Treatment Improvement Protocol (TIP)
Treatment for Stimulant Use Disorders:
Methamphetamine & Cocaine - 1999
Treatment Improvement Protocol (TIP) Series 33
Center for Substance Abuse Treatment
Chapter 6 Treatment Issues for Special Groups and Settings
This chapter has two purposes: (1) to provide specific recommendations for treatment tailored to the special needs of each group and (2) to underscore the need for cultural competence in the treatment setting. The second point is crucial to success in treatment for a variety of clients. The Consensus Panel feels strongly that cultural competence in the treatment setting extends beyond racial/ethnic sensitivity to understanding the mores of groups bound together by gender, age, geography, sexual preferences, criminal activity, substance use, and medical and mental illnesses. In addition, treatment providers need to understand the "culture" of their own organization, and determine how it may or may not be welcoming to members of other cultures.
This chapter discusses treatment issues specific to the following groups:
• Intravenous drug users
• Gay men
• Methadone maintenance clients
• Individuals with co-occurring mental disorders
• Medically ill clients (e.g., HIV, TB)
• Criminal justice clients
• Racial/ethnic minorities
• Rural populations
• Women
• Adolescents
Again, treatment for stimulant use disorders for members of any of these groups must occur against the backdrop of a solid understanding of the needs of the one or multiple groups in which a client may claim membership.
Intravenous Drug Users
The injecting cocaine user (ICU), like other injecting drug users (IDUs), poses a major public health problem by transmitting HIV and hepatitis. This transmission can occur in several ways. First, ICUs may spread infections by sharing injecting equipment with other IDUs. Second, ICUs may share needles with other populations that have their own independent risk for HIV and hepatitis, such as homosexuals and bisexuals. Third, ICUs may transmit the disease to nonsubstance users through sexual contact.
Prevalence of Injecting Drugs In Stimulant Users
Stimulant and other substance users make up the estimated 1 to 1.5 million IDUs in the United States. Approximately 85 percent of these IDUs do not receive any drug treatment services on any given day (Lurie and Drucker, 1997). Clearly, IDUs who are not in treatment are at great risk of suffering the many consequences of continued drug injection (Metzger et al., 1993).
The proportion of these IDUs who are ICUs can be best estimated by the National AIDS Demonstration Research (NADR) program, sponsored by the National Institute on Drug Abuse (NIDA). This program has provided the most comprehensive profile of active IDUs not in substance use disorder treatment. In that program 13,475 active IDUs were assessed from 28 sites across the country. The primary injected drugs were heroin (28 percent), cocaine (21 percent), and a combination of heroin and cocaine (35 percent). These estimates appear consistent with some treatment samples. For example, 20 percent of treatment-seeking cocaine users in the Los Angeles area were found to have injected drugs in the preceding year (Khalsa et al., 1992). Moreover, 94 percent of these ICUs reported sharing needles with other users. Together, these data suggest that somewhere between 20 percent and 51 percent (cocaine alone and combined cocaine-heroin users) of IDUs are cocaine users and that these users share injecting equipment that is putting them at risk for HIV, hepatitis, and other diseases.
Pattern of Use and Resulting Consequences
One factor that may increase risk of infection among ICUs is their pattern of use. Cocaine is frequently used in intermittent cycles of repeated multiple uses known as binges. Indeed, this pattern of use has been confirmed in human laboratory studies (Ward et al., 1997). This pattern often leads to more frequent injections during a binge than are generally observed in heroin-dependent populations. Moreover, injecting cocaine users often share needles with more people then those who report injecting other drugs.
Indeed, this greater frequency of injection during a binge appears to have as its consequence a greater likelihood of HIV infection. The frequent use of cocaine during binges, along with greater likelihood of shared needles, has been demonstrated to cause twice the risk of HIV infection for ICUs than for other IDUs (Chaisson et al., 1989; Anthony et al., 1991), and 1.5 times the risk of crack smokers (Kral et al., 1998).
Reducing Injection Drug Use And Its Consequences
A variety of interventions has been used to reduce the consequences of injection drug use (for reviews see Des Jarlais and Friedman, 1996; Sorenson, 1991). These interventions are tailored to injection drug users (IDUs) in general, yet the results from this research are more applicable to ICUs. It is important to note that education alone may not be effective in preventing the consequences of injecting drugs, because studies have shown that such programs increase knowledge without changing behavior.
Evidence shows that multicomponent HIV prevention programs, which include instruction on bleach disinfection along with skills training, counseling, and HIV testing, reduce the risk of transmission over time (Institute of Medicine [IOM], 1995). However, these results have not been supported in other studies, which failed to prove the efficacy of bleach disinfection. This may be caused by either ineffective disinfection procedures or inconsistent use of effective ones. The 1995 Report on the Prevention of HIV Infection, sponsored by the Institute of Medicine, recommends that bleach disinfection, when performed according to the guidelines provided by the Centers for Disease Control and Prevention (CDC) and the Center for Substance Abuse Treatment (CSAT), is likely to prevent HIV infection for IDUs who share injecting equipment. The IOM report recommends that IDUs be trained in effective procedures and more research be conducted to identify the simplest effective disinfection procedures. Expanding that view, Des Jarlais and Friedman stated that, as currently implemented, bleach disinfection should not be relied on by HIV prevention programs (Des Jarlais and Friedman, 1996). They suggest, however, that bleach disinfection is more effective than not and should be performed when equipment is shared.
Needle exchange programs have been implemented in a wide variety of circumstances throughout the world (Hurley et al., 1997). The vast majority of studies and reports on needle exchange procedures suggests that they reduce the risk of HIV and hepatitis, and neither lead to more injecting drug use nor create new IDUs (Hurley et al., 1997; IOM, 1995).
Some populations received no noticeable benefit from these programs, however. For example, a drop in HIV infection was not seen in Montreal. One possible reason for this is that Montreal's needle exchange program restricted the number of needles a client could obtain per visit--fewer needles than ICUs typically use in the course of their drug use. Consequently, clients turned to other needle sources, negating the effect of the program.
Although these data tend to support the use of needle exchange programs, no controlled trial has yet to be conducted. The IOM report recommends that communities that desire such programs be permitted to use them. It also recommends that needle exchange be implemented as part of a multicomponent treatment, and that additional research and evaluation be conducted to evaluate the effects of needle exchange programs.
Gay Men
Research has found that men who have sex with men (MSMs) and who abuse alcohol, stimulants, inhalants, and other noninjection street drugs are more likely than non-substance users to engage in unprotected sex and become infected with HIV (Paul et al., 1991, 1993, 1994). Sexual risk-taking among MSMs, like that among the general population, often occurs under the influence of substance use, particularly stimulants. Sexual risk-taking within the context of substance use is hypothesized to occur due to disinhibition effects, learned patterns (especially between stimulant use and certain high-risk sexual practices), low self-esteem, altered perception of risk, lack of assertiveness to negotiate safe practices, and perceived powerlessness (Paul et al., 1993).
Alternatively, sex networks and sexual mixing patterns (Renton et al., 1995) might better explain the higher risk of HIV infection related to substance abuse among MSMs. As suggested by Renton and colleagues, MSM substance users may form tightly defined groups characterized by higher HIV seroprevalence rates, higher sexual mixing, greater injection drug use, and more trading sex for money, food, and drugs. These factors, rather than the suggested links between substance use and high-risk sex, would therefore account for higher HIV risks among MSM substance users. Regardless of which hypothesis better explains the connection between substance abuse and HIV/AIDS among MSMs, HIV/AIDS clearly intertwines with substance abuse. Unfortunately, similar to IDUs, it is estimated that only 10 percent of all MSMs who abuse substances seek therapy at substance use disorder treatment centers. Because of the stigmatization of MSMs, HIV-infected MSM substance users either do not seek treatment at traditional substance use disorder treatment centers, or they remain "closeted" when they do attend treatment.
Outreach
Outreach strategies for HIV prevention may readily translate to substance use interventions. In addition, there tends to be a stigma against substance users in the gay community, and outreach workers must be prepared to help clients overcome the stigma in order to get into treatment.
Of concern in this population is that any injection drug use, and use of injected methamphetamine (MA) in particular, increases the risk of HIV and/or hepatitis transmission from needles as well as from drug-induced bad judgment, feelings of invulnerability, risky behaviors, and repetitive and prolonged sexual behavior. A study of MA-using gay men in Los Angeles found that 62.5 percent of all participants reported having anal sex without a condom, and 56.3 percent reported having sex with someone who had HIV (Frosch et al., 1996). For counselors and outreach workers, risk assessment, including use analysis focused on how sex fits into the use patterns, is critical. It is important in the assessment process to capture these patterns.
Education of counselors, as well as clients, regarding the particular effects of this class of drugs is extremely important. Recently, there has been some backsliding with regard to injection drug use and sexual behaviors because of the perception that the new AIDS drugs mean a positive diagnosis is no longer automatically a death sentence. Not only does this myth need to be countered, but information on the effects of long-term stimulant use could diminish the attractiveness of MA-enhanced sexual performance. Side effects of long-term use include diminished sexual desire and performance. With ice in particular, clients show decreased ability to achieve orgasm, briefer erection periods, and an increase in impotence. Finally, counselor education needs to ensure lack of bias and sensitivity to the sexual practices of gay men.
Methadone Maintenance Clients
Cocaine and heroin are sometimes used together in a practice commonly known as speedballing. Some clients claim that methadone lengthens and mellows the effects of cocaine, presumably attenuating the negative reinforcers associated with cocaine crash (Condelli et al., 1991). Some patients also use alcohol or benzodiazepines or both concurrently with cocaine and heroin to reduce these effects of the cocaine crash, often marked by anxiety, depression, fatigue, and jitteriness. Thus, just as heroin use can increase the likelihood of cocaine dependence, cocaine use can increase the risk of heroin dependence (Dunteman et al., 1992).
Although methadone is very rarely combined with MA, there are some issues in this population of which counselors should be aware: treatment difficulties, medical risks, cocaine use, counselor training, and need for enhanced services.
Epidemiology
Stimulant abuse rates among methadone clients vary by program but range from 40 to 60 percent in inner city populations, according to data on positive screens for cocaine. These data suggest that the routes to MA use are established, and further study may be required to determine the extent to which they are used. In addition, data show a very high number of sedative users, including users of benzodiazepines, among methadone clients.
Individuals With Co-Occurring Mental Disorders
Individuals with co-occurring mental disorders may be defined as those persons with coexisting stimulant use and/or other substance use disorders and any of the following disorders:
• Major depression
• Dysthymia
• Bipolar disorder
• Antisocial personality disorder
• Panic disorder
• Agoraphobia
• Social phobia
• Posttraumatic stress disorder (PTSD)
• Attention deficit/hyperactivity disorder (AD/HD)
• Schizophrenia
It is critical to be aware of the fact that a DSM-IV diagnosis of a mental disorder is different from the mere production of symptoms (American Psychiatric Press, 1994). For example, most stimulant users will enter treatment exhibiting symptoms of depression. Similarly, many MA users will exhibit psychotic symptoms that are quite common in schizophrenics. However, the symptoms of depression are not the same as the psychiatric illness of depression, nor are the psychotic symptoms evidence of schizophrenia. Many of the symptom clusters, commonly associated with specific psychiatric disorders (e.g., depression, anxiety, psychosis, bipolar mood fluctuations, antisocial behavior) are frequently seen during the use of stimulants or during the period of early abstinence.
In fact, many individuals will bring their psychiatric diagnosis into their substance use disorder treatment evaluation. Many stimulant users have sought psychiatric care for their stimulant problems before entering treatment (many individuals apparently feel it is preferable to have a diagnosis of depression or bipolar illness to substance dependence). Therefore, they will contend that they have a psychiatric disorder and require psychiatric care (i.e., medication, psychotherapy) rather than substance use disorder treatment.
It should not be assumed that because an individual has received a previous psychiatric diagnosis, or because she has symptoms typically associated with a psychiatric disorder, that she is necessarily a "dual diagnosis" client. The accurate diagnosis of psychiatric comorbidity among stimulant users requires considerable diagnostic sophistication. It is often necessary to make a provisional diagnosis, which is modified after additional data are collected. For many cocaine users, it is often necessary to have 1 to 2 weeks of cocaine abstinence; for MA users, it is often helpful to have 30 days of abstinence to make an accurate psychiatric diagnosis. Another important element in the diagnosis is to obtain a careful history regarding the historical relationship between the onset of psychiatric symptoms and the substance use history.
Dual diagnosis will often encompass three or more coexisting conditions. Clients who use stimulants may or may not have an underlying psychiatric disorder, and it is often impossible to discern the source of behaviors symptomatic of a psychiatric condition until the client is substance-free. In many cases, a month's abstinence will be required before an accurate psychiatric assessment can be completed. Although treatment of clients with a dual diagnosis can be complex, this population often hits bottom faster and therefore enters treatment more quickly, and often with more motivation, than do clients who use substances without the more serious underlying problems.
Specialized Treatment Interventions
Consensus Panel suggestions for treatment interventions for persons with a stimulant use disorder and a coexisting psychiatric disorder are discussed in the sections below.
Affective disorders
Symptoms of depression may occur as part of the use of or withdrawal from stimulants. Where possible, it is helpful to wait to treat depression until the client has begun recovery from a substance use disorder, and the Consensus Panel recommends waiting to use medication to treat depressive symptoms if at all feasible. However, if the client is suicidal, hospitalization is the recommended course of action.
Bipolar disorder
Clients with bipolar disorder may be treated in traditional treatment settings if they are well controlled on their medications for the bipolar condition. Use of stimulants can initiate a manic episode. Therefore, medication management is one of the most important issues in treating clients with bipolar disorder.
Antisocial personality disorder
The diagnosis of antisocial personality disorders (ASP) is directly affected by substance use behavior. For example, many behaviors associated with chronic MA use mimic ASP, including law breaking, aggressiveness, and poor impulse control. Both cocaine use and ASP are associated with violence.
Many clients with ASP are involved with the criminal justice system, so coordination between systems (substance use disorder treatment, mental health, physical health) is important. Generally, men are more likely than women to present with ASP, and men typically use substances at a higher rate. Therefore, programs that are geared toward male clients with ASP and criminal involvement are necessary in a substance use disorder treatment system.
Panic disorder
Cocaine use can induce panic disorders, which can act as a trigger for panic attacks even after a client is substance-free. Panic disorders seem to be common for both cocaine and MA users long after they have discontinued using the drug and are often associated with depressions secondary to cocaine withdrawal. Health care providers should exercise extreme care in prescribing benzodiazepines for this disorder, due to their high addiction potential. Cognitive-behavioral techniques to recognize and manage symptoms may be some clinically useful strategies.
Posttraumatic stress disorder
Often, women who use ice are at an increased risk of PTSD because of substance-related episodes of domestic violence, sexual assault, and incest.
Recommended treatment approaches include referring clients to sexual assault and incest support groups as quickly as possible. Group counseling should be available in a woman-only format and should include coaching on what to expect from dreams, fears, and sleep disruptions as a result of PTSD and withdrawal from ice. Information on practical tools to combat nightmares such as night lights, herb teas, relaxation techniques, as well as information on relapse triggers, will provide clients with reassurance and skills to get through this period.
Counselors need special training to work with individuals with a co-occurring substance use disorder and PTSD. Issues include relapse triggers, timing of addressing issues in group sessions, and the tools and social skills women need in order to facilitate a successful recovery.
AD/HD
The prevalence of AD/HD in the general population ranges between 3 and 9 percent of adults. In the population of adults with substance use disorders, the prevalence of AD/HD ranges between 1 and 5 percent. However, one study has found that in the population of persons with adult AD/HD 40 percent had co-occurring substance use disorders, generally involving marijuana or alcohol (Biederman et al., 1993, 1995). These substance use disorders were detected when the clients entered treatment for AD/HD.
It is critical to retrieve a clear longitudinal history of both substance use and symptoms of AD/HD prior to completing a diagnosis of co-occurring disorder. Side effects of cocaine use can mirror some symptoms of AD/HD, but they disappear when use ceases. Generally, persons with adult AD/HD had the disease when they were children, although it may not have been diagnosed as such. It is important to include an assessment of childhood symptoms when completing the client's history. The presence of AD/HD symptoms in childhood provides a reliability measure for the presence of the adult disease.
Schizophrenia
Estimates of the prevalence of substance use disorders in the schizophrenic population range from 30 to 50 percent. Much of this use stems from peer group-seeking behaviors. Using substances is normal, it's what the other people on the streets are doing, and substance use can give persons with schizophrenia the sense of well-being and fitting they otherwise lack.
It is important to treat substance use in clients with schizophrenia immediately in order to allow medication for the mental illness time to take effect. A person with schizophrenia who continues to use cocaine will become fully psychotic, and those who continue to use MA will develop a psychosis indistinguishable from that created by paranoid schizophrenia.
After a stabilization period, treatment for both conditions can occur simultaneously with slight modifications. Modified group counseling may be used to treat substance use disorders. However, groups must be smaller and more controlled than in traditional substance use disorder treatment, and confrontational settings should be avoided. To be effective, each group session should focus on a particular skill or topic.
Medically Ill Clients
This section refers to clients who are undergoing treatment for a substance use disorder and who have one or more co-occurring medical disorders. Good clinical practice suggests that, prior to initiation of treatment for a substance use disorder, each client should be given a thorough physical examination. Followup should include contact with the clients and other providers and review of treatment records from them. In addition, treatment providers should be trained in the following:
• How to detect changes in medical conditions
• How to differentiate behaviors related to substance use from behaviors related to a deteriorating medical condition
• How to decide whether or not a referral to a physician is in order
Finally, it is important to note that linkages between substance use disorder treatment providers and the physicians and specialists who treat the client can improve treatment outcomes for the client.
This section discusses some medical conditions that require particular attention on the part of the substance use disorder treatment provider: epidemiology, diabetes, and HIV/AIDS.
Epidemiology
Chapter 5 of this TIP discussed some of the common medical illnesses seen in substance-using populations. Because the stimulant-using population tends to be younger, the medical conditions are not generally as severe as observed in the population of substance users as a whole. For example, because most persons who use stimulants range in age from 25 to 35 years, they do not present with conditions common to middle and old age such as coronary artery disease. Generally, primary medical problems are dental, dermatological, ear, nose, and throat, otitis media, nutritional (very thin clients who either use cocaine, have AIDS, or both), asthma, neurological disorders, seizures, and residual problems from a stroke. Secondary conditions include blood borne diseases, HIV, hepatitis, and sexually transmitted diseases.
Stimulant users in particular present higher rates of thyroid problems, in the form of permanent hyperthyroidism or hypothyroidism. This may be attributed to impure MA, resulting in a chemical, tissue-specific reaction in the thyroid, but more research needs to be performed in this area. For a complete list of the general medical complications of stimulant use, please refer to Chapter 5.
Hepatitis
Persons who use stimulants are often at risk for hepatitis, which, due to the ease of global travel, is no longer restricted to Third World countries. The Centers for Disease Control and Prevention (CDC) estimates that 150,000 people in the United States are infected each year by hepatitis A alone. The CDC lists household or sexual contact, sharing of infected needles, and recent international travel as the major known risk factors for transmission of hepatitis A. Hepatitis B virus (HBV) is a more virulent form of the disease and is much more prevalent than HIV, with an estimated 1.2 million Americans currently chronic carriers of HBV. Hepatitis B may develop into a chronic disease (which means lasting more than 6 months) in up to 10 percent of the 200,000 newly infected people each year. If left untreated, the risk of developing cirrhosis (scarring of the liver) and liver cancer is increased in clients with chronic hepatitis B. Treatment programs for stimulant users should include a screening for hepatitis in each client's initial assessment.
HIV/AIDS
Another important initial screening for persons with stimulant use disorders is that for HIV. Clients may be reluctant to undergo an HIV test because they fear the results. However, being diagnosed negative can act as a powerful motivator for stimulant users to comply with treatment more fully, once they no longer fear that they will develop AIDS. Testing negative can also encourage clients to practice preventive measures in other areas of their lives. Testing positive, although discouraging to the client, is an important part of the screening that the treatment provider needs to be aware of. Once the HIV status of the client is known, treatment can be planned that will include a medical component in the substance use disorder recovery program.
However, some special issues remain. One of the critical aspects of providing substance use disorder treatment to persons with HIV or AIDS is the continuing education that providers need regarding the changing and complex array of medication regimens available to this population. In addition, providers should know that clients with HIV/AIDS, armed with these new medicines, are approaching life differently. Now that they know they will live longer, they may return to using substances.
An issue with stimulant use is the increased risk of contracting HIV through the high-risk sexual behavior facilitated by the drug. By and large, clients have grown more aware of the risk of transmission from needles, although this is an area that requires further study. Cocaine users have more opportunities for exposure to HIV than do other stimulant users because they require multiple injections to maintain a high and therefore may run out of needles more quickly and be tempted to share. Bartering sex for drugs is a more likely route to HIV infection than unclean needles for MA users, because MA requires fewer injections.
Treating clients with HIV/AIDS is another area in which program linkages become critical to successful treatment. It is helpful, where possible, to have staff and nurses skilled in each type of treatment situated to provide clients convenient access. Anecdotal data from providers indicate that clients tend to get lost on the way to a referral appointment, and co-locating providers, such as an obstetrician-gynecologist in a methadone clinic, helps to mitigate this problem. For more information on this topic, please refer to Treatment for HIV-Infected Alcohol and Other Drug Abusers (TIP 15) (CSAT, 1995a; revision in press).
Criminal Justice Clients
A significant amount of crime is committed by substance users, and it is important to carefully assess this population. Many persons in the criminal justice system commit crimes while inhibitions are reduced by substance use, and others steal in order to buy drugs. These types of clients form the target treatment population. Other persons in the criminal justice system simply sell drugs but do not use them, or use drugs but are not addicted to the particular drug they sell. Self-report data indicate that 72 percent of persons in the criminal justice system are substance-dependent. These clients are often extremely complex in terms of case management: One client may have simultaneous involvement in the criminal justice, substance use disorder treatment, and mental health systems. There is little research on the specific issues faced by criminal justice clients with stimulant use disorders.
For more information on this topic, please refer to TIP 12, Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System (CSAT, 1994c); TIP 17, Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System (CSAT, 1995c); TIP 21, Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the Justice System (CSAT, 1995e); TIP 23, Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing (CSAT, 1996); and TIP 29, Continuity of Offender Treatment for Substance Use Disorders From Institution to the Community (CSAT, 1998b).
Racial/Ethnic Considerations
One of the most important issues in developing treatment options for different racial/ethnic groups is to move beyond cultural sensitivity and into cultural competence. Cultural competence is not just an understanding of superficial ethic designations but instead a knowledge of regional and socioeconomic patterns.
Cultural competence is critical for working in the drug treatment field today, because providers need to be culturally sensitive when working with diverse populations. Progressively increasing levels of cultural capacity include:
• Cultural sensitivity
• Cultural competence
• Cultural proficiency
Cultural sensitivity involves a basic understanding and appreciation of sociocultural factors as these relate to the client's treatment needs and the choice of relevant treatment. Cultural competence involves a greater depth of understanding of the client's needs within the client's cultural context. It also involves greater skills and experiences that allow working with cultural nuances as presented by the client, and the capacity to interpret deeper meanings in the client's thoughts and behaviors. Cultural competence aids in making better treatment decisions because it is based on a more effective matching of the client's needs with the relevant treatment options.
Outreach
Outreach issues will be specific to the targeted ethnic population, but topics to consider for each include
• Location of treatment centers and community-based organizations
• Availability of drop-in centers
• Availability of nonconfrontational programs
• Programs that spend more time in the engagement phase prior to counseling
• Programs that offer individualized approaches, encourage the establishment of safe relationships, allow time for trust to develop, and assess the level of motivation for change
• Counselors trained to help clients identify their own ethnic issues
• Counselors matched to clients by cultural competence (not necessarily racial/ethnic background)
Many of the above considerations involve slowing down the course of treatment to accommodate racial/ethnic mores. Of concern to the Consensus Panel is the method of payment for this type of care. Managed care is reluctant to fund long-term treatment or treatments that cannot be reduced to billable units.
Rural Populations
According to 1990 census data, approximately 25 percent of the U.S. population lives in rural areas. Colorado, Idaho, Montana, New Mexico, North Dakota, Nevada, South Dakota, Utah, and Wyoming have been identified as "frontier States," with at least half of their counties possessing six or fewer persons per square mile. All of these are western States--in which MA use is high.
The National Household Survey, conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), revealed that large metropolitan areas and rural areas had similar rates for substance use among youths 12 to 17 years old (SAMHSA, 1998). What differed was the specific substances used, not the prevalence of substance usage.
Strict regulatory controls on lawfully manufactured MA limit its diversion from licit to illicit channels. The bulk of MA currently on the streets has been illegally manufactured in clandestine labs. Rural areas are at high risk for being targeted by drug manufacturers and dealers. A rural community offers secluded areas in which to produce illegal drugs and access to major transportation routes for distribution with minimal risk of discovery by law enforcement. Small towns tend to be on major highways and interstates, which facilitates transportation to other regions for sale and distribution. This is a risk factor that many rural and/or frontier communities are unprepared for because they often lack the treatment resources or the community infrastructure, such as police forces trained specifically in dealing with these issues. This can lead to swift and severe problems for ill-prepared communities.
Prevalence in Rural Areas
The number of MA treatment facility admissions is highest in the western States where they now surpass cocaine admissions. Primary MA admission rates are beginning to rise in some southern and midwestern States.
In the State of Nevada, (a frontier State), the client data system for 1997 admissions to publicly funded substance use disorder treatment centers reported that of those individuals seeking treatment for substance use disorders, 52 percent were seeking treatment for MA use.
Challenges, Limitations, and Barriers to Treatment Services Faced by Rural Areas
Rural areas face the challenge of providing access to services for clients who may live hundreds of miles away from the nearest treatment provider. An entire day might be spent traveling by car to a service provider, because most rural areas lack public transportation.
Rural areas usually have a fragmented service system and limited resources. The lack of medical and social services in rural areas prohibits any continuum of care or even referral for specialized care. In many rural communities there are no treatment services available. Often only one social service provider is available and is generally overwhelmed by the various needs of the community. Social service agencies in rural areas tend to be multiservice agencies out of necessity.
Rural communities are generally allocated minimal funding for treatment because funding is usually based on population, which results in the provision of minimal services. There are rarely any sources within the community from which to seek additional funding. The lack of adequate funding limits staffing, staff salaries (which contributes to a high staff turnover), and the ability to provide support services such as childcare or transportation in the areas where that support is needed most.
Confidentiality is rare in rural settings. There is no anonymity in a small rural community. Everyone knows everyone and observes each other's comings and goings. Most rural communities' lack of available and appropriate office space leaves treatment providers practicing in whatever space they can find--which often involves little privacy.
Continuing education for treatment providers is nonexistent in most rural areas. Consequently, treatment providers often lack the most current information in the field.
Strategies To Provide Services In Rural Areas
The following are various strategies that can help provide treatment services to rural populations:
• Providers can form a consortium between educators, counselors, and law enforcement officers. By forming linkages between various agencies, small communities can have equal access to treatment services. The consortium can then use local statistics on substance use-related mortality rates, arrests for driving under the influence, school survey data, crime rates, and so on, to evaluate community needs. If data cannot be compiled easily by community members, the State substance abuse treatment office can either provide that information or direct individuals where to find it.
• Different providers can share staff and cross-train professionals and paraprofessionals. If the welfare worker is knowledgeable about addictions, she may be alert to symptoms of substance abuse in the client who comes in for food stamps. Conversely, the addictions counselor can identify other needs and provide the proper case management.
• Treatment programs can provide basic training of medical personnel, community social workers, teachers, school counselors, law enforcement officers, judges, and child care providers within a community. This can go a long way toward stretching resources and raising community awareness of the issues.
• Programs can provide safe and substance-free living arrangements for clients while in treatment away from their home community. Funds for this can be especially designated, solicited through recovery community networking, or obtained through donations.
• Programs can provide treatment services that are flexible in scope and structure. For example, an intensive outpatient program might offer a 6-hour session on Saturday and Sunday instead of the more usual weekday sessions. Treatment providers can also practice flexibility by assigning homework, arranging phone check-in, having drug testing done by outlying clinics, using online communication, and holding weekend workshops or retreats instead of traditional weekly sessions.
• Nontraditional outreach sites can be used for treatment services. A treatment facility in a small rural community may not be realistic, but it may be feasible to employ a part-time person in a satellite office who travels to different satellite sites to provide outpatient services. Many rural States have mobile rural healthcare--a network of vans that take primary care medical services to rural and isolated communities. Substance use disorder treatment could become an additional service provided in this manner. Like the mobile approach, some rural States also contract treatment counselors to travel from one rural site to another during the course of a week and who work out of other community service providers' offices. Although many communities lack sufficient office space in which to set up a treatment center, nearly every community has a school and a church that can serve. There is generally a healthcare or government service office within a reasonable distance that may provide some space for treatment services on a limited basis.
• Programs can work to develop outreach efforts with sponsorship from State agencies. Such efforts can help foster a strong self-help network in rural communities. Every community has "recovered" and "recovering people." However, these individuals often have never considered organizing themselves into a mutual support network. Most chapters of organizations such as Alcoholics Anonymous, Narcotics Anonymous, and Rational Recovery have members who would gladly extend their help and experience in developing such a network.
• Continuing education videotapes are a possible resource for rural treatment providers. State substance abuse offices and urban treatment providers can provide videotapes for those who cannot attend or afford the ongoing training that is available in urban areas.
Women's Issues
Treating stimulant use disorders in women can involve a host of complex issues (including pregnancy, children, domestic abuse, and socioeconomic problems) that can impact diagnosis and treatment of stimulant use disorders. However, although women's use of stimulants has not been well studied, one recent study does point to a gender difference in women's response to cocaine (Lukas et al., 1996). In addition, in recent studies of MA use, the percentage of female MA users appears higher than with samples of cocaine or heroin users (Rawson et al., 1998a).
Epidemiology
Although MA use is traditionally associated with males, growing numbers of women are using this class of drug, for reasons ranging from a desire to lose weight to the wish to be a "superwoman" who must self-medicate to get through an overextended day. Data on women who were sexually abused as children suggest they use cocaine as adults in order to "feel better."
Outreach
There are a number of entry points in the system for women who might not present directly for treatment, including
• Pediatricians (mothers will take children to the doctor even when they will not go for their own problems)
• Child protective agencies
• Social service agencies
• Primary care providers
• Criminal justice system
Two types of barriers must often be addressed concerning outreach to women who use substances, including stimulants. First, internal barriers to seeking treatment for substance use disorders that include guilt, depression, fear of children being taken away, and fear of partners who are using or dealing drugs must be identified and mitigated. Second, external barriers to be examined include lack of accessibility to treatment programs, need for child care, or lack of community-based programs that prevent women from seeking treatment. Often, reducing just one barrier is enough to bring a woman into treatment. For example, treatment programs that provide child care may have higher participation levels than those that do not.
Treatment programs must focus on the physical health of the woman entering treatment. Anecdotal data suggest that women experience more rapid physical deterioration than men from MA and cocaine use, but there is no solid research base to support this observation. Generally, by the time women get into treatment they are sicker than their male counterparts. In addition, women who are not in the workplace may have used the drug for a longer period of time without detection than their working counterparts and will be in worse shape when they do enter treatment.
Treatment programs must also consider the type of stimulant used. Ice, because it is a drug that is often used in family or community settings, exacerbates all of the women's issues described in this section.
Treatment for women should involve a holistic approach, including consideration of the following:
• Relationships with family (after social functioning, issues of homelessness, social isolation)
• Treatment needs of children
• Domestic violence
• Parenting
• Life skills
• Education and vocational training
• Economic self sufficiency
• Reproductive health issues
• Education about long-term affects of using stimulants
• Mental health
• Dependency issues
• Self-esteem
• Independent living skills
• Nutrition
• Transportation
• Ethnic and cultural issues
• Day care and group counseling for children
• Gender specific groups/female group leaders
• Long-term effects of stimulants on reproductive health
One relapse issue to consider for female clients is the negative impact of long-term MA use on sexual performance--the drug may cause women to lose sexual desire and the ability to achieve orgasm. However, they may also resort to MA or cocaine use, if pressured for sex, in order to get through the experience. In addition, women who return to the community to live, but who are living in a dependent relationship, may need to trade sex for food and shelter. This pressure for sex can lead to a resumption of substance use.
Intensive outpatient programs, which at first glance may appear to be more accessible to women with children, in fact present their own barriers. Programs that require frequent onsite visits but do not provide child care onsite will not enhance compliance with the treatment regime.
Adolescents
Adolescents can present many issues of concern besides their stimulant use. The path to abuse and dependence for this group may start because of general substance and alcohol experimentation, negative peer group or gang exposure, attempts to self-medicate for undiagnosed mental health conditions, poor self image (e.g., the desire to lose weight), the need to fabricate confidence to facilitate criminal activities, or any combination of these and other issues confronting adolescents. Other contributing issues may include anxiety, depression, loneliness, coping with past sexual or physical victimization, homelessness, and teen pregnancy.
The adolescent population is comprised of three subgroups:
• Sixth through ninth graders (advanced children)
• Tenth graders through high school seniors
• Adolescents older than high school age
A common treatment principle across all subgroups is that, to adolescents, the concept of death is so remote as to render scare tactics useless in pursing lifelong sobriety. However, this population offers hope to treatment providers because adolescents are not yet entrenched in their illness, and if substances can be removed from their lives, they can move on and learn with the rest of their peer group. Although there are many problems inherent in treating this population, the rewards of success can be that much greater.
Epidemiology
Although national studies at this time do not show evidence of high usage rates of MA or cocaine, these substances warrant attention for at least two reasons. First, adolescents tend to be multiple substance users, so an increase in use rates reported for other substances and stimulants can be somewhat indicative of trends in use of MA, and second, adolescents tend to use substances that are convenient to obtain; therefore rates of use are likely to be higher in areas with ample availability.
Nationally, the 1996 Monitoring the Future Study revealed an increase in opiate and cocaine use among 8th, 10th, and 12th graders, and teens in particular doubled opiate use (NIDA, 1998b). Amphetamines are not high on the list of drugs, with 2 to 3 percent of adolescent respondents reporting use during the period surveyed.
In terms of regional use by adolescents, problem areas include the West Coast, Midwest, and Hawaii. In California, rates of MA use among adolescents are higher than marijuana use. In Hawaii, data from Adolescent Drug Abuse Diagnosis (ADAD) (treatment programs that receive State funding) show that younger people (11 to 12 years old) are coming into treatment for ice use, indicating an even earlier initiation of gateway drugs leading to ice. In Arizona, although there are no data on the prevalence of MA use among adolescents, the proliferation of labs in both the inner city and all over the region, including home-based labs, suggests higher availability and therefore higher use among youth in this State.
Cultural and socioeconomic factors may also predict use in the adolescent population. In Hawaii, use patterns among Hawaiian and Filipino youth are related to the higher use patterns of their cultural groups as a whole. By contrast, MA use is not yet a big issue among Native American adolescents. MA use by youth is higher in lower middle class and working class neighborhoods, but adolescents from all socioeconomic classes use MA.
Outreach
Outreach to the adolescent population must focus not only on identifying high-risk youth but must also on identifying the most effective methods to reach them. High-risk youth will often have low motivation, drop out of high school, and show early involvement in low-level criminal activity. Often they have a number of hard to treat psychiatric issues, such as conduct disorder, depression, and AD/HD.
Outreach workers should get to these youths as early as possible. Counselors, teachers, school administrators, and others who work with young adolescents need training to identify behaviors that, if left unaddressed, can contribute to later abuse of substances, including stimulants. Generally, the more problems observed in an adolescent, the more she will be at risk for substance and stimulant abuse and dependence.
Although data are not stimulant-specific, it is useful for persons who work with adolescents to know that very often there is a psychiatric disorder that precedes the substance use disorder. It is important to treat the psychiatric problems in order to prevent self-medication. In addition, this group of adolescents tends to be impulsive, which puts them at higher risk for using substances. Adolescents with depression and conduct disorders are more likely to get involved in substance use than are their counterparts who are not dealing with mental health issues.
Because the public substance use disorder treatment system is often adult-driven, it is hard to know where to refer adolescents for screening and assessment. Often they show up in the juvenile justice system. When adolescents are referred for a discipline problem, it is important to screen for coexisting or underlying mental health and substance use disorders. A number of good screening and assessment tools exist for this purpose--for a list of them, please refer to the upcoming revised TIP, Screening and Assessing Adolescents for Substance Use Disorders. Adults who can serve as referral sources for adolescent substance users include pediatricians, teachers, school nurses, and school psychologists. This mix of professionals is important in order to cast a wide net for detecting adolescent stimulant use disorders.
A cautionary note for counselors new to this population--adolescents often experiment with substances and other risk-taking behaviors without developing dependence. Therefore, it is a mistake to automatically label experimental substance use behavior as a problem or dependence. With this population in particular, it is important not to over identify or label adolescents as substance abusers. (More information on this topic will be available in the revised TIP, Screening and Assessing Adolescents for Substance Use Disorders [CSAT, 1999a].)
Outreach also includes prevention and early intervention efforts. Although prevention efforts should begin earlier, middle school children, 11 to 12 years old, form an ideal target for comprehensive prevention programs. One example includes life skills-training programs for truant youths (a high-risk group whether or not they are using substances). Prevention efforts that take into consideration the influences of culture and family are important to consider. In Hawaii, the police department runs a prevention program for Hawaiian youths that is grounded in the base of the local culture.
Treatment settings and approaches for adolescents include
• School-based clinics
• Traditional outpatient services
• Long-term residential
• Separate schools
• Developmental models
• Multisystemic therapy
• Experimental therapeutic camps
• Experimental wilderness-based programs
Programs for adolescents should focus on cessation of use as well as developing the life and educational skills that clients have missed while using substances. Adolescents need more intensity in programming, such as partial hospitalization, or attending treatment after school 5 days per week. It is generally better to avoid mixing adults and youths.
Programs for adolescents should involve the family, even when treatment takes place outside the home. Assessment should determine whether or not the family itself is substance-free. It is also important that assessment and treatment programs for adolescents be developmentally based.
Other Considerations
The adolescent population demands heightened attention because of the impact of stimulant and other substance use on this important develop-mental bridge into adulthood. Stimulant use can impede physical, emotional, and mental development.
Adolescents who use ice often move quickly into psychosis. This leads to a problem with differential diagnosis in cases of potential schizophrenia. With ice use, it can be difficult to determine whether psychosis is the result of schizophrenia or whether it was induced by MA use.
Stimulant use, especially of ice, may be a cause of an early onset of anorexia. Adolescents often abuse stimulants both to lose weight and to cope with sexual inhibitions. Dramatic weight loss in this population is a warning sign for MA use. However, physical health issues, other than anorexia and dental problems, are not as prevalent in the adolescent population as they are in the population of adults who use stimulants.
Teenage pregnancy is another concern because of the association of substance use and early sexual activity, compounded by impaired judgment regarding birth control and prevention of sexually transmitted diseases.
A final note on the adolescent population concerns the lack of community resources generally available to this group. Community-based organizations must be tapped, especially for adolescents from minority groups. Prevention of substance use disorders should be a part of the curriculum for professional groups and continuing education for any community member who works with the adolescent population. (More information on this topic will be available in the upcoming, revised TIP, Treatment of Adolescents With Substance Use Disorders [CSAT, 1999b]).
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