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To the extent that the use of many substances is illegal, the trafficking, sale, and use of many drugs also have a huge impact on the criminal justice system.  The average cost per prison inmate per year to taxpayers is approximately $20,000.  For the year 2000, 1.375 million adults were arrested for “drug abuse violations” and an additional 203,000 juveniles were likewise arrested.  Among state prisons 57% of inmates admitted to using drugs in the month prior to their arrest (45% among federal prisoners) in 1997.  For use anytime in life these numbers were 83% and 73% respectively.  These statistics represent a significant increase from a 1991 survey by the Department of Justice, Bureau of Justice Statistics.  Strategies to combat these rising numbers of incarcerated who are involved in substance abuse are wide ranging.  For instance in 2000, California Proposition 36 or the Substance Abuse Crime Prevention Act (SACPA) was passed by 61% of voters.  Under this law, “low-level” and non-violent drug offenders convicted of possession solely for personal use are diverted into community based treatment programs rather than incarceration.  The program is still too new to determine success or failure, however in seven California counties, over 9,500 persons who would have been otherwise incarcerated, have been referred to treatment.  The economic justification for this program is that while a year in prison costs taxpayers approximately $20,000/year, certain non-violent first time users can be provided drug treatment and rehabilitation for approximately $5,000/year.  A similar program however has been in existence in Arizona since 1996 (Arizona proposition 200).  According to proponents of the program, Arizona taxpayers were saved $6.7 million dollars in 1999. (Drug Policy Alliance)

 

IV.       Treatment and Prevention of Substance Abuse

 

The two state programs mentioned above are good examples of changing attitudes toward substance abuse.  Rather than viewing this as a criminal and punishable activity, abuse is now being seen as a treatable condition, much the same as mental illness.  For the current substance abuser or substance addict, what are the prospects for rehabilitation and treatment?  Is the substance abuser doomed to a lifetime of relapse and recovery?  What are the different treatment options available and which one (s) work the best?

 

As knowledge of drug and substance addiction has increased, there has been less of an emphasis on substance abuse as a matter of personal choice or “lack of will power” on the part of the substance abuser. The reality of treatment and the medical model of substance abuse and addiction is that the substance abuser by and large cannot get drug free without assistance.  Also as addiction has been increasingly viewed as a medical condition, there has been less of an emphasis on a quick “cure”, and more on control of addiction much like a chronic disease.  The disease of addiction is multi-factorial, with roots in biology, physiology and behavior.  The most successful treatment programs address all of these factors.  The goal of substance abuse treatment is to help the individual reduce or stop substance abuse altogether.  The National Institute on Drug Abuse has pointed out several keys to successful substance abuse treatment:


 

 

-Treatment should be readily available to individuals who need it

-Individuals need to be engaged in treatment for an adequate period of time  Participation in outpatient or residential programs for less than 90 days is of limited or no effectiveness  Individuals should receive a minimum of 12 months of methadone maintenance treatment

-Treatment involves dynamic decision processes requiring a person to decide to stay sober on a daily basis.  Recovery often involves relapse and multiple episodes of treatment

-Addiction is often accompanied by many physical and mental health problems (so called dual or multiple diagnoses), and treatment must incorporate considerations of these other diagnoses.

-Treatment works best if tailored to the individual, i.e. there is no “one” right way to treat the substance abuser/addict.  Likewise it should be reassessed and adjusted as needed.

 

Links to the NIH/National Institute on Drug Abuse are provided in the bibliography.  Interested readers are strongly recommended to review these documents as many useful, evidence-based guidelines for effective substance abuse treatment are provided in these documents.

 

More important than treatment of the active substance abuser are effective strategies to prevent the initiation of substance abuse.  The above link to the National Institute on Drug Abuse also has many useful links regarding tested programs that are effective in preventing substance abuse.  These “Prevention Principles” include designer programs to enhance “protective factors” and eliminating or reducing “risk factors” for substance abuse.


 

 

Protective factors for substance abuse

Risk factors for substance abuse

Strong and positive bonds with a prosocial family

Chaotic home environments especially where parents are active substance abusers

Parental monitoring

Ineffective parenting

Clear rules of conduct that are consistently enforced

Lack of mutual attachment and nurturing

Involvement of parents in the lives of their children

Overly shy or aggressive behavior

Success in school performance

Failure in school performance

Strong bonds with other prosocial institutions

Poor social coping skills

Adoption of conventional social norms about drug abuse

Affiliations with deviant peers

 

Perceptions of approval of drug using behaviors in family, work, school etc

 

 

 

Clearly prevention of substance abuse is not as simple as teaching slogans such as “Just Say No”.  Instead the focus has to be on teaching life skills and on identification of “at risk” youth and targeting these individuals with programs designed to avoid the initiation of substance abuse.

 

Summary and conclusions

 

Substance abuse is not a condition that an individual willfully engages in..  Instead patterns of behavior, coexisting mental and physical health issues often lead into repetitive use, dependence and addiction over a gradual basis.  Over time and in the most severe cases, the securing of a steady source and the use of various addictive substances can overwhelm even the most rational minds.    Fortunately as time has passed and attitudes have slowly evolved, the negative label of drug addiction has somewhat worn off, and more effective treatment and prevention programs have been developed. However given the number of people who are injured every year due to the direct and indirect consequences of substance abuse, we as a nation clearly have a long way to go in terms of effective prevention and treatment strategies.

 

Substance abuse is clearly a tremendous problem and as previously stated this introductory chapter only introduces a framework for identifying some of the issues involved with substance abuse and addiction.  Substance abuse is certainly a topic with its roots in public health, from the epidemiology of spread of addiction among at risk populations to health care economics and health care policy.  The interested reader is strongly recommended to several of the selected references in the following section for further information and statistics about this huge and growing area of public health and public policy.


 

References and suggestions for further reading

 

American Lung Association. www.lungusa.org

 

Butterfield F; “As drug use drops in big cities, small towns confront upsurge”; NY Times, section A, page 1, column 1

 

Centers for Disease Control and Prevention www.cdc.gov    Links are available to specific information regarding HIV transmission, surveillance and efforts to limit the spread of HIV disease

 

Chung PH, Garfield CF, et al; “Youth Targeting by Tobacco Manufacturers since the Master Settlement Agreement”; Health Affairs, 21(3):  254-163, (2002).

 

Cook PJ, Moore MJ; “The Economics of Alcohol Abuse and Alcohol Control Policies”; Health Affairs, 21(3): 120-133, 2002.

 

Daro D, Mitchell L; “Child Abuse Fatalities continue to rise:  Results of the 1988 annual fifty state survey” (fact sheet #14) Chicago:  National Committee for Prevention of Child Abuse.

 

Des Jarlais DC, Marmor M, Friedmann P, et al; “HIV incidence among Injection Drug Users in New York City, 1992-1997:  Evidence for a Declining Epidemic”; American Journal of Public Health; 90(3) 352-359, 2000.

 

The Drug Policy Alliance, Substance Abuse and Crime Prevention Act of 2000, California Proposition 36.  www.prop36.org

 

Drug Policy Alliance; Substance Abuse and Crime Prevention Act of 2000, progress report; March 2002.

 

Goldstein, A; Addiction, from biology to drug policy; 1994, W.H. Freeman and company.

 

Grossman M, Chaloupka FJ, Shim K; “Illegal Drug use and Public Policy”, Health Affairs, 21 (3):  134-145, (2002)

 

Gruber J; “The Economics of Tobacco Regulation”; Health Affairs, 21(3):  146-162, (2002).

 

Kosterman R, Hawkins JD, Guo J, et al; “The Dynamics of Alcohol and Marijuana Initiation:  Patterns and Predictors of First Use in Adolescence”; American Journal of Public Health; 90(3) 360-366, 2000.

 

McCrady BS, Epstein EE, Addictions a comprehensive guidebook, ed McCrady BS, Epstein EE, Oxford University Press, New York, 1999

 

McEnery, R; “HIV diagnoses in Cleveland rise for 1st time since ‘96”; The Cleveland Plain Dealer, March 3, 2002, b1.

 

National Highway Traffic and Safety Administration.  www.nhtsa.dot.gov search alcohol and impaired driver.

 

National Household Drug Abuse Survey, statistics on drug use and abuse indexed by various subgroups (inner city vs. rural, age groups, etc). Office of Applied Statistics of the Substance Abuse and Mental Health Services Administration (SAMHSA) division of the U.S. department of Health and Human Services.  www.samhsa.gov link to the office of applied statistics.

 

National Institute on Alcohol Abuse and Alcoholism, www.niaaa.nih.gov/press/2002/college.htm

 

National Institute on Drug Abuse.  Principles of drug addiction treatment:  a research-based guide.  NIH Publication No. 99-4180.  http://165.112.78.61/PODAT/PODATindex.html

 

“Substance Related Disorders” in Diagnostic and Statistical Manual of Psychiatry, 4th edition; Washington, DC  American Psychiatric Association

 

United States Department of Labor www.dol.gov working partners, small business workplace kit.

 

United States Department of Justice, Bureau of Justice Statistics www.usdoj.gov.bjs

 

United States Department of Health and Human Services, substance abuse and mental health services administration www.samhsa.gov “substance abuse and mental health services sourcebook”.  1995.

 

Woody GE, Cacciola J; Diagnosis and Classification:  DSM-IV and ICD 10 in Substance Abuse a Comprehensive Textbook 3rd edition, Editors Lowinson, Ruiz, Millman and Langrod.  Williams and Wilkins.

 

Zubretsky, Theresa M. and Karla M. Digirolamo. 1996. "The False Connection Between Adult Domestic Violence and Alcohol." Helping Battered Women, 1st edition. Ed., Albert R. Roberts.