: Six Major Ethnic Types within an Ethnic/Racial Group

Pluralistic (Afr.-Amer.)
or bilingual/bicultural
(Hisp., Asian-Amer., Traditional African-
Assimilated Acculturated Native Amer.) American Separatist Marginalized

African-Americans
Self-concept Identifies solely with Identifies mostly with Identifies both with Identifies mostly with Identifies solely with Identifies with no spe-
the white, domi- white dominant African-American African-American African-American cific culture; sees
nant culture culture; some iden- and white cultures culture; some culture; no identifi- self solely as an in-
tification with and communities; white or other cul- cation with the dividual
black culture and affirms African ture identification white, dominant
community American con- culture and com-
sciousness munity
Attitudes toward ethnicity Negative attitude to- Positive attitude to- Positive attitude to- Positive attitude to- Negative attitude to- Neutral attitude to-
ward race and eth- ward the dominant ward both the dom- ward own African- ward the dominant ward ethnicity; no
nicity; avoids eth- culture; ambiva- inant and ethnic American culture; culture; strong loy- feelings of pride or
nic/racial issues; lence about issues culture, and to- some interest in alty toward own Af- of belonging to
espouses white of race and eth- ward other ethnic the dominant cul- rican-American any ethnic/cultural
values nicity cultures ture and commu- culture and com- group
nity munity
Social and political involve- Involved solely with Involved mostly with Involved with people Involved mostly with Avoids persons from Indifference towards
ments people from the people from the from both the dom- people from own the dominant cul- others from own
dominant culture dominant culture inant and African African American ture; mostly in- ethnic/cultural
and community and community American cultures culture and com- volved in own Afri- group
and communities munity can American
culture and com-
munity
Hispanics, Asian-Americans,
Native American Indians
Language Speaks only English Speaks mostly En- Speaks English and Speaks mostly or May speak one or Likely to speak En-
glish own ethnic lan- only own ethnic more languages, glish
guage about language but prefers own
equally well ethnic language
Self-concept Identifies solely with Identifies mostly with Identifies both with Identifies mostly with Identifies solely with Identifies with no spe-
the white domi- the white domi- the dominant cul- own ethnic cul- own ethnic cul- cific culture; sees
nant culture nant culture; some ture and with own ture; some identifi- ture; may dislike self solely as an in-
identification with ethnic culture cation with the the dominant cul- dividual
own ethnic culture dominant culture ture and commu-
nity
Attitudes toward ethnicity Negative attitude to- Positive attitude to- Positive attitude to- Positive attitude to- Antipathy toward the Neutral attitude to-
ward race and eth- ward the dominant ward both the dom- ward own ethnic dominant culture; ward ethnicity; no
nicity; avoids eth- culture; ambiva- inant and ethnic culture; some inter- strong loyalty to- feelings of pride or
nic/racial issues lence about issues culture, and to- est in the domi- ward own ethnic of belonging to
of race and eth- ward other ethnic nant culture culture any ethnic/cultural
nicity cultures group
Social and political Involved solely with Involved mostly with Involved with people Involved mostly with Involved entirely Indifference toward
involvements people from the people from the from the dominant people from own with people from others from own
dominant culture dominant culture and ethnic cul- ethnic culture and own ethnic culture ethnic/racial or cul-
and community and community tures and commu- community and community tural group
nities
518 ISSUES IN SPECIFIC POPULATIONS

mother culture, and who seem uninterested in get- cence, a client might assimilate toward mainstream
ting involved in the mother culture. white (Euro-American) values and behaviors in order
Within this context and as an extension, table to "fit in," as the result of education and/or in rela-
27.3 presents six levels or types of cultural orienta- tion to efforts at upward social mobility. Subse-
tions that involve language (except for African- quently, in adulthood, that same client could exert
Americans), self-concept, attitudes toward ethnicity, efforts to move back toward the mother culture (to-
and social and political involvements as major as- ward lower acculturation or toward biculturalism)
pects of cultural orientation. These groups describe when seeking to recapture lost aspects of his or her
six recurring types of individuals who have been ob- culture and identity (White & Parham, 1990). This
served within each of the four major ethnic/racial shift back to the mother culture, to cultural roots,
groups. For Hispanics, Asian-Americans, and Native and toward recapturing a lost part of the self may
Americans, these six types of persons are (a) assimi- have therapeutic value for some recovering drug us-
lated, (b) acculturated, (c) bilingual/bicultural, (d) ers (Castro, Sharp, Harrington, Walton, & Rawson,
traditional, (e) separatist, and (f) marginalized. In 1991; Westermeyer, 1984). Further research is need-
parallel fashion, for African-Americans, these types ed to determine the therapeutic effects of this process
are better described as (a) assimilated, (b) accultur- of "cultural renaissance," as this identity shift may
ated, (c) pluralistic, (d) traditional African-American, promote effective recovery from illicit drug use and
(e) separatist, and (f) marginalized. addictive dependence on illicit drugs.
As presented in table 27.3, these are prototypical Beginning with Group 1 as shown in table 27.3,
profiles, and actual clients do not always exhibit all assimilated minority clients (white-oriented African-
the characteristics noted. However, these typologies American clients) exhibit a minimal identification
are intended to enhance the clinician's cultural ca- and involvement with traditional cultural values, eth-
pacity to understand, appreciate, and work with the nic issues, people, and communities. Within treat-
large within-group diversity found within each of the ment, these clients may disavow any identification or
major U.S. ethnic/racial groups. Each of these types involvement with their ethnic community and are
of minority clients offers distinct challenges to recov- often uncomfortable and resistant when dealing with
ery from drug abuse based on the type of cultural ethnic/racial issues. Usually, these clients are best
orientation. These six types are similar to the four treated using the conventional/standard mainstream
types of adaptation to the conflicts of acculturation: treatment program.
assimilation, integration, rejection, and decultura- Acculturated clients (Group 2), are culturally ori-
tion, described by Berry (1980). These six types are ented more toward the mainstream/dominant cul-
also similar to the typology that describes levels of ture than toward their own ethnic/racial culture.
involvement in American Indian culture, that is, the These clients can relate to ethnic issues in treatment,
five categories of "Indians" described by La From- although with some ambivalence. The provider should
boise, Trimble, and Mohatt (1990). assess the individual client's willingness to discuss
As noted, this schema provides a set of recurring ethnic/racial issues and the degree to which this cli-
types of clients as seen from the perspective of ent's lifestyle and social relations include sufficient
within-group differences. While presented along a ethnic interests to merit addressing these as part of
general continuum, these six types of cultural orien- treatment for recovery from drug abuse.
tations are not ordered by increasing degree of cul- The bilingual/bicultural (pluralistic African-Amer-
tural involvement. They do, however, represent dif- ican client; Group 3) has a dual-culture or multicul-
ferent types of orientations toward a core ethnic tural identity and social involvement. Accordingly,
culture. A client who presents for treatment may be this client type has a lifestyle and social relations that
evaluated according to this schema on his or her embrace ethnic/racial issues as important aspects of
here-and-now cultural orientation. his or her life. In the recovery of the bilingual/bicul-
Moreover, from a developmental perspective, for tural client, issues of ethnic identity, sources of fam-
some minority clients, a life history analysis of cul- ily support, and the challenges of shuttling between
tural orientation could also reveal a process of change two cultural environments should be examined, as
in cultural orientation across time in which the cli- these issues relate directly to the challenge of recov-
ent has shifted from one cultural orientation to an- ery from drug abuse.
other across a lifetime. For example, during adoles- Traditional (low acculturated; Group 4) clients
 ETHNIC AND CULTURAL MINORITY GROUPS 519

typically have a limited capacity to participate in from dysfunctional families who have received little
drug abuse treatment that is offered in English, al- or no ethnic cultural guidance and education from
though this language issue does not apply to African- their parents, would be expected to exhibit these
American clients. Thus, many of these clients need marginalized characteristics. These marginalized youth
a linguistically compatible treatment program. Tradi- may participate in nonconformist subcultures of
tional clients who have fewer years' residence in the their own and may belong to subcultural groups that
United States may also exhibit a lower awareness of have unique social norms and attitudes, including
mainstream U.S. social norms and expectations in attitudes accepting of illicit drug use.
treatment. These issues need attention in tailoring
the treatment to the needs of these traditional clients, Treatment
who exhibit linguistic and life values that differ from
those of persons from the mainstream culture. Among Enhancing Conventional
African-American clients, those described here as tra- Treatment Programs
ditional African Americans are involved primarily in
The literature on the treatment of drug-dependent
the African-American community. These clients iden-
ethnic/racial clients has little that provides clear
tify more closely with African-American culture and
guidelines. Currently, typical inpatient or residential
traditions and identify strongly with the African-Amer-
treatment programs for recovery from illicit drugs
ican values of spirituality, communal relations, col-
feature several basic treatment goals: (a) eliminating
laboration, extended-family relations, and experien-
substance use; (b) reducing criminal and/or mal-
tial ways of knowing (Montgomery et al., 1990).
adaptive behaviors; (c) reducing comorbidity, espe-
The separatist client (Group 5) exhibits a notable
cially among dual-diagnosis clients; (d) establishing a
resistance to any treatment that espouses Euro-Amer-
viable system of social supports; and (e) establishing
ican values and expectations. A culturally relevant
gainful employment and/or a stable living situation.
drug treatment program that promotes issues of eth-
Regarding programmatic content, the curriculum
nic cultural pride and respect for ethnic values and
of various drug treatment programs contains a series
practices may help the separatist client relate to the
of educational and training activities, for example,
treatment program. Resistance to participation in
(a) emotional management, or the management of
drug abuse treatment by drug-abusing clients with a
grief, anger, and stress, and self-concept enhance-
separatist cultural orientation has been described by
ment; (b) personal organization, or values clarifica-
drug researchers working with Hispanic heroin ad-
tion, goal setting, and relapse prevention; and (c) im-
dicts (Desmond & Maddox, 1984).
proving interpersonal relations, or conflict resolution,
Finally, a marginalized client (Group 6) exhibits
boundary setting, resisting peer pressure, developing
a notable lack of identification with both the main-
a support system, and effective community reentry.
stream and his or her own ethnic culture, thus "be-
The addition of other culturally relevant activities
longing" to neither culture (Stonequist, 1935). In the
would increase the cultural capacity of these drug
United States, this strongly nonconformist client, who
abuse recovery programs. Such culturally relevant
doesn't fit in, speaks English but expresses an individu-
activities include (a) cultural identity clarification
alized self-concept that disavows any identification
and development, (b) family systems issues affecting
with or involvement in the conventional mainstream
risks of relapse, and (c) minority community dynam-
or ethnic cultures. Ramirez (1991) described a "mis-
ics that affect the ability for reintegration into the
match syndrome," in which a socially alienated per-
local community.
son feels alone, helpless, and misunderstood. This
marginalized person expresses a lack of interest in
Client-Treatment Matching
affiliating with ethnic peers and in participating in
ethnic institutions or activities. These individuals can Matching clients with therapists by their shared atti-
be seen as being at the primitive "diffuse identity" tudes, values, and common life experiences may lead
stage of identity development (Phinney, 1989) in to a more effective therapeutic alliance than simply
which the person does little to explore his or her own matching client and therapist by demographic ethnic
ethnic identity and has no clear understanding or ap- label (e.g., having a Hispanic therapist assigned to a
preciation of his or her own culture and ethnicity. Hispanic client) (Beutler, Zetzer, & Yost, 1997).
Many drug-abusing youths, especially neglected youths This match by similarity of values and lifestyle is a
520 ISSUES IN SPECIFIC POPULATIONS

strategy to promote better treatment outcomes, as the assumption that certain traditional cultural values
client may better identify with a therapist who is may promote protection against drug use and abuse.
similar to himself or herself. In addition, this may The core values found within traditional/agrarian so-
prompt the client's perception of the therapist as a cieties, which promote the survival of the group, if
more credible individual who is capable of helping. reestablished within the modern social context might
More research is needed to identify key client factors contribute to successful drug avoidance (Castro &
(problem severity and coping style —internalizing Gutierres, 1997). Here the values of (a) collectivism
versus externalizing), and to examine the potential of and cooperation, (b) concerns for serving as a con-
client cultural orientation, as depicted in table 27.3, tributing member of the group or family, (c) respect
to establish more effective matching of ethnic/minor- for elders, and (d) spirituality that involves care and
ity clients to therapist and/or to treatment. For exam- concern for the well-being of other members of the
ple, ethnic minority clients who are assimilated or community may each serve to counter the effects of
acculturated would be expected to do well with con- certain modernistic values that promote drug use,
ventional/mainstream treatment programs that in- such as narcissism, self-centeredness, and hedonistic
clude no ethnic content. By contrast, bicultural (plu- self-gratification. In this regard, for drug-dependent
ralistic), traditional African-American and separatist bicultural, traditional, and separatist clients, cultur-
ethnic minority clients would be expected to relate ally relevant interventions can focus on ethnic self-
better to, and benefit more from, a drug treatment concept and values clarification that include promot-
program that includes culturally relevant content. ing (a) ethnic pride, (b) family responsibility, and (c)
The client-treatment matching literature suggests responsibility to contribute to one's community and
that improving such client-treatment matches yields culture (Castro & Gutierres, 1997). More research is
better treatment outcomes and is more likely to pro- needed to clarify the effects on treatment outcomes
mote the client's continued participation in treat- that may accrue by promoting positive antidrug atti-
ment (Onken et al., 1997). tudes, and by preventing drug relapse in clients
While client-treatment matching is a promising matched by using cultural orientation and examined
strategy, this approach may not be viable in drug in progress in a culturally relevant drug treatment
treatment agencies that focus on offering a single program.
treatment approach. A major challenge to drug treat-
ment programs nationally is to balance the complex-
Relapse Prevention
ity and cost of offering a diversity of programs with
the importance of a specific set of program options Relapse is a major problem among clients recovering
(e.g., treatment modules) to meet the treatment from drug abuse, and unfortunately, its occurrence
needs of a diverse client population. is the rule rather than the exception (Gorski &
Along these lines, a culturally relevant approach Miller, 1982; Marlatt & Gordon, 1985). Among eth-
to treatment of ethnic/racial minority clients would nic/cultural minority clients, the strong family rela-
emphasize the potential for successful recovery and tions and mutual obligations that are prominent fea-
drug avoidance by helping the client change his or tures of many ethnic/racial families can operate as
her identity as a "regular user" (Castro et al., 1991), sources of social support. However, conversely, fam-
with the aim of developing a new identity as a "re- ily relations may also operate as sources of distraction
covering addict." This identity includes a concept of from recovery or may prompt relapse episodes (Cas-
self as a nonuser and as a person with a renewed tro & Tafoya-Barraza, 1997).
or newly constituted ethnic identity that includes a In conveying the concepts of addiction and re-
commitment to be drug-free and to participate as a lapse with long-term Chicano heroin addicts, Jor-
contributing member to his or her family, to the lo- ques (1984) used the metaphor of the tecato guza.no
cal community, and to society (Castro et al., 1991). ("stomach worm"). This metaphor asserts that this
worm must be "kept asleep," because to awaken it
will induce the experience of cravings. This meta-
Role of Traditional Values and Practices
phor serves as a descriptive aid in reminding these
In addition, a culturally relevant intervention for mi- addicts that addiction, its related cravings, and the
nority clients would encourage a pursuit of tradi- potential for relapse are realities that the heroin ad-
tional ethnic values and practices, under the working dict must face constantly. Thus, the recovering drug
 ETHNIC AND CULTURAL MINORITY GROUPS 521

addict must always keep in mind that he or she must expected serve as the sole person responsible for ad-
cope with this tecato guzano actively and on an ongo- dressing a broad array of linguistic and cultural issues
ing basis. More research is needed on the effects of in treating a variety of minority clients. This practice
similar metaphors and related culturally relevant in- can create hostility and/or divisiveness in the ranks
terventions, as these may aid in helping ethnic/racial and becomes a source of job-related stress and/or dis-
minority clients to develop culturally meaningful satisfaction for that overburdened individual. Here,
cognitive and behavioral strategies and skills that will one concern is that ethnicity in and of itself does not
aid them in avoiding drug relapse. guarantee that the ethnic counselor is capable of be-
Identifying triggers to relapse is an important re- ing culturally competent. Cultural competence is a
lapse prevention strategy that should be taught to mi- set of acquired skills and is not a preestablished capa-
nority clients within the context of their life situation. bility just because the provider is a person of color.
Given the importance of the family to many minority Furthermore, the organization's cultural capacity is
clients, identifying sources of social support (includ- the product of an integrated program of activities, not
ing members of the extended family) is likely to be the product of the actions of a single "type-cast" indi-
an important strategy for relapse prevention. Con- vidual.
versely, some family members will themselves serve Another challenge to staff training involves the
as triggers to relapse, and here, culturally competent lack of preparation observed among newly graduated
strategies should be used to neutralize the disruptive college students who enter the professional social ser-
influences of these family members, without creating vice arena. Colleges and universities have not met
undue antagonism and conflict within the client's the challenge of preparing students to negotiate vari-
family (Szapocznik & Kurtines, 1989). ous aspects of fieldwork that involve issues of man-
aged care and cultural competence. Ethnic leaders
and communities must meet the challenge of im-
Agency Operations
pacting the system of higher education so that issues
The delivery of culturally competent drug treatment of color are not confined to a single course or class
services cannot be separated from the operational presentation. Issues of race/ethnicity and gender must
characteristics of the agency itself. Core agency prac- be incorporated into course work across the curricu-
tices that greatly affect an agency's capacity to offer lum. One significant activity for promoting cultural
culturally competent services to a diverse clientele competence is to teach students skills in "cultural de-
can be examined in the areas of (a) staffing and staff centering," in which a student must reframe his or
training, (b) program activities, (c) organizational her own academic and/or Eurocentric worldview by
structure, and (d) organizational policies. temporarily adopting the worldview of various people
of color. In addition, an activity to foster capabilities
for work in the managed-care environment is to pro-
Staffing and Staff Training
vide students with a variety of hands-on training ac-
For many ethnic groups, the messenger is as impor- tivities within a variety of community-based health
tant as the message. Therefore, the staff member's service organizations.
personal style and delivery are of paramount impor- Here also, staff training should target all agency
tance. Thus, to support staff training, agencies should personnel regardless of their job classification or role
hire qualified consultants to offer staff development within the agency. This is important because many
support groups in which staff can openly address and times, receptionists, administrative assistants, cooks,
reconcile their own prejudices and/or cultural biases and other agency staff have daily contact with clients
without fear of retribution. The goal is to have the or with individuals in the community, and these sup-
messengers of the agency (i.e., staff counselors, thera- port staff members should also develop skills in cul-
pists, and other providers) work to acknowledge and tural competence that relate to their roles within the
respect the individual client's cultural experiences agency.
while also encouraging these clients to participate in
behavioral and attitudinal change.
Program Activities
Moreover, for practitioners and clinicians, cul-
tural competence does not happen in a vacuum. Too Agencies should identify community resources (heal-
often, an agency hires an ethnic individual who is ers/spiritualists) to complement their conventional
522 ISSUES IN SPECIFIC POPULATIONS

treatment activities if these nonconventional activi- in defining and developing the characteristics of the
ties are part of the belief and/or support system of local managed-care system.
the individual client or group of clientele seen often And third, technology will also be important. Or-
within the agency. Agencies should also address the ganizations must develop or enhance their capacity
needs of multilingual ethnic groups (Hispanics, for automation and should develop a management
Asian-Americans) that need parallel and equally ef- information system so that clinical and financial data
fective treatments delivered in their own language. can be integrated and used in examining program
This addition will also improve and expand the mar- operations. This automated information can be used
ketability of the drug treatment program, while also to monitor and evaluate program outcomes, and to
providing clients the option to receive treatment in develop more potent programs based on data that
the language in which they feel most comfortable monitor program progress and that identify factors as-
and/or can best express themselves. sociated with more positive treatment outcomes.

Organizational Structure Organizational Policies

Providers/organizations of color (POCs) must rede- Treatment agencies must also be guided by govern-
fine themselves if they are to survive in this more ing policies, procedures, and quality assurance stan-
competitive climate of drug abuse service delivery dards (state/federal/licensing) that address and en-
under the rules of managed care (Kushner & Moss, dorse culturally appropriate programming for ethnic/
1996). This paradigm shift offers the greatest threat racial populations. In turn, these treatment agencies
to the survival of small social service agencies. Or- must also adopt policies and standards that mandate
ganizations that do not understand managed-care idi- the inclusion of a diverse representation of culturally
oms or principles, and/or that lack the requisite tech- competent community board members, managers,
nology, clinical capacity, or service diversity, will not providers (therapists/counselors), and support staff.
survive unless they reorganize in response to the new
demands of managed care. However, this threat can
also be seen as an opportunity to excel and diversify SUMMARY AND CONCLUSIONS
where POCs can serve as major players and providers
of substance abuse treatments that truly serve the The experience of ethnicity is unique and somewhat
needs of ethnic/racial communities. different for each of the more than 70 million per-
To survive and compete in the new-managed care sons of color who currently constitute over 25% of
environment, POC organizations must excel in the the U.S. population. This considerable diversity has
following three areas. First, network development is been typically described according to ethnic/racial
needed where smaller organizations should consider identity by referencing one of four major ethnic/ra-
a merger with larger organizations and/or consider cial groups: African-Americans, Hispanics/Latinos,
developing a partnership along with agreements for Asian-Americans and Pacific Islanders, and Native
joining existing networks that can support and utilize American Indians. Within each of these four groups,
their services. however, there exist subgroups and subcultures that
Second, advocacy is another strategy in which differ in their collective experiences of ethnicity
POCs can participate actively in defining the local based on variations in nationality, in the tribe or geo-
guidelines that govern managed care. At present, graphic region where raised, by urban-rural status,
there is no universal definition of managed care. and/or by the cultural orientation of the members of
Therefore, each site will need to define and structure a subgroup. Today, more refined analyses are needed
its own care system (eligibility, benefit plans, process, to move beyond "ethnic gloss" in order to better de-
and structure). To ensure ethnic participation, to en- scribe and understand how various experiences of
hance and support cultural competency, and to advo- ethnicity may relate to the use and abuse of various
cate for the needs of community-based providers, illicit drugs.
POCs must develop a unified community plan. This In understanding this diversity, along with the
strategy can also include advocacy so that ethnic cultural commonalities that bind a people and create
leaders in the field can participate on the policy level a sense of belonging, drug abuse service providers
 ETHNIC AND CULTURAL MINORITY GROUPS 523

should work diligently to develop and expand their dian youth. Journal of Addictive Diseases, 11(3),
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 28

Women

Edith S. Lisansky Gomberg

Addictive behaviors involve a wide range of sub- cantly more often than older women; the same kind
stances. Omitting recently discovered addictions to of age differences existed in a comparison of younger
work, exercise, chocolate, religion, love relationships, and older alcoholic men. It is probably safe to as-
and the like, we will confine this discussion of fe- sume that similar age differences exist in the general
male addiction to psychoactive substances. These in- population.
clude abuse of or dependence on nicotine, banned More female drinking is associated with higher
or illegal drugs, psychoactive medications, and alco- educational achievement (Celantano & McQueen,
hol. The gender ratio of male abusers to female abus- 1984), and more female drinking is associated with
ers varies with the substance: Men are abusers of al- nonmarried status (i.e., being single, divorced, sepa-
cohol and illegal drugs in greater numbers than rated, or cohabiting) (Wilsnack & Wilsnack, 1991).
women, but women outnumber men in the fre- Both social drinking and heavy drinking by a woman
quency of misuse/abuse of prescribed psychoactive are associated with the drinking of her significant
medications. In nicotine use, the gender ratio is al- other (Wilsnack & Wilsnack, 1991). Epidemiological
most even. In addition to gender, there are patterns surveys have consistently found women of higher in-
of use and abuse that vary with age, education, mari- come more likely to be drinkers than women of
tal status, employment, race and ethnicity, and the lower income. Data on employment have shown am-
alcohol/drug usage of spouse or significant other. biguous results (Parker & Harford, 1992; Wilsnack &
In a study of age differences among problem- Wilsnack, 1992); some studies show women at home
drinking women in treatment (Gomberg, 1989b), more likely to drink, and other studies show women
younger alcoholic women reported use of stimulants, in the workplace more likely to drink.
sedatives, marijuana, cocaine and heroin signifi- If we look at the percentage of drinkers by racial/

527
528 ISSUES IN SPECIFIC POPULATIONS

ethnic group, the largest percentage occurs among prefer one while using other substances, primarily al-
white women, followed by Native American, His- cohol, at the same time (Lex, 1993).
panic, African-American, and Asian-American wom- As with alcohol, it is generally noted that genetic,
en in that order; for heavy drinking, the rank order is family-related factors and environmental influences
most by white women and less by black and Hispanic are the base for the development of polysubstance
women (Wilson & Williams, 1989). Abstinence is abuse (Clayton, Voss, Robbins, & Skinner, 1986;
highest among black women, almost as high among Lex, 1993). Robbins (1989) examined gender differ-
Hispanic women, and quite a bit lower for white ences in consequences of illicit drug use: intrapsychic
women (68%, 66%, and 46%, respectively). Interest- problems, difficulties in social functioning and con-
ingly enough, heavy drinking occurs most frequently sequences of substance use episodes (e.g., blackouts,
among white, black, and Hispanic women in the age disputes with significant others). Robbins's findings
group 35-54. How to explain these differences and were that women showed more depression and dis-
similarities is not clear: We believe that the Hispan- trust, and that drug-abusing men reported more diffi-
ics in the United States bring their cultural attitudes culties in social functioning. Of great interest was the
about male and female behaviors with them, and un- lack of gender difference in belligerance associated
til they are assimilated, those attitudes influence with drug intake. As for comorbidity, comparison of
drinking patterns. Differences between black and male and female polydrug abusers showed a higher
white women may relate to the history of slavery, the rate for the polydrug abusers but did not differ by
composition of the family, perceived sex roles, and/ gender. Patterns of comorbidity did differ, however:
or the significance of religious participation. What- no gender differences for schizophrenia or affective
ever the reasons, Mexican-American women are disorders, but more female reports of bulimia, anxi-
more likely to be abstainers than Anglo women ety, and psychosexual disorders than male (Ross, Gla-
(Hoick, Warren, Smith, & Rochat, 1984), and black ser, & Stiasny, 1988).
women are more likely to be abstainers than white Nicotine has a more recent history for women
women (Herd, 1988). than for men. Nicotine has been used since the 16th
In a National Institute on Drug Abuse (NIDA) century, but women smoked little until World War
survey (1991), women between the ages of 18 and 34 I. The availability of cigarettes (rather than chewing
reported on their use of alcohol and/or drugs in the tobacco, snuff, etc.) and the relaxed standards en-
last month. More than half the sample reported alco- couraged female use of nicotine (first advertisement
hol use, but 13.4% of the 18- to 25-year-old women featuring a woman appeared in 1919). During World
and 11.2% of the 26- to 34-year-old women reported War II, when there was an increase in the number
use of some illicit drug during the last month. Ap- of women in the workplace, there was again an in-
proximately 10% of the women reported marijuana crease in the number of women who smoked.
use, and 1 % reported use of cocaine over the same Since the annual Surgeon General's reports warn-
time period. Past surveys have reported more men ing of the hazards of smoking, women's cigarette
than women using heroin, but the popularity of her- use —like men's—has dropped. The latest figures
oin picked up considerably during the 1990s. from the National Center for Health Statistics (1996)
When alcoholic women studied in treatment show that for all women, 18 and over, 22.7% were
were queried about experience with drugs other than smokers. For the whole group, the numbers were
alcohol ("Have you ever used . . . ?"), 29% report- 23.7% for white women and 19.8% for black women.
ed experience with cocaine and 8% with heroin Even more striking is the contrast between white and
(Gomberg, 1989b). A control group of age-matched black women in the 18-24 age grouping: 26.8% of
nonalcoholic women reported 16% had experienced white female adolescents and young adults smoked
use of cocaine and 1.5% of heroin (Gomberg, 1989b). while only 8.2% of black female adolescents and
The ages of the women surveyed were 20-50. Inter- young adults were smokers.
estingly enough, while 53% of alcoholic women had The consequences of smoking are well known
used marijuana, 50% of the control group reported (Pomerleau, Berman, Gritz, Marks, & Goeters, 1994).
similar use. Note that use and abuse are synonymous Association of nicotine and cancer, coronary disease,
with these drugs: They are all illegal. Typical behav- stroke, and pulmonary disease are known, and in
ior of those women using illicit substances was to 1986, female deaths from lung cancer surpassed the
 WOMEN 529

number of deaths from breast cancer. Smokers are noted—at least for alcohol abuse—that where de-
more likely to use other drugs: more caffeine, more pression and alcoholism occur together (in 66% of
alcohol, more prescription drugs. There are great dif- women studied), depression precedes drinking prob-
ferences in the proportion of alcoholic women who lems (Helzer, Burnam, & McEvoy, 1991). Perhaps,
are currently heavy smokers and matched control for women, alcohol/drugs are an attempt at self-med-
women of the same age and social class (Gomberg, ication.
1989a); interestingly enough, younger women, in
their 20s, have the largest proportion of smokers
Adolescents
compared to older alcohol women. The proportions
are reversed for the control women. The concern Risk factors for adolescent girls include peer use of
about the relationship between alcohol and tobacco alcohol/drugs, behavior problems and school prob-
has produced a research monograph from the Na- lems, feelings of alienation, and expectancies about
tional Institute on Alcohol Abuse and Alcoholism the effects of alcohol and/or drugs. High-risk adoles-
(Fertig & Allen, 1995). cent girls report early experience with alcohol and
marijuana, positive family history and a dysfunc-
tional early family environment, many school ab-
RISK FACTORS sences, and low educational aspiration. Frequently,
there is a history of antisocial or aggressive behavior,
Those events and experiences that put a woman at including vandalism, shoplifting, and tantrums
risk have been best studied in the development of (Gomberg, 1994). Schulenberg and his colleagues
alcohol abuse, but it is likely that addictive behaviors (1993) found that peer influence plays a more signifi-
in general follow approximately the same course of cant role with girls than with boys in the misuse of
risk. Although it is useful to distinguish risk factors at alcohol. Younger adolescent females used alcohol
different stages of the life span, one must first review because of a combination of individual vulnerability
those risk factors that are present throughout the life and exposure to alcohol through their peer group.
span. These include positive family history; heavy al- Cigarette use dropped among female adolescents
cohol/drug use by peers, by spouse, or by any signifi- from the late 1970s, leveled off in the 1980s, and
cant others in the woman's life; stress, distress, and began rising again in the 1990s; this was true for
coping mechanisms; impulse control; and depression 8th-, 10th-, and 12th-graders surveyed in the Na-
(Gomberg, 1994). The important role of genetics has tional High School Senior survey sponsored by the
been described frequently (e.g., Kendler, Neale, National Institute of Drug Abuse (University of
Heath, Kessler, & Eaves, 1994). The role of family, Michigan News and Information Service, 1995). The
friends, peer groups, and the community in women's problem is that in addition to alcohol, tobacco is an-
alcohol/drug use has been reported for all age groups other "gateway drug" for adolescents, its use appear-
(Gomberg, 1995b; Hesselbrock et al., 1984; Schulen- ing before the illicit drugs are used (Kandel & Lo-
berg, Dielman, & Leech, 1993), and in countries gan, 1984).
other than the United States (Hammer & Vaglum,
1989). The important role not so much of early un-
Young Adult Women
happy life events, but of response to such events (i.e.,
distress), has been emphasized, and the role of cop- Shifts in role behaviors occur as women get into the
ing mechanisms and their adequacy/inadequacy has workplace, get married, and have children. High risk
also been emphasized (Gomberg, 1989a). Impulse for problem drinking in the workplace is associated
control may be more heavily a risk factor among with nontraditional occupations, low-status jobs, part-
younger women, but it apparently is tied up with risk time employment, recent layoff, or unemployment
taking that remains a significant antecedent variable (Wilsnack & Wilsnack, 1991). Women who are sin-
throughout the woman's life. And finally, the associa- gle, divorced, separated, or cohabiting are more like-
tion between alcohol/drug abuse and depression ly to be using alcohol/drugs than married women.
among women is reported very frequently in the lit- Heavy drinking and/or drug use by a significant other
erature; while such depression may well be a result is a risk factor. Those women who drink and/or use
of the drug/alcohol abuse and its consequences, it is drugs are more likely to be users of nicotine, and
530 ISSUES IN SPECIFIC POPULATIONS

the combination of alcohol/drugs/nicotine raises the men, more frequent report of a heavy-drinking spouse
question of health consequences that may produce, by the women, more depression, and more depen-
in turn, more attempt at self-medication. Some of dence on prescribed psychoactive drugs. Research re-
the health consequences may be gynecological: It is ports have been few, but it would be of interest to
not clear which comes first, but problem-drinking study risk factors for older women (e.g., widowhood,
women show a significant relationship between their retirement, or the influence of moving to a retire-
drinking (Gomberg, 1986), on the one hand, and ment community) (Alexander & Duff, 1988).
miscarriage and hysterectomy, on the other.
Trauma as a Risk Factor
Middle Age
In 1957, a review of literature about female alcohol-
In American culture, middle age is considered loss ism described "precipitating circumstances . . . some
by most women: loss of sexual attractiveness, loss of concrete situation" as more likely to be associated
children as they leave home. Historically, the average with female alcoholism than with male (Lisansky,
age at which women showed up at alcoholism treat- 1957). The concept of such precipitants was chal-
ment facilities used to be between 40 and 45 (it is lenged by Allan and Cooke (1985), who argued that
now closer to the mid-30s). Risk factors in this age "heavy drinking produced an increased frequency of
group consist of difficulty in adaptation to new roles, stressful life events rather than vice versa" (p. 147).
"empty-nest" status, heavy spousal drinking, depres- They argued further that citing such stressful precipi-
sion, and heavy use of prescribed psychoactive medi- tants was likely to "elicit sympathy" (p. 147). In the
cations (Gomberg, 1994; Moos, Finney, & Cronkite, current scene, the trauma or stressful event often
1990). It should be noted, however, that though cited is physical and/or sexual abuse.
women may present themselves for treatment in their There are problems with definition: Incest is al-
40s, one study of alcoholic women in treatment in most always child or adolescent abuse, whereas rape
their 40s found the mean age at onset to be 36.5 may occur at any life stage. Violence, too, may occur
(Gomberg, 1986). For reasons that are not clear, the early in life or later; that is, it can be parental vio-
30s seem to be an at-risk decade; Fillmore (1987) lence, spousal violence, or assault by a stranger. Stud-
noted that the gender ratio of risk for heavy drinking ies consistently reveal a higher rate of self-reports of
and alcohol problems, although always larger for a history of sexual assault among alcoholic women
males, converges in the 30s. than among nonalcoholic comparison samples (Stew-
art, 1996). Younger alcoholic women who do more
drinking in public are significantly more likely to re-
Old Age
port an assault than the older women alcoholics. Fe-
Among older women, it is likely that the biggest drug male drinking and intoxication are more socially dis-
problem in terms of numbers is misuse/abuse of pre- approved than similar behavior by men (George,
scribed psychoactive drugs (Glantz & Backenheimer, Gournic, & McAfee, 1988; LeMasters, 1975; Ma-
1988). There are relatively few older women who rolla & Scully, 1979).
abuse banned substances, but it should be noted that The question remains: Is childhood sexual abuse
older men and women approach parity in their use a causal factor in the development of female alcohol
of nicotine. Although the numbers are relatively problems? There is a fair amount of evidence which
small compared to other age groups, there are older says yes (Wilsnack & Wilsnack, 1993); women prob-
women problem drinkers. Although many are unde- lem drinkers cite early-life abuse more frequently than
tected and others are viewed as responding to loss non-problem-drinking women. However, it should be
and widowhood with alcohol, there is evidence that noted that early sexual abuse is also associated with
there has been heavy drinking, frequently with the depression among problem drinkers and that suicidal
spouse, before widowhood (Hubbard, Santos, & San- thoughts, use of drugs other than alcohol, and vio-
tos, 1979). Still, a recent report of elderly alcoholic lent relationships characterize the lives of both prob-
women in treatment (Gomberg, 1995b) shows signif- lem drinkers and non-problem-drinkers with a his-
icantly later onset for older women than for older tory of early abuse (Wilsnack & Wilsnack, 1993).
 WOMEN 531

SUBSTANCE ABUSE PATTERNS, Most frequent comorbid diagnoses were depression

COURSE, AND CONSEQUENCES for women and antisocial personality for men. Wom-
en reported "a significantly lower level of overall so-
Heroin cial adjustment" (p. 125) than did men. Griffin et al.
noted that women reported significantly less guilt as
Interviews were conducted with 170 heroin-addicted an effect of cocaine than did men, and they con-
women, 175 nonaddicted women, and 202 heroin- cluded that the "guilt-reducing properties of co-
addicted men (Binion, 1982; Colten, 1982; Tucker, caine" (p. 125) may have made the drug particularly
1982). Binion (1982) compared men and women ad- reinforcing for women.
dicts in family dynamics and concluded that "drug
use for women was more closely related to interper-
sonal affiliative issues," (p. 43). Poor self-image and Marijuana
unhappy family situations are likely motivaters for Lex (1994) reviewed gender comparisons in moder-
women's drug use, but both genders are similar in ate or heavy use of marijuana and stated that "there
preference for mother rather than father and their may be distinct patterns of marijuana use for men
"need to work through early family relationships" and women, e.g., women's smoking patterns are like-
(p. 43). ly to reflect social influences such as weekday vs.
Colten (1982) compared mothering attitudes, ex- weekend smoking. Significant differences in alcohol
periences, and self-perceptions of the addicted and use distinguished heavy from light marijuana smok-
nonaddicted women and found few differences; ad- ers" (Lex, Griffin, Mello, & Mendelson, 1986).
dicted women expressed more concern about their Heavy marijuana smokers were somewhat younger
adequacy as mothers. Tucker (1982) compared male than light smokers and significantly younger at onset.
and female addicts and noted a pattern unique to the Job instability was associated with marijuana use by
women: The absence of social support is associated both men and women, and interpersonal factors,
with the use of "non-social, potentially dysfunctional such as social relationships, appeared to be more sig-
coping strategies" (p. 17). nificant for female smokers (Kandel, 1984).
Kosten, Rounsaville, and Kleber (1985) inter-
viewed 522 opiate addicts in treatment; a quarter of
the subjects were women. The women reported ALCOHOL ABUSE: PATTERNS,
more positive family history than the men, more co- COURSE, CONSEQUENCES
morbid depression and anxiety disorders, and more
medical, family, and social consequences. A recent Male/female comparisons of alcohol abusers show
ethnograph of women addicts in Scotland (Taylor, the following:
1993) indicates marked differences in drug experi- 1. Family history. Women report more positive
ence (e.g., women raise drug money by shoplifting, family history of alcohol abuse/dependence than do
fraud, or prostitution). Those women with children men. This is apparently true for both alcoholic (Bis-
deal with the constant threat of losing the children sell & Haberman, 1984) and general populations
to social services. (Schoenborn, 1991). However, although there is ap-
parently an association between positive family his-
tory and earlier onset among men, this association
Cocaine
did not seem to be true for alcoholic women (Gom-
Griffin, Weiss, Mirin, and Lane (1989) compared 95 berg, 1991).
male and 34 female cocaine abusers. The women 2. Onset. Women have their first drink at a later
reported fewer years of cocaine use (3.9 and 5.4 age than do men (Schuckit, Anthenelli, Bucholz,
years' duration), and although both genders' mean Hesselbrock, & Tipp, 1995). Problem-drinking men
age at hospitalization was in the 20s, the women start abusing alcohol earlier (Lisansky, 1957; Ross,
were significantly younger. Fewer women than men 1989). Since women show up in treatment with
cocaine abusers were married, but more women shorter duration and apparently telescoped develop-
lived with a drug-dependent partner than did men. ment of alcoholic pathology, they seek treatment ear-
532 ISSUES IN SPECIFIC POPULATIONS

Her in the course of their alcoholism than do men 8. Comorbidity patterns. Psychiatric symptoms
(Schuckit et al., 1995). that indicate dual diagnoses differ for men and wom-
3. Spouse drinking. The etiological significance en. Males who become alcoholic are more likely to
of spousal heavy/problem drinking as related to fe- be diagnosed as antisocial personality; women report
male problem drinking has been reported by many an association of alcoholism and depressive disorder,
investigators in the United States (Gomberg, 1994) estimates being that a quarter to a third of women
and in other countries. alcoholics show depression before the onset of alco-
4. Depression. Depression is linked more with fe- holism. While male alcoholics often present with de-
male problem drinking than with male; it is esti- pression, alcoholism seems to precede depression;
mated that about a third of problem-drinking women among women alcoholics, depression is more fre-
experienced depression antecedent to the heavy quently antecedent (Helzer & Prysbeck, 1988). In
drinking (Tumbull, 1988). the question of gender comparison in the prevalence
5. Quantity and contexts. Reports disagree. There of dual diagnoses, women alcoholics have a second
are reports that women drink smaller quantities (Bro- diagnosis significantly more frequently than males.
met & Moos, 1976; Orford & Keddie, 1985). Orford Helzer and Pryzbeck (1988), analyzing data from the
and Keddie (1985) added, "The size of the difference NIMH Epidemiology Catchment Area Study, found
was such that differences in body weight would not 44% of male alcoholics and 65% of female alcoholics
account for the difference" (p. 275). On the other to have secondary diagnoses.
hand, York and Welte (1994) reported that the 9. Consequences: Medical. There is general agree-
amount of alcohol consumed on drinking days, ex- ment that women are "more vulnerable than men to
pressed "as a function of total body water" (p. 745) the pathophysiological consequences of drinking
was very similar for men and women alcoholics. (NIAAA, 1992). Schenker (1997) recently put the
There is no ambiguity about the contexts of drinking: question: "Medical consequences of alcohol abuse:
Women drink at home, either alone or with a com- Is gender a factor?" He concluded that based on cur-
panion, more than do men, who are more likely to rent data, women are more at risk medically when
drink in public places (Gomberg, 1986). alcohol is abused than men. Women alcoholics are
6. Use of drugs other than alcohol. Women are at greater mortality risk than men; a greater percent-
more likely to use prescribed psychoactive drugs, age of female alcoholics develop alcohol-related con-
such as minor tranquilizers and sedatives, both in the sequences, such as cirrhosis, hemorrhagic stroke, or
general population and among alcoholic women brain damage (NIAAA, 1992). Hepatic disorder oc-
compared to alcoholic men (Ross, 1989). Data from curs more frequently among women and after a
national surveys suggest that males are more likely to shorter duration of heavy drinking in spite of lesser
be users of illicit substances, and this difference ap- consumption. Although lifetime intake is lower than
pears to be true of alcoholic men and women as well. that of men, female alcoholics are apparently as vul-
There are age differences in use of drugs other than nerable to cardiomyopathy and myopathy as male al-
alcohol for both sexes, but they are alike in being coholics (Urbano-Marquez et al., 1995).
multidrug abusers. Younger problem drinkers are Gynecological-reproductive disorders among wom-
more likely to use "street drugs." en alcohol abusers should be noted. Menstrual diffi-
7. Marital status. There is more marital disrup- culties and ovarian pathology have been observed,
tion among women problem drinkers than among and a comparison of 301 women alcoholics with 137
men (Lisansky, 1957; Ross, 1989). Interestingly matched controls showed the alcoholic women re-
enough, if widowhood is considered along with the porting significantly more history of miscarriage and
marital statuses of never-married, divorced, or sepa- hysterectomy (Gomberg, 1986). It is not a medical
rated, these spouseless categories describe women al- consequence which impinges on the woman drinker
coholics more than male alcoholics in all age groups per se, but fetal alcohol effects and the fetal alcohol
studied (Gomberg, 1995b). Marriage, however, does syndrome may occur with women who drink heavily
appear to lessen the effect of "an inherited liability through their pregnancies.
for drinking" (National Institute on Alcohol Abuse Both male and female alcohol abusers are at
and Alcoholism [NIAAA], 1990). some risk for contracting AIDS. The association of
 WOMEN 533

alcohol use with unsafe sexual activity has been re- Since men much more frequently drink in public
ported by Leigh (1990) and other investigators. Al- places than do women, they are also more likely to
though the major transmission category for the HIV encounter legal difficulties, and they are more likely
virus for women in the general population is injec- to be cited for driving under the influence; although
tion of drugs (Windle, Carlisle-Frank, Azizy, & Win- the trend is toward more drinking-and-driving conse-
die, 1994), women alcoholics need to be aware of quences for women, women still manifest this conse-
the risk involved in alcohol use and unsafe sex. quence less than do men (Wells-Parker, Popkin, &
10. Consequences: Familial and social. Women Ashley, 1996).
problem drinkers show a higher proportion of marital 12. Eating disorders. The relationship between
disruption than reported by male problem drinkers. eating disorders and addictive behaviors has been re-
Whether women's alcohol problems develop before viewed (e.g., Krahn, 1993; Wilson, 1993). A report of
or after marital disruption is a question: Drinking eating pathology among women with alcoholism
probably develops as a problem for some women as and/or anxiety disorders (Sinha et al., 1996) shows
a response to marital disruption and for some as an that both alcoholic women and women with anxiety
antecedent. Wilsnack and Wilsnack (1991) found the disorders have significantly higher scores on an
relationship between divorce/separation and women's eating disorders examination, and women with both
drinking weaker than it was a generation ago. Pres- alcoholism and anxiety disorders have higher rates of
sure from a spouse to enter treatment is different for bulimia.
the genders; one report cites 28% of male patients
enter treatment at the spouse's suggestion compared
with 6% of the female patients (Beckman & Amaro, ALCOHOL ABUSE: ASSESSMENT,
1986). The same report shows women entering treat- TREATMENT, PROGNOSIS
ment with a higher proportion of suggestion and
pressure from a parent or from the woman's children Assessment
than is true among men. At the same time, it is be-
Dissatisfaction has frequently been expressed with
lieved that women tend to drop out of treatment
the most widely used screening instruments as mea-
more readily because of family pressure.
surements of female alcoholism; the (MAST) and
An alcoholic mother's or father's relationship with
the (CAGE) contain items which are far less relevant
children is an open question. Traditionally, it was
to female experience with alcohol than male. One
assumed that an alcoholic mother was more destruc-
report of an attempt to identify unique measures of
tive of children's mental health, but there is some
women's drinking problems was summarized by
question about that; a review of relevant studies show
Saltz and Ames (1996): First, a list of "novel" indica-
the evidence to be ambiguous (Williams & Klerman,
tors was incorporated into a general population in-
1984). Clinical observation indicate that women al-
strument, and then the instrument was tested.
coholics are more concerned about the effect of their
drinking on the children than are male alcoholics.
Results suggest that indicators of "high capacity
There is some limited evidence of greater guilt on
for alcohol," "seeking out a 'wet' environment,"
this issue among women problem drinkers (Gom- and "planning opportunities to drink" are promis-
berg, 1989a), and there is more risk of social service ing for both women and men, with more quali-
intervention in families where the mother is a heavy fied support for less "frequent illness" for women.
drinker than for families where the heavy drinker is (Saltz & Ames, 1996, p. 1041)
the father.
11. Consequences: Occupational and legal. Since A report about gender differences in the Self-
men are more likely to be in the workplace than Administered Alcoholism Screening Test (Davis &
women, there may be greater consequences of alco- Morse, 1987) showed women more likely to report
holism for men in this area. Interestingly enough, "loss of control," to report alcohol problems in their
Beckman and Amaro (1986) reported that twice as families (gender differences in spousal heavy drink-
high a percentage of women alcoholic patients were ing?), to experience emotional consequences of their
referred to treatment by their employer as men. drinking, and to have sought help for their problems.
534 ISSUES IN SPECIFIC POPULATIONS

A comparison of "symptom profiles" among alcohol- (TWEAK; Russell, 1993)-they concluded that brief
ic men and women (Turnbull, Magruder-Habib, & questionnaires are easiest to administer, least expen-
Landerman, 1990) produced three significant sex dif- sive, and most effective. They also concluded that
ferences: Drinking a fifth or its equivalent in 1 day gender differences in alcoholism justify the use of
was more prevalent among men, while "inability to different gender-relevant screening methods.
function without drinking" and "physical fights"
were more prevalent among women. McCrady and
Patterns of Treatment Utilization
Raytek (1993) reported that "asking detailed ques-
tions about women's alcohol intake and asking these What of women's use of treatment resources and
questions by beverage type" (p. 325) is a better their availability? Data have indicated that women
screening approach to identifying female problem alcohol abusers are likely to seek help earlier than
drinkers than the frequently used MAST or CAGE. men in the course of the disorder (i.e., to come for
They also found laboratory tests (e.g., carbohydrate- help after a shorter duration of problem drinking)
deficient use transferin) useful in identification, al- (Dawson, 1996; Moos et al., 1990; Piazza, Vrbka, &
though questions have been raised about their value Yeager, 1989; Weisner & Schmidt, 1992). Schuckit
other than using them as adjuncts to clinical inter- and his colleagues (1995) examined clinical data for
views (Russell, Chan, & Mudar, 1997): Their value the sequence of alcohol-related behaviors in men
is limited because "they tend to develop after years and women. Dawson (1996) analyzed data from the
of abuse making them relatively insensitive to early 1992 National Longitudinal Alcohol Epidemiologi-
problem drinking" (Russell et al., 1997, p. 436). cal Survey. Both studies report male alcohol abusers
Braiker (1994) discussed some of the issues and presenting for treatment later than women.
methods in assessment, which is the initial stage of A clinical study of admissions to a variety of men-
treatment. Assessment usually begins with a detailed tal health facilities including alcoholism treatment
inquiry about consumption, including the contexts facilities (Weisner & Schmidt, 1992) showed that
of drinking and the consequences. A record of con- women alcohol abusers were more likely than males
sumption for outpatients (i.e., self-monitoring) is rec- to use "non-alcohol-specific health care settings, par-
ommended. Formal assessment instruments and ticularly mental health services" (p. 1872). It is rele-
questionnaires may be used, but at the same time, vant to note that women generally use medical ser-
the woman's own view of her drinking problem and vices more than men do; exceptions are males and
the role alcohol plays for her should be queried. females younger than 15 and the elderly, 75 and
Such an assessment might cover more than a single older, when the average number of physician visits
session and depends a good deal on the therapist's approached parity (Gomberg, 1995a).
sensitivity and rapport with the client. It is important Barriers to initiating treatment contact may come
to ask about significant others' drinking, about the from a number of sources. Some are external, for
woman's past attempts at treatment, and about other example, pressure on the woman to fill traditional
self-destructive behaviors. sex role expectations and take time from her respon-
It is useful to find out about the client's past work sibilities as wife and mother. Another external barrier
history and her financial status. It is absolutely neces- is the stigma attached to female alcoholism. Barriers
sary that there be a physical examination and that also include depression and guilt (i.e., internalized
the health status of the client be dealt with if there states); this is particularly true of women's feeling of
are problems. responsibility for child care. Women may also per-
Russell and her colleagues (1997) reviewed the ceive more negative consequences in treatment, per-
work on gender and screening, discussing the issue haps loss of a job or disrupted family relationships.
of "gold standards" and the development of the Diag- There are barriers within the treatment system: ste-
nostic Interview Schedule for epidemiological work. reotypes about women problem drinkers, the belief
After a review of the MAST, CAGE, the Alcohol Use in a poorer prognosis for women, and the like. It is
Disorders Identification Test (AUDIT; Saunders et useful to know that women tend to choose to enter
al., 1993), and two screening instruments designed treatment in services which include services for chil-
for detection to periconceptual and pregnancy risk dren and in treatment facilities which provide after-
drinking-the (T-ACE; Sokol et al., 1989) and the care.
 WOMEN 535

women will do better in programs which include

Presenting Problems
child care, assessment of comorbid states and treat-
When women problem drinkers arrive in treatment, ment, support of and work with family members, and
they very frequently present a clinical picture of de- training in coping strategies.
pression. In fact, a study of alcoholic women in treat- Do women do better in gender-specific treatment
ment (Gomberg, 1986) indicated that mounting, un- facilities? In spite of some evidence which supports
bearable depression was the major reason most of such facilities, evidence is not clear enough for pol-
them came for help. Low self-esteem is a major is- icy recommendation.
sue, and guilt and shame—particularly surrounding McCrady and Raytek (1993) discussed the hetero-
the maternal role—are great (Gomberg, 1988). geneity of women alcohol abusers in terms of age,
There is also a great load of anger and resentment, socioeconomic status, ethnic and racial diversity, sex-
often directed toward spouse, family members, and ual orientation, health status, and marital status. The
others who women feel have failed them. Because authors described a clinical model for treatment
they feel guilty and angry at the same time, these which includes a range of services (e.g., inpatient
ambivalent attitudes are very likely to be expressed and residential facilities, emergency counseling, af-
early in treatment. It has been hypothesized by some tercare, and community referral sources). Some au-
clinicians that women arrive at treatment facilities in thors have emphasized the primary need for child
poorer physical shape than men.Whether this proves care services as part of outpatient treatment and the
to be a valid observation or not, the questions of use of vocational and educational agencies, domestic
physical status and appearance need early attention. violence centers, and self-help groups such as Alco-
holics Anonymous. McCrady and Raytek (1993)
raised the question of treatment goals, and they dis-
Treatment Modalities
cussed the reported preference—when alternatives
Detoxification and the relief of physical distress are are offered—of male problem drinkers to choose
the early steps. A treatment plan may then be evalu- continued but controlled drinking and of women to
ated with other clinic workers, and such a plan may prefer abstinence as the goal.
include (a) pharmacological treatment (there is dis- There have been several comprehensive reviews
agreement among schools of therapy as to whether of research and clinical findings about alcohol-abus-
drugs such as antidepressants or benzodiazepines ing women in treatment (Annis & Liban, 1980;
should be used); (b) evaluation of the woman's life Braiker, 1984; McCrady & Raytek, 1993; Vannicelli,
situation, including assets and liabilities; (c) treat- 1984). All of these reviews have emphasized the lim-
ment recommended (counseling, psychotherapy, ited study of women and the extent to which past
cognitive behavior therapies, etc.); (d) choices and research has omitted women from subject pools; this
availability of group work; (e) didactics, including pa- has improved somewhat in the last decade, but there
rental effectiveness training and training in coping is still relatively little information about the woman
skills; (f) possible referrals to self-help organizations, problem drinker in treatment. Braiker (1984) exam-
physical rehabilitation, or vocational training; (g) the ined the evidence relating to the view of female
question of family therapy and its feasibility, possible problem drinkers as "more psychologically dis-
advantages, and disadvantages; and (h) relapse pre- turbed" than male problem drinkers: The evidence
vention. includes more psychiatric treatment reported by
The genders may vary in response to different women and more frequent reports of depression and
treatment modalities. Early clinical papers suggested anxiety. There are reports of "greater symptom sever-
that women did better in individual therapy and men ity" (Weisner & Schmidt, 1992) and of more comor-
did better in group therapy; there is, however, little bidity among women (Helzer & Przbeck, 1988). All
empirical support for this view (Vannicelli, 1984). reviews of work relating to women alcoholics stress
Related to this distinction is the evidence that the heterogeneity of the women: Groups of women
women problem drinkers are more successful in in treatment or in surveys include all ages, ethnic
medically oriented programs and men in peer-group- groups, socioeconomic classes, marital statuses, and
oriented programs (Moos et al., 1990). In the light of so on. Braiker (1984) examined the various classifica-
available information, it is a good assumption that tions or subtypes offered; these include primary ver-
536 ISSUES IN SPECIFIC POPULATIONS

sus secondary alcoholism (Schuckit, Pitts, Reich, prognosis, (b) the course and quality of recovery dif-
King, & Winokur, 1969); abuse of multiple sub- fers by gender, (c) women should be treated by
stances versus abuse of alcohol alone; age at onset; women therapists, and (d) woman-specific treatment
socioeconomic class; ethnicity; and marital status. facilities or modalities are essential for female treat-
ment.

Special Considerations in Treatment

The primary emphases which have emerged from ALCOHOL ABUSE: PREVENTION
clinical and research literature of female alcoholics
in treatment are attention to comorbid and physical Primary prevention (i.e., heading off any manifesta-
disease aspects of female alcoholism and the need tions of problem drinking) should be directed toward
for child care. One must also consider the fact that high-risk groups. Among adolescents, these include
women in treatment situations are worse off then children in alcoholic families and high school stu-
men financially: As heads of single-parent families dents who are not interested in school and who man-
and as individuals relatively untrained for good sala- ifest early sexual precocity and marijuana use.
ried jobs, this is part of the reality of female alco- Among adult women, these include young single
holism. women who are unemployed or part-time employed,
blue-collar women in high-stress occupations, de-
pressed divorced women with young children, and
Prognosis and Outcome
women in the military; those women whose signifi-
There are few studies of predictors of treatment out- cant other drinks heavily are also at risk. Prevention
come that include both men and women subjects. campaigns are also directed toward pregnant women
Several studies with a female sample alone report in- and toward those who manifest early eating disorder
dicators of poor outcome to be marital problems, dys- or phobic anxiety disorder.
functional relationships, isolation, and multiple life Secondary prevention involves early intervention
problems. Cronkite and Moos (1984) found unmar- with those who have early indications of alcohol
ried women doing better in treatment, while married abuse. Settings which are useful in identifying such
men did better. Rounsaville, Dolinsky, Babor, and abusers are (a) the employment setting, (b) the medi-
Meyer (1987) reported that depressed alcoholic cal setting, and (c) the legal system (McCrady &
women did better in treatment than those with no Raytek, 1993). Referrals in employment settings
comorbid condition, while men with depression did seem to relate to supervisor education, attitudes, and
worse than those with no comorbidity. And predict- training. The medical setting is apparently most use-
ably, patients with diagnoses of antisocial personality ful when the patient is asked in detail about her
and/or other drug abuse did relatively poorly in treat- drinking per se (e.g., amount, type of beverage, con-
ment. texts), rather than when a formal screening instru-
Although it was stated in earlier literature about ment is used. There are few data about women re-
female alcoholics that they had a poorer prognosis ferred through the legal system; in fact, it is primarily
than male alcoholics, several reviews of outcome lit- men who are referred, and women are more likely to
erature do not show a strong empirical base for such come with a "personal referral" (i.e., self, family,
a contention. Annis and Liban's (1980) review re- friends, an employer, or a clergyman).
ported 5 studies with significantly greater improve- Tertiary prevention is treatment, and one of the
ment among women patients, 3 studies with signifi- major sources of referral is through medical services;
cantly greater improvement for males in treatment, it should be noted, however, that women are likely
and 15 studies with no gender difference in out- to present with complaints of insomnia, gastritis, de-
come. The conclusion of these reviewers was that pression, and the like, and that heavy drinking must
women admitted to the treatment programs reviewed be inferred.
did not show poorer response to treatment. Vannicel- Why special prevention approaches for women?
li's (1984) review of treatment outcome studies con- Ferrence (1984) suggested that sex differences in
cluded that there was little empirical evidence to physiology and in social roles are relevant. A review
substantiate these views: (a) Women have poorer of prevention of alcohol/drug abuse for women (Nir-
 WOMEN 537

enberg & Gomberg, 1993) emphasized the heteroge- use and the course and consequences of abusive use
neity within the population of women (e.g., differ- of heroin, cocaine, and marijuana were reviewed
ences in age, health status, social class, ethnic briefly; there is a paucity of information about these
grouping) and suggested that a single message di- addictions among women. The patterns, course, and
rected to all women is not particularly effective. The consequences of alcohol use were reviewed, many of
review points to the difference between individual- the features probably being applicable to all female
oriented prevention strategies and community-ori- drug abuse. The consequences of abusive use of al-
ented ones. The former includes campaigns to mod- cohol are divided into medical consequences, famil-
ify and change individual behavior; the latter in- ial and social consequences, and occupational and
volves attempts to modify the law, the availability of legal consequences. Treatment, treatment outcome,
alcohol/drugs, and so on. (These approaches are dis- and prognosis were examined for women alcohol
cussed in greater detail in chapters 30 and 31 of this abusers. There is currently general agreement that
volume.) Nirenberg and Gomberg (1993) also em- neither gender has superior prognosis in treatment.
phasized the need for specific messages directed to- Prevention of alcohol/drug abuse was discussed, and
ward specific target groups (e.g., "Good friends don't some aspects of prevention strategies were outlined.
let their friends drive drunk"). Nonspecific messages
are those directed toward improving mental health
or lowering stress level. Multiple strategies, both indi- A C K N O W L E D G M E N T This review was supported by
vidual and community, are more effective than any National Institute on Alcohol Abuse and Alcoholism
strategy alone. Further research on the pre-sub- Grant P50 AA 07378.
stance-abusing behavior of women is needed; when
more is known about the early predictor behaviors, Key References
prevention strategies will be more effective.
Gomberg, E. S. L. (1993b). Women and alcohol: Use
and abuse. Journal of Nervous and Mental Disease,
181(4), 211-219.
AFTERTHOUGHTS Gomberg, E. S. L. (1994). Risk factors for drinking over
a woman's life span. Alcohol Health and Research
It was once believed that women patients had poorer World, 18(3), 220-227.
prognosis than men. Although there are signs of Gomberg, E. L. S., & Nirenberg, T. D. (Eds.). (1993).
greater severity (e.g., more comorbidity, more medi- Women and substance abuse. Norwood, NJ: Ablex.
cal consequences, more depression, more use of pre-
scribed psychoactive drugs), women seem to do as References
well as and, in some settings, even better than men
Alexander, ¥., & Duff, R. W. (1988). Drinking in retire-
in treatment. This occurs in spite of difficulties in
ment communities. Generations, 12, 58-61.
getting into treatment and pressures to get out of Allan, C. A., & Cooke, D. J. (1985). Stressful life events
treatment. Men and women are constituted differ- and alcohol misuse in women: A critical review.
ently, and there are strengths in those women who Journal of Studies on Alcohol, 46, 147-152.
do recover that need to be looked for and developed Annis, H. M., & Liban, C. B. (1980). Alcoholism in
in those who do not have these strengths. women: Treatment modalities and outcomes. In O.
Kalent (Ed.), Research advances in alcohol and drug
problems: Vol. 5. Alcohol and drug problems in
SUMMARY women (pp. 385-422). New York: Plenum.
Beckman, L. }., & Amaro, H. (1986). Personal and so-
cial difficulties faced by women and male heroin us-
In addition to gender differences, there are patterns
ers. Journal of Studies on Alcohol, 47(2), 135-145.
of female use and abuse of alcohol and drugs that
Binion, V.}. (1982). Sex differences in socialization and
vary with age, marital status, education, employment family dynamics of female and men entering alco-
status, race, and ethnicity. Risk factors may be viewed holism treatment. Journal of Social Issues, 38(2),
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 29

Gay Men, Lesbians, and Bisexuals

Rodger L. Beatty
Michelle O. Geckle
Tames Huggins
/ \j\j

Carolyn Kapner
Karen Lewis
Dorothy J. Sandstrom

The goal of this chapter is to assist those individuals rent research on substance use to distinguish specific
who treat persons with substance abuse to better drinking patterns; therefore, no conclusions can be
comprehend the unique substance abuse issues and made, and bisexuals will not be discussed separately
needs within the lesbian and gay male communities. in this chapter.
Overall, practitioners who treat gays for substance Lesbians and gay men are a substantial and in-
abuse will be more effective if they comprehend (a) creasingly visible minority of the American popula-
how these communities are constituted and defined, tion (D'Augelli & Patterson, 1995). Gays may be
(b) the distinctive patterns and unique risk factors of "passing" as heterosexual, living as an integral part of
substance abuse within gay communities, and (c) treat- the larger culture and wanting to remain that way,
ment options and resources for lesbians and gay men. or immersed in a subculture with its own norms, mo-
As a whole, individuals oriented to members of res, and activities, which differ from those of the
the same sex are often referred to as homosexuals. larger culture. Each subdivision of the gay commu-
However, because the term homosexual is often con- nity has its own distinct culture with its own books,
sidered too clinical and focused solely on sexual be- magazines, newspapers, music, activities, interests,
havior, the term gay will be used to refer to both gay and meeting places. Additionally, within each sub-
men and lesbian women throughout this chapter, ex- culture, there are many smaller subdivisions. In
cept where specific reference is being made to les- other words, the terms lesbian and gay refer not to
bian women. The term gay reflects more fully the unified, sharply definable communities, but to loose
social, cultural, and affective dimensions of this sub- aggregates of people who are diverse in character,
culture. The term bisexual has not been adequately values, and attitudes. Members of some of these sub-
defined nor sufficiently utilized in previous or cur- cultures may never intermix, while others may work

542
 GAY MEN, LESBIANS, AND BISEXUALS 543

together on common social and political goals and/ Golden (1987) described how some gay women
or may share certain social activities. perceive choice as an important element in their sex-
ual orientations. Gay men, on the other hand, typi-
cally perceive their sexual orientation as a given, a
LESBIANS AND GAY IDENTITY central aspect of themselves, and feel that choice has
DEVELOPMENT AND EXPRESSION little to do with it. Lesbians appear to perceive af-
fectional orientation and relationship dynamics as
According to Cabaj (1989), three characteristics dis- central to self-definition, while gay men appear to
tinguish sexual minorities from everyone else: (a) view sexual behavior and sexual fantasy as central. It
having a sexual orientation that leads to the desire to may even be that the nature of sexual orientation is
have affectional, sexual, sexual fantasy, and/or social different for men and women.
needs met more often by a same-sex partner than an Substance abuse treatment issues become com-
opposite-sex partner; (b) needing to negotiate a pro- plicated when alcohol and/or drugs are used by gay
cess of self-identity and self-recognition as a gay man clients to conceal inner conflict related to issues sur-
or woman who is different from the majority—a pro- rounding same-sex attraction, a not uncommon or
cess known as coming out; and (c) confronting wide- necessarily conscious process. Hence, presented here
spread, culturally sanctioned, and insidious dislike, is a basic, and widely utilized, model of gay identity
hatred, and/or fear of gays, homosexual sexual activ- development (Coleman, 1985) which conceives of
ity, and homosexual feelings, known as homophobia. the coming-out stages as (a) precoming out (aware-
To understand sexual minorities, it is important ness of a sense of difference which is not yet identi-
to distinguish between the terms gender identity and fied as same-sex attraction); (b) coming out (aware-
gender role, which are often erroneously used inter- ness and acceptance of same-sex attraction and
changeably, and to emphasize the difference be- disclosure of this to others); (c) exploration (experi-
tween sexual orientation and sexual behavior. Sexual mentation with same-sex social and sexual activity);
orientation refers to the desire for sex, love, and af- (d) first relationships (meeting needs for intimacy
fection from or with another person, including sex- and a more stable, committed relationship); and (e)
ual fantasies, whereas sexual behavior refers strictly to integration (of a gay sexual orientation into the larg-
sexual activities or conduct. For any individual, sex- er self-concept with an overall positive valence).
ual behavior may not always or consistently coincide Throughout this process, denial, ambivalence, per-
with the more primary and enduring sexual orienta- sonal and interpersonal conflicts, and resulting crises
tion. For example, a man could be homosexual in of identity may occur. Individual reactions vary and
orientation yet behave heterosexually. Gender iden- may shift between acting out and internalization.
tity is simply the sense of self as male or female. Gen- Thus, aggression, suicidal ideation, and substance
der role refers to the propensity to carry out "every- abuse are all major concerns in need of monitoring
day" behaviors which are viewed as appropriately throughout the coming-out process.
masculine or feminine by the mainstream/dominant In summary, to be identified as gay is more com-
culture. plex than is suggested by the typical dichotomies prev-
Gay men and lesbians have been described as alent in American thinking. It is a complex association
men or women whose primary sexual and affectional of sexual orientation, sexual behaviors, gender identity,
attractions are to men or women, respectively, and and gender role, as well as possible identification with
who have self-identified as a sexual minority. That is, a subculture and a defined or diffuse community. Dif-
they recognize through the use of language or sym- ferent cultural subgroups experience different alcohol
bolic expression that their sexual orientation places and drug abuse patterns and problems.
them apart from the sexual mainstream, even though
they may not describe themselves as "gay" or "les-
bian." Central to the definition is the view that gay EPIDEMIOLOGY
men and lesbian women see their relationships with
and connections to the same sex as primary, whether Earlier research (Fifield, DeCresenzo, & Latham,
acted upon or not, and identify themselves as outside 1975; Lohrenz, Connely, Coyne, & Spare, 1978;
the sexual mainstream. Saghir & Robins, 1973) has reported rates of alcohol-
544 ISSUES IN SPECIFIC POPULATIONS

ism and problem drinking to be about 33% of the gay ported by those aged 55 or older, least open about
population as compared to 10-12% of the general their sexual orientation, and least connected to the
population. However, these early studies suffer from organized lesbian community.
substantial methodological flaws (poor controls, poor In summary, more recent research on substance
samples, and failure to have uniform definitions of use indicates higher rates of alcohol-related problems
alcohol dependency and homosexuality). More re- among gays than among heterosexuals, but these dif-
cent studies (McKirnan & Peterson, 1992; Ostrow & ferences do not appear to be as great as many of the
Kessler, 1993; Stall & Wiley, 1988) have reported earlier, but methodologically flawed, studies indicat-
less dramatic contrasts between heterosexual and ed. Rates of heavy drinking are comparable among
gay/lesbian rates of heavy drinking and of drinking- gay and heterosexual men, but higher among lesbian
related problems, and these studies represent sub- than among heterosexual women.
stantial methodological improvements in sampling Discrete research on use of drugs other than alco-
lesbian/gay populations. hol is limited for gays; however, on occasions where
In a recent review, Bux (1996) drew four conclu- drug use was discussed, the most frequent associa-
sions from comparisons of previous and recent re- tions were with noninjectable drugs, referred to as
search relative to gays' use of alcohol. First, gays ap- recreational drugs, such as marijuana, amyl nitrates,
pear to be less likely than heterosexuals to abstain ecstasy, crystallized methamphetamine, and crack
from alcohol consumption. Second, gay men appear cocaine. Prior to 1978, gays indulged in the use of
to exhibit little or no elevated risk for alcohol abuse volatile nitrates more than any other group (Sigell,
or heavy drinking, using categories defined by the Kapp, Fusaro, Nelson, & Falck, 1978). Nitrates are
National Institute of Alcoholism and Alcohol Abuse used primarily during sexual activity because they re-
as 60 or more drinks per month, relative to heterosex- duce social and sexual inhibitions, heighten sexual
ual men. Third, lesbians appear to be at higher risk arousal, relax the sphincter, and are thought to pro-
for heavy drinking, and possibly for drinking-related long orgasm. Nitrates have become popular drugs
problems as well, than heterosexual women. At that are inhaled to alter consciousness, enhance
times, lesbians have been found to match gay and meditation, stimulate dancing, and intensify sexual
heterosexual men in rates of heavy and/or problem experience (Ortiz & Rivera, 1988).
drinking. Fourth, studies examining trends in drink- Over half of gay/bisexual respondents, compared
ing have reported recent decreases in drinking and to 33% of the overall sample in three California com-
alcohol-related problems among gay men. This may munities, reported injecting methamphetamine as
reflect the community's response to the health threat the primary mode of use (Frosch et al., 1996). San
of AIDS, changes in community norms around Francisco's Operation Concern reports that in their
drinking and other health-related behaviors, and de- treatment-seeking gay and bisexual men, metham-
clining rates of alcohol use among the general popu- phetamine has replaced alcohol as the most com-
lation, as reported by Midanik and Clark (1994) in mon drug use mentioned. Much of methamphet-
their study of the demographic distributions of U.S. amine's attraction for gays is its initial aphrodisiac
drinking patterns from 1984 to 1990. effects (National Association of Lesbian and Gay Ad-
The demographic, lifestyle, and mental health in- dictions Professionals [NALGAP], 1996).
formation on 1,925 lesbians from 50 states who par- Mailed surveys were returned by 1,067 self-identi-
ticipated as respondents in the National Lesbian fied gays and lesbians to the Trilogy Project, a 5-year
Health Care Survey (1984-1985) is the most com- longitudinal study of social issues relevant to gay
prehensive study of U.S. lesbians to date (Bradford, men and lesbians living in and around Lexington
Ryan, & Rothblum, 1994). Survey respondents indi- and Louisville, Kentucky (Skinner & Otis, 1992).
cated that 30% of them drank alcohol more than The data reveal that within this population, lesbians
once per week, 6% drank daily, and 16% of the sam- are more likely than gay men to experiment with dif-
ple had sought counseling for substance abuse prob- ferent types of drugs sometime in their life but do not
lems. The results of this survey correspond with those currently use these drugs. Lesbians are more likely to
of McKirnan and Peterson's (1989) large-scale survey currently use marijuana than any other illicit drug.
of 3,400 gays and lesbians in the Chicago area. The Gay men are significantly more likely than lesbians
highest rates of alcohol use among lesbians were re- to have ever used and to currently use inhalants.
 GAY MEN, LESBIANS, AND BISEXUALS 545

Prevalence rates for past-year and past-month use of and may be the only place available to meet and be
stimulants and sedatives are also significantly higher with other sexual minorities. Drinking for sexual mi-
for gay men than for lesbians. Gay men are signifi- norities may also be a way of relaxing in order to "fit
cantly more likely to currently use alcohol while sig- into" their communities, to provide the courage to
nificantly less likely than lesbians to have ever used approach other gays, and to deal with the fear of re-
or to currently use cigarettes. jection by gay peers. Thus, drinking may be used by
Research indicates that a problem with substance gays not solely or always to escape from something,
use and abuse may exist in the gay community. While but to join something: the gay community. For bet-
the extent of that problem is uncertain and, in fact, ter or ill, the primary means of identification and
may not be as pervasive as previous research indicates, connection with their own community for most gays
it does exist. One needs to recognize both the differ- remain the gay bars (Kus, 1988; McKirnan & Pe-
ences and the similarities between gay and lesbian terson, 1989).
substance abusers and their nongay/lesbian counter- A second risk factor for substance abuse among
parts. Given this reported rate of substance abuse prob- gays and lesbians has its basis in the fact that public
lems among gays, are there particular risk factors that attitudes and private sentiment about gays are still
may be contributing to this phenomenon? largely negative. Gays are openly barred or more sub-
tly discouraged from participation in most commu-
nity institutions which typically sustain heterosexuals
RISK FACTORS AND CONSEQUENCES (e.g., organized religion). While it has been proposed
that the natural remission of heavy drinking and al-
Although numerous theories have emerged to ex- cohol-related problems among young adults in the
plain the etiology of problem drinking in gays, em- general population is associated with an increase in
pirical support for most of these theories is lacking. conventionality and social stability achieved through
Among the factors that do enjoy at least some support the assumption of adult social roles such as marriage
as possible etiological influences are: (a) the role of and parenthood, these attenuating factors do not oper-
the gay bar as a primary socialization vehicle, (b) few- ate for most gays. Marriage is not an option, and gay
er family and societal supports, (c) socioeconomic "commitment ceremonies" are not accorded equal sta-
and psychosocial conditions associated with minority tus, legitimacy, or rights. Parenthood, while certainly
status, and most significant, (d) stresses related to the an option, can be an arduous and complicated under-
developmental process of gay identity formation/ taking for gays, so that only relatively few gays attain
coming out and (e) internalized homophobia. this status (Paul, Stall, & Bloomfield, 1991).
Gay bars are one of the major social institutions Many gays face life without the usual, full com-
in the gay community. Until recently, gay bars in plement of benefits from family, peer, and friendship
most cities were one of the few legitimate places supports. It is the rare gay person who enjoys undi-
where gays could meet and socialize with other gays. minished support from family, intimates, and associ-
As many gays are hidden to various degrees about ates following disclosure of gay sexual orientation.
their sexual orientation, the gay bar is perceived as a Some degree of ostracism is probably the norm, and
relatively safe place where one can openly be one's complete ostracism is not uncommon. Creating and
true self. Only large cities offer alternatives to gay maintaining a positive sexual minority identity and
bars, such as community centers, coffee houses, and larger self-concept while attempting to relate as ma-
clubs, and many of these also serve alcoholic bever- ture adults to family and friends present daily chal-
ages. Formal and informal communication and ac- lenges and stresses for gays that have no counterpart
tivity networks of the gay community continue to re- in the lives of heterosexuals. Young gays are particu-
volve around the gay bars and the concomitant use larly vulnerable in this respect. Alienation, isolation,
of alcohol. Thus, alcohol has been built into the fab- loneliness, and excessive reliance on an intimate
ric of gay and lesbian social life. Furthermore, many partner and/or a small number of select and trusted
gays perceive the bars as the major and often the only friends can all serve to increase the risk of substance
sanctuary from an uninformed, rejecting, or hostile abuse for gay men and lesbians (Neisen, 1993).
world (Nardi, 1982; Ziebold & Mongeon, 1982). Stress-related use of alcohol was strongly correlated
The bars provide an "it's okay to be me" atmosphere with alcohol problems; a substantial number of both
546 ISSUES IN SPECIFIC POPULATIONS

gay males and lesbians (23% and 13%, respectively) health counseling and hospitalization, psychoactive
reported using alcohol at least half the time to cope substance use, depression, suicidal thoughts and ac-
with personal stress (Paul et al., 1991). tions, sexual identity development disruption, and
Finally, there are socioeconomic and psychoso- HIV risk behavior.
cial realities of belonging to a minority community Sexual minority status may entail personal con-
that may negatively influence rates and patterns of frontation with prejudicial attitudes, discriminatory
substance abuse among gays and lesbians. McKirnan behaviors, unfairness and unequal power, hatred,
and Peterson (1992) found underemployment, resi- and verbal, emotional, or physical abuse. Minimally,
dential instability, low occupational status, and reli- gays can expect to be the object of strong antipathy.
gious nonaffiliation to be associated with problem This pervasive discrimination can lead to actual or
drinking for gay men, although not for lesbians. fear of loss of job and residence and rejection by fam-
However, the lesbian participants in the National ily and peers, which in turn might lead to a "double"
Lesbian Health Care Survey reported that almost life in an attempt to keep the discrimination from
one third used tobacco on a daily basis, 30% drank occurring. The overall result of these facts of life can
alcohol more than once a week, and 6% drank daily. be immeasurable psychological stress, and many gays
These lesbian participants actually constituted a seek an escape with alcohol and other psychoactive
more "privileged" group, or "best case scenario," substances. Mental health professionals have long ex-
among lesbians, as well as in comparison to women perience with what the available literature suggests:
in the general population. The majority of survey Alcohol use among gays is associated with reported
participants were white, young, well educated, met- low self-esteem, shame, guilt, depression, anxiety,
ropolitan, and employed full time in professional and anger, frustration, isolation, problems concerning
managerial positions and thus were not representa- sexuality and relationships, and the patronizing of a
tive of rural and isolated settings. Lesbians who were lesbian or gay bar in social interaction. These prob-
not represented in the study are more likely to be cut lems are likely to be exacerbated for gays who are
off from a sympathetic community and therefore to also members of racial/ethnic minority groups, since
be at greater risk of distress and need for supportive they are subjected to both antigay and racist attitudes
help. While "privileged," these lesbians were also and treatment. Moreover, they are stigmatized, in
found to be significantly underpaid relative to educa- turn, by their own racial/ethnic and sexual minority
tional status (all but 12% earned less than $30,000 communities, and they occupy a peripheral position
per year, and 64% earned less than $20,000). One is in these, as well as within the dominant/mainstream
left to wonder about the rates of substance abuse and culture (Icard & Traunstein, 1987).
related problems among poor and rural lesbians. Bux (1996) emphasized that research on the issue
Additionally, a high prevalence of stressful life of gay/lesbian cultural factors that facilitate alcohol
events and behaviors related to substance abuse and abuse has been sparse and results are inconclusive.
mental health problems were found among the na- Inconsistencies in the theoretical accounts warrant
tional lesbian sample. Over one third had been phys- caution in accepting them uncritically, and he fur-
ically abused, one third had been raped or sexually ther asserted that there is little reason at present to
assaulted, and nearly one fifth had been victims of conclude that a particular gay or lesbian "lifestyle"
incest while growing up. Unfortunately, the rate of contributes to heavy or problem drinking. It will be
incest among lesbians (18.7%) is quite similar to the essential in future research to separate preconcep-
rate reported among the general female population tions from reality in developing models that account
(16%; Russell, 1984). Childhood sexual abuse among for such factors in the development of drinking prob-
gay men, and its profound impact on their mental lems.
health and substance use patterns, has only very re-
cently been acknowledged by both health care pro-
fessionals and the gay community itself. Bartholow et ASSESSMENT ISSUES
al. (1994) focused on various health behaviors associ-
ated with a history of childhood and adolescent sex- Assessment of drug or alcohol use in the gay client,
ual abuse among approximately 1,000 adult gay men as in any client, must go beyond superficial and cur-
attending urban sexually transmitted disease clinics. sory questions concerning consumption. Specifics
Sexual abuse was found to be associated with mental concerning quantity and frequency of use must be
 GAY MEN, LESBIANS, AND BISEXUALS 547

obtained, along with details as to the impact of drink- sexuality, rather than jumping to conclusions or urg-
ing or drug use on major functional areas in clients' ing actions that may not be appropriate. It is impera-
lives. At minimum, therapists should know the im- tive that therapists be as clear as possible about issues
pact of drug and alcohol use on physical and psycho- regarding sexuality and sexual orientation, because
logical well-being, sexual functioning, functioning in clients, whether sexual minorities or not, are often
intimate relationships, and socially and within the confused and frightened about these matters. Many
family, and whether the client has experienced legal were confused about sexual matters before they
or financial problems as result of alcohol/drug use. It started drinking. During their active alcoholism,
is possible that the gay client may request therapy many clients engage in sexual behaviors or experi-
with an initial complaint of drug or alcohol prob- ence emotional attractions which further confuse
lems; however, this presentation is rare. More com- and frighten them. Knowledgeable therapists with
monly, clients present with global reports of anxiety nonjudgmental attitudes can help ease the turmoil
or depression or with specific problems in one or somewhat and reassure their clients (Finnegan &
more life areas that are the result of drug or alcohol McNally, 1987). Knowledge here allows the therapist
abuse (McCandlish, 1982). It is incumbent upon to help distinguish whether or not the client is sim-
therapists to assist clients in associating their present- ply having fantasies or thoughts versus activities and
ing problems with their drug or alcohol use, and this actions. Someone's fantasizing about same-sex sex
cannot be done if the therapist is uninformed of de- does not necessarily mean that she or he is gay or
tails of this use. lesbian.
There are no specific assessment instruments that A foremost concern for therapists of gay clients is
have been developed and tested relative to issues to identify which stage of the coming-out process
such as sexual orientation and stages of "coming out" their clients are in. This is significant, because cli-
and so on. Treatment facilities utilize standard assess- ents' degree of comfort with their sexual orientation
ments; therefore, the initial assessment needs to be will directly impact the therapeutic process. Al-
comprehensive and gay-sensitive. Finnegan and Mc- though there is variation in how far and at what rate
Nally (1987) asserted that counselors need to take individuals progress through the coming-out process,
a thorough psychosocial-sexual history in a caring, a common and highly stressful point is reached when
relaxed manner. They also reported that gay men clients begin to think about disclosing their sexual
and lesbians who have been in treatment repeatedly orientation rather than hiding it or "passing." Un-
reported they felt better when their counselors asked doubtedly, disclosure to family members and friends
questions that gave positive signals. The importance of gay sexual orientation is one of the major stressful
of asking these questions is underscored by the many events in the lives of gay men and women. While
gay and lesbian alcoholics who report they were this is so, it has also been well documented that "out-
never asked about their sexual orientation during ness" is positively correlated with better psychologi-
treatment. Substance abuse, among any population, cal adjustment (Anderson & Adley, 1997). To facili-
presents a myriad of challenges for therapists. For the tate and ease coming out and disclosure for gay
gay population, basic substance abuse issues are clients, therapists may assist in such tasks as perform-
compounded by sexual orientation issues. To be ef- ing a cost-benefit analysis regarding disclosure, plan-
fective, treating therapists need to develop a treat- ning and rehearsing "how to," and developing effec-
ment plan that incorporates both issues. tive means of coping with negative reactions from
The attempt to assess an individual's sexual orien- significant others. It also helps when clients realize
tation is difficult; however, it must be made, along that they are not "the only one" who has gone or is
with helping individuals address their alcohol and going through this process. However, the therapist
drug use, as sexual orientation issues might affect must be familiar with the process to help the client
their ability to remain sober. An accurate assessment recognize this.
requires a certain level of knowledge about sexuality
in general and, when dealing with gay clients, an
understanding of gay sexual activities and an aware- TREATMENT ISSUES
ness of the coming-out process. Therapists who are
relatively well versed in these matters, and comfort- Ratner (1988) believes that effective chemical depen-
able discussing them, can help clients explore their dency treatment, whether inpatient or outpatient,
548 ISSUES IN SPECIFIC POPULATIONS

should focus on the following specific sexual minor- teaching of relapse prevention skills but also a self-
ity concerns: (a) a treatment environment that affirms analysis and a redefining of self. If alcohol and/or
gay lifestyles as positive alternatives to traditional het- drugs were used to conceal inner conflict related to
erosexual lifestyles; (b) increased self-awareness and issues surrounding same-sex attraction, redefining
self-acceptance as a sexual minority; (c) appropriate oneself and one's self-worth, then it is essential to
ways of coping with the discrimination and rejection address those issues of internalized homophobia to
sexual minorities frequently encounter from society, help alleviate feelings of guilt and shame. To effectu-
their family of origin, and others, and with the stresses ate behavioral change, treatment plans need to cen-
they will encounter while recovering from substance ter on the underlying drives that are used as excuses
dependence; (d) a nontraditional family network; (e) for substance abuse. With the focus on issues of iden-
integration of their sexuality into a philosophy of life tity, orientation, self-esteem, self-worth, anger, de-
based on sobriety, quality, spirituality, and self-worth; nial, and the development of coping mechanisms,
(f) medical information that is tailored to their special effective and lasting treatment will also require the
needs; and (g) role models who illustrate the diversity identification of positive role models and community
of the gay community. supports that will facilitate the healing process.
In recognition of the special problems of alcohol- The excuses used to support substance abuse are
dependent gays, a small number of specialized resi- infinite in any population. However, with gay clients,
dential treatment programs have become available. these excuses are often confused with and/or com-
For example, Pride Institute in Minneapolis, estab- pounded by the negative effects of internalized ho-
lished in 1986, became the first inpatient treatment mophobia, which include feelings of low self-worth,
center for chemically dependent lesbians and gay men guilt, shame, and repressed anger, and the associated
in the United States. The Fellowship of Alcoholics issues of acceptance by family, friends, and society.
Anonymous reports over 500 gay groups throughout The construct of internalized homophobia is closely
the country, and many AA groups are "gay-friendly." related to the coming-out process and must be un-
Today, most major metropolitan communities have derstood and utilized in the treatment of gays with
outpatient centers that provide chemical dependency substance abuse problems (Finnegan & McNally,
services for gays. Other centers have added special 1987). Internalized homophobia is the process
"track" programs for these clients. Still, gay-specific in- wherein gays come to internalize and believe societal
patient treatment centers are scarce, considering the antigay attitudes, beliefs, and stereotypes, with resul-
number of gay individuals with alcohol and drug tant devaluation and negativity about the self. Ed-
abuse problems (Amico & Neisen, 1997). ucation around antigay prejudice and internalized
On July 4, 1979, the National Association of Les- homophobia can convey to clients the origin of prej-
bian and Gay Addictions Professionals (NALGAP) udice, the element of power, and how oppression
was created by a group of 15 lesbian and gay alcohol- leads to shame and guilt. Therapists can help gay
ism professionals who were attending the Rutgers clients eliminate residual self-hatred by recognizing
Summer School of Alcohol Studies in New Jersey. their shame as a product of homophobia, rather than
NALGAP operates to create a network for support of their sexual orientation or behavior. For some in-
and communications among addictions profession- dividuals, homophobia may, in fact, be reinforcing a
als, to educate agencies and organizations about sex- preexisting low self-esteem. Therapeutic efforts di-
ual minorities and addictions, to act as a clearing- rected toward helping clients understand this inter-
house for resources (the world's largest collection of nalization process should be accompanied by at-
unpublished literature on sexual minorities and ad- tempts to integrate sexual orientation with overall
dictions is housed at the Rutger's Center of Alcohol self-concept. Clients can then begin to develop or
Studies), to raise the sexual minority community's reconstruct a positive self-image, a process which is
consciousness and combat its denial of the problem best begun as early as possible in treatment.
of addictions, and to improve substance use treat- Denial and rationalization may play an adaptive
ment for sexual minorities. Therapists are encour- role in staving off anxiety related to an antigay cul-
aged to both utilize and contribute to the resources ture. That is, gay clients may at times employ denial
of this specialty organization. to protect themselves from the stress of dealing with
Early recovery issues for sexual minorities include and living in an uninterested, uncaring, or hostile
not only the cessation of the substance abuse and the environment. Therapists must be skillful in untan-
 GAY MEN, LESBIANS, AND BISEXUALS 549

gling enabling excuses (such as "Everyone is doing they bring with them will not be considered in AA
this"; "The bar is the only place I can meet people") meetings, and it is imperative that they maintain
from adaptive defenses (such as "It is easier to cope contact with gay support groups. The concepts of
with and talk to others"; "It is easier to accept myself "higher power" and "spirituality," central to Alco-
and have sex"). Therapists need to confront the for- holics Anonymous, have acted as barriers for many
mer and judge when and how to leave the latter in- gays to participating in traditional 12-step programs.
tact. Enabling excuses allow the abuse/addiction to Many religious organizations have been extremely
continue. Adaptive defenses help the individual cope judgmental and condemning of gays; hence, gays as-
and to live with herself or himself. If the ego is too sociate such terms with organized religion. Thera-
weak and the defenses are maladaptive and removed, pists may need to clarify for clients AA's definition
the person will function/adapt in a less healthy man- and use of these terms to help overcome client resis-
ner. The task is to concurrently support the individu- tance. Not all lesbians in recovery prefer lesbian AA
al's personal growth and strength, combat less effec- meetings. Some lesbian problem drinkers have
tive defense mechanisms, and teach new, healthier supplemented or replaced AA involvement with an
defense mechanisms/coping skills. Therapists must alternative mutual help group called Women for So-
also help clients understand how experiences with briety, which according to its founder stresses em-
antipathy and discrimination can undermine a posi- powerment and positive self-appraisal rather than
tive self-concept and efforts to value and care for one- powerlessness and ego deflation (Kirkpatrick, 1978).
self. All in all, it is the therapist's challenging task This program, however, is not as geographically ac-
to discern rationalizations and excuses from real or cessible as AA.
legitimate blocks to recovery and growth. Hall (1993) expounded upon the importance of
Hall (1993) recommended that providers explore considering the historical origins of alcohol use prac-
the degree to which lesbian clients associate drinking tices and sociocultural factors in the definition of al-
with other life experiences, such as family history cohol problems. Rather, alcohol problems are more
and sexual abuse. They should be prepared to ac- appropriately seen as substantially unique difficulties
knowledge and address the association of alcohol use experienced by specific subcultural groups, such as
practices with the political and social realities of les- lesbians.
bian life, without stereotyping individual experi- The consumption of alcohol has long been asso-
ences. Concerns about sexual trauma, social control, ciated with sexual behavior. Drinking often occurs in
heterosexism, and male dominance should not be social settings in which sexual contacts are sought.
dismissed as avoidance or denial of the real alcohol Substance use also frequently occurs at parties and
problem in lesbian clients. other social gatherings at which sexual encounters
Family therapy and aftercare treatment remain vi- are commonplace. Alcohol also acts as a depressant
tal for those in recovery. The traditional family net- which induces disinhibition, which in turn may be
work may not be in place for many gays. It is not conducive to sexual behavior combined with a de-
unusual for gays to be completely ostracized from cline in caution (Plant, 1990). Moreover, from the
their family. Depending on the situation, reconcilia- earliest reports of AIDS-defining illnesses in gay
tion and/or maintenance of ties with the biological men, clinical investigators have noted a high preva-
family may or may not be a focus of treatment. Iden- lence of recreational drug use by the affected pa-
tification and recognition of the nontraditional or tients (U.S. Department of Health and Human Ser-
"chosen" family support system are highly beneficial vices, 1981). Associations have been found between
for the continuance of recovery (Paul et al., 1991). unsafe sex and use of alcohol and drugs in both
Bittle (1982) offered two important suggestions cross-sectional studies (e.g., Kelly, Lawrence, & Bras-
for gays when utilizing AA: (a) The early acquisition field, 1991; Leigh, 1990) and longitudinal cohort
of a sponsor who is either lesbian or gay or who is studies (e.g., McCusker et al., 1990; Stall, McKusick,
altogether comfortable with and knowledgeable Wiley, Coates, & Ostrow, 1986). Gay men who drink
about sexual minorities is of prime importance, and heavily or use other drugs appear more likely to en-
(b) it must be assumed that a majority of lesbians gage in sexual risk-taking behaviors. However, within
and gay men coming into AA will need more than actual sexual situations, alcohol and drug use does
the AA group if their continued sobriety is to be suc- not consistently predict HIV-risk-related sexual be-
cessful and reasonably secure. Many of the problems haviors.
550 ISSUES IN SPECIFIC POPULATIONS

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lesbian alcohol use: Epidemiological and psychologi- trow, D. G. (1986). Alcohol and drug use during sex-
cal perspective. Paper presented at the Research sym- ual activity and compliance with safer sex guidelines
posium on alcohol and other drug problems among for AIDS. Health Education Quarterly, 13, 359-371.
lesbians and gay men, Los Angeles. Stall, R., & Wiley, J. (1988). A comparison of alcohol
Midanik, L. R., & Clark, W. B. (1994). The demo- and drug use patterns of homosexual and heterosex-
graphic distribution of U.S. drinking patterns in ual men: The San Francisco men's health study.
1990: Description and trends from 1984. American Drug and Alcohol Dependence, 22, 63-73.
Journal of Public Health, 84, 1218-1222. U.S. Department of Health and Human Services, Cen-
Nardi, P. M. (1982). Alcoholism and homosexuality: A ters for Disease Control and Prevention. (1981).
theoretical perspective. In T. Zeibold & J. Mongeon Morbidity and mortality report. Epidemiological
(Eds.), Journal of Homosexuality: Alcoholism and Notes and Reports, 30, 305-308.
Drug Abuse. New York: Haworth Press. Ziebold, T., & Mongeon, J. (Eds.). (1982). Journal of
National Association of Lesbian and Gay Addictions Pro- homosexuality: Alcoholism and drug abuse. New
fessionals. (1996, Spring). NALGAP Reporter, 17, 3-4 York: Haworth Press.
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 Part VII

Prevention, Policy, and Economics

of Substance Use Disorders
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 30

Prevention Aimed at
Individuals: An Integrative
Transactional Perspective

Mary Ann Pentz

After a hiatus in the 1980s, drug use, including to- ferences in these strategies can be aligned with
bacco, alcohol, and marijuana use, among youth is demand or supply reduction (Pentz, Bonnie, &
again on the rise (Johnston, O'Malley, & Bachman, Shopland, 1996). Since most prevention efforts are
1997). The increase, appearing since 1991, has been aimed at youth, this chapter focuses on a model of
attributed to poor implementation of prevention pro- prevention as it applies to children and adolescents.
grams, a decrease in perceived risk and conse- However, the model presented here should be appli-
quences of use, high demand for use, and increases cable to prevention with other populations as well,
in perceived social norms and acceptance of use, particularly young adults.
with access to drugs remaining high and unchanged The majority of interventions aimed at individu-
(Bachman, Johnston, & O'Malley, 1991; Pentz, in als are focused on changing their demand for drugs
press). All of these factors can be addressed in pre- by changing attitudes, perceptions, and behaviors
vention programs aimed at individuals. concerning drug use. In contrast, interventions aimed
Drug abuse prevention aimed at individuals typi- at systems, environments, or policies are focused pri-
cally means those programs and strategies that initi- marily on changing supply of or access to drugs. Ef-
ate from and radiate outward in impact from an indi- fective demand reduction approaches are those which
vidual's changing his or her own drug use behavior. train individuals to (a) counteract personal and social
These strategies are in contrast to strategies aimed at risk factors for drug use, sometimes referred to as so-
changing systems, environments, or policies that are cial influences or resistance programs; (b) promote
initiated apart from individuals but are expected at personal, social, and environmental protective fac-
some point to impact on individuals' behavior. In the tors; or (c) both (Hawkins, Catalano, & Miller,
field of drug abuse prevention, which includes to- 1992). These approaches tend toward programmatic
bacco, alcohol, marijuana, and other drugs, the dif- interventions; the more effective interventions in-

555
556 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

elude programmatic, process, and organizational in- In drug abuse prevention research, these interac-
tervention, such as student training that also includes tions have been expressed in several different theo-
school development or training that also includes ries and models that imply longitudinal rather than
community organization and policy change (Becker simultaneous transactions. For example, problem be-
et al, 1989). havior theory posits that person, situation, environ-
The most effective prevention programs aimed at ment, and drug use behavior factors interact to affect
individuals are those that focus on counteracting so- subsequent drug use behavior, and that the interac-
cial influences to use drugs (Hansen, 1992). These tion effects are accentuated during periods of adoles-
programs address person-level factors of resistance cent transition, such as school or peer group transi-
skills, appraisal of drug use situations and models (P) tion (Jessor, 1982; Perry & Jessor, 1985). Peer cluster
and situation-level factors of perceived social norms theory posits that the social influences represented by
and avoidance of drug-using groups and drug use op- an adolescent's peer group, as well as the personal
portunities (S) (Hansen, 1992; Pentz, 1986; Tobler, and environmental factors that contribute to the for-
1992). A few also include coping and support-seeking mulation of a particular peer group, predict the course
skills (e.g., Pentz, Pentz, & Gong, 1993) or general of drug use onset (Getting & Beauvais, 1986). The
social skills related to coping, such as problem-solving risk and protective factors model posits that individu-
and assertiveness skills (Botvin, Baker, Dusenbury, als and communities can be diagnosed for drug use
Botvin, & Diaz, 1995). Most P- and S-level prevention risk on the basis of the presence of certain personal,
programs are implemented in schools, agencies, or familial, peer, and community demographic risk fac-
familiar settings. Most are designed to affect psycho- tors (Hawkins et al., 1992). The theory of triadic in-
social risk factors operating at the P and S levels. fluence posits that intrapersonal factors affect behav-
Community-based programs, on the other hand, can ioral skills and self-efficacy, social situations affect
address individual and group-level risk factors with bonding and social normative beliefs, and cultural-
school and parent program components, and E-level environmental factors affect knowledge, values, and
risk factors by including mass media, community or- attitudes toward drug use (Flay & Petraitis, 1994).
ganization, and policy change strategies. Public health models interpret behavior change in
The magnitude and longevity of program effec- terms of the interactive and causal relationships
tiveness is dependent upon the extent to which inter- among the host of disease risk behaviors, the agent
vention acknowledges and involves the interaction of transmission of those behaviors, and the environ-
of intrapersonal, interpersonal, and environmental ment that supports those behaviors; such models
change. In personality research, these interactions have been applied primarily to the understanding of
have been expressed as a simultaneous series of trans- alcohol use prevention (e.g., Green, Wilson, & Bauer,
actions that affect the ecology or balance of an indi- 1983; Holder & Wallack, 1986).
vidual's personality (Magnusson, 1981). Integrative transactional theory (ITT) posits the
Transactional theory posits that an individual's cumulative and redounding influences of personal
personality is formed or changed as a result of the attitudes and behavior on social group norms and
interaction of intra-, inter-, and extrapersonal factors support and, consequently, on community norms,
(Magnusson, 1981). Applied to the understanding of media, fiscal resources, and policy change (Pentz,
drug use development and prevention, an adoles- 1986, 1993). The remainder of this chapter cate-
cent's drug use behavior is formed or changed as a gorizes individual-aimed prevention strategies ac-
result of the interaction of person-level (P) factors cording to integrative transactional theory involving
(intrapersonal history of prior drug use, skills, support person (P), situation (S), and environment (E) inter-
seeking, and physiological reaction), situation-level actions.
(S) factors (interpersonal and group influences on
drug use modeling, pressures or offers to use drugs,
peer and family communication and support, and UNDERSTANDING INDIVIDUAL-AIMED
peer group transitions), and environment-level (E) INTERVENTIONS IN TERMS OF P, S,
factors (extrapersonal media influences, resources, AND E LEVELS OF INFLUENCE
community norms and policies, and demographic
factors; cf. Hawkins et al., 1992; Murray & Perry, When first described, ITT focused on articulating P,
1985; Pentz, 1986, 1994a, b, 1995). S, and E levels of risk factors for adolescent drug use
 PREVENTION AIMED AT INDIVIDUALS 557

(Pentz, 1986). The model was intended to guide the drug use development (e.g., Hawkins et al., 1992;
development of a comprehensive community-based Pentz, 1993; Yamaguchi & Kandel, 1984).
drug abuse prevention intervention (Midwestern Pre- Although the general ITT model is useful for de-
vention Project) that consisted of five components: a scribing influences on drug use development, it does
school program, a parent education and organization not articulate specific variables that are useful as be-
program, community organization and training, mass havior change targets. Sometimes referred to as inter-
media programming, and community drug use pol- vention mediators, these change targets are shown for
icy change (Pentz et al., 1989). Since its original de- P, S, and E levels of intervention in figures 30.2,
scription, ITT has been expanded to include transi- 30.3, and 30.4, respectively.
tions, opportunity, and access as risk factors for drug
use based on research showing significant relation-
Person-Level Risk and Prevention
ships of these factors to drug use (Pentz, 1993). The
modified P x S x E risk factor model is shown in fig- Figure 30.2 differentiates the hypothesized paths of
ure 30.1. ITT assumes (a) that risk as well as behav- person-level (intrapersonal) risk factors for drug use
ior change targets operate on youth simultaneously; and the hypothesized paths of prevention program
(b) that intervention aimed at changing behavior can mediators that are aimed at reversing or counteract-
be focused initially on individuals' own behavior (P ing these risk factors. As multiple studies have shown,
or intrapersonal), with a sufficient "mass" of change the single risk factor accounting for the most vari-
subsequently affecting group (S) and environment ance in subsequent drug use is one's own prior ex-
(E) aggregates of individuals' behavior (i.e., behavior perimentation with drugs (Hawkins et al., 1992;
change effects initially radiate outward); and (c) that Pentz, 1993; Yamaguchi & Kandel, 1984). To con-
the different levels are reciprocally determined over tinue use, an individual may consciously rationalize
time. The factors shown in figure 30.1 are based col- the benefits of use (similar to the concept of re-
lectively on results of epidemiological research on ducing dissonance in cognitive dissonance theory;

PERSON SITUATION
Prior Drug Use Peer Influences
Intention to Use Positive Social Norms
Low Skills Family Influences
Positive Appraisal/Beliefs Low Social Support
Low Perceived Risk Transitions
Physiological Reaction Opportunity

ENVIRONMENT

Access
Media Influences
Availability of Prevention Resources
Prevailing Community Norms
Demographic Factors
Fiscal Resources
School/Community Policy

Change in Use:
Incidence Prevalence
Intensity Duration

FIGURE 30.1 Transactional theory model of behavior change.

558 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

Risk:
Positive Physiological
Intention
Prior Use Appraisal Use Reinforcement
of Drug Use to Use
for Use

Positive Low Perceived

Continued
Beliefs Risk/
About Use Consequences Use

Prevention:
Avoidance/ Intention
Low Decreased Increased
Resistance to Avoid
Skill Building Exposure Use Use Competence

Negative Negative Attitudes/

Appraisal Perceived
Personal Risk/ Beliefs About
Change
Consequences Use

FIGURE 30.2 Interventions aimed at individuals: Effects on person (P)-level behavior.

Flay & Petraitis, 1994; Pentz, 1993), that is, develop individual's knowledge about drugs and conse-
positive beliefs about use, minimize perceived risk quences of use, affect or feelings about drug use,
and consequences of use, and appraise drug use oc- feelings about self (self-esteem building), or personal
currences and opportunities as a positive experience decision making and problem solving about drug use
(Azjen & Fishbein, 1980). Alternatively, the individ- (Hansen, Johnson, Flay, Graham, & Sobel, 1988;
ual may spontaneously encounter a drug use oppor- Pentz, 1993; Tobler, 1992). None of these ap-
tunity that later appears to be positive, for example, proaches have shown effects on either delaying or
drinking at a party, which appears to increase fellow- reducing drug use in youth, when restricted to the P-
ship and camaraderie among peers. Whether positive level context without consideration of social contexts.
perceptions of use are rational decisions or spontane- Most of these programs have been used in schools as
ous outcomes of an opportunity, the perceptions are part of health education; some have been used in
hypothesized to increase intentions to use in the near student assistance programs (SAPs) as part of a coun-
future and subsequent use. Intentions to use ciga- seling process, or in agency settings or group homes
rettes, for example, are considered a major indicator where adolescents who are already users or at high
of an adolescent's susceptibility (predictor) of subse- risk for use receive counseling.
quent use (Pierce, Choi, Gilpin, Farkas, & Merritt, It is conceivable that a P-level prevention pro-
1996). A continued pattern of use is hypothesized to gram could achieve some effects on youth drug use
involve a repetition of positive perceptions about use, if all or most of the P-level risk factors were addressed
intentions to use, and positive physiological rein- in sequence as shown at the bottom of figure 30.2.
forcement for use. Positive physiological reinforce- However, there is no evidence in the published liter-
ment includes feelings of getting high, not getting ature that such a risk-inclusive program has been
sick, a general sense of well-being, and/or temporary evaluated. In such a hypothetical program, personal
diversion from depression or anxiety. drug avoidance/resistance skills would be taught first.
Most prevention programs aimed at changing P- As differentiated from resistance skills taught in S-
level risk factors have been limited to changing an level prevention programs (see below), personal resis-
 PREVENTION AIMED AT INDIVIDUALS 559

tance skills would focus on cognitive "self-talk" and of social transition, particularly the transition from
visualization of avoiding drug use and drug use op- elementary to middle school. This period represents
portunities, without the context of social pressures. a period of vulnerability and attempts by adolescents
Sufficient cognitive practice of these skills might be to emulate the behavior of older or more mature
expected to result in aversion to drugs (appraisal peers, including trying drugs (Jessor, 1982; Pentz,
change), avoidance of drug use opportunities (low 1993).
exposure), and an increase in perceived risks and The hypothesized sequence of S-level risk factors
negative consequences of drug use. Continued nega- is shown in the top half of figure 30.3. Exposure to
tive perceptions about drug use and avoidance of drug use models and social transition may contribute
drug use opportunities would be expected to rein- to attachment to users; attachment and exposure to
force avoidance intentions and negative beliefs in the models increases perceived (and actual) social norms
future and consequently decrease use. Based on what for use. Together, these risk factors increase opportu-
is known about risk and protective factors for drug nities for use and seeking opportunities for use, sub-
use, continued avoidance of use should contribute to sequent use, and social reinforcement, by peers, for
prosocial and academic competence (Hawkins et al., continued use.
1992). The bottom half of figure 30.3 shows the hypothe-
Person-level programs have at least three major sized sequence of change in drug use via changing
limitations. One is that they are likely to be labor- social situational influences. Skills training can be
intensive and to reach fewer youth than other types provided to youth that includes how to resist peer
of programs involving large groups or populations; pressure and drug use offers, and how to judge and
cognitive practice skills, for example, may have more avoid situations where drugs are used. Training that
utility in clinical settings with individuals or small also includes assertiveness and approach skills, such
groups. Second, P-level programs rely heavily on cog- as life skills training (Botvin et al., 1995), should in-
nitive processes. Changing perceptions have been crease a youth's resistance and avoidance ability, as
shown to be necessary but insufficient conditions of well as enable a youth's ability to seek social support
behavior change in youth (Flay et al., 1995). Third, from trusted adults when resistance skills are not suf-
P-level programs do not prepare youth for the consid- ficient to counteract peer pressure (Barrera, 1986).
erable social pressures they encounter to experiment Resistance, avoidance, and support seeking, if consis-
with drugs. tently applied, should promote gravitation or attach-
ment to nonusing peers as friends over time. Such
friends represent and confirm among each other a
Situation-Level Risk and Prevention
negative social norm for drug use and concern about
Consistently, etiological and epidemiological re- negative consequences of drug use. Attachment to
search has shown that the major risk factors for drug nonusing friends is likely, in turn, to increase avoid-
use onset are social influences, including the inter- ance of activities and situations that involve drug use
personal social situations that an adolescent encoun- (opportunity avoidance), decrease use, and promote
ters and perceives around him or her. These include selection of nonuse alternative activities for the non-
exposure to adult and peer modeling of drug use; using peer group.
peer pressure to try drugs; social situations that repre- To date, most S-level prevention programs imple-
sent immediate access, opportunity, and availability mented during the early adolescent years have in-
of drugs; perceived peer norms for drug use; per- cluded avoidance, peer pressure resistance, and/or
ceived approval or acceptability of drug use by peers assertiveness skills training, weighing positive and
and adults; and proximity and attachment to users negative consequences of drug use, and correction of
(Donaldson, Graham, & Hansen, 1994; Hansen, perceived social norms for use (Hansen, 1992; To-
1992). Along with prior use for youth who have al- bler, 1992). A few programs implemented during the
ready tried drugs, these immediate social influences elementary school years have focused on bonding
typically account for 30% or more of the variance in with nonusing peers (e.g., Hawkins et al., 1992).
youth drug use (Donaldson et al., 1994). According These programs are considered primary or universal
to problem behavior theory (Jessor, 1982), these so- prevention programs that include whole populations
cial influences escalate in importance during periods of school-attending youth. Only programs that are
560 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

Risk:
Positive Social
Exposure to Drug
Perceived Opportunity Use Reinforcement
Use Models Social Norms for Use

Social Access/ Continued

Attachment Use
to Users

Social Transition

Prevention:
Avoidance of Negative Selection of
Attachment Perceived Decreased
Use Situations Social Non-use
to Non-Users Use
Users Norms Alternatives

Social Pressure
Resistance Negative
Perceived Opportunity
Social Support Social Risk/ Avoidance
Seeking for Consequences
Non-Use

FIGURE 30.3 Interventions aimed at individuals: Effects on situation (S)-level behavior.

considered selective or indicated prevention pro- ura, 1977). Referred to as guided participant model-
grams (Kumpfer, 1989)—that is, programs that target ing, these principles include the use of modeling,
youth who are already exhibiting problem behav- role playing, group discussion and feedback, and ex-
ior—have emphasized social support seeking and se- tended skills practice in real-life settings, usually
lection of nonuse alternatives (e.g., Eggert, Seyl, & through the use of interactive homework activities in-
Nicholas, 1990; Kumpfer, 1989). volving peers or parents. There is substantial evi-
Both universal and selective prevention programs dence to indicate that social influence programs are
that target at least two to three of the influences in effective in delaying and reducing adolescent drug
figure 30.3 have demonstrated 20-40% net reduc- use for periods of 5 years or more (Botvin et al., 1995;
tions in drug use, calculated as the difference in rates Hansen, 1992; Pentz, 1993; Resnicow, Cross, & Wyn-
of drug use increase between program and control der, 1991; Tobler, 1992). In some cases, however,
groups divided by the control group rate of increase programs that have focused on counteracting social
(Pentz, 1994a). However, relatively little is known influences have shown either no effects on drug use
about the effects of either universal or selective/indi- (Ennett & Bauman, 1994), or effects dissipated short-
cated programs on the selection of nonuse activities, ly after the end of intervention (e.g., Ellickson,
or about the health or social benefits of such activi- Bell, & McGuigan, 1993). With the exception of
ties. poor program implementation, reasons for program
Most prevention programs focused on counteract- failure or weak effects have not been evaluated to the
ing social influences have been based in schools same extent as reasons for program effectiveness
(Hansen, 1992; Tobler, 1992); to a lesser extent, pro- (tests of program mediators; Donaldson et al., 1994;
grams have focused on or have included parents or Dusenbury & Falco, 1995; MacKinnon et al., 1991).
families (Aktan, Kumpfer & Turner, 1996; Dish- Some possibilities are worth noting. One may be the
ion & Andrews, 1995). Most rely on social learning type of individual(s), instructional method, or sup-
theory principles of training behavioral skills (Band- port to implement programs. For example, DARE,
 PREVENTION AIMED AT INDIVIDUALS 561

which is based on sound principles of social learning from others may be adolescents' positive beliefs
theory and addresses social influences of peer pres- about such images. Beliefs covary with youth expo-
sure, resistance skills, norms, and consequences of sure to a drug use environment, for example, an ur-
use, may show no effects on drug use because the ban housing complex where drugs are readily used
type of implementer (police) is not considered a nor- and acknowledged; exposure, in turn, is likely to be
mative educator by youth (Ennett & Bauman, 1994). related to youth access to drugs. However, the two
Programs with effects that dissipate after the end of factors are not redundant, since several studies have
intervention may encounter poor school support for shown that while over 90% of youth everywhere re-
prevention programs (Ellickson et al., 1993). Another port easy access to drugs, relatively few youth live in
possibility is that some social influence programs environments where they are likely to be exposed to
may not address all of the hypothesized risk factors drug use on a regular basis (e.g., Johnston et al.,
shown in figure 30.3. For example, most S-level pro- 1997). Collectively, these factors contribute to posi-
grams include social pressure resistance and avoid- tive perceived environmental norms for drug use, in-
ance skills, as well as changing social normative ex- cluding acceptability of drug use in the community
pectations and perceived risks and consequences of and consequent use (Pentz, 1994b). If policies are
drug use (Hansen, 1992). Bonding (attachment to poorly enforced as well as implemented, few negative
nonusers) is addressed in only a few programs (e.g., consequences such as school suspension or juvenile
Hawkins et al., 1992), as is seeking social support for court appearances ensue, and use continues.
nonuse (e.g., Eggert et al., 1990). In addition, few A preventive intervention sequence that mobi-
programs include or give equal attention to selecting lizes individuals to counteract environmental influ-
alternative nonuse situations. ences on drug use is shown in the bottom half of
figure 30.4. Radio, television, and print media man-
agers could develop mass media programs and cam-
Environment-Level Risk and Prevention
paigns that could focus on either direct advertising
Environment-level risk factors are those that repre- to counteract glamorized drug use images, training
sent influences larger than a youth's immediate fa- youth in media literacy to interpret the limitations of
milial or social group environment, including school, media, and/or providing messages that change per-
neighborhood, and larger community. After personal ceived environmental norms for use. Local law en-
use and family and peer influences, neighborhood forcement officers, town government leaders, school
and community influences have been shown to ac- administrators, and neighborhood volunteers could
count for a significant proportion of the variance of engineer attractive and safe no-use settings for adoles-
adolescent drug use (White, Boorman, & Breiger, cents to congregate in and, in the process, increase
1976).While other environmental factors such as avoidance of settings (environments) where drugs are
state drunk-driving laws and national alcohol-warn- used or sold. Business leaders can organize with com-
ing labels also have an impact on use (e.g., Hingson munity leaders to raise local funds and resources to
et al., 1996; MacKinnon et al., 1991), this chapter maintain prevention programs in schools, develop
focuses on local environmental influences that are campaigns and services that complement school pro-
modifiable by individuals. grams, provide parent prevention training, and strength-
Figure 30.4 shows the relationship of E-level risk en implementation and enforcement of policy. While
factors to drug use and a hypothesized sequence of no study has systematically evaluated the causal rela-
E-level prevention strategies. Five factors are shown tionship between resource generation and commu-
as initial influences on adolescent drug use, although nity organization for drug abuse prevention, existing
two—media beliefs and exposure—are somewhat models of community prevention interventions sug-
modified from factors evaluated in previous research gest that the order consists of interested leaders devel-
(e.g., Flynn et al., 1992). Glamorized images and oping a sense of empowerment, developing an
modeling of drug use in the media have been shown organization or partnership for prevention, and sub-
to affect, at a minimum, adolescents' attitudes toward sequently developing strategies to raise funds and
drug use. However, since such images are readily change policy (e.g., Butterfoss, Goodman, & Wan-
available to most youth everywhere, a more predic- dersman, 1996; Goodman, Wandersman, Chinman,
tive factor that differentiates some environments Imm, & Morrisey, 1996; Manger, Hawkins, Hag-
562 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

Risk:
Positive Media Beliefs
Positive
Exposure to Drug Perceived Low
Use Environment Environment Use Consequence:
for Use
Norms
Access

Continued
Low Fiscal/Prevention Use
Resources

Prevention:
Correction of Media Beliefs Negative Prevention
Perceived Decreased
Environment Policy
Use
Empowerment Norms Change

Development of Community
No-use Environment Organization

Access to Prevention
Restricted Access Resources/ Program
Policy Enforcement Programs lustitutionalization

FIGURE 30.4 Interventions aimed at individuals: Effects on environment (E)-level behavior.

gerty, & Catalano, 1992; Mansergh, Rohrbach, Mont- achieved in changing attitudes toward drug use and
gomery, Pentz, & Johnson, 1996). Collectively, these beliefs about consequences; small effects have been
changes would be expected to decrease adolescent noted on intentions to use drugs in the future (Dono-
drug use. Recent research also suggests that the com- hew, Sypher, & Bukowski, 1991; Flay et al., 1995;
bination of decreased drug use and increased em- Flynn et al., 1992). Studies of campaigns have been
powerment may contribute to subsequent efforts to focused primarily on young adults rather than adoles-
refine or change policy and institutionalize preven- cents, particularly in the area of drunk driving (e.g.,
tion programs (Florin & Wandersman, 1990; Pentz & Hingson et al., 1996; Holder & Blose, 1987); these
Newman, 1997). campaigns have shown changes in perceived conse-
The majority of interventions that have already quences of use as well as short-term changes in
addressed one or more E-level influences have con- drunk driving and related behaviors in young adults.
sisted of either mass media programs or campaigns, Local policy interventions for youth have concen-
policy enforcement or policy change intervention, or trated on restricting youth access to tobacco and al-
community coalitions or partnerships organized for cohol through community ordinances or school pol-
drug abuse prevention. While no study has systemati- icy (Pentz et al., 1996). Collectively, results of these
cally compared the efficacy of each E-level ap- studies suggest that (a) prevention or support-ori-
proach, several studies have combined them in an ented policies are associated with lower tobacco use,
attempt to reinforce each approach's prevention mes- while punishment-oriented policies have no rela-
sage and/or disseminate prevention to a larger com- tionship to lower use (Pentz et al., 1989); (b) re-
munity audience. stricted access policies that involve youth in enforce-
Mass media programs for drug abuse preven- ment—for example, through activism or "sting"
tion have mostly targeted youth (e.g., Flay et al., operations—have an effect on decreasing tobacco
1995; Flynn et al., 1992). Moderate effects have been sales and purchases by youth and may decrease alco-
 PREVENTION AIMED AT INDIVIDUALS 563

hoi consumption (Forster, Hourigan, & Kelder, 1992; smaller increases in youth drug use over time relative
Jason, Li, Anes, & Birkhead, 1991; Perry & Jessor, to comparison communities, differences were signifi-
1985); and (c) changes toward more restrictive policy cant on only two of eight drug use variables mea-
may represent a reactive effect to high rates of youth sured (Yin & Kaftarian, 1997). It is not known
tobacco or alcohol use in a community rather than whether the lack of statistically significant effects is
proactive support of restricted access policy. With the due to insufficient power to detect the small differ-
exception of one recent study (Forster, Wolfson, ences between community groups, as yet unanalyzed
Murray, Wagenaar, & Claxton, 1997), effects of re- mediational effects of coalition process on drug use
stricted access policy interventions appear to be lim- outcomes, or ineffectiveness of coalitions as a strategy
ited to decreased sales and short-term consumption to reduce youth drug use. Effects of E-level interven-
patterns rather than prevalence. tions aimed at individuals appear to be stronger to
Other interventions have focused on training the extent that interventions are combined. For ex-
servers and sales people to comply with restricted- ample, large short-term reductions (40%) in youth
access policy by voluntarily restricting sales of to- tobacco sales were achieved in one study by combin-
bacco and alcohol to minors in bars, restaurants, and ing a community ordinance with youth sting opera-
stores (e.g., Altman, Rasenick-Douss, et al., 1991; tions and mass media programming (Jason et al.,
Holder & Wallack, 1986; Mosher & Jernigan, 1988). 1991). In another study, relative reductions of up to
These studies have shown significant short-term re- 20% in youth tobacco use prevalence were achieved
ductions of up to 40% in sales to minors, although by combining community and youth activism to pro-
effects tend to erode after prompts for compliance, mote restricted access policy and local mass media
such as sting operations and media coverage, are re- support (Forster et al., 1997).
moved.
Community coalitions or partnerships organized
Person x Situation x Environment
for drug abuse prevention have been evaluated in a
Risk and Prevention
series of demonstration grants, for example, Center
for Substance Abuse Prevention (CSAP) Communi- The integration of all three levels of risk is shown in
ty Partnerships, Robert Wood Johnson Foundation figure 30.1. Interventions aimed at individuals as-
Fighting Back Initiative, and Kaiser Family Health sume an outward direction of influence; that is, P-
Foundation Community Organization program. Col- level interventions or intervention components affect
lectively, these represent organization efforts in over attitudinal and belief change in a critical mass of in-
300 cities and communities across the United States. dividuals; attitudinal change builds support and will-
Most of the results obtained to date have concen- ingness to participate in S- or group-level interven-
trated on changes in the process of community or- tions; participation in S-level interventions changes
ganization, rather than drug use outcomes for youth. perceived social norms for use and support for envi-
Results of process evaluations of these studies have ronmental changes such as changes in mass media,
shown that perceived empowerment, positive and policy enforcement, and program institutionaliza-
regular interpersonal communication, and develop- tion; and subsequent E-level changes effect reduc-
ment of specific, time-limited objectives predict tions in use prevalence and consumption among
community leader participation, intentions to con- youth. Over time, reversed and reciprocal directions
tinue to participate, satisfaction with work, and com- of influence may operate to maintain each level of
pletion of coalition objectives (Butterfoss et al., 1996; intervention. For example, policy changes that incor-
Carlson, 1990; Mansergh et al., 1996). For some porate set-aside funding for prevention skills training
communities, obtaining a champion or affiliating should affect future maintenance of S- and P-level
with a larger, credible organization predicted a coali- programs and program participation.
tion's ability to achieve objectives and maintain itself Interventions aimed at individuals have attempted
over time (Saxe et al., in press). The effects of com- to integrate P-, S-, and E-level components in com-
munity coalitions on changing youth drug use are prehensive community-based programs. Examples of
less clear. For example, initial results from the CSAP these types of programs include the youth-smoking-
Community Partnership grants indicated that while prevention program of the Minnesota Heart Health
the majority of partnership communities reported Project (Perry, Kelder, Murray, & Klepp, 1992), the
564 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

youth-smoking-prevention program of the North Kar- according to whether they directly address drug use
elia Project (Puska et al., 1982), Project Northland by focusing on skills and strategies to resist drug use
for youth alcohol use prevention (Perry et al., 1992), and avoid drug use environments or indirectly ad-
the Community Smoking Prevention Trial (Biglan dress use by either focusing on early risk factors for
et al., in press), and the Midwestern Prevention Proj- problem behavior or early protective factors against
ect for tobacco, alcohol, and drug use prevention later drug use. The distinction may have practical
(Pentz, in press, 1998; Pentz et al., 1989). All of these significance for planning or funding purposes. For
comprehensive programs have included multiple example, a school program focused specifically on
components representing P, S, and E levels of inter- drug use resistance may be funded by Safe and Drug
vention, usually by combining school programs with Free Schools funding, whereas a program focused on
parent, mass media, and/or community organization academic and social competence as protective factors
training. All have shown significant (20-60%) reduc- against later drug use may be funded as part of the
tions in use prevalence by youth compared to control regular school budget or as part of a special educa-
conditions; where evaluated over the long term, sev- tional grant. The distinction is not important for
eral have shown maintenance of effects of 8 years or judging effectiveness, since there is no research avail-
more. able that compares the relative effectiveness of direct
The capacity of comprehensive community-based and indirect approaches to drug use prevention.
prevention programs to address person, situation, and At the P level, some of the more common direct
environment risk factors across the board may be approaches include school health education pro-
more likely than school-based programs to produce a grams focusing on knowledge of tobacco or drug use
larger synergistic or interactive effect rather than a (e.g., SHEE; Connell, Turner, & Mason, 1985) and
simple additive effect on reducing drug use risk and, individual counseling student assistance programs fo-
consequently, drug use behavior. For example, cusing on seeking assistance for cessation as a means
avoiding drug use situations and peers is likely to pro- of harm reduction (McGovern & Dupont, 1991;
duce a decrease in perceived social norms for drug Swisher et al., 1993). Indirect approaches include
use and, over time, an actual decrease in social peer tutoring to enhance academic competence, in-
norms for drug use in the community (Hansen, dividual counseling focusing on stress reduction and
1992). Lower social norms, in turn, should produce anger management, and mentoring to build self-es-
an intolerant attitude toward drug use, which results teem (Tobler, 1992). Direct knowledge-based and
in a change in formalized drug policy. This sequen- self-esteem programs have shown no effect on drug
tial synergistic effect is larger than the simple effect use. Tutoring, as part of larger interventions aimed
of an individual's resistance to a drug use offer, re- at changing the school climate for learning, has
sulting in a decrease in that individual's drug use be- shown some effect on building academic compe-
havior. The synergistic effect is also larger than any tence, a protective factor against later drug use
additive effect derived from combining person- and (Hawkins et al., 1997). However, effects of the tutor-
situation- or group-level skills. For example, an indi- ing components, independent of other effects, have
vidual youth's resistance plus a parent's choice to no not been determined.
longer model drug use—for example, cigarette smok- At the S level, direct approaches include school
ing, in the presence of that youth — may affect family drug use resistance training programs, parent skills
members' drug use. However, youth resistance and training for monitoring youth and changing drug use
parent behavioral choices may steer the family to- modeling influences in the family (e.g., Kumpfer,
ward greater involvement in community prevention 1989), group counseling programs focused on mov-
activities, which reinforce nonuse social norms in ing adolescents away from drug-using peers and set-
the community. tings as a means of harm reduction (e.g., Eggert,
Thompson, Herting, Nicholas, & Dicker, 1994), and
DIRECT VERSUS INDIRECT school skills-training programs aimed at secondary
MODELS OF PREVENTION prevention, cessation, decision making about drug
AIMED AT INDIVIDUALS use, and motivation to achieve among youth identi-
fied as at high risk for school failure (e.g., Sussman,
On a cursory level, within and across levels of influ- 1996). Indirect approaches include school programs
ence, prevention efforts can be roughly categorized focused on building academic and social compe-
 PREVENTION AIMED AT INDIVIDUALS 565

tence among peer groups and bonding with schools, paigns and mass media programs focused directly on
competent peers, and parents (e.g., Hawkins et al., preventing drunk driving and heavy drinking, on the
1992); parent programs aimed at building parenting other hand, have shown significant short-term reduc-
support and parent-child communication skills to tions in alcohol use (e.g., Holder & Blose, 1987; Wa-
avoid the development of problem behavior (e.g., genaar, Murray, Wolfson, Forster, & Finnegan,
Dishion & Andrews., 1995); and job or recreational 1994). Local policy interventions aimed at restricting
time management skills training offered through youth access to tobacco and alcohol have also dem-
youth-serving agencies, such as Boys and Girls Clubs onstrated short-term reductions in sales to youth and
(e.g., Schinke, Orlandi, & Cole, 1992; St. Pierre, use prevalence (Forster et al., 1997; Jason et al.,
Kaltreider, Mark, & Aiken, 1992). Indirect approaches 1991; Perry & Jessor, 1985). Indirect approaches
also include group counseling programs for secon- have included neighborhood clean-ups and attempts
dary prevention, focused on providing support, stress to improve housing and public grounds (Wanders-
management, and anger control to youth who have man & Giamartino, 1980) as well as interventions
been identified as at high risk for school failure designed to improve school climate (Hawkins et al.,
(Gensheimer, Ayers, & Roosa, 1993; Sussman, Dent, 1997). These latter approaches have not yet been
Burton, Stacy, & Flay, 1995). Both direct (resistance) evaluated for their effectiveness in preventing drug
and indirect (competence) skills programs have use. However, there is evidence to suggest that im-
shown lasting effects on preventing tobacco, alcohol, proving and monitoring the physical environment
and marijuana use (e.g., Botvin et al., 1995; Hansen where drugs are used helps to decrease crimes and
et al., 1988). violence associated with drug use (Sampson, Rau-
Most longitudinal evaluations of S-level interven- denbush, & Earls, 1997). As with S-level interven-
tions have focused on school programs. Effects of tions, there are no studies that have systematically
school-based direct and indirect programs have been compared the efficacy of direct and indirect E-level
shown to last an average of 3-5 years, achieving 20- interventions. However, mechanisms by which each
40% relative net reductions in drug use (Tobler, approach might affect drug use behavior can be hy-
1992). The similarity in effectiveness of direct and pothesized according to figure 30.4. Direct approaches
indirect programs may be due to a focus on common attempt to develop empowerment and apply commu-
mediating mechanisms for behavior change. For ex- nity organization and resources directly to the prob-
ample, both drug-use-resistance skills-training pro- lem of restricting access to drugs and removing drugs
grams such as SMART and ALERT (Ellickson et al., from the environment. Indirect approaches attempt
1993; Hansen et al., 1988) and social-skills-training to develop empowerment and build safe environ-
programs such as Life Skills Training (Botvin et al., ments which are nontolerant of problem conditions
1995) teach assertiveness and counteracting per- and behaviors, including drug use and crime.
ceived social norms in the context of resisting peer
pressure. Both of these skills have been shown to me-
diate behavior change in adolescents (MacKinnon et TARGET POPULATIONS
al., 1991; Pentz, 1985). SMART and AAPT (Hansen
et al., 1988) teach self-efficacy to refuse drug use of-
Youth
fers; job skills and decision-making skills-training
programs teach self-efficacy to practice prosocial be- The majority of prevention programs have targeted
haviors that involve choosing alternatives to drug use youth, particularly school-attending adolescents.
(e.g., Schinke et al., 1992). Yet no published study Most of these programs are referred to as universal or
is available that systematically compares direct and primary prevention programs, that is, programs deliv-
indirect S-level interventions. ered to whole populations of youth in normative set-
At the E level, direct approaches include the de- tings such as classrooms, at the beginning of or just
velopment and monitoring of drug-free zones, com- prior to drug use onset (Kumpfer, 1989). Typically,
munity policing for drug use, and campaigns aimed these programs target early adolescents during the
at developing safe communities (Becker et al., 1989). transition year to middle or junior high school, con-
Where evaluated, these approaches have shown some sidered the first risk period for drug use onset (Pentz,
changes in attitudes toward drug use, but not in drug 1993). Evaluations of these programs suggest that in-
use behavior (e.g., Ennett & Bauman, 1994). Cam- tervention is effective with early adolescents regard-
566 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

less of sex, ethnicity, or risk background defined by adults, although there is some suggestion that post-
peer, family, or prior self use (e.g., Chou et al., 1998; high-school may represent a second risk period for
Johnson et al., 1990; Tobler, 1992). There is recent onset of drug use, particularly for tobacco use and
evidence to suggest that universal school-based pre- binge drinking in college students and young adults
vention programs may be more effective with early in blue-collar occupations (Haines & Spear, 1996;
adolescents in private/parochial compared to public Hingson et al., 1996; Holder & Wallack, 1986; John-
schools, although differences in effectiveness have ston et al., 1997; Wechsler, Isaac, Grodstein, & Sell-
been linked with differences in program implemen- ers, 1994). Prevention approaches offered on college
tation (e.g., Donaldson, Graham, Piccinin, & Han- campuses include the use of campaigns aimed at cor-
sen, 1995; Pentz, 1998). rection of perceptions of use, monitoring fraternities
Indirect approach programs, which seek to pro- and dorms for alcohol and drugs, counseling offered
tect against later drug use by building social and aca- through student counseling services, and cognitive
demic competence skills, are typically initiated dur- behavioral skills training to reduce acceptance of
ing the upper-elementary-school years (e.g., Hawkins binge drinking (Fromme, Marlatt, Baer, & Kivlahan,
et al., 1992; Kellam & Rebok, 1992). Programs that 1994; Haines & Spear, 1996; Wechsler et al., 1994).
are considered selective or indicated prevention pro- Community approaches targeting young adults in-
grams—that is, programs delivered to subgroups of clude the use of alcohol warning messages in bars,
youth who have been identified as at high risk for campaigns and server-training programs for limiting
drug use or who are already drug users—are typically alcohol consumption and using designated drivers,
targeted to older adolescents of high school age (e.g., tobacco and alcohol taxation and identification checks,
Eggert et al., 1994; Sussman, 1996). Exceptions in- and drunk-driving roadblocks and checks (e.g., Hing-
clude recent indirect approach programs for social son et al., 1996; Holder & Wallack, 1986; Mosher &
competence and impulse control, which target chil- Jernigan, 1988; Wagenaar et al., 1994). In controlled
dren and early adolescents who are at risk for conduct trials, cognitive behavioral skills training has shown
disorder or attention deficit disorder and their parents effects on reducing acceptance of drinking and
or families (e.g., Dishion & Andrews, 1995). These binge-drinking behavior among young adult drinkers
programs are usually delivered in small counseling (Fromme et al., 1994). Feedback to correct college
groups, in schools apart from the regular classroom student perceptions of self-drinking and social norms
setting, after school, or in youth-serving agencies. for drinking, either through surveys, diaries, or cam-
For adolescents of high school age, most preven- pus campaigns, has also shown effects on decreasing
tion efforts have focused drug use identification and perceived norms for drinking by 18% or more, and
referral on the use of no-use campaigns or organiza- for binge drinking by 8% or more (Agostinelli,
tional efforts, such as SADD, or indicated skills, or Brown, & Miller, 1995; Haines & Spear, 1996).
counseling programs for high risk youth, such as However, most alcohol and drug abuse prevention
SAPS (e.g., Kantor, Caudill, & Ungerleider, 1992; programs conducted as part of college campus ser-
Pentz, 1994a; Swisher et al., 1993). Programs target- vices are not effective (Werch, Pappas, & Castellon-
ing high-risk youth of high school age tend to show Vogel, 1996). Finally, relatively little is known about
the largest, most immediate reductions in drug use, the systematic use or efficacy of employee assistance
although most have not followed youth for several or community education programs for prevention of
years to determine how long effects maintain (50- drug use in young adults.
60% average reductions in use and problem behav-
iors related to use; e.g., Eggert et al., 1994; Kumpfer,
Women
1989; Sussman, 1996). In contrast, primary preven-
tion programs for early adolescents have shown large Universal and indicated prevention programs tend to
sustained effects (20-60% or greater net reductions include both males and females; most focus on S-
in use; Tobler, 1992). or E-level risk and prevention. These programs have
typically shown no differences in program effects on
drug use, with occasional exceptions of long-term
Young Adults
program effects on smoking males versus females (cf.
Compared to prevention programs for children and Schinke et al., 1992; Vartiainen, Fallonen, McAllis-
adolescents, fewer prevention programs target young ter, & Puska, 1990).
 PREVENTION AIMED AT INDIVIDUALS 567

There is some evidence to suggest that with low- have shown effects of prevention programs on His-
income pregnant women, nurse home visits may panic and African-American youth and have also re-
have a long-term impact on decreasing behavioral ported that tailoring the situational context of preven-
impairment due to alcohol or other drugs (Olds et tion material to reflect culture, language, and dress
a\., 1997). Home visits may have an effect by provid- of the particular group may enhance program effects
ing social support, since other studies suggest that the on drug use and HIV risk behavior (e.g., Schinke,
presence of supportive mentors or parents may con- Gordon, & Weston, 1990; Schinke et al., 1992). E-
tribute to reduced alcohol use (e.g., Rhodes, Gin- level interventions, primarily mass media and com-
giss, & Smith, 1994). Self-help manuals may improve munity-based prevention programs, have focused on
alcohol quit rates, at least for light drinkers (Reyn- specific ethnic groups rather than on cross-ethnic
olds, Coombs, Lowe, Peterson, & Gayoso, 1995). comparisons. Thus, assessment of relative efficacy of
Comprehensive health education programs for preg- these types of prevention programs compared to pro-
nant adolescents may encourage reduced alcohol grams for white populations is difficult. However,
and other drug use (Sarvela & Ford, 1993). However, some research suggests that mass media programs
most programs for pregnant women that have shown emphasizing strong family bonds and tailoring lan-
these effects are not randomized trials (Schorling, guage and content to culture might be effective with
1993); thus, definitive conclusions about the efficacy both Hispanic and African-American youth and com-
of these approaches are not possible. There is no munities (e.g., Kaufman, Jason, Sawlksi, & Halpert,
clear evidence to suggest that drug prevention pro- 1994; Romer & Kim, 1995). At least two studies sug-
grams are more or less effective with females than gest that community-based health promotion and or-
with males. Few drug prevention programs have ganization for alcohol and drug abuse prevention
been designed specifically for females; most of these may decrease rates of alcohol and marijuana use in
have included drug abuse prevention as part of a Native American communities compared to other,
larger set of program components or skills aimed at mixed-ethnicity communities (Ary et al., 1990; Chea-
protecting the health of pregnant adolescents and dle et al., 1995).
young adults, a population in which drinking has in-
creased substantially in the 1990s ("Alcohol con-
sumption," 1997). Results of these programs, which EFFECTIVENESS AND
include P- and S-level interventions, are mixed, with COST-EFFECTIVENESS
some showing no effects of indirect social skills train-
ing on pregnant adolescent use behavior (Jones & As noted earlier, S- and E-level prevention programs
Mondy, 1994; Palinkas, Atkins, Miller, & Ferreira, aimed at individuals can effect 20-40% or more aver-
1996) and some showing more declines in use from age net reductions in youth drug use, with a net re-
health education compared to a control condition duction defined as the difference between program
(Sarvela & Ford, 1993). and control group rates of increase divided by the
control group rate of increase, and 2-6% actual
changes in drug use prevalence (Pentz, 1994a). Costs
Ethnic Groups
of prevention have been estimated for school pro-
As with males and females, most prevention pro- grams (approximately $6 per student per year) and
grams include whatever ethnic groups are represent- community programs (approximately $24 per student
ed in the normative settings used for intervention. and family per year) (Kim, Coletti, Crutchfield, Wil-
Universal and indicated S-level prevention programs liams, & Hepler, 1995; Pentz, 1986; Rothman, 1995).
based in schools have shown significant program ef- Estimates of health care cost savings have been esti-
fects on different ethnic groups (e.g., Eggert et al., mated for smoking (ranging from $4,000 to $40,000
1990; Johnson et al., 1990; Schinke et al., 1992; per prevented smoker) and short-term treatment
Sussman, 1996). There is little published informa- ($2,000-$20,000 per individual; Pentz, 1994a). Thus,
tion on the relative efficacy of P- or S-level parent- cost-benefit can be estimated by calculating costs of
based prevention programs on different ethnic program delivery and prevented users in terms of the
groups, since most populations studied are primarily number of individuals reached by intervention. Cost-
white (Dishion & Andrew, 1995; Kumpfer, 1989). effectiveness may be estimated by comparing the in-
Programs that have utilized youth-serving agencies terventions discussed here with a typical school-
568 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

based health education program that shows no effects Alcohol consumption among pregnant and childbear-
on youth drug use. ing-aged women—United States, 1991 and 1995.
(1997). Morbidity and Mortality Weekly Report.
46(16), 346-350.
Altaian, D. G., Rasenick-Douss, L., et al. (1991). Sus-
SUMMARY
tained effects of an education program to reduce
sales of cigarettes to minors. American Journal of
This chapter discusses prevention programs aimed at Public Health, 81, 891-893.
individuals within a theoretical framework that repre- Ary, D. V., Biglan, A., Glasgow, R., Zoref, L., Black,
sents person (P), social situation (S), and environ- C., Ochs, L., Severson, H., Kelly, R., Weissman, &
ment (E) influences on drug use. In general, P-level Lichtenstein, E. (1990). The efficacy of social-influ-
interventions have had no effect on youth drug use. ence prevention programs versus "standard care":
The majority of evaluated programs have focused on Are new initiatives needed? Journal of Behavioral
S-level interventions, which have shown substantial Medicine, 1, 281-296.
and lasting effects on reducing youth tobacco, alco- Azjen, I., & Fishbein, M. (1980). Understanding atti-
hol, and other drug use. E-level interventions, in- tudes and predicting social behavior. Englewood
Cliffs, NJ: Prentice-Hall.
cluding mass media, community coalition building,
Bachman, J. G., Johnston, L. D., & O'Malley, P. M.
local policy, and multicomponent community inter-
(1991). Explaining the recent decline in cocaine use
ventions, have shown short-term effects on tobacco
among young adults: Further evidence that per-
and alcohol use, with multicomponent interventions ceived risk and disapproval lead to reduce drug use.
showing the most long-term effects. S- and E-level Journal of Health Social Behavior, 31(290), 173-184.
interventions aimed at individuals appear to be cost- Bandura A. (1977) Social learning theory. Englewood
effective methods to prevent health care costs associ- Cliffs, NJ: Prentice-Hall.
ated with drug use, particularly if implemented dur- Barrera, M., Jr. (1986). Distinctions between social sup-
ing the early adolescent years. port concepts, social support inventory: Measure and
models. American Journal of Community Psychology,
14(4), 413-445.
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 31

Prevention Aimed at
the Environment

Harold D. Holder

Environmental strategies for the prevention of alco- "catchment area" perspective, in which a "commu-
hol problems, smoking, and illicit drug use target the nity" is viewed as a collection of target groups with
context in which those substances are used, that is, adverse behaviors or associated risks. Prevention is in-
the physical, economic, social, and cultural sur- tended to reduce or eliminate these behaviors by
roundings. The environmental approach to preven- finding the individuals at risk and treating, educat-
tion seeks to reduce risk and harm for all persons ing, or otherwise responding to them in an appro-
rather than for specific subgroups or high-risk groups. priate manner to reduce their risk.
This chapter will first describe a systems or environ- For example, cirrhosis mortality might be an
mental prevention approach that is in contrast to an identified alcohol-induced problem in a low-income,
individual target group or catchment approach. Next, transient neighborhood. The city or a local service
the chapter will review a variety of environmental organization might naturally target this neighbor-
strategies beginning with the prevention of alcohol hood and seek to reduce the drinking levels of heavy,
problems (particularly acute problems), then the re- chronic (usually dependent) drinkers by establishing
duction of smoking (particularly by young people), a recovery center. Similarly, adolescents' use of alco-
and finally with illicit drug use (primarily interdic- hol and other drugs within a local middle school
tion of supply and severity of punishment). might be targeted with strategies aimed at increasing
preadolescents' resistance skills against peer pressure
CATCHMENT VERSUS to drink, along with developing afterschool activities
SYSTEMS PERSPECTIVES and school-based and family-focused education pro-
grams. Not affected in this model would be commu-
Health problem prevention has commonly focused nity members not directly involved with the targeted
on individuals at risk. Such a focus is based on a at-risk populations. Retail sales of alcohol and the in-

573
574 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

formal sources of alcohol and drugs to young people enters the blood, and the individual can become in-
might also be ignored. creasingly impaired over time as drinking continues.
Prevention planners using the catchment area ap- The rate of impairment is a function of such factors
proach select strategies that alter individual decisions as alcohol experience and tolerance, body weight,
and behavior or that provides direct services to indi- amount of food consumed while drinking, and rate
viduals. Education-based activities are favored, as are of alcohol intake.
early identification and intervention. Educational ef- A community systems approach to health prob-
forts often include mass media announcements, fo- lem prevention has been used less commonly than a
cus groups, targeted communication, health promo- catchment area approach, perhaps because the sys-
tion, health awareness, and physician education tems perspective is conceptually more complex. In
efforts. One-on-one and group treatment and coun- this perspective, a "community" is viewed as a set of
seling may be used. Many community prevention tri- persons engaged in shared social, cultural, political,
als for heart disease and cancer have employed some and economic processes. Prevention is intended to
form of a catchment area approach. The targets of modify the system in an appropriate manner to re-
these trials have been well-defined states or condi- duce health problems identified in the community
tions with which individual residents of a community (see Holder, 1998).
can be accurately associated. For example, if heavy Because substance abuse is viewed as a product
smoking is the target, then heavy smokers can be of the system (not simply attributable to a few mal-
identified so that education programs for smoking re- adapted individuals), prevention strategies focused
duction and cessation can be directed at them. Com- on the community at large can be more effective
munity heart disease projects make effective use of than those focused on specific individuals at risk.
the link between diet, exercise, smoking, and genet- Collective risk will be reduced by intervening to
ics to assist at-risk individuals in adjusting or moder- change the processes that contribute to alcohol prob-
ating their behaviors. lems, smoking, and illicit drug use.
The catchment area perspective has clear limita- Environmental strategies have been employed in
tions in substance abuse problem prevention. Heavy community public health initiatives, including some
users of alcohol and drugs have the greatest individ- heart disease and cancer prevention trials. For exam-
ual risk rates for most problems. For example, heavy ple, some projects have persuaded restaurants to offer
drinkers are more likely to have a traffic crash when low-fat menu alternatives, to make low-salt food prod-
they drink and drive. However, they are not collec- ucts available and prominently displayed in grocery
tively the largest at-risk group. Their absolute num- stores, to get warning labels on the hazards of smok-
bers are often so small that they contribute only mod- ing installed at points of sale for cigarettes, and to
estly to most aggregate problems. For example, increase the number of nonsmoking areas within
infrequent and moderate users of alcohol, who are public spaces and in the workplace. Some commu-
not currently nor likely ever to be dependent on alco- nity health trials have used public policy mandates
hol, account for a greater number of alcohol-in- requiring the availability of low-fat food alternatives,
volved traumas such as auto crashes, falls, or drown- or increasing the retail price of cigarettes, or legally
ings than do heavy users (see Edwards et al., 1994). restricting availability of cigarettes by banning vend-
Young people, in particular, account for a dispropor- ing machines.
tionately large number of alcohol-related problem The community is a dynamic system. The system
events, such as traffic crashes and accidental injuries. changes and adapts as new people enter and others
Most heavy, addicted drinkers continue their drink- leave, as alcoholic beverage or cigarette marketing
ing pattern throughout their lives and never incur an and promotion evolve, and as social and economic
alcohol-involved traffic crash or an encounter with conditions, including employment and disposable
the police. On the other hand, an 18-year-old with income, change. No single prevention program, no
limited driving and drinking experience may cause a matter how good, can sustain its impact, particularly
serious auto crash with only a small amount of alco- if system-level changes are not accomplished (see
hol in the blood system. Physical and cognitive im- Holder & Wallack, 1986; Wallack, 1981). Even if all
pairment begins as soon as the body begins to metab- high-risk individuals (e.g., alcoholics, drug addicts,
olize ethanol. Impairment increases as more ethanol or heavy smokers) could be identified and somehow
 PREVENTION AIMED AT THE ENVIRONMENT 575

magically "fixed," if the system structure remained in the drinking context. Alcohol availability received
unchanged then high-risk replacements naturally considerable attention worldwide during the early
would be generated by the system. part of the 20th century with Prohibition and, in
more recent years, with debates about increasing or
relaxing restrictions on retail availability of alcohol.
ALCOHOL PROBLEM PREVENTION
Of course, a number of countries have monopo-
lies on some form of retail sale, and total prohibition
Environmental strategies to prevent alcohol prob-
is practiced in many Muslim countries. The socialist
lems are those that affect the drinking context, in-
countries in central and eastern Europe, as well as
cluding the general economic and physical availabil-
France, Switzerland, and the Scandinavian coun-
ity of alcohol for consumption.
tries, operate some form of retail or wholesale mo-
nopoly. In North America, Canadian provinces and
Price some U.S. states operate monopolies for distilled spir-
Perhaps the area of research with the most consistent its and wine.
evidence is the study of alcohol price and consump- The opening of new types of alcohol outlets in
tion. Price has historically been an important part of many countries has been accompanied by increased
alcohol problem prevention in many parts of the consumption and, in many cases, associated in-
world. Alcoholic beverages appear to behave in the creases in problems. Kuusi (1957) showed that open-
market like other goods: As prices decline and/or in- ing state alcohol shops in Finnish rural communities
come increases, then alcohol consumption tends to increased consumption for males by 40% and 15-
increase. A number of studies have estimated this re- 19% for females. Amundsen (1967) found that open-
lationship (the elasticity or sensitivity of alcohol con- ing a wine outlet in Notodden, Norway, in 1961 in-
sumption to changes in price and income). See, for creased wine consumption, while spirits and illegal
example, Ornstein and Levy (1983), Saffer and Gross- alcohol declined only slightly. Nordlund (1974) con-
man (1987), Levy and Sheflin (1983), and Cook and cluded that opening off-license monopoly outlets in
Tauchen (1982). See Osterberg (1995) for a review Notodden, Elverum, and Alesund was associated with
of international research on the price elasticity of al- no essential changes in overall consumption. This re-
cohol. search has been subjected to some methodological
The price elasticity of alcohol is influenced by criticisms as using only self-reported survey data (Ahl-
many other factors. It has been pointed out that the strom-Laasko, 1975).
more restricted the availability of alcohol, the smaller The availability of distilled spirits for on-premise
the influence of changes in prices and incomes of consumption by the individual drink (called liquor
consumers will be. See Malmqvist (1948) and Huit- by the drink, or LED) is now commonplace in most
feld and Jorner (1972) for analyses of Swedish data of the United States and other countries. At the end
and Gruenewald, Ponicki, and Holder (1993) for re- of the U.S. Prohibition, all states except nine legal-
cent analyses of U.S. data. ized LED. Since 1968, however, all nine states have
Since the overall consumption of distilled spirits, legalized the sale of LED, and yet studies that specif-
as well as consumption of spirits by heavy drinkers, ically evaluated LED in the United States were rare
can be demonstrated to be sensitive to price, it is and provided limited information. Bryant (1954)
reasonable to hypothesize that other alcohol-related found no increase in alcohol problems after imple-
problems will also be price-sensitive. Cook (1981) in- mentation of LED in the state of Washington. His
vestigated the short-term effects of changes in liquor findings are confounded by limited time series data
tax on the auto accident death rates and found that (a long series of observations after the intervention
such fatalities declined as taxes increased (and thus, but only one prior), reliance entirely on measures that
increased retail prices). are particularly sensitive to enforcement (e.g., public
drunkenness arrests), and other biases. Womer (1978)
found a minor impact of LED on consumption in
Physical Access to Alcoholic Beverages
Virginia, but he used no control group and felt his
Restrictions on physical and economic availability analysis was inconclusive. Hoadley, Fuchs, and
are intended to limit consumer access or to intervene Holder (1984) utilized multiple-regression analysis
576 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

with cross-sectional time series data to analyze the a conclusion that ending state monopolies on retail
impact of state-level regulatory measures on per cap- sale of alcohol increases alcohol consumption.
ita distilled-spirits consumption during the period
1955-1980. Their results suggested that the absence
Density of Alcohol Outlets
of LED was associated with higher distilled-spirits
consumption. The number and concentration of alcohol retail out-
Holder and Blose (1987) conducted an inter- lets are suggested to increase consumer convenience
rupted-time-series analysis of counties within the and possibly provide a social reinforcement of drink-
state of North Carolina and found that spirit sales ing behavior. Support for this observation was pro-
rose by between 6% and 7.4% in counties imple- vided by Colon (1982), as well as for the counterob-
menting LED. LED was also associated with statisti- servation that outlet densities are only a response to
cally significant increases of 16-24% in both the demand for alcoholic beverages (Ornstein & Hans-
number of police-reported alcohol-related accidents sens, 1985). Restricting alcohol availability by using
and single-vehicle nighttime accidents among male the law has been a central part of policy efforts in
drivers 21 years of age and older in counties imple- Canada, the United States, and many other parts of
menting LED. No change in alcohol-related acci- the world (Kortteinen, 1989; Room, 1987).
dents was found for non-LBD counties. Therefore, The other domain of effects for public monopo-
when distilled spirits are made available in bars and lies is from overall reduction in alcohol availability.
restaurants, consumption and drinking and driving Nordlund (1981) examined the effect on total con-
increase. sumption in two towns of a net reduction of beer
Another change in alcohol availability has been outlets by concentrating beer in one or a few spe-
the introduction of wine sales into privately licensed cialty beer stores. Nordlund found that this so-called
outlets such as grocery stores and liquor stores. Mul- beer monopoly produced a reduction in beer sales
ford and Fitzgerald (1988) concluded that the end of but that some of this reduction was replaced by sale
the state retail wine monopoly in Iowa did not in- of wine and spirits. No overall reduction in total alco-
crease wine consumption. Macdonald (1986) found hol consumption was found.
that the introduction of wine privatization in Idaho, A critical subset of economic studies have been
Maine, Virginia, and Washington produced greater reported that included market variables in their anal-
wine consumption in three of the four states. Smart yses of time series (McGuinness, 1983; Walsh, 1982)
(1986) concluded that the introduction of wine into and time series cross-sectional (Wilkinson, 1987)
grocery stores in the Canadian province of Quebec data on physical availability and consumption. The
produced no increase in wine sales or total per capita first two studies, using data from the United King-
alcohol consumption. Wagenaar and Holder (199la) dom, suggest that availability (measured in terms of
completed interrupted-times-series (Box & Jenkins, outlet densities) may be related to consumption rates
1976) analyses of the elimination of the state retail but are limited by the shortness of the series studied
wine monopoly in Iowa in 1987 and West Virginia (at most, 25 years). A study by Wilkinson (1987) sug-
in 1981 and found statistically significant increases gested a small but significant relationship between
in both states for total absolute alcohol consumption. the variable number of outlets and alcohol sales.
Iowa was also the first state since the end of Prohi- Godfrey (1988) analyzed alcohol sales data and
bition in the United States to end its retail spirits indicators of availability in Great Britain. Using time
monopoly; it did so in 1987. In a separate study, series data, she found evidence that outlet densities
Holder and Wagenaar (1990) completed a time se- are related to use for spirits, wine, and beer but that
ries analysis of wine as well as spirits and beer sales only beer consumption is related to density of beer
for Iowa and for total alcohol consumption for all outlets.
bordering states. They concluded that there was a net A stronger design and associated analysis was re-
increase in absolute alcohol consumption, which ac- ported later by Gruenewald et al. (1993), who con-
counted for a 13.7% decrease in wine sales, no ducted a time series cross-sectional analysis of alco-
change in beer sales, and a 9.5% increase in spirit hol consumption and alcohol outlets by type of
sales. No changes were found in spirit sales in all beverage (beer, wine, and spirits) over the 50 U.S.
states bordering Iowa. Overall, the evidence supports states. The authors analyzed data over the period
 PREVENTION AIMED AT THE ENVIRONMENT 577

1975-1984 for spirits and wine. Beer had an insuffi- years old. A later study by O'Malley and Wagenaar
cient time series database to support an analysis of (1991) found that the minimum age effect on traffic
beer. The design and analyses used by these authors crashes continued well into young adulthood and did
included beverage prices and income as covariates, not decay after young people reached the legal drink-
as well as a subset of sociodemographic variables hy- ing age.
pothesized to be related to consumption. The design Surveys of students in Canada reported findings
includes a relatively large time series data set of 114- similar to those in the United States. In 1971, the
290 time series cross-sectional units. The results drinking age for Ontario was lowered from 21 to 18.
yielded elasticities of the response of retail sales of Cross-sectional surveys of Toronto high school stu-
alcohol to outlet densities of from .1 to .3 for spirits dents were undertaken in 1968, 1970, 1972, and
and .4 for wine. 1974. The proportion of students who had used alco-
There has been increased interest in the United hol at least once increased between the surveys im-
States in local regulation of the density of alcohol mediately before and after the age change (1970-
outlets (Curry, 1988; Wittman & Hilton, 1987; Witt- 1972), but an even larger increase occurred between
man & Shane, 1988). For example, the state of Cali- 1968 and 1970 (Smart & Fejer, 1975). A study of
fornia has limited the number of distilled spirits out- Toronto college students found an increase in fre-
lets per 100,000 population for both on-premise and quency, but not in quantity per occasion, due to the
off-premise sales in each county. law (Smart, Fejer, & White, 1972).
These studies of a variety of changes in alcohol Whitehead et al. (1975) and Williams, Rich, Za-
availability support a conclusion that the number dor, and Robertson (1975) found an increase in the
and concentration of alcohol retail outlets have been incidence of alcohol-related car crashes among the
suggested to increase consumer convenience, and young. Schmidt and Kornaczewski (1975) found sig-
thereby, to increase consumer purchases and con- nificant increases in the number of traffic accidents
sumption. among Ontario drivers 16-19 years old. Whitehead
(1977), following up an earlier study (Whitehead et
al., 1975), found that the higher rates of alcohol-re-
Minimum Age of Purchase
lated crashes among young drivers continued over
At the end of U.S. Prohibition, each of the states es- the 4 years of his study period after the age change.
tablished a minimum age of purchase or drinking. A study of alcohol-related crashes for 16- to 20-
The states varied in terms of the established legal year-old Saskatchewan drivers by Shattuck and White-
age: some 18, some 19, and some 21. In addition, head (1976) found that after the minimum drinking
some states established different legal ages by bever- age was lowered in 1972, there was an increase in
age (e.g., 18 for beer and wine and 21 for spirits). In such crashes. Bako, MacKenzie, and Smith (1976)
the 1980s, all U.S. states were required to adopt a found over a 100% increase in the incidence of auto
uniform 21 minimum age for all beverages. crash fatalities in Alberta among youthful drivers
A number of studies were undertaken to deter- whose blood alcohol levels were 0.08% or more, re-
mine the effect of this uniform age (see summaries lated to the lower minimum drinking age. Increasing
in Holder, 1987; Wagenaar, 1983). The U.S. Gen- the minimum age for purchase or drinking alcohol
eral Accounting Office (USGAO) (1987) reviewed can reduce consumption and alcohol-involved traffic
32 published research studies both before and after accidents among youth.
the law changed. However, many of these studies
were judged to be of insufficient scientific quality to
Service of Alcohol
inform policy decisions. Of the 14 studies that did
meet the USGAO's methodological criteria, 4 ad- Bars and restaurants licensed to serve alcohol are in-
dressed fatal crashes across several states and 5 ad- creasingly viewed as locations for interventions with
dressed fatal crashes in individual states. The US- drinkers. Reviews of the impact of beverage server
GAO concluded that there was solid scientific intervention can be found in Saltz (1987, 1989,
evidence that increasing the minimum age for pur- 1993), Russ and Geller (1986), Gliksman et al. (1993),
chasing alcohol reduced the number of alcohol-in- and McKnight (1988). More recent research studies
volved traffic crashes for young people under 21 of server training (Saltz, 1988; Saltz & Hennessy,
578 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

1990a, 1990b) have demonstrated that server training ument changes in server behavior in response to lia-
is most effective when coupled with a change in ac- bility, and further replication of the study in other
tual serving policy and practices of a bar or restau- locations is necessary. The potential for liability to
rant. A policy can reinforce the server. Such research affect bar and restaurant alcohol-serving practices is
supports a conclusion that changes in server behavior supported, however.
can lower the blood alcohol level (BAL) of patrons
leaving licensed establishments and thus the subse-
Restrictions on Time of Retail Sale
quent risk of becoming involved in a traffic crash or
other alcohol-involved problem (Saltz, 1989). Smith (1987, 1988a, 1988b, 1988c) conducted a se-
A study by Holder and Wagenaar (1994) found ries of studies on a variety of changes in hours and
that in the one U.S. state (Oregon) that mandated days of sale made in various cities and states of Aus-
server training for all persons who sell alcohol, such tralia (see also Lind & Herbert, 1982), and one de-
training produced a statistically significant reduction scriptive study has been reported on the impact of
in alcohol-involved traffic crashes when at least 50% extended operating hours at Scottish public houses
of servers had completed training. In general, server- and hotels (Bruce, 1980). These studies present
training and alcohol-serving policies by bars and res- some, at least anecdotal, evidence for impacts of
taurants can reduce acute alcohol problems. changes in hours and days of sale upon a number of
alcohol problems.
Smith (1988c), for example, presented a study in
Server Liability
which the introduction of Sunday alcohol sales in
Server liability is civil liability faced by both com- the city of Brisbane, Australia, was related to casualty
mercial servers and social hosts for injuries or dam- and reported property damage traffic crashes. How-
age caused by their intoxicated or underage drinking ever, these results are not unequivocal, as these ef-
patrons and guests. A study by Holder et al. (1993) fects could be contaminated by other trend effects
found that the level of actual liability in a state ap- on Sunday sales and nonequivalent distribution of
pears to be linked to the level of publicity about such crashes over days of the week (see Gruenewald, 1991).
liability and to the awareness of such liability by own- Olsson and Wikstrom (1982) examined the effects
ers and managers of licensed establishments and thus of an experimental Saturday closing of liquor retail
to differences in self-reported serving practices. This stores in Sweden. They found an 8% reduction in
liability directly affects outlets that serve or sell alco- alcohol sales and a corresponding reduction in intox-
hol. It is based upon a policy that alcohol-serving or icated persons and the number of police interven-
sales establishments are legally liable for the negative tions in domestic disturbances. Nordlund (1985) an-
consequences caused by customers who were inap- alyzed the effects of an experimental 1-year Saturday
propriately provided alcohol in the establishment. closing in Norway for state stores. The findings were
The prevention approach here is to encourage estab- that the Saturday closings had little effect on overall
lishments to engage in safer alcohol-serving and sales consumption and that consumers adjusted to the
practices. This liability has been established in many closing by purchasing wine and spirits on other days
U.S. states following such situations as alcohol being or by purchasing beer. He did find that effects on
served to an obviously intoxicated person who subse- heavy, problematic abusers were significant. The
quently crashes his or her car and injures others, or number of police reports of drunkenness and domes-
as serving to an underage drinker who is later in- tic problems on Saturdays and early Sundays de-
volved in a trauma event (Holder et al., 1993; Mo- creased dramatically.
sher, 1979). The potential of such liability to bring Reducing the days and times of alcohol sales re-
about positive changes in the serving practices of re- stricts the opportunities for alcohol purchasing and
tail establishments has not been comprehensively can reduce heavy consumption.
evaluated. Wagenaar and Holder (1991b) found that
a sudden change in server liability in the state of
Alcohol Content
Texas produced a statistically significant 6-7% reduc-
tion in alcohol-involved traffic crashes. Unfortunate- Lower-alcohol beverages have been used in recent
ly, this macrolevel study was not able to directly doc- years in many countries as a potential means to re-
 PREVENTION AIMED AT THE ENVIRONMENT 579

duce levels of absolute alcohol consumed and, thus, tiveness of per se laws, drinking and driving enforce-
associated levels of intoxication. These lower-alcohol ment, and sanctions or punishment.
beverages have often been taxed at lower levels, Per se laws specify the blood alcohol level or con-
which produces lower prices in countries such as centration at which a driver is considered legally im-
Sweden, Norway, and Finland, where such low-alco- paired (i.e., the level at which a driver can be ar-
hol beer is sold in grocery stores rather than in state- rested and charged with drinking and driving). The
monopoly retail stores. This lower taxation has been per se level has been declining in Europe, Australia,
used in many Scandinavian countries, which have New Zealand, and North America. This reduction in
encouraged three classes of beer according to their the legal level of driver impairment has been associ-
alcohol content and at least two classes of wine. See ated with reduced crash levels (Liben, Vingilis, &
Osterberg (1991) for a summary of such policies. Blefgen, 1987; Ross, 1982; Zador, Lund, Fields, &
The introduction of medium-strength (3.6% alco- Weinberg, 1989).
hol by weight) beer in Sweden and Finland provides Drinking-and-driving enforcement has also been
additional evaluation of the results of changes in the increased in many countries in the past decade. Ross
form of alcohol availability. Noval and Nilsson (1984) (1982) pointed out that it might be that the threat of
found that total alcohol consumption in Sweden was enforcement, or public expectation that one may be
substantially higher when medium-strength beer could stopped and arrested, has had more influence than
be purchased in grocery stores (i.e., between 1965 the actual enforcement. However, increased public
and 1977), rather than only in state monopoly stores. expectations of arrest must be reinforced with actual
The private sale of medium-strength beer in Sweden increased enforcement to have sustained effect (see
ended in 1977. In Finland, the sale of medium- reviews by Hingson, Howland, & Levenson, 1988;
strength beer began in 1969 in all food stores and Vingilis & Coultes, 1990; Zador et al., 1989).
most cafes. Medium-strength beer had been avail- The use of random roadside checks by police for
able for a number of years in the state monopoly alcohol-impaired drivers in such countries as Austra-
stores and restaurants (Osterberg, 1991). Makela lia (Homel, 1986, 1990), Canada (Mercer, 1985),
(1970) concluded that the number of drinking occa- and Great Britain (Ross, 1988a, 1988b) has demon-
sions on which the blood alcohol level reached strated the effectiveness of this type of drinking-and-
0.10% increased by as much as 25% in 1 year follow- driving enforcement. Sanctions or punishment of a
ing the change, and there was a substantial increase person convicted of drinking and driving has also in-
in the estimated numbers of heavy drinkers (Bruun creased in most countries. License revocation is one
et al., 1975). Skog (1988) analyzed the effect of the type of punishment that has been shown to be effec-
introduction of light beer in Norway in March 1985 tive in reducing repeated incidents of drinking and
and found a substitution of lower for higher alcohol driving. The threat of loss of one's driver's license has
content beer, but the estimate was not statistically been shown to have important effects in deterring
significant. He concluded that the data do not permit drinking and driving by persons previously convicted
unequivocal evidence of substitution or addition. of DUI (driving under the influence) (see review by
Providing beverages with lower alcohol content Ross, 1991).
provides the consumer with choices in strength of
beverage that has the potential to reduce the level of
Zero-Tolerance Laws
alcohol impairment.
The National Highway Systems Act in the United
States provides incentives for all states to adopt "zero-
Drinking and Driving Laws
tolerance laws" that set maximum blood alcohol con-
Public policy intended to reduce alcohol-involved centration (BAG) limits for drivers under 21 to 0.02%
traffic crashes and associated injuries and deaths is or lower beginning October 1, 1998 (National Insti-
most often represented in each country by laws con- tute on Alcohol Abuse and Alcoholism [NIAAA],
cerning drinking and driving. Most developed coun- 1996). An analysis of the effect of zero-tolerance laws
tries have increased the penalties for drunk driving in the first 12 states enacting them found a 20% rela-
and their enforcement of such laws. A considerable tive reduction in the proportion of single-vehicle
research base exists that documents the relative effec- nighttime (SVN) fatal crashes among drivers under
580 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

21, compared with nearby states that did not pass drinking-and-driving offender from starting his or her
zero-tolerance laws (Hingson, Heeren, & Winter, auto after drinking (Voas, 1988).
1994; Martin, Grube, Voas, Baker, & Hingson, 1996).

Self-Extinguishing Cigarettes
Administrative License Revocation Laws
Such cigarettes are an example of a safety approach
Laws permitting the withdrawal of driving privileges to reduce the likelihood of fire, for example, in bed.
without court action have been adopted by 38 states Research has shown that often persons are drinking
to prevent traffic crashes caused by unsafe driving and smoking and a fire is begun in bed or on a cloth-
practices, including driving with a BAG over the le- covered piece of furniture. Self-extinguishing ciga-
gal limit (Hingson et al., 1996). These laws were as- rettes will not continue to burn unless regularly used
sociated with a 5-9% decline in nighttime fatal by a smoker. Such cigarettes are proposed as a means
crashes in some studies (Hingson, 1993; Zador et al., to reduce the chance of fires at home or in hotels.
1989). There has been little published research on this
strategy.

Curfew Laws
Health Education and Warnings
Curfew laws establish a time when children and young
people below certain ages must be home. While this Health education is not typically an environmental
policy was not initially considered an alcohol-prob- strategy for prevention as education seeks to change
lem prevention strategy, research has shown positive the behavior of individuals directly. However, the use
effects. In those states that established such curfews, of warning messages in the environment also shapes
alcohol-involved traffic crashes for young people be- the overall drinking context. For example, the U.S.
low the curfew age have declined (Preusser, Wil- government has required, as of November 1989, that
liams, Zador, & Blomberg, 1984; Williams, Lund, & all containers for alcoholic products contain the fol-
Preusser, 1984). lowing warning:

GOVERNMENT WARNING: (1) According to

Restrictions on Drinking Locations the Surgeon General, women should not drink
alcoholic beverages during pregnancy because of
Specifying locations where drinking cannot occur is
the risk of birth defects. (2) Consumption of alco-
a policy that has been employed in a number of holic beverages impairs your ability to drive a car
forms throughout the world but has not been system- or operate machinery, and may cause health
atically evaluated. The policy has been implemented problems.
with laws about public drinking and/or public intoxi-
cation, as well as those prohibiting drinking in parks There are at least three rationales for requiring a
or recreational locations, or at the workplace. Discus- warning label on alcohol containers: (a) to acknowl-
sions of these types of interventions are contained in edge the government's recognition of health and
Giesbrecht and Douglas (1990) and "Communities safety risks associated with alcohol as a commercial
Mobilize to Rescue the Parks" (1991). product, (b) to inform the public that these risks exist
and reduce the specific alcohol-involved problems
cited on the label, and (c) to be a part of a compre-
Automobile Ignition Interlocks
hensive alcohol policy to reduce problems.
These are devices that can check the blood alcohol Alcohol warning labels are intended to lower risk
level of the driver before he or she begins to drive. associated with drinking while pregnant and/or while
The automobile cannot be started if the level is operating machinery. See Hilton (1992, 1993) for re-
above zero or some other preset limit. This device views of existing research on warning labels. For
has been discussed as a potential means to reduce all warning labels to be successful, people must read the
drinking and driving but has been used in the United warnings and thus be aware of the message. If read,
States primarily as a means to prevent a multiple the content of the warning should be familiar.
 PREVENTION AIMED AT THE ENVIRONMENT 581

Greenfield, Graves, and Kaskutas (1992) conducted ior is not surprising since educational efforts alone
three waves of national telephone surveys during the have rarely been shown to produce long-term behav-
survey years of 1989, 1990, and 1991 and found that ioral change.
the percentage of respondents reporting conversa- One illustration of this point comes from traffic
tions about dangers associated with drinking in- safety. Public service information campaigns on TV
creased from 45% in 1989 to 51% in 1991. have become the most frequent types of general edu-
A lower recognition of the warning among wom- cation and are produced by the federal government,
en of childbearing age was observed by Hankin et the National Association of Broadcasters, and bever-
al. (1993a) among black, inner-city pregnant women. age producers such as Coors and Anheuser-Busch.
Mazis, Morris, and Swasy (1991) found slow diffu- Public service announcements (PSAs) are intended
sion of the warning label in Gallup Polls from 1989 to change drivers' behavior by raising awareness of
to 1991. A report by Parker, Saltz and Hennessy (1994) risk.
comparing pre- and postwarning label data found Evaluation of the effects of PSAs on drinking and
that drinker-drivers and impaired drivers (based on driving is quite sparse. Worden, Waller, and Riley
self-reports) were more likely to recall the warning (1975) found that a media campaign conducted in
label and its content. conjunction with enforcement produced significant
For the warning to reduce risk, people must be changes in knowledge, attitudes, and related behav-
concerned about the content of the warning and ac- ior. However, the authors found that the effect de-
tually change their drinking. Greenfield et al. (1992) cayed rapidly over time. In a review of 15 years of
found an increase in self-reported limits on drinking mass communication campaigns designed to change
among women of childbearing age in the national drinking-and-driving behavior, Haskins (1985) con-
surveys. Hankin et al. (1993b) found little increase cluded that very little had been learned.
in the perceived risk of drinking during pregnancy Atkin (1988) concluded, following his review of
among pregnant women in prenatal clinics. Hankin public service information programs for the Surgeon
et al. (1993b) found a 7-month lag in the impact of General's Workshop on Drunk Driving, that drunk-
the warning label on the drinking of pregnant wom- driving educational campaigns appear to have rela-
en. Among pregnant drinkers, there was a signifi- tively little effect on drinking and driving. And this
cant reduction in alcohol consumption among light finding is consistent with campaigns concerning safe-
drinkers but no change among heavy drinkers. This ty belt promotion, substance abuse prevention, and
finding is similar to the conclusion of Parker et al. other health practices.
(1994), who found no change in drinking-and-driv- Publicity alone has rarely produced lasting changes
ing behavior among self-reported at-risk drinkers. in safety behavior (Wilde, L'Hoste, Sheppard, &
Greenfield et al. (1992) found in their national Wind, 1971). The best understanding of effects from
survey that the proportion of people who reported media attention to DUI enforcement can be seen as
deciding not to drive after "having too much to an interaction between mass media information and
drink" rose from 35% in 1989 (prelabel) to 43% in the personal experience of drivers. Thus, Ross (1982),
1990 (postlabel). Young males increased from 72% in his report on the British Road Safety Act of 1967,
to 81% in their response to this question. Andrews, noted that the public was initially led to believe that
Netemeyer, and Durvasula (1991) reported that col- the probability of being tested for alcohol and ar-
lege students found the drinking-and-driving warning rested was much higher than it actually proved to be.
to be believable. Overall, the U.S. alcohol container He stated, "It seems reasonable to me to ascribe (the
warning labels have achieved greater awareness over subsequent reduction in effectiveness of the law) to
time, particularly among drinkers most at risk for al- the gradual learning by U.K. drivers that they had
cohol-related problems noted in the warning. How- overestimated the certainty of punishment under the
ever, there is little evidence of behavioral change law" (p. 34).
among those at-risk groups as a result of the warning An alternative finding was reported by Worden,
label. But there is evidence of increased discussions Flynn, Merrill, Waller, and Haugh (1989), who con-
among people about the dangers associated with al- ducted a public information campaign using "BAG
cohol consumption as a result of the public's expo- Estimation" cards which told drivers the steps for
sure to warning labels. The limited change in behav- determining their own BACs. These "Know Your
582 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

Limit" cards were widely distributed in an experi- given to clean indoor air policies, restrictions on to-
mental community. Using roadside survey and com- bacco advertising and promotion, policies to limit ac-
munity survey data, the authors found, following the cess to tobacco by youth, comprehensive school
campaign, that only 0.06% of drivers in the experi- health programs, and excise tax and other economic
mental community were over the legal limit, while disincentives. Reid et al. (1995) reached similar con-
3.00% of drivers were over the limit in the control clusions and argued that isolated interventions target-
community. ing young people, particularly countersmoking ad-
Educational strategies such as warning labels can vertising, are less likely to have long-lasting effects.
play at least two important roles in a comprehensive They argue that schools alone cannot be expected
prevention program. First, warning labels seem to in- to change historical community values that tolerate
crease public awareness of the relationship between smoking. Such youth-targeted educational programs,
a specific health problem (e.g., birth defects related Reid et al. (1995) also concluded, are unlikely to af-
to drinking by a pregnant woman) and alcohol itself. fect the smoking behavior of high-risk (of multiple
This relationship, which may seem so obvious to sci- problems) youth. They do believe that public edu-
entists involved in the study of alcohol and to public cational efforts can affect the general attitudes and
health advocates, is simply not understood by either norms of the community and provide favorable sup-
the general population or women of childbearing port for environmental strategies. The following re-
age. The research summarized above does support views the research support for various smoking-
optimism that warning labels can increase awareness prevention strategies based upon an environmental
of alcohol risks among women of childbearing age approach.
and drinking drivers as well as the general public.
Thus, one can infer that the alcohol warning label
Price
contributes to public awareness and that public
awareness leads to support for preventive action and Price of cigarettes (and other tobacco products), like
public policy. price of alcohol, is directed at creating an economic
barrier against the purchase of such products. Ciga-
rette purchases respond to price changes as do other
SMOKING PREVENTION retail products.
Economists have often studied the link between
Like alcohol problem prevention, smoking preven- the price and consumption of cigarettes. Like alco-
tion and reduction have a history of research about hol, cigarettes are a commercial product subject to
the effectiveness of environmental or policy strategies the same laws of supply (expressed in level of price)
for the reduction of current smoking and reducing and demand as other products. This may be espe-
smoking initiation by young people. However, not as cially true for young people who are at the point of
many environmental prevention alternatives have initiation and who may not have as much disposable
been attempted for smoking as for alcohol problems. income as adults. For example, Baltagi and Levin
Environmental strategies for smoking prevention (1986) employed a pooled cross-sectional analysis of
described here are generally of three types: (a) price, cigarette demand in response to changes in price
(b) restrictions on availability, and (c) restrictions on from 1963 to 1980 from 46 U.S. states and found
location of smoking. Examples of prevention re- an important elasticity relationship; that is, as price
search conducted on these approaches are reviewed increased (relative to inflation), demand declined,
below. and when price declined, demand increased. This
Two overviews of the potential effectiveness of finding was replicated by Keeler, Hu, Barnett, and
prevention efforts to reduce smoking were provided Manning (1993), who used monthly time series data
by Brownson, Koffman, Novotny, Hughes, and Erik- from 1980 to 1990 from California. The price elastic-
sen (1995) and Reid, McNeill, and Glynn (1995). ity of cigarettes has also been confirmed in research
Brownson et al. (1995) concluded that environmen- in Canada, where it was possible to test the effects of
tal strategies are among the cost-effective strategies to a purposeful increase in taxes (thus affecting price)
reduce tobacco use and prevent cardiovascular dis- (Lewit, Coate, & Grossman, 1981), and in the
ease. The authors recommended that priority be United Kingdom (Godfrey & Maynard, 1988; Town-
 PREVENTION AIMED AT THE ENVIRONMENT 583

send, 1987). See discussion and review of the variety forcement are confirmed by Feighery, Altman, and
of estimates of the price elasticity of cigarettes by Shaffer (1991), who found in four Northern Califor-
Zimring and Nelson (1995). nia communities that increased community educa-
The major means available to alter the price of tion alone had limited effect in reducing illegal to-
cigarettes are the excise taxes applied to the product bacco sales to minors. But education did promote
by the federal and/or state governments. While pro- community support for more aggressive enforce-
ducers, wholesalers, and retail outlets can make ment, and education plus enforcement decreased
adjustments in prices to accommodate increases in over-the-counter cigarette sales significantly. Vend-
excise taxes, the net effect of any increase in ex- ing-machine sales were unaffected. Thus, the restric-
cise taxes is an increase in the final retail price (see tions or bans on vending machines as described be-
Sweanor et al., 1992). low become quite relevant.
In summary, the research evidence supports a Every state has a minimum purchase age that has
conclusion that smokers respond to cigarette prices a variety of levels of enforcement across states and
and that excise taxes can be an effective prevention across communities within a state. The control of re-
strategy. tail sources of cigarettes has been largely directed at
restrictions or bans on cigarette-vending machines
that provide an unsupervised source of cigarettes for
Restrictions on Availability
underage persons.
These are primarily directed at young people and DiFranza, Savageau, and Aisquith (1996) found
generally include the minimum age of purchase of that in communities with no requirements for lock-
cigarettes and the control of retail sources for ciga- out devices for cigarette-vending machines, illegal
rettes, especially vending machines. Establishment of sales were far more likely from vending machines
a minimum age for the purchase of cigarettes is the than from over-the-counter sources. Locks on vend-
same environmental strategy used in smoking pre- ing machines made them equivalent to over-the-
vention for youth as is the minimum age for purchas- counter sources in terms of illegal sales to youths.
ing alcohol (i.e., to create a legal barrier to purchase Vendors participating in voluntary industry-spon-
as a means to deter or reduce smoking). While many sored programs were as likely to make illegal sales as
governmental units, national, state, or local, have set nonparticipants.
a minimum age of cigarette purchase, there is good Forster, Hourigan, and McGovern (1992) found
evidence that the existence of such laws does not pre- that 12- to 15-year-old male and female confederates
vent purchase. A report in the state of California attempting to purchase cigarettes from all cigarette
(University of California, San Diego, 1990) found outlets in three communities achieved a success rate
very high rates of purchases of cigarettes by persons of 53% over the counter and 79% from vending ma-
under 18, the legal age of purchase. DiFranza and chines. According to the researchers, these results
Tye (1990) estimated that more than 3 million Amer- show that minors can purchase cigarettes in all types
icans under 18 consumed almost 1 billion packs of of businesses, even those characterized as "adult" lo-
cigarettes and 26 million containers of smokeless to- cations. Boys in this study had more difficulty than
bacco, which generated approximately 3% of tobacco girls in purchasing cigarettes over the counter, and
industry profits in 1988. younger individuals had more difficulty than 15-year-
Consequently, enforcement of the minimum pur- olds. However, these differences were not found in
chase age is an environmental strategy that has vending-machine sales. Similarly, over-the-counter
shown promise. Jason, }i, Anes, and Birkhead (1991), sales of cigarettes were significantly reduced follow-
in a survey of Woodbridge, Illinois, retail outlets for ing a statewide increase in the penalty for tobacco
cigarettes, showed that between 60% and 80% of un- sales to minors, but vending-machine sales were not
derage purchase attempts were successful. In the 3 affected.
months following initiation of increased enforcement In a study evaluating a requirement that vending
of the sales law by local police through warning let- machines be fitted with electronic locking devices in
ters and actual citations using "stings," the underage St. Paul, Minnesota, Forster, Hourigan, and Kelder
sales rate fell to 35%. Within the next 6 months, the (1992) used a random sample of vending-machine
sales rate fell below 5%. The effects of increased en- locations selected for cigarette purchase attempts
584 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

conducted before implementation of electronic lock- justment for socioeconomic, demographic, and
ing and at 3 and 12 months postimplementation. smoking-intensity variables. For those sites that were
The rate of noncompliance by merchants was 34% 5 years postban, the quit ratio (smokers who quit in
after 3 months and 30% after 1 year. The effect of the relation to the number of total smokers) was 0.506
law was to reduce the ability of a minor to purchase in smoke-free workplaces compared with 0.377 in
cigarettes from locations originally selling cigarettes workplaces where smoking was permitted. In all but
through vending machines from 86% at baseline to one category, the intervention group was further
36% at 3 months. The purchase rate at these loca- along the stages-of-change continuum toward quit-
tions rose to 48% at 1 year. The authors concluded ting smoking than the comparison group. The au-
from these results that cigarette-vending-machine thors concluded that American hospitals' experiences
locking devices may not be as effective as vending- with smoking bans, which directly affect more than
machine bans and require additional enforcement to 5 million workers, should be examined by other in-
ensure compliance with the law. dustries as a method of improving employee health.
The impact of a local ordinance designed to pre- Restrictions on location of smoking would appear
vent tobacco sales to minors was assessed (Hinds, to be a potentially effective strategy to encourage cur-
1992) via surveys of lOth-grade students before and rent smokers to quit. However, at this time, the re-
after the implementation of the ordinance. Tobacco search evidence is limited.
use declined from 25.3% to 19.7% overall, with a
statistically significant decline from 26.4% to 11.5%
among girls. There was also a statistically significant ILLICIT DRUG USE PREVENTION
increase from 29.3% to 61.5% in the proportion of
students reporting they were asked for proof of age Environmental approaches to the prevention of illicit
when they attempted to purchase tobacco. drug use have been concentrated on restrictions in
Restrictions on the availability of cigarettes have the supply of drugs, primarily interdiction of the sup-
been shown to reduce access to cigarettes by young ply at both the international and the local level.
people and consequently to reduce smoking initia- Such strategies have primarily been in the hands of
tion and smoking levels. law enforcement (local police, military, customs offi-
cials, and the U.S. Coast Guard). This interdiction
approach to drug supply has a complementary em-
Restrictions on Location of Smoking
phasis on sanctions against those convicted of supply-
Restrictions or bans on smoking location have as- ing drugs. As a result of the increased severity of
sumed a considerable public presence over the past sanctions against supplying drugs, a considerable
10 years, extending from bans on smoking on domes- amount of the jail and prison space in the United
tic airliners (as well as in airports themselves), to bans States is devoted to convicted drug-supplying felons.
on smoking in public buildings and on public
ground transportation, to nonsmoking areas in restau-
Reducing Drug Supply
rants or outright bans, to bans or restrictions on
smoking in the workplace. There is limited research While an environmental policy for reducing drug
concerning the effects of these restrictions, but the supply has received considerable attention in public
evidence of controlled studies or analyses generally discussion and debate, there have been few con-
supports the effectiveness of such efforts. trolled studies of the relative effectiveness of these
Longo et al. (1996), in a study of workplace smok- strategies in reducing drug use. A report by the U.S.
ing bans, found that beginning with the smoking ban General Accounting Office (1993) identified the ma-
and continuing for 5 years after implementation, sta- jor pro and con arguments regarding drug law en-
tistically significant differences in the postban quit forcement and the alternative approaches most often
ratio were observed between employees of smoke- discussed. The federal government has steadily in-
free hospitals who were smokers and counterparts in creased its annual drug control budget from $2.8 bil-
the community. Despite preban differences in smok- lion in 1986 to $12 billion in 1992, allocated approx-
ing intensity, the overall difference in postban quit imately 70% to supporting drug enforcement efforts
ratios remained significant even after multivariate ad- and 30% to prevention and treatment. Supporters of
 PREVENTION AIMED AT THE ENVIRONMENT 585

the enforcement emphasis claim that law enforce- smugglers as a function of the fraction of all routes
ment activities in recent years have led to substantial on which the interdiction rate is increased, and the
drug seizures and to the arrest, prosecution, and pun- reality that not all smuggling costs are caused by
ishment of many drug traffickers and users. Support- interdiction, it would appear that increasing interdic-
ers are content that these seizures and arrests have tion would not have a substantial impact on U.S. co-
reduced the availability and use of illegal drugs, both caine consumption except under extraordinary cir-
directly and through deterrence. They also claim cumstances.
that the connection between illegal drugs and crime
is so strong that an intense law enforcement response
Increasing Drug Prices
to drugs has been necessary. Advocates of alternative
strategies suggest that the federal strategy, with its Like the demand for alcohol and cigarettes, drug
emphasis on enforcement, has not made a serious demand is affected by retail price. However, since
dent in the nation's continuing drug problem. This drugs are illegal, the only current means to increase
report identifies a range of alternative approaches price is to reduce the supply.
that rely less on enforcement but present no research Rydell and Everingham (1994) presented a mod-
evidence of effectiveness. el-based policy analysis of alternative methods of
DiNardo (1993) examined the relationship be- controlling cocaine use in the United States. The
tween drug law enforcement and the price and use study focused on ways to intervene in the supply and
of cocaine, using data from the Drug Enforcement demand processes to mitigate the cocaine prob-
Administration's (DEA) System to Retrieve Informa- lem. Heavy users consumed cocaine at a rate approx-
tion from Drug Evidence (STRIDE) and Monitoring imately eight times that of light users, so the trend
the Future (MTF). His analysis applied a variety of in consumption by heavy users roughly canceled the
grouped data estimators and related these estimators downward trend in consumption by light users. The
to instrumental variables, techniques, quasi-experi- result was that total consumption of cocaine in the
ments, and classical experimental design. The data United States remained at its mid-1980s peak for al-
covered 1977-1987. Results revealed no indication most a decade. Four interventions were analyzed:
that regional and time variation in DEA seizures of source-country control, interdiction, domestic en-
cocaine is helpful in explaining variation in either forcement, and treatment of heavy users. This study
the demand for/or the price of cocaine. analyzed the relative and, to a lesser extent, absolute
A study undertaken by the U.S. Congress House cost-effectiveness of these programs. The first three
Subcommittee on Crime (1994) investigated the ef- programs focus on supply control, and the fourth is
fectiveness of strategies to reduce the supply of drugs a demand control program. The cost-effectiveness of
in the United States and the wisdom of readjusting these programs was examined. The analysis con-
the proportion of funds given to supply and demand cluded that money spent on supply control programs
efforts to combat illegal drug use. The study noted increases the cost to producers of supplying the co-
that interdiction programs failed to prevent the rapid caine. Further, they found that supply costs increase
growth of cocaine imports in the 1980s. In the last as producers replace seized product and assets, com-
few years, imports seem to have stabilized at his- pensate drug traffickers for the risk of arrest and im-
torically high levels, notwithstanding a significant prisonment, and devote resources to avoiding sei-
growth in late-1980s interdiction expenditures. zures and arrests. These costs get passed along to the
Caulkins, Crawford, and Reuter (1993) presented consumer as price increases, which in turn decrease
a computer simulation of the smuggling and inter- consumption.
diction of illicit drugs that specifically allows for ad-
aptation across routes and modes (air, land, sea). The
Severity of Punishment
Simulation of Adaptive Response (SOAR) is used to
examine several issues associated with the interdic- Cavanagh (1993) analyzed the methods that are cur-
tion of cocaine shipments into the United States. rently available in the United States for punishing
The authors concluded that when one considers the and controlling criminal behavior. Special attention
existence of a "backstop" technology (smuggling was given to the capacity of the U.S. corrections sys-
small shipments over land), the low cost incurred by tem and how that capacity is currently affected by
586 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

drug crime convictions. He also analyzed New York • Police involvement within neighborhoods can
City's Tactical Narcotics Teams, an attempt to re- include both foot patrol and working with com-
duce drug-related crime by increasing the certainty, munity groups to strengthen citizens' sense of
severity, and celerity of punishment for drug dealing security and solve neighborhood problems that
contribute to crime and fear of crime and re-
and possession. He concluded that increasing the
duce the visibility of drug use and drug sup-
certainty, severity, and/or celerity of punishment for
plies.
drug-related crimes would require large additional • Residents can work together to improve neigh-
investments in all parts of the criminal justice system borhood appearance and deter criminals.
and corrections system. Even if it were possible to • Government can use building codes and in-
increase punishment levels, current research pro- spection power to increase environmental secu-
vides no clear answer as to whether this would ulti- rity and discourage drug use and other criminal
mately reduce drug-related crime. activities.
Kleiman (1989) concluded that any change in
marijuana consumption that an increase in enforce- Uchida, Forst, and Annan (1992) used Oakland,
ment resources might produce should be weighed California, and Birmingham, Alabama, as test sites
against the adverse societal effects caused by the il- for the effectiveness of several different policing
licit market enterprise. In principle, drug enforce- models for controlling the problem of street-level
ment can create public benefits by reducing drug drug trafficking. The authors tested and assessed the
consumption, by controlling the "spillover" of vio- models to determine their effectiveness. The findings
lence and corruption from illicit markets, and by showed that the treatments had dramatic effects on
limiting the problems of perceived fairness and the citizen perceptions of quality of life, property crime,
damage to public morale caused by notorious crimi- and satisfaction with police services. Further, violent
nal wealth. Since new money spent on federal mari- crimes reported to the police declined substantially
juana enforcement efforts will have little effect on where police-citizen contacts occurred.
drug consumption, its justification must come from
its benefits in terms of "spillover" crime and per-
Summary Thoughts on Drugs
ceived fairness. It is not clear, however, that in-
creased enforcement will ameliorate these problems Illicit drugs represent a special challenge for envi-
rather than exacerbate them. According to Kleiman, ronmental (as well as any type of ) prevention ap-
a 13% rise in marijuana retail prices and localized proaches. As a commodity, illicit drugs respond to
marijuana shortages, although slightly ameliorating the economic rules of price and availability just as
the marijuana consumption problem, will tend to alcohol and cigarettes do. However, since these are
concentrate the marijuana-trafficking problem. illegal commodities that operate outside the adminis-
trative regulation and control domains utilized for al-
cohol and tobacco, special problems are presented.
The illicit drug market is unregulated and therefore
Community Policing
can become (and often does) a freewheeling eco-
Community policing has been proposed as a strategy nomic system (almost a pure system of supply and
to reduce crime and especially drug availability. demand, unaffected by government licensing or for-
Such a policy emphasizes crime prevention based mal restrictions). This is not to imply that restricting
upon close cooperation between police and residents the supply of illicit drugs is not a potentially effective
in reducing both crime and fear of crime. Fleissner prevention strategy. There is no reason to conclude
and Heinzelmann (1996) concluded that Crime Pre- that an unlimited supply of drugs would not produce
vention Through Environmental Design (CPTED) more problems. It most certainly would.
and community policing can be viewed as part of a The most central barrier to current efforts to elim-
comprehensive crime prevention strategy, including inate supply is that there are strong economic incen-
reducing drug supplies. The authors explained that tives to meet demand. Thus, the scarcer the product
police, citizens, and government have a role to play (when an unmet demand exists), the greater the po-
in preventing crime under the CTPED/community- tential profit for retail drug suppliers. In this situa-
policing approach: tion, police and military interdiction of supplies can
 PREVENTION AIMED AT THE ENVIRONMENT 587

actually increase profit opportunities by making sup- dence and prevalence of alcohol misuse or alcohol-
plies scarce. involved problems, smoking (primarily by youth),
On the other hand, if interdiction strategies do and illicit drug use. Many of the approaches de-
reduce supply and demand is unchanged, then price scribed above have been evaluated through research.
will increase, thus providing economic disincentives Other promising approaches await evaluation.
like those achieved for alcohol and tobacco through The largest number of environmental prevention
excise taxes. High prices can provide barriers to ex- strategies have been developed and tested for alco-
perimental or occasional drug users. The policy di- hol. For smoking reduction, environmental preven-
lemma for a supply strategy is that lowering the sup- tion strategies have been devised to reduce the initia-
ply increases the cost for heavy (often dependent) tion and smoking levels of young people. This is
users and stimulates other activities such as burglary based upon the premise that most smokers begin as
or prostitution to obtain money to purchase illicit young people and if an environmental barrier can be
drugs. A full discussion of this conundrum is beyond created for access to cigarettes, then youth smoking
the purpose of this paper, but see Levin, Roberts, and incidence and prevalence can be reduced. For illicit
Hirsh(1975). drugs, the environmental strategies that have re-
Therefore, it should be noted that a reduction-of- ceived a great deal of attention are efforts to reduce
supply strategy for illicit drugs has special by-prod- availability, including blocking the delivery of drugs
ucts that are more severe than those for licit (but and deterring suppliers of drugs via harsh penalties.
regulated) products. This chapter is not advocating Environmental strategies for reducing illicit drug use
a legalization of any drugs. Such legalization could are largely untested. They have not received as much
reduce price, increase supply, and increase use. scientific evaluation as have strategies directed at al-
Rather, this chapter points out the lack of scientific cohol problems and smoking.
evidence that the current ongoing interdiction strate-
gies are having the desired effect of reducing use.
Rationale for Environmental Strategies
This does not imply, however, that an environmental
strategy to reduce supply of illicit drugs cannot pre- Environmental strategies do not usually target a spe-
vent drug use, especially experimental or nondepen- cific risk group; rather, they alter existing structures
dent use. The main issue is one of effectiveness of to reduce the potential risk of harm or of a social
current approaches to reduce supply, given the de- problem. For example, setting a minimum drinking
mand for illicit drugs. age for alcohol or purchase age for cigarettes is a
Interdiction to physically confiscate illicit drug state policy to reduce access to alcohol or cigarettes
supplies is not the same as establishing very high by persons below a certain age.
sanctions and penalties for the possession, distribu- There are at least three positive features of envi-
tion, and sale of illicit drugs. There is no solid con- ronmental prevention policies:
trolled evidence that high sanctions do reduce sup- 1. Research evidence. In general, policy (which
ply. The high economic incentives and the low usually addresses environmental strategies) has scien-
certainty of being caught combine to override the tific evidence of effectiveness, especially for alcohol
major deterrent effect of reducing supply. In other and cigarettes. This includes such policies as retail
words, as long as there is sufficient profit, suppliers price, availability, location and type of alcohol out-
of illicit drugs are likely to find that potential gain lets including hours and days of sale, retail and social
exceeds the low risk of arrest even with severe pun- access to alcohol or cigarettes by young people, and
ishment. Experience from other environmental strat- enforcement and sanctions against high-risk alcohol
egies to deter use or abuse suggests that certainty of use (e.g., drinking and driving). See Edwards et al.
detection (not necessarily severe punishment) could (1994) for a review of policy research on alcohol.
be a more effective environmental approach. 2. Lower cost. There are few cases in which the
actual cost of environmental prevention programs or
SUMMARY policies has been documented. However, on the av-
erage, policies, as they involve changes in rules and
This chapter has provided a brief overview of some regulations or increased emphasis for existing ac-
environmental changes that may reduce the inci- tivities, are likely to be lower in cost than specially
588 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

funded local educational prevention programs, which In general, environmental approaches to preven-
require an ongoing investment in staff, materials, and tion of alcohol problems, smoking, and illicit drug
other resources. For example, the cost of teacher and use present alternatives to strategies that target indi-
school administrator time, curriculum materials, and viduals or high-risk groups. Environmental strategies
other elements of a school-based educational pro- are intended to alter the context in which these prob-
gram is likely to exceed the cost of a local policy of lems occur. Such strategies do not target specific per-
reduced retail sales of alcohol or cigarettes to under- sons at risk; rather, they reduce convenience, avail-
age persons via increased enforcement. Raising the ability, and access to the substances of abuse. There
retail price of alcohol or cigarettes at a local level by is substantial evidence of effectiveness for the envi-
imposing local special-purpose taxes generates in- ronmental strategies for alcohol problems and smok-
creased revenue and, at the same time, is a low-cost ing but little evidence for illicit drugs. Such a situa-
prevention strategy. tion suggests the need for more controlled research
3. Sustainability. Policies directed at the environ- into the interdiction and severe punishment strate-
ment have a longer potential effective life, once im- gies used to reduce illicit drug use that are the major
plemented, than prevention programs that must be environmental strategies being used.
maintained and thus funded each year. A policy of
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 32

Economic Issues and

Substance Abuse

Jeffrey Merrill

The economics of substance abuse encompasses a of the services provided. The reason is the fact that
variety of issues dealing with how substance abuse "services follow the money." In other words, what the
services have been financed in the past; the emerg- various payment mechanisms (Medicare, Medicaid,
ing phenomenon of managed care and its impact on private insurance) cover will determine what services
how substance abuse services are now financed, orga- will be available, how much will be offered, and who
nized, and delivered; and the costs, costs-benefits, will provide them. A good example of this phenome-
cost-effectiveness, and cost offsets associated with sub- non is nursing-home care. Until Medicaid started to
stance abuse prevention and treatment. This chapter cover nursing-home services in the mid-1970s, there
will address these issues both separately and from the were few nursing homes in existence for the elderly
perspective of how they interrelate. and disabled (there had been convalescent homes
before that, but they were available only to those who
either could pay or benefited from charity). How-
FINANCING SUBSTANCE ever, once Medicaid started to cover these services,
ABUSE SERVICES the nursing-home industry grew dramatically. Now,
we cannot imagine a time when this benefit did not
exist.
Payment Mechanisms
In addition, with the advent of managed care, fi-
In health care in general—and in substance abuse as nancing has become more intertwined even with clin-
well—financing is the critical component in deter- ical decision making. At one time, providers made de-
mining the location, scope and duration, and nature cisions about the extent and type of coverage, and the

595
596 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

insurance followed the clinical decisions. Increas-

Coverage Limitations
ingly, however, the nature and limitations of the cov-
erage as determined by the insurer dictate the ser- At one time, many of these plans offered a range of
vices to be provided. services, but it was common for them to include a
Traditionally, the financing of substance abuse 28-day hospital or residential treatment program as
services paralleled that of other health care services, the typical benefit used. However, over time, given a
albeit always on a more limited level and with more lack of convincing evidence that 28-day residential
public support. The main sources of dollars to pay programs—or, for that matter, any inpatient pro-
for substance abuse services are fourfold: private in- grams—were any more effective than either a shorter
surance, Medicaid and Medicare, the federal sub- length of stay or an alternative outpatient program,
stance abuse block grant to states, and state and local companies began to be less generous with this bene-
funding. In addition, some specific federal programs fit.2 As a result, there are often strict limits on the
fund treatment for groups that are eligible to receive number of residential days, or plans require that out-
their services. These include the Veterans Adminis- patient services be used instead. As managed care be-
tration and Community Health and Mental Health came more prevalent (see below), the limitations on
Centers. Obviously, this list includes only those these options increased, and inpatient and residential
sources that encompass the bulk of funding. Many services are even less likely to be covered.
people with private resources pay for their own treat- In addition to where the services may be pro-
ment, and voluntary and charitable organizations vided, a similar financing issue has to do with the
also help others to gain such services. level of provider that is covered. At one time, financ-
Private insurance, including Blue Cross/Blue ing for substance abuse treatment services might
Shield plans, as well as other commercial carriers have covered therapy provided by psychiatrists and
(e.g., Prudential, Aetna) and HMOs, offer plans with psychologists. Over time, however, coverage has tight-
a substance abuse treatment benefit. However, the ened, and services offered by lower level personnel,
existence of that benefit and the scope of the cover- including certified counselors, are more likely to be
age vary from plan to plan (i.e., private insurance paid for than those of higher cost practitioners. Fur-
plans offered by the same carrier differ depending on ther, rather than covering individual sessions, payers
the scope of benefits desired by an employer and the have encouraged greater use of group therapy.
amount the employer is willing to pay for such cov-
erage).
It should be noted that this discussion deals al-
Cost Sharing
most exclusively with payments for the treatment of
alcohol and drug abuse. While tobacco use remains One other aspect of the nature of private financing
the most prevalent of all drugs and is the most costly for substance abuse treatment has to do with the cost
to our health system, very little public or private in- sharing that may be required by private insurers. Cosf
surance funding is used to support smoking cessa- sharing refers to that portion of the bill that the indi-
tion. While there are efforts both at the government vidual is required to pay. Various mechanisms for
level and among some private employers in the areas cost sharing exist, including deductibles, copay-
of both the prevention and the treatment of tobacco ments, and coinsurance. A deductible is an up-front
addiction, these contribute a relatively small amount payment for services that patients must pay for their
of the total funding spent either on health care in own care before the insurance plan starts to cover
general or, more specifically, on substance abuse the services. In other words, if the deductible is $200,
treatment. In addition, prevention programs for drug then the first $200 of services must be paid by the
and alcohol use are not funded through these mech- beneficiary before the insurer will pay. Copayments
anisms either. Most prevention funding comes from are a fixed amount for each unit of service that the
direct government support through the Center for patient must pay (after the deductible, if any, has
Substance Abuse Prevention (CSAP) and the De- been met). The copayment is irrespective of the ac-
partment of Education Drug Free Schools and Com- tual amount of the charge. For example, a copay-
munities Program. ment of $10 per visit means that if the visit is $40,
 ECONOMIC ISSUES AND SUBSTANCE ABUSE 597

the patient pays $10 and the insurer $30, but if the if a patient uses a provider from a list offered by the
visit is $60, the patient still pays $10. insurer, the cost sharing may be reduced or even
On the other hand, coinsurance does vary with eliminated. The so-called preferred providers are
the cost of the service. Coinsurance is similar to co- those who have agreed to charge the payer less for
payments in that it is an ongoing responsibility, ex- services than ones not on that list. As a result, indi-
cept that it is a fixed percentage of the cost rather viduals who choose other providers would pay more
than a fixed amount. Therefore, 20% coinsurance on for their care. The most typical form of this arrange-
a $40 visit is $8, but if the visit costs $60, the coinsur- ment is referred to as a point-of-service plan, where
ance amount is $12. beneficiaries pay little or no cost sharing if they use
Two other mechanisms are used by private insur- the preferred providers in the plan's network. How-
ers, including managed-care plans, that are related to ever, they are free to choose other providers if they
cost sharing. One of these is a stop-loss provision, are willing to pay an increased portion of the bill.
which limits the total out-of-pocket responsibility of Private insurance has never been a major source
the insured. In other words, a policy might have a of payment for substance abuse treatment. One rea-
provision that once a patient has paid a predeter- son is that, because of their problem, many sub-
mined amount in deductibles or coinsurance, the in- stance abusers are either unemployed or employed
surer will pick up 100% of the costs. This approach in marginal jobs that do not offer health insurance.
is not prevalent with respect to substance abuse treat- In addition, insurers continue to be skeptical about
ment coverage. On the other hand, a lifetime (or an- the effectiveness of substance abuse treatment ser-
nual) limit on coverage is more likely to be in effect. vices. In an era of cost consciousness, payers are
Working the opposite way from stop-loss coverage, likely to evaluate different services in terms of their
the insurer caps its own risk by limiting the amount overall cost-effectiveness, and substance abuse treat-
it will cover either in a given year or over the life of ment has typically not fared well in comparisons with
the policy. In other words, once the insurance com- other, more "medical" care. As is discussed below,
pany has paid out this amount in benefits, the indi- this problem makes it more imperative that research
vidual is no longer covered. While this provision usu- do a better job of demonstrating the costs-benefits of
ally applies to overall medical coverage, what is substance abuse services.
common in substance abuse coverage may be a limit
on the number of treatment episodes that would be
Public Financing Mechanisms
paid for. Insurers might rationalize this on the basis
of the fact that a person who has not responded to Most public support for treatment comes either through
multiple treatments will not be a good candidate for Medicaid3 or the federal substance abuse block grant.
further treatment. Medicaid is a state program to pay for health care for
Cost sharing can be a critical factor in a patient's the poor, but the federal government actually reim-
access to care. Since these are out-of-pocket payments, burses the state for a portion of these funds (depend-
they can determine whether an individual can afford ing on the state, the federal matching share is any-
to seek treatment and limit how much care he or she where from 50% to 83%).
receives. Additionally, particularly in the case of coin- However, the federal government matches state
surance, cost sharing can determine what level of per- payments only for services covered under the federal
sonnel a patient sees, since the cost per visit for a psy- program and for people who meet the federal eligi-
chiatrist or psychologist could be much higher than bility guidelines. In order to be eligible for the fed-
that of a counselor (or group sessions), making the cost eral Medicaid share, an individual has to be either
of the coinsurance prohibitive. Policies may include eligible for welfare (now called Temporary Assis-
coinsurance rates as high as 50%. tance to Needy Families, or TANF) or permanently
and totally disabled. Those eligible by virtue of TANF
are usually single, unemployed parents (mostly
New Arrangements
women) and their children. With respect to the disa-
More recently insurers have begun offering preferred bled (who include male adults), until recently, hav-
provider arrangements (related to cost sharing) where, ing a drug or alcohol addiction could qualify an indi-
598 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

vidual for both Supplemental Security Income (SSI; The federal government also pays for substance
a federal income benefits program) and, as a result, abuse services through a number of other mecha-
for Medicaid. However, legislation passed in 1996 nisms as well although they are less well recognized.
took away this eligibility category. Now, to be eligible For example, the Department of Veterans Affairs pro-
for Medicaid as a disabled person requires a serious vides a significant amount of drug and alcohol treat-
physical or mental disability (not including alcohol ment for veterans. In addition, a network of both
or drug addiction) that makes it impossible for that community health centers and community mental
individual to be employed. health centers supported by government funds offers
In addition, in most states, a person can qualify substance abuse services to low-income individuals
for Medicaid if he or she has medical bills that are throughout the country. Some of the health centers,
sufficiently high to reduce that individual's income located in rural areas, are among the few treatment
below a level prescribed by that state. In other words, venues for residents of those communities.
if the state's income eligibility level is $5,000, a per-
son who earns $15,000 would have to "spend down"
at least $10,000 of her or his income in medical bills MANAGED CARE AND
to become eligible for Medicaid. SUBSTANCE ABUSE
Thus, Medicaid eligibility is limited to only the
group that meets these specific categorical or spend- Over the past decade, the world of health care has
down requirements. But even if a person is eligible changed significantly, and these changes have been
for Medicaid, there is still no guarantee that he or she felt particularly acutely in the financing, organiza-
will be able to get substance abuse treatment paid for. tion, and delivery of substance abuse services. The
There is no federal requirement that states offer sub- overarching event in our health care system that has
stance abuse treatment as a covered service under led to this dramatic change has been the emergence
their Medicaid program. To the extent that they do of managed care. While the term managed care is
cover these services, they are usually limited to outpa- used widely, it means many different things, and its
tient treatment or services provided in general hospi- specific implication, like that of beauty, is often in
tals. Medicaid excludes most residential care for both the eye of the beholder.
substance abuse and mental health services.
On the other hand, to the extent that a state does
What Is Managed Care?
pay for substance abuse services, Medicaid law does
prohibit any cost sharing on the part of the patient. Before talking about the myriad issues that encom-
In addition, in a growing trend, most states that offer pass the economics of substance abuse and its rela-
substance abuse treatment services under Medicaid tionship to the proliferation of managed care, it is
do so through managed-care arrangements. important to agree on what we mean by the term
A significant portion of substance abuse treatment managed care and how it has affected all facets of
is paid for through the federal Substance Abuse substance abuse services. Interestingly, if one were to
Block Grant (SABG). Money from this fund is allo- describe managed care a decade ago, the task would
cated to the states and covers the cost of prevention have been much simpler. At one time, managed care
and treatment services for those who cannot pay for was synonymous with the notion of the health main-
services and who are also not eligible for Medicaid. tenance organization (HMO). The traditional HMOs,
While a large portion of the SABG funds are di- like Kaiser Permanente, Group Health of Puget Sound,
rected at men (since many more women would qual- or the Harvard Community Health Plan, were not-
ify for TANK and Medicaid as single parents), there for-profit organizations with whom a group or indi-
are specific set-asides in the block grant for pregnant vidual contracted for a fixed amount to provide all
women. The funds, administered by the state sub- the agreed-upon health services. The provision of
stance abuse agency, pay providers to deliver these these services was accomplished through a group of
services. As with Medicaid, many states are contract- doctors and facilities closely related to the HMO.
ing with managed-care plans both to manage and to Most of these relationships were characterized as
provide these services. closed-panel arrangements where the individual pro-
 ECONOMIC ISSUES AND SUBSTANCE ABUSE 599

viders worked exclusively for that HMO (hospitals ing to increase—or at least maintain—the providers'
were either owned by the HMO or contracted with patient base in return for discounts and external
by the HMO, but the care of the HMO members management of clinical decisions. Providers often do
was controlled by the HMO's physician panel). The this for defensive reasons out of the fear that if they
closed-panel HMO was organized in either a staff or do not join a given managed care plan, they will lose
a group model. In the staff model, the providers patients or not get new ones.
worked directly for the HMO as employees, while in Rather than the providers' managing the patients'
the group model, the providers formed a group that care, the managed care plan now manages the physi-
had an exclusive contract with the HMO. cians' decisions through a series of utilization control
Some HMOs, referred to as independent practice mechanisms that range from review of referral and
associations (IPAs) used an open-panel model, where admissions decisions to concurrent review of the
the arrangements between the providers and the need for—and nature of—continuing care, to retro-
HMO permitted physicians to contract with the spective review of a physician's overall utilization
HMO for patients but also allowed them to have pri- practices.
vate practices or even contract with another HMO as Thus, no longer motivated by a philosophical pre-
well. It is out of this open panel model that the mod- dilection to join a managed-care plan, the current
ern-day breed of managed-care plans emerged. provider is often motivated out of a fear of losing
market share. In addition, rather than being granted
greater clinical discretion, the provider now is often
A Different Breed of Managed Care
a captive of the decisions of clerks and other review-
At first blush, it may seem like splitting hairs to dis- ers, who have wide discretion in permitting the prac-
tinguish the traditional HMO from its more contem- titioner to deliver a given service, make a desired
poraneous managed-care relative. Both contract with placement, or continue providing the service.
individuals and groups to provide all care, both re- Further, instead of the old model, where a pro-
quire a fixed per capita payment (capitation) as the vider tended to have allegiance to one HMO, a mod-
basis for financing services, and both use panels of ern-day provider is forced for economic reasons to be
physicians, other practitioners, and facilities under a part of many of these plans, with little or no loyalty
contract to them to provide those services. Yet the to any one managed-care group. In fact, what may
differences between managed care in its modern in- emerge instead of loyalty is conflict between the
carnation and its ancestors (many of which, like Kai- needs of the patients, on the one hand, and, on the
ser, still exist) are great and affect the nature, scope, other, the bottom line of the managed-care plan. Ul-
and duration of the services provided. timate success, now measured by Wall Street, may
The most fundamental difference between the be more a function of profits and losses than of indi-
historical HMO model and today's managed care is cators of quality, which are often elusive and thus
the arrangement between the providers and the man- easily disregarded.
aged-care entity. Traditionally, the providers joined Advocates of managed care correctly assert that in
an HMO out of a shared philosophy with the HMO a market economy, quality and consumer satisfaction
about how medicine was practiced. The notion was remain important elements of competition. How-
to have the provider manage the care of the patient, ever, opponents argue that most people's health care
acting not only as the gatekeeper but, more impor- needs are minimal in a given year, and therefore, it
tant, as the coordinator of care, guiding the patient is easy to satisfy them. They also point out that peo-
through the system, determining the nature and con- ple who are dissatisfied tend to disenroll and may not
tent of that care. Greater emphasis was placed on even be included in the assessment of a given plan.
health maintenance, including prevention, early in- Further, "quality" is not easily measured, and despite
tervention, and the judicious use of specialty and in- efforts by groups like the National Committee on
patient care. Today, the reasons for a physician to Quality Assurance (NCQA), there are no good, ob-
join a managed-care plan are much more economic jective measures of quality (this is particularly the
than philosophical. Managed-care plans create net- case for substance abuse treatment). Thus, despite
works of providers based on the quid pro quo of help- the usual market notion of product differentiation
600 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

based upon quality, this does not really exist with re- care's focus is on the treatment of acute problems
spect to health care in general and substance abuse (i.e., those that can be treated and cured). This
treatment in particular. ranges from treating an infection to removing an ap-
Clearly, there remain exceptions to the problems pendix to delivering a baby to repairing a broken
of the current managed-care system, and good mod- bone. Managed care does not view itself as a financ-
els of patient care management do continue to exist. ing mechanism for treating chronic diseases, where
However, much of managed care is driven by cost treatment is not curative but is geared to alleviating
and profit considerations. In addition, while it is pos- a problem that is continuous or relapsing.' In the
sible for providers and managed-care plans to work same way that nonacute services for Alzheimer's or
well in tandem, adversarial relationships characterize other dementia patients, as well as for other chronic
much of the managed health care system. ailments suffered by the elderly and disabled, are
usually excluded from managed-care coverage, sub-
stance abuse and mental health services are not in-
Substance Abuse and Managed Care
cluded. The concern of managed-care plans, as well
Managed care has had a particularly profound effect as most health insurance carriers, is that these are not
on the financing, organization, and delivery of sub- only expensive patients, but ones whose problems do
stance abuse services. Not the least of these effects is not end.Therefore, they must be carved out if they
the emergence of the notion of carving out substance are to be covered at all.
abuse services from the general set of health care Issues surrounding the notion of carving out be-
benefits, and merging substance abuse with mental havioral health care are even further complicated by
health in a new category called managed behavioral the population served. The fact is that the public
health care. In other words, under a carve-out, the does not necessarily view those with substance abuse
managed-care company responsible for treating med- and, to a lesser extent, mental health problems as
ical problems has no responsibility either to pay for having a disease. There is, at a minimum, skepticism
or to provide mental health or substance abuse ser- as to whether treatment interventions can be effec-
vices. While not all companies carve out behavioral tive and, at the other extreme, a too commonly held
health, this is currently a common practice among belief that substance abuse stems from character
managed-care plans. weakness rather than from a physical or medical eti-
The reasons for this carve-out are manifold but ology. Thus, despite the long-term expensive nature
are not necessarily justified. One reason for the carve- of these behavioral problems, the allocation of health
out is the notion that a high proportion of those with care dollars is likely to shortchange behavioral ser-
mental illness also suffer from substance abuse prob- vices by a financing system that places its emphasis
lems. Thus, the argument goes, by combining these on treating medical problems.
services, the patient can benefit from having both Whether this current carve-out will remain a per-
problems treated concurrently and in a coordinated manent change in the financing and organization of
fashion. While this may be true, many of these pa- health care or will eventually disappear is still de-
tients also have serious medical problems, ranging batable. What is more certain, however, is that the
from HIV infection, AIDS, or other infectious dis- carve-out already has a number of major implications
eases including hepatitis or TB, to problems with for the financing and delivery of substance abuse
pregnancy, to stroke, cancer, or enteric or liver prob- treatment. The first—and most obvious—is that sepa-
lems. Thus, treating their substance abuse is impor- rating medical care from substance abuse care can
tant, but it is equally critical to address these other lead to other health problems' being either addressed
conditions. The carve-out may make the coordina- poorly or not addressed at all. In the same way, peo-
tion of such services with substance treatment ple being treated in the medical care system may not
more—rather than less—difficult. be identified or referred to needed substance abuse
The rationale for carving out mental health and services. If different providers, in different locations,
substance abuse is also, in part, a function of the fact financed through different managed-care plans, are
that these services are not universally considered a attending to the patient's medical problems than
part of the acute medical care system. Managed those who are treating the substance abuse problem,
 ECONOMIC ISSUES AND SUBSTANCE ABUSE 601

gaps are bound to exist. Substance abuse providers COSTS, COST-BENEFIT,

may have trouble identifying health problems or get- AND COST OFFSETS
ting them treated once they are identified. On the
other hand, medical providers may not identify sub- Introduction
stance problems or know where to refer the patient
if they do find them. Little coordination of care is Managed care has put the substance abuse treatment
possible given this split in responsibility between two industry on the defensive. Basic questions are being
distinct entities. raised about both the value of treatment in general
But the problem is deeper than this. The focus and the comparative merit of one modality over an-
of managed care on keeping costs down can create other. In an era when economic concerns and judg-
conflicts between the overall managed-care company ments may take precedence over clinical decisions,
and the behavioral health concern. At the most basic knowing what substance abuse prevention and treat-
level, medical managed-care companies may try to ment programs cost and demonstrating their cost-
attribute a health problem to substance or mental benefit and cost-effectiveness become vital.
health causes to get out of paying for treatments. In
the same way, a behavioral health company may at-
The Costs of Substance Abuse
tribute a problem to a physical ailment so as not to
have to provide substance abuse care. An example The notion of the costs of substance abuse encom-
will show how this can play out in the real world: passes a variety of different concepts. We can, for ex-
ample, be referring to the actual cost of a prevention
A patient was admitted to a hospital with a serious or treatment program or even the costs of an individ-
heart condition requiring open-heart surgery. ual treatment episode or visit. But the notion of costs
However, the patient also had an alcohol prob- goes well beyond this narrow definition. Substance
lem, and it was deemed necessary to put the pa- abuse itself has costs associated with it that make the
tient through detox before operating. Detox was
cost of treatment pale in comparison. Some of these
not the responsibility of the medical managed-
are individual costs, some are costs to industry, and
care plan but fell to the behavioral health plan.
some are larger societal or public costs.
That plan agreed to the need for detox but did
not cover inpatient detox services and would not One of the most easily understood is the health
pay for hospital-based detox. It also contended care cost associated with tobacco, alcohol, and drug
that if this was related to a medical problem, it abuse. While we can immediately bring to mind
should be paid for by the medical managed-care smoking and lung cancer, or alcohol and cirrhosis,
company. Thus, it demanded that the patient be or IV drug use and HIV infection, the health effects
moved from his cardiac intensive-care hospital bed of substance use go far beyond this. The National
(CCU) to a nonhospital setting. The hospital re- Center on Addiction and Substance Abuse at Co-
fused, but the managed-care company refused to lumbia University found, after a search of the epide-
pay for the detox. While the behavioral health
miological literature, more than a thousand medical
care company eventually made an exception and
diagnoses where tobacco, alcohol, or drugs could be
paid for the inpatient detox, the delay unnecessar-
ily put the patient's life in increased danger and identified as the etiological or causal factor leading
actually increased the cost of care since, during to that health problem. For example, diseases rang-
the period that the two sides fought, someone had ing from different types of cancer to heart disease to
to pay for the patient's stay in the CCU. emphysema to adverse birth outcomes are associated
with smoking. In addition, even where a health prob-
While depicting an actual case, this story may be lem is not directly caused by tobacco, smoking can
an extreme. However, it does make the point that exacerbate a problem and increase the costs of treat-
dividing the responsibility for financing and care ing it. An individual with a respiratory problem like
responsibility between two different managed-care asthma or pneumonia who smokes is more likely
companies can create perverse incentives that may to have a serious or chronic case requiring hos-
not benefit the patient nor even cover the total costs pitalization, and even for those hospitalized for other
of care. illnesses, the costs of treating a problem that is com-
602 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

plicated by tobacco, alcohol, or drug abuse may re- high costs of substance abuse to the health care sys-
quire more services or a longer stay (Fox, Merrill, tem and a lack of greater investment in treatment? A
Chang, & Califano, 1995). number of factors explain this, but at the heart of
Alcohol and drugs also have serious health effects. much of this is a continuing skepticism about the
For example, as much as 70% of all trauma cases effectiveness of treatment. While, as will be discussed
among the nonelderly can be attributed to alcohol later in this chapter, there is a literature that demon-
and drug use (Fox et al., 1995). This includes not strates that treatment can be effective, this is not the
only traffic accidents but also violent injuries, includ- perception held either by the public or by those who
ing gunshot or stab wounds and fractures or burns. make decisions about how public and private health
Additionally, alcohol abuse is associated with many benefit dollars will be spent.
cancers (an individual who smokes and drinks heav- In part, this skepticism is due to the fact that we
ily is 133 times more likely to get a throat cancer tend to view all substance abuse as though it were an
than one who does neither) (National Center on Ad- acute rather than a chronic problem that has recur-
diction and Substance Abuse [NCASA], 1993). In ring acute episodes. As a society, we tend to hold
addition, pregnant women who drink or use drugs substance abuse treatment up to a higher standard
are placing themselves at considerably greater risk of for success than we do treatment for other, similar
an adverse birth outcome. Further, drug use ac- diseases, such as diabetes or even cancer. Successful
counts for almost two thirds of all strokes among peo- treatment is measured by complete and permanent
ple under the age of 65 (NCASA, 1993). abstinence from smoking, drinking, or drug use. If
The costs of these substance-use-attributable health this is not attained, then either treatment is viewed as
problems are enormous. While estimates differ, more ineffective or the problem is attributed to a character
than one in seven dollars spent on health care in the weakness in the patient rather than to a disease pro-
United States can be attributed to tobacco, alcohol, cess. We expect this treatment to function as though
or drug use. In a trillion-dollar health care system, it were both an antibiotic with immediate curative
this amounts to as much as $150 billion (Merrill, results and a vaccine that prevents long-term relapse.
Fox, Pulver, & Lewis, 1996). Imagine if treatment for a diabetic were held to the
It is interesting that despite the concern currently same standard of success.
expressed over rising health care costs, little mention In addition, even if the notion of a chronic prob-
or investment of dollars is made on treating sub- lem requiring more than one treatment episode is
stance problems that contribute so heavily to these accepted, the skepticism will not disappear. Many
other costs. As a result of the Medicare, Medicaid, view this not as a medical problem, but as one associ-
Veterans Health, and a variety of other health care ated more with social or personal characteristics. De-
programs, the federal government spent more than spite the evidence to the contrary, many still consider
$320 billion on paying for health care in 1995 (U.S. substance abuse a problem of the poor, or of those
Office of Management & Budget, 1996). Of this, who lack moral strength. To some extent, the notion
19%, or $60 billion, was spent treating health care of carving out behavioral health care from the main-
problems attributable to substance abuse (NCASA, stream of managed care reflects this distinction.
1995). Yet the amount of government spending on They also see treatment, to the extent that it does
substance treatment was less than $5 billion (NCASA, work, in terms more of AA or NA than of services
1995). provided by the medical care system. Why, there-
In the same way, while employers and managed- fore, should the system pay for such treatment when
care plans are increasingly cost-conscious, the amount it can be delivered for nothing through a local AA
spent on paying for substance treatment is actually chapter?
declining. It should also be noted that these costs do But the concerns over the effectiveness of treat-
not fall only to the medical needs of the substance ment extend beyond treatment's impact on health
abuser. The toll of substance abuse is felt by the care costs. On the one hand, many of the largest
abuser's whole family and can result in increased costs to society, including criminal justice, welfare,
health benefit costs to the spouses, parents, and chil- disability, and economic productivity, are associated
dren as well (Langenbucher, 1994). with substance abuse. On the other, the support for
Why does this apparent paradox exist between the treatment, particularly in the public sector, does not
 ECONOMIC ISSUES AND SUBSTANCE ABUSE 603

reflect this link. For example, more than half of all Myers, and Friedman (1988), and Merrill (1991)7 es-
criminal activity is closely linked with drug and al- tablished the strong link between crime and the use
cohol abuse. Whether we are referring to crime in- of drugs and alcohol (although they did not put cost
volving people trafficking in illegal substances (dis- figures on these links). Merrill and his colleagues
tributive crimes), people committing crimes to get have also estimated that at least one in five welfare
money to purchase drugs and/or alcohol (acquisitive recipients is suffering from an alcohol and/or drug
crimes), or people committing crimes as a result of problem (NCASA, 1994). While this does not mean
being under the influence of these substances (phar- that they necessarily became welfare recipients be-
macogenic crimes), substance abuse is at the heart of cause of substance abuse, it does mean that getting
the crime committed. Associated costs are manifold, them off welfare will be difficult if this problem is
including the costs of law enforcement, the courts, not addressed. In an era of welfare reform, this
and the corrections system. Yet those who make should be considered an important piece of informa-
funding decisions at the federal, state, and local lev- tion. In a paper on the impact of substance abuse
els do not look to treatment as the best way of invest- and its impact on federal entitlement programs, Mer-
ing dollars to reduce crime in our society. More jail rill and his colleagues estimated that in 1995, the
cells, longer and determinate sentences, and charg- cost to the federal government resulting from its in-
ing juveniles as adults—all take precedence over ability to get people off the public assistance roles
treatment as the desired solutions. In the same way, because of their substance abuse problems was $3
solutions to the welfare problem, and to reducing billion (Merrill, in press; NCASA, 1995).
worker's compensation and other disability expendi- Making people aware of the costs of substance
tures, seldom highlight substance abuse treatment. abuse to society is far from sufficient. As has been
Despite a bipartisan concern at the federal level noted, the real concern is to convince those who
about the drug problem and its influence on crime make decisions about program funding (whether in
and other social problems, in 1996 two thirds of the the public or in the private sector) that an investment
federal money spent in the so-called War against in substance abuse treatment does, in fact, yield divi-
Drugs went to supply reduction, and only one third dends not only by reducing the chance of relapse,
to demand reduction. This means that instead of in- but also by decreasing a variety of other costs. The
vesting in prevention and treatment efforts to reduce managed-care company must be convinced of the
the demand for drugs, funds were more targeted on fact that substance abuse treatment is effective and
law enforcement activities here and abroad intended that it can also reduce other health and mental
to reduce the supply of drugs. health costs. The employer will be interested in a
variety of other costs ranging from health benefits, to
disability and workers' compensation, to absenteeism
and productivity, to even the quality of the product
Assessing the Economic Costs
or service produced. Finally, both government and
and Benefits of Treatment
society as a whole will be concerned about treat-
What role does the study of the economics of sub- ment's impact on health care, criminal justice, pub-
stance abuse play in addressing this decoupling of lic assistance, and taxes. As a staff member of the
the relationship between substance abuse treatment White Office on National Drug Control Policy
and the reduction of both the prevalence and the (ONDCP) put it, "The public is more concerned
costs of the societal problems? Part of the answer is with whether, after treatment, the addict will rob
to increase public awareness about the costs of sub- them and hit them over the head than with whether
stance abuse to society. For example, the research of he is drug free."
Kelman, Miller, and Dunmeyer (1990), as well as The success of substance abuse treatment must
of Harwood, Napolitano, Kristiansen, and Collins therefore be measured not only in clinical terms (i.e.,
(1984), points to the link between substance abuse abstention, clean urines, and no relapse), but also in
and the its high cost to society. Rice et al. estimated economic terms. Treatment research must demon-
that in 1990, substance abuse cost American society strate not only that a dollar spent on treatment yields
$166 billion. In addition, studies by Inciardi, Mc- savings that exceed that dollar (cost-benefit), but also
Bride, McCoy, and Chitwood (1994), Ball, Lange, that spending the dollar on substance abuse treat-
604 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

ment will yield greater savings than investing that

Cost-Effectiveness
same dollar in something else (cost-effectiveness). In
other words, not only is a given intervention com- Often, cost-effectiveness is defined as the marginal
pared to no intervention, but it is also weighed improvement in some outcome given a marginal in-
against other interventions as well. crease in the cost of the studied intervention. In
But in an era of budget constraints and managed other words, if we were to increase treatment from
care, cost-effectiveness comparisons go beyond sim- two to three sessions a week for a 50% increase in
ply testing one substance abuse intervention against the costs of treatment, would the number of people
another. A dollar spent on substance abuse preven- who avoid relapse within 6 months increase by more
tion and treatment must also yield greater benefit or less than 50%? If this added cost leads to a propor-
than if the same dollar is spent on a medical proce- tionately greater increase in reduced relapses (in this
dure. For example, will a managed-care company de- case, 50%), then the added costs are deemed to be
rive more cost savings from putting more of its re- cost-effective.
sources into substance abuse treatment than into an However, for the purposes of this discussion, cost-
exercise and diet program? effectiveness is a comparison of the cost-benefit of
two or more interventions. In other words, how can
we reap the biggest return on our investment? If we
Cost-Benefit
compare two different interventions, which will yield
To determine the cost-benefit and cost-effectiveness the most benefit?
of substance abuse programs, it is important to define But this might lead to somewhat misleading con-
exactly what we mean by these terms. For the pur- clusions. For example, Intervention A costs $50 per
poses of this discussion, we will define cost-benefit as person and yields a 5 :1 cost-benefit ratio, and Inter-
a comparison of the costs of a given intervention and vention B costs $100 per capita and yields a cost-
its benefits. The cost-benefit involves looking at the benefit ratio of 4 :1. Thus, it would appear that Inter-
costs and benefits of a given intervention compared vention A is more cost-effective. Possibly, but another
with doing nothing. Cost-benefit can be defined as a way of looking at this is that by investing $100 per
ratio of the benefits to the costs. In other words, if capita, we can save a net of $300 with Intervention
the ratio has a value greater than 1, then the benefits B, while A saves only $200. Which is a more effec-
outweigh the costs. We can then say, for example, tive intervention? The answer is that this would de-
that a cost-benefit ratio of 4: 1 means that for every pend upon a number of variables. First, it depends
$1 we spend, we yield $4 in benefit. The recent on whether the benefit accrues to the entity that is
CALDATA study found that in California, for every paying the costs. In other words, if state money is
$1 spent by the state for substance abuse services, $7 being used for the treatment, but half of the savings
were saved through reduced health, criminal justice, is reaped by the federal government (as with Medic-
and welfare expenditures (Gerstein et al., 1994). aid), then the cost-benefit of A is reduced to 1:1,
Thus, CALDATA demonstrated a 7: 1 cost-benefit while the cost-benefit of B is 1.5:1, making B the
ratio. clear winner. On the other hand, if there is a limited
However, some argue that using a cost-benefit ra- pot of money to treat a large population, then A may
tio may be misleading. For example, if the benefits be the only option, since its lower per capita cost
equal $4 and the costs equal $1, is this the same as would permit more people to be served. Conversely,
an intervention that costs $100 but saves $400? for a given population and with no limit on the avail-
While the ratios are the same, the potential savings able funds, spending more money—as in Alternative
are greater in the latter case (when we discus cost- B—will yield greater savings. Thus, there is no sim-
effectiveness, this will become clearer). Thus, an- ple answer, and each situation must be viewed in
other way of looking at cost-benefit might be in terms terms the individual conditions involved.
of a net cost offset. Under this approach, rather than
dividing benefits by costs, the costs are subtracted
Costs and Benefits
from the benefits. In this way, a positive result would
indicate a cost-benefit, and the larger the result, the What do we mean by costs and benefits? Costs are
greater the net benefit. defined as the personnel, facilities, equipment, and
 ECONOMIC ISSUES AND SUBSTANCE ABUSE 605

supplies (including medications) that are required.10 hand, drug and alcohol treatment may yield immedi-
However, depending on the context, costs have to be ate or short-term benefits. The impact of drug and
further defined (i.e., costs to whom?). For example, alcohol use on a variety of health problems ranging
the costs that a managed-care company is interested from HIV infection and other needle-related infec-
in are only the ones for which it is responsible. Costs tious diseases to adverse birth outcomes to stroke to
being borne by the patient or a provider may not trauma related problems is short-term.
enter into its evaluation of cost-benefit. On the other Thus, eliminating or reducing these substance
hand, an overall evaluation of cost-benefit might problems can yield immediate benefits. An example
have to define costs more broadly to include the total might be the benefits resulting from a methadone
costs, regardless of who is responsible for them. An- program. Just looking at HIV seroconversion rates of
other issue in defining costs is to ensure that we ac- those receiving methadone maintenance and treat-
count for all the costs. An example can be seen in ment for their heroin addiction compared to the
much of the early work done on evaluating the cost- rates of those who are not is dramatic. Given the
benefit of home care services for the elderly. If we high cost of this disease, particularly in a drug-abus-
look at the costs of the actual home care services and ing population, fairly dramatic decreases in health
evaluate them in terms of the benefits accrued, we care costs can be realized quickly. The author's own
see considerable cost-benefit for the Medicare pro- research shows as much as a 4: 1 difference in the
gram compared to nursing-home care. However, by seroconversion rates between the two groups (Mer-
keeping people in their homes, we now have many rill, 1997).
other costs, including housing, food, and transporta- Benefits can be defined in a number of ways.
tion, which may also be paid by the government (al- Clearly, the most narrow definition of benefits would
though not by Medicare). Using this definition of include only the costs saved in terms of having to
costs, as well as looking at the cost-benefit of home treat the disease (in the case of prevention programs)
health care to the entire government (not just Medi- or to prevent relapse (in the case of treatment pro-
care), we may not find that home care is more cost- grams). Ironically, however, this is the most problem-
effective than nursing-home services.11 atic benefit to isolate and define. Substance abuse
Defining benefits is an even more complex un- treatment is not like an antibiotic, where administra-
dertaking. Benefit can be defined narrowly in terms tion of the drug can actually eliminate the infection
of simply the cost of future treatment (e.g., relapse), and prevent future medical costs. Instead, like diabe-
or it might be viewed very broadly in terms of all the tes, substance abuse is a chronic, recurring problem,
health and social cost reductions that are generated. where long-term or permanent abstinence is less
Again, we must view this in the context of "benefits likely (particularly as a result of a single treatment
to whom?" For example, the concerns of a managed episode). Instead, the benefit may more likely be de-
behavioral health care company would revolve exclu- laying the problem, and the savings may be both
sively around the question of whether the cost of an harder to quantify (than, in the case of an infection,
intervention will yield benefits in terms of reduced the costs of continuing to treat the disease) and
relapse rates and less mental health morbidity. On longer term. Thus, cost-benefit analysis of treatment
the other hand, a full-service managed-care plan may not provide convincing evidence where a short-
(which includes physical, mental health, and sub- term, easily understood result is required.
stance abuse services) might be more interested in The benefits of substance abuse interventions can
the benefits that result from fewer health problems be more easily identified in terms of their cost offsets
overall. to other programs. In other words, offsetting the cost
An issue related to the above is the timing of of, for example, treatment are savings to the medical
when the benefits will accrue. For example, while care (including mental health), criminal justice, and
there is no question that smoking cessation can have welfare systems. In addition, the impact on employ-
a tremendous impact on reducing some cancers and ment can be viewed in terms of such measures as
cardiovascular diseases, the savings will probably not gains in productivity (e.g., reduced absenteeism) and
be seen for years. Thus, while a managed-care plan increased tax revenues. These measures can be
must pay the costs of that intervention now, they may viewed separately or can be combined to calculate a
never benefit from any of the savings. On the other total cost offset. If we subtract the costs of the actual
606 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

intervention from this, the result can be called the While it may not be possible to determine whether
net cost offset. This net cost offset provides us with a there was any cost-benefit, the impact of prevention
measure of the net savings that result from the inter- or treatment programs in terms of their social benefit
vention. still must be considered an important measure of
An example of this type of calculation is a study the efficacy (defined as the nonmonetary benefit) of
done in the state of Oregon which looked at the cost these interventions.
savings that could be attributed to publicly supported Another caveat about how we define benefits is
treatment programs. For those who had completed that from a cost perspective, not all benefits are actu-
treatment, the state estimated that the savings to the ally "benefits." This apparently contradictory state-
Medicaid, food stamp, child welfare, and criminal ment stems from the fact that while a beneficial out-
justice systems amounted to more than $83.1 mil- come is attained, it may not actually save money. For
lion. The total cost of public treatment programs was example, while health prevention programs involving
almost $14.9 million. Thus, the net cost offset was exercise, better nutrition, and smoking cessation have
$68.2 million, and the cost-benefit ratio was almost led to healthier people who live longer, the effect of
5.6:1 (Finigan, 1996). this on overall health care costs is actually to increase
As already mentioned, a cost offset can be coun- those costs. People dying at younger ages from strokes
ted only if it is relevant to the group for whom one and heart attacks are now living much longer lives at
is calculating the benefit. Obviously, to a state gov- considerably greater expense to Medicare and Med-
ernment, while many of these measures are impor- icaid. More acute services and a much greater need
tant, only that portion of the costs that it pays can be for long-term care contribute greatly to the costs
counted. For example, with respect to health care of these programs. Thus, while we cannot argue
costs, a state is responsible only for those costs which about the benefits of a more healthy lifestyle, there
are paid by Medicaid or through other state funds. may actually be no cost-benefit (i.e., the ratio is less
In addition, even for Medicaid, only those reduced than 1).
costs that the state pays (the federal government pays This problem may or may not apply to substance
more than half) can be considered a potential bene- abuse. An example is the argument that despite the
fit. On the other hand, benefits accrue to more that costs of smoking to the health care system, smoking
just the individual being treated. As Langenbucher cessation would actually increase overall health care
(1996) and Lennox, Scott-Lennox, and Holder (1992) costs, particularly for Medicare (Manning, Keeler,
have pointed out, treating the alcoholic improves not Newhouse, Sloss, & Wasserman, 1991). Opponents
only his or her health status, but also that of the of current efforts at both the state and federal levels
whole family, thus reducing health care costs even to increase tobacco taxes as a way of reducing smok-
further. ing argue that these increased taxes, while raising
It should also be noted that, for some of these revenues in the short term, may lead to increased
measures, it would be difficult to quantify the actual longer term public expenditures. On the other hand,
cost offset in terms of dollars saved. While reducing to date, research would refute this argument. For ex-
crime is important, one cannot say that for each re- ample, the study by Manning et al. (1991) found that
duced arrest, the full savings can be counted. When the cumulative impact of excess medical care re-
we talk about health care cost savings to, for exam- quired by smokers at all ages outweighed the shorter
ple, Medicaid, we can say that if someone did not life expectancy. In addition, a study by Hodgson
get sick, Medicaid actually saved the money for those (1992) showed that, in fact, payers that cover the
services. However, simply because someone is not ar- younger groups (i.e., private insurance and Medic-
rested does not mean that the criminal justice system aid) bear a greater burden of smokers' costs than does
saves money. It is not as though a jail cell can be Medicare.
eliminated, or the number of police officers or
judges will change. Significant reductions in crime
Some Examples
have to occur before any sizable offsets can be identi-
fied. On the other hand, because crime is of such Cost-benefit analysis has been used to examine treat-
concern to society, and substance abuse and crime ment effectiveness for many years. For example, in
are so closely linked, we cannot ignore this measure. the early 1970s, researchers like Holohan (1979),
 ECONOMIC ISSUES AND SUBSTANCE ABUSE 607

Leslie (1971), Maidlow and Berman (1972), and reduces the debate to purely economic terms. On
Tabbush [1986) were attaching cost-benefit ratios in the other hand, in an era of fiscal conservatism, as
the range of 7.9:1 to 18.7:1 to methadone mainte- well as the fact that there is little public sympathy for
nance programs. The wide range may, in part, be the problems of much of the population being
explained by the fact that not all of these researchers treated, economic arguments will be more persuasive
defined benefits in the same way, some looking more with respect to influencing public policy.
at criminal justice, others including hospital benefits
or employment and earnings.1 But, regardless of
how the benefits were specified, all of these studies FINAL THOUGHTS
essentially were designed to show how a dollar spent
on treatment can lead to benefits that exceed that In every sense, economic issues surrounding sub-
cost. stance abuse are undergoing dramatic changes. A
Many of these earlier efforts focused on the cost- changing financing environment, the growing influ-
benefit associated with a single program or a small ence of managed care, the carving out of behavioral
set of such programs. One of the difficulties with this health services from other medical care, and a gen-
"micro" approach is that it may be hard to generalize eral cost consciousness in both the private and the
from such information. For public policy purposes, public sectors create an unsettling situation for all
using individual studies may not convince policy- those involved in preventing and treating substance
makers of the benefits of investing more dollars in abuse.
prevention and treatment programs. One example of These effects can already be seen in reduced
an effort to look more broadly at the cost-benefit asso- funding for prevention and no increases—if not re-
ciated with treatment was the Treatment Outcome ductions—in spending for treatment. Not all of this
Prospective Study (TOPS), which assessed the im- is necessarily bad, however. Many argue that the sys-
pact of 41 treatment programs. While not showing tem was throwing money away on ineffective and un-
quite the high cost-benefit in some of the individual necessarily costly prevention and treatment programs.
studies, TOPS nevertheless found a benefit of $1.66 The era of the 28-day hospital treatment program, of
for every $1 spent on treatment (Hubbard, Rachal, inpatient detoxification, and even of some forms of
Craddock, & Cavanaugh, 1984). lengthy outpatient care are over. Instead, new, shorter
More recently, a number of "macro" studies have modalities, provided by lower level personnel, are the
been done that attempt to evaluate the cost-benefit of rule.
an entire state program. These efforts, in California But these changes are not necessarily positive.
(Gerstein et al., 1994), Ohio (Ohio Department of Al- The truth is that we currently know little about what
cohol and Drug Addiction, 1996), and Oregon (Fini- the impact of the emerging, leaner system will be on
gan, 1996), were not focused on the cost-benefit of access, quality, and outcome of services. Part of this
an individual program or modality, nor did they ex- requires clinical studies that assess these new inter-
amine the outcomes of treatment on preventing ab- ventions from the perspective of their outcomes.
stention or relapse. Rather, their focus was on reduc- However, particularly as costs become such a critical
tions in other state expenditures that result from factor in the decision-making process, cost-benefit
treatment, and all of these studies reported sizable and cost-effectiveness analyses grow in their impor-
cost-benefits to the state resulting from substance tance. We now must prove not only that a given
abuse treatment expenditures. As discussed earlier, modality makes a difference in patient status, but
their emphasis was on savings in terms of overall also that it represents a wise investment of those treat-
Medicaid, welfare, and criminal justice expenditures. ment dollars when compared to other modalities,
In this way, such studies have tried to demonstrate and that cost-effectiveness must also be demonstrated
in the language of hard dollars and cents that invest- in terms of comparing the benefits of a given modal-
ing in drug and alcohol treatment represents a bene- ity to other, non-substance-abuse services.
ficial use of public dollars. Some might argue that To many, this may appear as a bleak perspective,
this is a callous approach to evaluating treatment, one that does not bode well for growth in substance
since it puts no emphasis on patient outcomes with abuse programs. As has already been mentioned,
respect to reducing the substance problem and rather given the chronic, recurring nature of the disease of
608 PREVENTION, POLICY, AND ECONOMICS OF SUBSTANCE USE DISORDERS

addiction, it may be difficult to demonstrate that a 4. It should be noted that, while what is described
given episode of treatment is effective, particularly are the federal Medicaid rules, many states have their
compared with a medical or surgical intervention for own general assistance category (mainly for men),
an acute disease. The future may require us to assess which may also pay for services under Medicaid. How-
substance abuse programs in different ways that may ever, these funds are not matched by the federal pro-
gram.
put a more positive light on their impact. For exam-
5 Ironically, there is no clear dividing line, since di-
ple, we may find it more accurate to look at sub-
abetes and even some heart conditions and cancers are
stance abuse treatment from the perspective of the relapsing but are grouped with acute diseases. The rea-
cumulative effects of multiple treatment episodes son is that as opposed to substance abuse or mental
rather than to assess the impact of a single episode. health, these are considered "mainstream" medical ser-
In addition, we must ensure that we are comparing vices (i.e., they respond to medical interventions such as
treatment impact with that of the treatment of other drug therapy or surgery). While both mental health and
chronic, recurring diseases like diabetes. To some ex- substance abuse may also respond to chemotherapeutic
tent, this requires correcting the prevailing public at- interventions, they (particularly substance abuse treat-
titude about the nature of substance abuse as an ment) are still not viewed as "mainstream."
acute disease. 6. This was a true story told to me by the director of
Finally, we must start to look at the cost-benefit the Employee Assistance Program for the company
of prevention and treatment programs in terms of where the patient worked.
their cost offsets to other programs including health 7. Unpublished analysis of data from the Survey of
inmates in state correctional facilities (1991) conducted
care, welfare, criminal justice, employment, and
by the national Bureau of Justice Statistics, the U.S. De-
worker productivity. While society may not care as
partment of Justice. This survey (the data tapes are pub-
much about whether an individual addict recovers, licly available) interviews about 12,000 inmates in state
they do care about reducing public expenditures and prisons throughout the country and provides data on all
crime, and about increasing taxes and profits. facets of their lives including information on prior ar-
These may be tough times for the substance rests and convictions as well as on substance abuse his-
abuse treatment industry. But they also represent a tory.
challenge, one that will depend on a better under- 8. A comment made by a senior policy official at the
standing of all of the issues associated with the eco- Office of National Drug Control Policy at a meeting in
nomics of substance abuse. April 1997.
9. For a good discussion of these terms see Langen-
Notes bucher (1996).
10. For discussion on how the costs of substance
1. It should be noted that managed care is not a fi- abuse treatment may be calculated, there are a number
nancing mechanism per se. Instead, as will be discussed of good articles, for example, Dunlap and French (1995)
below, managed care is a means of using financing to and Zarkin, French, Anderson, and Bradley (1994).
organize care and control the available resources. Man- 11. It should be noted that this discussion is entirely
aged care is used by all financing mechanisms, both pri- about cosf-benefit. There may be very compelling non-
vate insurance and public funding programs. cost reasons for keeping people in their own homes that
2. It should be noted that the 28-day hospitalization totally outweigh the notion of cost-effectiveness of home
was an arbitrary length of stay. In some ways, it was sim- versus nursing-home care.
ply a compromise between 6-week and 2-week stays. 12. For a more thorough description of the cost-ben-
Actually, there is a dearth of articles that would demon- efit literature related to drug treatment, a paper by Cart-
strate the comparative effectiveness of inpatient sub- wright (1997) is available from the National Institute on
stance abuse treatment. One example is McLellan, Gris- Drug Abuse.
som, Brill, and Durell (1993).
3. While Medicare does provide some funding in
this area for individuals over the age of 65 and for work- Key References
ing people who have become disabled, most of this is
for inpatient alcohol treatment only. In addition, with Finigan, M. (1996). Societal outcomes and cost savings
respect to outpatient care, the cost sharing is very high of drug and alcohol treatment in the State of Oregon.
(50%), and there is a limit on total expenditures that Portland: Oregon State Office of Alcohol and Drug
Medicare will cover. Abuse Programs.
 ECONOMIC ISSUES AND SUBSTANCE ABUSE 609

Langenbucher, J. (1996). Socioeconomic analysis of ad- Hubbard, R. L., Rachal, J. V., Craddock, S. G., & Cav-
dictions treatment. Public Health Reports, 111(2), anaugh, E. R. (1984). Treatment Outcome Prospec-
135-137. tive Study (TOPS) client characteristics and behaviors
Manning, W. G., Keeler, E. B., Newhouse, J. P., Sloss, before, during and after treatment. NIDA Monograph
E. M., & Wasserman, }. (1991). The costs of poor 51. Rockvillle, MD.
health habits. Cambridge: Harvard University Press. Inciardi, }. A., McBride, D. C., McCoy, H. V., & Chit-
wood, D. D. (1994). Recent research on the crack/
cocaine/crime connection. In: Studies on crime and
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Ball, J. C., Lange, W. R., Myers, C. P., & Friedman, S. Langenbucher, J. (1994). Offsets are not add-ons: The
R. (1988). Reducing the risk of AIDS through meth- place of addictions treatment in American health care
adone maintenance treatment. Journal of Health and reform. Journal of Substance Abuse, 6(1), 117-122.
Social Behavior, 29(3), 214-216. Langenbucher, }. (1996). Socioeconomic analysis of ad-
Cartwright, W. (1997). Cost-benefit and cost-effectiveness dictions treatment. Public Health Reports, 111(2),
analysis of drug treatment services. Washington, DC: 135-137.
National Institute on Drug Abuse. Lennox, R. D., Scott-Lennox, }. A., & Holder, H. D.
Dunlap, L. J., & French, M. T. (1995). A comparison of (1992). Substance abuse and family illness: Evi-
two methods for estimating the costs of drug abuse dence from health care utilization and cost-offset re-
treatment. Chapel Hill, NC: Research Triangle Insti- search. Journal of Mental Health Administration,
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Finigan, M. (1996). Societal outcomes and cost savings Leslie, A. C. (1971). A benefit/cost analysis of New York
of drug and alcohol treatment in the State of Oregon. City's heroin addiction problems and programs. New
Salem, OR: Office of Alcohol and Drug Abuse Pro- York: Health Services Program.
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nal of Public Health, 85(1), 48-54. E. M., & Wasserman, }. (1991). The costs of poor
Gerstein, D. R., Johnson, R. A., Harwood, H. J., Foun- health habits. Cambridge: Harvard University Press.
tain, D., Suter, N., & Malloy, K. (1994). Evaluating McLellan, A. T., Grissom, G. R., Brill, P., & Durell, J.
recovery services: The California Drug and Alcohol (1993). Private substance abuse treatments: Are some
Treatment Assessment (CALDATA). Sacramento: programs more effective than others? Journal of Sub-
California Department of Alcohol and Drug Pro- stance Abuse Treatment, 10(3), 243-254.
grams. Merrill, J. (1997, November). The impact ofmethadone
Harwood, H. J., Hubbard, R. L., Collins, J. J., & Rachal, maintenance on HIV sero-conversion rates and related
J. V. (1988). The costs of crime and the benefits of costs. Delivered as part of the NIH Consensus Devel-
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TOPS data. In C. Leukfeld & F. Tims (Eds.), Com- Washington, DC.
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 Index

Note: Page numbers followed by "f' indicate figures.Those followed by "t" indicate tables.

AA. See Alcoholics Anonymous substitute dependencies, 43

"AA Member and Medications, The" (booklet), 463 test period, 340
AASs. See anabolic-androgenic steroids as therapeutic community goal, 319, 390
ABC model of emotion, 252 as treatment evaluation standard, 419
abdominal pain, 82, 84, 224, 356 as treatment goal, 221-23, 255
abecarnil, 96 as treatment requirement, 424
Abrams, D. B., 252, 257-58 as 12-step fellowship goal, 282, 337, 338, 386
abstinence as uncommon outcome, 3-4
Antabuse used for, 296 See also craving; lapse and relapse; recovery and resolution;
assessment sequence, 202 withdrawal
behavioral reinforcement, 256, 257, 297 abstinence violation effect (AVE), 43, 373-74, 378
cocaine signs, 450 abstract thinking, 54
cognitive behavioral reinforcement, 257-58 acamprosate, 77, 352, 390, 391, 428
commitment and, 42 acceptance, 245, 333
controlled drinking vs., 222-23 accidents
course of alcoholism and, 32 acute hallucinogenic state and, 135
degree of recovered cognitive functioning with, 86 adolescent drunk drivers, 483, 574
depression remission, 86 alcohol-related deaths from, 39, 87-88
as disease model's primary tenet, 269, 282, 283 alcohol-related injuries from, 427, 431, 602
elderly treated substance users, 492 alcohol restrictive sale laws preventing, 577, 578
ethnic women, 528 elder substance users, 489
incentive system, 259 inhalant abuse and, 174
as long-term outcome of alcoholic treatment, 35 public service prevention campaigns, 581
and lowest posttreatment mortality rate, 39 stimulant use and, 117
motivation as predictor, 387 zero-tolerance laws, 579-80
opioid dependence symptoms, 146, 150-51 Acculturation Rating Scale for Mexican Americans, 515
during pregnancy, 85 acetaldehyde, 76
psychiatric symptom improvement, 36 acetaminophen (Tylenol), 76, 80t
as relapse prevention goal, 380 acetate, 76
risk reduction vs., 255 acetylcholine, 130, 134, 163
as self-help groups' goal, 331, 338, 340 Acierno, R., 251

611
612 INDEX

Ackerson, T. H., 457 stereotype challenges, 478

acquired habits, 11, 371 temperament as use factor, 58-60
ACTH, 153 therapeutic community residents, 318
active listening, 238, 244, 245, 246 treatment, 486-87
ACT programs, 464 treatment assessment, 484-86
acupuncture, 358 treatment choice, 218
ADA. See Americans with Disabilities Act warning label effects on, 581
adaptive consequences, 290 Adolescent Self-Assessment Profile, 486
ADD. See attention deficit disorder adoption studies, 51, 53, 55, 272, 292
Adderall Biphetamine, 109t adrenal gland, 163, 483
"Addiction Is a Brain Disease and It Matters" (Leshner), 271 adrenergic overflow, 350, 356
addiction models ADS. See alcohol dependence syndrome
abstinence vs. moderation goal, 3 Adult Children of Alcoholics, 289
disease, 268-83, 385-86, 444-45 advice, as motivational component, 237, 243-44
learned behaviors, 61-62, 371-72 Advil, 80t
moral, 445, 602 aerosols, 172t
neurobiological, 271-72 aesthetic experience, 131
nonunified views, 440 affective disorders, 318, 440, 446, 448
personality deficits, 440 affective regulation disturbance, 61, 86-87
psychoanalytic, 60-61, 444 African-Americans, 506-8
sociocultural, 62-65 adolescent substance use, 479
spiritual malady, 329, 332 Afrocentricity assessment, 515
See also dependence; treatment models and methods alcohol abuse/dependence rates, 19, 20t
Addiction Research Foundation, 427 cocaine use, 503, 504, 507
Addiction Severity Index, 255, 294, 389, 452, 486 cultural beliefs and practices, 507-8
addictive behaviors model, 371-72 demographic characteristics, 501-4, 50It, 503t, 510
addictive personality, 440 drinking patterns, 14
addictive voice recognition technique, 339-40 low rate of women drinkers, 528
adenyl cyclase channels, 147 low rate of women smokers, 528
ADHD. See attention deficit hyperactivity disorder male heroin use, 151
adhesives, 172t minority experience, 499
ADI. See Adolescent Diagnostic Interview; Adolescent Drinking patterns of drug use, 507
Index prevalence of alcohol and drug use, 14-17, 15t, 16t, 17t
Adolescent Alcohol Involvement Scale, 484 prevalence of alcohol and drug use disorders, 19-21, 20t
Adolescent Assessment/Referral System, 487 sociocultural features, 506-8
Adolescent Diagnostic Interview, 484-85 Afrocentricity, 515
Adolescent Drinking Index, 484 Afrocentrism, 507-8
Adolescent Drug Abuse Diagnosis, 486 age, 477-93
adolescents, 477-87, 493 of alcohol vs. drug abuse patients, 40, 41
alcohol-related traffic accidents, 483, 574 childhood behavioral problems as alcoholism predictor, 57-58
anabolic-androgenic steroid use, 177, 478t comorbid depression and substance use disorders, 24-25, 25t
cannabis increased use trend, 121, 366 course of alcoholism, 32, 39, 489
cannabis use effects, 129 drinking patterns and, 14-16
comorbid psychiatric disorders, 484 genetic factors in alcoholism onset, 56
conduct disorders as use predictor, 57, 58 identification of substance abuse problem, 225
consequences of use, 483-84 illicit drug lifetime use, 16-19
course of use, 482-83 "maturing out" of substance use, 38, 483
cultural factors and use, 63-66 mortality risks for alcoholic vs. drug abuse patients, 41
curfew laws, 580 prevalence of alcohol abuse and dependence, 19-21
data collection on use, 18 prevalence of lifetime and past-year alcohol use, 15t
deviant behavior theories, 63-64, 479-82 prevalence of lifetime and past-year drug DSM-/V use disorders,
epidemiology and patterns of use, 477-79, 478t 22t
ethnic minority stressors, 500, 506 prevalence of lifetime and past-year illicit drug use, 16-17t
family systems therapy, 290 smoking progression and, 37-38
female alcohol abuse prevention, 536 treatment prognosis and, 38
female alcohol and nicotine use, 529 women's problem drinking and, 527, 529-30
female nicotine use, 528 See also adolescents; elderly people
gateway theory, 19, 482 Ager, J. W., 581
heroin middle-class user trend, 151 aggressivity
inhalant abuse, 173, 174, 175, 513 alcoholic P3 voltages and, 55
intervention criticality, 477 as alcoholism predictor, 57
MDMA use, 180 androgens and, 175, 179
minimum age of purchase laws, 65, 404, 563, 565, 577 childhood indicators, 58
multiple drug users, 478, 493 heritability of, 53, 54
Native American Indian users, 513-14 agitation, 81, 364
peer modeling, 63-64, 65, 251, 479, 493, 500, 556 agnostics, 337
prevention strategy, 555-66, 582, 583 agonists
rates of abuse and dependence, 478 adrenergic, 350
restricted alcohol/tobacco sales to, 562-63 cholinergic, 163
rise in substance use, 555 dopamine, 362, 365t
risk factors, 57-60, 63-65 opioid, 150, 152, 354, 356, 392
risk/protective factors, 479-82, 48It as pharmacological substitution, 459
smoking motivations, 166 agoraphobia, 86, 102, 443
smoking prevention approaches, 582, 583 Agosti, V., 391
smoking rates, 37-38 Ahadi, S. A., 60
 INDEX 613

AIDS. See HIV virus lifetime prevalence, 440

AIDS Research Program, 153 medical risks, 82-83, 83t, 350-51, 427, 431, 483, 602
Aisquith, B. F., 593 mental illness comorbidity, 431, 442, 443, 464
Al-Anon, 288, 296, 331, 332, 334-35, 388 mortality, 3, 38-39, 41, 75
Alateen, 289, 331, 334-35 in multiple family members, 299
Alatot, 334-35 in Native American Indians, 503, 504, 513
Albert,}., 225 nicotine use comorbidity, 360
Alcohol Attitude Scale for Teenagers, 485 opioid dependence and, 156
alcohol autobiography, 297, 375 pharmacotherapies, 76-77, 96, 291, 296, 348-53, 365t, 390-91,
alcohol content, 578-79 459-60
alcohol dehydrogenase, 76, 78, 79, 83 as physical allergy to alcohol, 270
alcohol dependence syndrome, 10-11, 33 progression of symptoms, 32-34, 270-71, 273-74, 385
Alcohol Effects Questionnaire, 377-78 and sedative-hypnotic prescription, 101
Alcohol Expectancy Questionnaire, 378 as "self-limiting" disease, 30
Adolescent Version, 485 as spiritual malady, 329, 332
Alcohol-Focused Spouse Involvement with Behavioral Marital suicidality, 446, 466
Therapy, 291 temperament as factor, 59-60
alcoholic dementia, 82, 83t treatment long-term outcomes, 34-36, 38
alcoholic hepatitis, 82 treatment relapse, 370, 371, 375, 376
Alcoholics Anonymous, 32, 36, 44-45, 226, 276, 322, 386-87, 423, Type A/Type B, 56
424 Type I vs. Type 2, 13-14, 55-56, 59
adolescent outcomes, 486 withdrawal, 349-51, 386, 482, 490
conceptual development of, 329 withdrawal course, 10, 33, 78, 80, 81-82
and disease model, 269, 275-80, 282, 385 withdrawal treatment, 349-51
and family disease model, 289, 296 in women, 56-57, 528, 529, 530
gay and lesbian members, 548, 549 women's patterns/course/consequences, 528, 529, 530-37
group conscience of, 330 women's preventive measures, 536-37, 566
mandatory referrals, 405, 424 See also treatment
medications policy, 463 alcohol use, 75-88
meeting formats, 333-34, 386-87 abusers vs. addicts, 31
membership numbers, 329, 331, 386 adolescent, 18, 57, 478, 478t, 482, 483, 485
networking, 342, 387 alcoholism vs. heavy drinking, 270
overview, 331-34 anabolic-androgenic steroids with, 177-78
personal history narratives, 334 Asian-American, 511
precursor, 329 assessment measures, 190-9H, 193, 485
rituals, 343 autobiography, 375
Secular Organization for Society compared with, 337t base abuse rate, 268
self-diagnosis abstinence test period, 340 biochemical markers, 204
slogans, 278 biological markers, 203-4
spiritual element, 330-31, 332-33, 332t, 336-37 chronicity defined, 31
success outcomes, 239, 343-44, 387 classifications, 55-57
support system, 283, 342-43 clinical aspects, 78-82
as therapeutic community antecedent, 307 collateral informants, 203
12 steps, 277-80, 332t community samples outcomes, 31-32
women members, 338 comorbidity with psychiatric disorders, 21-25
Alcoholics Anonymous, 270, 277, 334 continuum-of-severity approach, 11
alcoholism controlled vs. abstinence, 222-23, 255, 340-41, 388
acceptance of, 245, 333 course of disorders, 31-34
age and course of, 32, 39, 489 decision matrix, 375, 376f
alcohol dependence syndrome vs., 11 dependence and tolerance mechanisms, 77-78, 194-95,
antisocial personality disorder comorbidity, 442, 446 482
aversive counterconditioning, 253 drinking locations restrictions, 580
behavioral marital therapy, 291-92, 301 drinks-per-day cutoffs, 23
biological factors, 54-55, 76-78, 292 drug interactions, 76, 79-80, 80t, 152
blackouts, 80-81, 270, 385, 482 drugs used with, 113, 125, 156, 451, 488, 532
brief interventions effectiveness, 387 by elderly people, 487-88, 489, 490-91
client-treatment matching, 220 environmental problem-prevention strategies, 575-82
clinical heterogeneity, 55-57 by ethnic/racial groups, 502, 503, 504
comorbidity with other substance abuse, 451 expectancies from, 377-78
conduct disorder/antisocial personality as risk factors, 57-58 family systems model, 62-63, 291-93
denial and defense system, 272-73 future direction of classification, 25-26
depression comorbidity, 56, 202, 274, 441, 446, 459, 460, 466 gateway hypothesis, 129, 529
disease model, 10, 268-83, 371, 385-86, 444 by gay men, 544, 545, 546
early-onset, 56 genetic factors, 51-54
in elderly people, 488-91 harm reduction approach, 223
ethnic/racial differences, 503 heavy drinking defined, 14
etiology of, 271-72 high-risk situations, 219
family disease model, 62-63, 287-90, 291, 292, 301 historical classification of disorders, 10-26
first use of term, 10 improved patterns as treatment outcome, 35
four stages, 13, 185 intergenerational influences, 53
full recovery chances, 35-36, 38 legal consequences, 88, 404
genetic factors, 51-54, 271, 272 by lesbians, 544, 545, 546
geriatric early vs. late-onset, 489 lifetime abstention data, 18
hallucinations, 350, 448 as marijuana augment, 80, 125
historical overview, 10-26 minimum age of purchase laws, 65, 404, 563, 565, 577
614 INDEX

alcohol use (continued) mortality risks vs. opiate addicts, 40

mortality rates, 3, 38-39, 41, 75, 82, 84 physiological effects, 115-17, 125
motivations to alter, 237-38 potency as reinforcement agent, 108
natural change in, 237 prevalence of disorders, 21
as nicotine augment, 80, 167, 529 prevalence of illicit lifetime use, 16-18
outcome expectancies, 198 prevalence of lifetime and past-year DSM-/V use disorder,
pathological effects, 82-88 22t
pharmacological actions, 75-78, 96, 101, 349 symptoms of use, 113-14
physical symptoms, 80-81 therapeutic uses, 109, 110
physiological effects, 82-85 withdrawal course and symptoms, 114-15
posttreatment status and mortality, 39 Amundsen, A., 575
prevalence data, 14-16, 18 amygdala, 163
prevalence of disorders, 19-21 amyl nitrates, 173
progression of disorders, 32-34 Amytal. See amobarbital
psychological effects, 85-87 anabolic-androgenic steroids, 175-79
relapse assessment, 375-76 adolescent use, 177, 478t
restricted access effects, 575-77 trade names and dosages, 176t
sale conditions, 404, 576, 577-78, 579 Anadrol. See oxymetholone
self-efficacy and, 198 analgesics
self-report verification, 226 addiction, 152
social consequences, 85, 87-88, 425, 426-27 elder abuse of, 488, 489
social expectancies, 87 opioids as, 141, 144, 147-48, 152, 354
social policy and, 65 PCPas, 133
social reinforcement, 372 anandamide, 123
socioeconomic status/recognition of problems, 42 Anatrofin. See stenobolone
suicidality, 446, 466 Anavar. See oxandrolone
temperament as factor, 58-60 Anderson, H. R., 174
toxic ingestion, 349 Anderson, L, 78-79
treatment goals, 222-23 Andrews, J. C., 581
treatment implications, 44-45 androgen, 175
warning labels, 580-81 Android. See methyltestosterone
by women, 527-30, 531-37 Anes, M. D, 583
women's problem-prevention strategies, 536-37, 566-67 anesthetics, 111, 133
Alcohol Use Disorders Identification Test, 534 angel dust. See PGP
alcohol withdrawal (AW) symptoms, 81-82 anger
aldehyde dehydrogenase, 76, 352 management, 221-22, 223
ALERT program, 565 as relapse trigger, 372
Alfano, A. M., 201 therapist's ability to deal with, 298
alkaloid cocaine. See crack of woman alcoholic, 535
alkaloids, 141 Anglin, D., 36-37
Allan, C. A., 530 anhedonia, 25, 114,447,448
Allen, J. P., 201, 204, 220, 416, 419 Annan, S., 586
Allport, Gordon, 59-60 Annis, H., 52-53, 197, 198, 219, 221, 376, 536
alpha alcoholism, 10, 13 anorexia, 82, 100, 149, 364
alpidem, 96 Antabuse contract, 291, 296, 389 (see also disulfiram)
alprazolam (Xanax), 97t, 99, 100, 101, 461 antagonists
altered states, 131 dopamine, 362
Alterman, A. I., 391 as drug-effect blockers, 459
Altman, D. G., 593 GABA, 349
Amanita muscarina (fly agaric), 124t, 130, 163 nicotine, 359
overview, 134 opioid, 150, 152, 351, 355-56, 360, 390, 460
amantadine, 362 Antes, D., 39, 41
Amaro, H., 533 Anthenelli, R. M., 32, 270-71, 534
Ambien. See zolpidem antianxiety medication, 359, 391
ambivalence, treatment, 224, 245 anticholinergic hallucinogens, 130, 134
American Board of Professional Psychology, 415 anticoagulants, 80t
American Indians. See Native American Indians anticonvulsants, 80t, 82, 96
American Psychiatric Association, 10, 102 anticraving agents, 351-52
American Psychological Association, 3-4, 415 antidepressants
American Society of Addiction Medicine, 220-21, 415 for alcoholic depression, 352, 391
Americans with Disabilities Act, 404, 405 alcohol interaction, 80t
Ames, G., 533 for anxiety disorder, 96
amino acids, 77 for cocaine abuse, 461
amobarbital (Amytal), 97t drug interactions, 360, 363
amotivational syndrome, 25, 129 for nicotine withdrawal, 359, 360
amphetamines, 105-18 for stimulant craving, 113
administration routes and dosages, 110-11, HOt See also tricyclics
comorbidity with psychiatric disorders, 15t, 447 antidiscrimination laws, 404, 405
delusional disorder, 461 antihypertensives, 359
designer drugs, 180 antikindling effects, 363
dopamine binding, 107-8, 130 anti-Parkinson medication, 362
free-based form, 109 antipsychotics, 360, 461-62
generic/trade/street names, 109t alcohol interaction, 80t
long duration of effects, 108 street drug interactions, 466-67
metabolic pathway, 105, 106f antiretroviral agents, 154-55
 INDEX 615

antisocial personality for ethnic/racial minority treatment, 515-19

assessment of, 199 family model, 294-95
cocaine abuse symptoms of, 450-51 for female alcoholics, 533-34
comorbid gender differences, 56-57, 532 interviewing techniques and style, 205-6
etiological pathways, 50, 52, 53-54, 56-58, 59 multiple substances, 449
machismo as, 510 outcome expectancies, 196
multiple drug use, 19 of personality variables, 198-99, 201
opioid dependence, 156 of potential barriers to treatment, 224-25
poor response to incentive approach, 260 practical aspects, 200-206
substance use comorbidity, 23, 24t, 53, 199, 308, 442, 446 problem assessment tools, 190-9It
substance use comorbidity treatment, 454 of readiness to change, 199-200, 387
substance use comorbidity treatment outcome, 446 relapse prevention, 379-80
Anton, R. F., 76, 204 relapse risk, 196-97
Anton, S. F., 442, 450-51 screening process, 188-92
anxiety self-report measures, 197, 203, 204, 205t
alcoholic pharmacotherapy for, 352, 391 stages and levels, 193f
alcoholic relief drinking, 271 standards, 416, 417t
as alcohol withdrawal symptom, 81, 349 of substance abuse as presenting problem, 225-26
amphetamine as counter, 447 therapeutic community, 310
anabolic-androgenic steroid use and, 179 timing and sequence, 201-2
assessment instruments, 1911 utilization for treatment plan, 218-19, 224-27
cannabis intoxication and, 125 validity and reliability methods, 202-5
hallucinogen use and, 131 See also treatment
MDMA and, 181 AST (aspartate aminotransferase), 204
nicotine withdrawal and, 166 asterixis, 83
opioid-induced, 149, 156 asthma, 108, 167
and phases of treatment/recovery, 201 ataxia, 82, 83t
rebound, 100 atenolol (Tenormin), 350
as relapse risk, 372 atheists, 337
as sedative-hypnotic withdrawal symptom, 364 athletes, 175-79
stimulants-related, 114, 117 Ativan. See lorazepam
in women alcohol users, 528 Atkin, C. K., 581
anxiety disorder Atkinson, R. M., 492
eating disorder comorbidity, 533 atropine, 134
lifetime prevalence rate, 440 attention deficit disorder
nicotine use comorbidity, 360 as alcoholism predictor, 57
opioid dependence comorbidity, 156 amphetamines prescribed for, 108, 111
pharmacotherapy, 391, 461 conduct disorder vs., 58
sedative-hypnotic and anxiolytic agents, 95-102 attention deficit hyperactivity disorder, 443
substance-induced, 448 attention span, 54
substance use comorbidity, 23, 24t, 61-62, 86-87, 440-41, 442t, Attorney's Guide to Drugs in the Workplace (Denenberg and
536 Denenberg), 405
anxiolytic agents. See sedative-hypnotic and anxiolytic agents AUDIT. See Alcohol Use Disorders Identification Test
aortic aneurysm, 166 auditory hallucinations, 173, 350, 448
apathy, 25, 149 Auerbach, A., 259
Apollonian-type alcoholism, 13-14 Augustine Fellowship, 329
appetite suppressants, 166, 180 autobiography, substance use, 297, 334, 375
arculate nucleus, 141 automobile ignition interlocks, 480
Areas of Change Questionnaire, 294 automobile use. See motor vehicle operation
arrhythmias, 83t, 108, 118, 149, 349 autonomic nervous system, 125, 135
ARSMA (Acculturation Rating Scale for Mexican Americans), 515 autonomy, 401
ASAM. See American Society of Addiction Medicine AVE. See abstinence violation effect
ASI. See Addiction Severity Index aversive counterconditioning, 253, 358, 359, 459, 460 (see also di-
Asian-Americans, 499, 510-12, 515 sulfiram)
demographic characteristics, 501-4, 501t, 503t, 510 AVRT. See addictive voice recognition technique
patterns of drug use, 503, 504, 511 Ayre, F. R., 53
Asians, 76 azidothymidine. See zidovudine
ASP. See antisocial personality Azrin, N. H., 251
aspirin, 80t AZT. See zidovudine
assertive community treatment (ACT) programs, 464
assertiveness training, 556, 565 Babor, T. F., 11-13, 56, 59, 194, 203, 205, 225, 536
assessment strategies and measures, 187-206 BAG. See blood alcohol concentration
for adolescent substance users, 484-86 Bachman, J. G., 177
appropriate instruments and interviews, 190-92t Backenheimer, M. S., 488
appropriate level of care selection, 217-18 bacterial infections, 155-56
areas covered, 217, 219 Badger, G. J.,251,260, 262
behavioral and cognitive behavioral treatments, 254-55, 388 "bad trips" (hallucinogenic), 131
biological markers, 203-5 Baeumler, R., 282
collateral informants, 203 Bahrke, M. S., 177
coordinated care system, 432 Bailey, S. L, 483
diagnosis determination, 194-95 Bako, G., 577
disease model, 275, 276 balanced lifestyle, 279, 382
documentation, 416-17, 417t, 419 balance sheet, decisional, 239, 240t, 387
dual diagnosis, 446-51 Ball, J. C., 603
for elderly substance users, 490-91 Ball, S. A., 56
616 INDEX

gi, B. H., 582 belladonna, 130, 134

barbiturates, 18, 79, 95, 96, 97t Benefield, R. G., 205
adverse effects on elderly, 489 Bennell, D. L, 177
for alcohol detoxification, 350 Bennett, L. A., 63, 289-90, 292
dependence, 364 benzathine nasal spray, 108
drug interactions, 98-99 Benzedrine, 109t
tolerance, 98 benzodiazepines, 79, 80t, 82, 96, 97t
Barker, T. A., 282 abuse potential and toxicity, 98
Barnett, L. W., 42, 370 advantages over barbiturates, 95, 96
Barnett, P. G., 582 as alcohol detoxification agent, 349-50, 352, 365t
Barr, H. L, 39 drug interactions, 360
barrios, 509 elder abuse of, 488, 489
Barren, A. P., 60 ineffectiveness for nicotine withdrawal, 359
Barry, K. L., 427 neurotransmitter systems and, 98
Bartholow, B. N., 546 as opioid detoxification agent, 356
basal ganglia, 123 as pharmacotherapeutic agent, 461
Bauer, L, 55 pharmacotherapy, 363-64, 36 5t
BDI. See Beck Depression Inventory physiological effects, 102
Beattie, M., 492 stimulants used with, 112
Beck, A. T., 252, 446 withdrawal reaction, 100
Beck Depression Inventory, 255, 450 benzomorphan opiates, 146
Becker, C. A., 282 benzopyrenes, 360
Beckman, L.J., 533 benzotropine, 130
Begleiter, H., 52, 54 benzoylmethylecogonine. See cocaine
behavioral contracting, 296, 389 Berenson, D., 63
behavioral dependence, 127, 149, 152 Berkson,J., 34
behavioral marital therapy, 291-301, 371, 389 Berkson's bias, 23
behavioral pharmacology, 251, 257 Berman, H., 607
behavioral relapse models, 196-97 Berry,]. W., 518
behavioral science, 11, 61-62, 63, 273 Besalel, V. A., 251
behavioral tolerance, 77 best practice models, 431-33
behavioral treatments, 250-63, 387-88 beta alcoholism, 10, 13
active ingredients, 258-59, 388 beta-blockers, 350
for adolescent substance use, 487 beta-endorphins, 141, 146, 148, 163
assessment procedures, 254-55, 388 biaxial concept, 11
for cocaine abuse, 262 Bickel, W. K., 251, 253, 257, 258-59, 260, 262
for comorbid conditions, 458 Biederman, J., 443
effectiveness data, 260-62 Biernacki, P., 44
family interactions and, 289, 290-97, 389 Bierut, L. J., 52
goals, 255-56, 388 Big Book. See Alcoholics Anonymous
historical origins, 251-52 Bigelow, G. E., 251,261,262
major techniques, 256—57 binges, 108, 513
marital therapy, 291-99 Binion,V. ]., 531
for nicotine addiction, 358, 359 biochemical markers, 204
patient characteristics/outcome variability, 260 biological factors. See genetic factors
relapse prevention, 375-79, 380, 382 biopsychosocial model, 269
research support, 301 bipolar disorder, 360
strengths and weaknesses, 262-63 intervention timing, 458
structured session, 256 substance use disorder comorbidity, 441-42, 442t, 446, 447, 454,
therapist role, 259-60 461
therapist training, 298 suicide risk, 466
use in 12-step approach, 278 See also manic disorder
See also cognitive behavioral treatments Birchler, G. R., 291-92
behavior changes Birkhead, S. H., 583
behavioral/cognitive behavioral assumptions, 253-54, 387- birth defects, 85, 116-17, 118, 134, 582, 602
clinician's empathy and, 244 Bissell, L., 400
cognitive, 254 Bittle, W. E., 549
commitment reinforcement, 189 Black, A., 391,460
discrepancy discernment, 245-46 Black, C., 289
disease model assumptions, 275-80 Black, J. L., 261
disease model rationalization against, 445 blackouts, 80-81, 270, 385, 482
in family model, 293-94, 298-99, 300 blacks. See African-Americans
idiosyncratic beliefs, 375 Elaine, J. D., 446, 515
maintenance factors, 42-43, 44 blaming, 299
motivational factors, 235-46, 375, 387 Block, J., 482
natural, 236-37, 239 blood alcohol concentration, 78-79, 79t, 80, 81
readiness for, 189, 192, 199-200, 241, 242f, 387 legal limits, 404, 579-80
reasons for, 42 self-determination campaign, 581-82
relapse prevention assumptions, 375-79 as self-report verification, 226
stages of, 199, 240-41, 24If server intervention effect on, 578
as 12-step-program basis, 269, 278-80 trauma relationship, 87-88, 427
therapeutic model assumptions, 309-11 blood clotting, 83t, 84
behavior modification, 216 blood coagulation disorders, 181
Beitman, B. D., 86 blood pressure, 81, 125, 131, 181 (see also hypertension)
Bell, A., 240-41 blood samples, 203
 INDEX 617
Blose, J. O., 576 Bux, D. A, 544, 546
Blow, P., 491 Buydens-Branchey, L., 55, 56
Blue Cross/Blue Shield, 596 BZD. See benzodiazepines
blunts, 125
BMT. See behavioral marital therapy CA. See Cocaine Anonymous
Boat, B. W., 197-98 Cadoret, R. J., 52, 53, 272
bogus pipeline procedure, 203 caffeine, 105, 529
Bohman, M, 13, 55 abstinence syndrome, 360
Bohnen, E, 221 CAGE questionnaire, 491, 533, 534
Bolan, C, 546 calcium-dependent protein phosphorylation, 147
Bolfortan (testosterone nicotinate), 176t calcium metabolism, 78, 84-85
bongs, 125 CALDATA study, 604, 607
borderline personality disorder, 446, 451, 454 California Psychological Inventory Socialization Scale, 199, 255
Borders, O. T., 261 Calix Society, 329, 331, 332t
boredom, 114, 196,372 overview, 335-36
Boren, J. J., 515 Calsyn, D. A., 261
Bowman, K. M., 13 cancer
Boyle, M. H., 57 alcohol-related deaths, 39, 602
BPD. See borderline personality disorder nicotine-related deaths, 166, 167, 528-29
Bradford, S., 39 Cancrini, L., 14
Braiker, H. B., 534, 535 cannabinoids, 122, 123, 130
brain cells, 271 cannabis (marijuana), 121-30
brain damage, 483 absorption and metabolism, 122
brain functioning impairment. See cognitive functioning acute effects, 125-26
brain stem, 148, 163, 175 adolescent use, 478, 478t, 482, 514
Branch, L. G., 42, 370 adolescent use peak/decline, 483
Branchey, L, 391 adolescent use predictors, 58
Branchey, M. H., 55, 56 African-American use, 507
breast cancer, 85, 529 alcohol commonly used with, 80, 125
breast enlargement, male, 83, 85 common names, 124t, 125
breathalyzer, 226, 255, 294, 389 decline in perceived risks of, 121
Breuer, A., 123 dependency rate, 127
Brevital. See methohexital familial nature of dependence, 52
Brewer, D., 486-87 gateway hypothesis, 129, 482
Brief Intervention Study Group, 244 illicit market spillover, 586
Brief Symptom Inventory, 36 laws concerning, 404
Brighrwell, D. R., 391 lesbian users, 545
Brill, P., 282, 452 mixed-drug use of, 112, 125, 478
British Road Safety Act of 1967, 581 as most commonly used illicit drug, 16, 18, 121
bromocriptine, 352, 362 Native American Indian adolescent users, 514
bronchitis, 166, 167 neuropharmacology, 122-23, 130
Broskowski, H., 492, 493 pharmacotherapies, 364-65, 393
Brown, J., 203, 205 population use percentages, 121
Brown, J. L., 100 preparations/dosage/administration routes, 123-25, 124t
Brown, S. A., 201, 485 prevalence of lifetime and past-year DSM-/V use disorder, 22t
Brownson, R. C., 582, 584 prevalence of lifetime users, 16-18
brownies, marijuana, 123, 125 psychiatric disorders comorbidity, 15t
Bruhl-Cramer, C. von, 10 and schizophrenic relapse rate, 446
Brunet, S., 577 supply and price, 586
Bry, B. H, 479 tolerance/dependence/withdrawal, 126—27
Bryant, C. W., 575 use detection, 204
Bucholz, K. K., 32, 534 user typology, 14
Buckley, W. E., 177 women users, 531
Budde, D., 442, 450-51 Caplehorn, J. R., 41
Buddhism, 511, 512 carbamazepine, 82, 101, 363
Budney, A. J., 251, 253, 257, 258-59, 260, 262 carbohydrate-deficient transferrin, 204
Bukstein, O., 59 Carbonari, J. P., 198
bulimia, 528, 533 cardiomyopathy, 83t, 84, 532
Bullock, K. D., 39 cardiovascular system
Buopane, N., 57 alcoholic disorders, 39, 83t, 84
buprenorphine (Buprenex), 143t, 144, 148, 150, 152 inhalant abuse effects, 174
as opioid detoxification, 391-92 MDMA effects, 181
as opioid maintenance treatment, 355, 365t, 392 morphinelike opioids effects, 148
studied as cocaine therapy, 363 nicotine effects, 40, 166
bupropion (Zyban), 360, 392 nicotine risks, 166, 358
Bureau of Indian Affairs, U.S., 512 stimulant effects, 115, 116t, 361
burn victims, 87-88 caring detachment, 33
Burton, H. L., 457 Carpenter, W. B., 10
businessman's lunch/businessman's LSD (DMT), 124t, 132, Carroll, J. F., 456
180 Carroll, K. M., 56, 259, 296, 380, 381, 388, 442, 450-51
buspirone (Buspar), 96, 97t, 99, 352, 359, 391, 461 Cartwright, A., 428
butabarbital (Butisol), 97t "carve-outs," 427
butane gas refills, 174 Case, G. W., 99
Butisol (butabarbital), 97t Case Manager Rating Form, 452
butyl nitrates, 173 Castro, Fidel, 509
618 INDEX

Catalano, R. F., 64, 486-87 church-state separation, 405

Catapres. See clonidine Cicero, T. J., 177, 178
cataracts, 166 cigarettes. See nicotine
catecholamine neurotransmitters, 130 (see also dopamine; norepi- cigars. See nicotine
nephrine) cimetidine, 79
Catholicism, 335-36, 510 Ciraulo, D. A., 101
CATOR. See Chemical Abuse Treatment Outcome Registry cirrhosis, 82-83, 83t, 155
Cattell, R. B., 59-60 civil disobedience, 400
Caulkins, J., 585 civil rights groups, 507
Cavanagh, D. P., 585-86 civil rights issues, 404, 405
CB. See cognitive behavioral (CB) models civil rights movement, 506
CBTs. See cognitive behavioral treatments Clark, D., 59
CCRs. See conditioned compensatory responses Clark, W. B., 544
CDT (carbohydrate-deficient transferrin), 204 classical conditioning, 61, 62, 108, 251, 252, 253
Center for Substance Abuse Prevention, 563, 596 learning theory, 290, 371, 388
Centers for Disease Control, 152 S-O-R-C models, 292-93
central nervous system classifications of disorders, 10-26
alcohol and, 54-55, 76-78, 82, 83t Clayton, P. J., 52
anabolic-androgenic steroids and, 177 cleaning agents, 172t
androgens and, 175 client-treatment matching, 219, 220-21, 487, 515, 519-20
nicotine and, 163, 167, 360 Clinical Institute Withdrawal Assessment for Alcohol (revised), 81,
opiate-responsive regions, 145 350
opioid actions and, 141, 144-45, 148, 149 clinician, 399-436
opioid withdrawal symptoms, 149 advice from, 243-44
sedative-hypnotic/anxiolytic agents and, 95, 96, 98, 99, 364 behavioral/cognitive behavioral role of, 259-60, 298
stimulants and, 105, 107-8, 115, 116t client relationship, 298-99
See also neurotransmitter system and client's 12-step program participation, 333, 341-43, 386-87
cerebellar syndrome, 82, 83t, 174 and client's motivation, 235-36, 238-39, 242-45
cerebellum, 123 confidentiality, 401-3
cerebral cortex, 123 confrontation avoidance, 244, 245, 246
cerebral vascular accident, 361 and coordinated care system, 432-33
Certificate of Proficiency in the Treatment of Alcohol and Other credentials, 414-15, 416, 419
Psychoactive Substance Use Disorders, 415 cultural competence, 504-5, 521
certification. See credentials disease model, 275, 280, 386
Chadwick, O. F. D., 174 and dual diagnoses, 439-67
Chalmers, R., 42 duty of care, 406-11
Champoux, R., 177 empathy, 224, 237, 238, 244, 245, 298
Chan, A. W. K., 534 ethical issues, 399-400, 406-12
Chan, F., 431 ethnic client relationship, 514-15
Chaney, E. F., 252 evaluation by, 418-19
change. See behavior changes family asssessment by, 294-95
Chang, G., 390 family systems approach, 290, 295-99
chaplains, 274-75, 386 feedback vs. confrontation, 243, 244, 246
Chassin, L., 37, 479 gay client issues, 546-49
Chater, K., 82 initial goals, 223-24
Chemical Abuse Treatment Outcome Registry, 282 interfaces with other services, 421-33
chemical dependence counselors, 275, 280 legal issues, 399-400, 401-6, 418
Chemical Dependency Adolescent Assessment Package, 485 motivational interviewing, 245-46, 371, 387
Chen, K., 482 record keeping, 416-18, 419
Cherokee, 512 relapse prevention, 375, 376, 378, 379, 380, 382
chewing tobacco, 164, 164t therapeutic alliance, 259-60, 519
Chicanos/Chicanas. See Mexican-Americans therapeutic community, 311, 316-17
Chick, J., 391 training, 259, 280, 297-98, 316, 380
childhood risk factors, of alcoholism, 13, 57-59 treatment assignment decisions, 216-29
child neglect and abuse, 87, 117, 546 12-step methodology use, 275-80
clinician duty of care vs., 409-8 types of, 415,423
fetal risks from maternal substance use, 85, 425-26 See also physician; treatment
as precipitating female alcoholism, 530 clinician's illusion, 30
protection systems, 422, 425-26, 432 clomipramine, 360
Childress, A. R., 460 clonazepam (Klonopin), 97t, 100, 101
Chinese-Americans, 510, 511 for agitated psychotic, 466
Chippewa, 512 for alcoholic detoxification, 350
Chitwood, D. D., 603 for benzodiazipine detoxifaction, 364
chloral hydrate (Noctec), 97t clonidine (Catapres), 150, 350, 356-57, 359, 365t, 391
chlordiazepoxide (Librium), 97t, 99-100, 179 Cloninger, C. R., 13, 39, 53, 55, 57, 59, 60
for alcohol detoxification, 350 clozepine, 360, 461
for benzodiazepine detoxification, 364 club drug (ketamine), 133-34
cholesterol level, 83t Cluff, M. C., 41
cholinergic receptors, 163, 167 cluster analysis, 13, 14, 56
cholinesterases, 108 CoAMD (co-occuring addiction and mental disorder), 444
Christian Scripture, 329, 335, 336t Coca-Cola, 109
Christopher, James, 336-37 cocaethylene, 79-80, 106, 113, 117
Chrits-Christoph, K., 156 cocaine, 105-18
chronic pain, 371 addictive nature of, 108
Chunt, T., 482 administration routes and dosages, 110-11, HOt
 INDEX 619

adolescent users, 478t, 483-84 cognitive change, 254

African-American users, 503, 504, 507 cognitive dissonance, 373
alcohol used with, 79-80, 391 cognitive factors
anabolic-androgenic steroids used with, 178 in disease model treatment, 281
Asian-American users, 503 expectancies of substance effects, 252-53
behavioral treatment effectiveness, 262 preceding substance abuse, 254-55, 273
biological functions and, 55 in relapse, 196
delusional disorder, 461 in remission and resolution, 42-43
dependence and genetic factors, 52 in self-resolution of problem, 192
depression comorbidity, 441, 448, 451, 459, 460 cognitive functioning
disulfiram treatment, 391 alcohol and, 54, 80, 82, 85, 86, 271
dopaminergic agents, 107, 145, 392 alcohol withdrawal and, 81
elderly users, 488 assessment timing, 201
fetal effects from, 116-17 benzodiazepines and, 102
gender and abuse-depression comorbidity, 24 cannabis and, 25, 125-26, 128, 129, 130
gender use differences, 528, 531 elder substance-related impairment, 489-90, 493
generic/trade/street names, 109, 109t hypnotic-sedative withdrawal and, 100
historical terms for addiction, 10 inhalants and, 174
marijuana augmenting, 125 LSD and, 25, 131
metabolic pathway, 106, 107f MDMA and, 180, 181
mood disorder mimics, 450 nicotine and, 167
mortality, 3, 117 nicotine withdrawal and, 166
neurotransmitters, 76, 108 opioids and, 149
panic disorder comorbidity, 443 stimulant withdrawal and, 114
paranoia induced by, 117, 118, 361, 448 See also memory
patient characteristics/treatment response, 260 Cohen, J., 30
personality disorder comorbidity, 442 Cohen, P., 30
pharmacotherapy research, 361-63, 365t, 392, 461 "coke bugs," 117
physiological effects, 115-17, 361 Colder, C. R., 479
potency as reinforcement agent, 108 "cold turkey" detoxification, 356
prevalence of disorders, 21 Collaborative Study on the Genetics of Alcoholism, 62
prevalence of lifetime and past-year DSM-IV use disorder, 22t collective risk, 574
prevalence of lifetime users, 16-18 collectivism, African-American, 507-8, 520
price and supply, 585 College of Professional Psychology, 415
psychiatric disorders comorbidity, 15t, 442, 443, 447 College sample
schizophrenia comorbidity, 447 age of deaths, 39
seasonal dysphoria comorbidity, 447-48 course of alcohol use study, 31-32, 34f, 42
symptoms of use, 113-14 Collins, D. A., 447, 448
total consumption, 585 Collins,}. J., 603
transient acute effects, 108 Colon, I., 576
Type A/Type B classification, 56 Colten, M. E., 531
types of preparations, 109 Columbus, M., 201, 416, 419
use detection, 204 coma, opioid, 149
user typology, 14 commitment, institutional, 218, 465-66
withdrawal course and symptoms, 114-15 community as method. See therapeutic community
women users, 531 community-based initiatives, 429, 464-65, 492, 515
Cocaine Anonymous, 44-45, 322, 331, 332t, 423 drug abuse prevention intervention, 556, 563, 566, 574-75
overview, 334 illicit drug traffic policing, 586
Cocaine Craving Questionnaire, 255, 388 community-based residence. See therapeutic community
Cocaine Effects Expectancy Questionnaire, 485 Community Health and Mental Health Centers, 596
cocaine HC1, 109, HOt Community Older Persons Alcohol (COPA) program, 492
Cocaine Relapse Interview, 255, 388 Community Partnerships, 563
coca leaves, HOt community reinforcement approach, 251, 257, 258-59, 262
coca paste, 109, HOt comorbid disorders (dual diagnoses), 439-67
codeine, 141, 142t adolescents, 484, 487
codependency, 62, 273, 289, 296, 301, 388 as clinically inadequate, 444
Coffman, G. A., 282 continuity of care, 462
cognitive behavioral (CB) models, 61, 62 differential diagnosis, 448
of relapse, 196-97, 373-75, 374f, 378, 382 effects on addiction treatment outcome, 445-5
and self-efficacy, 198 in elderly, 488, 490-91, 493
cognitive behavioral treatments, 216, 220, 238, 250-63, 387-88 emergency situations, 466-67
active ingredients, 258-59, 388 gender differences, 24, 25t, 442, 443, 528, 532
for dual diagnosis, 458 integration of psychological therapies, 457-58
effectiveness data, 260-62 interaction models, 447, 447t
for elderly users, 493 lifetime, 463-65
goals, 256, 388 patient problems, 443-46
guided self-help groups, 330, 339, 340-41 pharmacotherapies, 352, 458-63, 460t
historical origins, 252 relapse emergency, 467
major techniques, 257-58 relapse rates, 445
for nicotine addiction, 358, 359 team case-management approach, 462
patient characteristics associated with improved outcome, 260 treatment four-box severity model, 452-54, 453t
range of, 250-51 treatment intervention timing, 458
strengths and weaknesses, 262-63 treatment settings, 455-56, 462-63
structured sessions, 256 treatment stages and states of change, 456-57
therapist role, 259-60, 298 in women, 24, 528, 529, 530, 532, 534, 535, 536
620 INDEX

comorbidity research, 21-25, 85-86 costs of substance abuse, 601-3

etiological factors, 53 alcohol-related, 75, 602
general epidemiology, 440-41 as primary cessation impetus, 41-42
opioid dependence, 156 secondary medical conditions, 601-2
standardized diagnostic and assessment instruments, 255 stimulant abuse, 118
See also comorbid disorders See also accidents; medical conditions and risks
Comprehensive Addiction Severity Index for Adolescents, cotinine, 162, 163
486 Cotton, N. S., 272
Comprehensive Effects of Alcohol scale, 377 CoTylenol, 488
compulsion, 10, 11, 12t counselor credentials, 415
compulsory supervision, 43 CR. See conditioned response
concentration problems. See cognitive functioning CRA. See community reinforcement approach
Concool, B., 41 crack, 110, HOt, 111, 112,363
conditioned compensatory responses, 61 adolescent use, 478t
conditioned craving, 114-15, 256-57 comorbid schizophrenic effects, 448
negative mood states and, 460 prevalence of lifetime users, 16
nicotine, 358 related psychiatric problems, 117
conditioned response, 61, 251, 252 (see also cue exposure) "crack lung," 115
conditioned stimuli, 61, 358 Craig, J., 577
conditioned withdrawal, 61, 251 Craighead, L. W., 251
conduct disorder, 54, 57-58, 60, 484 Craighead, W. E., 251
attention deficit disorder vs., 58 "crank bugs," 117
confabulation, 82 craving
confidentiality, 401-3 alcoholic obsessive, 272, 273
of documentation, 402, 418 cannabis, 123
federal provisions, 402-3, 403t, 409 classical conditioning to decrease, 253, 388
of outcome studies participants, 418 cocaine, 347
vs. harm to others, 407-9, 426 conditioned, 114-15, 256-57, 460
Conflict Tactics Scale, 294 detachment from, 378
confrontation, 244, 245, 246 management of, 221-22, 223
Confucianism, 511, 512 negative mood states and, 460
Connors, G. J., 188, 189, 220, 259 nicotine, 166, 359, 392
conscientiousness, 59 opioid, 149, 150, 347
consent. See informed consent pharmacotherapies, 351-52, 459, 460
contingency management approaches, 257, 260, 261-62, 388 relapse prevention techniques, 377, 378
contracts as stimulant withdrawal symptom, 114-15
behavioral, 296, 389 Crawford, G., 585
therapeutic community, 315 creativity, 131
controlled drinking, 222-23, 340-41 credentials, 414-15, 416, 419
Cooke, D. J., 530 Crime Prevention Through Environmental Design, 586
cookies, marijuana, 125 criminal behavior
Cooney, N. L, 199, 252, 257-58, 260 alcohol use correlation, 88
coordinated care. See network of care systems daily drug use cessation and, 36
COPA. See Community Older Persons Alcohol (COPA) program illicit drug sanctions, 585-86, 587
C'OPAD model, 464, 465 inhalant abuse and, 173, 174, 175
coping resources juvenile delinquency theories, 63-64
acquisition through treatment, 221, 226 substance abuse as mitigation argument, 405-6
assessment instruments, 1911, 255 substance abuse correlation, 40, 429-30, 587, 603
cognitive behavioral approaches, 259, 262, 373 See also deviant behavior
for lapses and relapses, 227, 373, 378-79 criminal justice system, 422, 429-30, 432
learned maladaptive, 371, 372 Croghan, I. T., 41
multiple drug use and, 19, 339 Cronkite, R. C., 536
prevention model and, 556 cross-sectional analysis, 449-50
and relapse risk, 196, 197-98, 219 Crothers, T. D., 10
as remission and resolution factor, 42-43, 44, 192 Croughan, J. L., 52
as treatment goal, 223 Crowe, R. R, 52
and women's drinking, 529 Crowley, T. J., 261
Core City sample CS. See conditioned stimulus
age of deaths, 39 CSAP. See Center for Substance Abuse Prevention
course of alcohol use study, 31-32, 33f, 42 Cubans/Cuban-Americans, 508, 509, 510
core-shell model (treatment), 221 cue exposure, 251, 254, 256
Cornelius, J. R., 391, 460 in behavioral treatment, 256-57, 261, 388
Cornelius, M. D., 391, 460 in disease model, 273, 278
coronary artery disease, 358 cultural blindness, 505
Coronary Artery Surgery Study Registry, 40 cultural competence, 504-5, 515, 521
corrections systems, 307, 585-86 cultural decentering, 421
cortex, 163 cultural destructiveness, 504
cost-benefit analysis, 604-7, 608 cultural incapacity, 505
definition of, 604 cultural minorities. See ethnic and cultural minority groups
cost-effectiveness cultural orientations, 515-19, 516-17t
definition of, 604 cultural proficiency, 505
prevention programs, 567-68, 582, 585, 587-88 cultural sensitivity, 505
cost offset, 605-6 Cupplies, L. A., 282
cost sharing, insurance, 596-97 curfew laws, 580
costs of health care. See health care costs Curran, P. J., 479
 INDEX 621

cutaneous symptoms, 149-50 early recognition of, 42, 45

Cutler, R. B., 391 hallucinogen low potential for, 134, 135
Cutter, H. S. G., 300 historical background of concept, 10
cyclic AMP system, 147 mechanisms of, 78, 108
cycling (steroids), 178 nicotine mechanisms, 163, 165-66, 167
cytochrome P450IIE1 (CYP2E1), 76, 79 opiate prescription drugs, 152
cytochrome P-450 monoxygenases, 106, 154, 162 opioid deficiency disorder, 353
opioid mechanisms, 145-47, 149-51, 152
Daily Want-Should Tally Form, 379 as physical illness, 269
Dalmane. See flurazepam prevalence of, 19-21
Dalton, M. S., 41 psychological, 149
Dana, R. H., 515 relapse chronicity, 348
DARE program. See Drug Abuse Resistance Education relapse prevention, 379
Darvon. See propoxyphene sedative-hypnotic agents, 98
datura, 130, 134 stimulant characterizations, 108, 114
Davanagh, D. P., 585-86 substitutions, 43
Davies, M., 58 survey criteria differences, 19
Davila, R., 222-23 See also withdrawal
Davis, C. S., 219 dependence syndrome, 194-95
Davis, C. W., 446 Depo-Testosterone. See testosterone cypionate
Davis, D. I., 63 depression
Davis, E, 193 alcohol as self-medication for, 23
DAWN. See Drug Abuse Warning Network alcoholic pharmacotherapy, 352, 391, 460
Dawson, D. A., 534 alcoholism comorbidity, 56, 202, 274, 441, 446, 459, 460, 466
DEA. See Drug Enforcement Agency amphetamines prescribed for, 110
Dean, L, 222 anabolic-androgenic steroids use and, 179
death. See mortality assessment instruments, 191t
death penalty, 400 chronic stimulant use and, 117
Deca-Durabolin. See nandrolone decanoate cigarette smoking linked with, 166, 360
decision making as cocaine abuse risk factor, 441, 448, 460
balance sheet, 239-40, 240t, 297, 387 in early treatment and recovery phases, 201-2
skill learning, 112 in elderly, 488, 489, 493
for treatment type, 216-29, 228f, 424 as inhalant use cause and consequence, 173, 175
decision matrix, 297, 375, 376f lifetime prevalence of substance use disorder, 442t
Deckel, A., 55 MDMA and, 181
Dederich, Charles, 307 misdiagnosis as primary mood disorder, 450
defensiveness, 244, 272, 273 multiple drug use and, 19
deficiency disorder, 353 opioid dependence comorbidity, 156, 460
DeFord, H. A., 261 persisting after alcohol/cocaine cessation, 459
DeHart, S. S., 491 pharmacotherapy, 352
Delaney, D. D., 253, 257, 262 and relapse prevention, 371
Delatestryl. See testosterone ethanate as relapse risk, 196, 372, 460
DelBoca, F., 56, 203 stimulant-induced, 450
DeLeon, G., 308, 318, 319, 390 substance use comorbidity, 23-25, 24t, 25t, 86, 274, 441, 448
delirium tremens, 10, 81, 100, 349, 350, 490 suicide risk, 466
delta-9-tetrahydrocannabinol. See THC and women's alcohol use, 24, 528, 529, 530, 532, 534, 535,
delta alcoholism, 10, 13 536
delta opiate receptor, 146 Derman, R. M., 391
delusional disorder, 461 Descartes, Rene, 508
dementia designated driver programs, 223
alcoholic, 82, 83t designer drugs, 109, 171-72, 179-81
elder substance-related, 489-90 generic/trade/street names, 109t
Demerol. See meperidine hallucinogenic, 133
DeNelsky, G. Y., 197-98 MDMA as prototype, 180
Denenberg, R. V., 405 desipramine, 352, 360, 391, 460
Denenberg, T. S., 405 desmethyldiazepam, 360
denial, 189, 224 De Soto, C. B., 36
as disease model key feature, 272, 273-74, 386 De Soto, J. L., 36
of gay abuser, 548-49 Desoxyn, 109t
as opposite of acceptance, 333 detoxification
DeObaldia, R., 54, 57 alcoholic pharmacological, 348-51, 365t
dependence benzodiazepine pharmacological, 364
abuse distinction, 477 "cold turkey," 356
alcohol, 19-21, 31-32, 270-71, 385, 386, 482 heroin, 150, 152,356
alcohol heritability, 52, 271 as immediate need, 219
anabolic-androgenic steroids, 178 from methadone vs. heroin, 354
behavioral syndrome, 127, 165 as negative contingency, 253
cannabis, 126-27, 364 nicotine, 358-59
comorbidity studies, 21-25 opioid rapid anesthesized, 357
craving and, 347 opioids, 150, 152, 354, 355, 356-57, 391-92
cues, 165 primary care physician and, 428
depression association, 23-24 prior to naltrexone therapy, 352
disabilities vs., 194-95 treatment setting, 217
disease model of, 385-86 See also withdrawal
drug criteria, 127 Devane, W. A., 123
622 INDEX

deviant behavior obstacles to successful treatment, 280-81

adolescent risk/protective factors, 479-82, 557-64 as rationalization, 445
problem behavior theory, 479, 559 as relapse predictor, 371
social control theory, 63-64 spirituality fostering, 274-75, 277-78, 386
See also criminal behavior; violent behavior strengths and weaknesses, 282-83, 386
De Witte, P., 76 therapeutic community model vs., 309
Dexedrine, 109t treatment ingredients, 273-80, 385-86
diabetes mellitus, 84 treatment outcome data, 281-82, 386
diacetylmorphine. See heroin vs. other treatment approaches, 424
Diagnostic and Statistical Manual of Mental Disorders (DSM-IH, vs. spiritual/psychological deficit model, 329, 332
Ill-R, IV) disulfiram (Antabuse), 76, 365t, 459, 460
abuse and dependence, 11, 477, 488 Antabuse contract, 291, 296, 389
adolescent substance abuse, 482, 484-85 effectivenss study, 391
alcohol and drug use disorders survey based on, 16-17t, 19, 20t, overview, 352
21, 22t, 25t, 26 Ditzler, T., 491
alcohol withdrawal symptoms, 81 d-lysergic acid diethylamide. See LSD
in assessment process, 194-95, 255 DMT (dimethyltryptamine), 124t, 130, 132
behavioral and psychological dependence, 149, 152 doctor. See physician
diagnostic categories, 448-49 documentation, 416-18, 419
diagnostic criteria, 12-13t, 24, 31, 32, 127, 194, 276, 416, confidentiality of, 402
450-51 Dolan, M. P., 261
and disease model, 276 Dole, Vincent, 353
elderly substance abusers, 487 Dolinsky, Z. S., 56, 59, 536
hallucinogenic flashback disorders, 135 Doll, L. S., 546
mental disorders lifetime prevalence rate, 440 dollies (methadone), 143t
mental illness/substance use disorder comorbidity, 440, 441, 442, DOM (dimethoxymethyl amphetamine), 124t, 130, 133
443, 446, 447 domestic violence, 87, 294, 295, 299, 301
nicotine withdrawal symptoms, 166 Donham, R., 262
nondependent substance use disorders, 10, 11 Donohue, B., 251
opioid dependence, 152 Donovan, D. M., 42, 196, 259
polythetic diagnosis, 448 Donus, W., 450
diagnostic criteria dopamine, 76, 77t, 107, 123, 352, 361, 365
differential, 448 cocaine therapy research, 362-63, 365t
documentation of, 416 hallucinogen structural similarity, 130, 134
missed or inadequate dual diagnoses, 225-26, 427, 443, 444, MDMA stimulation of, 180
447, 450, 490, 491 nicotinic receptors and, 163, 392
multidimensional assessments of substance abuse, 190t opiate reinforcement, 145, 147
substance-related systems, 194-95 dopamine reuptake inhibitors, 362-63, 392
survey differences, 19 dopamine transporter, 363, 392
Diagnostic Interview Schedule, 443, 484, 487, 534 Doriden. See glutethemide
Dianabol. See methandrostenolone Double Trouble, 463
diazepam (Valium), 80t, 97t, 99-100, 179 Douglas, J. M., Jr., 546
for agitated psychotic, 466 Douglas, R., 577
for alcoholic detoxification, 350 doxepine, 360
DiClemente, C. C., 189, 198, 199, 236-37, 239, 240, 241, 259, Drake, R. E., 457, 463, 464, 465
456-57 Drew, L. R. H., 30
didanosine, 155 DrlnC, 255, 294, 388, 389
Dielman, T. E., 529 Drinker's Check-Up, 237-38
differential diagnosis, 448 drinking behavior. See alcoholism; alcohol use
DiFranza, J. R., 583, 593 driving impairment. See motor vehicle operation
Dilantin, 80t Drug Abuse Resistance Education (DARE), 429, 560-61
Dilaudid. See hydromorphone Drug Abuse Warning Network, 18, 488
dimethoxymethyl amphetamine. See DOM Drug and Alcohol Testing Rules, 404
dimethyltryptamine. See DMT Drug Enforcement Agency, 129-30, 405, 585
DiNardo, J., 585 Drug Free Schools and Communities Program, 596
Dinwiddie, S., 52 Drug-Free Workplace Act of 1988, 404, 405
Dionysian-type alcoholism, 13-14 drug testing. See urine drug screening
dipsomania, 10 drug use
DIS. See Diagnostic Interview Schedule by adolescents, 477-87
disability payment, 597-98 as alcohol accompaniment, 113, 152, 156, 451, 488, 532
discharge summary, 418 alcohol interactions, 76, 79-80, 80t
"Disease Concept of Alcoholism, The" (Jellinek), 10 assessment instruments and interviews, 190-9It, 194
disease model, 268-83, 385-86, 444-45 autobiography, 375
abstinence focus, 269, 282, 283 biological screening measures, 204
for adolescent treatment, 486, 487 cessation impetus, 41-42
assessment procedures, 275, 276 childhood conduct disorders as predictors, 57, 58
behavioralist-based alternative approach, 11, 388 clinical heterogenity, 55-57
categorization of alcoholism, 13 collateral informants, 203
defense system, 272-73, 386 comorbidity with psychiatric disorders, 21-25, 439-67
definition of, 268-69 controlled vs. abstinence, 223
denial as key feature, 386 course of treated disorders, 36-37, 38
dependent vs. nondependent, 10 course of treated vs. nontreated disorders, 30
etiological factors, 50-66, 271-72 criminal convictions, 585-86
family model, 62-63, 273, 289 cyclical abuse epidemics, 105
history and origin, 10, 269-71 dependence syndrome, 127, 194-95
 INDEX 623

disease model, 268-69, 385-86 ecstasy. See MDMA

by elderly people, 488, 489 Edholm, M., 56
by ethnic/racial groups, 500-501, 507, 509-10, 511, 513-14 Edwards, G., 10, 11,44
expectancies, 378 EEG. See electroencephalographic (EEC) disturbances
family disease model, 288-89, 290, 301 Effects of Drinking Alcohol scale, 377
family/marital treatment studies, 301 Ehler, J. G., 391, 460
five typologies, 14 Ehrman, R. N., 460
future direction of classification, 25-26 Eisen, S. A., 54
gateway hypothesis, 19, 129, 482, 529 Eisler, R. M., 291
by gay men and lesbians, 544, 545 elderly people, 487-93
gender differences in consequences, 528 comorbid symptoms, 488, 490-91, 493
harm reduction approach, 223 risk factors, 488-89
heritability patterns, 52-53 treatment, 218, 490-93
historical classification of disorders, 10-26 women drinkers, 530
illicit rate, 502 electroencephalographic (EEG) disturbances, 54, 55
illicit traffic interdiction, 585-87 electroencephalographic (EEG) sleep recordings, 81
interactions, 111-14, 112t, 113t Ellis, A., 252, 339
legal prohibitions, 404, 429 emergency commitment, 218
lifetime abstention data, 18 emergency room episodes
lifetime prevalence, 16-18, 441 alcohol-related traumas, 427
maintenance drugs, 41, 144, 392 (see also methadone treatment comorbid disorders, 466
programs) multiple drug users, 18
mortality rate among treated abusers, 39-40, 41 severe opioid intoxication, 148-49, 151, 152
multiple, 19, 111-14, 148, 167 emotional problems
by multiple family members, 299 childhood, 57
prevalence of lifetime and past-year DSM-IV disorders, 21, 22t and relapse risks, 196
price/supply/demand, 585, 586-87 stimulant effects, 116t
reinforcing properties, 372 and substance craving, 254
self-report measures, 204 See also anxiety; depression
self-report verification, 226 Emotions Anonymous, 329
temperament as factor, 58-60 empathy
treatment implications, 44 cultural, 505, 515
Type A/Type B, 56 importance of clinician's, 224, 238, 244, 245, 298
women, 531 as motivational component, 237, 244
workplace laws and regulations, 405-6 Employee Assistance Programs, 404, 424, 430, 431
See also treatment; specific drug types and names employment. See work; workplace
Drug Use Screening Inventory, 484 "empty-nest" status, 530
drunk driving. See motor vehicle operation Emrick, C. D., 239, 391
drunkenness. See intoxication enabling, 289, 296, 388
dry drunk, 333 Endholm, M., 55
DSM-III, III-R and IV. See Diagnostic and Statistical Manual of Endicott, J., 34
Mental Disorders endocrine system, alcoholic disorders, 83t, 84-85
DTs. See delirium tremens endogenous opioid system, 353, 360
dual diagnoses. See comorbid disorders endorphins
Dual Disorder Recovery Book, 277 definition of, 141
Dual Recovery, 463 nicotinic receptors and, 163
DuBreuil, E., 222 opioid action and, 144-45
DUI (driving under the influence), 404, 424, 429, 533, 581 Engels, G. L., 269
Dunmeyer, S., 603 enkephalins, 141, 144, 146
Dupree, L. W., 492, 493 Enoltestovis. See hexoxymestrolum
Durabolin. See nandrolone phenpropionate environmental factors. See family environment; social and interper-
Durell, ]., 282 sonal situation
Durvasula, S., 581 environmental prevention strategies, 573-88
duty of care, 406-11 catchment vs. systems perspective, 573-75
DWI (driving while impaired or intoxicated), 404, 424, 429, 533, health warnings, 580-82
581 legal penalties, 579-80
Dyadic Adjustment Scale, 294 minimum age of purchase, 577-78, 583
dynorphins, 141, 146 physical access, 575-77, 583-84
dysphoria price, 575, 582-83
as cocaine effect, 450 rationale for, 587-88
cocaine withdrawal syndrome, 114-15 supply reduction, 585-87
as prime cause of substance abuser relapse, 445, 447-48, environmental tobacco smoke, 167
460 environment-level risk and prevention (individual), 561-63, 562f
See also depression enzymes, 76
Epidemiologic Catchment Area Study, 19, 23, 24t, 127, 268, 440-
EAPs. See Employee Assistance Programs 41, 442, 443, 447, 487
Earls, F., 60 epidemiology
eating disorders, 371, 533, 536 adolescent users, 477-79
Eaves, L. J., 54 alcohol and drug use disorders, 19-21, 26
EGA. See Epidemiologic Catchment Area Study anabolic-androgenic steroid use, 175-77
Eclipse (novelty nicotine product), 164t, 165 cannabis dependence, 127
economics, 595-608 designer drugs use, 179-80
high pricing of alcohol and tobacco, 575, 582-83, 585 elderly users, 487-88
of illicit drug market, 586-87 ethnic/racial demographic characteristics, 501t, 503t
of prevention programs, 567-68 gay men and lesbians users, 543-45
624 INDEX

epidemiology (continued) family disease model, 62, 273, 288-89, 292

heroin initiates, 151, 152 lack of controlled studies on, 300-301
inhalant abuse, 172-73 overview, 289
mental illness-substance use disorder comorbidity, 440-41 support groups, 287, 288, 296, 331, 332, 334-35, 386, 388
opiate dependence, 152 treatment approach, 388-89
tobacco smoking, 167 family environment, 62-63, 66
women drinkers, 527 adolescent substance use treatment, 487
epinephrine, 163 African-American, 506, 507
episodic excessive drinking, 10 alcohol-related dysfunction, 62-63, 87, 292, 479-81, 480f
epsilon alcoholism, 10, 13 comorbidity treatment involvement, 454
Epstein, E. E., 62, 291, 292-93, 297, 301 as drug-of-choice influence, 52-53
Equipoise (voldenone-veterinary), 176t and ethnic/racial treatment approaches, 520-21
Eriksen, M. P., 582 interventions to improve, 297
Erythmxylon coca plant, 109 Native American Indian, 514
Escallier, E. A., 59 preservation programs, 426
esophageal reflux, 148 and women's drinking consequences, 533, 534
esophagus enlargement, 83 as women's drinking factor, 529, 530, 532, 535, 536
Esquirol, E., 10 family history. See genetic factors
estradiol, 85 family models, 287-302
estrogen, 483 assumptions of, 293-94
ethchlorvynol (Placidyl), 97t, 364 behavioral, 290-92, 296, 389
ethical issues, 399-401, 406-12 best candidates for treatment, 299-300, 389
resolution models, 411-12 etiology and maintenance of substance abuse, 292-93
substance abuse treatment costs, 602 historical origins, 288—92
Ethics for Addiction Professionals (Bissell and Royce), 400 multiple active abusers, 299
ethnic and cultural minority groups, 499-523 obstacles to treatment, 299
adolescent substance use, 479 structured therapy sessions, 298
and alcohol tolerance, 76 therapist role, 297-99
common sociocultural factors, 505-14 treatment approach, 293-99, 388-89
cultural orientations assessment, 515-19, 516-17t treatment strengths and weaknesses, 301
drinking pattern lifetime differences, 14-16 treatment success obstacles, 299
experience of ethnicity, 499-501 family rituals, 63, 292
heroin use, 151 family systems model, 288-89, 289-90, 389
illicit drug lifetime use, 16-18 family therapy, 217, 218, 288, 386, 389
inhalant use, 172, 173 adolescent substance use, 487
prevalence of lifetime and past-year alcohol use, 15t behavioral, 290-92
prevalence of lifetime and past-year DSM-JV drug use disorders, structure of sessions, 295
22t therapeutic community, 321
prevalence of lifetime and past-year illicit drug use, 16-17t Faraone, S. V., 54
prevention programs, 567 FAS. See fetal alcohol syndrome
relapse prevention, 520-21 FDA. See Food and Drug Administration
and social consequences of drinking, 88 federal government
treatment, 519-22 alcohol and drug agencies, 4
women drinkers, 528 confidentiality regulations, 402-3
ethnic gloss, 500 drug traffic control, 584-85
ethylcocaine. See cocaethylene health care costs, 602
ethylestrenol (Maxibolin), 176t treatment financing, 596, 597-98
Etinger, A., 123 feedback
etiology, 50-66 confrontation vs., 243, 244
behavioral models, 61-62 in family therapy, 294-95, 389
psychoanalytic model, 60-62 as motivational component, 237, 245
social policy and, 65 Feighery, E., 593
sociocultural models, 62-65 Feingold, A., 56
euphoria Fejer, D., 52
alcoholic, 80 fellowship. See self-help groups
cannabis, 121, 125 fentanyl (Sublimaze), 143t, 149
hallucinogenic, 131, 132, 133 Fenwick, J. W., 253, 257, 258-59, 262
inhalant, 173 Ferrence, R. G., 536-37, 577
opioid, 144, 149 Fertig, J. B., 201
stimulant, 108, 110, 113, 114, 117, 361 Festinger, L., 373
evaluation of treatment, 418-19 fetal alcohol syndrome, 85, 425, 532
event-related potential (ERP) disturbances, 54, 55 Feuerlein, W., 39
Everingham, S. S., 585 fibrosis, 82
excise taxes, 583 Fighting Back Initiative, 563
exercise, 43, 379 Filipino-Americans, 510, 511
exogenous obesity, 108, 111 Finajet. See trenbolone
expectancies, 62, 198, 377-78, 388 Fink, E., 492
adolescent substance use, 484, 485 Finnegan, D. G., 547, 550
extinction approaches, 256 Finney, J. W., 42
extroversion, 60 Firestone, I. J., 581
First Amendment rights, 405
Falkowski, W., 391 Fisher, J., 282
Fals-Stewart, W., 291-92, 388 Fitzgerald, J. L., 576
Family and Medical Leave Act, 404 five-factor personality model, 59-60
Family Assessment Measure, 294 flashbacks, LSD, 135,484
 INDEX 625

Flay, B. R., 62, 63 choice of abused substance, 52, 527

Fleissner, D., 586 cirrhosis development, 83
Fleming, J. E., 57 in clinical heterogeneity, 56-57
Fleming, M. F., 427 cocaine use, 528, 531
Flohrschutz, T., 39 comorbid disorders, 528, 532
Flower, M. C., 489, 493 comorbidity between antisocial disorder and alcoholism, 442
flumazenil, 363, 365t comorbidity between substance abuse and depression, 24, 25t
fluoxetine, 352, 359, 391, 460 comorbid posttraumatic stress disorder, 443
fluphenazine (Prolixin), 360, 466 delinquency/drug use relationship, 58
flurazepam (Dalmane), 97t dependence risk, 127
fly agaric. See Amanita muscarina depression persistence, 86
Flynn, B. S., 581-82 elderly users, 488
Foerg, F., 253, 257, 258-59, 262 ethnic/racial AIDS cases, 503-4
folk medicine, 330 heroin use, 151, 528, 531
Food and Drug Administration, 352, 358, 359, 360, 390, 392 illicit drug lifetime use, 16-18
Forgatch, M. S., 238 illicit drug use consequences, 528
formication, 117 illicit drug use inception, 482
Forst, B., 586 lifetime and past-year DSM-IV drug use disorders, 22t
Forster, J. L., 583-84 marijuana use, 531
four-box treatment severity model, 452-54, 453t medical risks, 532-33
Fox, S., 446 multiple drug use, 19
FRAMES (key motivational components), 237-39, 242-45, 246 nicotine remission rates, 38
Framingham Heart Study, 38 nicotine use, 38, 527
Franklin, Benjamin, 239-40 nicotine use reasons, 478, 482
Freeman, R. C., 204 occupational and legal, 533
Freud, Sigmund, 444 panic disorder incidence, 443
Frey, R. M., 281 posttreatment drinking, 281
Friedman, S. R., 603 prevalence of lifetime and past-year alcohol use, 15t
Fromme, K., 375 prevalence of lifetime and past-year illicit drug use, 16-17t
Fuchs, B. C., 575-76 prevalence of lifetime and past-year total substance use, 14-19,
Fuller, R. K., 203, 281, 391 15t, 16-17t
functional analysis, 253-54, 388 problem behaviors, 52
proof-of-age tobacco purchases, 583, 584
GABA (gamma aminobutyric acid), 76, 77t, 78, 96, 98, 147, 173, Self-Administered Alcoholism Screening Test, 533-34
349, 352 therapeutic community residents, 318
Gabaj, R. P., 543 treatment modalities, 535
Galanter, M., 456, 462 treatment outcomes, 536
gamma alcoholism, 10, 13, 32 See also men; women
gamma aminobutyric acid. See GABA gender identity vs. gender role, 543
gamma-glutamyltransferase (GGT), 204 gene-environment interaction (GxE), 53
gamma-hydroxybutyrate, 352-53 genetic factors
Gandhi, Mohandas, 400 alcoholic gender differences, 531
gangs, 509 alcoholism, 2, 10, 50, 54-55, 58, 62-63, 65, 66, 252, 271, 272,
Garcia-Espana, F., 99 274, 292, 479-81, 48It
Gartner, L., 221 alcohol tolerance, 76, 77
gases, 172t antisocial personality disorders, 58
Gaspari. J. P., 446 clinical heterogeneity, 55-57
gastrointestinal system, 82, 83-84, 83t cognitive behavioral theory, 62
alcohol effects, 427 comorbidity studies, 2?
opioids effects, 148 depression, 274
opioid withdrawal symptoms, 149 etiology of substance abuse/dependence, 50, 51-54, 58, 65, 66,
stimulant effects, 116t 292-93
gateway theory, 19, 129, 482, 529 heritability mechanisms, 53-54
Gawin, F., 442, 450-51 heterogeneous inheritance pattern, 52
gay bars, 545, 546, 549 male Type 2 alcoholism, 2
gay men, lesbians, and bisexuals, 542-50 physical alcohol dependence, 78
assessment and treatment, 546-50 temperament characteristics, 58-59
epidemiology, 543-45 women drinkers, 528, 529, 532
risk factors, 545-46 gepirone, 96
Gazda, P., 221 geriatrics. See elderly people
GBR 12909, 363, 365t Gerontology Alcohol Project, 492
Geller, A., 200-201 Gerrish, R., 222
Geller, E. S., 477 Getter, H., 260
gender differences GGT (gamma-glutamyltransferase), 204
adolescent deviant peer involvement, 63 Gibbons, R. D., 450
adolescent treatment outcome, 486 Gibson, D., 123
adolescent use, 19-21, 478, 479, 493, 529 Gilbertini, M., 239
alcohol problems of elderly, 487-88 Gillin, J. C., 201
alcohol abuse patterns/course/consequences, 14-16, 531-33 Gilmore, K., 282
alcohol effects, 76 Gilpin, E., 37-38
alcoholic suicide attempts, 86 gingival ulceration, 115
alcoholic types, 13, 531 Glantz, M. D., 488
alcoholism heritability liability, 51, 52 Glaser, F. B., 221
athlete steroid use, 177 Gliksman, L., 577
blood alcohol concentration, 78, 79t glucose metabolism, 84
626 INDEX

glutamate, 76, 77, 77t, 147 hallucinogens, 130-35

glutethemide (Doriden), 97t, 364 acute effects, 130-31
Glynn, T. J., 582 adolescent use, 478, 478t, 483, 514
goal setting, treatment, 221-24 cannabis laced with, 125
behavioral and cognitive behavioral, 255-56 common names, 124t
guidelines, 222 comorbidity with psychiatric disorders, 15t, 24
mutual help groups, 331 cultural/religious use of, 500
short-term, 221-22 designer drugs and, 180
therapeutic community, 310-11 dosages/administration routes/preparations, 124t, 131-32
goal violation effect, 373 gender and depression comorbidity, 24
Godfrey, C., 576 Native American Indian adolescent use, 514
Goldberg, J., 54 persisting perception disorder, 135
Golden, C., 543 pharmacotherapies, 364
Goldman, D., 391 prevalence of disorders, 21
Goldman, M. S., 201 prevalence of illicit lifetime use, 16-18
Gomaz-Dahl, L, 41 prevalence of lifetime and past-year DSM-JV use disorder, 22t
Gomberg, E. S. L., 58, 537 stimulants used with, 112
Goodwin, D. W., 51, 55 tolerance/withdrawal/dependence, 134
Goodwin, F. K., 450 use trends, 121-22
gooseflesh, 150 haloperidol (Haldol), 360, 466
Gordon, J. R., 43, 196, 197, 252, 371, 375, 376, 381, 382, Hamilton, S. K., 282
460 hangover, 78, 88
Gostin, L. O., 430 Hankin, J. R., 581
Gottesman, I. I., 59 Hanus, L, 123
Gough, K., 391 harm avoidance, 59
G protein subunits, 147 duty of care and, 407-8
Graham, J. M., 197, 198 mental disorder commitment, 466
Graham, K., 489, 493 harm reduction, 223, 255, 380, 382
Grant, B. F., 34, 195 adolescent treatment as, 487
Grant, I., 39 as comorbid substance abuse-psychiatric disorder treatment
gratification substitution, 378 model, 454
Graves, K. L., 581 environmental prevention strategies, 587
Greenfield, T. K., 581 as treatment evaluation standard, 419
Griffin, G., 123 Harper, R., 339
Griffin, M. L., 350,442, 531 Harrell, T. H., 193
Griffin v. Coghlin, 405 Harris, R. J., 239, 371
Grissom, G. R., 282, 452 Harrison, J. S., 546
Gross, M. M., 10, 11 Harrison, P, 282
group conscience, 329, 330 Harrison Narcotics Act of 1914, 353
Group Health of Puget Sound, 598 Hartnoll, R., 42
group identity, 514 Harvard Community Health, 598
group modeling, 251-52 Harvard University, 31, 32
group therapy, 217, 218, 220, 289, 535 Harwin, J, 428
couples behavioral marital therapy, 291 Harwood, H. J., 603
as inappropriate for elders, 492 hash. See cannabis
for wives of treatment-resistant substance abusers, 296 hash brownies, 123
growth hormone, 153, 483 hashish, 123, 125, 124t
Gruenewald, P. J., 576 hash oil, 125, 124t
guided participant modeling, 560 Hasin, D. S., 34, 195
guided self-help groups, 330, 332t, 338-41 Haskins, J. B., 581
guilt Hauge, K. J., 100
of gay alcohol abuser, 546, 548 Haugh, L. D., 581-82
relapse, 227, 373, 378 Haupt, H. A., 175-76
of woman alcoholic, 535 Hawkins, J. D., 64, 486-87
gum, nicotine, 164t, 165, 166, 358-59, 392 Haygood, J. M., 201
Gunderson, J. G., 442 Hazelden program (Minnesota), 269, 275, 281-82
GVE. See goal violation effect headache
gynecological problems, 530, 532 alcohol withdrawal, 81
and initial nicotine ingestion, 165
Haastrup, S., 36 sedative-hypnotic withdrawal, 81
habitual excessive drinking, 10 stimulant withdrawal, 115
hair analysis, 204 health care costs
Halcion. See triazolam for drug-exposed child, 425
Haldol. See haloperidol mutual-help organizations as alternative option, 328
Hall, J. M., 549 of substance abuse, 601-2, 605
Halliday, K. S., 60-61 substance abuse interventions as cost offsets, 605-6
hallucinations, 81, 117, 450, 461 substance abuse services financing, 595-98
alcoholic, 350, 448 as treatment decision-making factor, 216, 220
auditory, 173, 350, 448 See also economics; health insurance companies; managed care
inhalant intoxication, 173 health care services
LSD flashbacks, 135,484 confidentiality, 401-3
PGP sensations, 133 lack of integrated treatment systems, 443
substance-exacerbated schizophrenic, 448 network interfaces with substance abuse treatment, 421-33
visual, 131, 132, 135, 173 therapeutic community, 321-22
 INDEX 627

health consequences. See medical conditions and risks; specific Hingson, R. W., 282
conditions hippie movement, 132
health insurance companies, 422, 596-97 hippocampus, 123
copayments, 596—97 Hirsh, G., 487
preferred provider arrangements, 597 Hispanics (Latinos/Latinas), 508-10
See also managed care acculturation assessment, 515
health warnings, 580-82 adolescent substance use, 479
heart disease. See cardiovascular system demographic characteristics, 501-4, 501t, 503t, 508
heart rate, 181 experience of ethnicity, 499
Heath, A. C., 33, 272 heroin use, 503, 504, 509, 519, 520
Heather, N., 240-41 inhalant abuse, 172, 173
heavy drinking, definition of, 14-15 low rate of women drinkers, 528
Heeren, T., 282 histamine, 148
Heinzelmann, F., 586 historical autobiography, 297, 334, 375
Hellerstein, D. J., 464 HIV virus, 117, 148, 502,605
Helzer, J. E., 442, 532 alcohol abuse risk, 532-33
hemp. See cannabis anabolic-androgenic steroid use risk, 179
henbane, 130, 134 ethnic/racial rates, 502, 503-4
Hennessy, M., 581 and gay sexual risk-taking, 549-50
hepatitis, 81, 82, 83, 483, 484, 532 harm reduction approach, 223
hepatitis B, 83, 155 heroin addiction and spread of, 151, 152-55, 156, 392, 483,
hepatitus C, 83, 155 504
heritability. See genetic factors therapeutic community policies, 320, 321
Herman, I., 446 viral load tests, 154
Herman, M., 462 women's risk, 533
heroin HMOs (health maintenance organizations), 422, 596, 598-99
abuse patterns, 151-52 Hoadley, J. F., 575-76
addiction history, 353 Hodgins, D. C., 222
adolescent use, 151,478t Hodgson, T. A., 606
and biological functions, 55 Hoffman, Albert, 132
conditioned withdrawal, 61 Hoffmann, N. G., 282, 491
course of treated abusers, 36 Hofmann, M, 56, 59
dependence treatment, 150, 152 Holder, H. D., 261, 575-76, 576-77, 578, 606
detoxification, 150, 152, 356 Holohan, ]., 606-7
gender use differences, 151, 528, 531 homeless people, 462-63
Hispanic users, 503, 504, 509, 519, 520 homicides, 87, 117
HIV infection spread, 151, 152-55, 156, 392, 483, 504 homophobia, 543, 548, 549
liver disease risk, 155 homosexuality. See gay men, lesbians, and bisexuals
maintenance treatments, 354-55, 392 (see also methadone main- Honaker, L. M., 193
tenance programs) Hoodecheck-Schow, E. A., 203
"maturing out" of, 30 Hore, B., 391
metabolism, 144 horse (heroin), 142t, 151
mortality rates, 3, 40 Horton, A. M., Jr., 195
neurotransmitters and, 76 hospital-based treatment
opiate receptor, 146 for comorbid disorders, 455
stimulants used with, 112 inpatient, 217
street names, 142t, 151 involuntary commitment, 465-66
substitute dependencies, 43 mental illness-substance abuse comorbidity, 441
tobacco smoking with, 167 partial, 217, 221
treatment relapse time, 370 therapeutic community, 307
trends in use, 151 treatment plans, 417
use detection, 204 Hourigan, M., 583-84
withdrawal onset, 149 House Subcommittee on Crime, U.S., 585
women users, 531 Hewlett, T. A., 148
Hersen, M., 291 Hser, Y., 36-37, 40
Hesselbrock, M. N., 56, 57, 59, 61, 66 Hu, T-W., 582
Hesselbrock, V., 32, 52, 55, 59, 61, 62, 66, 534 huffing, 173
Heston, L. L., 52 Hufford, C., 442
Hewett, J. E., 584 Hughes, J. R., 253, 257, 258-59, 262
hexoxymestrolum (Enoltestovis), 176t Hughes, R. G., 582
Higgins, P., 282 Hughes, S. O., 198
Higgins, S. T., 251, 253, 257, 258-59, 260, 262 human immunodeficiency virus. See HIV virus
high. See intoxication human rights, 405
high-density lipoprotein (HDL), 84 humor, 298
Higher Power, 277-78, 329, 330-31, 335, 549 Hunt, W. A., 42, 370
high-risk behavior, cocaine and, 117 Hurt, R. D., 41
high-risk relapse situations, 196, 197, 198 Huss, M., 10
cognitive behavioral treatments, 252, 373 Hussong, A. M, 479
hierarchy of, 219 Huxley, Aldous, 3
learning to identify, 221-22 Hycodan. See hydrocodone
relapse prevention model, 372-75, 379 hydrocarbons, 173
High School Seniors Survey, 173, 507, 514 hydrochloric acid, 148
Hill, S. Y., 53 hydrocodone (Hycodan), 142t, 152
Hilton, M. E., 580 hydromorphone (Dilaudid), 142t, 144
628 INDEX

Hyman, S. E., 271 intoxication

hyoscyamine, 134 alcohol, 10
hyperactivity, 57, 58 cannabis, 122, 125, 126
hyperglycemia, 83t, 84 inhalant, 173
hyperpyrexia, 115 MDMA, 181
hypertension, 83t, 84, 427 opioid dangers and symptoms, 148-49
from elder withdrawal, 490 as psychiatric symptoms trigger, 449, 467
from opioid withdrawal, 356-57 signs of, 80-81
from sedative/hypnotic withdrawal, 364 stimulants, 114
from stimulants, 115, 361 suicidal threats, 466
hyperthermia, 115, 181 intranasal insufflation ("snorting"), cocaine, 15, 108, 115, 118, 125,
hypnosis, 358 151,483-84
hypnotic agents. See sedative-hypnotic and anxiolytic agents intravenous injection. See IV injection
hypochondriasis, 447 Inventory of Drinking Situations, 219, 376
hypoglycemia, 83t, 84 involuntary commitment, 465-66
hypomania, 156 ion channel-receptor complexes, 349
hypotension, 148, 350 IQ, 481-82
hypothermia, 100 irritability
hysterectomy, 530 as alcohol withdrawal symptom, 81
from anabolic-androgenic steroids, 179
Iber, F. L, 391 as nicotine withdrawal symptom, 166
ICD-8, 9 and 10. See International Classification of Diseases as sedative-hypnotic withdrawal symptom, 100
ice (street name), 109, 112, 133t Irwin, M., 56, 59, 207, 270-71
Iguchi, M. Y., 251,262 ITT. See integrative transaction theory
Ilardi, S. S., 251 Iversen, P., 82
illicit drugs. See drug use; specific drugs and drug types IV injection
imipramine, 352, 360, 391, 460, 461 bacterial infection risks, 155-56
immediate gratification, 378 ethnic/racial rates, 504
immune system, morphine effects, 148 hepatitis risk, 155
impaired control, 12t of heroin, 151
Important People and Activities Scale, 255 and HIV infection, 153, 179, 483, 504, 533
impulse control, 371, 529 of morphine, 144
impulsivity, 57, 87, 272 to reverse opioid intoxication, 149
Inaba, R. K., 201 of stimulants, 110, 118
incentive system, 257, 259, 260, 262 syringe exchange programs, 153, 156, 223, 400, 405
incest, 530, 546
Inciardi, J. A., 603 Jackson, A. H., 101
independent practice associations, 599 Jackson, P., 460
Inderal. See propranolol Jacob, T., 59
indinavir, 154 Jacobs, L., 203
individually targeted prevention, 555-68, 582 Jaffe, A. J., 390
individual therapy, 217, 218 Jainchill, N., 318, 319
inebriety, 10 James, K. E., 391
informal help, 330 James, William, 270, 329
informed consent, 243, 402, 408-9 Janes, K., 578
Ingraham, K., 431 Janis, I. L, 239
inhalants, 18, 171, 172-75 Japanese-Americans, 510, 511
adolescent use, 478t Jarrett, P. J., 391, 460
common, 172t Jason, L. A., 583
Native American Indian use, 172, 173, 513, 514 jaundice, 82
use consequences, 174-75 JCAHO. See Joint Commission on Accreditation of Health Care
inhalation Organizations
nicotine absorption, 164, 164t Jellinek, E. M., 10, 13, 32, 269-70, 271, 276, 283, 385, 445
See also intranasal insufflation Jepsen, P. W., 36
inhalers, nicotine, 165, 359 Jesus Christ, 335
inheritance. See genetic factors Ji, P. Y., 583
injectable anabolic steroids, 176t, 179 Joe, G. W., 36, 39, 44
inpatient treatment Johnson, C., 427
pharmacological detoxification, 349, 350 Johnson, J. C., 584
types, 217 Johnson, V., 282
See also hospital-based treatment; residential treatment Johnson Institute "intervention" procedure, 295
insomnia. See sleep disruption Johnston, O. D., 177
inspirational groups. See self-help groups Joint Commission on Accreditation of Health Care Organizations,
Institute of Medicine, 193, 201, 203, 205, 427 287, 416, 417, 417t
integrated treatment systems. See network of care systems joints. See cannabis
integrative transaction theory, 5 56-68 Jones, A. W., 78-79
intemperance, 10 Jones, M., 307
intensive outpatient treatment, 221 Jerques, J. S., 520
intermediate treatment, 217, 221 Joy, D., 546
International Certification Reciprocity Consortium, 415 June, L, 167
International Classification of Diseases (ICD-8, 9, and 10), 10, 11, Jung, Carl, 329
26 juvenile delinquency, 173, 174, 175
diagnostic criteria, 12-13t, 194
interpersonal factors. See social and interpersonal situation Kabene, M., 59
intestinal ischemia, 115 Kaczynski, N. A., 60, 482
 INDEX 629

Kadden, R. ML, 194, 199, 220, 252, 257-58, 260 Langford, N., 577
Kahler, C., 62 lapse and relapse
Kaiser Family Health Foundation Community Organization, 563 abstinence violation effect, 43, 373-74, 378
Kaiser Permanente, 598 adolescent rates, 486
Kandel, D. B., 58, 482 alcoholic mortality risks, 39
Kaplan, S., 431 chronicity of, 30, 348, 370, 605, 608
kappa opiate receptor, 146, 147 clinician's skill and, 238
Kaskutas, L. A., 581 cognitive behavioral model, 196-97, 373-75, 374f
Katz, D. L., 177, 179 comorbidity patients' higher rates of, 445, 467
Keddie, A., 532 countering skills, 42-43, 378-79
Keeler, E. B., 65, 606 disease model client characteristics and, 281, 445
Keeler, T. E., 582 dysphoria as most common precipitant, 445, 447-48, 460
Kelder, S., 583-84 as error vs. failure sign, 227, 371
Keller, M., 11 factors in, 31,43, 219
Kelly, C. A., 282 fantasies, 377
Kelman, S., 603 first-year heroin treatment, 36
Kendler, K. S., 53 high-risk situations, 43, 252, 372-75, 379
Kenkel, D. S., 65 as learning experience, 467
Kennard, D., 307 naltrexone as opioid lapse prevention, 355-56
Kennedy, J., 450 personality disorder patient's high rates, 446
Kennedy, N. J., 177 rates, 370
Kercher. C., 39 rationalizations, 373, 445
Kerr, N., 10 smokers' curves, 42
Ken v. Farrey and Lind, 405 treatment differences over, 424
Kersha\v, P., 391 trigger events, 219, 349, 372-73, 521
Kessler, R. C., 33 See also relapse prevention
ketamine, 124t, 130, 133-34 Larkin, Stephen, 452
Khantizian, E. ]., 60-61 Latinos/Latinas. See Hispanics
khat, 105 Lauerman, R., 11-13
Kidorf, M., 251,262 laughing gas, 173
King, A. S., 239 Laundergan, J. C., 281-82
King, Martin Luther, Jr., 400 law. See legal issues
Kinsei, L., 59 law enforcement agencies, 584-85
Kishline, A., 340 LED. See liquor by the drink
Kivlahan, D. R., 261 LC neurons. See locus coeruleus
Kleber, H. D., 53, 156,450 Leake, G. J., 239
Kleiman, M. A. R., 586 learned phenomenon, alcohol dependence syndrome as, 11
Kleinke, C., 300 learning experience, 467
Klonopin. See clonazepam learning theory. See social learning theory
Koch, R., 445 Leary, Timothy, 132
Kochakian, C. D., 175-76 Lee, K. K., 391
Kocsis, J. H., 391 Leech, S. L, 529
Koffman, D. M., 582 Leeds, J., 60, 61
Kofoed, L. L., 457, 464, 492 legal issues, 399-406, 418, 579-80
Kogan, E. S., 251 curfew laws, 580
Kopstein, A. N., 177 drinking and driving laws, 404, 424, 429, 533, 579
Korean-Americans, 510, 511 drug crime sanctions, 585-86, 587
Kornaczewski, A., 577 illicit drug use prevention, 585-87
Korsakoffs psychosis, 82, 83t involuntary commitment, 465-66
Kosten, T. B., 531 mandated server training, 578
Kotin, J , 450 minimum age of purchase laws, 65, 404, 563, 565, 577, 583
Kraeplin, E., 10 zero-tolerance laws, 579-80
Kranzler, H. R., 56, 76, 194, 461 legal system. See criminal justice system
Kressel, D., 319 Lehman, W. E. K., 36, 39, 44
Kristiansen, P. L., 603 Leigh, B., 533
Kruse, R. L., 584 Leigh, G., 222
Krystal, H., 61 Lennox, R. D., 606
Kufner, H., 39 Leo, G. L, 192, 194
Kushner, M. G., 61, 86 Lerner, J. V., 59
Kuusi, P., 575 Leshner,A. I., 271
Leslie, A. C., 607
LAAM (levo-alpha acetyl methadol; ORLAAM), 143t, 150, 155, Levenson, S. M., 282
354-55, 365t Levin, D., 582-84
advantages and disadvantages, 391 Levin, G., 487
labels, diagnostic, 246 levo-alpha acetyl methadol. See LAAM
labels, warning, 580-81, 582 Lewis, C. E., 39
Laber, H. D., 531 Lewis, D. C., 269
Labouvie, E., 281 Lex, B. W., 531
Lacoursiere, R. B., 391 Liban, C. B., 536
lacrimation, 150 Librium. See chlordiazepoxide
La Fromboise, T. D., 518 licensing, 405, 415
Laird, S. B., 59 Lieber, C. S., 55
Lane, U., 531 Liebowitz, N., 205
Lange, W. R., 603 Liebson, I. A., 261
Langenbucher, J. W., 482, 606 Life Experiences Survey, 379
630 INDEX

Life Skills Training, 565 flashbacks, 135,484

lifestyle and circumstances overview, 132
assessment of, 198-99 tolerance buildup and loss, 134
balanced, 379, 382 Luborsky, L., 259, 446
based on abstinence, 269 Luminal. See phenobarbital
based on alcohol, 270 lung cancer, 528-29
elderly drinking relationship, 490 lungs. See respiratory system
Hispanics, 509 Lurigo, A. J., 430
Moderation Management, 340 Lykken, D. T., 52
motivation for changing, 189 Lyons, M. J., 54
parallel chronology with substance use, 224 lysergic acid diethylamide. See LSD
potentially problematic behaviors and, 372
problem areas for substance use, 219 Maany, I., 391
resolution and changes in, 43, 44 MacArthur, C., 577
therapeutic community focus on change in, 309, 323 Macdonald, S., 576
treatment focused on improvement in, 45, 273 machismo, 510
treatment goal setting, 223 MacKenzie, W. C., 577
12-step guide for changes in, 276-80 MacRae, J., 460
Lifetime Drinking History, 485 magnesium depletion, 351
Lifshutz, H., 456, 462 Magura, S., 204
light beer, 579 Mahler, H., 59
limbic system, 123 Maidlow, S. T., 607
Lindberg, U., 56 maintenance medications, 41, 144, 392 (see also methadone main-
Lindstrom, L., 220 tenance programs)
Links, P. S., 57 Maisto, S. A., 60, 76, 194, 195
Lipha Pharmaceuticals, 391 Malcolm, R., 352
lipids, 84 managed care, 216, 328, 515, 522, 598-601
Lipton, D. S., 204 cost consciousness, 602, 605
liquor. See alcohol use documentation requirements, 416
liquor by the drink, 575-76 elderly substance use, 490
lithium, 352, 446 primary' health providers, 422, 426-28, 432
Litman, G., 460 substance abuse treatment, 422, 427, 433, 595, 600-601
Litt, M. D., 199, 260 traditional vs. contemporary, 598-600
Litten, R. Z., 204 Mandelbaum, A., 123
Little, L., 239 mandrake, 130, 134
Little, R. J. A., 33 manic disorder, 23, 24t, 156, 448 (see also bipolar disorder)
liver Mann, L., 239
alcoholic deterioration of, 82-83, 83t, 85 Manning, W. G., 65, 582, 606
alcohol metabolism, 75-76, 78, 79, 85 Manwell, L. B., 427
amphetamine metabolism, 105-7 Marcus, S. M., 42
LSD metabolism, 132 marijuana. See cannabis
naltrexone as nondangerous to, 352 Marijuana Effects Expectancy Questionnaire, 485
nicotine etabolism, 162, 163 marital distress, 371, 373, 529, 532, 533, 536
opiate metabolism, 144 Marital Status Inventory, 294
opioid abuse risks, 155 marital therapy. See behavioral marital therapy; family models
liver function tests, 255 Marlatt, G. A., 43, 196, 197, 203, 219, 252, 371, 373, 375, 376,
lobeline, 359 379, 381-82, 460
locus coeruleus, 145, 163 Martier, S. S., 581
lofexidine, 350 Martin, C. S., 59, 60, 482
Logan, J. A., 482 Mason, B. J., 391
Logan, R. A., 584 Masse, L. C., 59
London, R. L., 427 mass media campaigns, 561, 562, 565, 574, 581
loneliness, 488, 489, 493 Master Addictions Counselor, 415
Longabaugh, R., 220, 259, 261, 492 MAST-G. See Michigan Alcoholism Screening Test
longitudinal studies Mastria, M. A., 219, 227
adolescent heavy marijuana use, 129 MATCH. See Project MATCH
childhood behavioral problems as alcoholism predictor, 57, 58 Mattson, M. E., 220
cognitive effects of heavy drinking, 86 "maturing out," 38, 483
course of treated vs. untreated substance use, 30-37 Maxibolin. See ethylestrenol
fetal alcohol syndrome, 85 Mayo Clinic, 488
need for, 26 mazindol, 362-63
schizophrenia-substance abuse comorbidity, 442 Mazis, M. B., 581
See also National Longitudinal Alcohol Epidemiologic Survey McAuliffe, W. E., 61, 225
Longo, D. R., 584 McBride, C. A., 10
lorazepam (Ativan), 97t McBride, D. C., 603
for alcoholic detoxification, 350, 352 McBride, H., 57
for psychotic disorders, 461, 466 McCarthy, J. J., 261
love drug (MDA), 124t, 133, 180 McClellan, A. T., 452
low birth weight, 166 McCord, J., 57
lower-alcohol beverages, 579 McCord, W., 57
Lowstam, I., 391 McCoy, H. V., 603
lozenge, nicotine, 164t, 165 McCrady, B. S., 62, 222, 281, 291, 292-93, 296, 297, 301, 389,
LSD (lysergic acid diethylamide), 124t, 130, 131, 133 492, 534, 535
adolescent use, 478t, 484 McDougall, ]., 61
as designer drug precursor, 180 McGinley, J. J., 456
 INDEX 631
McGovern, P., 583 machismo behavior pattern, 510
McGrath, P. ]., 391 See also family models; gay men, lesbians, and bisexuals; gender
McGue, M., 52 differences
McGuire, T. G., 282 Mendelson, J. H., 63
McHugo, G. ]., 457, 464, 465 menopause, 166
McKay, J. R., 194, 195 menstrual irregularity, 83t
McKenzie, D., 577 mental activity. See cognitive functioning
McKeon, P., 479 mental health delivery systems, addiction treatment, 439-40, 465-
McKiman, D. J., 544 66, 600-601
McKirnan, D, 546 mental illness. See psychiatric disorders
McKnight, A. J., 577 mentally ill chemical abusers. See comorbid disorders; MICA
McLellan, A. T., 259, 282, 446, 460 mental retardation, 85
McMahon, P. T., 251 meperidine (Demerol), 143t, 144, 149
McNally, E. B., 547, 550 meprobamate (Miltown), 97t
McNamara, G., 14 Merikangas, K. R., 51
McNeill, A. D., 582 Merrigan, D. M., 282
MCOs. See managed care Merrill, D. G., 581-82
MDA (methylenedioxyphenylisopropylamine), 124t, 130 Merrill, J., 603
as prototype designer drug, 133 mescaline, 124t, 130, 131, 133
MDEA. 180 overview, 132-33
MDMA (methylenedioxymethamphetarnine; ecstasy), 105, 109, tolerance buildup and loss, 134
117, 130, 133, 172, 180-81 mesolimbic dopamine system, 145, 163
mean corpuscular volume, 204 mesterolone (Proviron), 176t
mecamylamine, 359, 365t MET. See motivational enhancement treatment
Mechoulam, R., 123 metabolic pathways
media. See mass media campaigns alcohol, 75-78, 79, 84-85
Medicaid/Medicare, 490, 595, 596, 597, 598, 602, 605, 606, 607 anabolic-androgenic steroids, 177-78
medical conditions and risks cannabis, 122
adolescent substance use, 483 inhalants, 173
alcohol-related, 82-85, 83t, 350-51, 427, 483, 602 LSD, 132
as alcohol use contraindications, 222 MDMA, 180
anabolic-androgenic steroids use, 178-79 nicotine, 162-63
cannabis smoking, 127 opioids, 144
costs of, 602, 605 sedative-hypnotic and anxiolytic agents, 96-97
disease model, 268-69, 274 stimulants, 105-7, 106f, 118
elder substance use, 489-90 methadone
ethnic and racial minorities, 502, 506 administration route/dosage/street names, 143t
gender differences, 532-33 detoxification time, 356
hallucinogen use, 135 withdrawal onset, 149
as impetus for quitting smoking, 41-42 as withdrawal therapy, 391
inhalant abuse, 174 zidovudine possible interaction, 154-55
MDMA use, 181 methadone maintenance programs, 41, 148, 149, 150, 153, 154,
morphine use, 148 155, 348, 365t, 392, 459, 605
nicotine patch contraindication, 358 basis of, 354
nicotine use, 164, 166, 167, 528-29, 601-2 combined with other therapies, 354
opioiduse, 148-49, 152-56 contingency management approaches, 253, 261-62
primary care providers, 422, 426-28, 432 cost-benefit analysis, 607
stimulant-related, 115-16, 116t, 118, 361 inception of, 353
substance use overlooked as problem, 225, 427 methamphetamine, 105, 108-9, llOt, 112, 115
as treatment assessment factor, 218, 219, 223 gay men/bisexual users, 544
warning labels, 580-81, 582 methamphetamine hydrochloride, 109
women's drinking, 85, 530, 532-33 methandrostenolone (Dianabol), 176t
See also comorbid disorders; specific conditions methaqualone, 112, 514
medications Methedrine, 109t
alcohol interactions, 76, 79-80, 80t methenolone (Primobolan), 176t
androgens uses, 175 methohexital (Brevital), 97t
See also drug use; pharmacotherapies; prescription drugs; specific methylenedioxymethamphetarnine. See MMDA
drugs and drug types methylenedioxyphenylisopropylamine. See MDA
meditation, 43, 379 methylphenidate, 362
medulla, 141, 148 Metzger, D. S., 282
Mee-Lee, D., 221 Metzger, E. J., 456
Mehta, B., 391 Meuller, W. H., 52
Meichenbaum, D. H., 252 Mexican-Americans (Chicanos/Chicanas), 508, 509, 510, 515, 528
Melnick, G., 319 Meyer, J. M., 54
memory Meyer, R. E., 56, 59, 271, 390-91, 536
alcohol impairment of, 54 Mezzich, A., 59
benzodiazepines impairment of, 102 MICA (mentally ill chemical abuser), 444. See also comorbid
cannabis impairment of, 125 disorders
cocaine withdrawal effects on, 114 Michael, J., 52
hallucinogen effects on, 131 Michigan Alcoholism Screening Test, 432, 533, 534
opioid effects on, 149 elder-specific, 491
men Midanik, L. R., 544
alcoholic Type 2 category, 13 midazolam (Versed), 97t
course of treated heroin-addicted patients, 36 middle-class heroin users, 151
DWI citations, 513 Miller, J. Y., 64, 486-87
632 INDEX

Miller, L. S., 603 psychiatric, 440

Miller, P.M., 219,227, 291 as treatment motivator, 44
Miller, T. Q., 62, 63 Moser, J., 11
Miller, W. R., 205, 222, 224, 237, 239, 241, 245, 261, 371, 375, Mosher, J., 578
387, 485 Moss, P. M., 546
Milne, R., 222 motivation, 235-46, 387
Miltown. See mepromate adolescent drinking, 484
Miner, C. R., 464 beliefs about, 235-36
minimal brain dysfunction, 57 brief interventions, 127
minimum age of purchase laws, 65, 404, 563, 565, 577, 583 chronic cannabis use effect on, 129
Minkoff, K., 452 common elements, 237-39
Minnesota Multiphasic Personality Inventory, 87 comorbidity treatment, 457, 458
minority groups. See ethnic and cultural minority groups decisional matrix, 297, 375, 376f
miosis (pinpoint pupils), 149 of help seeker, 189, 192, 196, 224, 300
Mirin, S. M., 52,442,450, 531 measurement of, 239-41, 387, 388
miscarriage, 530 modifiability of, 236t
mixed addictions. See multiple addictions and naltrexone opioid dependency treatment, 392
MM. See Moderation Management relapse prevention, 371, 375
MMDA (methylenedioxymethamphetamine), 124t research results, 236-41
modeling, 63, 65, 251-52, 254, 388 for substance abuse, 199
"model minority," 511 therapeutic community beliefs, 309-10, 317, 390
moderation and treatment success, 44, 223, 393
as relapse prevention goal, 380 vectors, 241
as substance abuser goal, 3, 340, 388 motivational enhancement treatment, 220, 235-46, 458
as treatment evaluation standard, 419 motivational interviewing, 245-46, 371, 387
as treatment goal, 424 motor vehicle operation
vs. abstinence, 222-23, 255, 340-41, 388 adolescent drunk driving accidents, 483, 574
Moderation Management, 329, 331, 332t, 340-41 alcohol-related accidents, 87, 88, 268, 427, 574, 602
nine-step program, 341t blood alcohol levels, 78-79
Modified Selective Severity Assessment, 350 cannabis use effects, 128
Moffatt, K., 577 designated driver programs, 223
Mohatt, G. V., 518 drinking and driving laws, 404, 424, 429, 533, 579
monaminergic receptors, 361-62 duty of care and, 408
Monitoring the Future, 18, 585 ignition interlocks, 580
monkey (morphine), 142t license revocation laws, 580
monoamine oxidase inhibitors male DWI citations, 513
alcohol interaction, 80t minimum age alcohol laws, 577
for stimulant cravings, 113 nicotine effects, 167
monomania, 10 public service warnings, 581
Montgomery, H., 239 random roadside checks, 579
Montgomery, R. P. G., 198 mouth cancers, 166
Monti, P. M., 252, 257-58 MTF. See Monitoring the Future
mood disorders mucocutaneous symptoms, 150
androgens and, 175 Muder, P., 534
pharmacotherapy, 460-61 muestra cultura Latina, 509
relapse and, 460-61 Mulford, H. A., 576
substance-induced, 448, 450, 484 multiple addictions, 19
See also specific disorders of adolescents, 478, 493
Moos, R. H., 42, 536 anabolic-androgenic steroids users, 177
moral model of addiction, 445, 602 cannabis combinations, 125
moral questions. See ethical issues common illicit combinations, 112-13, 112t
Morey, L. C., 221 drug interactions, 111-14
Morgenstern, J., 60, 61, 281 of dually diagnosed, 443, 451
morphine, 141 of elderly, 488
action, 144 nicotine users, 80, 112, 127, 162, 167, 529
anabolic-androgenic steroids used with, 177 opioid users, 148
analgesic effect, 148, 353 premature deaths, 41
dosage and administration route, 142t of women, 528, 529-30
metabolism, 144 multiple-risk-factor model, 479
opiate receptor, 146 Munich "beer heart," 84
physiological effects, 147-48 Mufioz, R. F., 222
street name, 142t mu opiate receptor, 146, 147, 148, 149, 150
See also heroin Murphy, G. E., 466
morphism, 10 muscarine, 163
morpho (morphine), 142t muscle aches, 224
Morris, L. A., 581 muscle disorders. See myopathy
mortality, 31, 36, 38-41 muscle relaxants, 96
alcoholic cirrhosis, 82-83 mushrooms. See Amanita muscaria; psilocybin
alcohol use disorders and, 3, 38-39, 41, 75, 84 mutual help groups. See self-help groups
cocaine as leading illicit drug linked with, 117 myelin, 174
drug vs. alcohol same-age patients, 41 Myers, C. P., 603
elderly drug-related rate, 488 myocardial infarction, 115, 178, 361
multiple addictions, 41 myocardium, 148
nicotine smoking and, 3, 40, 80, 162, 166, 167, 357, 528-29 myoclonus, 364
opioid abuse and, 40, 41, 151 myopathy, 82, 83t, 532
 INDEX 633

NA. See Narcotics Anonymous needle exchange programs. See syringe exchange programs
Nace, E. P., 446 negative contingencies, examples of, 253
nalorphine, 147 negative thinking, 223
naloxone neglect of activities, 12t
and alcohol toxicity, 349 Neiderhiser, D., 391
as opioid maintenance treatment, 355 neighborhood disorganization, 64
-precipitated symptoms, 146 Neighbors, C. J., 285
to reverse opioid intoxication, 149, 150, 152, 353, 357, 365t Nelson, C. B., 33
naloxone hydrochloride, 149 Nelson, W., 583
naltrexone, 76, 150, 152, 365t, 428 Nembutal. See pentobarbital
as alcohol anticraving agent, 351-52, 365t, 390-91, 460 nervous system. See autonomic nervous system; central nervous sys-
as opiate blockade, 347, 355-56, 357, 391, 392, 459 tem; sympathetic nervous system
nandrolone decanoate (Deca-Durabolin), 176t Nestler, E. J., 147
nandrolone phenpropionate (Durabolin), 176t Netemeyer, R. G., 581
Napolitano, D. M., 603 networking, 342, 387
Naranjo, C. A., 82 network of care systems, 421-33
Nar-Anon, 331, 334-35 best practice model, 431-33
narcolepsy, 108, 111 coordination barriers, 424-25
narcomania, 10 for ethnic/racial minority treatment, 522
Narcotics Anonymous, 44, 226, 296, 322, 329, 331, 332, 332t, 386, for gay men and lesbians, 548
423, 424 for high-severity mental illness, 464-65
adolescent outcomes, 486 integrated comorbidity treatment, 443-46, 456-57, 464, 467
overview, 334 service types, 425-31
Narcotics Anonymous, 334 neurobiological theories, 271
nasal snuff, 162, 164t neuroendocrine function, 148
Natale, M, 460 neurological damage, 484
National Association of Alcohol and Drug Abuse Counselors, 415 neurological syndromes, 82
National Association of Lesbian and Gay Addictions Professionals, neuropathy, 82
548 neurophysical functioning
National Center for Health Statistics, 528 alcoholic risks, 54-55, 65
National Certified Addictions Counselor Level I and II, 415 as central to craving, 347
National Committee on Quality Assurance, 599 and elder substance abuse, 490
National Comorbidity Survey, 19, 23, 24t, 127, 440, 442-43 neuroticism, 59-60
National Disease and Therapeutic Index, 95 neurotransmitter system
National Drug and Alcoholism Treatment Unit Survey, 18 alcohol and, 76-77, 77t, 349
National Drug Control Strategy, 151 anabolic-androgenic steroids and, 177
National High School Senior Survey, 529 cannabis and, 122-23
National Highway Systems Act, 579 designer drugs and, 180
National Household Survey on Drug Abuse, 17, 18, 121 hallucinogen similarities, 130, 131, 134
National Institute of Mental Health, 440 nicotine and, 163, 167
National Institute on Alcohol Abuse and Alcoholism, 4, 87, 268, opioids and, 76, 144-47, 150
282,418 sedative-hypnotic and anxiolytic agents and, 98
Adolescent Assessment/Referral System, 487 stimulants and, 107-8, 361
heavy drinking definition, 544 Newhouse,}. P., 65, 606
longitudinal survey (1992), 14, 17, 19, 20t, 23, 24t, 534 New Life Acceptance Program, 338, 338t
standardized assessment, 416 NHSDA. See National Household Survey on Drug Abuse
See also Project MATCH NIAAA. See National Institute on Alcohol Abuse and Alcoholism
National Institute on Drug Abuse, 4, 108, 153, 487, 529 Nickless, C. J., 220
drug testing guidelines, 405 nicotine, 162-68
methamphetamine study, 544 abuse and dependence symptoms, 165-66
survev of women substance users, 528 adolescent users, 37-38, 478, 478t, 482, 483, 529
National Labor Relations Act, 404 Asian-American smoking rates, 511
National Lesbian Health Care Survey, 544, 546 augmenting alcohol, 80, 167, 529
National Longitudinal Alcohol Epidemiologic Survey, 14, 17, 19, augmenting cannabis, 127
20t, 23, 24t, 534 augmenting other drug use, 112, 162, 529
National Prescription Audit, 95 cigarette smoking, 164, 164t, 165-66, 167, 478t
Native American Indian Church, 132 cigars, 164, 164t, 165, 166
Native American Indians (American Indians), 512-14 conditioning, 358
alcohol abuse, 503, 504, 513 course of smoking, 37-38
cultural orientation assessment, 515, 518-19 declining use of, 528
demographic characteristics, 501-4, 501t, 503t, 512 delivery systems, 162, 164-65, 164t, 357
experience of ethnicity, 499 dependence mechanisms, 163, 165-66, 167
inhalant abuse, 172, 173, 513, 514 ethnic use rates, 502, 513
patterns of drug use, 513-14 as gateway drug, 129, 482, 529
sociocultural features, 512-13 gender ratio, 38, 527
women drinkers, 528 lesbian users, 545, 546
natural change, 45, 236-37, 239 medical risks, 164, 166, 167, 528-29, 601-2
"natural healing processes," 45 mortality risks, 3, 40, 80, 162, 166, 357, 528-29
nausea mutual support group, 45
as alcohol withdrawal symptom, 81, 224 nasal spray, 162, 164t, 165, 359, 392
initial nicotine ingestion and, 165 pharmacological actions, 162-63, 357-58
opioids causing, 148, 149, 356 pharmacotherapy, 358-60, 365t, 392
Navajo, 512 price/consumption link, 582-83
NCS. See National Comorbidity Survey psychiatric comorbidities, 359-60
NDATUS. See National Drug and Alcoholism Treatment Unit Survey quitting and lifestyle changes, 43
634 INDEX

nicotine (continued) occupational performance. See work; workplace

quitting impetus, 41-42 Ocepek-Welikson, K., 391
quitting on own, 237 O'Connor, L. H., 177, 178
relapse curves and rates, 42, 370 O'Donnell, W. E., 36
replacement products, 164-65, 164t, 358-59, 392 O'Farrell, T. ]., 291-92, 296, 300, 388
restrictive sales laws, 65, 562-63, 583-84 Office of National Drug Control Policy, 151
self-extinguishing cigarettes, 580 Offord, D. R., 57
smoking location restrictions, 584 Offord, K. P., 41
smoking prevention, 582-84 Ogborne, A. C., 221
smoking rituals, 358 Ohannessian, C. M., 59
street names, 164 Ohio, 607
as weight-control measure, 166, 358, 478 Ojesjo, L, 31, 32, 35, 38-39
withdrawal symptoms and course, 166, 358 olanzepine, 462
women smokers, 528-29 older people. See elderly people
Nicotine Anonymous, 45, 334 O'Leary, M. R., 252
nicotine fading, 358 Olsson, O., 578
nicotine polacrilex. See gum, nicotine O'Malley, P. M., 177, 577
NIDA. See National Institute on Drug Abuse O'Malley, S., 200, 390-91
Nigrescene, 515 Onken, L. S., 515
Nilsson, T, 579 operant conditioning, 61-62, 108, 251
1960s counterculture, 132 behavioral/cognitive behavioral applications, 253-54, 388
Nirenberg, T. D., 227, 537 learning theory, 290, 371, 388
nitrates, 544 S-O-R-C- models, 292-93
nitric oxide synthase inhibitors, 146 Operation Concern (San Francisco), 544
nitrous oxide (laughing gas), 173 opiates. See opioids
NLAES. See National Longitudinal Alcohol Epidemiologic Survey opioid blockers, 351, 355-56
NMDA (N-methyl-D-aspartate), 77, 77t, 80-81, 146, 349 opioid receptors, 76-77, 77t, 145-46, 147, 353, 392
Nocks, J. J., 391 three major classes, 146
Noctec. See chloral hydrate opioids, 141-56
"nodding" state, 149 abuse as deficiency disorder, 353
Noel, N. E., 291, 296 abuse patterns, 151-52
Nolimal, D., 261 acute effects, 148-49
nonaddicted person, 43 administrative routes and dosage, 142-43t
nonbenzodiazepine hypnotic agent, 96 adolescent use, 478t
nondependent disorders, 10 alcohol interaction, 79, 152
non-Hispanic whites antisocial personality disorder comorbidity, 442
demographic characteristics, 501-4, 501t, 503t blockades, 355-56
women drinkers, 528 clinical aspects, 147-52
nonnucleoside reverse transcriptase inhibitors, 154 commonly abused and prescribed, 142-43t
nonproblem drinking, 35 comorbid high rate of psychopathology, 156, 459
nonsteroidal antiinflammatories, 80t comorbidity outcomes, 446
non-substance-related (NSR) mental disorders. See psychiatric conditioned withdrawal symptoms, 251
disorders definition of, 141
Noonan, D. L, 292 dependence and withdrawal symptoms, 149-51, 152, 356-57
Noordsy, D. L., 464, 465 dependency and HIV infection, 152-55
noradrenergic release, 150 depressive disorders, 156, 460
Norcross, J. C., 457 detoxification, 150, 152, 354, 355, 356-57, 391-92
Nordlund, S., 575, 576, 578 elder abusers, 488, 489
norepinephrine, 361 genetic transmission of dependency, 53
cocaine therapy research, 361 historical terms for addiction, 10
hallucinogen structural similarity, 130, 134 illegal and prescription, 142-43t
nicotinic receptors and, 163 long-term outcome of treated dependence, 36-37, 38
opioid mechanisms and, 145 mixed-drug use of, 148
stimulant activation, 107 mortality incidence, 40, 41, 151
normeperidine, 144 neurotransmitters and, 76, 144-47, 150
norococaine, 106 pharmacological actions, 144-47, 149, 347
North American Syringe Exchange Network, 15 3 pharmacotherapies, 149, 150, 152, 154, 156, 347, 353-57, 365t,
Noumair, D., 56 390, 391-92, 459
Noval, S., 579 prevalence of disorders, 21
novelty seeking, 13, 14, 59 prevalence of illicit lifetime use, 16-18
Novotny, T. E., 582, 584 reinforcing actions, 146
NSC. See National Comorbidity Survey opium, 141, 353
nucleus accumben, 145 Oppenheim, A. N., 460
Nunes, E. V., 391 optimism, 245
Nuremberg code, 400 oral cancers, 166
Nurnberger, J. I., Jr., 52 oral ingestion
nutritional deficiencies, alcohol-related, 82, 84-85, 483 anabolic-androgenic steroids, 175
Nyswander, Marie, 353 cannabis, 122, 123, 124t, 125
hallucinogens, 124t
obesity, 371 nicotine, 164, 164t
object relations disturbance, 61 Oregon, 578, 607
O'Brien, C. P., 259, 282, 391, 446, 452, 460 Orford, J., 44, 532
obsessive-compulsive disorder, 272, 371 ORLAAM. See LAAM
lifetime prevalence of substance use disorder, 442t Orrok, B., 205
substance use comorbidity, 24t Osher, F. C., 457, 464
 INDEX 635
osteoporosis, 83t, 85, 166 and ethnic/cultural minority groups, 500
Osterberg, E., 579 as prevention model focus, 556, 560-61, 565
otis media, 167 self-help groups, 330, 342-43, 386-87
Ottawa Prenatal Prospective Study, 128 as therapeutic community positive force, 307, 311-12, 313-14,
Ottenberg, D. J., 39, 41 317, 323
outcome expectancies. See expectancies and women's alcohol use, 529, 536
outpatient treatment, 217, 218, 220, 221 PEL See Personal Experience Inventory
adolescent, 487 Peleg, M, 460
behavioral marital therapy, 389 Penk, W. E., 261
gay men and lesbians, 547-48 pentazocine (Talwin), 142t, 146, 147
pharmacological detoxification, 349, 350 pentobarbital (Nembutal), 97t
probation/parole-mandated, 430 peptic ulcer, 166
therapeutic community, 310 •peptides, 76, 144, 146
Overcomers Outreach, 329, 331, B32t, 335 perception alteration, 121
overdose Percodan. See oxycodene
adolescent accidental, 483 Perel, J. M., 391, 460
naloxone reversal of opioid, 357 Perocet. See oxycodene
opioid effects, 148-49 Personal Experience Inventory, 484-85
Overeaters Anonymous, 329 Personal Experience Screening Questionnaire, 484
Owen, P., 281 Personal Feedback Report, 243
oxandrolone (Anavar), 176t personality, 58-60
oxazepam (Serax), 97t, 99, 101, 360 addictive concept, 440
for alcoholic detoxification, 350, 352 assessment strategies, 191t, 198-99, 201
Oxford Groups, 329, 331, 334, 336 changes with recovery, 87
oxidation, 75-78 five-factor model, 59-60
oxycodene (Percodan; Perocet), 142t preaddict vs. clinical, 199
oxymetholone (Anadrol), 176t substance-induced changes, 450
personality disorders
Pacific Islanders, 499, 510 as alcoholism risk factor, 57-58
demographic characteristics, 501-4, 501t, 503t changes after drinking cessation, 87
pain perception. See analgesics; anesthetics diagnosis in substance use assessment, 195
Pan-Asian values, 511-12 as disease model relapse factor, 281
pancreatitis, 81, 83, 83t, 84 etiology, 50
Pandina, R. J., 479, 481 and high treatment dropout rates, 446
panic disorder machismo as, 510
benzodiazpine as treatment for, 102 and opioid dependency, 156
lifetime prevalence of substance use disorder, 442t substance abuse comorbidity, 26, 255, 442, 446
pharmacotherapy, 461 substance-induced changes vs., 450-51, 452
relapse prevention, 371 therapeutic community treatment, 456
stimulants increasing, 117 See also antisocial personality; borderline personality disorder
substance use comorbidity, 24t, 442-43, 448 Pert, C. B., 353
panic reactions, hallucinogenic "trips," 131, 135 Pertwee, R. G., 123
paranoia PET. See positron emission tomography
cannabis intoxication, 125 Peterson, P. L, 544
cocaine-related, 117, 118, 361,448 Petraitis, J., 62, 63
elderly, 489 Petrenas, A. M., 41
hallucinogenic acute state, 135 peyote cactus. See mescaline
paraphernalia possession laws, 405 P450 system, 76, 106
parathyroids, 84 phantasticants. See hallucinogens
parental alcoholism. See family environment; family models; pharmacodynamic tolerance, 98
genetic factors pharmacokinetics, 98
Parker, R. N., 581 pharmacological actions
parole, 429, 430 of alcohol, 75-78, 349
Parsons, O., 54, 57 behavioral, 251
partial hospital treatment. See intermediate treatment of nicotine, 162-63, 357-58
"party drugs," 117 of opioids, 144-47
Pasternak, G. W., 148 of sedative-hypnotic and anxiolytic agents, 96-98
patch, nicotine, 162, 164t, 165, 358-59, 392 of stimulants, 105-9
patient placement criteria, 220-21 pharmacotherapies, 347-66, 390-93, 459-60
in therapeutic community, 322 agents, 365t
patient's rights, 401 for alcoholism, 76-77, 96, 291, 296, 348-53, 365t, 390-91,
Patterson, G. A., 238 459-60
Pavlov, 1., 251 for alcohol withdrawal symptoms, 81-82, 101, 349-51
payment mechanisms (health care), 595-96 for anxiety disorders, 391, 461
PBT. See problem behavior theory basic principles for dual diagnoses, 458-59
PCP (phencyclidine), 112, 121, 124t, 125, 130, 131, 392 for benzodiazepines, 363-64, 364t
adolescent users, 478t, 484 for cannabis, 364-65, 393
agitation treatment, 466 for cocaine, 361-63, 365t, 391, 392, 461
overview, 133 for comorbid disorders, 352, 458-63, 460t
tolerance and withdrawal symptoms, 134, 135 for hallucinogens, 364
Pearlman, S., 221 for nicotine, 358-60, 365t, 392
peer cluster theory, 479 for opioid dependence, 149, 150, 152, 154, 156, 353-57, 365t,
peer group influences 391-92, 459
and adolescent substance abuse, 63-64, 65, 251, 479, 493, 500, opioids, 149, 150, 152, 154, 156, 347, 353-57, 365t, 390, 391-
556 92, 459
636 INDEX

pharmacotherapies (continued) Powers, K., 36-37

primary-care collaboration, 428 PPT [2-propanoyl-3-(-4-toyl)-tropane], 363, 365t
for stimulant craving, 113, 113t practitioner. See clinician
as treatment decision-making factor, 216 Pratt, O. E., 85
phencyclidine. See PCP preferred provider arrangements, 597
phenobarbital (Luminal), 97t, 100-101, 364, 365t pregnancy
phenothiazines, 79 alcohol use prevention, 536, 567
phenylcyclidine. See PCP alcohol use risks, 85, 425-26, 427, 532, 602
phenytoin, 351 cigarette smoking risks, 166
Philadelphia Study, 351 fetal substance exposure, 425-26
Phillips, A. N., 40 hallucinogen use risks, 134
phobia marijuana smoking risks, 128, 130
lifetime prevalence of substance use disorder, 442t opiate-dependent complications, 156
substance use comorbidity, 24t, 156, 536 stimulant use risks, 115-17
physical abuse. See child neglect and abuse; domestic violence; teenage, 506
sexual assault; violent behavior as treatment factor, 218
physical dependence. See dependence warning label effects, 581, 582
physician Preludin, 109t
addiction treatment credentials, 415 premature death. See mortality
primary health care providers, 422, 426-28, 432 prescription drugs
physiological effects adolescent abuse, 482
alcohol abuse, 82-85 Alcoholics Anonymous official position on, 463
benzodiazepines, 102 comorbidity with psychiatric disorders, 15t
cannabis, 125 conservative anxiolytic use, 95-96, 101
drug interactions with stimulants, 112t, 125 elder abuse, 488
hallucinogens, 131 laws concerning, 404
opioids, 147-48 opiate abuse and dependence, 152
stimulants, 108, 115-17, 118, 125, 361 opiates, 142-43t
Pickens, R. W., 52 prevalence of illicit lifetime use, 16t, 17t
Pierce, J. P., 37-38 prevalence of lifetime and past-year DSM-IV use disorder,
Pietrapaolo, A. Z., 489, 493 22t
piloerection (gooseflesh), 150 self-medication, 225-26
Pinkham, L, 318 women as main abusers, 527, 530, 532
pinpoint pupils, 149 Presson, C. C., 37
piperazine, 363 prevention, 555-88
pipes aimed at environment, 573-88
hashish, 125 aimed at individuals, 555-68, 582
tobacco, 164, 164t catchment vs. systems perspectives, 573-75
placenta! abruption, 166 direct vs. indirect models, 564-65
placenta previa, 166 effectiveness and cost-effectiveness, 567-68
Placidyl. See ethchlorvynol person-level risk, 557-59, 557f, 558f
Plant, R. W., 200 person x situation x environment, 563-64
platelet aggregation decrease, 83t, 84 restricted access policy, 65, 562-63
Plutarch, 292 situation-level risk, 559-61, 560f
Pneumocytis carinii (PCP) pneumonia, 153, 154 target populations, 565-67
pneumonia, 81, 167 women's alcohol abuse, 536-37, 566-67
POCs. See providers/organization of color See also relapse prevention
point-of-service plan, 597 pricing, 575, 582-83, 585, 586-87
police, 586 Pride Institute (Minneapolis), 548
polyneuropathy, 82, 83t primary health care providers, 422, 426-28, 432
polypeptide precursor, 141 Primobolan. See methenolone
polythetic diagnosis, 448 prisons. See corrections systems
POMC (proopiomelanocortin), 141 privacy. See confidentiality
Ponicki, W. B., 576 probation, 429, 430
pontine, 148 problem assessment. See assessment strategies and measures
Pope, H. G., Jr., 177, 179 problem behavior theory, 479, 559
poppers (amyl nitrates), 173 Problem Oriented Screening Instrument for Teenagers,
Porjesz, H., 53 484
POSIT. See Problem Oriented Screening Instrument for problem-solving skill learning, 223, 226
Teenagers Prochaska, J. O., 189, 199, 236-37, 239, 240, 241, 456-57
positive contingencies, examples of, 253, 388 prodynorphin, 141
positron emission tomography (PET scans), 81, 347 proenkephalin, 141
Post, R. M., 450 progression
post-cocaine-abstinence symptomatology, 450 of alcohol use disorders, 34, 270-71, 273-74
posthallucinogen perception disorder, 135, 484 successful resolution and degree of, 45
postmenopausal women, 85 Prohibition, 65, 575
posttraumatic stress disorder, 353 Project MATCH, 220, 238, 258, 259, 260, 387
in elderly, 490 on AA effectiveness, 387
pharmacotherapy, 461 on cognitive behavioral vs. 12-step vs. motivational enhancement
substance use comorbidity, 24t, 443, 456 therapies, 344
pot. See cannabis and Minnesota model, 269, 281
potassium depletion, 351 objectives, 282
poverty, 64, 502, 506, 513,693 prolactin, 153
Power, R., 42 Prolixin. See fluphenazine
 INDEX 637

proopiomelanocortin (POMC), 141 psychomimetics. See hallucinogens

propoxyphene (Darvon), 142t, 149, 152 P3 waveform, 53, 54
propranolol (Inderal), 350 public health
prostitution, 117, 151, 587 alcohol risk prevention, 575-82
protease inhibitors, 154 elderly substance abusers, 487
providers/organization of color, 522 harm reduction approach, 223
Proviron. See mesterolone nicotine addiction, 162
Prusoff, B. A., 442, 450-51 nicotine use prevention, 582-84
Pryzbeck, T. R., 442, 532 opioid dependence, 152-53, 156
pseudodementia, 489-90 substance abuse consequences, 268
psilocin, 132 substance abuse definitions, 11
psilocybin, 124t, 130, 131 substance abuse treatment, 424
overview, 132 Public Health Service, 36
tolerance buildup and loss, 134 Public Health Service Act, 418
psychedelics. See hallucinogens public information campaigns, 581-82
psychiatric disorders Puerto Ricans, 508, 509, 510
assessment strategies, 199 pulmonary complications
cognitive behavioral treatment, 252, 388 opiate-use contraindications, 148, 149
comorbidity treatments, 439-67, 487 from smoking cannabis, 127, 130
comorbidity with alcohol and drug use, 21-25, 85-86, 156, 274, from smoking cigarettes, 164, 166
281,299,431, 532 from smoking stimulants, 115, 118
comorbidity with nicotine use, 359-60 Pulse Check (publication), 151
comorbid symptom differentiation, 449 Purcel, J., 203
diagnoses, 195
dual diagnosis. See comorbid disorders quality assurance (QA), 419
and etiology of substance use disorders, 50 Quigley, L. A., 43, 371
four-box treatment severity model, 452-54, 453t Quitkin, F. M, 391
gender differences, 532
hallucinogen effects and, 130, 133, 134, 135, 484 Rabinowitz, R., 261
high-severity cases, 463-65 race. See ethnic and cultural minority groups
inhalant use and, 174-75 Racine, Y. A., 57
lifetime prevalence of substance use disorder, 442t racism, 506, 506-7, 508, 511, 512
missed diagnoses of substance abuse comorbidity, 225, 443, 444, radioimmunoassay of hair, 204
447, 450, 490, 491 Rains, V. S., 491
morbidity, 440 Ramirez, M., 519
relapse prevention, 380 Randall, M., 452
specific, 441-43 ranitidine, 79
stimulants triggering, 117, 118, 134 Rapoport, R. N., 307
substance abuse as largest category, 268 rapport building, 243
substance abuse disorders interaction models, 447t rational-emotive therapy, 339
substance-exacerbated, 448 rationalization
substance-induced, 448 disease model, 445
symptom improvement linked with length of alcohol abstinence, of gay abuser, 548-49
36 relapse, 373
therapeutic community residents, 318, 319, 322, 323 Rational Recovery, 296, 329, 330, 332t, 339-40, 342, 386,
as treatment type factor, 218, 219, 223 423
See also comorbidity research; psychosis; specific disorders Ratner, E., 548
psychiatric hospitals, 307 Raveis, V. H., 482
Psychiatric Research Interview for Substance and Mental Disor- Ravi, S. D., 450
ders, 484 Raytek, H., 534, 535
psychoanalytic models, 60-62, 440, 444 readiness for change, 189, 192, 199-200, 240, 241, 242f, 387
psychological dependence, 149, 482 Readiness Ruler, 241, 242f, 387
psychological effects Readiness to Change Questionnaire, 199, 240
alcohol, 85-87 receptors
androgenic-anabolic steroids, 179 dopaminergic, 362, 392
benzodiazepines, 102 monaminergic, 361-62
cannabis, 125 nicotinic, 163, 167, 359
nicotine, 167 opioid, 76-77, 77t, 145-46, 147, 353, 392
opiates, 146 See also neurotransmitter system
stimulants, 108, 116t, 117, 118, 361 record keeping. See documentation
psychological problems. See psychiatric disorders recovery and resolution
psychological therapies alcoholic, 35-36, 201, 352
for dual disorders, 457-58 alcoholic role models, 282-83
for women alcoholics, 535 catalysts in, 44
psychologists, addiction specialty credentials, 415 definition of, 42
psychomotor activity, 105, 117 as developmental process, 308, 309, 390
psychosis disease concept view of, 273
agitation control, 466 dual-diagnosis nonlinear process, 457, 465
pharmacotherapy, 461-62, 466 factors in, 31,42-43, 45, 192
and substance use disorders, 446, 449-50, 454 holistic approach, 283
time course of substance-induced, 461 maintenance factors, 42-43
See also specific types personality changes with, 87
psychosomatic defenses, 61 primary impetus for substance use, 40-42
psychotherapy. See group therapy; psychological therapies rates of, 201
638 INDEX

recover)' and resolution (continued) residential treatment, 217, 218

relapse jeopardy, 348 adolescent, 487
role of treatment in, 44 gay men and lesbian, 547-48
as spiritual growth, 332-33 insurance coverage limits, 596
strong cohort effects on smoker's, 38 therapeutic community, 306, 310-11, 389-90, 429, 455-56
See also abstinence; remission See also hospital-based treatment
Recovery Attitude and Treatment Evaluator Questionnaire, resistance
457 clinician's impact on, 238, 246
recriminations, 299 in disease model, 273-74, 386
Red Horse, 514 in family model, 299
Reed, R. J., 39 and self-help group attendance, 342
Rees, L. H., 148 to treatment recommendations, 218, 224-25
reflective listening. See active listening See also denial
rehabilitation Resnick, E. B., 442
alcoholic pharmacotherapy, 351-53 Resnick, R. B., 442
criminal justice system approaches, 430 resolution. See recovery and resolution
legal protections, 404 respiratory system
opioid maintenance treatments, 354 opiate depression of, 148, 149
services, 217 tobacco smoke effects, 167
vocational programs, 422, 430-31 See also pulmonary complications
Reich, T. R., 52 responsibility
Reid, D. J., 582 to fellow therapeutic community members, 312
Reilly, B. A., 65 and moral model of addiction, 445
reinforcement as motivational component, 237, 243
of abstinence, 257 restlessness, 166, 349
of abused substances, 251, 273, 372 Restoril. See temazepam
of drug use alternates, 254 restricted-access policy, 562-63
in substance-abusing families, 291 Renter, P., 585
Reiss, D., 63, 290, 292 Revia. See naltrexone
relapse. See lapse and relapse reward dependence, 59, 252, 296, 358
relapse prevention, 370-82 reward pathways, 76
assessment procedures, 379-80 rhabdomyolysis, 181
characteristics of successful clients, 380-81 Rhines, J. S., 391
clinician-client partnership, 376, 380 Rhines, K. C., 391
comorbid patients, 458, 460 rhinitis, 108
effectiveness data, 381-82 rhinorrhea, 150
ethnic/racial minority, 520-21 Rice, D. P., 603
general strategies, 376 Rich, R. F., 577
goals, 371, 380 Richmond, R., 240-41
key constructs and terms, 372-73 Rickels, K., 99
pharmacotherapies, 460 right conduct. See ethical issues
strengths and weaknesses, 382 right living, 313, 390
therapeutic change assumptions, 375-79 Riley, T. J., 581
therapeutic community training in, 322 Rinehart, R., 52
treatment obstacles, 380 risk reduction, 255
Relapse Replication and Extension Project, 381 risk-taking behavior, 483
relaxation training, 261 Ritalin, 109t
remission, 42-43 ritonavir, 154
criteria differences, 36 Ritson, B., 391
data on, 31-32 Ritvo, E. C., 391
definition of, 35, 42 R. J. Reynolds, 164t, 165
disease model view of, 273 Roach, C., 82
factors in, 31, 192 Robbins, C., 528
failure to maintain. See lapse and relapse Roberts, E., 487
as full recovery, 35-36 Robertson, L. S., 577
lowering smoker mortality risks, 40 Robert Wood Johnson Foundation, 563
maintenance factors, 42-43 Robins, E., 544
nicotine addiction rate, 38 Robins, L. N., 57
primary impetus, 41-42 Rode, S., 390
relapse risk, 196-97 Rogers, Carl, 238, 244
role of treatment in, 44 role models, 282-83
timing of assessments, 201-2 therapeutic community, 311-12, 313-14, 317, 323
for treated alcoholics, 35t See also peer group influences
for treated alcoholics vs. treated drug-dependent persons, role play methods, 197, 254, 342, 376, 387
38 Rollnick, S., 224, 237, 240-41, 245, 375, 387
for treated drug users, 36-37, 37t Room, R., 11
See also recovery and resolution Ropner, R., 391
Renner, J., 167 Rose, J. S., 37
reproductive system Rosen, A., 39, 41
alcohol effects, 84, 85 Rosenthal, R. N., 464
anabolic-androgenic steroid-induced changes, 178 Ross, H. L., 581
See also pregnancy Rossi, A., 452
Research Diagnostic Criteria, 451 Roszell, D. K., 261
resentment, 535 Rotgers, F., 61, 62, 262-63
 INDEX 639

Rothbart, M. K., 60 as psychotic pharmacotherapy, 461-62, 466

Rounsaville, B., 53, 56, 156, 194, 195, 202, 390-91, 442, 450-51, self-medication, 225
531,536 withdrawal symptoms, 99-100, 99t, 102, 364
Rovere, G. D., 175-76 withdrawal treatment, 100-101
Royce, J. E., 400 women's use of, 532
RP model. See relapse prevention See also specific types
RR. See Rational Recovery Segal, B. M., 63-64
Rubonis, A. V., 261 Segal, R. L, 221
Ruggieri-Authelet, A., 492 seizures, 81, 95, 108, 149, 349, 351, 364, 490
running nose, 150 Self-Administered Alcoholism Screening Test, 533-34
Rush, Benjamin, 269 self-attribution effect, 373
Russ, N. N, 477 self-blame, 378
Russell, M., 534 self-concept, 42, 43, 44
Rutgers Alcohol Problem Index, 485 self-discovery, 277
Rutgers Summer School of Alcohol Studies, 548 self-efficacy
Ryan, R. M., 200 assessment of, 255
Rydell, C. P., 585 client's perceived, 226
as cognitive behavioral construct, 62, 198
SABG. See Substance Abuse Block Grant definition of, 198, 245
Saghir, M. T., 544 as motivational component, 237, 241, 244, 245, 246, 373
Salloum, I. M., 391,460 as optimism, 245
Salomon, R., 205 and outcome assessment, 196, 197, 198
Saltz, R. F., 533, 577-78, 581 and relapse prevention, 372
SAMI (substance-abusing mentally ill), 444 in 12-step program, 277-78
Sanchez, V. C., 237 self-esteem, 63, 535, 546, 548, 549
Sanchez-Craig, M., 222-23 self-extinguishing cigarettes, 580
Sands, B. F., 101 self-help books, 277
saquinavir, 154 self-help groups (mutual help), 43, 44-45, 328-44, 386-87, 423
SARA. See Substance Abuse Relapse Assessment addiction philosophy, 440
Saunders, S. J., 489, 495 bonding process, 341-43, 386
Savageau, J. A., 593 classification of, 329-31, 332t
Saxon, A. J., 261 clinician integration with, 333, 341-43, 386-87
Scandinavia, 579 for comorbid conditions, 462-63
scapegoating, 298 early development, 329
Schaef, A., 289 effectiveness data, 343-44
Schafer, J., 485 for family members, 287, 296, 334-35, 386, 389
Schedler, J., 482 fellowship as component, 329
Schenzler, C. M., 65 guided, 330, 332t, 338-41
schizophrenia, 117, 129, 135, 156, 281, 371, 484 networking, 342
alcohol remission treatment success, 464 overview, 331-41
lifetime prevalence of substance use disorder, 442t rituals and traditions, 343
nicotine use, 360 spiritual vs. secular, 330-31
psychotic break, 466 therapeutic community, 307-8, 310, 311, 312, 390
substance use disorder comorbidity, 440, 442, 445, 446, 447, 12-step-program components, 276-78, 330-31, 331-38, 386-87,424
448,451,454 See also specific groups
suicide risk, 466 self-image, 375
Schmidt, W., 577 self-inventory, 279
Schneider, D., 57 Self-Managment and Recovery Training. See S.M.A.R.T. Recovery
Schoenbaum, Ellie, 153 self-medication hypothesis, 21, 23, 61, 86, 101, 117, 225, 447
Schonfeld, L. I, 492, 493 cocaine dysphoria, 460, 461
school-based prevention programs, 565, 566, 582 overview, 444
school dropouts, 506 women's alcohol/drug use, 529
Schottenfeld, R. S., 224, 390-91 self-monitoring, 376
Schuckit, M. A., 32, 52, 56, 59, 62, 201, 270-71, 292, 534 self-reports, 197, 203, 204, 205t
Schulenberg, J., 529 disease model review, 276
Schweizer, E., 99 drinking situations, 376
SCID, 255 verification of validity, 226
scopolamine, 134 Sellers, E. M., 82
Scott-Lennox, J. A., 606 Sells, S. B., 36, 39, 44
screening. See assessment strategies and measures Seneca, 348
Scripture, 335, 336t sensory dysfunction, 489
secobarbital (Seconal), 97t "separate but equal" treatment, 505, 506
secondhand smoke, 167 septum, 163
Secular Organizations for Sobriety, 329, 331, 332t, 336-37, 386 sequencing of treatment, 452, 456
secular self-help groups, 329, 330, 331, 332t, 336-38, 386 sequential filtration, 358
sedative-hypnotic and anxiolytic agents, 95-102 Serax. See oxazepam
abuse and dependence symptoms, 99-100 Serenity Prayer, 278, 343
abuse potential and toxicity, 98-99 serotonergic antidepressants, 352
major pharmacological actions, 96-98 serotonergic system, 76-77
pathological effects, 101-2 serotonin, 76, 77t, 107, 115, 352, 361
pharmacotherapies, 363-64 cocaine therapy research, 361-62
prevalence of disorders, 21, 101-2 hallucinogens and, 130, 131, 134
prevalence of illicit lifetime use, 16-18 MDMA stimulation of, 180
prevalence of lifetime and past-year DSM-IV use disorder, 22t nicotinic receptors and, 163
640 INDEX

serotonin-specific reuptake inhibitors, 359 Smith, T., 56, 59, 270-71

alcohol interaction, 80t, 391 smokeless tobacco, 166, 513-14, 583
for anxiety disorders, 96 smoking
for panic disorder, 461 cannabis, 122, 123, 124t, 125, 127, 130
SES. See socioeconomic status heroin, 151
sexual assault, 530, 536, 546, 549 methamphetamine, 105, 115, 118
sexual behavior, 549 tobacco. See nicotine
sexual deviance, 371 sneezing, 149
sexual function sniffing, 173
alcohol effects on, 85 snorting. See intranasal insufflation
cannabis effects on, 125 snow lights, 117
designer drugs and, 180 snuff, 162, 164, 164t, 165
inhalant enhancement, 173 Snyder, S. H., 353
nitrate enhancement, 544 SOAR. See Simulation of Adaptive Response
stimulant effects on, 115 Sobell, L. C., 192, 194, 197, 201, 227, 294
sexually transmitted diseases, 117, 118, 151, 483 Sobell, M. B., 192, 194, 197, 201, 227, 294
sexual orientation vs. sexual behavior, 543 sobriety trust contract, 296, 389
shabanging, 151 social and interpersonal situation
Shader, R. I., 101 as addictive behavior model, 372
Shadish, W. R., 301 as adolescent substance use factor, 479-81, 480f, 48It
Shaffer, G., 593 alcohol use, 87-88
Shalala, Donna, 151 alcohol use reinforcement, 372
shame, 535, 546, 548 benaodiazepines use, 102
Shattuck, D., 577 cannabis use, 125, 129
Shaw, S., 391, 428 as elderly women's abuse motivation, 488, 489
Sher,K.J., 61,86 and ethnic substance use, 500-501, 502
Sherer, M, 201 hallucinogen use, 131
Sherman, S. J., 37 heroin addiction, 151
Siddiqi, Q., 204 as lapse/relapse determinants, 373
SIDS. See sudden infant death syndrome as prevention model focus, 556-68
Siegel, S., 61 as relapse trigger, 219
Sigvardsson, S., 13, 55 as remission resolution factor, 42, 43
Silberstein, C., 456 stimulant abuse, 116, 117-18
silent ischemia, 115 and substance abuse etiology, 53, 62-66, 292-93, 347
Silkworth, W. D., 269-70 therapeutic community, 307-8
silver acetate, 359, 365t therapist interventions in, 258
Simcha-Fagan, O., 58 tobacco smoking, 167
Simpson, D. D., 36, 39, 44 and verification of self-reports, 226
Simulation of Adaptive Response, 585 and women's drinking, 533
Single, E., 577 See also family environment; family models; peer group influ-
sinsemilla, 123 ences
Sioux, 512 social competence, 371
Sisson, B., 221 social control theory, 63-64
Situational Competency Test, 255 social learning theory, 61, 62, 63, 64, 290, 388
Situational Confidence Questionnaire, 226, 375 behavioral changes based on, 387-88
Skinner, B. F., 251 and family model of substance abuse, 292-93, 389
Skinner, H. A., 201,221 prevention programs to counteract social influences, 560-
skin sensations, 81 61
Skog, O.-J., 579 relapse prevention model, 371-72, 381, 382
slavery, 506, 507, 508 as therapeutic community model, 307, 308-9, 310, 323
sleep disruption social phobia, 86
alcohol withdrawal, 81, 349 social policy, 65
as elder substance abuse factor, 489 social pressure
nicotine withdrawal, 166 adolescent drug and alcohol use, 63-64
opioid withdrawal, 149 as lapse/relapse trigger, 373
rebound insomnia, 100 smoking cessation and, 38
sedative-hypnotic drugs for, 95, 96 social security benefits, 405
as sedative-hypnotic withdrawal symptom, 100, 364 social services system, 422, 428-49, 522
from stimulant use, 117 social skills, 221
Sloan, F. A., 65 social withdrawal, 25
Sloan, ]. J., 581 social workers, addiction certification, 415
Sloss, E. M., 65, 606 social work movement, 288
SLT. See social learning theory societal costs. See costs of substance abuse
slurred speech, 149 sociocultural models, 62-65
smack (heroin), 142t, 151 socioeconomic status
Smart, R., 52 and ethnic/racial substance use, 500-501, 502, 504-14
S.M.A.R.T Recovery, 329, 330, 332t, 338-39, 339t, 343, 386, of gay and lesbian drinkers, 546
565 and heroin addiction, 151
Smigan, L., 56 and identification of substance abuse as problem, 225
Smith, D. E., 100, 101 inhalant abuse, 173
Smith, D. I., 578 and recognition of problem drinking, 42
Smith, E., 39 and social consequences of drinking, 88
Smith, E. S. O., 577 as substance abuse risk factor, 64-65
Smith, G. D., 40 of women drinkers, 527
Smith, H., 41 sociological stress models, 288
 INDEX 641

SOCRATES. See Stages of Change Readiness and Treatment Ea- Stinchfield, R., 281
gerness Scale Stitzer, M. L, 251, 262
Sokol, R. J., 581 stomach, 76, 78, 79
Sollogub, A., 52 stoned, 125
solvent inhalation, 172t, 173, 175 Stout, R., 492
S-O-R-C model, 292-93 STP. See DOM
SOS. See Secular Organizations for Sobriety Strauss, R. H., 177
sound sensitivity, 81, 100 street names
Sowder, B. J., 195 cannabis, 123, 124t, 125, 364
Spanish language, 509, 510 designer drugs, 172, 180
specific populations, 437-550 hallucinogens, 123, 124t, 133
modified therapeutic communities for, 323 heroin, 142t, 151
treatment programs geared to, 218 illicit drug combinations, 113t, 124t
See also specific groups inhalants, 173
Spenser, T. J., 443 morphine, 142t
Spilich, G. J., 167 nicotine products, 164
spinal cord injuries, 430 opioids, 142-43t
spirituality stimulants, 109, 109t, HOt, 112
African-American, 507, 508 stress
Native American Indian, 514 coping skills, 42
self-help programs, 274-75, 277-78, 329, 330, 332-33, 332t, of ethnic otherness, 499-500
343, 386, 387, 549 as gay alcohol use factor, 545-46
Spitznagel, E., 39 as impetus for therapeutic community treatment, 318
spleen enlargement, 83 inducing physiological opioid production, 353
sponsorship, 343, 549 as smoking excuse, 167
spontaneous remission, 236-37, 239 as women's drinking precipitator, 530
sports. See athletes STRIDE. See System to Retrieve Information from Drug Evidence
spousal drinking, 529, 530, 532, 536 stroke, 115, 166,602
spousal problems. See family models; marital distress Structured Clinical Interview (DSM-JV), 255, 485
Spratley, T., 428 stupor, 80
spray paint, 172t, 173 stuttering, 371
Spurr, S., 578 Stuyt, E. B., 167
SSRIs. See serotonin-specific reuptake inhibitors subjective intoxication, 122, 126
Stabenau, J. R., 53, 61 Sublimaze. See fentanyl
stacking (steroids), 178 Substance Abuse and Mental Health Services Administration, 502
Stages of Change Readiness and Treatment Eagerness Scale, 199, Substance Abuse Block Grant, 598
241, 255, 387, 388 Substance Abuse Relapse Assessment, 375-76, 378
stages-of-change theory, 240-41, 241f, 273, 293-94 substance use disorders
Stall, R., 44 abuse/dependence/use distinctions, 477, 488
stanozolol (Winstrol), 176t assessment strategies and measures, 187-206
Stanton, B., 577 base rate of, 268
Stanton, M. D., 290, 301 cessation impetus, 41-42
Stapletori, J., 460 clinical heterogeneity, 55-57
Star Tobacco and Pharmaceuticals, 164t, 165 cognitive factors, 252-53
state statutes, 404, 415, 465-66 comorbidity research, 21-25
STDS. See sexually transmitted diseases comorbidity treatments, 439-67
Stein, L. I., 464 costs of, 601-3
Steinglass, P., 63, 289-90, 292 course of treated vs. untreated disorders, 30-45
stenobolone (Antrofin), 176t current /CD and DSM formulations, 11
Stephens, R. S., 203 definition as controversial, 477
steroids. See anabolic-androgenic steroids dependence vs. disabilities, 194-95
Stevenson, L. A., 123 diagnostic labeling, 246
Stewart, I. C., 63-64 diagnostic systems, 194-95
Stewart,}. W., 391 economics of, 595-608
Stewart, M. A., 32, 52, 53, 55, 59, 62, 201 ethnic/racial minority groups, 502, 503t
Stimmel. B., 41 etiology and maintenance, 50-66, 252-53, 308, 371-72
stimulants, 105-18 future direction of classification, 25-26
administration routes and dosages, 110-11, HOt, 118 gateway theory, 19, 129, 482, 529
adolescent use, 478t harm reduction approach, 223
cannabis interactions, 125 historical terminologies, 10
clinical aspects, 108-15 identification as problem, 225-26 (see also diagnostic criteria)
cyclical epidemics of abuse, 105 life-problem precipitants/consequences of use, 219
depression induced by, 450 lifetime prevalence rates, 14-21, 440
euphoria from, 107, 110, 113, 114, 117, 361 "maturing out" of, 38, 483
gay and bisexual use of, 544 multiple drugs, 19, 112-13, 112t, 113t, 125, 148, 162, 167, 177,
major pharmacological actions, 105-9 443, 451, 478, 488, 493, 528, 529-30
names of common preparations, 109t parental influence on drug of choice, 52-53
pathological effects, 115-18 recognition of problem, 42
physical symptoms of use/abuse, 113-14, 361 reinforcing properties, 251, 273, 372
schizophrenic use comorbidity, 447, 448 spontaneous remission, 236-37, 239
street names, 109, 109t, HOt subtypes of disorders, 11-14
withdrawal symptoms and course, 114-15, 118 as whole person disorder, 308, 309, 390
See also amphetamines; cocaine; nicotine See also alcohol use; dependence; drug use; specific substances
stimulus-reponse models. See classical conditioning; operant condi- substitute dependencies, 43
tioning Sudden Infant Death Syndrome, 116, 156, 166
642 INDEX

sudden sniffing death syndrome, 174 thebaine, 141

SUDs. See substance use disorders therapeutic alliance, 259-60, 519
suffocation, 174 relapse prevention, 376, 380
suicide in therapeutic community, 317
adolescent substance-use as risk factor, 483 therapeutic community, 306-27, 389-90, 429
as alcoholic consequence, 86 active treatment ingredients, 316, 389-90
and comorbid psychiatric disorders, 446, 466 admissions profiles, 318, 390
as depression conseqence, 86 assessment procedures, 310
early-onset alcoholism, 56 best candidates, 318-19
in family assessment, 294 community enhancement activities, 314-15
and multiple drug use, 19 comorbid high-severity disorders treatment, 455-56
physician-assisted issue, 400 components, 312-16
prevention, 466 effectiveness evaluation data, 320-21
from stimulant-triggered delusions, 117 family services, 321
and treatment recommendation, 218 four forms of group activity, 314
Sullivan, W. C., 85 health care services, 321-22
Supplemental Security Income, 405, 598 hierarchical upward mobility, 311, 315
support groups. See self-help groups; 12-step programs historical origins, 307
suppositories, 144 house run, 315-16
Surgeon General's Workshop on Drunk Driving, 581 precepts and values, 308-9, 313
Sustanon 250, 176t privileges related to status within, 315
Svikis, D. S., 52 relapse prevention training, 322
Swanson, S., 222 retention rates, 320-21
Swartz, J., 430 settings, 306, 310-11, 389, 390
Swasy, J. L, 581 social and psychological profiles, 318
sweating, 81, 100, 364 staff roles and functions, 311, 312, 313, 317, 390
Sykora, K., 82 strengths and weaknesses, 323
sympathetic nervous system structural components, 311-12, 313, 390
opioid-intoxication rebound, 149 therapist role, 316-17
stimulant activation of, 115, 118, 361 treatment contraindications, 319-20, 390
Synanon, 307 treatment goals, 310-11
synaptic cleft, 107 vs. other major drug treatment models, 307-8, 322
synesthesia, 131 therapist. See clinician
syringe exchange programs, 153, 156, 223 therapy. See clinician; treatment
as ethical and legal issue, 400, 405 Therobolin, 176t
System to Retrieve Information from Drug Evidence, 585 thiamine deficiency, 82, 84, 350-51
Szatmary, P., 57 Thomson, A., 40
Thorazine, 80t
Tabbush, V. C., 607 Thoreau, Henry David, 400
tachycardia, 115, 149, 181, 356, 361, 364 thought disorder, 448
tachyphylaxis, 357-58 thought process. See cognitive factors; cognitive functioning
TAG solution, 110, HOt Three Community Study of Methamphetamine, 544
Talwin. See pentazocine thrombosis, 178
TANF. See Temporary Assistance to Needy Families Tiebout, Harry, 333
TAO. See targeted assertive outreach Tilleskjor, C., 203
Taoism, 511, 512 time
Tarasoff case, 407 cannabis and hallucinogen distortions of, 125, 131
tardive dyskinesia, 446 spent in substance use, 12t
targeted assertive outreach, 464-65 Time-Line Follow-Back, 255, 294, 388, 389, 485
Tarter, R. E., 57, 59, 60 Timney, C. B, 489, 493
taurine, 76 Tims, F. M., 195, 318
taxation, 65, 83, 583, 606 Tipp, J., 32, 534
Taylor, C., 45 TLFB. See Time-Line Follow-Back
TC. See therapeutic community tobacco. See nicotine
Teen Addiction Severity Index, 486 Todd, T. C., 290
teenagers. See adolescents tolerance, 10, 11
Teitelbaum, M. A., 63, 292 alcoholic's progressive, 32, 33, 270, 271, 385
television. See mass media campaigns anabolic-androgenic steroids, 178
temazepam (Restoril), 97t, 350, 352 benzodiazepines, 363
temperament. See personality cannabis, 122, 126-27
Temporary Assistance to Needy Families, 597, 598 definition of, 77, 98
Tennen, H., 56, 59, 194 diagnostic criteria, 12t
Tenormin (atenolol), 350 elderly alcoholic, 491
Test, M. A., 464 hallucinogens, 134, 135
testicular function, 85 inhalants, 173
testosterone, 83t, 85, 177, 483 mechanisms of, 77-78, 98, 108, 118, 163
synthetic. See anabolic-androgenic steroids nicotine, 163, 165, 167
testosterone cypionate (Depo-Testosterone), 176t opioids, 145-47, 149
testosterone emanate (Delatestryl), 176t pharmacokinetic, 98
testosterone nicotinate (Bolfortan), 176t Tolson, R. L, 492
Textbook of Psychiatry (Kraeplin), 10 toluene abuse, 174, 175
thalamus, 163 Tommasello, A., 261
Thase, M. E., 391,460 Toneatto, T., 192, 194, 197, 201
THC (delta-9-tetrahydrocannabinol), 112, 122, 123, 125, 126, 129, 133 tonic-clonic seizures, 149
 INDEX 643
Tonigan, J. S., 205, 239,241, 371 mandatory, 405, 424, 430, 466
topical anesthetic, cocaine as, 111 models and methods. See treatment models and methods as sepa-
TOPS. See Treatment Outcome Prospective Study rate listing below
toques, 173 modification of plan, 226-27
Torley, D., 391 motivation and, 44, 189, 192, 196, 223, 224, 235-46, 387, 393
Toth, R. L, 492 multiple-drug use implications, 19
"To the Doctor" (AA booklet), 463 natural change and, 45, 236-37
Towle, L. H., 195 outcome effects of concurrent mood disorders, 460-61
Townsend, J., 581 outcome factors, 259-60
toxicity hypothesis, 21 outcome factors for adolescents, 486
training outcome of comorbid diagnoses, 445-46, 460-61
behavioral therapist, 259 outcome surveys, 344, 418-19
chemical dependency counselors, 280 patient placement criteria, 220-21
credentials, 414-15 payment mechanisms, 595-98
for culturally empathetic treatment approach, 515, 521 pharmacological. See pharmacotherapies
joint systems, 432-33 planning process, 200, 219-21, 227-28
marital/family therapist, 297-98 progress evaluation, 227
and misdiagnoses of comorbid substance use disorders, 443 readiness determination, 199-200
relapse prevention therapist, 380 resistance to, 218, 224-25, 238, 273-74
therapeutic community therapist, 316-17 response monitoring, 226
trait measures, 203-4 success measures, 603-4
tranquilizers therapeutic alliance, 259-60
abuse comorbidity with psychiatric disorders, 15t triggers for entry into, 42, 45
adolescent use, 478t waiting period as deterrent, 224-25
alcohol interaction, 80t written plan, 417-18
Native American Indian adolescent users, 514 See also assessment strategies and measures; clinician; recovery
parent-child concordance rate of use, 52 and resolution; remission
prevalence of disorders, 21 Treatment Alternatives to Street Crime, 405
prevalence of illicit lifetime use, 16-19 treatment models and methods
prevalence of lifetime and past-year DSM-IV use disorder, 22t behavioral model, 250-63, 387-88
women users, 532 cognitive behavioral model, 287-302, 387-88
transactional theory, 556 cognitive behavioral outcomes vs. 12-step programs, 344
transdermal patch. See patch, nicotine comorbid four-box severity model, 452-53, 453t
transient ischemic attack, 115 disease model, 268-83, 385-86, 444-45
transtheoretical model, Readiness for Change Questionnaire, 240, family models, 287-302, 388-89
241 functional analysis, 253-54, 388
trauma. See accidents; specific types motivational enhancement, 220, 235-46, 458
treatment, 233-393 overview of major strategies, 385-93
adjustments in plan, 227-28 pharmacotherapies, 347-66, 390-93
of adolescents, 486-87 relapse prevention, 370-82
alcoholic long-term outcomes, 34-35 self-help groups, 328-44, 386-87
alcohol use remission rates, 35 therapeutic community, 306-27, 389-90
alcohol user mortality rates, 39, 41 Treatment Outcome Prospective Study, 607
assessment utilization, 218-19, 224-25 Tremblay, R. E., 59
brief interventions, 432 tremor, 81, 83, 100, 349, 364
as chronic, 30, 348, 370, 605, 608 trenbolone (Finajet), 176t
client involvement, 219, 220-21, 487, 515, 519-20 triadic influence theory, 556
client roadblocks to, 223, 224 triazolam (Halcion), 97t, 100
comorbid disorders, 451-67 triazolobenzodiazepines, 100
compliance factors, 238-39 tricyclics
confidentiality, 402-3, 418 for alcohol-dependent depression, 460
course of change from, 237 alcohol interaction, 80t, 352, 391
course vs. nontreated disorders, 30-45 for anxiety disorder, 96
credentialing, 414-15, 416, 419 ineffectiveness for nicotine withdrawal, 359
cultural competence in, 504-5, 515, 521 for sedative/hypnotic withdrawal, 364
decision making and goal setting, 216-29, 228f for stimulant craving, 113
depression reduction during, 202 for substance-abuse-related depression, 461
discharge summary, 418 trigger events, 254, 273, 296, 349
diversity of services, 422-23 lapse and relapse, 219, 349, 372-73, 521
documentation, 416-18, 419 treatment entry, 42, 45
of dual diagnoses. See subhead comorbid disorders above trihexyphenidyl, 130
of elderly people, 491-93 Trilogy Project, 544-45
emergency commitment, 218 Trimble,]. E., 518
of ethnic and cultural minority groups, 514-15, 519-22 Trimpey, Jack, 330, 339, 340
evaluation of outcome, 418-19 trip (hallucinogenic), 130-31, 135, 180
of gay men and lesbians, 547-50 Trophobolene, 176t
gender-response differences, 535, 536 Troughton, E., 52, 53
goal setting, 221-24 Trudeau, K., 458
immediate vs. long-term needs, 219 True, W. R., 54
implications of, 44-45 Tsuang, M. T., 54
initial plan, 218-19 tuberculosis, 153, 154, 155-56
interfaces with other health and social systems, 421-33 Tuchfeld, B. S., 42
legal and ethical issues, 399-412 Tucker, M. B., 531
level of care selection, 217-18 Tunving, K., 40, 41
644 INDEX

12-step programs, 220, 225, 226, 238, 239 vomiting. See nausea
abstinence goal, 282, 337, 338, 386 von Knorring, A.-L., 56
adolescent treatment, 486, 487 von Knorring, L., 56
anonymity rule, 333 voucher system, 257, 259, 262
as behavorial contract stipulation, 296 VTA. See ventral tegmental area
bonding with, 340-43
Christian Scripture correlates, 336t Wagenaar, A. C., 576, 577, 578
current status, 329 waiting period, treatment, 224-25
disease model treatment based on, 269, 273 Waldron, H, B, 485
diversity of groups, 329, 386 Walker, M., 40
dually diagnosed patient's potential problems with, 463 Walker, N. D., 39
effectiveness surveys, 343-44 Wallach, M. A., 463
effectiveness vs. behavioral treatments, 262 Waller, J. A., 581-82
effectiveness vs. cognitive behavioral treatment, 260 Walsh, D. C., 282
and family disease model, 289 Wannamethee, S. G., 40
fellowship of, 329, 330 War against Drugs, 603
meeting formats, 333-34, 386-87 warfarin, 79, 80t
methodology, 275, 276-80 Warner v. Orange County Department of Probation, 405
overview, 331-38 warning labels, 580-81, 582
as professional treatment adjunct, 423 Wasserman, J., 65, 606
rituals and traditions, 343 water pipes. See bongs
specific steps, 277-80, 332t, 333 Watson, C. G., 203
spiritual vs. secular, 330-31 Watson, J., 251
as support system, 282-83 Wegsheider, S., 289
therapeutic community and, 322 weight
therapist-fostered involvement in, 333, 341-43, 386-87 blood level concentration and, 79t
See also Alcoholics Anonymous; other specific programs cigarette smoking as control measure, 166, 358, 478
Twelve Steps and Twelve Traditions, 330-31 ethnic demographics, 502, 506
twin studies, 51-52, 54, 272, 292 loss from chronic stimulant use, 117
Tye, J. B., 583 Weiner, S., 63
Tylenol. See acetaminophen Weis, J. G., 64
Type A/Type B abuser classification, 56 Weiss, R. D., 52, 442, 447, 448, 450, 531
Type I vs. Type 2 alcoholism, 13-14, 55-56, 59 Weissman, M. M., 53, 156
welfare recipients, 607, 693
Uchida, C., 586 Wellbutrin. See bupropion
UFT. See unilateral family therapy Wells, E. A., 486-87
unconditioned stimulus or response, 61 Welte, J. W., 532
unilateral family therapy, 295-96 Wernicke's encephalopathy, 82, 83t
University of Rhode Island Change Assessment Instrument, 199, Wesson, D. R., 100, 101
240, 241, 255, 387, 388 Westerberg, V. S., 239, 371,485
University sample. See College sample Westreich, L., 456
urge surfing, 378 Wetzel, R. D., 466
URICA. See University of Rhode Island Change Assessment WFS. See Women for Sobriety
urine drug screening, 106, 203, 204, 226, 255, 257, 294, 296, 316, whippettes (butyl nitrates), 173
354, 389, 430 White-Campbell, M., 489, 493
state and federal laws, 404, 405 Whitehead, P. C., 577
urticaria, 148 White House Office on National Drug Control Policy, 603
WHO. See World Health Organization
Vaccaro, D., 14 widowhood, 488, 530, 532
Vaillant, G. E., 31, 32, 34, 35, 36, 37, 39, 42, 43 Wikler, A., 61,251
Valium. See diazepam Wikstrom, P-O. H., 578
valproate, 82 Wilber, C., 53, 156
values. See ethical issues Wilens, T. E., 443
VA Medical Center (Dallas), 492 Wilkinson, A., 222-23
Vannicelli, M., 536 Wilkinson, J. T., 576
vending machines, 583-84 Williams, A. F., 577
ventral tegmental area, 145, 163, 167 willpower, 330, 342, 445
Versed. See midazolam Wills, T. A., 14
Veterans Administration Wilsnack, R. W., 533
elder-specific programs, 492 Wilsnack, S. C., 533
substance abuse treatment, 596, 598, 602 Wilson, Bill, 329, 330, 333
Vicary, J. R, 59 Windle, M., 57
Vietnamese-Americans, 510, 511 wine sales, 576
violent behavior Winick, C., 30
family models, 87, 294, 295, 299, 301 Winstrol. See stanozolol
hallucinogenics and, 133, 134 withdrawal, 10, 11, 12t
as precipitating female alcoholism, 530 alcohol abuse symptoms and course, 10, 33, 78, 81-82, 349-51,
sexual assault, 530, 536, 546, 549 386, 482, 490
stimulants and, 117, 118 anabolic-androgenic steroids, 178
See also criminal behavior cannabis, 123, 126-27
viruses, 83 conditioned, 61, 251
visual hallucinations, 131, 132, 135, 173 detoxification program, 219
vocational rehabilitation programs, 422, 430-31, 487 discomforts as treatment barrier, 224
Volpicelli, J. R., 391 disease model treatment of, 273
Volpicelli, L. A., 391 elder problems, 490
 INDEX 645

inhalant duration and symptoms, 173 Woody, J. D., 412

nicotine, 166, 358 Worden, J. K., 581-82
opioid conditioned symptoms, 251 work
opioid symptoms, 149-51, 152, 356-57 alcohol use and, 88
PCP, 134, 135 cannabis use and, 129
pharmacotherapies for, 348, 349-51, 364 as therapeutic community therapy, 311, 313, 390
sedative-hypnotic, 99-100, 99t, 102, 364 women's drinking and, 527, 533
sedative-hypnotic treatment, 100-101 Working Alliance Inventory, 259
stimulants, 114-15, 118 workplace
symptoms as mimic of psychiatric symptoms, 449, 467 Employee Assistance Programs, 404, 424, 430, 431
See also detoxification gender differences in abuse consequences, 533
Wolin, S, 63, 290, 292 laws and regulations, 404-6
women, 527-37 rehabilitation programs, 422, 430-31, 487
African-American cultural roles, 507 smoking restrictions, 584
alcohol abuse patterns, 531-37 World Health Organization, 10, 244
alcohol abuse prevention, 536-37, 566 written contracts. See contracts
alcohol effects on health, 85, 530-32, 533 written records. See documentation
alcoholic antisocial personality comorbidity, 56-57 Wurmser, L., 60
alcoholic stigma, 534
assessment strategies, 533-34 Xanax. See alprazolam
depression comorbidity with substance use, 24, 528, 529, 530,
532, 534, 535, 536 Yamaguchi, K., 482
drinking correlates, 527-28 Yates, W. R., 53
drug abuse patterns, 531 yawning, 149
elderly substance abuse factors, 488, 530, 532 Yesalis, C. E., 177
family protection treatment, 426 Yohman, 54, 57
mixed drug uses, 529-30 York, J. L., 532
nicotine as gateway drug, 482 Young Adult Alcohol Problems Screening Test,
nicotine use, 528-29 485
nicotine used for weight control, 166, 478 young adults
substance abuse numbers, 425 prevention program, 566
substance abuse risk factors, 529-30, 536 women alcohol/drug users, 529-30
treatment prognosis and outcome, 536 Youth Evaluation Services, 487
treatment utilization, 534-36 youths. See adolescents
twelve-step program members, 337-38
See also family models; gay men, lesbians, and bisexuals; gender Zador, P. L., 577
differences; pregnancy Zanis, D., 452
Women for Sobriety, 329, 330, 331, 332t, 336, 343, 386 zero-tolerance laws, 579-80
lesbian members, 549 zidovudine (azidothymidine; AZT), 154
overview, 337-38, 338t Ziedonis, D. M., 458
Women's Way Through the 12 Steps, 277 Zimberg, S., 489
Womer, W. W., 575 Zimmerman, T., 221
Wood, M. D., 61 Zimring, F. E., 583
Wood, P. K., 61 zolpidem (Ambien), 96, 97t
Woodworth, G., 53 Zucker, R. A., 58
Woody, G. E., 259, 446 Zyban. See bupropion